Mania and mortality: why the excess cardiovascular risk in bipolar disorder?

A History of Suicide Attempt Is Associated with Increased Sympathetic Activation in Bipolar Disorder

OBJECTIVE

Suicide risk in bipolar disorder (BD) is estimated to be up to 20 times higher than in the general population. While there is a large body of evidence suggesting that increased sympathetic activation is associated with disease and death, there is a paucity of research on the role of autonomic nervous system (ANS) dysfunction in patients with BD who have attempted suicide.

METHODS

Fifty-three participants with BD used a wearable device to assess the association between history of suicide attempt, current suicidal ideation, and ANS dysfunction, including measures of heart rate variability (HRV) and respiratory rate. Data were analyzed in a series of unadjusted and adjusted bivariate models of association controlling for relevant variables.

RESULTS

A history of suicide attempts was significantly associated with an increase in respiratory rate (p < 0.01). These results remained significant after adjusting for age, BMI, and current mood state. There was no association between current suicidal ideation and heart rate or respiratory rate. In the frequency domain, HRV parameters suggest reduced parasympathetic (i.e., vagal) activity in participants with a history of suicide attempts and in those with current suicidality, suggesting changes in sympathicovagal balance in BD.

CONCLUSIONS

Our results suggest that changes in the ANS in patients with BD and a history of suicide attempt are not restricted to pure vagally mediated HRV parameters, but rather signal a general ANS dysregulation. This ANS imbalance may be contributing to illness burden and cardiovascular disease. Further research on the relationship between ANS and suicidality in BD is needed.

Antimanic Efficacy, Tolerability, and Acceptability of Clonazepam: A Systematic Review and Meta-Analysis

(1) Background: The use of benzodiazepines for the treatment of acute mania remains prevalent. This systematic review and meta-analysis provides an updated assessment of Clonazepam's antimanic efficacy, tolerability, and acceptability. (2) Methods: A systematic search of multiple databases and clinical trial registries was conducted, aiming to identify any controlled studies of Clonazepam vs. placebo or any other pharmacotherapy for the treatment of acute mania. Pairwise meta-analytic evaluations were performed. (3) Results: Six studies were included with a total number of 192 participants, all of which were randomized controlled trials. Clonazepam may be superior to a placebo in the acute phase of treatment and no different to Lithium and Haloperidol in terms of efficacy, both acutely and in the medium to long term. Clonazepam may be an acceptable and well-tolerated treatment for acute mania, especially when used as an augmentation strategy. Comparisons were underpowered, with minimal sample sizes and only one study per comparison in many cases, thus limiting the generalizability of our findings and hindering firm clinical conclusions. (4) Conclusions: Given the prevalence of benzodiazepine use in current practice, more and larger studies are urgently needed.

Management challenges and choices in patients with bipolar disorder: An Egyptian observational study

BACKGROUND

Patients with bipolar disorder (BD) had contributed immensely to high health service utilization. Variation in clinical practices that miss to follow the standard guidelines all with the disorder complexity, deepened the management gap. This study aimed to provide an Egyptian epidemiological database of the ongoing clinical practices that framed different diagnostic and management choices in a sample of patients with bipolar disorder. Highlighting challenges and the need for optimized clinical practices.

METHODS

Over 4 months in 2014, 20 clinicians filled in a designed sheet of their routine healthcare practice with information about; caseload /month, management guidelines knowledge background. Out of 301 patients in acute episode BD, 300 patients aged 20 to 60 years from both sexes, completed their assessment using; (1) a semi-structured interview sheet, (2) Structured Clinical Interview for DSM-IV Axis I (SCID I) for psychiatric diagnoses, (3) Global Assessment of Functioning scale for illness impact.

RESULTS

Psychiatrists received 49.5 ± 37.0 (mean ± SD) patient /month. 95% of them reported positive knowledge background on BD diagnostic guidelines and treatment recommendations (G/R), 89.6% of patients had different initial diagnosis than BD.The most commonly given initial diagnosis was major depressive disorder (33%) followed by brief psychotic disorder(20.7%) and others. The median of time taken from the initial to bipolar diagnosis was 12.3 months. Majority of patients had evident functional impairment. Atypical antipsychotics were mostly used. Drug abuse and obesity were high comorbidities.

CONCLUSION

The evident gap in practice and BD complexity have negative impact on clinical outcomes. Physician's continuous medical education programs and individually tailored standard medical care are recommended for optimized practices.

Impact of menstrual cycle events on bipolar disorder course: a narrative review of current evidence

Several lines of research suggest that reproductive-related hormonal events may affect the course of bipolar disorder in some women. However, data on associations between bipolar disorder and menarche, menstrual cycle, and menopause are mixed. This article reviews the literature on the potential effects of menarche, menstrual cycle, and menopause on bipolar disorder.A narrative review of published articles on bipolar disorder and menstrual cycle events was conducted. The primary outcome assessed was the impact of menarche, menstrual cycle and menopause on the course of bipolar illness. Databases searched were PubMed, Ovid, Scopus, PsycINFO, Medline, and Cochrane Libraries from inception to August 2021.Twenty-two studies were identified and included in the narrative synthesis. Research suggested that a subset of women with bipolar disorder are vulnerable to the impact of menstrual cycle events. Menarche seems to be associated with age at onset of bipolar illness especially in case of bipolar disorder type I and the specific age at menarche may predict some clinical features of the disorder. Menstrual cycle likely affects the course of bipolar disorder but the pattern of mood variability is not clear. Menopause appears to be not only a period of vulnerability to mood alteration, especially depressive episodes, and impairment of quality of life, but also a potential trigger of bipolar illness onset.The impact of menarche, menstrual cycle, and menopause on bipolar disorder is largely understudied. Preliminary evidence suggests that a subset of women with bipolar disorder may have their mood shifts affected by menstrual cycle events, with different patterns depending on the type of bipolar disorder also. Further researches are needed to deep the impact of menarche, menstrual cycle, and menopause on bipolar illness.

Reduced heart rate variability is associated with higher illness burden in bipolar disorder

BACKGROUND

Bipolar disorder (BD) is associated with premature death and ischemic heart disease is the main cause of excess mortality. Heart rate variability (HRV) predicts mortality in patients with or without cardiovascular disease. While several studies have analyzed the association between HRV and BD, none has analyzed the association of HRV with illness burden in BD.

METHODS

53 participants with BD I and II used a wearable device to assess the association between HRV and factors characterizing illness burden, including illness duration, number and type of previous episode(s), duration of the most severe episode, history of suicide attempts or psychotic symptoms during episodes, and co-morbid psychiatric disorders. We ran unadjusted models and models controlling statistically for age, sex, pharmacotherapy, baseline functional cardiovascular capacity, BMI, years of education, and marital status. We also explored the association between HRV and an overall illness burden index (IBI) integrating all these factors using a weighted geometric mean.

RESULTS

Adjusted and unadjusted models had similar results. Longer illness duration, higher number of depressive episodes, longer duration of most severe manic/hypomanic episode, co-morbid anxiety disorders, and family history of suicide were associated with reduced HRV, as was bipolar depression severity in the participants experiencing a depressive episode. Finally, a higher IBI score was associated with lower HRV.

CONCLUSIONS

High illness burden is associated with reduced HRV in BD. While the IBI needs to be validated in a larger sample, it may provide an overall measure that captures illness burden in BD.

