Obesity in bipolar disorder: an overview

Genomic SEM applied to explore etiological divergences in bipolar subtypes

BACKGROUND

Bipolar disorder (BD) is an overarching diagnostic class defined by the presence of at least one prior manic episode (BD I) or both a prior hypomanic episode and a prior depressive episode (BD II). Traditionally, BD II has been conceptualized as a less severe presentation of BD I, however, extant literature to investigate this claim has been mixed.

METHODS

We apply genomic structural equation modeling (Genomic SEM) to investigate divergent genetic pathways across BD's two major subtypes using the most recent GWAS summary statistics from the PGC. We begin by identifying divergences in genetic correlations across 98 external traits using a Bonferroni-corrected threshold. We also use a theoretically informed follow-up model to examine the extent to which the genetic variance in each subtype is explained by schizophrenia and major depression. Lastly, transcriptome-wide SEM (T-SEM) was used to identify neuronal gene expression patterns associated with BD subtypes.

RESULTS

BD II was characterized by significantly larger genetic overlap across non-psychiatric medical and internalizing traits (e.g. heart disease, neuroticism, insomnia), while stronger associations for BD I were absent. Consistent with these findings, follow-up modeling revealed a substantial major depression component for BD II. T-SEM results revealed 35 unique genes associated with shared risk across BD subtypes.

CONCLUSIONS

Divergent patterns of genetic relationships across external traits provide support for the distinction of the bipolar subtypes. However, our results also challenge the illness severity conceptualization of BD given stronger genetic overlap across BD II and a range of clinically relevant traits and disorders.

Liraglutide in Obese or Overweight Individuals With Stable Bipolar Disorder

BACKGROUND

Obesity is common among persons with bipolar disorder (BD). Liraglutide 3.0 mg/d subcutaneous injection is indicated for chronic weight management and associated with minimal adverse neuropsychiatric effects. This study evaluated whether liraglutide 3 mg/d reduced body weight, improved metabolic factors and eating psychopathology, and was safe and well tolerated in persons with stable BD who were obese (body mass index [BMI] >30 kg/m 2 ) or overweight (BMI ≥27 kg/m 2 ) with at least one weight-related comorbidity.

METHODS

This was a 40-week, randomized (1:1 ratio), placebo-controlled, double-blind, parallel-group, 2-arm clinical trial of liraglutide targeted to 3.0 mg/d (in combination with a reduced-calorie diet and increased physical activity) in 60 participants with stable BD who were obese or overweight. Primary outcome was percent change in body weight from baseline to study end. Secondary outcomes included percentage of patients who lost ≥5% of baseline body weight, and changes in metabolic variables and measures of eating psychopathology.

RESULTS

There were no significant baseline differences between the 29 liraglutide recipients and the 31 placebo recipients, except that liraglutide recipients had higher levels of binge eating and lower levels of high-density lipoprotein cholesterol. Compared with placebo, liraglutide was associated with significantly greater reductions in percent change in body weight, percentage of participants who lost at least 5% of body weight, and reductions in weight, BMI, hemoglobin A 1c levels, binge eating, and hunger. Liraglutide was well tolerated.

CONCLUSIONS

Liraglutide 3 mg/d may be efficacious and safe for weight loss in individuals with stable BD and obesity or overweight.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03158805).

International Trends in Lithium Use for Pharmacotherapy and Clinical Correlates in Bipolar Disorder: A Scoping Review

Lithium remains an effective option in the treatment of bipolar disorder (BD). Thus, we aim to characterize the pharmaco-epidemiological patterns of lithium use internationally over time and elucidate clinical correlates associated with BD using a scoping review, which was conducted using the methodological framework by Arksey and O'Malley (2005). We searched several databases for studies that examined the prescriptions for lithium and clinical associations in BD from inception until December 2023. This review included 55 articles from 1967 to 2023, which collected data from North America (n = 24, 43.6%), Europe (n = 20, 36.4%), and Asia (n = 11, 20.0%). The overall prescription rates ranged from 3.3% to 84% (33.4% before and 30.6% after the median year cutoffs). Over time, there was a decline in lithium use in North America (27.7% before 2010 to 17.1% after 2010) and Europe (36.7% before 2003 to 35.7% after 2003), and a mild increase in Asia (25.0% before 2003 to 26.2% after 2003). Lithium use was associated with specific demographic (e.g., age, male gender) and clinical factors (e.g., lower suicide risk). Overall, we found a trend of declining lithium use internationally, particularly in the West. Specific clinical correlates can support clinical decision-making for continued lithium use.

Epidemiology studies on effects of lithium salts in pregnancy are confounded by the inability to control for other potentially teratogenic factors

INTRODUCTION

In bipolar women who took lithium during pregnancy, several epidemiology studies have reported small increases in a rare fetal cardiac defect termed Ebstein's anomaly.

METHODS

Behavioral, environmental, and lifestyle-associated risk factors associated with bipolar disorder and health insurance status were determined from an Internet search. The search was conducted from October 1, 2023, through October 14, 2023. The search terms employed included the following: bipolar, bipolar disorder, mood disorders, pregnancy, congenital heart defects, Ebstein's anomaly, diabetes, hypertension, Medicaid, Medicaid patients, alcohol use, cigarette smoking, marijuana, cocaine, methamphetamine, narcotics, nutrition, diet, obesity, body mass index, environment, environmental exposures, poverty, socioeconomic status, divorce, unemployment, and income. No quotes, special fields, truncations, etc., were used in the searches. No filters of any kind were used in the searches.

RESULTS

Women who remain on lithium in the United States throughout their pregnancy are likely to be experiencing mania symptoms and/or suicidal ideation refractory to other drugs. Pregnant women administered the highest doses of lithium salts would be expected to have been insufficiently responsive to lower doses. Any small increases in the retrospectively determined risk of fetal cardiac anomalies in bipolar women taking lithium salts cannot be disentangled from potential developmental effects resulting from very high rates of cigarette smoking, poor diet, alcohol abuse, ingestion of illegal drugs like cocaine or opioids, marijuana smoking, obesity, and poverty.

CONCLUSIONS

The small risks in fetal cardiac abnormalities reported in the epidemiology literature do not establish a causal association for lithium salts and Ebstein's anomaly.

Recent Secular Trends of Body Mass Index in Individuals With Bipolar Disorders and in the General Population

OBJECTIVE

The aims of this study were to investigate secular trends and distribution of body mass index (BMI) among individuals with bipolar disorders and the general population between 2008 and 2019.

METHODS

Data were from the Swedish National Quality Register for Bipolar Disorder, where 24,423 adults with bipolar disorders were identified, and from the national Swedish Living Conditions Surveys, where 77,485 adults from the general population were identified. Quantile regression was used to compare the 15th, 50th, and 85th percentiles of BMI across age and study years.

RESULTS

The study sample included 22,127 individuals with bipolar disorders (mean age, 48 years; 63% women) and 71,894 individuals from the general population (mean age, 52 years; 51% women). BMI percentiles were higher among individuals with bipolar disorders. At the 50th percentile, the BMI group differences were 1.1 (95% CI=0.8-1.14) for men and 1.8 (95% CI=1.5-2.1) for women. The gap was widest at the 85th BMI percentile: men, 2.3 (95% CI=1.8-2.8); women, 4.1 (95% CI=3.7-4.6). BMI increased over time in both study groups, but more in the group with bipolar disorders. The changes per decade in mean BMI were 0.4 (95% CI=0.3-0.5) among men in the general population, 1.1 (95% CI=0.7-1.4) among men with bipolar disorders, 0.6 (95% CI=0.5-0.7) among women in the general population, and 1.4 (95% CI=1.1-1.7) among women with bipolar disorders. Women with bipolar disorders had the highest prevalence and the greatest rate of increase of obesity. In 2019, the obesity prevalence was 33% among women and 29% among men with bipolar disorders, compared with 13% and 15%, respectively, among women and men in the general population.

CONCLUSIONS

Adults with bipolar disorders had a higher BMI and a higher prevalence of obesity than the general population, indicating a higher cardiometabolic risk. Annually, BMI increased more in the group with bipolar disorders than in the general population, particularly among women and among those with high BMI.

Lurasidone and risk of metabolic syndrome: results from short and long-term studies in patients with bipolar depression

OBJECTIVE

The elevated prevalence of metabolic syndrome (MetS) in patients with depression has been associated with increased mortality. This post hoc analysis assessed the effect of treatment with lurasidone on risk of MetS in patients with bipolar depression.

