Bipolar disorder and substance abuse

Environmental risk factors for schizophrenia and bipolar disorder from childhood to diagnosis: a Swedish nested case-control study

BACKGROUND

Shared genetic risk between schizophrenia (SCZ) and bipolar disorder (BD) is well-established, yet the extent to which they share environmental risk factors remains unclear. We compare the associations between environmental exposures during childhood/prior to disorder onset with the risk of developing SCZ and BD.

METHODS

We conducted a Swedish register-based nested case-control study using 4184 SCZ cases and 18 681 BD cases diagnosed 1988-2013. Cases were matched to five controls by birth year, birth region, and sex. Conditional logistic regression was used to estimate incidence rate ratios (IRR) for SCZ and BD for each exposure (severe childhood infections, adverse childhood experiences (ACEs), substance use disorders (SUDs), urban birth/longest residence).

RESULTS

All SUD types were associated with very high risk (IRR 4.9-25.5), and all forms of ACEs with higher risk (IRR 1.5-4.3) for both disorders. In the mutually adjusted models, ACEs demonstrated slightly higher risk for BD (SCZ IRR 1.30, 1.19-1.42; BD IRR 1.49, 1.44-1.55), while for SUD, risk was higher for SCZ (SCZ IRR 9.43, 8.15-10.92; BD IRR 5.50, 5.15-5.88). Infections were associated with increased risk of BD (IRR 1.21, 1.17-1.26) but not SCZ. Urban birth and urban longest residence were associated with higher risk of SCZ (IRR 1.19, 1.03-1.37), while only the combination of urban birth and rural longest residence showed higher risk for BD (IRR 1.24, 1.13-1.35).

CONCLUSIONS

There were both shared and unique environmental risk factors: SUDs and ACEs were risk factors for both disorders, while infections were more strongly associated with BD and urbanicity with SCZ.

Mania-related effects on structural brain changes in bipolar disorder - a narrative review of the evidence

Cross-sectional neuroimaging studies show that bipolar disorder is associated with structural brain abnormalities, predominantly observed in prefrontal and temporal cortex, cingulate gyrus, and subcortical regions. However, longitudinal studies are needed to elucidate whether these abnormalities presage disease onset or are consequences of disease processes, and to identify potential contributing factors. Here, we narratively review and summarize longitudinal structural magnetic resonance imaging studies that relate imaging outcomes to manic episodes. First, we conclude that longitudinal brain imaging studies suggest an association of bipolar disorder with aberrant brain changes, including both deviant decreases and increases in morphometric measures. Second, we conclude that manic episodes have been related to accelerated cortical volume and thickness decreases, with the most consistent findings occurring in prefrontal brain areas. Importantly, evidence also suggests that in contrast to healthy controls, who in general show age-related cortical decline, brain metrics remain stable or increase during euthymic periods in bipolar disorder patients, potentially reflecting structural recovering mechanisms. The findings stress the importance of preventing manic episodes. We further propose a model of prefrontal cortical trajectories in relation to the occurrence of manic episodes. Finally, we discuss potential mechanisms at play, remaining limitations, and future directions.

Cannabis use and its relationship with bipolar disorder: A systematic review and meta-analysis

Cannabis use has been stated as a causal risk factor for the occurrence of schizophrenia and other psychotic disorders. There is a dearth of literature stating the association of cannabis with bipolar disorder. This review aimed to find the repercussion of cannabis use on the onset of the first episode of bipolar disorder and the worsening of the symptoms in pre-existing illness. A thorough systematic review of the existing literature was carried out using the PRISMA guidelines. PubMed, Medline, EMBASE, SCOPUS, and Google-scholar databases were searched for studies fitting our study's inclusion and exclusion criteria. A total of 25 studies were included in the systematic review and out of these 25 studies, five prospective studies met the inclusion criteria for the primary outcome meta-analysis. A total sample of 13,624 individuals was included in these five studies. A fixed effect model was used in the meta-analysis of these five studies and it revealed an association between cannabis and bipolar disorder with an effect size of 2.63 (95% CI: 1.95-3.53) (heterogeneity: chi² = 3.01, df = 3 (P = 0.39); I² = 0%). Our findings propose that cannabis use may precipitate or worsen bipolar disorder. This highlights the importance of the detrimental effect of cannabis use on bipolar disorder and the need to discourage cannabis use in the youth culture. High-quality prospective studies are required to delineate the effect of cannabis use on bipolar disorder.

The Use of a Single Dose of Phenobarbital for Inpatient Management of Benzodiazepine Withdrawal: A Case Report

INTRODUCTION

The current standard of care for physiological dependence to benzodiazepines requires prolonged outpatient tapers, which present challenges for patients and providers. Novel protocols for accelerated benzodiazepine tapers are needed. We describe a case of successful management of benzodiazepine withdrawal in the inpatient setting using a single, loading dose of phenobarbital with adjunctive valproate therapy.

CASE REPORT

A 61-year-old woman with benzodiazepine use disorder using 3 to 4 mg of alprazolam daily presented to an inpatient medically supervised withdrawal unit requesting discontinuation of all benzodiazepines and other recreational substances by the time of discharge. Benzodiazepine withdrawal was treated with a single, loading dose of intravenous phenobarbital in line with an approved protocol for the treatment of alcohol withdrawal, as well as adjunctive valproate therapy. The patient experienced resolution of withdrawal symptoms, had no complications, and ongoing abstinence at 60 days of follow-up.

DISCUSSION

A single loading dose of phenobarbital in the inpatient setting is a viable alternative to prolonged outpatient tapers for the management of benzodiazepine withdrawal. Although this strategy requires further optimization, the prospect of a single-dose treatment for benzodiazepine withdrawal creates exciting opportunities for alternative management options and settings.

CONCLUSIONS

This case describes the successful management of benzodiazepine withdrawal syndrome using a single loading dose of intravenous phenobarbital derived from an approved protocol for alcohol withdrawal syndrome.

