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

No association between history of psychiatric treatment and postoperative weight reduction after bariatric surgery

PURPOSE

The objective of the study was to assess whether the history of psychiatric treatment was associated with (1) body weight and BMI on admission for bariatric surgery, (2) weight loss > 5 kg prior to bariatric surgery, and (3) postoperative body weight reduction.

METHODS

Data from medical records of all consecutive patients admitted for surgical treatment of obesity in the 2nd Department of General Surgery Jagiellonian University Medical College were obtained. There were 1452 records of patients who underwent bariatric surgery between 2009 and 2021 included in the study.

RESULTS

History of psychiatric treatment was found in 177 (12%) of the sample and was inversely associated with body weight and BMI on admission for surgery in women. Men with history of psychiatric treatment were 54% less likely to lose > 5 kg before the surgery (OR = 0.46 95% CI = 0.24-0.88). Both in men and women %TWL did not differ significantly by history of psychiatric treatment (Me: 40.7 vs. 45.9; p = 0.130 and Me: 27.0 vs. 23.9; p = 0.383, respectively). After adjustment for covariates no association was found between history of psychiatric treatment and body weight reduction one year after surgery.

CONCLUSION

Although men with preoperative history of psychiatric treatment had lower odds of losing weight before the surgery, psychiatric treatment did not differentiate the effectiveness of bariatric treatment in 1 year of observation. Bariatric surgery appears to be an effective obesity care for people treated for mental disorders.

LEVEL OF EVIDENCE

III Evidence obtained from cohort or case-control analytic studies.

The impact of body mass index on the clinical features of bipolar disorder: A STEP-BD study

INTRODUCTION

The effects of body mass index (BMI) on the core symptoms of bipolar disorder (BD) and its implications for disease trajectory are largely unexplored.

OBJECTIVE

To examine whether BMI impacted hospitalization rate, medical and psychiatric comorbidities, and core symptom domains such as depression and suicidality in BD.

METHODS

Participants (15 years and older) were 2790 BD outpatients enrolled in the longitudinal STEP-BD study; all met DSM-IV criteria for BD-I, BD-II, cyclothymia, BD NOS, or schizoaffective disorder, bipolar subtype. BMI, demographic information, psychiatric and medical comorbidities, and other clinical variables such as bipolarity index, history of electroconvulsive therapy (ECT), and history of suicide attempts were collected at baseline. Longitudinal changes in Montgomery-Åsberg Depression Rating Scale (MADRS) score, Young Mania Rating Scale (YMRS) score, and hospitalizations during the study were also assessed. Depending on the variable of interest, odds-ratios, regression analyses, factor analyses, and graph analyses were applied.

RESULTS

A robust increase in psychiatric and medical comorbidities was observed, particularly for baseline BMIs >35. A significant relationship was noted between higher BMI and history of suicide attempts, and individuals with BMIs >40 had the highest prevalence of suicide attempts. Obese and overweight individuals had a higher bipolarity index (a questionnaire measuring disease severity) and were more likely to have received ECT. Higher BMIs correlated with worsening trajectory of core depression symptoms and with worsening lassitude and inability to feel.

CONCLUSIONS

In BD participants, elevated BMI was associated with worsening clinical features, including higher rates of suicidality, comorbidities, and core depression symptoms.

Mapping the scientific research on bipolar disorder: A scientometric study of hotspots, bursts, and trends

Bipolar disorder (BD) is a severe psychiatric illness with an increasing prevalence worldwide. Although the pathological mechanism of and pharmacological interventions for BD have been extensively investigated in preclinical and clinical studies, a scientometric analysis of the developmental trends, interdisciplinary frontiers, and research hotspots in this field has not yet been conducted. Therefore, we performed a comprehensive scientometric review of 55,358 published studies on BD over the past two decades (2002-2021) to identify the most frequently used keywords and explore research hotspots and trajectories. The present findings revealed the main distribution, knowledge structure, topic evolution, and emerging topics of BD research. Analysing the risk factors, pathogenesis, key brain regions, comorbid conditions, and treatment strategies for BD contributed to understanding of the aetiology, progression, and treatment of this disorder. These findings provided substantial support for continued research in this area.

Controversies regarding lithium-associated weight gain: case-control study of real-world drug safety data

BACKGROUND

The impact of long-term lithium treatment on weight gain has been a controversial topic with conflicting evidence. We aim to assess reporting of weight gain associated with lithium and other mood stabilizers compared to lamotrigine which is considered free of metabolic adverse drug reactions (ADRs).

