The impact of co-morbid alcohol use disorder in bipolar patients

Quality of life among people with mental illness attending a psychiatric outpatient clinic in Ethiopia: a structural equation model

Background

Mental illness is one of the most severe, chronic, and disabling public health problems that affects patients' Quality of life (QoL). Improving the QoL for people with mental illness is one of the most critical steps in stopping disease progression and avoiding complications of mental illness. Therefore, we aimed to assess the QoL and its determinants in patients with mental illness in outpatient clinics in Northwest Ethiopia in 2023.

Methods

A facility-based cross-sectional study was conducted among people with mental illness in an outpatient clinic in Ethiopia. The sampling interval was decided by dividing the total study participants who had a follow-up appointment during the data collection period (2400), by the total sample size 638, with the starting point selected by lottery method. The interviewer-administered WHOQOL BREF-26 tool was used to measure the quality of life (QoL) of people with mental illness. The domains of QoL were identified, and indirect and direct effects of variables were calculated using structural equation modelling with SPSS-28 and Amos-28 software. A p-value of < 0.05 and a 95% CI were used to evaluate statistical significance.

Results

A total of 636 (99.7%) participants agreed to participate and completed the data collection. The mean score of overall QoL of people with mental illness in the outpatient clinic was 49.6 ± 10 Sd. The highest QoL was found in the physical health domain (50.67 ± 9.5 Sd), and the lowest mean QoL was found in the psychological health domain (48.41 ± 10 Sd). Rural residence, drug nonadherence, suicidal ideation, not getting counselling, moderate or severe subjective severity, family does not participate in patient care and a family history of mental illness had an indirect negative effect on QoL. Alcohol use and psychological health domain had direct positive effect on QoL. Furthermore, objective severity of illness, having low self-esteem, and having history of mental illness in the family had both direct and indirect effect on QoL. Furthermore, sociodemographic factors (rural residence, illiterate educational status, not married marital status), social support-related factors (poor self-esteem, family not participating in patient care), substance use factors (alcohol use, tobacco use) and clinical factors (high objective and subjective severity of illness, not getting counselling, suicidal ideation, higher number of episodes, comorbid illness, family history of mental illness, poor drug adherence) directly and indirectly affected QoL.

Conclusions

In this study, the QoL of people with mental illness was poor, with the psychological health domain the most affected. Sociodemographic factors, social support-related factors, drug use factors, and clinical factors, directly and indirectly affected QoL through the mediator variables of physical health domains, psychological health domains, social relation health domains, and environmental health domains. In order to improve the QoL of people with mental illnesses, we recommend that emphasis be given to addressing the QoL of those with mental illness, including the development of policy and practice responses that address the above identified factors.

Longitudinal Interplay Between Alcohol Use, Mood, and Functioning in Bipolar Spectrum Disorders

Importance

Alcohol use disorder (AUD) is present in nearly half of individuals with bipolar disorder (BD) and is associated with markedly worsening outcomes. Yet, the concurrent treatment of BD and AUD remains neglected in both research and clinical care; characterizing their dynamic interplay is crucial in improving outcomes.

Objective

To characterize the longitudinal alcohol use patterns in BD and examine the temporal associations among alcohol use, mood, anxiety, and functioning over time.

Design, Setting, and Participants

This cohort study selected participants and analyzed data from the Prechter Longitudinal Study of Bipolar Disorder (PLS-BD), an ongoing cohort study that recruits through psychiatric clinics, mental health centers, and community outreach events across Michigan and collects repeated phenotypic data. Participants selected for the present study were those with a diagnosis of BD type I (BDI) or type II (BDII) who had been in the study for at least 5 years. Data used were extracted from February 2006 to April 2022, and follow-up ranged from 5 to 16 years.

Main Outcomes and Measures

Alcohol use was measured using the Alcohol Use Disorders Identification Test. Depression, mania or hypomania, anxiety, and functioning were measured using the 9-Item Patient Health Questionnaire, the Altman Self-Rating Mania Scale, the 7-item Generalized Anxiety Disorder assessment scale, and the Life Functioning Questionnaire, respectively.

Results

A total of 584 individuals (386 females (66.1%); mean [SD] age, 40 [13.6] years) were included. These participants had a BDI (445 [76.2%]) or BDII (139 [23.8%]) diagnosis, with or without a lifetime diagnosis of AUD, and a median (IQR) follow-up of 9 (0-16) years. More problematic alcohol use was associated with worse depressive (β = 0.04; 95% credibility interval [CrI], 0.01-0.07) and manic or hypomanic symptoms (β = 0.04; 95% CrI, 0.01-0.07) as well as lower workplace functioning (β = 0.03; 95% CrI, 0.00-0.06) over the next 6 months, but increased depressive and manic or hypomanic symptoms were not associated with greater subsequent alcohol use. These latter 2 associations were more pronounced in BDII than BDI (mania or hypomania: β = 0.16 [95% CrI, 0.02-0.30]; workplace functioning: β = 0.26 [95% CrI, 0.06-0.45]). Alcohol use was not associated with anxiety over time.

Conclusions and Relevance

This study found that alcohol use, regardless of diagnostic status, was associated with mood instability and poorer work functioning in BD, but increased mood symptoms were not associated with subsequent alcohol use. Given its prevalence and repercussions, dimensional and longitudinal assessment and management of alcohol use are necessary and should be integrated into research and standard treatment of BD.

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.

Alcohol use disorders in patients with bipolar disorder: a systematic review and meta-analysis

Alcohol consumption has a key role in more than 200 diseases and health injuries, being an important factor for social and public health costs. Studies with clinical populations show an association between alcohol use disorders (AUD) and bipolar disorder. In this meta-analysis we included studies, reports, or summaries identified in Google Scholar, Lilacs, Medline, and MedCaribe that reported original data published up to 31 January 2023. We included cross-sectional and longitudinal observational studies that investigated the prevalence of AUD in patients with bipolar disorder. We calculated the prevalence rates and conducted a meta-analysis using a random effects model. The meta-analysis included 20 unique studies conducted in 12 countries, with a total sample of 32,886 individuals with bipolar disorder, comprising 17,923 women and 13,963 men, all aged 18 years or older. The prevalence of AUD in individuals with bipolar disorder was found to be 29.12%, while the prevalence of Alcohol Dependence (AD) was 15.87% and the prevalence of Alcohol Abuse (AA) was 18.74%. The high prevalence of AUD individuals with bipolar disorder is important because it highlights the need for targeted interventions to prevent and address comorbid conditions, which may improve treatment outcomes, reduce harm, and promote public health.

Risk for alcohol use problems in severe mental illness: Interactions with sex and racial/ethnic minority status

BACKGROUND

Alcohol use disorder (AUD) is exceedingly common among individuals with bipolar disorder and schizophrenia. However, studies on alcohol use in psychiatric illness rely largely on population surveys with limited representation of severe mental illness (SMI); schizophrenia and bipolar disorder.

METHODS

Using data from the Genomic Psychiatry Cohort (GPC) (Pato MT, 2013), associations of bipolar disorder and schizophrenia with alcohol use problems were examined in a diverse US based sample, considering the influence of self-described race (African Ancestry (AA), European Ancestry (EA), or Latinx Ancestry (LA)), sex, and tobacco use. Participants answered alcohol use problem items derived from the CAGE instrument, yielding a summed "probable" alcohol use disorder (pAUD) risk score.

RESULTS

This study included 1952 individuals with bipolar disorder with psychosis (BDwP), 409 with bipolar disorder without psychosis (BD), 9218 with schizophrenia (SCZ), and 10,416 unaffected individuals. We found that SMI (BDwP, BD, SCZ) was associated with elevated AUD risk scores (B = 0.223, p < 0.001), an association which was strongest in females, particularly those of AA and LA, and in tobacco users. Schizophrenia was associated with the greatest increase in pAUD score (B = 0.141, p < 0.001). pAUD risk scores were increased among participants with bipolar disorder, with greater increases in BDwP (B = 0.125, p < 0.001) than in BD without psychosis (B = 0.027, p < 0.001).

LIMITATIONS

Limitations include reliance on self-report data, screening items for AUD, voluntary recruitment bias, and differences in race/sex distribution between groups, which were statistically adjusted for in analytic models.

CONCLUSIONS

SMI is associated with risk for AUD, particularly among females from racial minority groups, smokers, and those with psychotic disorders.

Incidence of and risk factors for alcohol dependence in bipolar disorder: A population-based cohort and nested case-control study

OBJECTIVES

Although alcohol dependence is highly prevalent in patients with bipolar disorder, the causal relationship is not yet well-established. This study estimated the incidence of alcohol dependence in a nationwide bipolar disorder cohort and examined risk factors for alcohol dependence.

METHODS

Patients aged 15-65 years with consistent bipolar disorder who had their first psychiatric admission between 1999 and 2012 (n = 21,791) were enrolled from the National Health Insurance Research Database in Taiwan. We calculated the adjusted incidence rate ratio of alcohol dependence in the bipolar cohort relative to the general population after stratification by age and sex. In the nested case-control study, we included patients with incident alcohol dependence as cases and four age- and sex-matched controls for each case to analyze health care utilization, comorbidities and concomitant medications between them.