Ketamine for Bipolar Depression: Biochemical, Psychotherapeutic, and Psychedelic Approaches

Bipolar disorder (type 1) is a serious and chronic psychiatric illness that can be difficult to treat. Many bipolar patients have refractory depressive episodes. Racemic ketamine, a glutamate modulator with prominent dissociate and psychedelic properties, has been demonstrated to have rapid acting antidepressant and anti-obsessional effects which may be useful for treating the symptoms of bipolar depression. Most of the existing research literature on unipolar and bipolar depression has looked at racemic ketamine in the sub-psychedelic dose range given by infusion as a stand-alone treatment (without concurrent psychotherapy). This article expands on the existing research by articulating three different paradigms for ketamine treatment: biochemical, psychotherapeutic, and psychedelic. The authors use composite clinical vignettes to illustrate different ways of working with ketamine to treat bipolar depression, and discuss a variety of clinical considerations for using ketamine with this population, including route, dose, frequency, chemical mitigators, and adverse events. Note that the conceptual paradigms could be applied to any ketamine treatment, with broad applicability beyond bipolar treatment.

Newer antipsychotics: Brexpiprazole, cariprazine, and lumateperone: A pledge or another unkept promise?

Antipsychotic agents are used for various indications in the treatment of psychiatric disorders. Despite their proven roles in multiple conditions, the treatment-emergent side effects of antipsychotic medications, such as metabolic side effects, are often the limiting factor for their long-term and short-term uses. Moreover, antipsychotic medications are often criticized for being less effective in treating different disabling symptoms such as negative symptoms of schizophrenia. As a result, the search for safer and more efficacious antipsychotic agents is ongoing. Newer antipsychotic agents are gaining attention related to emerging efficacy and tolerability data in treating neuropsychiatric conditions. In this review, we attempt to appraise the scientific data on psychopharmacology, safety profile, and efficacy of the newer additions to the list of second-generation antipsychotics, namely brexpiprazole, cariprazine, and lumateperone. We conducted a selective review utilizing PubMed, clinicaltrials.gov, and Cochrane databases to gather appropriate publications, keeping broad inclusion criteria. There were no restrictions on the age of the study population or the year of publication. We also cross-referenced articles and references to capture all existing studies. Our review of the current literature indicates that all three antipsychotic agents appear to be promising based on their short-term studies, while long-term studies remain limited. There is also a need for a head to head comparison between the newer antipsychotics with the other antipsychotic agents to ascertain if the newer agents are any better than the others.

Lithium as a Neuroprotective Agent for Bipolar Disorder: An Overview

Lithium (Li⁺) is a first option treatment for adult acute episodes of Bipolar Disorder (BD) and for the prophylaxis of new depressed or manic episodes. It is also the preferred choice as maintenance treatment. Numerous studies have shown morphological abnormalities in the brains of BD patients, suggesting that this highly heritable disorder may exhibit progressive and deleterious changes in brain structure. Since treatment with Li⁺ ameliorates these abnormalities, it has been postulated that Li⁺ is a neuroprotective agent in the same way atypical antipsychotics are neuroprotective in patients diagnosed with schizophrenia spectrum disorders. Li⁺'s neuroprotective properties are related to its modulation of nerve growth factors, inflammation, mitochondrial function, oxidative stress, and programmed cell death mechanisms such as autophagy and apoptosis. Notwithstanding, it is not known whether Li⁺-induced neuroprotection is related to the inhibition of its putative molecular targets in a BD episode: the enzymes inositol-monophosphatase, (IMPase), glycogen-synthase-kinase 3β (GSK3), and Protein kinase C (PKC). Furthermore, it is uncertain whether these neuroprotective mechanisms are correlated with Li⁺'s clinical efficacy in maintaining mood stability. It is expected that in a nearby future, precision medicine approaches will improve diagnosis and expand treatment options. This will certainly contribute to ameliorating the medical and economic burden created by this devastating mood disorder.

Functional and Mood Outcomes in Bipolar Disorder Patients With and Without Substance Use Disorders Undergoing Psychotherapy

Objectives: Research suggests that patients with co-morbid bipolar disorder (BD) and substance use disorder (SUD) have a poorer illness course and clinical outcome. The evidence is limited as SUD patients are often excluded from BD studies. In particular, evidence regarding long term outcomes from studies using psychotherapies as an adjunctive treatment is limited. We therefore examined data from two studies of Interpersonal Social Rhythm Therapy (IPSRT) for BD to determine whether lifetime or current SUD affected outcomes. Methods: Data were analyzed from two previous clinical trials of IPSRT for BD patients. Change in scores on the Social Adjustment Scale (SAS) from 0 to 78 weeks and cumulative mood scores from 0 to 78 weeks, measured using the Life Interval Follow-Up Evaluation (LIFE), were analyzed. Results: Of 122 patients (non-SUD n = 67, lifetime SUD but no current n = 43, current SUD n = 12), 79 received IPSRT and 43 received a comparison therapy-specialist supportive care-over 18 months. Lifetime SUD had a significant negative effect on change in SAS score but not LIFE score. There was no effect of current SUD on either change in score. Secondary analysis showed no correlation between symptom count and change in SAS total score or LIFE score. Conclusion: Current SUD has no impact on mood or functional outcomes, however, current SUD numbers were small, limiting conclusions. Lifetime SUD appears to be associated with impaired functional outcomes from psychotherapy. There is limited research on co-morbid BD and SUD patients undergoing psychotherapy.

Reducing Addiction in Bipolar Disorder via Hacking the Dopaminergic System

The dopaminergic system plays a central and decisive role in substance use disorder (SUD), bipolar disorder (BD), and possibly in a subgroup of patients with refractory depression. Common genetic markers and underlying cellular processes, such as kindling, support the close link between these disorders, which is also expressed by the high rate of comorbidity. Although partial dopamine agonists/antagonists acting on D₂ and D₃ receptors have an established role in treating BD, their usefulness in SUD is less clear. However, dopamine D₃ receptors were shown to play a central role in SUD and BD, making D₂/D₃ partial agonists/antagonists a potential target for both disorders. This narrative review examines whether these substances bear the promise of a future therapeutic approach especially in patients with comorbid BD and SUD.