METHODS

Data used in the current analyses consisted of 3 double-blind (DB), placebo-controlled, 6-week studies in adults with bipolar I depression (N = 1192), consisting of 1 monotherapy, and 2 adjunctive trials (lithium or valproate). Also analyzed was a 6-month open-label (OL) extension study (monotherapy, N = 316; adjunctive therapy, N = 497); and a 5-month, OL, stabilization phase followed by randomization to a 28-week DB, placebo-controlled, adjunctive therapy study with lurasidone (N = 490). MetS was defined based on NCEP ATP III criteria (2005 revision).

RESULTS

The proportion of patients with new-onset MetS was similar for lurasidone vs placebo in the short-term studies (monotherapy, 13.9% vs 15.3%; adjunctive therapy, 13.6% vs 11.0%); and remained stable during both the 6-month extension phase study (monotherapy, 15.2%; adjunctive therapy, 16.9%), and the 5-month stabilization study (adjunctive therapy, 12.2%). After 28 weeks of DB treatment (following 5-month treatment in the stabilization study), new onset MetS was observed at endpoint (OC) in 26.2% of the lurasidone group, and 30.8% of the placebo group.

CONCLUSIONS

This post hoc analysis found that both short and long-term treatment with lurasidone was associated with a relatively low risk for the development of MetS in patients with bipolar I disorder. These findings are consistent with similar analyses in patients with schizophrenia.

Risk factors associated with overweight and obesity in people with severe mental illness in South Asia: cross-sectional study in Bangladesh, India, and Pakistan

Obesity is one of the major contributors to the excess mortality seen in people with severe mental illness (SMI) and in low- and middle-income countries people with SMI may be at an even greater risk. In this study, we aimed to determine the prevalence of obesity and overweight in people with SMI and investigate the association of obesity and overweight with sociodemographic variables, other physical comorbidities, and health-risk behaviours. This was a multi-country cross-sectional survey study where data were collected from 3989 adults with SMI from three specialist mental health institutions in Bangladesh, India, and Pakistan. The prevalence of overweight and obesity was estimated using Asian BMI thresholds. Multinomial regression models were then used to explore associations between overweight and obesity with various potential determinants. There was a high prevalence of overweight (17·3 %) and obesity (46·2 %). The relative risk of having obesity (compared to normal weight) was double in women (RRR = 2·04) compared with men. Participants who met the WHO recommendations for fruit and vegetable intake had 2·53 (95 % CI: 1·65-3·88) times greater risk of having obesity compared to those not meeting them. Also, the relative risk of having obesity in people with hypertension is 69 % higher than in people without hypertension (RRR = 1·69). In conclusion, obesity is highly prevalent in SMI and associated with chronic disease. The complex relationship between diet and risk of obesity was also highlighted. People with SMI and obesity could benefit from screening for non-communicable diseases, better nutritional education, and context-appropriate lifestyle interventions.

Long-term weight loss outcomes after bariatric surgery: a propensity score study among patients with psychiatric disorders

INTRODUCTION

To analyze the safety and long-term result of bariatric surgery in patients with psychiatric disorders.

MATERIAL AND METHODS

From January 2009 to December 2018, n = 961 patients underwent bariatric surgery in a tertiary center. Among them, two groups of patients were created: a group of patients with psychiatric disorders (PG) and a group without psychiatric disorders (CG), using a propensity score matched (PSM). Primary endpoint was long-term outcomes and secondary endpoints were the postoperative morbidity 90 days after surgery, late morbidity, occurrence of psychiatric adverse events, and resolution of obesity-related comorbidities.

RESULTS

Analysis with PSM permitted to compare 136 patients in each group, with a ratio 1:1. TWL% at 2 years in the PG was 32.7% versus 36.6% in the CG (p = 0.002). Overall surgical morbidity was higher in the PG than the CG (28% vs 17%, p = 0.01). Severe surgical complications were not statistically significant (4% vs 3%, p = 0.44). Psychiatric adverse events were significantly more frequent in the PG than in the CG. The resolution of obesity comorbidities was equivalent for both groups at 2 years.

CONCLUSION

Substantial weigh loss was reported among patients with psychiatric disorders receiving bariatric surgery at the cost of more non-severe surgical complications. Further, a psychiatric postoperative follow-up visit may be warranted for patients with preoperative psychiatric disorders, given the incidence of psychiatric adverse events.

Type 2 diabetes mellitus is associated with manic morbidity in elderly patients with mood disorders

The association between mood disorders, especially bipolar disorder (BD), and metabolic disorders, is long known. However, to which extent metabolic disorders affect the course of mood disorders in late life is still open to inquiring. To assess the impact of type 2 diabetes mellitus (T2DM) on late-life mood disorders a retrospective chart review was performed. Elderly depressive patients (≥ 65 years) diagnosed with Major Depressive Disorder (N = 57) or BD (N = 43) and followed up for at least 18 months were included and subdivided according to the presence of T2DM comorbidity. Vascular encephalopathy (39.1% vs. 15.6%, P  = 0.021) and neurocognitive disorders (21.7% vs. 5.2%, P  = 0.028), were more frequently reported in patients with T2DM than in those without. Patients with T2DM showed a greater percentage of follow-up time in manic episodes (r = -0.23, P  = 0.020) and a higher rate of manic episode(s) during follow-up (21.7% vs. 5.2%, P  = 0.028) than those without. When restricting longitudinal analyses to patients with bipolar spectrum disorders, results were confirmed. In line with the well-known connection between BD and metabolic disorders, our data support an association between T2DM and unfavorable course of illness in the elderly with BD.

Bariatric surgery outcomes in patients with bipolar or schizoaffective disorders

BACKGROUND

Obesity is associated with many co-morbidities and can cause harm to physical and mental well-being. While much has been studied in the general population about the outcomes of bariatric surgery, its implications in patients with bipolar/schizoaffective disorder (BSD) are less well understood.

OBJECTIVE

We aimed to describe outcomes of bariatric surgery in patients with BSD.

SETTING

Referral center for bariatric surgery.

METHODS

We conducted a retrospective chart review analysis of bariatric surgical procedures in patients with BSD between 2008 and 2021 at Mayo Clinic. Patients with BSD (cases) were matched via propensity score matching (1:2) with non-BSD controls based on surgical procedure, age, sex, body mass index, and type 2 diabetes. Hierarchical logistic regression model was performed using SAS software.

RESULTS

We matched 71 patients with BSD with 142 controls in a 1:2 ratio. After adjusting for baseline preoperative weight, patients with BSD had a 3.4% greater total weight loss compared with controls over 24 months (P = .02 [95% CI, .65-6.08]). Remission in obesity-related diseases, such as diabetes, hypertension, dyslipidemia, and sleep apnea, was similar in both groups. Perioperative complication rates were similar other than deep venous thrombosis, which showed a higher rate in patients with BSD (P = .04). Patients with long-term BSD were at increased risk of alcohol use compared with controls.

CONCLUSIONS

When compared with the general bariatric population, weight loss was similar to slightly improved, with a comparable risk and complication profile. Patients with BSD have increased alcohol use after bariatric surgery, highlighting the need for psychological care before and after surgery in this population.

Genetic Correlates as a Predictor of Bariatric Surgery Outcomes after 1 Year

This study analyzed genetic risk assessments in patients undergoing bariatric surgery to serve as a predictive factor for weight loss parameters 1 year after the operation. Thirty (30) patients were assessed for Genetic Addiction Risk Severity (GARS), which analyzes neurogenetic polymorphisms involved in addiction and reward deficiency. Genetic and psychosocial data collected before the operation were correlated with weight loss data, including changes in weight, body mass index (BMI), and percent of expected weight loss (%EWL). Results examined correlations between individual gene risk alleles, 1-year body weight data, and psychosocial trait scores. Spearman's correlations revealed that the OPRM1 (rs1799971) gene polymorphism had significant negative correlation with 1-year weight (rs = -0.4477, p < 0.01) and BMI (rs = -0.4477, p < 0.05). In addition, the DRD2 risk allele (rs1800497) was correlated negatively with BMI at 1 year (rs = -0.4927, p < 0.05), indicating that one risk allele copy was associated with lower BMI. However, this allele was positively correlated with both ∆Weight (rs = 0.4077, p < 0.05) and %EWL (rs = 0.5521, p < 0.05) at 1 year post-surgery. Moreover, the overall GARS score was correlated with %EWL (rs = 0.4236, p < 0.05), ∆Weight (rs = 0.3971, p < 0.05) and ∆BMI (rs = 0.3778, p < 0.05). Lastly, Food Cravings Questionnaire (FCQ) scores were negatively correlated with %EWL (rs = -0.4320, p < 0.05) and ∆Weight at 1 year post-surgery (rs = -0.4294, p < 0.05). This suggests that individuals with a higher genetic addiction risk are more responsive to weight loss treatment, especially in the case of the DRD2 polymorphism. These results should translate clinically to improve positivity and attitude related to weight management by those individuals born with the risk alleles (rs1800497; rs1799971).