Why are cardiovascular diseases more common among patients with severe mental illness? The potential involvement of electronegative low-density lipoprotein (LDL) L5

Despite tremendous efforts of experimental and clinical studies and knowledge, the pathophysiology of severe mental illness (SMI), including bipolar disorder (BD), unipolar depression (mood disorders, MD), and schizophrenia (SCZ), remains poorly understood. Besides their chronic course and high prevalence in society, mental and somatic comorbidities are really serious problems; patients with these disorders have increased risk of cardiovascular (CV) diseases (CVD) including coronary artery diseases (CAD, i.e. myocardial infarction and angina), stroke, sudden cardiac death, hypertension, cardiomyopathy, arrhythmia, and thromboembolic disease. Although it is determined that triglycerides, cholesterol, glucose, and low-density lipoprotein (LDL) levels are increased in MD and SCZ, the underlying reason remains unknown. Considering this, we propose that electronegative LDL (L5) is probably the main crucial element to understanding CVD induced by SMI and to discovering novel remedial approaches for these diseases. When it is hypothesized that L5 is greatly presupposed in CV system abnormalities, it follows that the anti-L5 therapies and even antioxidant treatment options may open new therapeutic opportunities to prevent CVD diseases secondary to SMI. In this review article, we tried to bring a very original subject to the attention of readers who are interested in lipoprotein metabolism in terms of experimental, clinical, and cell culture studies that corroborate the involvement of L5 in physiopathology of CVD secondary to SMI and also the new therapeutic approaches for these disorders.

Frequency and clinical correlates of bipolar features in acute coronary syndrome patients

Background:

Depression and acute coronary syndrome (ACS) are both extremely prevalent diseases. Studies aimed at evaluating whether depression is an independent risk factor for cardiac events provided no definitive results. In most of these studies, depression has been broadly defined with no differentiation between unipolar (MDD) versus bipolar forms (BD). The aim of this study was to evaluate the frequency of DSM-IV BD (bipolar I and bipolar II subtypes, cyclothymia), as well as temperamental or isolated bipolar features in a sample of 171 patients hospitalized for ACS. We also explored whether these psychopathological conditions were associated with some clinical characteristics of ACS.

Methods:

Patients with ACS admitted to three neighboring Cardiac Intensive Care Units (CICUs) in a 12-month continuative period of time were eligible for inclusion if they met the criteria for either acute myocardial infarct with or without ST-segment elevation or unstable angina, verified by standard ACS criteria. All patients underwent standardized cardiological and psychopathological evaluations.

Results:

Of the 171 ACS patients enrolled, 37 patients (21.7%) were found to have a DSM-IV mood disorder. Of these, 20 (11.7%) had bipolar type I or type II or cyclothymia, while 17 (10%) were the cases of MDD. Rapid mood switches ranged from 11% of ACS patients with no mood disorders, to 47% of those with MDD to 55% of those with BD. Linear regression analysis showed that a diagnosis of BD (p = .023), but not that of MDD (p = .721), was associated with a significant younger age at the index episode of ACS. A history of previous coronary events was more frequent in ACS patients with BD than in those with MDD.

Conclusions:

Our data indicate that bipolar features and diagnosis are frequent in ACS patients. Bipolar disorder has a negative impact on cardiac symptomatology. Further research in this area is warranted.

Sex difference in the progression of manic symptoms during acute hospitalization: A prospective pilot study

OBJECTIVES

Acute mania is a serious medical condition that impacts men and women equally. Longtime presentation of manic symptoms is sex-dependent; however, little is known about acute symptoms of mania. The objective of this study is to track and compare acute manic symptoms for sex differences during inpatient hospitalization.

METHODS

All patients with bipolar mania admitted to a large university hospital between January and October 2017 were invited to participate in this longitudinal naturalistic follow-up study. Manic (YMRS), depressive (MADRS), and psychotic (PAS) symptoms were tracked daily from admission to discharge.

RESULTS

The total YMRS scores decreased significantly overtime (p < .0001) in both male (n = 34) and female (n = 23) patients (p = .7). However, male patients scored significantly higher in sexual interest (p = .01), disruptive and aggressive behavior (p = .01), and appearance (p < .001) while females had better insight into their illness (p = .01). Males and females received similar doses of lithium (p = .1), but males received significantly higher doses of valproic acid (VPA) in comparison with females (p = .003). However, plasma lithium and VPA concentrations at discharge were not significantly different between sexes.

CONCLUSION

Our results show sex differences in the progression of certain domains of manic symptoms in a cohort of 23 female and 34 male patients admitted to a large academic center in Turkey. Males, in this sample, exhibited more sexual interest, disruptive and aggressive behaviors, better grooming, and less insight compared to females. While these results are concordant with our preclinical findings and with anecdotal clinical observations, replication in larger samples is needed.

THE MANAGEMENT OF CARDIOVASCULAR DISEASE RISK FACTORS IN BIPOLAR DISORDER PATIENTS IN PRIMARY HEALTHCARE SETTINGS

Accumulating evidence supports the association between cardiovascular disease (CVD) risk factors and bipolar disorder (BD). CVD is the leading cause of morbidity and mortality in patients with bipolar disorder. However, there is a need to study the management of the risk factors in the primary healthcare context. This narrative review aims to appraise the different approaches of care that have been used in the management of these patients to address CVD risk factors in primary care. We reviewed articles from PubMed, Science Direct and other studies cited in the articles found. The keywords used for this review included "bipolar," "bipolar disorder," "cardiovascular" or "metabolic syndrome," "screening," "primary care," and "integrative" or "integrated care model" or "collaborative care model." This review includes studies published over a period of 48 months (January 2016 through December 2019). We identified 128 articles, removing two duplicates. From them, 115 articles are excluded based on the inclusion/exclusion criteria leaving eleven relevant articles. Upon full-text review, six studies were excluded. The final studies included are five. We used the study-quality assessment tools from the National Heart, Lung, and Blood Institute to assess the quality of the articles found. CVD risk factors in patients with BD and forms of other severe mental illness (SMI) are often underdetected. Primary healthcare providers need to identify these risk factors in the management of these patients to determine and recommend appropriate strategies.

Impact of Mood on Endothelial Function and Arterial Stiffness in Bipolar Disorder

Background

Previous research in bipolar disorder demonstrates greater than expected vascular dysfunction later in the course of illness, proportionate to the cumulative burden of mood symptoms. However, little is known about the effect of acute mood states on vascular function. Here we examine the relation between vascular function and mood state in individuals with bipolar disorder.

Method

This prospective study followed 40 individuals with bipolar disorder for up to 6 months. Participants were assessed for mood state and vascular function at baseline, 2 weeks, and 6 months. Mood state was determined using clinician-administered Montgomery-Åsberg Depression Rating Scale and Young Mania Rating Scale. Vascular function was assessed by flow-mediated dilation (FMD) of the brachial artery, forearm vascular resistance (FVR), and arterial stiffness.

Results

Participants had a mean age of 30.1 years and 75% were male. Primary outcome measures FMD and nitroglycerine-mediated dilation were not found to have statistically significant associations with depressive or manic symptoms. In unadjusted models, higher manic symptoms were significantly associated with increased FVR nitroprusside-mediated dilation and diastolic blood pressure. In adjusted models, higher depressive symptoms were significantly associated with increases in augmentation index adjusted for heart rate of 75 bpm, and higher manic symptoms remained associated with increases in diastolic blood pressure.

Conclusion

FMD may have limited sensitivity as a biomarker for measuring short-term effects of mood state. Longer-term prospective studies are needed to clarify the temporal relation between chronic mood symptoms and vascular function in bipolar disorder.

Risk of cardiometabolic diseases among siblings of patients with bipolar disorder

BACKGROUND

Cardiometabolic diseases are suggested to be associated with bipolar disorder. However, the risk of metabolic disorders in unaffected siblings of patients with bipolar disorder remains unclear.

METHODS

From the Taiwan National Health Insurance Research Database, 7,225 unaffected siblings of bipolar probands and 28,900 age-/sex-/income-/residence-matched control individuals were included and followed until the end of 2011. Individuals who developed metabolic disorders during the follow-up period were identified.