METHODS

We conducted a case/non-case pharmacovigilance study using data from the AMSP project (German: "Arzneimittelsicherheit in der Psychiatrie"; i.e., Drug Safety in Psychiatry), which collects data on ADRs from patients treated in psychiatric hospitals in Germany, Austria, and Switzerland. We performed a disproportionality analysis of reports of weight gain (> 10% of baseline body weight) calculating reporting odds ratio (ROR). We compared aripiprazole, carbamazepine, lithium, olanzapine, quetiapine, risperidone, and valproate to lamotrigine. Additional analyses related to different mood stabilizers as reference medication were performed. We also assessed sex and age distributions of weight-gain reports.

RESULTS

We identified a total of 527 cases of severe drug-induced weight gain representing 7.4% of all severe ADRs. The ROR for lithium was 2.1 (95%CI 0.9-5.1, p > 0.05), which did not reach statistical significance. Statistically significant disproportionate reporting of weight gain was reported for olanzapine (ROR: 11.5, 95%CI 4.7-28.3, p < 0.001), quetiapine (ROR: 3.4, 95%CI 1.3-8.4, p < 0.01), and valproate (ROR: 2.4, 95%CI 1.1-5.0, p = 0.03) compared to lamotrigine. Severe weight gain was more prevalent in non-elderly (< 65 years) than in elderly patients, with an ROR of 7.6 (p < 0.01) in those treated with lithium, and an ROR of 14.7 (p < 0.01) in those not treated with lithium.

CONCLUSIONS

Our findings suggest that lithium is associated with more reports of severe weight gain than lamotrigine, although this difference did not reach statistical significance. However, lithium use led to fewer reports of severe weight gain than some alternative drugs for long-term medication (olanzapine, quetiapine, and valproate), which is consistent with recent studies. Monitoring of weight gain and metabolic parameters remains essential with lithium and its alternatives.

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.

Assessment of vitamin D levels and adipokines mediated obesity among psychiatric patients on treatment and treatment naïve: A comparative cross-sectional study

Background and aims

Antipsychotic treatment may contribute to low vitamin D levels and have impact on direct anti-inflammatory activity such as adiponectin activity and indirect proinflammatory activity such as leptin and resistin activity. However, vitamin D levels and adipokines mediated effect on weight gain and increased adiposity are not well evaluated. This study, therefore, assessed vitamin D and adipokines-mediated obesity among Ghanaian psychiatric patients.

Methods

This comparative cross-sectional study was conducted at psychiatric unit of Komfo Anokye Teaching Hospital, Kumasi, Ghana. Anthropometric measurements, sociodemographic and previous medical history were taken from 300 antipsychotics treatment naïve and active patients. Obesity was classified using World Health Organization (WHO) body mass index (BMI)-specific cut-offs. Blood samples were collected for serum vitamin D and adipokines (adiponectin, leptin, and resistin) analysis using enzyme-linked immunosorbent assay. Statistical analyses were done using SPSS version 26.0 and GraphPad Prism version 8.0.

Results

We observed higher prevalence of obesity among treatment active psychiatric patients (40.7%) compared to treatment naïve group (16.8%). Vitamin D insufficiency and deficiency prevalence were significantly higher among the treatment active group (25.3%; 39.5%; p < 0.001) and associated with increased odds of obesity (91.8%; cOR = 91.84, 95% confidence interval [CI]: 24.94-338.13). Moreover, adiponectin (84.2%: cOR = 14.15, 95% CI: 5.52-36.27), leptin (55.6% cOR = 2.20, 95% CI: 1.04-4.67), and resistin (79.4%: cOR = -8.34, 95% CI: 3.39-20.55) were significantly associated with increased odds of obesity among treatment active psychiatric. Furthermore, treatment active psychiatric patients exhibited inverse correlation for adiponectin and leptin with BMI (r = -0.62; -0.24), and WHtR (r = -0.53; -0.24); however, a moderate positive correlation for resistin with BMI (r = 0.80), HC (r = 0.67), and WHtR (r = 0.65).

Conclusion

Obesity is more prevalent in psychiatric patients on antipsychotics such as Olanzapine and Clozapine. Obesity among treatment active psychiatric patients is associated with vitamin D insufficiency and deficiency, low adiponectin and leptin levels but higher resistin level.

[COVID-19 and Bipolar Affective Disorder: Subjective Changes in Lifestyle Variables During the First Lockdown During the COVID-19 Pandemic in Austria]

INTRODUCTION

The COVID-19 pandemic with its protective measures (e. g. lockdown) had far-reaching effects on everyone's well-being. The aim of this study was to examine lifestyle variables during the first Austrian lockdown in patients with bipolar disorder in comparison to a healthy control group and to assess subjective changes caused by the pandemic.

