Insight Across the Different Mood States of Bipolar Disorder

Efficacy of life goals collaborative care for bipolar disorder: A systematic review

BACKGROUND

Bipolar disorder remains a disabling mental health condition despite the availability of effective treatments. Collaborative chronic care models (CCMs) represent an evidence-based way to structure care for conditions like bipolar disorder. Life Goals Collaborative Care (LGCC) was designed specifically for bipolar disorder, featuring psychoeducation alongside collaborative components (e.g. nurse care management or expert psychiatric consultation). Despite the use of Life Goals across health systems, a systematic review summarizing its effectiveness has never been conducted.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs) of LGCC through December 2023 to help guide the field in treating bipolar disorder (PROSPERO: #404581). We evaluated study quality and outcomes in several symptom and quality of life domains.

RESULTS

Ten articles describing eight studies met inclusion criteria. All studies featured group-based LGCC; most were compared to treatment as usual (TAU). Three of eight studies found LGCC to be associated with statistically significant effects for the prevention of manic episodes. Most studies finding positive effects featured additional collaborative care components beyond psychoeducation and were conducted in capitated healthcare systems.

LIMITATIONS

Limitations include: several types of potential bias in included studies; exclusion of observational studies of LGCC; lack of generalizability to pediatric populations; insufficient studies to conduct subgroup analyses; and low confidence in the quality of the evidence.

CONCLUSIONS

In this systematic review, group-based LGCC demonstrated some positive effects for reducing mania recurrence; results for other outcome domains were equivocal. Future studies should investigate one-on-one LGCC, both in person and virtually, to enhance well-being for people with bipolar disorder.

Utilization of Cultural Formulation Interview to understand the factors affecting treatment adherence and help-seeking in mood disorders: A qualitative study from Western India

Introduction

Treatment adherence rates among patients of affective disorders remain sub-par across the world. Sociocultural factors affecting the same remain poorly understood. The current study aimed to explore and conceptualize the same.

Methodology

The study utilized a qualitative grounded and phenomenological approach study design. The patients who fulfilled the Diagnostic and Statistical Manual of Mental Disorders - Fifth edition (DSM-5) criteria of unipolar depression or bipolar affective disorder, and were presently under our treatment for at least three months and currently in remission, aged 18-60 years, and were able to understand Hindi or English, scored less than 6 on the Medication Adherence Rating Scale were included. Furthermore, key caregivers were also included in the study. Using purposive sampling and data saturation, a total of 30 participants were recruited. In-depth interviews were conducted using the cultural formulation interview as given in DSM-5, which was used as the interview tool. Thematic analysis of data was performed using Atlas.ti version 8.4.3.

Results

A total of 14 themes (deductive and inductive) emerging from 171 codes were identified. Some of the important inductive themes included cultural and societal attitude toward illness and treatment-seeking, trust, experience, and expectations from available health care, faith healing-related practices and beliefs. The implicit themes such as cultural understanding of the problem and cultural factors affecting help-seeking, also showed prudent findings.

Conclusion

The study findings demonstrate the various features of the sociocultural milieu and identity of an individual and family that have an influence on treatment-seeking behavior.

Smartphone-based interventions in bipolar disorder: Systematic review and meta-analyses of efficacy. A position paper from the International Society for Bipolar Disorders (ISBD) Big Data Task Force

BACKGROUND

The clinical effects of smartphone-based interventions for bipolar disorder (BD) have yet to be established.

OBJECTIVES

To examine the efficacy of smartphone-based interventions in BD and how the included studies reported user-engagement indicators.

METHODS

We conducted a systematic search on January 24, 2022, in PubMed, Scopus, Embase, APA PsycINFO, and Web of Science. We used random-effects meta-analysis to calculate the standardized difference (Hedges' g) in pre-post change scores between smartphone intervention and control conditions. The study was pre-registered with PROSPERO (CRD42021226668).

RESULTS

The literature search identified 6034 studies. Thirteen articles fulfilled the selection criteria. We included seven RCTs and performed meta-analyses comparing the pre-post change in depressive and (hypo)manic symptom severity, functioning, quality of life, and perceived stress between smartphone interventions and control conditions. There was significant heterogeneity among studies and no meta-analysis reached statistical significance. Results were also inconclusive regarding affective relapses and psychiatric readmissions. All studies reported positive user-engagement indicators.

CONCLUSION

We did not find evidence to support that smartphone interventions may reduce the severity of depressive or manic symptoms in BD. The high heterogeneity of studies supports the need for expert consensus to establish ideally how studies should be designed and the use of more sensitive outcomes, such as affective relapses and psychiatric hospitalizations, as well as the quantification of mood instability. The ISBD Big Data Task Force provides preliminary recommendations to reduce the heterogeneity and achieve more valid evidence in the field.