RESULTS

We identified 1261 patients with bipolar disorder with incident alcohol dependence. Relative to the general population, the adjusted incidence rate ratio of alcohol dependence was 9.20 in the bipolar cohort. All adjusted incidence rate ratios were high across all age subgroups. Cases had higher psychiatric and nonpsychiatric health care utilization than did controls. Multivariate analysis revealed that cases tended to have cardiovascular disease, diabetes mellitus, chronic hepatic disease, pneumonia and delirium before alcohol dependence diagnosis. Cases had higher psychiatric comorbidities, namely drug-induced mental disorders, anxiety disorder, personality disorder, adjustment disorder and sleep disorder.

CONCLUSION

The bipolar cohort had a higher incidence of alcohol dependence. We identified specific groups with a high risk of alcohol dependence. Additional strategies for early detection, treatment and intervention for alcohol dependence should be developed.

Outcomes of Hospitalized Acute Alcoholic Hepatitis (AH) in Patients With Bipolar 1 Disorder (B1D)

Introduction: Alcoholic hepatitis (AH) is a common cause of hospital admissions and is associated with a high mortality rate. AH occurs frequently in patients with heavy alcohol use. Alcohol use disorder (AUD) commonly presents with comorbid psychiatric disorders such as bipolar disorder. Bipolar disorder patients are also known to be at an increased risk for chronic liver diseases. Bipolar 1 disorder (B1D) is often considered the most severe presentation among different types of bipolar disorder. This study assesses the clinical outcomes of patients admitted for AH with concomitant B1D.

Methods: Adult patients with AH were identified within the 2014 National Inpatient Sample (NIS) database. International Classification of Diseases, Ninth Edition Revision, Clinical Modification (ICD-9 CM) codes were used to select for all of the diagnoses for this study. AH patients were subdivided into those with and without B1D. The outcomes of interest were sepsis, hepatic encephalopathy, acute respiratory failure, acute kidney injury, ischemic stroke, hepatic failure, coagulopathy, and inpatient mortality. A multivariate logistic regression analysis was performed to explore whether B1D is an independent predictor for the outcomes.

Results: Among 4,453 patients with AH identified, 166 patients also had B1D. AH patients with comorbid B1D were seen to be younger (42.9 years old vs. 46.2 years old, p < 0.05) and more commonly female (55.4% vs. 36.5%, p < 0.05). The B1D subgroup of AH patients were found to less likely develop acute hepatic failure (adjusted odds ratio (aOR) 0.13, 95% confidence interval (CI): 0.02-0.97, p < 0.05). The adjusted odds ratios for the remaining outcomes were not statistically significant.

Conclusions: Our study indicates that B1D may be an independent protective factor against acute hepatic failure in patients hospitalized with AH. This finding can be explained by frequent laboratory monitoring and psychiatric assessments performed by psychiatrists treating B1D patients, as well as the impact B1D has on cortisol release induced by hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis.

Genetic Basis of Dual Diagnosis: A Review of Genome-Wide Association Studies (GWAS) Focusing on Patients with Mood or Anxiety Disorders and Co-Occurring Alcohol-Use Disorders

(1) Background: Comorbidity between Alcohol Use Disorders (AUD), mood, and anxiety disorders represents a significant health burden, yet its neurobiological underpinnings are elusive. The current paper reviews all genome-wide association studies conducted in the past ten years, sampling patients with AUD and co-occurring mood or anxiety disorder(s). (2) Methods: In keeping with PRISMA guidelines, we searched EMBASE, Medline/PUBMED, and PsycINFO databases (January 2010 to December 2020), including references of enrolled studies. Study selection was based on predefined criteria and data underwent a multistep revision process. (3) Results: 15 studies were included. Some of them explored dual diagnoses phenotypes directly while others employed correlational analysis based on polygenic risk score approach. Their results support the significant overlap of genetic factors involved in AUDs and mood and anxiety disorders. Comorbidity risk seems to be conveyed by genes engaged in neuronal development, connectivity, and signaling although the precise neuronal pathways and mechanisms remain unclear. (4) Conclusion: given that genes associated with complex traits including comorbid clinical presentations are of small effect, and individually responsible for a very low proportion of the total variance, larger samples consisting of multiple refined comorbid combinations and confirmed by re-sequencing approaches will be necessary to disentangle the genetic architecture of dual diagnosis.

Comorbid Bipolar and Alcohol Use Disorder-A Therapeutic Challenge

Comorbidity rates in Bipolar disorder rank highest among major mental disorders, especially comorbid substance use. Besides cannabis, alcohol is the most frequent substance of abuse as it is societally accepted and can be purchased and consumed legally. Estimates for lifetime comorbidity of bipolar disorder and alcohol use disorder are substantial and in the range of 40-70%, both for Bipolar I and II disorder, and with male preponderance. Alcohol use disorder and bipolarity significantly influence each other's severity and prognosis with a more complicated course of both disorders. Modern treatment concepts acknowledge the interplay between these disorders using an integrated therapy approach where both disorders are tackled in the same setting by a multi-professional team. Motivational interviewing, cognitive behavioral and socio- therapies incorporating the family and social environment are cornerstones in psychotherapy whereas the accompanying pharmacological treatment aims to reduce craving and to optimize mood stability. Adding valproate to lithium may reduce alcohol consumption whereas studies with antipsychotics or naltrexone and acamprosate did not affect mood fluctuations or drinking patterns. In summary, there is a continuous need for more research in order to develop evidence-based approaches for integrated treatment of this frequent comorbidity.

Patterns and clinical correlates of lifetime alcohol consumption in women and men with bipolar disorder: Findings from the UK Bipolar Disorder Research Network

OBJECTIVES

Despite previous literature on comorbid alcohol use disorders (AUDs) in bipolar disorder (BD), little is known about patterns of alcohol use more widely in this population. We have examined lifetime heaviest average weekly alcohol consumption levels in a large well-characterised UK sample including lifetime clinical correlates of increasing levels of alcohol use.

METHODS

Participants were 1203 women and 673 men with bipolar I disorder interviewed by semi-structured interview who had consumed alcohol regularly at any point in their life.

RESULTS

Over half of both women (52.3%) and men (73.6%) had regularly consumed over double the current UK recommended guideline for alcohol consumption. In women and men increasing levels of lifetime alcohol consumption were significantly associated with the presence of suicide attempts (women: OR 1.82, P < .001; men: OR 1.48, P = .005) and rapid cycling (women: OR 1.89, P < .001; men: OR 1.88, P < .001). In women only, increasing levels of alcohol consumption were significantly associated with more episodes of depression (OR 1.35, P < .001) and mania (OR 1.30, P < .004) per illness year, less impairment in functioning during the worst episode of mania (OR 1.02, P < .001), fewer psychiatric admissions (OR 0.51, P < .001), comorbid panic disorder (OR 2.16, P < .001) and eating disorder (OR 2.37, P < .001).

CONCLUSIONS

Our results highlight the clinical importance of obtaining detailed information on levels of alcohol consumption among patients with BD. Increased levels of alcohol use, not necessarily reaching criteria for AUD, may be helpful in predicting BD illness course, in particular eating disorders comorbidity in women.

Quality of life in patients with severe mental illness: a cross-sectional survey in an integrated outpatient health care model

PURPOSE

This study (a) assessed quality of life (QoL) in a patient sample with severe mental illness in an integrated psychiatric care (IC) programme in selected regions in Germany, (b) compared QoL among diagnostic groups and (c) identified socio-demographic, psychiatric anamnestic and clinical characteristics associated with QoL.

METHODS

This cross-sectional study included severely mentally ill outpatients with substantial impairments in social functioning. Separate dimensions of QoL were assessed with the World Health Organisation's generic 26-item quality of life (WHOQOL-BREF) instrument. Descriptive analyses and analyses of variance (ANOVAs) were conducted for the overall sample as well as for diagnostic group.

RESULTS

A total of 953 patients fully completed the WHOQOL-BREF questionnaire. QoL in this sample was lower than in the general population (mean 34.1; 95% confidence interval (CI) 32.8 to 35.5), with the lowest QoL in unipolar depression patients (mean 30.5; 95% CI 28.9 to 32.2) and the highest in dementia patients (mean 53.0; 95% CI 47.5 to 58.5). Main psychiatric diagnosis, living situation (alone, partner/relatives, assisted), number of disease episodes, source of income, age and clinical global impression (CGI) scores were identified as potential predictors of QoL, but explained only a small part of the variation.

CONCLUSION

Aspects of health care that increase QoL despite the presence of a mental disorder are essential for severely mentally ill patients, as complete freedom from the disorder cannot be expected. QoL as a patient-centred outcome should be used as only one component among the recovery measures evaluating treatment outcomes in mental health care.

Alcohol misuse in bipolar disorder. A systematic review and meta-analysis of comorbidity rates

Aims:

To assess the comorbidity rates of alcohol use disorders (AUDs) in bipolar disorder (BD) and to explore possible sources of heterogeneity.