Prevalence of eating disorders in patients with bipolar disorder: a scoping review of the literature

BACKGROUND

Eating disorder (ED) and bipolar disorder (BD) exhibit certain phenomenological similarities rooted in eating behavior and emotional regulation. However, despite the growing body of research on the comorbidity of ED and BD, scientific data on the concurrent course of these disorders has remained poorly systematized.

AIM

To conduct a scoping review of published data on the prevalence of various types of ED among patients with BD types I and II in the context of the sex and clinical features of the concurrent course of these disorders.

METHODS

The analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The search was conducted in the MEDLINE electronic database. Studies were included if they were focused samples of patients diagnosed with BD and ED, and the Diagnostic and Statistical Manual of Mental Disorders, fourth and fifth editions (DSM-IV, DSM-5), or International Statistical Classification of Diseases and Related Health Problems, tenth Revision (ICD-10), were used for the verification of the ED and BD diagnoses. The descriptive analysis method was used to summarize the review findings.

RESULTS

A total of 41 studies were selected for the review. Lifetime ED in patients with BD ranged from 2.2% to 31.1%, and the prevalence rates of BD among patients with ED varied from 11.3% to 68.1%. ED nominally had a higher prevalence among individuals with BD type II and females. Additionally, the presence of ED in patients with BD was associated with earlier onset of mood disorder, a higher number of depressive episodes, higher levels of atypical depressive symptoms, suicide attempts, as well as a higher frequency of comorbid obsessive-compulsive and anxiety disorders, addictions, and various metabolic disorders.

CONCLUSION

Despite the high degree of volatility in the results, the prevalence rates of a concurrent course of ED and BD are rather high. For this reason, screening for ED in patients with BD and vice versa holds significant value in the accurate diagnosis and selection of the most effective therapy. The patterns of comorbidity among different types of ED and BD, depending on gender, need further exploration in future research.

Characteristics of the gut microbiota in bipolar depressive disorder patients with distinct weight

BACKGROUND

Preliminary studies have indicated metabolic dysfunction and gut dysbiosis in patients with bipolar disorder (BD). In this study, we aimed to clarify the impact of the gut microbial composition and function on metabolic dysfunction in BD patients with an acute depressive episode.

METHODS

Fresh fecal samples were provided from 58 patients with BD depression, including 29 with normal weight (NW) and 29 with overweight/obesity (OW), and 31 healthy controls (HCs). The hypervariable region of 16 S rRNA gene (V3-V4) sequencing was performed using IonS5TMXL platform to evaluate the bacterial communities. Differences of microbial community and correlation to clinical parameters across different groups were analyzed.

RESULTS

Compared to NW and HCs, the OW group showed a decreased tendency in alpha diversity index. Beta diversity was markedly different among these groups (PERMANOVA: R2  = 0.034, p = 0.01) and was higher in patients versus HCs. A total number of 24 taxa displayed significantly different abundance among OW, NW, and HCs. At the family level, the abundance of three taxa was remarkably increased in NW, one in OW, and one in HCs. At the genus level, five taxa were enriched in OW, eight in NW, and two in HCs. The relative abundance of the genera Megamonas was positively associated with BMI, while Eggerthella was negatively correlated with BMI. Functional prediction analysis revealed the metabolism of cofactors and vitamins and amino acid were highly enriched in OW compared to HCs. In addition, microbial functions involved in "lipid metabolism" were depleted while the "fructose and mannose metabolism" was enriched in OW compared to NW group.

CONCLUSIONS

Specific bacterial taxa involved in pathways regulating the lipid, energy, and amino acid metabolisms may underlie the weight concerns in depressed BD patients. Potential targeting gut microbial therapy is provided for overweight/obesity patients with BD, which still need further studies in the future.

Genomic SEM Applied to Explore Etiological Divergences in Bipolar Subtypes

Background

Bipolar Disorder (BD) is an overarching diagnostic class defined by the presence of at least one prior manic episode (BD I) or both a prior hypomanic episode and a prior depressive episode (BD II). Traditionally, BD II has been conceptualized as a less severe presentation of BD I, however, extant literature to investigate this claim has been mixed.

Methods

We apply Genomic Structural Equation Modeling (Genomic SEM) to investigate divergent genetic pathways across BD's two major subtypes using the most recent GWAS summary statistics from the PGC. We begin by identifying divergences in genetic correlations across 89 external traits using a Bonferroni corrected threshold. We also use a theoretically informed follow-up model to examine the extent to which the genetic variance in each subtype is explained by schizophrenia and major depression. Lastly, Transcriptome-wide SEM (T-SEM) was used to identify gene expression patterns associated with the BD subtypes.

Results

BD II was characterized by significantly larger genetic overlap with internalizing traits (e.g., neuroticism, insomnia, physical inactivity), while significantly stronger associations for BD I were limited. Consistent with these findings, the follow-up model revealed a much larger major depression component for BD II. T-SEM results revealed 41 unique genes associated with risk pathways across BD subtypes.

Conclusions

Divergent patterns of genetic relationships across external traits provide support for the distinction of the bipolar subtypes. However, our results also challenge the illness severity conceptualization of BD given stronger genetic overlap across BD II and a range of clinically relevant traits and disorders.

Heightened inflammation in bipolar disorder occurs independent of symptom severity and is explained by body mass index

Inflammation is hypothesized to be a key component of bipolar disorder (BP) development and progression. However, findings linking BP prevalence and symptomology to immune functioning have been mixed, with some work suggesting that obesity may play an important role in BP-relevant inflammation. Here we investigate differences in biomarkers of inflammation [C-reactive protein (CRP), interleukin (IL)-1β, IL-6, IL-8, IL-10] between healthy controls (HC) and individuals with BP or other mental illness (MI). Adults with BP, MI, or HC (n = 545, 70% BP, 21% HC, 9% MI) self-reported depressive and manic symptoms close to a blood draw and physical exam that included measurement of height and weight. A composite score was calculated from the four cytokines measured in plasma; follow-up analyses explored a pro-inflammatory composite and IL-10, individually. BP individuals had elevated cytokine concentrations compared to HC (B = 0.197, [0.062, 0.333], t (542) = 2.855, p = .004); this difference was also evident for the pro-inflammatory composite and for IL-10. Cytokine concentrations were not associated with BP mood states. Body mass index (BMI), an indicator of obesity, was significantly higher in BP compared to HC (B = 3.780, [2.118, 5.443], t (479) = 4.457, p < .001) and differences in cytokines between the two groups was no longer significant after controlling for BMI. No differences in CRP were evident between BP and HC. These results suggest that cytokine concentrations are elevated in BP and this difference from HC is associated with obesity. Interventions targeting immune modulators in BP must carefully consider the complex relationships within the BP-inflammation-obesity triangle.

The bi-directional association between bipolar disorder and obesity: Evidence from Meta and bioinformatics analysis

BACKGROUND

The globally high prevalence of both obesity and bipolar disorder makes the bidirectional relationship between the two disorders a pivotal phenomenon; hence, a meta-analysis to synopsize their co-occurrence is indispensable. Psychotropic-induced obesity has been reported to be an important factor linking bipolar disorder and obesity. Nonetheless, the molecular signature of this connection is perplexing.

METHODS

Here, we leverage both meta-analysis and bioinformatics analysis to provide a conspectus and deduce the molecular signature of obesity in bipolar disease patients following psychotropic treatment. Searches were performed on a diverse collection of databases through June 25, 2020. The Newcastle-Ottawa Scale was used to rate the quality of the studies. Analysis of OR, 95% CI, and tests of homogeneity were carried out with STATA software. For the bioinformatics analysis, the LIMMA package which is incorporated into the Gene Expression Omnibus database was used.