METHOD

At the beginning of April 2020, an online survey of n=75 participants (35 people with bipolar disorder and 40 healthy controls) with standardized questionnaires (Beck Depression Inventory-2, Food Craving Inventory, Altman Self Rating Mania Scale) as well as non-standardized COVID-19-specific questions on the subject of "Psychological stress and effects of the COVID-19 pandemic in bipolar disorder" was created and distributed via LimeSurvey.

RESULTS

Both groups reported a negative impact on their mental health. The participants with bipolar disorder showed significantly higher values in the Beck Depression Inventory-2 score (p<0,001), in emotional distress due to social distancing (p=0,003) and significantly lower values in muscle-strengthening exercise (p=0,039) and in sport units (p=0,003) compared to the control group. In addition, patients with bipolar disorder smoked more often than individuals of the control group. People with bipolar disorder were 42,9% more likely to report they were less efficient during the pandemic, and 22,9% experienced weight gain compared to before the pandemic. The control group, on the other hand, was less efficient at 17,5% and 5,0% reported weight gain. However, a comparison with pre-pandemic data showed a decrease in food craving in both groups.

CONCLUSION

This study provided first evidence of self-reported adverse effects on mental stress and lifestyle in people with bipolar disorder at the beginning of the COVID-19 pandemic. Psychiatric care and early interventions for patients with bipolar disorder would be particularly important in times of crisis in order to help maintain a healthy lifestyle and thus counteract unfavourable developments.

Lithium toxicity following Roux-en-Y gastric bypass: Mini review and illustrative case

Lithium is among the mainstays of treatment for bipolar disorder. Bariatric surgery can considerably change the oral bioavailability of drugs, particularly lithium. In this review, a 36-year-old male patient is described, who presented with lithium toxicity, including neurologic and gastric symptoms after undergoing Roux-en-Y gastric bypass. The mechanism of lithium toxicity is discussed; recommendations for clinicians regarding lithium use in postsurgical patients are provided; and previous case reports of lithium toxicity post-gastric bypass surgery are analyzed. Awareness and education of lithium absorption changes postbariatric surgery is essential for optimal patient care. Close clinical and drug concentration level monitoring is warranted.

Effect of medication on risk of traumatic brain injury in patients with bipolar disorder: A nationwide population-based cohort study

BACKGROUND

Increased traumatic brain injury (TBI) risk was found in patients with bipolar disorder (BPD). Whether the medications for BPD and dosage moderate the risk of TBI is not clear.

AIM

This study aimed to determine whether an association exists between BPD and TBI and whether the prescription of psychotropics moderates TBI risk.

METHODS

A total of 5606 individuals who had received diagnoses of BPD between January 1, 1997 and December 31, 2013 and 56,060 matched controls without BPD were identified from Taiwan's National Health Insurance Research Database. Cases and controls were followed until the date of TBI diagnosis.

RESULTS

BPD was associated with a high risk of TBI (adjusted hazard ratio (aHR): 1.85; 95% CI: 1.62-2.11). Patients with BPD, with or without a history of psychiatric hospitalization, had increased risks of TBI (aHR: 1.94, 95% CI: 1.57-2.4 and aHR: 1.82, 95% CI: 1.55-2.1, respectively). The prescription of typical antipsychotics (0 < defined daily dose (DDD) < 28: hazard ratio (HR) = 1.52, 95% CI: 1.19-1.94; ⩾28 DDD: HR = 1.54, 95% CI: 1.15-2.06) and tricyclic antidepressants (TCAs) (0 < DDD < 28: HR = 1.73, 95% CI: 1.26-2.39; ⩾28 DDD: HR = 1.52, 95% CI: 1.02-2.25) was associated with higher TBI risk. Patients receiving higher doses of benzodiazepines (BZDs) (cumulative dose ⩾28 DDD) had a higher TBI risk (HR = 1.53, 95% CI: 1.13-2.06).

CONCLUSION

Patients with BPD have a higher risk of TBI. The use of typical antipsychotics, TCAs, or high-dose BZDs increases the risk of TBI in BPD.

Body Mass Index and Somatic Symptom Severity in Patients with Somatic Symptom Disorder: The Mediating Role of Working Memory

Objective

In somatic symptom disorder (SSD), cognitive dysfunction is related to perceptive distortion that excessively amplifies bodily sensations. The association between high body mass index (BMI) and cognitive dysfunction could be attributed to underlying systemic inflammation. We aimed to evaluate whether patients with SSD and high BMI exhibit increased somatic symptom severity and whether this is mediated by cognitive dysfunction.