Methods:

Studies were identified through database searches. Meta-analytic techniques were employed to aggregate data on lifetime comorbidity and to explore possible sources of heterogeneity. Funnel plots were used to detect publication bias.

Results:

In clinical studies, AUDs affected more than one in three subjects with BD. Significant heterogeneity was found, which was largely explained by the geographical location of study populations and gender ratio of participants. AUDs affected more than one in five women and two in five men.

Conclusion:

AUDs are highly prevalent in BD. Our study revealed a substantial heterogeneity across studies. Further research including control groups is needed. Patients with BD should be assessed for current and previous AUDs.

Latent structure of the symptomatology of hospitalized patients with bipolar mania

Several studies have attempted to understand the dimensions of psychiatric symptoms in manic episodes, but only a few have been able to model the latent structure of mania in bipolar disorder patients using confirmatory factor analysis. The objective of the present study was to search for the best model of the symptomatology of hospitalized manic patients. To achieve this goal, 117 manic inpatients during a manic crisis participated in this research. Exploratory factor analysis was conducted followed by confirmatory factor analysis using an exploratory factor analysis solution and three other theory-based models. The exploratory factor analysis results revealed a six-factor structure: depression, suicide, insomnia, mania, psychosis, and anxiety. This solution also presented the best fit to the data when tested with confirmatory factor analysis. A five-factor solution, without suicide as a separate dimension, appeared to be more theoretically suitable. Another important finding was that anxiety was an independent dimension in mania. Some hypotheses are discussed in light of contemporary theories, and future studies should investigate this aspect further.

Demographic and Clinical Differences Between Bipolar Disorder Patients With and Without Alcohol Use Disorders

BACKGROUND

Bipolar disorder (BD) and alcohol use disorder (AUD) are two major independent causes of psychopathology in the general population. The prevalence of AUD in BD is high. Identifying the clinical and demographic features of patients with BD who may develop AUD could help with early identification and intervention.

METHODS

Data from 238 patients diagnosed with BD were gathered on alcohol use, social demographics, longitudinal course of BD, clinical features of the most severe lifetime manic and depressive episodes, comorbid physical diseases, anxiety disorders, and other substance use disorders.

RESULTS

We found that 74 of 238 BD patients had AUD (67 with alcohol dependence and 7 with alcohol abuse). Bivariate logistic regression analysis and multivariate logistic regression analysis found that the best predictors of AUD in patients with BD were being male (OR = 2.086, 95% CI = 1.094-3.979, p = 0.001), younger (OR = 0.965, 95% CI = 0.935-0.996, p = 0.026), and comorbidity with other unclassified substance dependence (OR = 10.817, 95% CI = 1.238-94.550, p = 0.031).

CONCLUSIONS

Male, younger current age, and having other substance use disorders were independently associated with AUD.

Binge drinking: Prevalence, correlates, and expectancies of alcohol use among individuals with first-episode psychosis

AIM

This study examines the prevalence and correlates of binge drinking and its association with expectancies of alcohol use, within a sample of patients with first-episode psychosis enrolled in the Early Psychosis Intervention Programme (EPIP) in Singapore's Institute of Mental Health.

METHODS

A total of 280 patients from the EPIP were recruited for an on-going longitudinal study examining cigarette smoking and alcohol habits. Only baseline data were used, pertaining to socio-demographics, alcohol use, clinical symptomology, quality of life, and expectancies of alcohol use.

RESULTS

Overall 23.9% (N = 67) reported ever binge drinking in their lifetime, and 11.4% (N = 32) had binged in the past 2 weeks. Controlling for all other socio-demographic and clinical factors, binge drinking was significantly associated with higher education levels, having children, current or past history of cigarette smoking, and lower negative symptom scores. Binge drinkers were also more likely to endorse statements relating to the themes of enhancement seeking (ie, using alcohol to alter or enhance experiences in a pleasurable way), coping with distress, and socializing-related expectancies of alcohol use.

CONCLUSION

Similar to past studies, the prevalence of binge drinking among our first-episode sample was relatively high. Our findings suggest certain lifestyle and social factors associated with risky drinking behaviour that future prevention efforts may address. Additionally, the three motivations of enhancement seeking, coping, and socializing also suggest psychological processes and coping styles that could be targeted for interventions.

Feasibility and acceptability of integrated psychological therapy versus treatment as usual for people with bipolar disorder and co-morbid alcohol use: A single blind randomised controlled trial

BACKGROUND

Alcohol use is a common problem in bipolar disorder (BD) and evidence indicates more promising outcomes for alcohol use than other substances. No trials have evaluated individual integrated motivational interviewing and cognitive behaviour therapy (MI-CBT) for problematic alcohol use in BD. We therefore assessed the feasibility and acceptability of a novel MI-CBT intervention for alcohol use in BD.

METHODS

A single blind RCT was conducted to compare MI-CBT plus treatment as usual (TAU) with TAU only. MI-CBT was delivered over 20 sessions with participants followed up at 3, 6, 9 and 12 months post-randomisation. Primary outcomes were the feasibility and acceptability of MI-CBT (recruitment to target, retention to follow-up and therapy, acceptability of therapy and absence of adverse events). We also conducted preliminary analyses of alcohol and mood outcomes (frequency and severity of alcohol use and time to mood relapse).

RESULTS

44 participants were recruited with 75% retention to 6 and 12 months follow-up. Therapy participants attended a mean of 17.6 (SD 4.5) sessions. Therapy alliance and treatment fidelity were acceptable. Qualitative interviews indicated the intervention was experienced as collaborative, and helpful, in addressing mood and alcohol issues, although risk of overconfidence following therapy was also identified. Clinical outcomes did not differ between arms at 12 months follow-up.

LIMITATIONS

As a feasibility and acceptability trial any secondary results should be treated with caution.

CONCLUSIONS

Integrated MI-CBT is feasible and acceptable, but lack of clinical impact, albeit in a feasibility study, suggests need for further development. Potential adaptations are discussed.

Long-acting injectable antipsychotics as maintenance treatments for bipolar disorder-A critical review of the evidence

OBJECTIVES

The maintenance phase of bipolar disorder is arguably the most important. The aim of management during this time is to maintain wellness and prevent future episodes of illness. Medication is often the mainstay of treatment during this phase, but adherence to treatment is a significant problem. In recent years, long-acting injectable (LAI) solutions have been proposed, but these too have limitations. This paper discusses the options that are currently available and critically appraises the effectiveness of this strategy.

METHOD

The authors reviewed the small number of open-label and randomised studies on LAI medications in bipolar disorder and evaluated the efficacy and safety of these medications.

RESULTS

The studies reviewed show benefit of LAIs for the management of bipolar disorder but have several key limitations to the generalisability of findings to routine practice.

CONCLUSIONS

LAIs have an emerging role in the management of bipolar disorder and, although it is not without limitations, this strategy addresses some issues of long-term treatment and medication. Patients with bipolar disorder that are non-adherent or have an unstable illness with a predilection towards mania are possibly better suited to the use of LAIs, though more research is required to fully assess the effectiveness of this approach.

Substance use among older adults with bipolar disorder varies according to age at first treatment contact

BACKGROUND

The use of alcohol and drugs is common among people with bipolar disorder, but it is unclear if age of onset modifies this association.

AIMS

To determine the cross-sectional and longitudinal association between age of onset of bipolar disorder (BD) and disorders associated with the use of alcohol or other substances in later life, as well as their impact on mortality.

METHODS

Cohort study of a community-representative sample of 38,173 men aged 65-85 years at the start of the follow up period of 18 years. We used the Western Australian Data Linkage System to ascertain the presence of BD and substance use disorders according to the International Classification of Diseases (ICD). We also collected information on concurrent morbidities: diabetes, hypertension, ischaemic heart disease and stroke.

RESULTS

175 men had BD onset < age 60 years and 75 ≥ 60 years. Compared with older men without BD, the adjusted odds of alcohol use disorders were 3.87 (95%CI = 2.52, 5.93) for men with BD onset < 60 years and 2.38 (95%CI = 1.08, 5.25) for those with onset ≥ 60 years. The adjusted hazard ratio of incident disorders associated with the use of alcohol and other substances was 3.23 (95%CI = 1.87, 5.58) and 2.38 (95%CI = 1.38, 4.11) respectively for men with BD onset < 60 years. BD with onset ≥ 60 years was not associated with substance use disorders. The mortality hazard was not affected by the interaction between BD and the use of substances.

CONCLUSIONS

Substance use disorders (alcohol or others) are more prevalent among older adults with than without BD, but new cases are only more frequent among men with BD onset < 60 years of age. Grouping BD into early and late onset is clinically informative and may affect approach to assessment and management.

Reducing relapse and suicide in bipolar disorder: practical clinical approaches to identifying risk, reducing harm and engaging service users in planning and delivery of care – the PARADES (Psychoeducation, Anxiety, Relapse, Advance Directive Evaluation and Suicidality) programme

Background

Bipolar disorder (BD) costs £5.2B annually, largely as a result of incomplete recovery after inadequate treatment.