A Naturalistic Study of Youth Referred to a Tertiary Care Facility for Acute Hypomanic or Manic Episode

Background: Bipolar Disorders (BD) in youth are a heterogeneous condition with different phenomenology, patterns of comorbidity and outcomes. Our aim was to explore the effects of gender; age at onset (prepubertal- vs. adolescent-onset) of BD; and elements associated with attention deficit hyperactivity disorder (ADHD) and Substance Use Disorder (SUD) comorbidities, severe suicidal ideation or attempts, and poorer response to pharmacological treatments. Method: 117 youth (69 males and 57 females, age range 7 to 18 years, mean age 14.5 ± 2.6 years) consecutively referred for (hypo)manic episodes according to the Diagnostic and Statistical Manual of Mental Disorders, 54th ed (DSM 5) were included. Results: Gender differences were not evident for any of the selected features. Prepubertal-onset BD was associated with higher rates of ADHD and externalizing disorders. SUD was higher in adolescent-onset BD and was associated with externalizing comorbidities and lower response to treatments. None of the selected measures differentiated patients with or without suicidality. At a 6-month follow up, 51.3% of the patients were responders to treatments, without difference between those receiving and not receiving a psychotherapy. Clinical severity at baseline and comorbidity with Conduct Disorder (CD) and SUD were associated with poorer response. Logistic regression indicated that baseline severity and number of externalizing disorders were associated with a poorer outcome. Conclusions: Disentangling broader clinical conditions in more specific phenotypes can help timely and focused preventative and therapeutic interventions.

The development of a theoretically derived measure exploring extreme appraisals of sleep in bipolar disorder: a Delphi study with professionals

BACKGROUND

Sleep and mood are known to be linked and this is particularly evident in people with a diagnosis of bipolar disorder (BD). It has been proposed that psychological interventions improving sleep can be a pathway for improving mood. In order for a psychological sleep intervention to be appropriate, the common cognitive processes maintaining the range of sleep disturbances need to be investigated.

AIM

This study aimed to explore and identify expert consensus on positive and negative sleep appraisals in the context of low and high mood states, using the Integrative Cognitive Model as a theoretical guide.

METHOD

A Delphi approach was utilized to allow clinical and research professionals, with experience in the field of BD, to be anonymously consulted about their views on sleep appraisals. These experts were invited to participate in up to three rounds of producing and rating statements that represented positive and negative sleep appraisals.

RESULTS

A total of 38 statements were developed and rated, resulting in a final list of 19 statements that were rated as 'essential' or 'important' by >80% of the participants. These statements represent the full range of extreme sleep appraisals this study had set out to explore, confirming the importance of better understanding and identifying positive and negative sleep cognitions in the context of high and low mood.

CONCLUSION

The statements reviewed in this study will be used to inform the development of a sleep cognition measure that may be useful in cognitive therapy addressing sleep disturbances experienced along the bipolar spectrum.

Sleep and sleep treatments in bipolar disorder

Sleep and circadian disturbances in bipolar disorder are common and persistent within and between illness episodes. Insomnia, hypersomnia, reduced need for sleep, sleep schedule variability and circadian rhythm disorders are frequently observed. In this article, recent research is reviewed suggesting that the presence of sleep disturbance is associated with functional impairment, interacts with other physical and environmental systems (e.g. physical activity, light exposure), and may attenuate response to treatment. Established and emerging treatments for various sleep disturbances are reviewed, with emphasis on applications for light therapy and adapted cognitive behavioral therapy. There remains a critical need to understand the co-occurrence of various sleep disturbances, develop, and refine treatment approaches (especially for hypersomnia/long sleep duration) and adapt wearable and smartphone technologies to aid assessment and intervention.

The link between bipolarity and substance use: A controlled clinic based study

OBJECTIVES

Because of high rates of co-occurrence, common familial risk, and phenotypic similarities, we conjectured that substance use and bipolar disorder might have a common substrate of origin in bipolarity and that they might lie on a continuum of bipolarity. Thus it was aimed to investigate the association between bipolarity and substance use through a controlled, clinic based study.

METHODS

Cross sectional assessment and comparison of bipolarity as trait in four groups, namely the substance use disorder (SUD), bipolar disorder (BPAD), dual diagnosis (DD), and the healthy control (HC) groups. Bipolar spectrum diagnostic scale (BSDS) was used. The quality of life in these four groups was also assessed using WHOQOL-Bref scale.

RESULTS

The mean Bipolar spectrum diagnostic scale (BSDS) score in SUD was 11.0 ± 5.3 which was more than that of HC (6.2 ± 3.9) and lesser than that in BPAD (18.4 ± 4.2) and DD (20.6 ± 3.6). Differences among all four groups were statistically significant. SUD group was found to have significantly higher score than healthy control. The BSDS score of DD and BPAD groups were higher than those of SUD but the difference between BPAD and DD was non-significant.

DISCUSSION

The results showed a potential association between substance dependence and bipolarity. Mood dysregulation appears to be the link between the two. The gradient of bipolarity detected by BSDS screener suggests a continuum model between substance use and bipolar disorder. However, this is a clinic based study and only male patients have been taken for study.

A Prospective Comparison of Bipolar I and II Subjects With and Without Comorbid Alcohol Dependence From the COGA Dataset

Objective: Comorbidity of alcohol use disorders in bipolar subjects is high as indicated by epidemiological and clinical studies. Though a more severe course of bipolar disorder in subjects with comorbid alcohol dependence has been reported, fewer studies considered the longitudinal course of alcohol dependence in bipolar subjects and the prospective course of comorbid bipolar II subjects. Beside baseline analysis, longitudinal data of the COGA (Collaborative Study on Genetics in Alcoholism) were used to evaluate the course of bipolar I and II disordered subjects with and without comorbid alcohol dependence over more than 5 years of follow-up. Methods: Characteristics of bipolar disorder, alcohol dependence and comorbid psychiatric disorders were assessed using semi-structured interviews (SSAGA) at baseline and at a 5-year follow-up. Two hundred twenty-eight bipolar I and II patients were subdivided into groups with and without comorbid alcohol dependence. Results: Of the 152 bipolar I and 76 bipolar II patients, 172 (75, 4%) had a comorbid diagnosis of alcohol dependence. Bipolar I patients with alcohol dependence, in particular women, had a more severe course of bipolar disorder, worse social functioning and more suicidal behavior than all other groups of subjects during the 5-year follow-up. In contrast, alcohol dependence improved significantly in both comorbid bipolar I and II individuals during this time. Conclusions: A 5-year prospective evaluation of bipolar patients with and without alcohol dependence confirmed previous investigations suggesting a more severe course of bipolar disorder in comorbid bipolar I individuals, whereas bipolar II individuals were less severely impaired by comorbid alcohol use disorder. While severity of alcohol dependence improved during this time in comorbid alcohol-dependent bipolar I patients, the unfavorable outcome for these individuals might be due to the higher comorbidity with personality and other substance use disorders which, together with alcohol dependence, eventually lead to poorer symptomatic and functional clinical outcomes.