Methods

This retrospective, cross-sectional study was conducted on 54 patients with SSD (20 males/34 females, mean age ± standard deviation 40.65 ± 13.23 years). Participants’ BMI, laboratory data including complete blood count and lipid profile, results from the Korean Wechsler Adult Intelligence Scale-IV, and scores of the Korean-Symptom Checklist 95-Somatization (SCL95-SOM) were analyzed. We performed a path analysis to evaluate BMI as a predictor of somatic symptoms.

Results

In a path analysis, the SCL95-SOM score was directly influenced by working memory (b = −0.326, p = 0.032), which was significantly influenced by BMI (b = −0.338, p = 0.009), although there was no direct effect of BMI on the SCL95-SOM score. The path analytic model showed a close fit to the data with the following values c² (df) = 0.918 (1), p = 0.338, root mean square error of approximation = 0.000 (< 0.001), and comparative fit index = 1.00.

Conclusion

Patients with SSD and high BMI may exhibit increased somatic symptom severity, and this is mediated by working memory dysfunction. Weight management may help improve symptoms in patients with SSD and high BMI.

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.

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.

Symptoms of bipolar disorder are associated with lower bariatric surgery completion rates and higher food addiction

BACKGROUND

Bipolar disorder (BP) is highly comorbid with obesity, however, little is known about how BP might be associated with bariatric surgery outcomes.

METHODS

In this retrospective clinical cohort study, 1034 patients completed a psychological evaluation, and screening positive for possible BP was defined as a score ≥7 and moderate disability on the Mood Disorders Questionnaire. Food addiction (FA), subthreshold binge eating disorder (BED), and illegal drug use were also assessed using standardized questionnaires.

RESULTS

The 54 (5.2%) patients screening positive for BP were less likely to have bariatric surgery compared to 980 (94.8%) patients who screened negative for BP (5 patients or 9.3% vs 273 patients, or 27.9%). Patients with possible BP also had significantly higher prevalence of FA (37% vs 13.2%), subthreshold BED (29.6% vs 8.3%) and illegal drug use (7.4% vs 2.1%).

CONCLUSIONS

In this retrospective clinical cohort study, patients who screened positive for BP had a higher prevalence of food addiction, subthreshold binge eating disorder and recent illegal drug use. They also demonstrated lower completion rates for having bariatric surgery. Clearly, more needs to be learned about how to help patients with symptoms of bipolar disorder manage their obesity and behavioral challenges.

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.

Hidradenitis Suppurativa and Bipolar Disorders: A Population-Based Study

BACKGROUND

Psychological comorbidities have been reported in patients with hidradenitis suppurativa (HS), yet only a few studies have investigated the possible association between HS and severe psychiatric disorders. The current study aimed to assess the association between HS and bipolar disorder, a major, chronic, psychiatric disease.

METHODS

A nationwide, population-based study was performed utilizing data from the Clalit Health Services (CHS) database in Israel. The study included 4,191 HS patients and 20,941 age- and gender-matched controls. A multivariate binary logistic regression, adjusted for demographic and behavioral risk factors, was performed.

RESULTS

A higher proportion of bipolar disorders was found among HS patients compared to controls (0.7 vs. 0.1%, respectively). There was an increased proportion of active smokers among HS patients than among controls (53.4 vs. 13.5%, respectively). In the multivariate analysis, adjusting for age, sex, and smoking, HS was found to be independently and positively associated with bipolar disorders (OR 2.12, 95% CI 1.21-3.27, p < 0.01), yet after controlling for body mass this association became nonsignificant.

CONCLUSIONS

Bipolar disorders are associated with HS. Future studies should explore whether cardiometabolic deficiencies might account for this association. Healthcare providers should consider this potential co-occurrence as it may impede patient compliance and require appropriate screening and treatment. Results also stress the need for a multidisciplinary approach to optimize management of the disease and its associated comorbidities.

Weight Gain During Treatment of Bipolar Disorder (BD)-Facts and Therapeutic Options

Bipolar disorder (BPD) is a mood disorder, which is characterized by alternating affective states, namely (hypo)mania, depression, and euthymia. Evidence is growing that BPD has indeed a biologic substrate characterized by chronic inflammation, oxidative stress, and disturbed energy metabolism. Apart from this, there is obviously a hereditary component of this disease with multi-genetic factors. Most probably a susceptibility threshold favors the outbreak of clinical disease after a cascade of stress events that remain to be elucidated in more detail. Evidence is also growing that weak points in brain energy metabolism contribute to outbreak and severity of BPD. Conventional psychopharmacologic therapy must be reassessed under the aspects of weight cycling and development of central obesity as a deterioration factor for a worse clinical course leading to early cardiovascular events in BPD subgroups.