RESULTS

Our search yielded 138 studies, of which 18 fitted our inclusion criteria. Individuals who are obese have an increased risk of developing bipolar disorder (pooled adjusted OR = 1.32, 95% CI = 1.01-1.62). In a manner analogous to this, the pooled adjusted odds ratio reveals that patients with bipolar disorder have an increased chance of obesity (OR = 1.68, 95% CI = 1.35-2). To deduce the molecular signature of obesity in bipolar disorder patients following psychotropic treatment, three data sets from the Gene Expression Omnibus database (GSE5392, GSE87610, and GSE35977) were integrated and the genes obtained were validated by a cohort of known single nucleotide polymorphism of obesity via direct overlap. Results indicate genes that are activated after psychotropic treatment. Some of these genes are CYBB, C3, OLR1, CX3CR1, C3AR1, CD53, AIF1, LY86, BDNF, ALOX5AP, CXCL10, and the preponderance falls under mesodermal and PI3K-Akt signaling pathway. The ROC analysis reveals a strong discriminating value between the two groups (UBAP2L AUC = 0.806, p = 1.1e-04, NOVA2 AUC = 0.73, p = 6.7e-03).

CONCLUSION

Our study shows unequivocal evidence of a bi-directional association between bipolar disorder and obesity, but more crucially, it provides a snapshot of the molecular signature of obesity in bipolar patients as a result of psychotropic medication.

Eating disorder features in bipolar disorder: clinical implications

BACKGROUND

Bipolar disorder (BD) is associated with elevated rates of eating disorders (EDs), but the nature and impact of specific ED features are unclear.

AIMS

This study sought to identify which ED features are common in BD, and whether these relate to quality of life (QoL) impairment and body mass index (BMI).

METHOD

A clinical sample of 73 adults with BD completed self-report measures of health, ED features, emotion regulation ability, impulsivity, and QoL.

RESULTS

Binge eating (45%), excessive dietary restriction (39%), overvaluation of weight/shape (51%), purging (16%) and driven exercise (27%) were common, and associated with a poorer clinical picture, including poorer QoL and poorer emotion regulation. Furthermore, regular binge eating episodes explained a significant proportion of variance in QoL impairment after controlling for other significant predictors. The best predictors of BMI were number of medical conditions, impulsivity and positive beliefs about binge eating.

CONCLUSIONS

ED features that may not meet criteria for a fully diagnosable ED - particularly overvaluation of weight/shape and binge eating - warrant greater attention, as they may still significantly worsen QoL. Future research should focus on modifying existing psychological interventions to better target ED features among individuals with BD and thereby improve clinical outcomes.

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

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

Exploring Lead loci shared between schizophrenia and Cardiometabolic traits

Individuals with schizophrenia (SCZ) have, on average, a 10- to 20-year shorter expected life span than the rest of the population, primarily due to cardiovascular disease comorbidity. Genome-wide association studies (GWAS) have previously been used to separately identify common variants in SCZ and cardiometabolic traits. However, genetic variants jointly influencing both traits remain to be fully characterised. To assess overlaps (if any) between the genetic architecture of SCZ and cardiometabolic traits, we used conditional false discovery rate (FDR) and local genetic correlation statistical framework analyses. A conjunctional FDR was used to identify shared genetic traits between SCZ and cardiometabolic risk factors. We identified 144 genetic variants which were shared between SCZ and body mass index (BMI), and 15 variants shared between SCZ and triglycerides (TG). Furthermore, we discovered four novel single nucleotide polymorphisms (SNPs) (rs3865350, rs9860913, rs13307 and rs9614186) and four proximate genes (DERL2, SNX4, LY75 and EFCAB6) which were shared by SCZ and BMI. We observed that the novel genetic variant rs13307 and the most proximate gene LY75 exerted potential effects on SCZ and BMI comorbidity. Also, we observed a mixture of concordant and opposite direction associations with shared genetic variants. We demonstrated a moderate to high genetic overlap between SCZ and cardiometabolic traits associated with a pattern of bidirectional associations. Our data suggested a complex interplay between metabolism-related gene pathways in SCZ pathophysiology.

Elevated C-reactive protein among symptomatic youth with bipolar disorder

RATIONALE AND OBJECTIVES

Increased levels of high-sensitivity C-reactive protein (CRP) are associated with mood symptoms in adults with bipolar disorder (BD). The few studies on this topic in youth with BD have not included controls. We, therefore, examined CRP levels in relation to symptomatic status in youth with and without BD.

METHODS

Participants included 154 youth (mean age 17 years; 48 asymptomatic BD, 39 symptomatic BD, 67 healthy controls (HC)). Rank analysis of covariance test examined group differences in CRP, controlling for age and sex. Correlation between CRP and mood symptom severity was examined using Spearman's correlation within the BD group.

RESULTS

There were significant group differences in CRP levels (F_(2,151) = 5.06, p = 0.007, ηp2=0.06); post hoc analyses showed higher CRP levels in the symptomatic BD group compared with HC (p = 0.01). In sensitivity analyses, this finding was no longer significant after controlling for body mass index (BMI). CRP was not significantly associated with symptomatic severity.

CONCLUSIONS

CRP levels are elevated among symptomatic youth with BD, partly related to BMI. As elevated BMI is associated with mood symptom burden, prospective studies are warranted to parse the associations among mood symptoms, BMI, and inflammation. Given the proportion of time that youth with BD are symptomatic, present findings raise concern about the long-term impact of elevated CRP on blood vessels, brain, and related clinical outcomes.

Peroxisome Proliferator-Activated Receptor Gamma (PPARγ) Levels in Adolescent with Bipolar Disorder and Their Relationship with Metabolic Parameters

Peroxisome proliferator-activated receptor gamma (PPARγ) is one of the immune and metabolic regulatory agents. This study examined the serum PPARγ levels and metabolic syndrome (MetS) parameters in pediatric bipolar disorder (PBD) adolescents and compared them with healthy subjects. Serum PPARγ levels, fasting blood glucose (FBG), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), and fasting insulin levels of 39 PBD-type I (age range: 14-18) and 36 age- and sex-matched healthy control subjects were compared. The anthropometric measurements were also analyzed, including body weight, height, body mass index (BMI), waist circumference (WC), and blood pressure measurements. The PPARγ levels were significantly lower, and the MetS prevalence was significantly higher in the PBD group than in the control group. The mean BMI, WC, serum TG, and FBG values of the PBD group were statistically higher than the healthy control group. There was no significant relationship between the PPARγ levels and metabolic parameters except fasting glucose. Lower PPARγ activity and higher MetS prevalence in PBD indicate dysregulation of immune and metabolic regulatory parameters. These results may shed light on developing new PBD medications.

Obesity and Cerebral Blood Flow in the Reward Circuitry of Youth With Bipolar Disorder

BACKGROUND

Bipolar disorder (BD) is associated with elevated body mass index (BMI) and increased rates of obesity. Obesity among individuals with BD is associated with more severe course of illness. Motivated by previous research on BD and BMI in youth as well as brain findings in the reward circuit, the current study investigates differences in cerebral blood flow (CBF) in youth BD with and without comorbid overweight/obesity (OW/OB).

METHODS

Participants consisted of youth, ages 13-20 years, including BD with OW/OB (BDOW/OB; n = 25), BD with normal weight (BDNW; n = 55), and normal-weight healthy controls (HC; n = 61). High-resolution T1-weighted and pseudo-continuous arterial spin labeling images were acquired using 3 Tesla magnetic resonance imaging. CBF differences were assessed using both region of interest and whole-brain voxel-wise approaches.

RESULTS

Voxel-wise analysis revealed significantly higher CBF in reward-associated regions in the BDNW group relative to the HC and BDOW/OB groups. CBF did not differ between the HC and BDOW/OB groups. There were no significant region of interest findings.

CONCLUSIONS

The current study identified distinct CBF levels relating to BMI in BD in the reward circuit, which may relate to underlying differences in cerebral metabolism, compensatory effects, and/or BD severity. Future neuroimaging studies are warranted to examine for changes in the CBF-OW/OB link over time and in relation to treatment.

Obesity and metabolic comorbidity in bipolar disorder: do patients on lithium comprise a subgroup? A naturalistic study

BACKGROUND

Bipolar disorders (BD) are associated with increased prevalence of obesity and metabolic syndrome (MetS). Nevertheless, there is a wide range in prevalence estimates, with little known about the contributions of pharmacotherapy. It has been suggested that lithium might have a more favorable metabolic profile. We hypothesized that lithium use is associated with less increased body mass index (BMI), MetS, and type II diabetes, when compared with non-lithium users (those on anticonvulsants, second-generation antipsychotics).