RESULTS

The unaffected siblings of bipolar probands had a higher prevalence of dyslipidemia (5.4% vs. 4.5%, p = 0.001), younger age at diagnosis of type 2 diabetes mellitus (34.81 vs. 37.22, p = 0.024), and higher prevalence of any stroke (1.5% vs. 1.1%, p = 0.007) than the controls. Moreover, only male siblings of bipolar probands had an increased risk of dyslipidemia (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.10-1.48) and higher rates of any stroke (OR: 1.38, 95% CI: 1.02-1.85) and ischemic stroke (OR: 2.43, 95% CI: 1.60-3.70) during the follow-up compared with the controls.

DISCUSSION

Unaffected siblings of bipolar patients, particularly brothers, had a higher prevalence of dyslipidemia and ischemic stroke compared with the controls. The result suggests the familial association between cardiometabolic diseases and bipolar disorder. Further research may be necessary to identify this shared etiology between the disorders.

QT and P-wave dispersion during the manic phase of bipolar disorder

BACKGROUND AND AIM

Patients with bipolar disorder (BD) are at increased risk for cardiovascular diseases and complications. This increased risk is considered to be associated with the autonomic nervous system (ANS) abnormalities. However, there is little or no documentation of the relationship between this increased risk and the phases of BD. In this study, we aimed to compare the changes in the QT dispersion (QTd) and P-wave dispersion (Pd), which are predictors of sudden cardiac death and atrial fibrillation, between the patients with manic BD and healthy controls.

PARTICIPANTS AND METHODS

The study included a patient group of 44 patients (26 female and 18 male) that were hospitalized due to a diagnosis of manic BD and met the inclusion criteria, and a control group of 34 age- and gender-matched healthy individuals (21 female and 13 male) with no history of psychiatric and neurological disorders. The QTd and Pd values were determined in each participant by performing the standard 12-lead body surface electrocardiography (ECG).

RESULTS

The principal electrocardiographic indicators including corrected maximum QT interval, corrected QT dispersion, and minimum P-wave duration significantly increased in the patient group compared to the control group (t=2.815, p<0.01; t=4.935, p<0.001; t=3.337, p<0.001, respectively).

CONCLUSION

The results indicated that patients with manic BD are at increased risk for cardiovascular autonomic dysfunction. Therefore, clinicians should be more careful about ECG changes and related possible cardiac conduction problems such as cardiac arrthythmias in patients with manic BD. Further longitudinal studies are needed to investigate BD and its phases (depression, mania, and hypomania) with regard to ANS and cardiac abnormalities.

Bipolar disorder and related mood states are not associated with endothelial function of small arteries in adults without heart disease

BACKGROUND

Individuals with bipolar disorder are at increased risk for adverse cardiovascular disease (CVD) events. This study aimed to assess endothelial function and wave reflection, a risk factor for CVD, as measured by finger plethysmography in bipolar disorder to investigate whether CVD risk was higher in bipolar disorder and altered during acute mood episodes. We hypothesized that EndoPAT would detect a lower reactive hyperemia index (RHI) and higher augmentation index (AIX) in individuals with bipolar disorder compared with controls. Second, we predicted lower RHI and higher AIX during acute mood episodes.

METHODS

Reactive hyperemia index and augmentation index, measures of microvascular endothelial function and arterial pressure wave reflection respectively, were assessed using the EndoPAT 2000 device in a sample of 56 participants with a DSM-IV diagnosis of bipolar I disorder with 82 measures spanning different mood states (mania, depression, euthymia) and cross-sectionally in 26 healthy controls.

RESULTS

RHI and AIX were not different between adults with and without bipolar disorder (mean age 40.3 vs. 41.2years; RHI: 2.04±0.67 vs. 2.05±0.51; AIX@75 (AIX adjusted for heart rate of 75): 1.4±19.7 vs. 0.8±22.4). When modeled in linear mixed models with a random intercept (to account for repeated observations of persons with bipolar disorder) and adjusting for age and sex, there were no significant differences between those with bipolar disorder and controls (p=0.89 for RHI; p=0.85 for AIX@75).

CONCLUSIONS

Microvascular endothelial function and wave reflection estimated by finger plethysmography were unable to detect differences between adults with and without bipolar disorder or changes with mood states. Future research is necessary to identify more proximal and sensitive, yet relevant, biomarkers of abnormal mood-related influences on CVD risk or must target higher risk samples.

Cardiovascular risk and bipolar disorder: factors associated with a positive coronary calcium score in patients with bipolar disorder type 1

Objective:

Cardiovascular disease is the leading cause of death in patients with bipolar disorder. The aim of this study was to evaluate the factors associated with positive coronary calcium score (CCS) in individuals with bipolar disorder type 1.

Methods:

Patients from the Bipolar Disorder Program at Hospital de Clínicas de Porto Alegre, Brazil, underwent computed tomography scanning for calcium score measurement. Clinical and sociodemographic variables were compared between patients according to their CCS status: negative (CCS = 0) or positive (CCS > 0). Poisson regression analysis was used to examine the association of CCS with number of psychiatric hospitalizations.

Results:

Out of 41 patients evaluated, only 10 had a positive CCS. Individuals in the CCS-positive group were older (55.2±4.2 vs. 43.1±10.0 years; p = 0.001) and had more psychiatric hospitalizations (4.7±3.0 vs. 2.6±2.5; p = 0.04) when compared with CCS- negative subjects. The number of previous psychiatric hospitalizations correlated positively with CCS (p < 0.001).

Conclusion:

Age and number of psychiatric hospitalizations were significantly associated with higher CCS, which might be a potential method for diagnosis and stratification of cardiovascular disease in bipolar patients. There is a need for increased awareness of risk assessment in this population.

Risk factors for early cardiovascular mortality in patients with bipolar disorder

AIM

We attempted to determine risk factors, particularly pathophysiological changes, for early cardiovascular mortality in bipolar disorder (BD).

METHODS

A total of 5416 inpatients with bipolar I disorder were retrospectively followed through record linkage for cause of death. A total of 35 patients dying from cardiovascular disease (CVD; ICD 9: 401-443) before the age of 65 years were identified. Two living BD patients and two mentally healthy adults were matched with each deceased patient as control subjects according to age (±2 years), sex, and date (±3 years) of the final/index admission or the date of general health screening. Data were obtained through medical record reviews.

RESULTS

Eighty percent of CVD deaths occurred within 10 years following the index admission. Conditional logistic regression revealed that the variables most strongly associated with CVD mortality were the leukocyte count and heart rate on the first day of the index hospitalization, as the deceased BD patients were compared with the living BD controls. Systolic pressure on the first day of the index hospitalization can be substituted for heart rate as another risk factor for CVD mortality.

CONCLUSION

It is suggested that systemic inflammation and sympathetic overactivity during the acute phase of BD may be risk factors for early CVD mortality.

Prescribing patterns of psychotropic medications and clinical features in patients with major depressive disorder with and without comorbid dysthymia in China

INTRODUCTION

Little has been reported about the demographic and clinical features of major depressive disorder (MDD) with comorbid dysthymia in Chinese patients. This study examined the frequency of comorbid dysthymia in Chinese MDD patients together with the demographic and clinical correlates and prescribing patterns of psychotropic drugs.

METHODS

Consecutively collected sample of 1178 patients with MDD were examined in 13 major psychiatric hospitals in China. Patients' demographic and clinical characteristics and psychotropic drugs prescriptions were recorded using a standardized protocol and data collection procedure. The diagnosis of dysthymia was established using the Mini International Neuropsychiatric Interview. Medications ascertained included antidepressants, antipsychotics, benzodiazepines, and mood stabilizers.