Facilitators and Barriers of Medication Adherence Based on Beliefs of Persons with Bipolar Disorder: A Qualitative Study

One of the big challenges in treating individuals with bipolar disorder (BD) is nonadherence to medication. This is the principal factor associated with a worse prognosis or outcome of the disease. This study aimed to explore and analyze the individual perceptions that people with BD have about the positive and negative aspects when taking medication. A descriptive and interpretative study was carried out using the qualitative research paradigm with the use of the analytical technique of discourse analysis, extracting the data through the completion of focus groups. Participants’ speech was digitally audio-recorded in digital format. In order to complete the codification of the participants’ speech content, we relied on the qualitative data analysis (using the QRS NVivo 10 computer software). Thirty-six participants diagnosed with bipolar disorder took part in our study. In the participants’ speech concerning the main barriers to pharmacological treatment, three key topics were identified. Perceived facilitators were summarized in four factors. The main facilitators regarding the use of pharmacological treatment in individuals with BD were the ones related with the perceived need for treatment in the acute phase, the recognition of the illness, the shared clinical decision, and the causal biological attribution in the chronic phase. In terms of perceived barriers, social control was identified in both phases, adverse effects in the acute phase, and the absence of effective treatment in the chronic state.

Mental Health and Related Factors of Adolescent Students During Coronavirus Disease 2019 (COVID-19) Pandemic

OBJECTIVE

Adolescents are at a special stage of physical and mental development, which is a susceptible period for mental disorders. Since the outbreak of coronavirus pneumonia in December 2019, long term stress may have negative effects on the mental health of the adolescents. In the context of the coronavirus disease 2019 (COVID-19), the study was designed to investigate the mental and psychological health of adolescents in China and its possible related factors.

METHODS

A cross-sectional study design was adopted using a structured questionnaire which were distributed through the Internet to measure depression, anxiety, life events and stress related factors. Descriptive statistics and multiple regression analyses were conducted to process the data.

RESULTS

The final sample comprised 795 adolescents. The total detection rate of depression was 76.48% and the total detection rate of anxiety was 33.08%. ANOVA showed that there were significant differences in depression scores in terms of gender, anxiety scores, history of mental disorders, COVID-19 knowledge reserve, family and social contradictions (p<0.05). And there were significant differences in anxiety scores in terms of gender, depression scores, mental health knowledge reserves, family and social contradictions (p<0.05). Multiple regression analysis showed that anxiety score, health status and COVID-19 knowledge reserve were positively associated with depression score (p<0.01), and history of psychosocial disorders was negatively associated with depression score (p<0.05); depression score, family and social contradictions were significantly positively correlated with anxiety score (p<0.01), and history of mental disorders was significantly negatively correlated with SDS score (p<0.01).

CONCLUSION

During the outbreak of COVID-19, adolescent students with better understanding of the pandemic, more complete knowledge of mental health, and better family and social relationship had less impact on their mental health. Therefore, to ensure a sound social support system, elaborate health instruction, and family communication and mutual understanding are conducive to alleviating the psychological stress caused by the epidemic, and it is positive for adolescent students to maintain a good mental health.

Voice analyses using smartphone-based data in patients with bipolar disorder, unaffected relatives and healthy control individuals, and during different affective states

BACKGROUND

Voice features have been suggested as objective markers of bipolar disorder (BD).

AIMS

To investigate whether voice features from naturalistic phone calls could discriminate between (1) BD, unaffected first-degree relatives (UR) and healthy control individuals (HC); (2) affective states within BD.

METHODS

Voice features were collected daily during naturalistic phone calls for up to 972 days. A total of 121 patients with BD, 21 UR and 38 HC were included. A total of 107.033 voice data entries were collected [BD (n  = 78.733), UR (n  = 8004), and HC (n  =  20.296)]. Daily, patients evaluated symptoms using a smartphone-based system. Affective states were defined according to these evaluations. Data were analyzed using random forest machine learning algorithms.

RESULTS

Compared to HC, BD was classified with a sensitivity of 0.79 (SD 0.11)/AUC  = 0.76 (SD 0.11) and UR with a sensitivity of 0.53 (SD 0.21)/AUC of 0.72 (SD 0.12). Within BD, compared to euthymia, mania was classified with a specificity of 0.75 (SD 0.16)/AUC  =  0.66 (SD 0.11). Compared to euthymia, depression was classified with a specificity of 0.70 (SD 0.16)/AUC  =  0.66 (SD 0.12). In all models the user dependent models outperformed the user independent models. Models combining increased mood, increased activity and insomnia compared to periods without performed best with a specificity of 0.78 (SD 0.16)/AUC  =  0.67 (SD 0.11).

CONCLUSIONS

Voice features from naturalistic phone calls may represent a supplementary objective marker discriminating BD from HC and a state marker within BD.