The impact of substance use disorders on recovery from bipolar depression: Results from the Systematic Treatment Enhancement Program for Bipolar Disorder psychosocial treatment trial

OBJECTIVE

Up to 60% of patients with bipolar disorder develop a substance use disorder during their lifetime. The purpose of this paper was to assess the impact of substance use disorders on depression recovery among bipolar patients randomly assigned to different psychotropic medications and psychosocial interventions. We hypothesized that patients with a comorbid substance use disorder would benefit less from psychotherapy regardless of treatment intensity/length compared to patients without a comorbid substance use disorder.

METHOD

We conducted post hoc analyses among bipolar disorder patients ( n = 270) with and without comorbid substance use disorders enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder randomized psychosocial intervention trial. All patients entered during or shortly after the onset of a bipolar depressive episode. Logistic regression and Cox proportional hazard models were used to assess whether current or past substance use disorders moderated the response of patients to intensive psychosocial intervention or brief psychoeducation with collaborative care, operationalized as full recovery from an episode of bipolar depression.

RESULTS

Current comorbid substance use disorders significantly predicted likelihood of recovery (odds ratio = 2.25, p = 0.025) and time to recovery (odds ratio = 1.71, p = 0.006) from bipolar depression. We found that 74.5% of patients with a current substance use disorder, compared to 56.5% without a current substance use disorder, recovered from bipolar depression. Past substance use disorders did not predict likelihood of recovery or time to recovery. Current substance use disorders did not significantly moderate response to intensive psychotherapy versus collaborative care.

CONCLUSION

Contrary to our hypotheses, bipolar disorder participants with a current comorbid substance use disorder were more likely to recover from psychosocial treatment for bipolar depression than patients without a current comorbid substance use disorder. If this finding is replicated, it has implications for the ordering of treatment for patients with comorbid bipolar disorder and substance use disorders.

Factors associated with lifetime suicidal ideation and suicide attempts in outpatients with substance use disorders

Risks factors for suicide are multiple and highly prevalent in addicted patients (previous suicide attempts, substance abuse, impulsivity, history of sexual abuse and other factors). The aim of this study is to identify and to compare the clinical and socio-demographic profile of SUD outpatients with lifetime suicidal behavior (previous suicidal ideation and/or suicide attempts) and to analyze the factors related to it. A retrospective cohort study of 696 addicted patients, according to DSM-IV-TR criteria (APA, 2000) were collected from the Addiction Unit of Vall d'Hebron University Hospital. Lifetime suicidal ideation in addicted patients is associated with presence of: borderline personality disorder (BPD), depressive disorders, sexual abuse, polydrug abuse, attention-deficit hyperactivity disorder, and motor impulsivity. The factors associated with suicide attempts were: borderline personality disorder, lifetime abuse (whether emotional, physical or sexual), co-occurrent psychotic disorders, polydrug abuse, anxiety disorders and depressive symptoms. We conclude that previous suicidal ideation and lifetime suicide attempts should be considered in the clinical care of addicted patients. Factors related to both suicidal behaviors share similarities and differences according to our findings and need to be deeply explored in the future.

Demographic, physical and mental health assessments in the adolescent brain and cognitive development study: Rationale and description

The Adolescent Brain and Cognitive Development (ABCD) Study incorporates a comprehensive range of measures assessing predictors and outcomes related to both mental and physical health across childhood and adolescence. The workgroup developed a battery that would assess a comprehensive range of domains that address study aims while minimizing participant and family burden. We review the major considerations that went into deciding what constructs to cover in the demographics, physical health and mental health domains, as well as the process of selecting measures, piloting and refining the originally proposed battery. We present a description of the baseline battery, as well as the six-month interim assessments and the one-year follow-up assessments. This battery includes assessments from the perspectives of both the parent and the target youth, as well as teacher reports. This battery will provide a foundational baseline assessment of the youth's current function so as to permit characterization of stability and change in key domains over time. The findings from this battery will also be utilized to identify both resilience markers that predict healthy development and risk factors for later adverse outcomes in physical health, mental health, and substance use and abuse.

Who's the Leader, Mania or Depression? Predominant Polarity and Alcohol/Polysubstance Use in Bipolar Disorders

BACKGROUND

Predominant polarity characterises patients who mainly manifest recurrences of depression or mania/hypomania. Alcohol use disorder (AUD) and polysubstance use (PSU), which often complicate bipolar disorder (BD) and affect its clinical course, can influence predominant polarity. Nevertheless, previous studies have not clarified if BD patients differ in predominant polarity from BD patients with substance use disorder (SUD) comorbidity.

OBJECTIVE

The aim of this study was to compare predominant polarity between BD without SUD, BD with AUD and BD with PSU. We also investigated the association between predominant polarity and first episode polarity in each diagnostic group.

METHOD

We evaluated predominant polarity (≥2:1 lifetime depressive vs. manic/hypomanic episodes) in 218 DSM-IV-TR BD patients. Specifically, data were obtained from 86 patients with BD without SUD, 69 patients with BD and AUD, and 63 patients with BD and PSU with alcohol as the primary substance abused.

RESULTS

The three groups significantly differed for predominant polarity. The most common predominant polarity in BD without SUD was manic, while in BD with AUD and in BD with PSU it was depressive. Uncertain predominant polarity was the least common in BD without SUD and BD with PSU, whereas in BD with AUD, manic predominant polarity was least common. Predominant polarity matched onset polarity in all groups.

CONCLUSION

BD without SUD, BD with AUD, and BD with PSU have different predominant polarities. The correspondence between predominant polarity and polarity at the onset may impact diagnosis and treatment of BD.

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.

Alcohol use is associated with thinner cerebral cortex and larger ventricles in schizophrenia, bipolar disorder and healthy controls

BACKGROUND

Excessive alcohol use is associated with brain damage but less is known about brain effects from moderate alcohol use. Previous findings indicate that patients with severe mental illness, particularly schizophrenia, are vulnerable to alcohol-related brain damage. We investigated the association between levels of alcohol consumption and cortical and subcortical brain structures in schizophrenia and bipolar disorder patients and healthy controls, and investigated for group differences for this association.