Objectives

A programme of linked studies to reduce relapse and suicide in BD.

Design

There were five workstreams (WSs): a pragmatic randomised controlled trial (RCT) of group psychoeducation (PEd) versus group peer support (PS) in the maintenance of BD (WS1); development and feasibility RCTs of integrated psychological therapy for anxiety in bipolar disorder (AIBD) and integrated for problematic alcohol use in BD (WS2 and WS3); survey and qualitative investigations of suicide and self-harm in BD (WS4); and survey and qualitative investigation of service users’ (SUs) and psychiatrists’ experience of the Mental Capacity Act 2005 (MCA), with reference to advance planning (WS5).

Setting

Participants were from England; recruitment into RCTs was limited to certain sites [East Midlands and North West (WS1); North West (WS2 and WS3)].

Participants

Aged ≥ 18 years. In WS1–3, participants had their diagnosis of BD confirmed by the Structural Clinical Interview for theDiagnostic and Statistical Manual of Mental Disorders.

Interventions

In WS1, group PEd/PS; in WS3 and WS4, individual psychological therapy for comorbid anxiety and alcohol use, respectively.

Main outcome measures

In WS1, time to relapse of bipolar episode; in WS2 and WS3, feasibility and acceptability of interventions; in WS4, prevalence and determinants of suicide and self-harm; and in WS5, professional training and support of advance planning in MCA, and SU awareness and implementation.

Results

Group PEd and PS could be routinely delivered in the NHS. The estimated median time to first bipolar relapse was 67.1 [95% confidence interval (CI) 37.3 to 90.9] weeks in PEd, compared with 48.0 (95% CI 30.6 to 65.9) weeks in PS. The adjusted hazard ratio was 0.83 (95% CI 0.62 to 1.11; likelihood ratio testp = 0.217). The interaction between the number of previous bipolar episodes (1–7 and 8–19, relative to 20+) and treatment arm was significant (χ2 = 6.80, degrees of freedom = 2;p = 0.034): PEd with one to seven episodes showed the greatest delay in time to episode. A primary economic analysis indicates that PEd is not cost-effective compared with PS. A sensitivity analysis suggests potential cost-effectiveness if decision-makers accept a cost of £37,500 per quality-adjusted life-year. AIBD and motivational interviewing (MI) cognitive–behavioural therapy (CBT) trials were feasible and acceptable in achieving recruitment and retention targets (AIBD:n = 72, 72% retention to follow-up; MI-CBT:n = 44, 75% retention) and in-depth qualitative interviews. There were no significant differences in clinical outcomes for either trial overall. The factors associated with risk of suicide and self-harm (longer duration of illness, large number of periods of inpatient care, and problems establishing diagnosis) could inform improved clinical care and specific interventions. Qualitative interviews suggested that suicide risk had been underestimated, that care needs to be more collaborative and that people need fast access to good-quality care. Despite SUs supporting advance planning and psychiatrists being trained in MCA, the use of MCA planning provisions was low, with confusion over informal and legally binding plans.

Limitations

Inferences for routine clinical practice from WS1 were limited by the absence of a ‘treatment as usual’ group.

Conclusion

The programme has contributed significantly to understanding how to improve outcomes in BD. Group PEd is being implemented in the NHS influenced by SU support.

Future work

Future work is needed to evaluate optimal approaches to psychological treatment of comorbidity in BD. In addition, work in improved risk detection in relation to suicide and self-harm in clinical services and improved training in MCA are indicated.

Trial registration

Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 6. See the NIHR Journals Library website for further project information.

Substance use and suicidal ideation and behaviour in low- and middle-income countries: a systematic review

Background

Understanding relationships between substance use and suicidal ideation and behaviour (SIB) has important public health implications for suicide prevention in low- and middle-income countries (LMICs), where 75% of suicides occur. This systematic review explored the associations between substance use and SIB in LMICs.

Methods

We searched five databases using a combination of keywords for substance use, SIB and LMICs to identify English-written quantitative studies published between January 2006 and February 2016. Data were extracted to provide an overview of what is known about the topic, highlight gaps in the literature, and explore the implications of current knowledge for suicide prevention. Studies included in the review were assessed for methodological quality using the Scottish Intercollegiate Guidelines Network checklist.

Results

Analysis of included studies (N = 108) demonstrated a consistent positive association between substance use and SIB across all substances (i.e. alcohol, tobacco, cannabis, illicit drugs, non-medical use of prescription drugs), all substance use dimensions (i.e. intoxication, use, and pathological use) and all SIB dimensions (i.e. suicidal ideation, non-fatal suicidal behaviour, and suicide). Most of the available research evidence comes from upper-middle-income countries, only 22% comes from lower-middle-income and low-income countries. Most studies focused on alcohol and tobacco, while neglecting substances such as cannabis, opioids, sedatives, stimulants, misuse of prescription medication, inhalants, and hallucinogens. Most of the studies employed a cross-sectional design, were conducted within a risk-factor paradigm, and provided little information about the potential interaction between variables.

Conclusions

Public health suicide prevention policy and research in LMICs should take account of the fact that: substance use is a potentially modifiable risk factor; assessment and management of substance use is integral to the care of at-risk patients; reducing consumption and hazardous use of substances in LMICs is important for suicide prevention; and research needs to be expanded to include more theory driven research that focuses on all substance use dimensions and SIB dimensions, while employing more sophisticated statistical methods.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5425-6) contains supplementary material, which is available to authorized users.

Bipolar disorder and tobacco smoking: Categorical and dimensional clinical correlates in subjects from the Brazilian bipolar research network

BACKGROUND

People with bipolar disorder (BD) have high rates of smoking. However, the scientific literature examining the association between clinical outcomes in BD and tobacco smoking is still limited and there are conflicting results. The objective of the current study was to comprehensively investigate associations between BD and tobacco smoking in a large Brazilian sample.

METHODS

This study evaluated 336 outpatients from the Brazilian Bipolar Research Network, which is a collaboration between three large academic centers in Brazil.

MAIN FINDINGS

Regarding the categorical analysis (i.e. current smokers versus non-smokers), tobacco smokers showed: 1) a higher percentage of individuals identifying as Non-Caucasians; 2) a longer duration of illness; 3) a longer duration of untreated illness; 4) more severe manic symptoms; 4) a stronger family history of mood disorder; and 6) a higher current prevalence of alcohol/substance use disorder. The dimensional analysis in smokers (i.e. number of cigarettes per day versus clinical variables) found a positive correlation between number of cigarettes per day and a) age, b) age at onset of BD, c) duration of illness, and d) current diagnosis of panic disorder.

CONCLUSION

This study found important clinical correlates of tobacco smoking in BD subjects. We observed that the variables associated with current smoker status (categorical approach) are not necessarily correlated with number of cigarettes per day (dimensional approach). Duration of illness appears to be a particularly relevant clinical variable in the association between BD and tobacco smoking.

No differences in manic-like behaviors between voluntary ethanol and water drinking in Lateral Hypothalamic Kindled (LHK) alcohol preferring rats

This study investigates phenotypic differences of manic-like behaviors during voluntary ethanol (vs. water) intake in alcohol preferring (P) rats, using the lateral hypothalamus kindled (LHK) rat mania model. Alcohol preferring (P) rats exhibited classic manic-like behaviors during kindling and the post-kindling intervals in all coded behaviors (p < 0.0001), lending further validity to the lateral hypothalamus kindled rat as a useful model to study mania. However, there was no significant phenotypic difference between alcohol and water drinking alcohol preferring (P) rats.

Nalmefene in Alcohol Use Disorder Subjects with Psychiatric Comorbidity: A Naturalistic Study

INTRODUCTION

Nalmefene is the first drug to be approved for reducing alcohol consumption in alcohol use disorder (AUD) patients at high drinking risk. In real-world settings, there is a high prevalence of concurrent psychiatric disorders in AUD subjects, with associated increased morbidity and worse prognosis. This study evaluated the use of nalmefene in AUD patients with stabilized psychiatric comorbidity previously treated unsuccessfully for alcohol dependence, and assessed craving reduction and safety.

METHODS

Sixty-five AUD outpatients treated with as-needed 18 mg nalmefene for 24 weeks were included. Primary outcome measures were: changes in heavy drinking days (HDDs) and total alcohol consumption (TAC, g/day). Secondary outcome measures were: changes in drinking risk level and craving (obsessive-compulsive drinking scale and visual analogue scale for craving).

RESULTS

Forty-two AUD subjects (64.6%) had one or more stabilized psychiatric comorbidity. There was a significant reduction in HDDs, TAC and craving measures (p < 0.001), with no differences between subjects with and without psychiatric comorbidity. Nalmefene was safe and well tolerated in all patients.

CONCLUSION

As-needed nalmefene reduced drinking and craving in AUD subjects with and without psychiatric comorbidity. These findings suggest that nalmefene is a valid therapeutic option in real-world clinical settings, where comorbid conditions are common, and has the potential to engage AUD patients who may otherwise not have sought help.

FUNDING

Lundbeck Italia S.P.A.