Ecological momentary assessment of mood and movement with bipolar disorder over time: Participant recruitment and efficacy of study methods

OBJECTIVES

Mobile technology and ambulatory research tools enable the study of human experience in vivo, when and where it occurs. This includes cognitive processes that cannot be directly measured or observed (e.g., emotion) but can be reported in the moment when prompted.

METHODS

For the Bipolar Affective Disorder and older Adults (BADAS) Study, 50 participants were randomly prompted twice daily to complete brief smartphone questionnaires. This included the Bipolar Disorder Symptom Scale which was developed to briefly measure symptoms of both depression (cognitive and somatic) and hypo/mania (affrontive symptoms and elation/loss of insight). Participants could also submit voluntary or unsolicited app responses anytime; all were time- and GPS-stamped. Herein, we describe BADAS study methods that enabled effective recruitment, adherence and retention.

RESULTS

We collected 9600 app responses over 2 year, for an average response rate of 1.4×/day. Over an average of 145 consecutive days (range 2-435 days), BADAS participants reported depression and hypo/mania symptom levels (a.m. and p.m.), sleep quality (a.m.), medication adherence (a.m.) and any significant events of the day (p.m.). They received $1/day for the first 90 days after submitting both a.m. and p.m. questionnaires.

CONCLUSION

BADAS study methods demonstrates the utility of ecological momentary assessment in longitudinal psychiatric research.

A comparative study evaluating insight in different phase of illness among patients with bipolar disorder by using multiple scales

AIM

This cross-sectional study aimed to evaluate insight and its correlates among patients with bipolar disorder (BD).

METHODOLOGY

180 patients with BD were evaluated on Scale to Assess Unawareness of Mental Disorders (SUMD), Insight scale for affective disorders (ISAD), Mood Disorders Insight Scale (MDIS), and Beck Cognitive Insight Scale (BCIS).

RESULTS

About half of the patients were in clinical remission (N = 94; 52.2%), one-fifth (N = 37; 20.55%) were in the phase of mania and one-fourth (N = 49; 27.2%) were in a depression. There was no significant difference in the level of insight between those in clinical remission and those in depression except for one of the domains of BCIS. Patients with mania had poorer insight compared to those in remission and depression. In terms of association of insight as assessed by different scales, in the whole sample and all the three subgroups, SUMD current and past scores had a significant positive correlation with the ISAD total score. In the whole sample, among patients currently in remission and those currently in depression, ISAD total score had significant negative correlation with MDIS total score. Poorer insight as assessed on SUMD (current and past), ISAD and MDIS was associated with poorer medication adherence.

CONCLUSION

The present study demonstrates that patients with mania have poor insight when compared to the patients in clinical remission and depression. The present study also demonstrates that the assessment of clinical insight is not affected much by the type of scale used.

Daily mobility patterns in patients with bipolar disorder and healthy individuals

BACKGROUND

Alterations in energy and activity in bipolar disorder (BD) differ between affective states and compared with healthy control individuals (HC). Measurements of activity could discriminate between BD and HC and in the monitoring of affective states within BD. The aims were to investigate differences in 1) passively collected smartphone-based location data (location data) between BD and HC, and 2) location data in BD between affective states.

METHODS

Daily, patients with BD and HC completed smartphone-based self-assessments of mood for up to nine months. Location data reflecting mobility patterns, routine and location entropy was collected daily. A total of 46 patients with BD and 31 HC providing daily data was included.

RESULTS

A total of 4,859 observations of smartphone-based self-assessments of mood and mobility patterns were available from patients with BD and 1,747 observations from HC. Patients with BD had lower location entropy compared with HC (B= -0.14, 95% CI= -0.24; -0.034, p=0.009). Patients with BD during a depressive state were less mobile compared with a euthymic state. Patients with BD during an affective state had lower location entropy compared with a euthymic state (p<0.0001). The AUC of combined location data was rather high in classifying patients with BD compared with HC (AUC: 0.83).

LIMITATIONS

Individuals willing to use smartphones for daily self-monitoring may represent a more motivated group.

CONCLUSION

Alterations in location data reflecting mobility patterns may be a promising measure of illness and illness activity in patients with BD and may be used to monitor the effects of treatments.

Daily estimates of clinical severity of symptoms in bipolar disorder from smartphone-based self-assessments