METHODS

Cross-sectional study of 129 patients aged 18-85 with bipolar disorder, followed at tertiary care clinics in Montreal. Patients using lithium were compared with those not on lithium, for body mass index and metabolic syndrome.

RESULTS

The prevalence of obesity and metabolic syndrome in the sample of lithium-using patients with BD was 42.4 and 35.7% respectively, with an average BMI of 29.10 (+/- 6.70). Lithium and non-lithium groups did not differ in BMI or prevalence of MetS. However, compared to the non-lithium group, lithium users had lower hemoglobin A1C (5.24 +/- 0.53 versus 6.01 +/- 1.83, U = 753.5, p = 0.006) and lower triglycerides (1.46 +/- 0.88 versus 2.01 +/- 1.25, U = 947, p = 0.020).

CONCLUSIONS

There is a high prevalence of obesity and metabolic syndrome among patients with bipolar disorder. However, this did not appear to be associated with lithium use, when compared to those not on lithium. The lithium subgroup was also associated with lower prevalence of type II diabetes. Future prospective and intervention studies with larger sample sizes are necessary to further explore the association between lithium and insulin resistance, as well as its underlying mechanisms.

Increased Risks of Death and Hospitalization in Influenza/Pneumonia and Sepsis for Individuals Affected by Psychotic Disorders, Bipolar Disorders, and Single Manic Episodes: A Retrospective Cross-Sectional Study

Individuals with severe mental disorders (SMDs) such as psychotic disorders, bipolar disorders, and single manic episodes have increased mortality associated with COVID-19 infection. We set up a population-based study to examine whether individuals with SMD also had a higher risk of hospitalization and death from other infectious conditions. Anonymized and summarized data from multiple Swedish patient registers covering the entire Swedish population were supplied by the Swedish National Board of Health and Welfare. The frequencies of hospitalizations and deaths associated with influenza/pneumonia and sepsis in individuals with SMD were compared with the rest of the population during 2018–2019. Possible contributing comorbidities were also examined, of which diabetes, cardiovascular disease, chronic lung disease, and hypertension were chosen. A total of 7,780,727 individuals were included in the study; 97,034 (1.2%) cases with SMD and 7,683,693 (98.8%) controls. Individuals with SMD had increased risk of death associated with influenza/pneumonia (OR = 2.06, 95% CI [1.87–2.27]) and sepsis (OR = 1.61, 95% CI [1.38–1.89]). They also had an increased risk of hospitalization associated with influenza/pneumonia (OR = 2.12, 95% CI [2.03–2.20]) and sepsis (OR = 1.89, 95% CI [1.75–2.03]). Our results identify a need for further evaluation of whether these individuals should be included in prioritized risk groups for vaccination against infectious diseases other than COVID-19.

Body mass index and height in young adult men in relation to subsequent risk of mood disorder

Adolescence represents an important period in brain and mental development, which raises the question of whether measures of body size at entry into adult life influence the risk of developing mood disorders. We examined the association of BMI and height in a cohort of young men with risk of mood disorders throughout life. The study included 630,807 Danish men born 1939-1959 and 1983-1997 with measures of height and weight at conscription board examinations. Psychiatrist's diagnosis of mood disorders was obtained from national patient registries from 1969 to 2016. The associations of BMI and height with mood disorders were estimated by Cox proportional hazard regression analyses adjusting for education, cognitive ability, migration status drug and alcohol misuse. During a mean follow-up of 26.3 years, 2,608 (0.6%) and 19,690 (3.1%) men were diagnosed with bipolar disorder and depression, respectively. We found an inverse linear association of BMI with risk of bipolar disorder, whereas the association of BMI with depression was curve-linear with a decline in risk until BMI around 25 kg/m², and an almost constant risk across the BMI range above 25 kg/m². Height was not associated with bipolar disorder or depression. Comparison of brothers, assumed to share family factors of possible influence on the risk of mood disorders, showed similar results although with wider confidence intervals. BMI in the lower range at men's entry into adulthood is inversely associated with risk of bipolar disorder and depression throughout adult life, whereas height is not related.

Prevalence of risk for obstructive sleep apnea in patients with bipolar disorder

AIM

To evaluate the prevalence of risk for obstructive sleep apnea (OSA) among patients with bipolar disorder (BD).

METHODOLOGY

Eighty-seven patients with BD and 50 matched controls were assessed by using the Berlin questionnaire.

RESULTS

One-fifth of the patients with BD was found to be at high risk for OSA, compared to the 6% prevalence in the control group. Patients in high risk for OSA were more often females, had significantly higher body mass index, high waist circumference, and comorbid physical illnesses. In terms of pharmacotherapy, there was association of use of antipsychotics with higher risk of OSA at the trend level (p=0.052).

CONCLUSION

The prevalence of high risk for OSA is significantly higher among patients with BD and higher prevalence is related to obesity and comorbid physical illnesses.

Food addiction comorbid to mental disorders: A nationwide survey and register-based study

OBJECTIVE

Substance use disorder is highly prevalent among individuals with mental disorders. However, it remains largely unknown whether this is also the case for "food addiction"-a phenotype characterized by an addiction-like attraction to predominantly highly processed foods with a high content of refined carbohydrates and fat. Therefore, the primary aim of this study was to estimate the weighted prevalence of food addiction among individuals with mental disorders.

METHOD

A total of 5,000 individuals aged 18-62 were randomly drawn from eight categories of major mental disorders from the Danish Psychiatric Central Research Register and invited to participate in an online questionnaire-based survey, which included the Yale Food Addiction Scale 2.0. Data on health care and sociodemographics from the Danish registers were linked to all invitees-enabling comprehensive attrition analysis and calculation of the weighted prevalence of food addiction.

RESULTS

A total of 1,394 (27.9%) invitees participated in the survey. Across all diagnostic categories, 23.7% met the criteria for food addiction. The weighted prevalence of food addiction was highest among individuals with eating disorders (47.7%, 95%CI: 41.2-54.2), followed by affective disorders (29.4%, 95%CI: 22.9-36.0) and personality disorders (29.0%, 95%CI: 22.2-35.9). When stratifying on sex, the prevalence of food addiction was higher among women in most diagnostic categories.

DISCUSSION

Food addiction is highly prevalent among individuals with mental disorders, especially in those with eating disorders, affective disorders and personality disorders. Food addiction may be an important target for efforts aimed at reducing obesity among individuals with mental disorders.

Mood disorders comorbidity in obese bariatric patients: the role of the emotional dysregulation

BACKGROUND

Obese patients seeking bariatric surgery are known to show high rates of mental disorders, mainly mood and eating disorders. The aim of the present study is to evaluate psychiatric comorbidities, affective temperamental dimensions, emotional dysregulation and impulsivity in a sample of obese bariatric patients, exploring the differences between obese patients with and without mood disorders (MD).

METHODS

A total of 69 obese patients were consecutively enrolled between March and November 2019 during the presurgical evaluation routinely performed before the bariatric intervention. Sociodemographic and clinical features were collected by psychiatrists during a single consultation. Affective temperaments, emotional dysregulation and impulsivity were also investigated through self-report questionnaires. Epidemiological and clinical variables were compared between patients with and without MD.

RESULTS

In our sample, almost 3 out of 4 patients presented a lifetime psychiatric disorder, mainly MD (n=33, 48%), binge eating disorder (BED) (n=34, 49%) and anxiety disorders (n=30, 43%). Compared to N-MD patients, those with MD showed higher rates of psychiatric comorbidity with BED, bulimia and panic disorder. In addition, obese patients with MD showed more frequently cyclothymic, depressive and anxious temperaments, and higher mean scores on the psychometric questionnaires assessing emotional dysregulation and impulsivity compared to obese subjects without MD.

LIMITATIONS

the small sample size, the retrospectively assessment of psychiatric disorders and the self-report questionnaires.

CONCLUSIONS

A subgroup of obese patients, especially among those with MD, show high emotional dysregulation, affective lability and impulsiveness that could represent suitable substrates for the development of compulsive and addictive eating habits.