METHOD

1.5 T structural magnetic resonance images were acquired of 609 alcohol-using participants (165 schizophrenia patients, 172 bipolar disorder patients, 272 healthy controls), mean (s.d.) age 34.2 (9.9) years, 52% men. Past year alcohol use was assessed with the Alcohol Use Disorder Identification Test - Consumption part (AUDIT-C). General linear models were used to investigate associations between AUDIT-C score and cortical thickness, surface area, and total brain and subcortical volumes.

RESULTS

Increasing AUDIT-C score was linearly associated with thinner cortex in medial and dorsolateral frontal and parieto-occipital regions, and with larger left lateral ventricle volume. There was no significant interaction between AUDIT-C score and diagnostic group. The findings remained significant after controlling for substance use disorders, antipsychotic medication and illness severity.

CONCLUSION

The results show a dose-dependent relationship between alcohol use and thinner cortex and ventricular expansion. The findings are present also at lower levels of alcohol consumption and do not differ between schizophrenia or bipolar disorder patients compared to healthy controls. Our results do not support previous findings of increased vulnerability for alcohol-related brain damage in severe mental illness.

Comorbidity of bipolar and substance use disorders in national surveys of general populations, 1990-2015: Systematic review and meta-analysis

BACKGROUND

Substance use disorders (SUDs) are common in people with a bipolar disorder (BD). This systematic review and meta-analysis aimed to estimate the prevalence rates of SUDs in persons with BD based on national or international surveys of household populations.

METHODS

Studies published from 1990 to Dec 31, 2015 were identified from MEDLINE, EMBASE. psychINFO, and CINAHL databases and reference lists. We calculated prevalence rates and conducted meta-analysis with random-effects model.

RESULTS

We identified 9 unique surveys of which two surveys were repeated 10 years later using independent samples. The total sample size was 218,397 subjects. The mean prevalence for any illicit drug use disorder was 17%, for alcohol use disorder (AUD) it was 24% and SUD it was 33%. The strongest associations were found between BD and illicit drug use (pooled odds ratio (OR) 4.96, 95% CI 3.98-6.17) followed closely by BD and AUD (OR 4.09, 95% CI 3.37-4.96). The association was higher for BD respondents using illicit drugs compared to bipolar II respondents (ORs 7.48 vs. 3.30).

LIMITATIONS

Some of the meta-analysis grouped illicit substances together without taking into consideration types of substance use which may differ widely between countries and over time. All included studies were cross-sectional so onset and causality can not be determined.

CONCLUSIONS

The meta-analysis revealed that people with an alcohol use disorder were 4.1 times of greater risk of having a BD compared to those without an AUD. The risks were even higher for illicit drug users where they were 5.0 times of greater risk of having BD compared to non-users. These data confirm strong associations between co-occurring SUDs and BD, indicating a need for more informative studies to help develop better interventions in treating persons with BD and comorbid SUDs.

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.

Interventions for Sleep Disturbance in Bipolar Disorder

Bipolar disorder is a severe and chronic disorder, ranked in the top 10 leading causes of disability worldwide. Sleep disturbances are strongly coupled with interepisode dysfunction and symptom worsening in bipolar disorder. Experimental studies suggest that sleep deprivation can trigger manic relapse. There is evidence that sleep deprivation can have an adverse impact on emotion regulation the following day. The clinical management of the sleep disturbances experienced by bipolar patients, including insomnia, hypersomnia delayed sleep phase, and irregular sleep-wake schedule, may include medication approaches, psychological interventions, light therapies and sleep deprivation.

Demographic and clinical characteristics associated with comorbid cannabis use disorders (CUDs) in hospitalized patients with bipolar I disorder

BACKGROUND

Published data suggest that cannabis use is associated with several negative consequences for individuals with bipolar disorder (BD), including new manic episode onset, psychosis, and functional disability. Yet much less is known about cannabis use disorders (CUDs) in this population, especially in more acutely symptomatic groups.

METHODS

To evaluate correlates of CUD comorbidity in BD, a retrospective chart review was conducted for 230 adult patients with bipolar I disorder (BDI) who were admitted to a university-affiliated private psychiatric hospital. Using a computer algorithm, a hospital administrator extracted relevant demographic and clinical data from the electronic medical record for analysis.

RESULTS

Thirty-six (16%) had a comorbid CUD. CUD comorbidity was significantly associated with younger age, manic/mixed episode polarity, presence of psychotic features, and comorbid nicotine dependence, alcohol use disorder (AUD), and other substance use disorders, but was associated with decreased likelihood of anxiety disorder comorbidity. With the exception of manic/mixed polarity and AUD comorbidity, results from multivariate analyses controlling for the presence of other SUDs were consistent with univariate findings.

CONCLUSION

Patients with BD and comorbid CUDs appear to be a complex population with need for enhanced clinical monitoring. Given increasing public acceptance of cannabis use, and the limited availability of evidenced-based interventions targeted toward CUDs in BD, psychoeducation and other treatment development efforts appear to be warranted.

Identification of circadian gene variants in bipolar disorder in Latino populations

BACKGROUND

Variations in circadian genes can impact biological rhythms. Given the rhythm disturbances that characterize bipolar disorder (BD), genes encoding components of molecular clocks are good candidate genes for the illness.

METHODS

A family based association analysis of circadian gene single nucleotide polymorphisms (SNPs) and BD was conducted in Latino pedigrees. 884 individuals from 207 pedigrees (473BP phenotype and 411 unaffected family members) were genotyped. Family based single marker association testing was performed. Ancestral haplotypes (SNPs found to be in strong LD defined using confidence intervals) were also tested for association with BD.

RESULTS

Multiple suggestive associations between circadian gene SNPs and BD were noted. These included CSNK1E (rs1534891, p=0.00689), ARNTL (rs3789327, p=0.021172), CSNK1D (rs4510078, p=0.022801), CLOCK (rs17777927, p=0.031664). Individually, none of the SNPs were significantly associated with BD after correction for multiple testing. However, a 4-locus CSNK1E haplotype encompassing the rs1534891 SNP (Z-score=2.685, permuted p=0.0076) and a 3-locus haplotype in ARNTL (Z-score=3.269, permuted p=0.0011) showed a significant association with BD.

LIMITATIONS

Larger samples are required to confirm these findings and assess the relationship between circadian gene SNPs and BD in Latinos.