Currently, the golden standard for assessing the severity of depressive and manic symptoms in patients with bipolar disorder (BD) is clinical evaluations using validated rating scales such as the Hamilton Depression Rating Scale 17-items (HDRS) and the Young Mania Rating Scale (YMRS). Frequent automatic estimation of symptom severity could potentially help support monitoring of illness activity and allow for early treatment intervention between outpatient visits. The present study aimed (1) to assess the feasibility of producing daily estimates of clinical rating scores based on smartphone-based self-assessments of symptoms collected from a group of patients with BD; (2) to demonstrate how these estimates can be utilized to compute individual daily risk of relapse scores. Based on a total of 280 clinical ratings collected from 84 patients with BD along with daily smartphone-based self-assessments, we applied a hierarchical Bayesian modelling approach capable of providing individual estimates while learning characteristics of the patient population. The proposed method was compared to common baseline methods. The model concerning depression severity achieved a mean predicted R2 of 0.57 (SD = 0.10) and RMSE of 3.85 (SD = 0.47) on the HDRS, while the model concerning mania severity achieved a mean predicted R2 of 0.16 (SD = 0.25) and RMSE of 3.68 (SD = 0.54) on the YMRS. In both cases, smartphone-based self-reported mood was the most important predictor variable. The present study shows that daily smartphone-based self-assessments can be utilized to automatically estimate clinical ratings of severity of depression and mania in patients with BD and assist in identifying individuals with high risk of relapse.

The Influence of Current Mood States on Screening Accuracy of the Mood Disorder Questionnaire

Objective

In this study we investigated whether current mood states of patients with bipolar disorder have an influence on the screening accuracy of the Mood Disorder Questionnaire (MDQ).

Methods

A total of 452 patients with mood disorder (including 192 with major depressive disorder and 260 with bipolar disorder completed the Korean version of the MDQ. Patients with bipolar disorder were subdivided into three groups (bipolar depressed only, bipolar euthymic only, bipolar manic/hypomanic only) according to current mood states. The screening accuracy of the MDQ including sensitivity, specificity and area under the curve (AUC) of receiver operating characteristic (ROC) curves were evaluated according to current mood states.

Results

The optimal cutoff of MDQ was 5 in this study sample. Sensitivity and specificity were not significantly different according to current mood states. Significant differences in AUCs of four independent ROC curves were not found (ROC 1st curve included all bipolar patients; ROC 2nd curve included only bipolar depressed patients; ROC 3rd curve included only bipolar manic/hypomanic patients; ROC 4th curve included only bipolar euthymic patients).

Conclusion

The study results showed that current mood states (either euthymic state, depressed or manic/hypomanic) did not significantly influence the screening accuracy of the MDQ suggesting that the MDQ could be a useful screening instrument for detecting bipolar disorder in clinical practice regardless of the current mood symptoms of subjects.

Clinical validation of the BDSx scale with bipolar disorder outpatients

PURPOSE

The BDS_x (Bipolar Disorder Symptom Scale) is a brief self-report instrument designed for repeated measurement of bipolar disorder (BD) symptoms over time. Previous research indicates that the BDS_x measures two depression (cognitive and somatic symptoms) and two hypo/mania factors (affrontive symptoms and elation/loss of insight). The purpose of this study was to validate BDS_x responses relative to diagnoses of BD mood episodes.

METHODS

Sixty BD outpatients attending routine clinic appointments completed the BDS_x, the Hamilton Rating Scale for Depression, the Altman Self-Rating Mania Scale, and the Satisfaction with Life Scale. Blind to scale responses by patients, a clinic psychiatrist determined if patients were currently symptomatic.

RESULTS

BDS_x depression and hypo/mania subscales showed good construct validity vis-à-vis clinical diagnoses, and concurrent/discriminant validity with other self-report scales. And though not designed as a screening measure, sensitivity for the depression subscale is high at 88% (6+, 76% specificity), yet lower at 57% for the hypo/mania subscale (5+, 90% specificity).

CONCLUSIONS

The results of this study indicate that BDS_x responses distinguish patients experiencing depressive and hypo/manic mood episodes. Findings support the psychometric properties of the Hebrew version of this scale. The BDS_x enables those with bipolar disorder to monitor their symptoms, gauge symptom variability, and identify factors that proceed and sustain BD symptoms over time.

The influence of the working alliance on the treatment and outcomes of patients with bipolar disorder: A systematic review

BACKGROUND

The working alliance plays an essential role in the treatment of patients with different diseases. However, this variable has received little attention in patients with bipolar disorder. Therefore, this systematic review aimed to examine the working alliance's influence on these patients' treatment outcomes, analyze its role in the adherence to pharmacotherapy, and identify the variables that are related to a good working alliance.

METHODS

PubMed, PsycINFO, and Web of Science databases were searched until January 5, 2018 using a predetermined search strategy. Then, a formal process of study selection and data extraction was conducted.

RESULTS

Seven articles fulfilled the inclusion criteria and they included a total of 3,985 patients with bipolar disorder type I and II. Although the working alliance's ability to predict the duration and presence of manic and depressive symptoms is unclear, a good working alliance facilitates the adherence to pharmacological treatment. In addition, good social support for patients is associated with a strong working alliance.

LIMITATIONS

The selected studies used different definitions and measures of the working alliance and adherence, and most used self-reports to assess the working alliance. Furthermore, the relationships found among the variables were correlational.

CONCLUSIONS

The working alliance can play an important role in adjunctive psychological therapies and in pharmacological and somatic treatments for patients with bipolar disorder. However, the number of studies on working alliance in bipolar disorder is rather limited and there is methodological heterogeneity between the studies.