RESULTS

One hundred and three (8.7%) patients fulfilled criteria for dysthymia. In multiple logistic regression analyses, compared to non-dysthymia counterparts, MDD patients with dysthymia had more depressive episodes with atypical features including increased appetite, sleep, and weight gain, more frequent lifetime depressive episodes, and less likelihood of family history of psychiatric disorders. There was no significant difference in the pattern of psychotropic prescription between the 2 groups.

CONCLUSIONS

There are important differences in the demographic and clinical features of comorbid dysthymia in Chinese MDD patients compared with previous reports. The clinical profile found in this study has implications for treatment decisions.

Three-year mortality in relation to early hospitalization and number of outpatient clinic visits in people with newly diagnosed bipolar disorder

OBJECTIVE

Whether the early treatment pattern in people with bipolar disorder (BD) could influence later mortality remains to be determined. We aimed to explore the potential effects of early hospitalization and number of outpatient clinic visits on the 3-year mortality in patients with newly diagnosed BD.

METHOD

Adult participants with newly diagnosed BD were identified in Taiwan's National Health Insurance Research Database in 2008. Survival analyses were performed with this national cohort to examine the associations between the first-year treatment pattern (hospitalization and number of outpatient clinic visits) and mortality over a follow-up period of 3 years (2008-2011).

RESULTS

A total of 15,254 participants were included. The mean age was 44.9 (S.D.=16.7) years and around 39.9% were male. The average follow-up time was 1055 days. Compared to BD patients with ≥7 times outpatient clinic visits within the first year, the risk of mortality was found elevated [hazard ratio=1.74; 95% confidence interval (CI), 1.40-2.15] for those who needed inpatient treatment. Number of outpatient clinic visits within the first year was found to be negatively associated with later mortality. Besides cancer (hazard ratio=2.14; 95% CI, 1.74-2.63), diabetes mellitus (hazard ratio=1.61; 95% CI, 1.38-1.89) and renal disease (hazard ratio=1.65; 95% CI, 1.36-2.00) were associated with the highest risk of mortality among the physical comorbidities. Substance use disorder stood out as the single comorbid mental illness associated with the highest mortality risk (hazard ratio=1.74; 95% CI, 1.37-2.21).

CONCLUSIONS

Early treatment pattern, including hospitalization and number of outpatient clinic visits, was associated with later mortality in BD patients. Special care should be given to enhance treatment adherence and to give psychoeducation to those with certain comorbid mental/physical illnesses to reduce health harming behavior and to improve health outcome.

Distinguishing bipolar II depression from unipolar major depressive disorder: Differences in heart rate variability

OBJECTIVES

Bipolar II (BPII) depression is commonly misdiagnosed as unipolar depression (UD); however, an objective and reliable tool to differentiate between these disorders is lacking. Whether cardiac autonomic function can be used as a biomarker to distinguish BPII from UD is unknown.

METHODS

We recruited 116 and 591 physically healthy patients with BPII depression and UD, respectively, and 421 healthy volunteers aged 20-65 years. Interviewer and self-reported measures of depression/anxiety severity were obtained. Cardiac autonomic function was evaluated by heart rate variability (HRV) and frequency-domain indices of HRV.

RESULTS

Patients with BPII depression exhibited significantly lower mean R-R intervals, variance (total HRV), low frequency (LF)-HRV, and high frequency (HF)-HRV but higher LF/HF ratio compared to those with UD. The significant differences remained after adjusting for age. Compared to the controls, the patients with BPII depression showed cardiac sympathetic excitation with reciprocal vagal impairment, whereas the UD patients showed only vagal impairment. Depression severity independently contributed to decreased HRV and vagal tone in both the patients with BPII depression and UD, but increased sympathetic tone only in those with BPII depression.

CONCLUSIONS

HRV may aid in the differential diagnosis of BPII depression and UD as an adjunct to diagnostic interviews.

High H1-affinity antidepressants and risk of metabolic syndrome in bipolar disorder

RATIONALE

Metabolic syndrome (MetS) is common in patients with bipolar disorder, with a relative risk of 1.6-2 compared to the general population. The increased risk is believed to be due to unhealthy lifestyles and use of medications. Although antipsychotics and mood stabilizers have been associated with weight gain and MetS, the impact of antidepressants has not been comprehensively evaluated.

OBJECTIVE

The objective of the study is to assess the risk of MetS in patients exposed to different types of antidepressants.

METHODS

In this cross-sectional study, 294 patients with bipolar disorder were consecutively recruited. MetS was diagnosed according to NCEP ATP-III modified criteria. Antidepressants used by the patients were classified according to the usual nomenclature (SSRI, TCA, SNRI, and other antidepressants) and a pharmacodynamic classification taking into account histamine 1-receptor (H1-R) affinity.

RESULTS

Use of antidepressants in general was not associated with MetS (prevalence ratio [PR], 1.08; 95% confidence interval, 0.73 to 1.62; p = 0.70). However, subjects using H1-R high-affinity antidepressants (N = 15) showed a substantial increase in the prevalence of MetS (PR, 2.17; 95 % confidence interval, 1.24 to 3.80; p = 0.007). When we included the inhibition constant (Ki) as a continuous covariate in the models, we found an inverse association between Ki and prevalence of MetS (p = 0.004).

CONCLUSION

We observed for the first time in a clinical setting that a pharmacodynamic-based classification of antidepressants could be more useful than the traditional one to predict the risk of MetS in patients with bipolar disorder. Clinical consequences may be relevant. However larger studies are warranted to generalize these results.

Major Depressive Disorder and Bipolar Disorder Predispose Youth to Accelerated Atherosclerosis and Early Cardiovascular Disease: A Scientific Statement From the American Heart Association

In the 2011 "Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents," several medical conditions among youth were identified that predispose to accelerated atherosclerosis and early cardiovascular disease (CVD), and risk stratification and management strategies for youth with these conditions were elaborated. Major depressive disorder (MDD) and bipolar disorder (BD) among youth satisfy the criteria set for, and therefore merit inclusion among, Expert Panel tier II moderate-risk conditions. The combined prevalence of MDD and BD among adolescents in the United States is ≈10%, at least 10 times greater than the prevalence of the existing moderate-risk conditions combined. The high prevalence of MDD and BD underscores the importance of positioning these diseases alongside other pediatric diseases previously identified as moderate risk for CVD. The overall objective of this statement is to increase awareness and recognition of MDD and BD among youth as moderate-risk conditions for early CVD. To achieve this objective, the primary specific aims of this statement are to (1) summarize evidence that MDD and BD are tier II moderate-risk conditions associated with accelerated atherosclerosis and early CVD and (2) position MDD and BD as tier II moderate-risk conditions that require the application of risk stratification and management strategies in accordance with Expert Panel recommendations. In this scientific statement, there is an integration of the various factors that putatively underlie the association of MDD and BD with CVD, including pathophysiological mechanisms, traditional CVD risk factors, behavioral and environmental factors, and psychiatric medications.

Unipolar mania: a necessary diagnostic concept

In the classification of mood disorders, major depressive disorder is separate from bipolar disorders whereas mania is not. Studies on pure mania are therefore rare. Our paper reviews the evidence for distinguishing pure mania (M) and mania with mild depression (Md) from bipolar disorder. Two large epidemiological studies found a prevalence of 1.7-1.8% of M/Md in adolescents and adults. Several clinical follow-up studies demonstrated good stability of the diagnosis after a previous history of three manic episodes. Compared to bipolar disorder, manic disorder is characterised by a weaker family history for depression, an earlier onset, fewer recurrences and better remission, and is less comorbid with anxiety disorders. In addition, mania is strongly associated with a hyperthymic temperament, manifests more psychotic symptoms and is more often treated with antipsychotics. Twin and family studies find mania to be more heritable than depression and show no significant transmission from depression to mania or from mania to depression. Cardiovascular mortality is elevated among patients with mood disorders generally and is highest among those with mania. In non-Western countries, mania and the manic episodes in bipolar disorder are reported to occur more frequently than in Western countries.