What Happens to Patients with Bipolar Disorder after Bariatric Surgery? A Review

Bipolar disorder (BD) patients are at high risk of obesity, which affects their quality of life (QOL). Since there is a high comorbidity between BD and obesity, most BD patients seek surgical intervention for obesity. Nowadays, bariatric surgery (BS) is considered appropriate for carefully selected patients with BD. Evaluations before performing BS and careful follow-up of patients with the bipolar spectrum are highly recommended. This study reviews the effects of BS on the course of BD and, at the same time, assesses the effect of BD on the consequences of the surgery. Our results showed that the number of studies approving the promising impact of surgery on BD was more than those disapproving it. However, more accurate results require more than 3-year follow-ups.

Elevated Brain Glutamate Levels in Bipolar Disorder and Pyruvate Carboxylase-Mediated Anaplerosis

In vivo ¹H magnetic resonance spectroscopy studies have found elevated brain glutamate or glutamate + glutamine levels in bipolar disorder with surprisingly high reproducibility. We propose that the elevated glutamate levels in bipolar disorder can be explained by increased pyruvate carboxylase-mediated anaplerosis in brain. Multiple independent lines of evidence supporting increased pyruvate carboxylase-mediated anaplerosis as a common mechanism underlying glutamatergic hyperactivity in bipolar disorder and the positive association between bipolar disorder and obesity are also described.

The Renin Angiotensin System and Bipolar Disorder: A Systematic Review

Bipolar Disorder (BD) is a chronic a multifactorial psychiatric illness that affects mood, cognition, and functioning. BD is associated with several psychiatric conditions as well clinical comorbidities, particularly cardiovascular diseases. The neurobiology of BD is complex and multifactorial and several systems have been implicated. Considering that the Renin Angiotensin System (RAS) plays an important role in cardiovascular diseases and that recently evidence has suggested its role in psychiatric disorders, the aim of the present study is to summarize and to discuss recent findings related to the modulation of RAS components in BD. A systematic search of the literature using the electronic databases MEDLINE and LILACS was conducted through March 2019. The search terms were: "Bipolar Disorder"; "Renin Angiotensin System"; "Angiotensin 2"; "Angiotensin receptors"; "Angiotensin 1-7"; "ACE"; "ACE2"; "Mas Receptor". We included original studies assessing RAS in BD patients. Two hundred twenty-two citations were initially retrieved. Eleven studies were included in our systematic review. In the majority of studies (6 of 8), the ACE insertion/deletion (I/D) polymorphism did not differ between BD patients and controls. BD patients presented higher plasma renin activity in comparison with controls. The studies evaluating the RAS molecules in BD are very scarce and heterogeneous. The literature suggests a potential role of RAS in BD. Further studies are necessary to investigate this relationship.

Physical health in affective disorders: a narrative review of the literature

This article reviews the most common non-psychiatric comorbidities associated with affective disorders, examining the implications of their possible bidirectional link. A narrative review was conducted on the association among the three most common non-psychiatric diseases in major depressive disorder and bipolar disorder (obesity, metabolic syndrome, and cardiovascular diseases) in articles published from January 1994 to April 2020. The evidence suggests that obesity, metabolic syndrome, and cardiovascular diseases are highly prevalent in patients diagnosed with affective disorders. The presence of non-psychiatric comorbidities significantly worsens the therapeutic management and prognosis of affective disorders and vice versa. In many cases, these comorbidities may precede the onset of affective disorders, although in most cases they appear after it. The presence of these concurrent non-psychiatric diseases in an individual diagnosed with an affective disorder is associated with a more complex disease presentation and management. For professionals, the evidence unequivocally supports routine surveillance of comorbidities from a multidisciplinary approach.

A unified framework for association and prediction from vertex-wise grey-matter structure

The recent availability of large‐scale neuroimaging cohorts facilitates deeper characterisation of the relationship between phenotypic and brain architecture variation in humans. Here, we investigate the association (previously coined morphometricity) of a phenotype with all 652,283 vertex‐wise measures of cortical and subcortical morphology in a large data set from the UK Biobank (UKB; N = 9,497 for discovery, N = 4,323 for replication) and the Human Connectome Project (N = 1,110). We used a linear mixed model with the brain measures of individuals fitted as random effects with covariance relationships estimated from the imaging data. We tested 167 behavioural, cognitive, psychiatric or lifestyle phenotypes and found significant morphometricity for 58 phenotypes (spanning substance use, blood assay results, education or income level, diet, depression, and cognition domains), 23 of which replicated in the UKB replication set or the HCP. We then extended the model for a bivariate analysis to estimate grey‐matter correlation between phenotypes, which revealed that body size (i.e., height, weight, BMI, waist and hip circumference, body fat percentage) could account for a substantial proportion of the morphometricity (confirmed using a conditional analysis), providing possible insight into previous MRI case–control results for psychiatric disorders where case status is associated with body mass index. Our LMM framework also allowed to predict some of the associated phenotypes from the vertex‐wise measures, in two independent samples. Finally, we demonstrated additional new applications of our approach (a) region of interest (ROI) analysis that retain the vertex‐wise complexity; (b) comparison of the information retained by different MRI processings.

Psychiatric Aspects of Obesity: A Narrative Review of Pathophysiology and Psychopathology

In the last decades, obesity has become a major concern for clinical and public health. Despite the variety of available treatments, the outcomes remain—by and large—still unsatisfactory, owing to high rates of nonresponse and relapse. Interestingly, obesity is being associated with a growing surge of neuropsychiatric problems, certainly related to the pathogenesis of this condition, and likely to be of great consequence as for its treatment and prognosis. In a neurobiologic direction, a sturdy body of evidence has recently shown that the immune–metabolic–endocrine dyscrasias, notoriously attached to excess body weight/adiposity, affect and impair the morpho-functional integrity of the brain, thus possibly contributing to neuroprogressive/degenerative processes and behavioral deviances. Likewise, in a neuropsychiatric perspective, obesity displays complex associations with mood disorders and affective temperamental dimensions (namely cyclothymia), eating disorders characterized by overeating/binge-eating behaviors, ADHD-related executive dysfunctions, emotional dysregulation and motivational–addictive disturbances. With this review, we attempt to provide the clinician a synoptic, yet exhaustive, tool for a more conscious approach to that subset of this condition, which could be reasonably termed “psychiatric” obesity.

Higher Prevalence of Metabolic Syndrome in Child-adolescent Patients with Bipolar Disorder

Objective

Previous studies have indicated a convergent and bidirectional relationship between metabolic syndrome (MetS) and bipolar disorder (BD). As most of these studies focused mainly on adults diagnosed with BD, our study aims to investigate and characterize metabolic disturbances in child-adolescents diagnosed with BD.

Methods

We retrospectively examined the medical records of psychiatric hospitalizations with admitting diagnosis of BD in child-adolescents (age < 18 years). Body mass index (BMI), lipid profile, fasting blood glucose, and blood pressure were primary variables. National Cholesterol Education Program criteria were used to define MetS. Reference group data was obtained from the National Health and Nutrition Examination Survey study. Statistical analyses included ttests, chi-square tests, and Fisher’s exact tests.

Results

We identified 140 child-adolescent patients with BD (mean age = 15.12 ± 1.70 years, 53% male). MetS was significantly more common in BD compared to the reference group: 14% (95% confidence interval [95% CI] 8−20) vs. 6.7% (95% CI 4.1−9.2), p = 0.001 with no significant difference by sex. MetS components were higher in the BD group, particularly BMI ≥ 95% (25% vs. 11.8%, p < 0.001) and high blood pressure (17% vs. 8%, p = 0.05). Moreover, female patients had lower odds of high blood pressure (odds ratio = 0.24 [95% CI 0.08−0.69], p = 0.005).

Conclusion

Compared with the general child-adolescent population, the prevalence of MetS was significantly higher in patients with BD of same age. This reiterates the notion of an increased risk of MetS in patients diagnosed with BD; and thus, further exploration is warranted.

Shared Genetic Loci Between Body Mass Index and Major Psychiatric Disorders: A Genome-wide Association Study

Importance

People with major psychiatric disorders (MPDs) have a 10- to 20-year shorter life span than the rest of the population, and this difference is mainly due to comorbid cardiovascular diseases. Genome-wide association studies have identified common variants involved in schizophrenia (SCZ), bipolar disorder (BIP), and major depression (MD) and body mass index (BMI), a key cardiometabolic risk factor. However, genetic variants jointly influencing MPD and BMI remain largely unknown.

Objective

To assess the extent of the overlap between the genetic architectures of MPDs and BMI and identify genetic loci shared between them.