Gender-related differences in patients with bipolar disorder: a nationwide study

OBJECTIVE

The possible presence of gender-related differences in patients with bipolar disorder (BD) may have diagnostic and therapeutic implications. This multicenter study aimed to investigate gender differences in BD in the largest Italian database collected to date, on behalf of the Italian Chapter of the International Society of Bipolar Disorders.

METHODS

A total of 1674 patients (males: n = 714; females: n = 960) from different psychiatric departments were compared according to gender on demographic/clinical variables. Owing to the large number of variables statistically related to the dependent variable (gender) at the univariate analyses, preliminary multiple logistic regression analyses were performed. A final multivariable logistic regression was then performed, considering gender as the dependent variable and statistically significant demographic/clinical characteristics as independent variables.

RESULTS

The results of the final multivariable logistic regression analysis with previous statistically significant demographic and clinical variables were the following: female gender was less frequently associated with employment (odds ratio [OR] = 0.7, P < 0.01), lifetime single marital status (OR = 0.45, P < 0.01), and substance abuse in the last year (OR = 0.35, P < 0.01), whereas it was more frequently associated with a major number of lifetime major depressive episodes (OR = 1.78, P < 0.01) and psychiatric visits in the last year (OR = 1.38, P = 0.01).

CONCLUSION

Few significant differences were found between genders in BD, particularly for those clinical features that are associated with poor prognosis (substance abuse for males and number of depressive episodes for females). Transcultural studies are needed to identify cultural versus illness-related variables possibly explaining the different clinical presentation of BD in relation to gender.

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.

The relationship between insight and affective temperament in bipolar disorder: an exploratory study

INTRODUCTION

In recent years, the association between temperament and clinical characteristics of mood disorders has been studied. Most bipolar patients show deficits in their awareness of signs and symptoms. The relationship between affective temperament and insight in bipolar patients has not been carried out in the literature so far.

OBJECTIVE

To evaluate the relationship between affective temperament and insight in bipolar disorder.

METHOD

A group of 65 bipolar patients were followed during a year. Patients underwent a clinical assessment and were diagnosed using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Insight was evaluated through the Insight Scale for Affective Disorders (ISAD), and affective temperament, through the TEMPS-Rio de Janeiro. The relationship between affective temperament and insight was explored with Spearman rho correlations between scores on each item of the ISAD and on the TEMPS-Rio de Janeiro subscales.

RESULTS

In euthymic phases, bipolars with depressive temperament were associated with a higher level of insight about the consequences of the disorder; when in mania, patients showed better insight about having an affective disorder, presenting psychomotor alterations, and suffering from guilt or grandiosity. Similarly, bipolar patients with higher scores of anxious temperament, when in mania, had better insight on alterations in attention. Bipolar patients with higher scores of hyperthymic temperament, when in mania, showed the worst insight about thought disorder.

CONCLUSION

In addition to being determined by the phase of the disease and several varying symptoms, the level of insight in bipolar patients is also influenced by affective temperament.

The impact of dementia, depression and awareness on activities of daily living in a sample from a middle-income country

OBJECTIVE

Previous studies have indicated that dementia and depression have a considerable impact on the functional capacity of older adults, also influencing awareness about ability. The purpose of the current study was to investigate the impact of dementia, depression and awareness on activities of daily living (ADL) in a sample from a middle-income country.

METHODS

The current study explored impairments in basic, instrumental and advanced ADL using a factorial design comparing four groups: people with dementia and depression, people with dementia without depression, older adults with depression but no dementia and healthy older adults. For each type of ADL, self-report and informant report was contrasted in order to investigate the issue of lack of awareness in relation to ADL.

RESULTS

Results indicate that dementia is associated with impairments in all types of ADL. Advanced ADL were also reduced in depressed participants. In addition, in the case of instrumental and basic ADL, informant report indicated less preserved abilities than participant self-report, particularly in people with dementia.

CONCLUSIONS

The findings highlight the importance of developing interventions and compensatory strategies to prevent loss of ADL in dementia, also suggesting that early intervention in older adults with depression should focus on advanced ADL to prevent social isolation and withdrawal. Finally, the findings indicate that self-information about ADL may be compromised in dementia, so clinicians exploring disability should consider fully different aspects of ADL in this group. Copyright © 2017 John Wiley & Sons, Ltd.

Illness perceptions and adherence in bipolar disorder: An exploratory study

BACKGROUND

According to the Self-Regulation Model, illness perceptions influence an individual's coping (such as the taking of treatment) and emotional response to their illness. Emerging research suggests that this model could be used to explore illness perceptions in mental health. The aim of this exploratory study is, firstly, to measure and describe illness perception in French patients with a bipolar diagnosis and, secondly, to explore associations between illness perceptions and adherence in this population.