Metabolic syndrome in patients with bipolar disorder: comparison with major depressive disorder and non-psychiatric controls

OBJECTIVE

We aimed to investigate the prevalence of the metabolic syndrome (MetS) and its individual components in subjects with bipolar disorder (BD) compared to those with major depressive disorder (MDD) and non-psychiatric controls.

METHODS

We examined 2431 participants (mean age 44.3±13.0, 66.1% female), of whom 241 had BD; 1648 had MDD; and 542 were non-psychiatric controls. The MetS was ascertained according to NCEP ATP III criteria. Multivariable analyses were adjusted for age, sex, ethnicity, level of education, smoking status and severity of depressive symptoms, and in the case of BD subjects, also for psychotropic medication use.

RESULTS

Subjects with BD had a significantly higher prevalence of MetS when compared to subjects with MDD and non-psychiatric controls (28.4% vs. 20.2% and 16.5%, respectively, p<0.001), also when adjusted for sociodemographic and lifestyle factors (OR 1.52, 95% CI: 1.09-2.12, p=0.02 compared to MDD; OR 1.79, 95% CI: 1.20-2.67, p=0.005 compared to non-psychiatric controls). The differences between BD subjects with controls could partly be ascribed to a higher mean waist circumference (91.0 cm vs. 88.8, respectively, p=0.03). In stratified analysis, the differences in the prevalence of MetS between patients with BD and MDD were found in symptomatic but not in asymptomatic cases.

CONCLUSION

This study confirms a higher prevalence of MetS in patients with BD compared to both MDD patients and controls. Specifically at risk are patients with a higher depression score and abdominal obesity.

Increased cerebral blood flow associated with better response inhibition in bipolar disorder

Impairment on inhibitory tasks has been well documented in bipolar disorder (BD). Differences in cerebral blood flow (CBF) between BD patients and healthy comparison (HC) participants have also been reported. Few studies have examined the relationship between cognitive performance and regional CBF in this patient population. We hypothesized that group differences on an inhibitory task (the Delis-Kaplan Executive Function Scale's Color-Word Inhibition task) would be associated with differential CBF in bilateral anterior cingulate cortex (ACC), inferior parietal lobule (IPL) and dorsolateral prefrontal cortex (DLPFC) regions. Whole brain resting CBF was measured using Multiphase Pseudocontinuous Arterial Spin Labeling MR imaging for 28 euthymic BD and 36 HC participants. Total gray matter (GM) CBF was measured, and regional CBF values were extracted for each region of interest (ROI) using Freesurfer-based individual parcellations. Group, CBF, and group-by-CBF interaction were examined as predictors of inhibition performance. Groups did not differ in age, gender or education. BD patients performed significantly worse on Color-Word inhibition. There were no significant group differences in CBF in either total GM or in any ROI. There was a group by CBF interaction in the bilateral ACC, right IPL and right DLPFC such that better inhibitory performance was generally associated with higher resting state CBF in BD subjects, but not HC participants. Although CBF was not abnormal in this euthymic BD sample, results confirm previous reports of inter-episode inhibitory deficits and indicate that the perfusion-cognition relationship is different in BD compared to HC individuals.

Depression and cardiovascular disease: an update on how course of illness may influence risk

Depression constitutes a novel and independent risk factor for cardiovascular disease, which despite extensive support in the literature has been underappreciated. While much of the evidence for depression as a risk factor for cardiovascular disease is based on studies following myocardial infarction, the elevated vascular risk conveyed by depression is not confined to periods following acute coronary syndromes. For that matter, the risk appears across mood disorders with evidence for even greater risk in bipolar disorder. This review summarizes the literature linking depressive disorders to cardiovascular mortality with a focus on how the course of illness of mood disorders may influence this risk. Mood disorders may influence risk over decades of illness in a dose-response to symptom burden, or the persistence of affective symptomatology. This may be mediated through changes in the activity of the autonomic nervous system, the hypothalamic-pituitary-adrenal axis, and inflammatory cytokines. Whether treatment of depression can mitigate this risk is not established although there are suggestions to support this contention, which could be better studied with more effective treatments of depression and larger standardized samples. Directions for future study of mechanisms and treatment are discussed. Regardless of causal mechanisms, persons with depressive disorders and other risk factors for vascular disease represent a neglected, high-risk group for cardiovascular events. In addition to the appropriate treatment for depression, screening and optimized management of traditional risk factors for cardiovascular diseases is necessary.

Heart rate variability in unmedicated patients with bipolar disorder in the manic phase

AIMS

Decreased heart rate variability (HRV) has been proposed in bipolar disorder. To date, there has been no adequate study that has investigated resting HRV in unmedicated patients with bipolar disorder in the manic state.

METHODS

To examine whether bipolar mania is associated with decreased HRV, 61 unmedicated patients with bipolar mania and 183 healthy volunteers aged 20-65 years were recruited for this case-control analysis. The Young Mania Rating Scale (YMRS), Clinical Global Impression-Severity, Hamilton Depression Rating Scale (HAM-D), and Hamilton Anxiety Rating Scale (HAM-A) were used for the clinical ratings. Cardiac autonomic function was evaluated by measuring HRV parameters and the frequency-domain indices of HRV were obtained.

RESULTS

Patients with bipolar mania exhibited significantly lower mean RR interval, variance, low-frequency (LF)-HRV, and high-frequency (HF)-HRV but higher LF/HF compared to controls. Decreased HRV (variance) was associated with the YMRS total scores. Both the YMRS total scores and the Clinical Global Impression-Severity scores were positively correlated with the LH/HF ratio and inversely correlated with the HF-HRV. There was no significant correlation between the HAM-D/HAM-A scores and any HRV parameter.

CONCLUSIONS

Bipolar mania is associated with cardiac autonomic dysregulation, highlighting the importance of assessing HRV in manic patients. Further studies examining the influence of anti-manic psychotropic drugs on cardiac autonomic regulation in bipolar mania are needed.

The diagnosis and treatment of bipolar disorder: decision-making in primary care

Bipolar disorder is a chronic episodic illness, characterized by recurrent episodes of manic or depressive symptoms. Patients with bipolar disorder frequently present first to primary care, but the diversity of the potential symptoms and a low index of suspicion among physicians can lead to misdiagnosis in many patients. Frequently, co-occurring psychiatric and medical conditions further complicate the differential diagnosis. A thorough diagnostic evaluation at clinical interview, combined with supportive case-finding tools, is essential to reach an accurate diagnosis. When treating bipolar patients, the primary care physician has an integral role in coordinating the multidisciplinary network. Pharmacologic treatment underpins both short- and long-term management of bipolar disorder. Maintenance treatment to prevent relapse is frequently founded on the same pharmacologic approaches that were effective in treating the acute symptoms. Regardless of the treatment approach that is selected, monitoring over the long term is essential to ensure continued symptom relief, functioning, safety, adherence, and general medical health. This article describes key decision-making steps in the management of bipolar disorder from the primary care perspective: from initial clinical suspicion to confirmation of the diagnosis to decision-making in acute and longer-term management and the importance of patient monitoring.

Effects of antipsychotic drugs on cardiovascular variability in participants with bipolar disorder

OBJECTIVE

The risk for cardiovascular diseases is elevated in persons with bipolar disorder. However, it remains unknown how much of this excess risk is secondary to pharmacologic treatment. We tested the hypothesis that current and cumulative antipsychotic drug exposure is associated with increased cardiovascular risk as indicated by lower heart rate variability (HRV) and increased blood pressure variability (BPV).