Design, Setting, and Participants

Using a conditional false discovery rate statistical framework, independent genome-wide association study data on individuals with SCZ (n = 82 315), BIP (n = 51 710), MD (n = 480 359), and BMI (n = 795 640) were analyzed. The UK Biobank cohort (n = 29 740) was excluded from the MD data set to avoid sample overlap. Data were collected from August 2017 to May 2018, and analysis began July 2018.

Main Outcomes and Measures

The primary outcomes were a list of genetic loci shared between BMI and MPDs and their functional pathways.

Results

Genome-wide association study data from 1 380 284 participants were analyzed, and the genetic correlation between BMI and MPDs varied (SCZ: r for genetic = -0.11, P = 2.1 × 10-10; BIP: r for genetic = -0.06, P = .0103; MD: r for genetic = 0.12, P = 6.7 × 10-10). Overall, 63, 17, and 32 loci shared between BMI and SCZ, BIP, and MD, respectively, were analyzed at conjunctional false discovery rate less than 0.01. Of the shared loci, 34% (73 of 213) in SCZ, 52% (36 of 69) in BIP, and 57% (56 of 99) in MD had risk alleles associated with higher BMI (conjunctional false discovery rate <0.05), while the rest had opposite directions of associations. Functional analyses indicated that the overlapping loci are involved in several pathways including neurodevelopment, neurotransmitter signaling, and intracellular processes, and the loci with concordant and opposite association directions pointed mostly to different pathways.

Conclusions and Relevance

In this genome-wide association study, extensive polygenic overlap between BMI and SCZ, BIP, and MD were found, and 111 shared genetic loci were identified, implicating novel functional mechanisms. There was mixture of association directions in SCZ and BMI, albeit with a preponderance of discordant ones.

Decreased working memory capacity among individuals with a mood disorder who have increased metabolic burden

BACKGROUND

Individuals with mood disorders experience a higher rate of obesity than the general population, putting them at risk for poorer outcomes. The relationship between obesity and a core feature of the mood disorders, neurocognition, is less understood. We examined the interaction of obesity as indexed by body mass index (BMI) and working memory performance in a large sample of individuals with bipolar disorder (BD), major depressive disorder (MDD), and healthy controls (HC).

METHODS

Participants with BD (n = 133), MDD (n = 78), and HC (n = 113) (age range 18-40) completed a spatial working memory (SWM) task that included three-graded increases in the number of target locations. Participants were subdivided by BMI classification into six diagnostic-BMI (BMI groups: Normal Weight, Overweight/Obese) subgroups. Performance on the task was indexed by number of errors within each difficulty level.

RESULTS

The number of errors, across all groups, increased with task difficulty. There was an interaction between errors and diagnostic-BMI group. Post-hoc analyses indicated that while the Normal Weight-BD group did not differ in performance from the other groups, the Overweight/Obese-BD group performed significantly worse than HC groups.

LIMITATIONS

Metabolic effects of psychotropic medications due to the naturalistic nature of the study, younger age of the MDD sample, and utilizing self-reported indicators of obesity may limit generalizability.

CONCLUSIONS

Individuals with BD with increased metabolic burden exhibit increased working memory errors than non-psychiatric controls who also have increased metabolic burden. Future work could address prevention and amelioration of such difficulties to reduce associated functional morbidity.

Benefits and risks of bariatric surgery in patients with bipolar disorders

The prevalence of bipolar disorders in patients requesting bariatric surgery is estimated to be 1.5% to 3.4%. There are currently no specific recommendations regarding the way bariatric surgery should be managed in the context of bipolar disorder. The aim was to document the benefit-risk of bariatric surgery in patients with bipolar disorders. A systematic literature review was carried out. In addition, results were reported from a survey of current clinical practice in French referent centers for obesity care. Finally, 3 clinical cases from the "Severe Obesity Outcome Network" cohort are described. This systematic review shows there are few studies in the literature regarding the outcomes of bariatric surgery in patients with bipolar disorders and no randomized, controlled trials. Weight loss appeared similar in all patients, but psychiatric complications were sometimes reported in those with bipolar disorders. Almost all 11 referent centers for obesity care that responded had carried out bariatric surgery in patients with stable bipolar disorders. Postsurgical psychiatric destabilization occurred and included, at least, a need to reinforce treatment and follow-up. In the 3 case studies, postsurgical manic or hypomanic decompensation occurred. Thus, although effective in terms of weight loss, bariatric surgery could be a destabilizing factor for those with bipolar disorders. Current practice is to contraindicate surgery in patients with unstable disorders. There are insufficient data to conclude on the benefits and safety of bariatric surgery in patients with stable bipolar disease. Further studies are required to fully determine the benefits and risks.

Prevalence and Associated Factors of Metabolic Syndrome among Patients with Severe Mental Illness Attending a Tertiary Hospital in Southwest Uganda

Globally, the prevalence of metabolic syndrome (MetS) and its components which are the major cardiovascular disease (CVD) risk factors, is higher among patients with severe mental illness (SMI) compared to the general population. This is mainly due to the deleterious lifestyles characterized by physical inactivity, excessive alcohol consumption, smoking, and unhealthy diets common among patients with SMI as well as due to cardiometabolic effects of psychotropic medications. Despite these conditions being highly prevalent among patients with SMI, little attention is given to these conditions during routine reviews in the mental health clinics in most low-income countries including Uganda. The main objective of this study was to determine the prevalence and associated factors of MetS among patients with SMI at Mbarara Regional Referral Hospital (MRRH), a tertiary hospital in southwestern Uganda. Through a cross-sectional study at the mental health clinic of the hospital, we recruited 304 patients with SMI and evaluated them for MetS using the National Cholesterol Education Programme Adult Treatment Panel III (NCEP ATP III) criteria. We defined the prevalence of MetS as the proportion of patients meeting the NCEP ATP III criteria. We used logistic regression to evaluate associations between MetS and independent variables. We included a total of 302 (44.37% male, 55.63% female) patients with a diagnosis of SMI in the analysis. The prevalence of MetS was 23.51% (95% CI 18.84–28.71). At multivariable logistic regression, age >40 years and long duration of mental illness (>10 years) were significantly associated with MetS. The prevalence of MetS is high among patients with psychiatric disorders, and thus metabolic screening, especially among the high-risk groups, is critical.

Insulin resistance takes center stage: a new paradigm in the progression of bipolar disorder

Bipolar Disorder (BD) is a major psychiatric illness affecting up to 5% of the population. BD can progress over time to a chronic "neuroprogressive" course with cognitive and functional impairment. Currently, there are no validated predictors indicating which patients will develop a neuroprogressive course and there are no specific treatments. This review presents data supporting a novel hypothesis on the mechanisms underlying bipolar neuroprogression. Insulin resistance (IR) is present in 52% of BD patients and is associated with chronic course, treatment nonresponse, adverse brain changes and cognitive impairment. Further, bipolar morbidity increases 12-fold following the onset of IR indicating that IR may modify disease progression. I review evidence that IR is a testable and treatable modifying factor in neuroprogression and that reversing IR may be an efficient (and perhaps the only) means of obtaining remission in some patients. I draw a parallel with Helicobacter pylori in peptic ulcer disease (a novel mechanism that brought together two previously unrelated phenomena that uncovered a new treatment approach). This model of bipolar progression combines shared dysregulated mechanisms between IR and BD, allowing for early screening, case finding, and monitoring for neuroprogression, with the potential for intervention that could prevent advanced bipolar illness. KEY MESSAGES Neuroprogression in bipolar disorder is defined by a more severe form of illness and poor outcome. Currently, there are no validated predictors of neuroprogression, which could help inform treatment and improve prognosis. Insulin resistance is present in more than half of all bipolar patients and is associated with a chronic course of illness, lack of response to mood stabilizing treatment, cognitive impairment and poor functional outcomes. Insulin resistance may modify the course of bipolar disorder and promote neuroprogression. Insulin resistance may be a testable and potentially modifiable risk factor for neuroprogression in bipolar disorder.

Differential effects on neurodevelopment of FTO variants in obesity and bipolar disorder suggested by in silico prediction of functional impact: An analysis in Mexican population

INTRODUCTION

Several studies indicate that polygenic obesity is linked to fat-mass and obesity-associated (FTO) genetic variants. Nevertheless, the link between variants in FTO and mental disorders has been barely explored. The present work aims to determine whether FTO genetic variants are associated with bipolar disorder and obesity, and to perform an in silico prediction of variant-dependent functional impact on the developing brain transcriptome.