METHOD

Thirty-eight French patients with bipolar disorder completed the Illness Perception Questionnaire for Schizophrenia (except the identity dimension). We measured medication adherence with the Medication Adherence Rating Scale.

RESULTS

Our results showed that patients with high perceptions concerning treatment control, low perceptions of negative emotions of their mental illness, low perception of consequences and high comprehension of their disorder had a better adherence.

CONCLUSIONS

Illness perceptions can provide a framework for understanding adherence in bipolar disorder, and the findings could have important clinical and research implications.

The influence of current mood state, number of previous affective episodes and predominant polarity on insight in bipolar disorder

BACKGROUND

Although many studies have explored the effect of current affective episodes on insight into bipolar disorder, the potential interaction between current mood state and previous affective episodes has not been consistently investigated.

OBJECTIVE

To explore the influence of dominant polarity, number of previous affective episodes and current affective state on insight in bipolar disorder patients in euthymia or mania.

METHODS

A total of 101 patients with bipolar disorder were recruited for the study, including 58 patients in euthymia (30 with no defined predominant polarity and 28 with manic predominant polarity) and 43 in mania (26 with no defined predominant polarity and 17 with manic predominant polarity). Patients underwent a clinical assessment and insight was evaluated through the Insight Scale for Affective Disorders.

RESULTS

Bipolar disorder patients in mania had worse insight than those in euthymia, with no effect of dominant polarity. In addition, positive psychotic symptoms showed a significant effect on insight and its inclusion as a covariate eliminated differences related to mood state. Finally, the number of previous manic or depressive episodes did not correlate with insight level.

CONCLUSIONS

Mania is a predictor of loss of insight into bipolar disorder. However, it is possible that its contribution is linked to the more frequent presence of psychotic symptoms in this state. Dominant polarity and number/type of previous affective episodes have a limited impact on insight.

Characterizing the experience of auditory verbal hallucinations and accompanying delusions in individuals with a diagnosis of bipolar disorder: A systematic review

OBJECTIVES

The aim of the current study was to inform ongoing attempts to identify clinically meaningful subcategories of auditory verbal hallucination (AVH), and to evaluate evidence that might pertain to the suitability of current psychological interventions for people with bipolar disorder (BD) who experience psychotic symptoms.

METHODS

A comprehensive synthesis of findings on the phenomenology of AVH and delusions in BD is included, alongside a critical review of clinical and cognitive correlates. Studies published in the previous 20 years, until December 2016, were retrieved from the following databases: Embase, CINAHL, MEDLINE, PsycINFO and Web of Science. Thirty-two articles were reviewed after applying a set of predetermined inclusion criteria.

RESULTS

Psychotic symptoms were common in both manic and depressive phases, although higher frequencies were indicated in mania. Few detailed characterizations of AVH phenomenology were identified. Delusions with persecutory, grandiose and referential themes were the most common in BD. AVHs were associated with delusions and there was evidence to suggest that delusion subtype may vary according to mood state and type of AVH. Data on clinical correlates of AVH in BD were sparse. However, the results indicated that cognitive appraisals or interpretations of voices might be different in BD from those established to be predictive of clinical outcomes in schizophrenia spectrum disorders.

CONCLUSIONS

Clear gaps exist in our current understanding of the first-person experience of AVH in BD and the potential relationship to co-occurring symptoms, including delusions. Further research into cognitive interpretations of AVH in BD might inform adapted psychological interventions for psychotic symptoms in this population.

Behavioral and Psychological Symptoms Impact Clinical Competence in Alzheimer's Disease

Decision-making is considered a fundamental aspect of personal autonomy and can be affected in psychiatric and neurologic diseases. It has been shown that cognitive deficits in dementia impact negatively on decision-making. Moreover, studies highlighted impaired clinical competence in neuropsychiatric disorders, such as schizophrenia and bipolar disorder. In this context, the current study explored the relationship between behavioral and psychological symptoms of dementia (BPSD) and clinical competence, especially the capacity to consent to treatment, in Alzheimer's disease (AD). Seventy-one patients with mild to moderate AD participated, completing assessments for capacity to consent to treatment, general cognition and neuropsychiatric disturbances. For each neuropsychiatric symptom, patients with and without the particular disturbance were compared on the different subscales of the MacArthur Competence Tool for Treatment (MacCAT-T; Understanding, Appreciation, Reasoning and Expression). The results showed that patients presenting delusions, as well as apathetic patients, had a lower ability to express a clear treatment choice compared to patients without these symptoms. By contrast, patients with dysphoria/depression had higher scores on this variable. Additionally, AD patients with euphoria had more difficulties discussing consequences of treatment alternatives compared to patients without this disturbance. None of the differences were confounded by global cognition. There were no between-group differences in clinical decision-making for patients with hallucinations, agitation/aggression, anxiety, irritability, disinhibition and aberrant motor behavior. These findings highlight the importance of taking BPSD into account when assessing decision-making capacity, especially clinical competence, in AD. Furthermore, reducing BPSD may lead to better clinical competence in patients with AD, as well as to improvements in patients and caregivers' quality of life.