CONCLUSIONS

The results suggest that ARNTL and CSKN1E variants may be associated with BD. Further studies are warranted to assess the relationships between these genes and BD in Latino populations.

Impact of Cannabis Use on Long-Term Remission in Bipolar I and Schizoaffective Disorder

OBJECTIVE

To investigate the impact of regular cannabis use on long-term remission of mood symptoms in bipolar spectrum disorders.

METHODS

The 24-month prospective observational study included patients (n=239) with bipolar I disorder and schizoaffective disorder, bipolar type. Participants were classified as regular cannabis users (three times or more per week) or non-users. The primary outcome measure was the achievement of remission on the evaluations during the 24 months.

RESULTS

Of the 234 participants for whom data was available, 25 (10.7%) were regular cannabis users, and the group comprised significantly more males than females. In the total population, cannabis use was significantly associated with decreased likelihood of remission during the 24-month follow-up period. Subgroup analyses showed that cannabis use was significantly associated with lower remission rates on the Hamilton Depression Rating Scale in females (n=139) and patients prescribed mood stabilizers alone (n=151), whereas in males (n=95) and patients prescribed olanzapine and/or a mood stabilizer (n=83), cannabis use was significantly associated with lower remission rates on the Young Mania Rating Scale. Remission rates were lowest in the concurrent cannabis and tobacco smoking group (n=22) followed by the tobacco smoking only group (n=97), and the non-smoker group (n=116). The post-hoc analysis revealed that all remission rates were significantly lower in the concurrent cannabis and the tobacco smoking group compared to the non-smoker group.

CONCLUSION

Cannabis use negatively affects the long-term clinical outcome in patients with bipolar spectrum disorders. A comprehensive assessment and integrated management of cannabis use are required to achieve better treatment outcomes for bipolar spectrum disorders.

A comparative study of caregivers' perceptions of health-care needs and burden of patients with bipolar affective disorder and schizophrenia

BACKGROUND

Although many studies in schizophrenia have evaluated health-care needs, there is a lack of data on the needs of patients with bipolar affective disorder (BPAD), with only occasional studies evaluating them, and no study has evaluated the relationship of health-care needs of patients with caregiver's burden.

AIM

To study the relationship of caregiver's burden and needs of patients as perceived by caregivers of patients with BPAD and schizophrenia.

METHOD

Caregivers of patients with BPAD and schizophrenia were assessed using the Camberwell Assessment of Needs - Research version (CAN-R) and Supplementary Needs Assessment Scale (SNAS), the Family Burden Interview schedule (FBI) and the Involvement Evaluation Questionnaire (IEQ).

RESULTS

Mean total needs of patients on CAN-R were 7.54 (SD 3.59) and 7.58 (SD 4.24) for BPAD and schizophrenia respectively. Mean total needs for SNAS were 7.24 (SD 3.67) and 7.68 (SD 5.02) for BPAD and schizophrenia groups, respectively. Total objective and subjective burden as assessed on FBI was significantly more for the schizophrenia group. Caregivers of patients with BPAD perceived significantly less disruption of routine family activities and lower impact on the mental health of others. On IEQ, the mean score on the domain of supervision was significantly higher for the BPAD group. In the schizophrenia group, positive correlations were seen between the total number of unmet and total (met and unmet) needs and certain aspects of burden, but no such correlations emerged in the BPAD group.

CONCLUSION

There is no correlation between number of needs and burden in the BPAD group; however, in the schizophrenia group the number of needs correlated with the perceived burden. Accordingly, orienting services to address needs of patients with schizophrenia can lead to reduction in burden among caregivers.

Six-month outcome in bipolar spectrum alcoholics treated with acamprosate after detoxification: a retrospective study

Background: Glutamate system is modified by ethanol and contributes both to the euphoric and the dysphoric consequences of intoxication, but there is now growing evidence that the glutamatergic system also plays a central role in the neurobiology and treatment of mood disorders, including major depressive disorders and bipolar disorders. We speculate that, using acamprosate, patients with bipolar depression (BIP-A) can take advantage of the anti-glutamate effect of acamprosate to “survive” in treatment longer than peers suffering from non-bipolar depression (NBIP-A) after detoxification. Method: We retrospectively evaluated the efficacy of a long-term (six-month) acamprosate treatment, after alcohol detoxification, in 41 patients (19 males and 22 females), who could be classified as depressed alcoholics, while taking into account the presence/absence of bipolarity. Results: During the period of observation most NBIP-A patients relapsed, whereas a majority of BIP-A patients were still in treatment at the end of their period of observation. The cumulative proportion of ‘surviving’ patients was significantly higher in BIP-A patients, but this finding was not related to gender or to other demographic or clinically investigated characteristics. The treatment time effect was significant in both subgroups. The treatment time-group effect was significant (and significantly better) for bipolar patients on account of changes in the severity of their illness. Limitations: Retrospective methodology and the lack of DSM criteria in diagnosing bipolarity. Conclusions: Bipolarity seems to be correlated with the efficacy of acamprosate treatment in inducing patients to refrain from alcohol use after detoxification (while avoiding relapses) in depressed alcoholics. Placebo-controlled clinical trials are now warranted to check the validity of this hypothesis.

Future pharmacological treatments for substance use disorders

Substance use disorders represent a serious public health and social issue worldwide. Recent advances in our understanding of the neurobiological basis of the addictive processes have led to the development of a growing number of pharmacological agents to treat addictions. Despite this progress, there are no approved pharmacological treatments for cocaine, methamphetamine and cannabis addiction. Moving treatment development to the next stage will require novel ways of approaching substance use disorders. One such novel approach is to target individual vulnerabilities, such as cognitive function, sex differences and psychiatric comorbidities. This review provides a summary of promising pharmacotherapies for alcohol, opiate, stimulant and nicotine addictions. Many medications that target positive and negative reinforcement of drugs, as well as individual vulnerabilities to addiction, are in different phases of development. Clinical trials testing the efficacy of these medications for substance use disorder are warranted.

Association between family history of mood disorders and clinical characteristics of bipolar disorder: results from the Brazilian bipolar research network

OBJECTIVES

To compare clinical characteristics of bipolar disorder (BD) in patients with and without a family history of mood disorders (FHMD) in a large sample from the Brazilian Research Network of Bipolar Disorders.