Associations among Substance Use, Mental Health Disorders, and Self-Harm in a Prison Population: Examining Group Risk for Suicide Attempt

Substance use disorders (SUD) and mental health disorders are significant public health issues that co-occur and are associated with high risk for suicide attempts. SUD and mental health disorders are more prevalent among offenders (i.e., prisoners or inmates) than the non-imprisoned population, raising concerns about the risk of self-harm. This cross-sectional study examined the population of a state prison system (10,988 out of 13,079) to identify associations among SUD (alcohol, cannabis, intravenous drugs, narcotics, and tobacco smoking), mental health disorders (anxiety, bipolar, depression, and psychotic disorders), and suicide attempts. The primary aim was to determine which groups (SUD, mental health disorders, and co-occurrences) were strongly association with suicide attempts. Groups with a documented SUD or mental health disorders compared to peers without these issues had 2.0 and 9.2 greater odds, respectively, for attempting suicide, which was significant at p < 0.0001 for both conditions. There were also significant differences within SUD and mental health disorders groups in regard to suicide attempts. Groups with the greatest odds for suicide attempts were offenders with comorbid bipolar comorbid and anxiety, alcohol combined with depression, and cannabis co-occurring with depression. Documentation of suicide attempts during imprisonment indicates awareness, but also suggest a need to continue enhancing screening and evaluating environmental settings.

Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990-2015: Systematic review and meta-analysis

BACKGROUND

Comorbidity between substance use disorders (SUDs) and bipolar disorder (BD) is highly prevalent to the extent it may almost be regarded the norm. This systematic review and meta-analysis aimed to estimate the prevalence rates of SUDs in treatment seeking patients diagnosed with BD in both inpatient and outpatient settings.

METHODS

A comprehensive literature search of Medline, EMBASE, psychINFO and CINAHL databases was conducted from 1990 to 2015. Prevalence of co-morbid SUDs and BD were extracted and odds ratios (ORs) were calculated using random effects meta-analysis.

RESULTS

There were 151 articles identified by electronic searches that yielded 22 large, multi-site studies and 56 individual studies describing comorbid rates of SUDs amongst community dwelling, BD inpatients or outpatients. The SUDs with the highest prevalence in BD were alcohol use (42%) followed by cannabis use (20%) and other illicit drug use (17%). Meta-analysis showed males had higher lifetime risks of SUDs compared to females. BD and comorbid SUDS were associated with earlier age of onset and slightly more hospitalisations than non-users.

LIMITATIONS

The results do not take into account the possibility that individuals may have more than one comorbid disorder, such as having more than one SUD, anxiety disorder, or other combination. Some of the meta-analyses were based on relatively few studies with high rates of heterogeneity. Most included studies were cross-sectional and therefore causality cannot be inferred.

CONCLUSIONS

This systematic review shows comorbidity between SUDs and bipolar illness is highly prevalent in hospital and community-based samples. The prevalence of SUDs was similar in patients with bipolar I and bipolar II disorders. This study adds to the literature demonstrating that SUDs are common in BD and reinforces the need to provide better interventions and properly conducted treatment trials to reduce the burden conferred by comorbid SUD and BD.

Monitoring of alcohol consumption in primary care among adults with bipolar disorder: A cross-sectional and retrospective cohort study

BACKGROUND

Screening for alcohol use disorders is an important priority in the healthcare of people with bipolar disorder, incentivised in UK primary care since 2011, through the Quality and Outcomes Framework (QOF). The extent of alcohol monitoring in primary care, and impact of QOF, is unknown. The aim was to examine recording of alcohol consumption in primary care.

METHODS

Poisson regression of biennial alcohol recording rates between 2000 and 2013 among 14,051 adults with bipolar disorder and 90,023 adults without severe mental illness (SMI), from 484 general practices contributing to The Health Improvement Network UK-wide primary care database.

RESULTS

Alcohol recording rates among people with bipolar disorder increased from 88.6 records per 1000 person-years (95% confidence interval 81.2-96.6) in 2000/2002 to 837.4 records per 1000 person-years (817.4-858.0) in 2011/2013; a more than nine-fold increase, mainly occurring after the introduction of the QOF incentive in 2011. In 2000/2002 alcohol recording levels among people with bipolar disorder were not statistically significantly different from those without SMI (adjusted rate ratio 0.96, 0.88-1.05). By 2011/2013, people with bipolar disorder were over four times as likely to have an alcohol record: adjusted rate ratio 4.45 (4.15-4.77).

LIMITATIONS

The routinely collected data may be incomplete. Alcohol data entered as free-text was not captured.

CONCLUSIONS

The marked rise in alcohol consumption recording highlights what can be achieved. It is most likely attributable to QOF, suggesting that QOF, or similar schemes, can be powerful tools in promoting aspects of healthcare.

Prevalence and impact of comorbid alcohol use disorder in bipolar disorder: A prospective follow-up study

OBJECTIVE

Alcohol use disorder may very well increase the likelihood of affective episodes in bipolar disorder, but prospective data on survival are inconsistent.

METHOD

The authors examined the prevalence of alcohol use disorders and their impact on the risk of relapse. A total of 284 consecutively admitted International Classification of Diseases-10 bipolar I (n = 161) and II (n = 123) patients were followed up naturalistically over a period of 4 years.

RESULTS

The prevalence of alcohol use disorders was higher in bipolar II disorder than in bipolar I disorder (26.8% vs 14.9%; χ(2) = 5.46, p = 0.019), with a global prevalence of alcohol use disorders of 20.1% in the whole sample. A total of 8.7% of bipolar I patients suffered from alcohol abuse and 6.2% from alcohol dependency, whereas 13% bipolar II patients had alcohol abuse and 13.8% alcohol dependency. Male bipolar subjects had a higher prevalence of alcohol use disorders than female patients (38.3% vs 12.8%; χ(2) = 21.84, p-value < 0.001). The presence of alcohol use disorders was associated with an increased risk of depressive relapse in bipolar I patients (Cox regression analysis hazard ratio = 2.7, p = 0.005). The increased risk was not modulated by medication.

CONCLUSION

Our data underline the negative long-term impact of alcohol use disorders on bipolar disorder with more depressive bipolar I episodes and the importance of its detection and treatment.

Substance use is a risk factor for violent behavior in male patients with bipolar disorder

BACKGROUND

To determine the factors involved in violent behavior in patients with bipolar disorder (BD) and to investigate the relationship between violence and substance use disorder (SUD).

METHODS

A sample of 100 male inpatients diagnosed with BD type I who were experiencing a current mood episode participated in the study. Violent behavior was defined as physical aggression against others. All patients were evaluated using the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), Positive and Negative Syndrome Scale-positive subscale (PANSS-p), Barratt Impulsivity Scale-11 (BIS-11), Buss-Perry Aggression Questionnaire (BPAQ) and Overt Aggression Scale (OAS). Lifetime SUD and current use of substances were evaluated. Logistic regression analysis was conducted to predict violent behavior.

RESULTS

Current substance use (CSU) rather than lifetime SUD was found to be related to violent behavior in patients with BD, and CSU was associated with a threefold increase in the risk of violence. The rate of lifetime SUD in our sample was 59%, and the rate of CSU was 39%. The most commonly abused substances were cannabis and alcohol, followed by synthetic cannabinoids, in both groups of patients with lifetime SUD and CSU. Individuals abusing any substance were more likely to have a criminal record and history of incarceration than other patients. One of the most significant risk factors for violence was a previous history of violent behavior.

LIMITATIONS

The sample was limited to male patients. Data on some participants' recent substance use from standard urine analysis was not obtained. The data on the use of synthetic cannabinoids was obtained from patients and their families owing to the lack of equipment for detecting synthetic cannabinoids using laboratory analysis.

CONCLUSIONS

CSU appears to be a significant predictive factor in violent behavior in male patients. Further investigation of co-occurrence of violence with CSU and improvement in treatment strategies might reduce or prevent violence in patients with BD.

Affective temperaments and concomitant alcohol use disorders in bipolar disorder

BACKGROUND

Alcohol misuse (AM) is more common in bipolar disorder (BD) than within the general population but the mechanisms of this association are unclear. We hypothesized that certain affective temperaments (including hyperthymic, cyclothymic, anxious, depressive and/or irritability) might represent 'fundamental states' contributing to risk of both AM and BD and we aimed to assess whether extremes of these five affective temperaments were associated with BD and concomitant AM status.

METHODS

Our sample comprised 1420 individuals with BD who were recruited into a clinical-genetic study conducted by the Bipolar Disorder Research Network. Phenotypic assessments, including evaluation for AM and the 32-item TEMPS-A questionnaire, were conducted. Binary logistic regression was used to determine the effect of TEMPS-A scores on the likelihood of concomitant AM, with adjustment for confounders.

RESULTS

Mean scores for four affective temperaments (hyperthymic, cyclothymic, depressive and irritable) were higher in cases (BD+AMs) than controls (BD only) (p<0.001). Hyperthymic and irritable temperaments in particular significantly increased the odds of concomitant AM within the BD sample after adjustment for potential confounders.

LIMITATIONS

The definition of AM was not directly based on formal diagnostic classification systems. A retrospective, cross-sectional design was used. Our findings may not generalize to other countries and cultures.