Correlation Between Insight Level and Suicidal Behavior/Ideation in Bipolar Depression

Suicide is a relatively common outcome along the course of bipolar disorder. Studies have shown a positive correlation between ideation or attempts of suicide and higher insight in schizophrenic patients. Nevertheless there are still few studies that evaluate the relationship between suicide and insight in mood disorders. Evaluate the relationship between insight and suicidal ideation or behavior in bipolar depression. A group of 165 bipolar patients were followed up along 1 year. Each patient's mood was assessed in every consultation according to DSM-IV-TR criteria. Suicidal ideation and behavior were prospectively assessed through item 3 of HAM-D whenever a major depressive episode was diagnosed. Insight was evaluated through the Insight Scale for Affective Disorders. A history of suicidal attempts was associated with worse insight in 60 patients with one episode of bipolar depression. The difference remained even when the supposed effect of depression over insight was controlled. No correlation between current suicidal ideation and insight level was found though. Our results suggest that a history of suicide attempts may correlate with higher impairment of insight in bipolar depression. No relationship was found between current suicidal ideation and insight.

Clinical outcomes of long-acting injectable risperidone in patients with bipolar I disorder: A 1-year retrospective cohort study

OBJECTIVES

We explored the effect of risperidone long-acting injection (LAI) treatment on patients with bipolar I disorder in a real-world setting.

METHODS

In this retrospective cohort study, 469 patients with bipolar I disorder were enrolled and treated with risperidone LAI and different oral antipsychotics and followed for 1 year. Concomitant medications, such as mood stabilizers, antidepressant, anxiolytics, hypnotics, or anticholinergics, were administered. On the basis of risperidone LAI use and treatment compliance, the patients were classified into 4 groups: the first long-acting injectable antipsychotics (LAI1) group (compliant patients receiving risperidone LAI treatment) (N=44), the second long-acting injectable antipsychotics (LAI2) group (non-compliant patients receiving risperidone LAI treatment) (N=33), the first non-LAI (NLAI1) group (compliant patients receiving oral medications) (N =337), and the second non-LAI (NLAI2) group (non-compliant patients receiving oral medications) (N=55). The rate of re-hospitalization, length of hospital stay, and rate of emergency room visit were assessed.

RESULTS

Compared with the non-LAI groups, the LAI groups had longer mean duration of illness (8.5 years, P=0.0001), higher rate of admission due to mood episodes (P<0.0001), depressive episodes (P<0.0001), or manic episodes (P=0.0002), and higher rate of emergency room visit (P=0.0003) before enrollment. After a 1-year follow-up, re-hospitalization rates were significantly lower in the LAI1 group than that before enrollment for any episodes (P=0.0001), manic episodes (P=0.005), and depressive episodes (P=0.002). The rates of emergency room visit were significantly lower in the LAI1 (P=0.0001), LAI2 (P=0.013), and NLAI1 (P=0.0001) groups compared with those before enrollment.

CONCLUSIONS

Risperidone LAI reduces the clinical severity of bipolar I disorder.

Assessment of Healthcare Decision-making Capacity

It is often necessary for neuropsychologists, clinical psychologists, and other healthcare professionals to assess an individual's capacity to consent to treatment related to healthcare. This task can be challenging and requires a delicate balance of both respect for individuals' autonomy, as well as the protection of individuals with diminished capacity to make an autonomous decision. The purpose of the present review is to provide an overview of the conceptual model of decisional capacity as well as a brief summary of some of the currently available instruments designed to help evaluate medical decision making. In addition, current empirical literature on the relationship between neuropsychological abilities and decision-making capacity is discussed and a brief set of recommendations is provided to further aid clinicians or consultants when they are required to complete the ethically important but difficult task of making determinations about healthcare decision-making capacity.

Insight in bipolar mania: evaluation of its heterogeneity and correlation with clinical symptoms

BACKGROUND

Studies on insight in bipolar mania are not numerous and usually consider insight as a unitary construct.

OBJECTIVE

Evaluate how different facets of insight are affected in bipolar mania and investigate correlations between insight for each specific object in bipolar disorder and manic symptomatology.

METHOD

A group of 165 bipolar patients were followed during a year, with 51 patients having manic episodes according to DSM-IV-TR criteria. Patients underwent a clinical assessment and insight was evaluated through the Insight Scale for Affective Disorders.

RESULTS

The study found that insight regarding symptoms is worse than insight of having bipolar disorder, social relationships and self esteem. Moreover, poor global insight (total ISAD) correlates with more severe changes in mood, speech and thought structure, with worse insight about symptoms correlating with the same alterations and also with more severe symptoms of agitation/energy.