METHODS

Four-hundred eighty-eight DSM-IV BD patients participating in the Brazilian Research Network of Bipolar Disorders were included. Participants were divided between those with FHMD (n=230) and without FHMD (n=258). We compared these two groups on demographic and clinical variables and performed a logistic regression to identify which variables were most strongly associated with positive family history of mood disorders.

RESULTS

BD patients with FHMD presented with significantly higher lifetime prevalence of any anxiety disorder, obsessive-compulsive disorder, social phobia, substance abuse, and were more likely to present history of suicide attempts, family history of suicide attempts and suicide, and more psychiatric hospitalizations than BD patients without FHMD. Logistic regression showed that the variables most strongly associated with a positive FHMD were any comorbid anxiety disorder, comorbid substance abuse, and family history of suicide.

LIMITATIONS

Cross-sectional study and verification of FHMD by indirect information.

CONCLUSION

BD patients with FHMD differ from BD patients without FHMD in rates of comorbid anxiety disorder and substance abuse, number of hospitalizations and suicide attempts. As FHMD is routinely assessed in clinical practice, these findings may help to identify patients at risk for particular manifestations of BD and may point to a common, genetically determined neurobiological substrate that increases the risk of conditions such as comorbidities and suicidality in BD patients.

Effect of alcohol use on the course of bipolar disorder: one-year follow-up study using the daily prospective Life Chart method

OBJECTIVES

Relatively little is known about the temporal relationship between alcohol use and subsequent mood changes in patients with bipolar disorder, and the available findings are inconsistent. The present study was a fine-grained analysis of the temporal relationship between alcohol use and short-term mood-switching probabilities.

METHODS

The study included 137 patients with bipolar disorder who performed daily self-ratings of their mood symptoms and the number of alcohol units consumed for a period of up to 52 weeks by using the National Institute of Mental Health self-rated prospective Life Chart Method. At baseline, the Structured Clinical Interview for DSM-IV was administered and demographic, social, and clinical characteristics were obtained. Multi-state models were used to assess the impact of the number of alcoholic drinks on patients' transition through different states of mood (depression, euthymia, and mania).

RESULTS

The effect of alcohol use on the change in mood states was limited. For women in a depressive state, higher alcohol use was associated with a shorter time before entering the euthymic state [hazard ratio (HR) = 1.18, 95% confidence interval (CI): 1.03-1.36, p < 0.05], whereas, for men in an euthymic state, higher alcohol use was associated with a longer time before entering a manic state (HR = 0.81, 95% CI: 0.71-0.92, p < 0.05). The correlation between the consumed number of drinks per week and the average mood severity score of the following week was -0.01 (p < 0.001), indicating that only 0.01% of the variance in mood severity in this population is explained by alcohol use. Possible explanations for these findings are discussed.

CONCLUSIONS

The current study, using a fine-grained analysis, suggests that alcohol use does not have a direct effect on the course of bipolar disorder in patients using mood stabilizers.

Insomnia comorbid to severe psychiatric illness

In psychiatric illness, there is a growing body of evidence indicating that sleep disturbances exert a detrimental influence on the course of these disorders and contribute to impaired function. Even when psychiatric disorders are successfully treated or stabilized, insomnia and other sleep disturbances often fail to remit. The present review focuses on sleep in two severe mental illnesses, namely bipolar disorder and schizophrenia. This article discusses the role of sleep disturbances and altered sleep architecture in relation to symptom status, functional impairment, quality of life, and the course of these disorders. Current evidence regarding pharmacological and psychological treatment approaches for insomnia in these populations is presented. This review also notes considerations for adapting Cognitive Behavioral Therapy for insomnia (CBT-I) procedures for severe mental illness and proposes directions for future research.

Characterizing the longitudinal patterns of substance use among individuals diagnosed with serious mental illness after psychiatric hospitalization

AIM

To characterize longitudinal patterns of substance use across a large sample of psychiatric patients discharged from inpatient admission, followed for 1-year post-hospitalization.

DESIGN

Prospective cohort study.

SETTING

Kansas City, MO, USA; Pittsburgh, PA, USA; Worcester, MA, USA.

PARTICIPANTS

Eight hundred and one schizophrenia-spectrum (n = 204), bipolar (n = 137) and depressive disorder (n = 460) patients from the MacArthur Violence Risk Assessment Study.

MEASUREMENTS

Symptoms, functioning, drug/alcohol use assessed by the Brief Psychiatric Rating Scale, the Global Assessment of Functioning, and substance use interviews.

FINDINGS

Patients used alcohol (67.0%; n = 540) and cannabis (30.0%; n = 237) more frequently than other substances up to 30 days before admission, and those with depressive and schizophrenia-spectrum used heroin more than individuals with bipolar (P = 0.023). Post-hospitalization, patients using alcohol (B = -0.15, P < 0.001) and cannabis (B = -0.27, P < 0.001) decreased, but patterns varied across diagnosis and genders. Patients using cannabis decreased at greater rates in depressive and schizophrenia-spectrum compared with bipolar (all P < 0.05), and more men used alcohol (B = 0.76, P < 0.001) and cannabis (B = 1.56, P < 0.001) than women. Cannabis (B = 1.65, P < 0.001) and alcohol (B = 1.04, P = 0.002) were associated with higher symptomatology; cannabis (B = -2.33, P < 0.001) and alcohol (B = -1.45, P = 0.012) were associated with lower functioning.

CONCLUSIONS

Substance use is frequent and associated with poor recovery in patients with serious mental illness recently discharged from psychiatric hospitalization. Addiction treatments personalized by diagnosis and gender may be effective for improving outcomes in people with serious mental illness.

Predictors of good outcome in patients with refractory bipolar disorder after a drug or a drug and cognitive-behavioral treatment

OBJECTIVE

The objective of the present research study was to analyze the variables involved in the favorable prognosis of patients with refractory bipolar disorder after a drug or a drug and cognitive-behavioral treatment.