METHODS

Fifty-five individuals with bipolar disorder (33 ± 7 years; 67% female) underwent noninvasive electrocardiogram assessment of time-domain and frequency-domain HRV, as well as BPV analysis. Medication histories were obtained through systematic review of pharmacy records for the past 5 years.

RESULTS

Current antipsychotic exposure was associated with lower standard deviation of NN intervals. Second-generation antipsychotics were associated with lower standard deviation of NN intervals and root mean square of successive differences. There was no significant relationship between 5-year antipsychotic exposure and HRV in subjects with bipolar disorder. Exploratory analysis revealed a possible link between selective serotonin reuptake inhibitor exposure and increased low-frequency spectral HRV.

CONCLUSIONS

Current antipsychotic use (particularly second-generation antipsychotics with high affinities for the D2S receptor) is associated with reduced autonomic-mediated variability of the HR. The absence of an association with cumulative exposure suggests that the effects are acute in onset and may therefore relate more to altered autonomic function than structural cardiovascular abnormalities. Future studies should prospectively examine effects of these antipsychotics on autonomic function.

Vascular mortality in participants of a bipolar genomics study

BACKGROUND

In prior work, we identified a relationship between symptom burden and vascular outcomes in bipolar disorder.

OBJECTIVE

We sought to replicate these findings using a readily accessible measure of mood disorder chronicity and vascular mortality.

METHODS

We conducted a mortality assessment using the National Death Index for 1716 participants with bipolar I disorder from the National Institute of Mental Health Genetics Initiative Bipolar Disorder Consortium. We assessed the relationship between the duration of the most severe depressive and manic episodes and time to vascular mortality (cardiovascular or cerebrovascular) using Cox proportional hazards models, adjusting for potentially confounding variables.

RESULTS

Mortality was assessed a mean for 7 years following study intake, at which time 58 participants died, 18 of vascular causes. These participants had depression for much longer than their counterparts did (Wilcoxon rank sum Z = 2.30, p = 0.02) and the duration of the longest depressive episode in years was significantly associated with time to vascular mortality in models (hazard ratio = 1.16, 95% confidence interval: 1.02-1.33, p = 0.02), which controlled for age, gender, vascular disease equivalents, and vascular disease risk factors. The duration of longest mania was not related to vascular mortality.

CONCLUSION

The duration of the most severe depression is independently predictive of vascular mortality, lending further support to the idea that mood disorders hasten vascular mortality in a dose-dependent fashion. Further study of the relevant mechanisms by which mood disorders may hasten vascular disease and of integrated treatments for mood and cardiovascular risk factors is warranted.

Immunity, inflammation, and bipolar disorder: diagnostic and therapeutic implications

Bipolar disorder is now known to be associated not only with highly prevalent co-occurring psychiatric and substance use disorders but also with medical comorbidities, such as cardiovascular diseases, diabetes mellitus, obesity and thyroid dysfunction. Inflammatory disturbances repeatedly observed in bipolar disorder, can explain some of the comorbidity between bipolar disorder and medical disorder. This revised perspective of bipolar disorders should promote the development of therapeutic tools. Immuno-inflammatory dysfunction may well represent a significant component of the underlying pathophysiology of the disorder. We therefore propose to review the immuno-inflammatory hypothesis in bipolar disorder considering the co-occurence with autoimmune diseases, immunological and inflammatory markers, as well as immuno-genetic markers which could lead to personalized treatments.

Life expectancy and death by diseases of the circulatory system in patients with bipolar disorder or schizophrenia in the Nordic countries

Objective

Excess mortality from diseases and medical conditions (natural death) in persons with psychiatric disorders has been extensively reported. Even in the Nordic countries with well-developed welfare systems, register based studies find evidence of an excess mortality. In recent years, cardiac mortality and death by diseases of the circulatory system has seen a decline in all the Nordic countries, but a recent paper indicates that women and men in Denmark, Finland, and Sweden, who had been hospitalised for a psychotic disorder, had a two to three-fold increased risk of dying from a cardiovascular disease. The aim of this study was to compare the mortality by diseases of the circulatory system among patients with bipolar disorder or schizophrenia in the three Nordic countries Denmark, Sweden, and Finland. Furthermore, the aim was to examine and compare life expectancy among these patients. Cause specific Standardized Mortality Rates (SMRs) were calculated for each specific subgroup of mortality. Life expectancy was calculated using Wiesler’s method.

Results

The SMR for bipolar disorder for diseases of the circulatory system was approximately 2 in all countries and both sexes. SMR was slightly higher for people with schizophrenia for both genders and in all countries, except for men in Denmark. Overall life expectancy was much lower among persons with bipolar disorder or schizophrenia, with life expectancy being from 11 to 20 years shorter.

Conclusion

Our data show that persons in the Nordic countries with schizophrenia or bipolar disorder have a substantially reduced life expectancy. An evaluation of the reasons for these increased mortality rates should be prioritized when planning healthcare in the coming years.

Sociodemographic and clinical features of bipolar disorder patients misdiagnosed with major depressive disorder in China

OBJECTIVES

Bipolar disorder (BD) is frequently misdiagnosed as major depressive disorder (MDD), which may lead to inappropriate treatment and poor outcomes. This study aimed to compare demographic and clinical features between patients with MDD and those with BD, but being misdiagnosed as MDD, in China.

METHODS

A total of 1487 patients diagnosed with MDD were consecutively evaluated in 13 psychiatric hospitals or psychiatric units of general hospitals nationwide in China. The patients' sociodemographic and clinical characteristics were recorded using a standardized protocol and data collection procedure. The Mini-International Neuropsychiatric Interview (MINI) was used to establish DSM-IV diagnoses, and identify patients with MDD and those with BD, but being misdiagnosed with MDD.

RESULTS

The proportions of BD (all types), bipolar I disorder (BD-I), and bipolar II disorder (BD-II) misdiagnosed as MDD in clinical practice were 20.8%, 7.9%, and 12.8%, respectively. Multiple logistic regression analyses revealed that compared to MDD patients, BD-I was characterized by more atypical depressive features (increased appetite, increased sleep, and weight gain) [odds ratio (OR) = 2.0, 95% confidence interval (CI): 1.2-3.2], more psychotic symptoms (OR = 2.1, 95% CI: 1.3-3.5), more lifetime depressive episodes (OR = 1.1, 95% CI: 1.1-1.2), and earlier age of onset (OR = 0.97, 95% CI: 0.9-0.99); BD-II was characterized by more psychotic symptoms (OR = 2.1, 95% CI: 1.4-3.1) and earlier age of onset (OR = 0.96, 95% CI: 0.9-0.97). In addition, compared to BD-II patients, BD-I patients were characterized by more frequent depressive episodes per year (OR = 3.1, 95% CI: 1.5-6.6).

CONCLUSIONS

Depressive episodes in the context of BD-I and BD-II, among those who were misclassified as MDD, present some different clinical features compared to MDD. This finding should be taken into account in guiding diagnostic practices in China.

Sleep duration is associated with dyslipidemia in patients with bipolar disorder in clinical remission

BACKGROUND

The pathways to increased cardiovascular risk in bipolar disorder include health behaviors, psychosocial stress and long-term medication exposure. However, the evidence that the association between cardiovascular risk factors and bipolar disorder remains significant after controlling for these co-factors suggests that additional important risk factors have yet to be identified. Our hypothesis is that disturbances in the sleep-wake cycle are an important and under-recognized pathway through which affective disorders lead to increased cardiovascular risk.