METHODS

Four hundred and forty-six Mexican mestizos were included in a genetic association analysis. SNP-sequence kernel association test and linear mixed models were implemented for genetic association assessment. For functional impact prediction, we analyzed the mapping of regulatory elements, the modification of binding sites of transcription factors and the expression of transcription factors in the brain developing transcriptome, searching on different databases.

RESULTS

In the set-based analysis, we found different associated regions to BD (bipolar disorder) and obesity. The promoter flanking region of FTO intron 1 was associated with differential effects on BMI, while intron 2 of RPGRIP1L and FTO upstream regions were associated with BD. The prediction analysis showed that FTO BD-associated variants disturb binding sites of SP1 and SP2; obesity-associated variants, on the other hand, disturb binding sites of FOXP1, which are transcription factors highly expressed during prenatal development stages of the brain.

CONCLUSION

Our results suggest a possible effect of FTO variants on neurodevelopment in obesity and bipolar disorder, which gives new insights into the molecular mechanism underlying this association.

Using Mendelian randomisation to assess causality in observational studies

OBJECTIVE

Mendelian randomisation (MR) is a technique that aims to assess causal effects of exposures on disease outcomes. The paper aims to present the main assumptions that underlie MR, the statistical methods used to estimate causal effects and how to account for potential violations of the key assumptions.

METHODS

We discuss the key assumptions that should be satisfied in an MR setting. We list the statistical methodologies used in two-sample MR when summary data are available to estimate causal effects (ie, Wald ratio estimator, inverse-variance weighted and maximum likelihood method) and identify/adjust for potential violations of MR assumptions (ie, MR-Egger regression and weighted Median approach). We also present statistical methods and graphical tools used to evaluate the presence of heterogeneity.

RESULTS

We use as an illustrative example of a published two-sample MR study, investigating the causal association of body mass index with three psychiatric disorders (ie, bipolar disorder, schizophrenia and major depressive disorder). We highlight the importance of assessing the results of all available methods rather than each method alone. We also demonstrate the impact of heterogeneity in the estimation of the causal effects.

CONCLUSIONS

MR is a useful tool to assess causality of risk factors in medical research. Assessment of the key assumptions underlying MR is crucial for a valid interpretation of the results.

Neurococognitive and neuroimaging correlates of obesity and components of metabolic syndrome in bipolar disorder: a systematic review

BACKGROUND

Individuals with bipolar disorder (BD) have a higher prevalence of obesity and metabolic syndrome (MetS) compared with the general population. Obesity and MetS are associated with cognitive deficits and brain imaging abnormalities in the general population. Obesity and components of MetS might potentially associate with neuroimaging and neurocognitive findings in BD.

METHODS

A literature search of studies investigating the association between obesity (and other components of MetS) and neurocognitive and neuroimaging findings in BD was conducted. In addition to a systematic review, a random-effects meta-analysis was conducted when sufficient data were available.

RESULTS

Twenty-three studies were included in the current systematic review. Overweight/obese patients were significantly associated with impaired neurocognition compared normal weight individuals with BD (d = 0.37). The most robust association between obesity and cognitive deficits in BD was observed in the cognitive subdomain of executive functions (d = 0.61). There was also evidence for a significant relationship between cognitive impairment in BD and other components of MetS including hypertension, dyslipidemia, and diabetes. Overweight/obese individuals with BD had more pronounced brain imaging abnormalities than normal weight individuals with BD.

CONCLUSIONS

Obesity and related cardiovascular risk factors significantly are associated with more severe cognitive and brain imaging abnormalities in BD. Medical co-morbidities can potentially contribute to functional decline observed in some patients throughout the course of BD.

Bipolar Disorder and Obesity: Contributing Factors, Impact on Clinical Course, and the Role of Bariatric Surgery

PURPOSE OF REVIEW

Bipolar disorder (BD) is a severe, common, and chronic affective disorder. This review highlights the BD and obesity connection and the role of treatments for obesity in this population.

RECENT FINDINGS

Patients with BD are at a significantly increased risk for obesity, as compared to those without BD, with obesity serving as a proxy for severity and predictor of poorer outcome. BD is characterized by substantial medical burden, with obesity-related conditions contributing to premature mortality. Pharmacotherapy for BD can cause weight gain and may be moderated by binge eating behavior. Bariatric surgery may be the most robust intervention for weight loss in patients with stable BD, but access may be limited. There is a greater need for interventions to prevent weight gain in BD, the development weight-neutral medications for BD, and more research into the role of bariatric surgery for patients with BD.

Low-grade inflammation in first-episode psychosis is determined by increased waist circumference

Psychosis is associated with low-grade inflammation as measured by high-sensitivity C-reactive protein (hs-CRP), a risk factor for cardiovascular events and mortality in the general population. We investigated the relationship between hs-CRP and anthropometric and metabolic changes in first-episode psychosis (FEP) during the first treatment year. We recruited 95 FEP patients and 62 controls, and measured longitudinal changes in hs-CRP, weight, waist circumference, insulin resistance, and lipids. We used linear mixed models to analyze the longitudinal relationship between hs-CRP and clinical, anthropometric and metabolic measures. At baseline, patients with FEP had higher levels of insulin resistance, total and low-density lipoprotein cholesterol, apolipoprotein B, and triglycerides. Baseline weight, waist circumference, hs-CRP, fasting glucose, and high-density lipoprotein cholesterol were similar between patients and controls. Marked increases in anthropometric measures and hs-CRP were observed in FEP during the 12-month follow-up. However, glucose and lipid parameters did not change significantly. In the mixed models, waist circumference and female sex were significant predictors of hs-CRP levels in FEP. Prevention of the early development of abdominal obesity in FEP is crucial, as abdominal obesity is accompanied by chronic low-grade inflammation, which increases further the cardiovascular risk in this vulnerable population.

Association between binge eating disorder and psychiatric comorbidity profiles in patients with obesity seeking bariatric surgery

BACKGROUND

Eating disorders could be an important factor in the development of obesity, but psychiatric comorbidities are very heterogeneous in patients with obesity. Moreover, relationship between binge eating disorder and other psychiatric comorbidities is not clear. Our objective was to identify psychiatric comorbidity profiles of bariatric surgery candidates and to analyze the association between these profiles and binge-eating disorder.

METHODS

Our sample consisted of bariatric surgery candidates (n = 92) with mean Body Mass Index at 41.3 ± 0.6 kg/m². To construct profiles, we classified patients according to their psychiatric comorbidities using cluster analysis techniques. We used logistic regression modelling to analyze associations between the presence of binge-eating disorder and the psychiatric comorbidity profiles.

RESULTS

We identified four profiles of psychiatric phenotypes. One of these profiles was not associated with any psychiatric disorder. Binge eating disorder was significantly associated with two profiles (p < 0.05): a profile with bipolar and obsessive-compulsive disorder (OR = 7.7 [1.7; 35.1]), and a profile with bipolar and panic disorder (OR = 20.7 [3.1; 137.5]).

CONCLUSIONS

Our multidimensional approach identified certain profiles specifically associated with binge-eating disorder in patients with obesity seeking bariatric surgery. These results may lead to a better understanding of the relationship between obesity and psychiatric disorders.

Underdocumentation of Obesity by Medical Residents Highlights Challenges to Effective Obesity Care

OBJECTIVE

The goal of this study was to determine attitudes and practices of physicians in training with respect to the evaluation and treatment of obesity.

METHODS

Resident-generated admission and discharge notes of all 1,765 general medicine hospital admissions during 4 nonconsecutive months were analyzed, and any references to weight, obesity, BMI, adiposity, and body fat were identified. The full general resident cohort was then surveyed for perceptions and behaviors related to obesity.

RESULTS

Obesity was considered a highly important medical issue by 98.5% of residents; 90% correctly identified a class II obesity Stunkard phenotype, and 80% accurately calculated a BMI given height and weight in metric units. Residents overestimated inpatient obesity prevalence (estimate = 75%; actual = 35%) and the rate of obesity recording in the hospital admission note (estimate = 94%; actual = 49.5%). A BMI or current weight in the admission note or discharge summary was reported in none of the 1,765 patient records, and only 6% of the patients with obesity had obesity noted in either the inpatient admission or discharge assessment or plan.

CONCLUSIONS

Though residents recognize obesity and its clinical implications, it is underreported in the assessment of inpatients. This low level of documenting obesity and its impact on clinical care planning underscores a missed opportunity to establish appropriate referrals and initiate treatment at a clinically opportune time.