LIMITATIONS

Although a large sample of bipolar patients was followed up, the final sample composed of patients with at least one manic episode was relatively smaller. Moreover, the fact that the study was performed in a university hospital may have led to selection biases.

CONCLUSION

Results suggest that patients with BD are reasonably capable of identifying that their condition implies consequences but have more impaired awareness of their energy and activity levels. A lower level of insight specifically about symptoms correlates with more severe symptoms of agitation/energy, which suggests a psychomotor nucleus able to impair insight in mania.

Metacognitive knowledge and experience in recently diagnosed patients with bipolar disorder

INTRODUCTION

Metacognition, which refers to an individual's ability to assess their own cognitive ability or performance, is poorly understood in bipolar disorder. This study was conducted to evaluate two aspects of metacognitive ability in recently diagnosed patients with bipolar disorder: (a) metacognitive knowledge, pertaining to awareness of one's own general cognitive functioning; and (b) metacognitive experience, referring to awareness of one's cognitive performance on a specific, online cognitive task.

METHOD

Participants consisted of 50 clinically euthymic patients recently diagnosed with Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) bipolar I disorder who were within three months of resolution of their first manic episode, and a comparison group of 38 demographically similar healthy volunteers. To assess metacognitive knowledge, participants provided a general rating of their estimated cognitive ability prior to completing a neuropsychological battery, and self-ratings were compared to actual ability based on a composite score of overall cognitive functioning. To assess metacognitive experience, subjects provided a postdiction rating of their perceived memory performance after completing a list learning verbal memory test, and self-ratings were compared to actual memory performance. Measures of both relative and absolute accuracy of ratings were obtained.

RESULTS

Results indicated that patients showed diminished accuracy in rating their general cognitive ability, implying deficits in metacognitive knowledge. In contrast, patients were accurate in rating their online memory performance, suggesting intact metacognitive experience.

CONCLUSIONS

Findings suggest that in patients with bipolar disorder, intact task-specific cognitive self-appraisals may fail to generalize to or to modify inaccurate global cognitive self-appraisals. Further research using more comprehensive metacognitive tasks is warranted in bipolar disorder.

Daily electronic self-monitoring in bipolar disorder using smartphones - the MONARCA I trial: a randomized, placebo-controlled, single-blind, parallel group trial

BACKGROUND

The number of studies on electronic self-monitoring in affective disorder and other psychiatric disorders is increasing and indicates high patient acceptance and adherence. Nevertheless, the effect of electronic self-monitoring in patients with bipolar disorder has never been investigated in a randomized controlled trial (RCT). The objective of this trial was to investigate in a RCT whether the use of daily electronic self-monitoring using smartphones reduces depressive and manic symptoms in patients with bipolar disorder.

METHOD

A total of 78 patients with bipolar disorder according to ICD-10 criteria, aged 18-60 years, and with 17-item Hamilton Depression Rating Scale (HAMD-17) and Young Mania Rating Scale (YMRS) scores ≤17 were randomized to the use of a smartphone for daily self-monitoring including a clinical feedback loop (the intervention group) or to the use of a smartphone for normal communicative purposes (the control group) for 6 months. The primary outcomes were differences in depressive and manic symptoms measured using HAMD-17 and YMRS, respectively, between the intervention and control groups.

RESULTS

Intention-to-treat analyses using linear mixed models showed no significant effects of daily self-monitoring using smartphones on depressive as well as manic symptoms. There was a tendency towards more sustained depressive symptoms in the intervention group (B = 2.02, 95% confidence interval -0.13 to 4.17, p = 0.066). Sub-group analysis among patients without mixed symptoms and patients with presence of depressive and manic symptoms showed significantly more depressive symptoms and fewer manic symptoms during the trial period in the intervention group.

CONCLUSIONS

These results highlight that electronic self-monitoring, although intuitive and appealing, needs critical consideration and further clarification before it is implemented as a clinical tool.

Insight in bipolar disorder: a comparison between mania, depression and euthymia using the Insight Scale for Affective Disorders

Objective: To evaluate whether having general insight into bipolar disorder and its symptoms is affected by the mood state of the patient, using the Insight Scale for Affective Disorders, a hetero-application scale for people with mood disorders.Methods: Ninety-five patients with bipolar disorder were evaluated and divided into different groups according to the mood state presented during assessment (i.e., euthymia, mania and depression). Sociodemographic and clinical data (Hamilton Depression Scale, Young Mania Rating Scale, and Clinical Global Impressions Scale) were recorded. Insight was evaluated using the Insight Scale for Affective Disorders.Results: Patients with bipolar disorder in mania show less insight about their condition than patients in depression or euthymia, and less insight about their symptoms than patients with depression, with the exception of awareness of weight change.Conclusions: Loss of insight during mania may have important implications for treatment compliance and adherence and needs to be taken into account in the clinical management of people with bipolar disorder.