METHODS

In patients with bipolar disorder type 1 in clinical remission, we: 1) explored whether sleep disturbance predicted the endorsement of NCEP ATP-III criteria for dyslipidemia, independent of other lifestyle factors and 2) tested the association between low HDL (NCEP-ATP III) and sleep duration measured with actigraphy over an eight-day period.

RESULTS

Median sleep duration is significantly associated with low HDL. The risk of having low HDL increases by 1.23 with every 30 minutes of reduced sleep time.

LIMITATIONS

Since sleep patterns in patients with bipolar disorder are variable and irregular, it is possible that other sleep characteristics, not present during the span of our study, or the variability itself may be what drives the increased cardiovascular risk.

CONCLUSIONS

Sleep characteristics of patients with bipolar disorder in clinical remission are associated with cardiovascular risk. More specifically, sleep duration was associated with low HDL. Clinicians should pay special attention to sleep hygiene in treating individuals with bipolar disorder, even when they are in clinical remission.

Can bipolar disorder be viewed as a multi-system inflammatory disease?

BACKGROUND

Patients with bipolar disorder are known to be at high risk of premature death. Comorbid cardio-vascular diseases are a leading cause of excess mortality, well above the risk associated with suicide. In this review, we explore comorbid medical disorders, highlighting evidence that bipolar disorder can be effectively conceptualized as a multi-systemic inflammatory disease.

METHODS

We conducted a systematic PubMed search of all English-language articles recently published with bipolar disorder cross-referenced with the following terms: mortality and morbidity, cardio-vascular, diabetes, obesity, metabolic syndrome, inflammation, auto-antibody, retro-virus, stress, sleep and circadian rhythm.

RESULTS

Evidence gathered so far suggests that the multi-system involvement is present from the early stages, and therefore requires proactive screening and diagnostic procedures, as well as comprehensive treatment to reduce progression and premature mortality. Exploring the biological pathways that could account for the observed link show that dysregulated inflammatory background could be a common factor underlying cardio-vascular and bipolar disorders. Viewing bipolar disorder as a multi-system disorder should help us to re-conceptualize disorders of the mind as "disorders of the brain and the body".

LIMITATIONS

The current literature substantially lacks longitudinal and mechanistic studies, as well as comparison studies to explore the magnitude of the medical burden in bipolar disorder compared to major mood disorders as well as psychotic disorders. It is also necessary to look for subgroups of bipolar disorder based on their rates of comorbid disorders.

CONCLUSIONS

Comorbid medical illnesses in bipolar disorder might be viewed not only as the consequence of health behaviors and of psychotropic medications, but rather as an early manifestation of a multi-systemic disorder. Medical monitoring is thus a critical component of case assessment. Exploring common biological pathways of inflammation should help biomarkers discovery, ultimately leading to innovative diagnostic tools, new methods of prevention and personalized treatments.

Evidence for accelerated vascular aging in bipolar disorder

OBJECTIVE

Persons with bipolar disorder face excess risk of cardiovascular disease, although the biobehavioral mechanisms and time course are unclear. We measured vascular stiffness in a cross-sectional sample of participants with bipolar disorder and compared results to published normative data to assess time-course and relationship to behavioral risk factors.

METHODS

62 individuals with bipolar disorder (33±6.7years; 64% female) underwent non-invasive assessment of arterial stiffness through arterial applanation tonometry. Lifetime tobacco exposure was estimated on clinical interview. Physical activity was assessed using the long-version of the International Physical Activity Questionnaire (IPAQ). A food frequency questionnaire was used to compute Alternate Healthy Eating Index (AHEI), a measure of overall dietary quality. Medication histories were systematically abstracted from pharmacy records.

RESULTS

Participants over the age of 32 (median split) had greater arterial stiffness than expected from age-based population norms for pulse wave velocity (PWV) (7.6 vs. 7.0m/s, p=.02) and estimated aortic augmentation pressure (AIx) (14.2 vs. 8.2%, p=.0002). The younger portion of the sample did not differ from population norms on these measures (PWV 6.3 vs. 6.4m/s, p=.45 and AIx 7.6 vs. 7.4%, p=.60). In the older half of the sample, physical activity was inversely associated with AIx and poorer diet marginally associated with PWV. These findings were independent of body mass index (BMI), which was strongly related to arterial stiffness.

CONCLUSION

Risk for vascular disease may be acquired over the long-term course of affective illness. This risk appears to reflect maladaptive health behaviors, which may be amenable to intervention.

Metabolic syndrome in a cohort of affectively ill patients, a naturalistic study

BACKGROUND

Patients with affective disorder have higher mortality not only because of their affective illness but also because of a higher risk of death from physical illness especially cardiovascular diseases.

AIM

To investigate the prevalence in a naturalistic cohort of patient treated at a Mood Disorder Clinic.

METHODS

Patients were evaluated for the presence of metabolic syndrome (MeS) according to modified NCEP ATP III criteria.

RESULTS

Of the 143 patients eligible for participation, 100 patients participated in the study (32% male, mean age 43.6 ± 14.2); the prevalence of MeS was 26%. Higher age and high body mass index (BMI) were significantly associated with MeS. No association between present medication and MeS was seen.

CONCLUSION

More than a quarter of affectively ill patients had MeS, which emphasizes the importance of integrated somatic and psychiatric care in order to reduce this group of patients' risk profile concerning cardiovascular diseases and diabetes. Clinically, it seems reasonable to prioritize overweight and obese patients for further examination.

Vascular function is not impaired early in the course of bipolar disorder

OBJECTIVE

Individuals with bipolar disorder face a nearly two-fold increased risk of cardiovascular mortality relative to the general population. Endothelial dysfunction precedes cardiovascular disease and serves as a quantifiable phenotype for vasculopathy. We investigated whether individuals with bipolar disorder had poorer vascular function than controls using a case-control design.

METHODS

The sample of 54 participants included 27 individuals with bipolar disorder and 27 age- and gender-matched controls. Participants underwent an assessment of metabolic (weight, lipids, and insulin resistance) and vascular parameters (endothelial function using flow-mediated dilation; arterial stiffness using pulse wave velocity and estimated aortic pressure).

RESULTS

Participants had a mean age of 32 years and 41% were female. No significant differences were found between groups in endothelial function or arterial stiffness. Individuals with bipolar disorder demonstrated 100% greater insulin resistance.

CONCLUSION

The lack of clinically significant differences in vascular function in this young sample suggests any increased risk either occurs later in the course of illness or is largely due to behavioral risk factors, such as smoking, which was balanced between groups. Substantial insulin resistance is identifiable early in course of illness, perhaps secondary to treatment.

Metabolic syndrome in Italian patients with bipolar disorder: a 2-year follow-up study

BACKGROUND

Metabolic syndrome (MetS) is highly prevalent in patients with bipolar disorder (BD). Few prospective studies have demonstrated an increase of MetS prevalence over time in patients with BD, but no study has tried to unveil the characteristics of patients with BD eventually developing the MetS. In our study we assessed the prevalence of MetS and its criteria over a period of 2-years; then, we identified the baseline clinical features of patients who developed the MetS during the follow-up with the intent to identify potential predictors for developing the MetS.

METHODS

Subjects with BD consecutively admitted from April 2006 to September 2008 were included. MetS was diagnosed according to NCEP ATP-III modified criteria at baseline and after 2 years. We then selected patients without MetS at baseline and analyzed the association between clinical characteristics at baseline and the presence of MetS at follow-up by means of logistic regression analysis.

RESULTS

70 patients underwent all baseline and follow-up analyses. MetS prevalence significantly increased from 28.6 to 44.3% during the 2-years naturalistic follow-up (p=0.027). Significant predictors of MetS at follow-up were older age, higher BMI, and baseline exposure to antipsychotics.