CONCLUSIONS

Higher scores on measures of hyperthymic and irritable temperament may contribute to the association between AM and BD. Assessing affective temperaments early in the course of BD may help to predict the development of an AM problem in vulnerable individuals.

Comorbid alcohol dependence disorder may be related to aldehyde dehydrogenase 2 (ALDH2) and alcohol dehydrogenase 1B (ADH1B) in bipolar II disorder, but only to ALDH2 in bipolar I disorder, in Han Chinese

OBJECTIVES

A high prevalence rate of bipolar disorder (BP) comorbid with alcohol dependence (AD) (BP+AD) in Western patients with BP has been reported, but whether this is true for Han Chinese with BP is uncertain. We explored the prevalence of BP+AD in a Han Chinese population with BP, and investigated the effect of alcohol-metabolizing genotypes on bipolar I disorder (BP-I) + AD and bipolar II disorder (BP-II) + AD.

METHODS

Healthy controls (HCs) (n = 672) and 18- to 65-year-old patients with BP (BP-I: n = 530; BP-II: n = 788) were recruited. Patients with any other major or minor mental illnesses, neurological disorders, or organic mental disorders were excluded. A polymerase chain reaction and restriction fragment length polymorphism analysis was used to determine genotypes for alcohol dehydrogenase 1B (ADH1B) and aldehyde dehydrogenase 2 (ALDH2), two alcohol-metabolizing enzymes.

RESULTS

AD comorbidity rates were 11.7% with BP-I and 17.1% with BP-II. Significantly fewer patients with BP not comorbid with AD (BP-AD) carried the AHD1B*1 allele than did the HCs. Logistic regression analysis showed a main effect of ALDH2*1/*1 only in the BP-I-AD group. In BP+AD patients, logistic regression analysis showed main effects of ALDH2*1/*1 and ADH1B*1/*1 only in the BP-II+AD group.

CONCLUSIONS

Having BP-II+AD may be related to ALDH2 and ADH1B, but having BP-I+AD may be related only to ALDH2. We conclude that ALDH2 and ADH1B have different effects in Han Chinese patients with BP-I+AD and BP-II+AD.

Characteristics of Bipolar I patients grouped by externalizing disorders

BACKGROUND

Bipolar disorder co-occurs with a number of disorders with externalizing features. The aim of this study is to determine whether Bipolar I (BPI) subjects with comorbid externalizing disorders and a subgroup with externalizing symptoms prior to age 15 have different clinical features than those without externalizing disorders and whether these could be attributed to specific genetic variations.

METHODS

A large cohort (N=2505) of Bipolar I subjects was analyzed. Course of illness parameters were compared between an Externalizing Group, an Early-Onset Subgroup and a Non-Externalizing Group in the Discovery sample (N=1268). Findings were validated using an independent set of 1237 BPI subjects (Validation sample). Genetic analyses were carried out.

RESULTS

Subjects in the Externalizing Group (and Early-Onset Subgroup) tended to have a more severe clinical course, even in areas specifically related to mood disorder such as cycling frequency and rapid mood switching. Regression analysis showed that the differences are not completely explainable by substance use. Genetic analyses identified nominally associated SNPs; calcium channel genes were not enriched in the gene variants identified.

LIMITATIONS

Validation in independent samples is needed to confirm the genetic findings in the present study.

CONCLUSIONS

Our findings support the presence of an externalizing disorder subphenotype within BPI with greater severity of mood disorder and possible specific genetic features.

Alcohol and lithium have opposing effects on the period and phase of the behavioral free-running activity rhythm

Bipolar patients have a high prevalence of comorbid alcohol use and abuse disorders, while chronic alcohol drinking may increase the presence and severity of certain symptoms of bipolar disorder. As such, there may be many individuals that are prescribed lithium to alleviate the manic symptoms of bipolar disorder, but also drink alcohol concurrently. In addition, both alcoholics and individuals with bipolar disorder often exhibit disruptions to their sleep-wake cycles and other circadian rhythms. Interestingly, both ethanol and lithium are known to alter both the period and the phase of free-running rhythms in mammals. While lithium is known to lengthen the period, ethanol seems to shorten the period and attenuate the responses to acute light pulses. Therefore, the present study aimed to determine whether ethanol and lithium have opposing effects on the circadian pacemaker when administered together. C57BL/6J mice were provided drinking solutions containing lithium, alcohol, or both, and their free-running rhythms along with their response to photic phase shifts were investigated. Mice treated with lithium displayed period lengthening, which was almost completely negated when ethanol was added. Moreover, ethanol significantly attenuated light-induced phase delays while the addition of lithium partially restored this response. These results indicate that alcohol and lithium have opposing effects on behavioral circadian rhythms. Individuals with bipolar disorder who are prescribed lithium and who drink alcohol might be inadvertently altering their sleep and circadian cycles, which may exacerbate their symptoms.

Attempted suicide in people with co-occurring bipolar and substance use disorders: systematic review and meta-analysis

BACKGROUND

Both individuals with bipolar (BD) and those with alcohol (AUD) and other substance (SUD) use disorders are likely to attempt suicide. Comorbidity of BD and AUD/SUD may increase the likelihood of suicide attempts. We conducted a meta-analysis to estimate the association of comorbid AUD/SUD and suicide attempts in subjects with BD in the literature to date.

METHODS

Electronic databases through January 2013 were searched. Studies reporting rates of suicide attempts in people with co-occurring BD and AUD/SUD were retrieved. Comorbid AUD and SUD and suicide attempts rates as well as demographic, clinical, and methodological variables were extracted from each publication or obtained directly from its authors.

RESULTS

Twenty-nine of 222 studies assessed for eligibility met the inclusion criteria, comprising a total of 31,294 individuals with BD, of whom 6308 (20.1%) had documented suicide attempts. There were consistent findings across the studies included. As compared to controls, subjects with BD and comorbid AUD/SUD were more likely to attempt suicide. The cross-sectional association estimates showed random-effects pooled crude ORs of 1.96 (95% CI=1.56-2.47; p<0.01), 1.72 (95% CI=1.52-1.95; p<0.01), and 1.77 (95% CI=1.49-2.10; p<0.01), for combined AUD/SUD, AUD, and SUD. There was no publication bias and sensitivity analyses based on the highest quality studies confirmed core results.

LIMITATIONS

The effects of the number and the type of suicide attempts could not be investigated due to insufficient information.

CONCLUSIONS

Comorbid AUD and SUD in individuals with BD are significantly associated with suicide attempts. Individuals with this comorbidity should be targeted for intensive suicide prevention efforts.

A longitudinal proton magnetic resonance spectroscopy study investigating oxidative stress as a result of alcohol and tobacco use in youth with bipolar disorder

Alcohol and tobacco have been suggested to be "aggravating factors" for neuroprogression in bipolar disorder (BD), however the impact of these substances on the underlying neurobiology is limited. Oxidative stress is a key target for research into neuroprogression in BD and in accordance with this model, our previous cross-sectional studies have found that risky alcohol and tobacco use in BD is associated with increased oxidative stress, investigated via in vivo glutathione (GSH) measured by proton magnetic resonance spectroscopy ((1)H-MRS) in the anterior cingulate cortex (ACC). What remains unknown is whether the negative impact on GSH levels can be modified as a result of limiting alcohol and tobacco use. Thirty BD patients were included in the study. (1)H-MRS and tobacco and alcohol measures were conducted at baseline and follow-up assessments (15.5±4.6 months apart). Pearson׳s correlations were performed between percentage change in GSH concentration and changes in alcohol/tobacco use. Regression analyses were then conducted to further explore the significant correlations. An increase in GSH was associated with a decrease in alcohol consumption (r=-0.381, p<0.05) and frequency of tobacco use (-0.367, p=0.05). Change in alcohol consumption, tobacco use and age were significant predictors of change in GSH concentration (F (3, 26)=3.69, p<0.05). Due to the high comorbidity of alcohol and tobacco use in the sample, the individual effects of these substances on GSH levels could not be determined. This study offers longitudinal evidence that changing risky drinking patterns and tobacco use early in the course of BD is associated with improvements in antioxidant capacity, and therefore may be specific targets for early intervention and prevention of neuroprogression in BD.

Cerebellar volume in schizophrenia and bipolar I disorder with and without psychotic features

OBJECTIVE

There is growing evidence that cerebellum plays a crucial role in cognition and emotional regulation. Cerebellum is likely to be involved in the physiopathology of both bipolar disorder and schizophrenia. The objective of our study was to compare cerebellar size between patients with bipolar disorder, patients with schizophrenia, and healthy controls in a multicenter sample. In addition, we studied the influence of psychotic features on cerebellar size in patients with bipolar disorder.

METHOD

One hundred and fifteen patients with bipolar I disorder, 32 patients with schizophrenia, and 52 healthy controls underwent 3 Tesla MRI. Automated segmentation of cerebellum was performed using FreeSurfer software. Volumes of cerebellar cortex and white matter were extracted. Analyses of covariance were conducted, and age, sex, and intracranial volume were considered as covariates.