LIMITATIONS

Lack of a healthy control group.

CONCLUSION

MetS can rapidly develop in patients with BD, especially if antipsychotics are prescribed. Our paper highlights the importance of regularly screening the MetS in patients with BD despite the presence of metabolic disturbances at baseline.

Systematic Review and Meta-analysis of Pharmacological Interventions for Weight Gain from Antipsychotics and Mood Stabilizers

Pharmacological treatments for serious mental illness (SMI) can cause weight gain and adverse metabolic effects. Many second generation antipsychotics and mood stabilizers appear to be particularly problematic in this regard. Several studies have investigated interventions for antipsychotic-induced, or less commonly mood stabilizer -induced, weight gain. Both lifestyle and pharmacological interventions have demonstrated effectiveness. We systematically review randomized controlled trials of pharmacological interventions for weight gain related to these medications. We conducted a meta-analysis of clinical trials for the most studied agents to estimate mean weight loss: metformin (2.93 kg, 95% C.I. 0.97-4.89, p=0.003), H(2) antagonists (1.78 kg (95% C.I. -0.50-4.06, p=0.13), topiramate (3.95 kg 95% C.I. 1.77-6.12, p=0.0004), and norepinephrine reuptake inhibitors (1.30 kg (95% C.I. -0.06-2.66, p=0.06). Among the studied options for antipsychotic-related weight gain, metformin has the strongest evidence base and may improve vascular risk factors beyond obesity. The use of topiramate is also supported by the literature and may improve psychotic symptoms in those refractory to treatment. A marginal benefit is seen with norepinephrine reuptake inhibitors, and any vascular benefits from such weight loss may be counteracted by increases in blood pressure or heart rate. Pharmacological therapies may offer benefits as a means of supplementing the effects of lifestyle changes for weight loss. However, the existing evidence provides little evidence of specificity for pharmacological therapies to antipsychotic-induced weight gain and has not studied any connection between benefits and reduced incidence of diabetes mellitus or any vascular outcomes.

Vasculopathy related to manic/hypomanic symptom burden and first-generation antipsychotics in a sub-sample from the collaborative depression study

BACKGROUND

Mood disorders substantially increase the risk of cardiovascular disease, though the mechanisms are unclear. We assessed for a dose-dependent relationship between course of illness or treatment with vasculopathy in a well-characterized cohort.

METHODS

Participants with mood disorders were recruited for the National Institute of Mental Health Collaborative Depression Study (CDS) and followed prospectively. A cross-sectional metabolic and vascular function evaluation was performed on a sub-sample near completion after a mean follow-up of 27 years.

RESULTS

A total of 35 participants from the University of Iowa (33) and Washington University (2) sites of the CDS consented to a metabolic and vascular function assessment at the Iowa site. In multivariate linear regression, controlling for age, gender, and smoking, manic/hypomanic, but not depressive, symptom burden was associated with lower flow-mediated dilation. Cumulative exposure to antipsychotics and mood stabilizers was associated with elevated augmentation pressure and mean aortic systolic blood pressure. This appeared specifically related to first-generation antipsychotic exposure and mediated by increases in brachial systolic pressure. Although second-generation antipsychotics were associated with dyslipidemia and insulin resistance, they were not associated with vasculopathy.

CONCLUSIONS

These results provide evidence that chronicity of mood symptoms contribute to vasculopathy in a dose-dependent fashion. Patients with more manic/hypomanic symptoms had poorer endothelial function. First-generation antipsychotic exposure was associated with arterial stiffness, evidenced by higher augmentation pressure, perhaps secondary to elevated blood pressure. Vascular phenotyping methods may provide a promising means of elucidating the mechanisms linking mood disorders to vascular disease.

Insulin dysfunction and allostatic load in bipolar disorder

Bipolar disorder (BD) is associated with substantial morbidity, as well as premature mortality. Available evidence indicates that 'stress-sensitive' chronic medical disorders, such as cardiovascular disease, obesity and Type 2 diabetes mellitus, are critical mediators and/or moderators of BD. Changes in physiologic systems implicated in allostasis have been proposed to impact brain structures and neurocognition, as well as medical comorbidity in this population. For example, abnormalities in insulin physiology, for example, insulin resistance, hyperinsulinemia and central insulinopenia, are implicated as effectors of allostatic load in BD. Insulin's critical role in CNS physiological (e.g., neurotrophism and synaptic plasticity) and pathophysiological (e.g., neurocognitive deficits, pro-apoptosis and amyloid deposition) processes is amply documented. This article introduces the concept that insulin is a mediator of allostatic load in the BD and possibly a therapeutic target.

Risperidone long-acting injectable (Risperdal Consta®) for maintenance treatment in patients with bipolar disorder

Poor adherence to pharmacotherapy during maintenance-phase treatment of bipolar disorder is a common occurrence, exposing patients to a high risk of illness relapses, rehospitalization and other negative outcomes. In view of this, there has been a reawakening of interest in the potential of long-acting injectable antipsychotic medications to improve treatment outcome during bipolar maintenance therapy. Indeed, long-acting injectable medications have practical advantages of assuring delivery of medication at a prescribed dose, and perhaps also making it easier to monitor adherence, at least to the long-acting drug. However, there are important limitations to the long-term use of depot typical neuroleptics in patients with bipolar disorder, including risk of extrapyramidal side effects and tardive dyskinesia, which may exceed that of patients with schizophrenia, and the potential for treatment-emergent exacerbation of depressive symptoms. Long-acting injectable risperidone (RLAI) has recently been approved for maintenance treatment in patients with bipolar I disorder. Evidence supporting the use of RLAI for this indication consists of several nonrandomized, open-label studies; one randomized, open-label trial; and two adequately powered randomized, double-blind trials. In general, these studies have shown RLAI to be effective for the prevention of relapse or hospitalization during bipolar maintenance treatment. In the double-blind studies, RLAI was associated with reduced relapse rates, increased time to relapse and greater control of clinical symptoms during maintenance treatment following initial stabilization, compared with oral medication treatment or placebo injection. RLAI appeared to be more effective for preventing manic/mixed episodes than depressive episodes. RLAI showed good tolerability across studies; however, dose-related extrapyramidal effects, sedation, weight gain and prolactin elevation may occur during long-term treatment. Responder-enriched designs and exclusion of important clinical subgroups in the double-blind trials may limit translation of these results to routine care settings.

Age-specific prevalence of metabolic syndrome in Italian patients with bipolar disorder

AIM

Metabolic syndrome (MetS) is highly prevalent in patients with bipolar disorder (BD). Little research has evaluated the risk profile of MetS and cardiovascular disease in different gender and age groups in these patients. Our aim is to evaluate the prevalence of MetS in Italian patients with BD stratified by gender and age, and to determine the correlates of MetS.

METHODS

Subjects with BD were included and stratified by sex and age according to the following age groups: <30; 30-39; 40-49; 50-59; ≥ 60 years. Socio-demographic and clinical characteristics, lifestyle information, and comorbidity for cardiovascular diseases and diabetes were collected. MetS was diagnosed according to National Cholesterol Education Program Adult Treatment Panel III modified criteria.

RESULTS

MetS was evaluated in 200 patients, with a prevalence of 26.5%. Men had higher rates of hypertension and hypertriglyceridemia, women had more abdominal obesity. Women had a peak of prevalence in the ≥ 60 years group, while men displayed high rates even in the young age groups. In young patients, MetS was associated with Cluster B personality disorders and less physical exercise.

CONCLUSION

Our paper highlights the importance of evaluating MetS even in young patients with bipolar disorder, especially males. The strong association with lack of physical exercise suggests that the implementation of healthy behaviors might be relevant in order to prevent MetS and future adverse cardiovascular outcomes.