RESULTS

Bilateral cerebellar cortical volumes were smaller in patients with schizophrenia compared with patients with bipolar I disorder and healthy controls. We found no significant difference of cerebellar volume between bipolar patients with and without psychotic features. No change was evidenced in white matter.

CONCLUSION

Our results suggest that reduction in cerebellar cortical volume is specific to schizophrenia. Cerebellar dysfunction in bipolar disorder, if present, appears to be more subtle than a reduction in cerebellar volume.

The N-methyl-D-aspartate receptor as a neurobiological intersection between bipolar disorder and alcohol use: a longitudinal mismatch negativity study

BACKGROUND

Comorbid risky alcohol use in bipolar disorder (BD) is recognized for its high prevalence and clinical relevance, though understanding of its neurobiological underpinning is limited. The N-methyl-D-aspartate (NMDA) receptor has recognized alterations in BD and is a major site of ethanol's effects in the brain. The present study aimed to examine the NMDA receptor system in adolescents and young adults with BD by evaluating the longitudinal changes in a robust marker of NMDA function, mismatch negativity (MMN), in relation to changes in alcohol use patterns.

METHODS

Forty-six BD patients (aged 16-30) were recruited at baseline and 59% (n = 27) returned for follow-up 17.9 +/- 7.3 months later. At both time-points a two-tone, passive, duration-deviant MMN paradigm was conducted and alcohol measures were collected. Pearson's correlations were performed between changes in MMN amplitudes and changes in alcohol use. Multiple regression was used to assess whether MMN amplitudes at baseline could predict alcohol use at follow-up.

RESULTS

Reduction in risky drinking patterns was associated with increased temporal MMN and decreased fronto-central MMN. Larger temporal MMN at baseline was a significant predictor of greater alcohol use at follow-up.

CONCLUSIONS

Results suggest risky alcohol use in BD may further compound pre-existing NMDA receptor abnormalities and, importantly, reducing alcohol use early in stages of illness is associated with changes in MMN. This highlights the importance of monitoring alcohol use from first presentation. In addition, preliminary results present an exciting potential for utility of MMN as a neurobiological marker used to determine risk for alcohol misuse in BD.

Psychological Outcomes and Medical Morbidity of Patients With Bipolar Disorder and Co-Occurring Alcohol Use Disorder

OBJECTIVE

Patients with bipolar disorder are at a high risk for comorbid alcohol use disorder, and both disorders are associated with poor outcomes and multiple morbidities. This study aimed to explore not only the psychosocial functioning and psychopathological outcomes but also the medical morbidity of patients with bipolar disorder with and without alcohol use disorder.

METHODS

Outpatients with bipolar I disorder (DSM-IV) were recruited from a psychiatric teaching hospital in Taiwan (N = 393). Data on psychiatric symptoms, psychosocial functioning, and physical health were obtained through interviews with patients and collaterals, patient self-report, and medical record reviews.

RESULTS

Participants had a mean age of 41.1 years (SD = 11.9) and were mostly female (n = 255, 64.9%). Fewer than 10% (n = 34, 8.7%) met criteria for alcohol use disorder, and these participants were more likely to be male, to smoke, and to have a history of rapid cycling, higher mean body mass index, and higher incidences of gastrointestinal and hepatobiliary morbidities. A multiple logistic regression analysis revealed that patients with, versus those without, alcohol use disorder were more prone to gastrointestinal diseases (adjusted OR = 4.25, 95% CI [1.44-12.53], p <.01), hepatobiliary diseases (adjusted OR = 3.14, 95% CI [1.20-8.25], p <.025), and history of rapid cycling (adjusted OR = 2.53, 95% CI [0.91-7.01], p <.075).

CONCLUSIONS

Comorbid alcohol use disorders may have a stronger impact on physical health than on psychosocial or psychopathological outcomes of patients with bipolar disorder.

Prevalence and clinical correlates of alcohol use disorders among bipolar disorder patients: results from the Brazilian Bipolar Research Network

OBJECTIVES

To investigate prevalence rates and clinical correlates of alcohol use disorders (AUD) among bipolar disorder (BD) patients in a large sample from the Brazilian Bipolar Research Network.

METHODS

Four hundred and eighty-three DSM-IV BD patients, divided according to the presence or absence of a lifetime AUD diagnosis (BD-AUD vs. BD-nonAUD), were included. Demographic and clinical characteristics of these two groups were compared. Logistic regression was performed to identify which characteristics were most strongly associated with a lifetime AUD diagnosis.

RESULTS

Nearly 23% presented a lifetime AUD diagnosis. BD-AUD patients were more likely to be male, to present rapid cycling, post-traumatic stress disorder (PTSD), anorexia, other substance use disorders (SUD), family history of SUD, any substance misuse during the first mood episode, history of psychosis, suicide attempts, and younger age at onset of illness than BD-nonAUD patients. Logistic regression showed that the variables most strongly associated with a lifetime AUD diagnosis were SUD (non-alcohol), any substance misuse during the first mood episode, PTSD, male gender, suicide attempt, family history of SUD, and younger age at onset of BD.

CONCLUSIONS

BD-AUD patients begin their mood disorder earlier and present more suicidal behaviors than BD-nonAUD patients. Personal and family history of SUD may be good predictors of comorbid AUD among BD patients. These variables are easily assessed in the clinical setting and may help to identify a particularly severe subgroup of BD patients.

Residual symptoms and functional performance in a large sample of euthymic bipolar patients in France (the OPTHYMUM study)

BACKGROUND

Some residual symptoms were found to be associated with impaired functioning in euthymic bipolar patients, but their impact and relevance are unclear in clinical practice. We re-examined the functional influence of a large set of residual symptoms in 525 euthymic bipolar outpatients using self- and clinician-rated questionnaires (OPTHYMUM study).

METHODS

This was a multi-centre, cross-sectional, non-interventional study of adult bipolar outpatients. All patients were euthymic at the time of assessment (YMRS score <8 and BDRS ≤8). Patients with low functioning (GAF score <60) were compared with the rest of the sample. Patients filled in specific questionnaires concerning their perceptions of different residual and subsyndromal symptoms.

RESULTS

Ninety-seven (97) psychiatrists included 525 patients. Of them, 35 patients had a GAF score <60. These "low functioning patients" were more frequently unemployed, had presented more manic episodes and psychotic symptoms, used more atypical antipsychotics or benzodiazepines and received less adjunctive psychotherapy. Concerning residual symptoms, they had more frequent emotional subsyndromal symptoms, disruption of circadian rhythms and sexual disorders. They perceived some cognitive deficits and suffered more social and family stigma.

LIMITATIONS

Our study used an arbitrary GAF cut-off score (60) to separate bipolar patients in two groups (low and satisfactory functioning).

CONCLUSIONS

Residual symptoms are associated with functional impairment and may represent specific treatment targets. A personalized approach through specific psychotherapeutic programs may lead to more efficient support by the clinician.

Smoking and suicidality in patients with a psychotic disorder

Cigarette smoking has been associated with an increased risk of suicide. Patients with psychosis are more likely to smoke cigarettes and are also at an increased risk of suicide. The aim of this study was to compare risk for suicidal behavior among patients with psychosis who were current smokers, previous smokers and nonsmokers. We studied 1812 of the 1825 participants who took part in the Australian Survey of High Impact Psychosis (SHIP) for whom smoking data was available. We identified predictors for lifetime suicide attempts using univariate logistic regression analysis. These variables were retained for the multiple logistic regression models if they were a significant predictor of lifetime suicide attempts. A series of multiple logistic regressions were then conducted to predict lifetime suicide attempts using current smoking status and lifetime smoking status as independent variables, respectively, while controlling for the retained predictor variables. Current smoking and lifetime smoking were statistically significant predictors of lifetime suicide attempts. However adding the covariates to a logistic regression model reduced this association to non-significance. The strongest predictors were self-harm in the past 12 months, the presence of lifetime depressive symptoms and a diagnosis of psychotic depression. Identification of suicide risk factors is essential for successful suicide prevention. While previous research highlights the importance of cigarette smoking as an important risk factor for suicidal behaviors including in patients with psychosis, these results must be interpreted within the context of methodological issues.

Trait impulsivity is increased in bipolar disorder patients with comorbid alcohol use disorders

BACKGROUND

Up to 60% of bipolar disorder (BD) patients develop alcohol use disorders (AUD) at some point in their lives. The causes of this highly prevalent comorbidity are unknown. High trait impulsivity characterizes both isolated BD and AUD and may be a link to explain the association between BD and AUD. In this study, our aims were to investigate whether BD patients with comorbid AUD would present higher trait impulsivity levels compared to BD patients without comorbid AUD, and whether trait impulsivity levels differ within subgroups of BD according to the subcategory of AUD (abuse vs. dependence, alcoholism alone vs. alcoholism plus drug use disorders).

SAMPLING AND METHODS

Forty-seven outpatients with BD with comorbid AUD (alcoholic BD group) were compared to 66 outpatients with BD alone (nonalcoholic BD group) and to 90 healthy controls (HC). BD and AUD diagnoses were obtained using the Structured Clinical Interview for DSM-IV diagnoses. Impulsivity was assessed using the Barratt Impulsiveness Scale (BIS-11), a self-report instrument that measures trait impulsivity in three domains: nonplanning, attentional and motor.

RESULTS

Alcoholic BD patients scored significantly higher than nonalcoholic BD and HC on the total and on each subscale BIS scores. Within the alcoholic BD patients, alcohol abusers and alcohol dependents did not statistically differ from each other on the BIS-11 scores. BD patients with AUD plus drug use disorders presented statistically higher nonplanning impulsivity than BD patients with AUD alone.

CONCLUSIONS

This was a cross-sectional study and causal inferences about the relationship between impulsivity and the comorbidity phenomenon cannot be made. Increased impulsivity may be a trait marker for the co-occurrence between BD and AUD, and mediate some severe manifestations of this comorbidity.

Bipolar disorder and alcohol use disorder: a review

Bipolar disorder and alcohol use disorder represent a significant comorbid population, which is significantly worse than either diagnosis alone in presentation, duration, co-morbidity, cost, suicide rate, and poor response to treatment. They share some common characteristics in relation to genetic background, neuroimaging findings, and some biochemical findings. They can be treated with separate care, or ideally some form of integrated care. There are a number of pharmacotherapy trials, and psychotherapy trials that can aid program development. Post-treatment prognosis can be influenced by a number of factors including early abstinence, baseline low anxiety, engagement with an aftercare program and female gender. The future development of novel therapies relies upon increased psychiatric and medical awareness of the co-morbidity, and further research into novel therapies for the comorbid group.

Clinical presentations of substance abuse in bipolar heroin addicts at time of treatment entry

BACKGROUND

Studies on the 'self-medication hypothesis' have focused on substance abuse as an attempt to alleviate emotional suffering.

METHODS

We have investigated concomitant substances of abuse in 150 bipolar heroin addicts clustered according to their clinical presentation at treatment entry (depressive episode, hypomanic episode, manic episode and mixed episode). Bipolar heroin addicted patients were chosen because they tend to have a concomitant poly-substance abuse and because, as compared with patients suffering for other mental illnesses, they more clearly reveal a variety of identifiable affective states.

RESULTS

Patients with a depressive episode more frequently used non-prescribed anxiolytic-hypnotics. They were found to use cocaine-amphetamines more frequently during a hypomanic episode, whereas the use of cannabis and cocaine-amphetamines occurred more frequently during a manic episode. The associated use of alcohol, cocaine-amphetamines and cannabinoids was more frequently encountered during a mixed episode.

LIMITATIONS

apart from the difficulty in determining whether the substance use modifies the mood or the mood state determines the substance used, this is a report on a retrospective analysis, rather than a study specifically designed to elucidate the issue; in addition, no information was available on the temperament of our subjects. Assessments of the same subject in various clinical presentations would have provided a better level of information.

CONCLUSIONS

Besides one expected result - the prominent use of CNS stimulants during a depressive phase of bipolar patients - this study supports the hypothesis that mood elation is a pleasurable, rewarding experience that, in bipolar patients, can be started or prolonged by means of CNS stimulant drugs. Stimulant use was, therefore, more prevalent during the 'up' rather than the 'down' phase of the illness.

Neuropsychological functions in bipolar disorders I and II with and without comorbid alcohol dependence

OBJECTIVE

Bipolar disorder (BP) is a mental disorder most likely to co-occur with substance dependence and abuse, especially alcohol dependence (ALD). Whether the effect of comorbid alcoholism is different between the BP-I and BP-II subtypes remains unclear. We aimed to identify the neuropsychological performance of BP patients with and without comorbid ALD in partial remission from depression or mania, and compare it with that of healthy controls (HCs).

METHODS

We recruited 29 HCs and 94 BP patients, whom we categorized into four groups: (1) BP-I without a history of alcohol abuse or dependence (BP-I(-ALD); n=22), (2) BP-II without a history of alcohol abuse and dependence (BP-II(-ALD); n=38), (3) BP-I with comorbid ALD (BP-I(+ALD); n=16), and (4) BP-II with comorbid ALD (BP-II(+ALD); n=18). Only males were recruited in this study.

RESULTS

When patients comorbid with ALD were not excluded, there were no significant differences on neuropsychological tests between the BP-I and BP-II groups. However, when patients with comorbid ALD were excluded, there were significant differences between the two BP(-ALD) groups. The BP-I(-ALD) group had lower scores on memory subtests (p≤0.01) than the HC and BP-II(-ALD) groups, but the BP-II(-ALD) and HC groups had similar scores.

CONCLUSION

We found it important to exclude ALD comorbidity when evaluating neuropsychological functions due to our finding that ALD affected the cognitive performance in BP-I more severely than in the BP-II group. ALD not only impairs neuropsychological function, but also worsen the clinical course and leads to a more pernicious status and negative cycle.

Comorbid anxiety in bipolar spectrum disorders: a neglected research and treatment issue?

BACKGROUND

Anxiety disorders are highly prevalent among patients with bipolar disorder and have a substantial impact on the course of illness and response to treatment. Despite the substantial impact that comorbid anxiety disorders have on the prognosis of individuals with bipolar disorder, many aspects of this comorbidity have received little attention from researchers. This study aims to document the current state of the literature on the comorbidity between anxiety and bipolar disorders by analyzing publication trends on the subject.

METHOD

This study is a quantitative and qualitative review of articles on the comorbidity between anxiety disorders and bipolar disorder published between 1990 and 2010 in the ISI Web of Science, Medline and PsycINFO databases. The number of articles published each year on this comorbidity was calculated and compared to the literature published on bipolar disorder as a whole. Articles were classified into five categories and 13 subcategories to identify the main focuses of the literature and current gaps in the knowledge on the subject.

RESULTS

Interest in the comorbidity between anxiety disorders and bipolar disorder grew continually since 1990, but seems to have reached a plateau. The majority of articles addressing this comorbidity are descriptive in nature, with very few concrete studies examining the mechanisms and treatment approaches that might lead to positive advancements in the field.

LIMITATIONS

Articles written in languages other than English or French were not reviewed.

CONCLUSIONS

It is time to step up research efforts to better understand and manage this under-studied combination of disorders.

Palliative models of care for later stages of mental disorder: maximizing recovery, maintaining hope, and building morale

BACKGROUND

The concept of staging of disease in psychiatry has developed over the past years. A neglected component of this model pertains to people in the advanced stages of a mental illness, who remain symptomatic and functionally impaired despite treatment. These patients are often high service utilizers, receiving complex multimodal treatments where the balance of risk and benefit shifts perceptibly. In this paper, we argue the need to adopt 'palliative' models of care for some individuals, and consider changing the therapeutic goals to follow care pathways similar to those used in other chronic and refractory medical illnesses.

METHOD

Data was sourced by a literature search using Medline and a hand search of scientific journals. Relevant articles were selected.

RESULTS

Clinical staging can help us better define subgroups of patients who will benefit from different goals and treatment. In the most advanced stage group, we find patients with persistent symptoms and treatment resistance. In these situations, it may be preferable to follow some of the principles of palliative care, which include the setting of attainable goals, reduction of side-effects, limited symptom control, targeting identified psychological and social problems, and attempting to attain the best quality of life for these patients and their families.

CONCLUSIONS

It is in the interest of those in the advanced phases of a disorder that clinicians acknowledge the limitations of treatment and actively attempt to plan treatment utilizing alternate models. It is essential to be clear that such approaches do not equate to the abandonment of care, but rather to the reconceptualizing of feasible and personalized treatment goals, a rebalancing of the risks and benefits of intervention, the management of illness behaviour, and the approaches that allow the patient to live gainfully within their limitations.

Association between prior alcohol use disorders and decreased prefrontal gray matter volumes in bipolar I disorder patients

Up to 50% of bipolar disorder (BD) patients present a lifetime diagnosis of alcohol use disorders (AUD). BD patients with comorbid AUD, even when in remission from the AUD, have a poorer outcome and functional impairment than patients with BD alone. The neurobiological abnormalities that potentially characterize this severe subgroup of BD patients are unknown. Our goal was to investigate gray matter (GM) volume abnormalities in BD I patients with comorbid AUD. Twenty-one BD-AUD patients, 21 BD-nonAUD BD patients, and 25 healthy controls (HC), matched by age, gender, and handedness were studied. The BD-AUD patients were in remission from AUD on average for 6.8 years. 3D SPGR MRIs (TR=25 ms, TE=5 ms, slice thickness=1.5 mm) were acquired from all subjects using a 1.5 T GE Signa Imaging System. We used an optimized voxel-based morphometry protocol to compare GM volumes among the groups. BD-AUD patients presented smaller GM volumes in the left medial frontal and the right anterior cingulate gyri compared to BD-nonAUD patients. BDnon-AUD patients did not present GM volume differences compared to HC. These findings provide evidence for an effect of comorbid AUD on regional brain structure of BD I patients and warrant further research on neurobiological aspects of this prevalent and severe comorbidity.