METHODS

A sample of 40 patients was divided into 2 groups: (1) combined drug plus psychoeducational and cognitive-behavioral treatment or (2) drug treatment only (control group). We used a multigroup design with repeated measures at different times (baseline, posttreatment, 6-month follow-up, and 12-month follow-up) to evaluate the following variables: age, sex, number of hospitalizations, type of treatment, mania (Young Mania Rating Scale, or YMRS) and depression (Beck Depression Index, or BDI) symptoms, subsyndromal symptoms (BDI >7; YMRS >6), global suffering index, general index of social ability, self-esteem (Rosenberg scale), inadaptation (inadaptation Scale), anxiety (State-Trait Anxiety Inventory), quality of life (Global Activity Functioning), and health (European Quality of Life Scale). We considered favorable prognosis for subjects without persistent affective symptoms (BDI <7; YMRS <6) and/or without relevant difficulties in adaptation (Inadaptation Scale <14) in a 12-month follow-up.

RESULTS

A binary logistic regression showed that the type of treatment (combined therapy corresponded to better progression), the number of prior hospitalizations (fewer hospitalizations corresponded to better progression), and self-esteem (higher self-esteem corresponded to better prognosis) were statistically significant.

CONCLUSIONS

The type of treatment, the number of prior hospitalizations, and the level of self-esteem were the most influencing factors for a favorable progression of refractory bipolar disorder. Differently from other studies, no significant influences of age, sex, subsyndromal symptoms, anxiety, and depression symptoms on the prognosis of refractory bipolar disorder were observed in our study.

Differences in substance-related risk behavior between dual and triple diagnosed severely mentally ill adults

OBJECTIVES: The purpose of this study was to determine if differences exist between adults with dual and triple diagnoses with regard to substance-related risk behaviors. METHODS: This secondary analysis was a cross-sectional study. There were 252 subjects with dual and triple diagnoses recruited from residential crisis programs in San Francisco. Using descriptive and logistic regression analyses, subjects in the two groups were compared with regard to demographic data, types of substances, and routes of administration used in the previous 30 days to determine risk for exposure and/or transmission of HIV/HCV. RESULTS: When compared to the dual diagnosis group, subjects with triple diagnoses were four times more likely to have engaged in IDU (p=.001) and 2.6 times more likely to use amphetamines (p=.05). They also reported using more types of substances over the lifetime (p<.0001). But with regard to other risk behaviors such as alcohol use to intoxication and cocaine/crack use, there were no significant differences. CONCLUSION: Though many substance-related risk behaviors occurred in both groups, adults with triple diagnoses were more likely to engage in IDU, amphetamine use, and to use more types of substances over the lifetime. This information has the potential to inform interventions that might prevent/reduce substance-related risk in this population.

Treatment of substance abusing patients with comorbid psychiatric disorders

OBJECTIVE

To update clinicians on the latest in evidence-based treatments for substance use disorders (SUD) and non-substance use disorders among adults and suggest how these treatments can be combined into an evidence-based process that enhances treatment effectiveness in comorbid patients.

METHOD

Articles were extracted from Pubmed using the search terms "dual diagnosis," "comorbidity" and "co-occurring" and were reviewed for evidence of effectiveness for pharmacologic and psychotherapeutic treatments of comorbidity.

RESULTS

Twenty-four research reviews and 43 research trials were reviewed. The preponderance of the evidence suggests that antidepressants prescribed to improve substance-related symptoms among patients with mood and anxiety disorders are either not highly effective or involve risk due to high side-effect profiles or toxicity. Second generation antipsychotics are more effective for treatment of schizophrenia and comorbid substance abuse and current evidence suggests clozapine, olanzapine and risperidone are among the best. Clozapine appears to be the most effective of the antipsychotics for reducing alcohol, cocaine and cannabis abuse among patients with schizophrenia. Motivational interviewing has robust support as a highly effective psychotherapy for establishing a therapeutic alliance. This finding is critical since retention in treatment is essential for maintaining effectiveness. Highly structured therapy programs that integrate intensive outpatient treatments, case management services and behavioral therapies such as Contingency Management (CM) are most effective for treatment of severe comorbid conditions.

CONCLUSIONS

Creative combinations of psychotherapies, behavioral and pharmacological interventions offer the most effective treatment for comorbidity. Intensity of treatment must be increased for severe comorbid conditions such as the schizophrenia/cannabis dependence comorbidity due to the limitations of pharmacological treatments.

Sleep and circadian functioning: critical mechanisms in the mood disorders?

Evidence for the importance of sleep in the mood disorders has mushroomed over the past decade. Among adolescents and adults with a mood disorder, sleep disturbance is a risk factor for episodes, can contribute to relapse, has an adverse impact on emotion regulation, is critical for cognitive functioning, compromises health, and may contribute to substance use comorbidity and suicidality. This evidence has triggered a shift away from viewing sleep disturbance as an epiphenomenon, toward viewing sleep disturbance as an important but under-recognized mechanism in the multifactorial cause and maintenance of the mood disorders. Because the biology underpinning the sleep and circadian system is an open system, readily influenced by inputs from the environment, sleep in the mood disorders represents a unique and exciting domain for interdisciplinary research across behavioral, social, cognitive, and neurobiological levels of explanation. Together, the accumulated evidence has informed a range of novel, powerful, simple, and inexpensive treatments with potential for massive improvements to public health, including improving quality of life, reducing length and severity of episodes, and reducing the risk of subsequent episodes in the large number of individuals who suffer from mood disorders.

Animal model and neurobiology of suicide

Animal models are formidable tools to investigate the etiology, the course and the potential treatment of an illness. No convincing animal model of suicide has been produced to date, and despite the intensive study of thousands of animal species naturalists have not identified suicide in nonhuman species in field situations. When modeling suicidal behavior in the animal, the greatest challenge is reproducing the role of will and intention in suicide mechanics. To overcome this limitation, current investigations on animals focus on every single step leading to suicide in humans. The most promising endophenotypes worth investigating in animals are the cortisol social-stress response and the aggression/impulsivity trait, involving the serotonergic system. Astroglia, neurotrophic factors and neurotrophins are implied in suicide, too. The prevention of suicide rests on the identification and treatment of every element increasing the risk.

Improving treatment adherence in patients with bipolar disorder and substance abuse: rationale and initial development of a novel psychosocial approach

Patients with comorbid bipolar and substance use disorders are at particularly high risk for treatment nonadherence and a host of negative consequences. However, no previous interventions have been designed specifically to address this problem. In the current study, we describe the rationale for and initial development of an adjunctive psychosocial intervention that targets adherence in patients with bipolar disorder who are substance abusers. The intervention involves brief in-person sessions and follow-up phone contacts with the patient and a significant other/family member. We describe the effects of this novel intervention on adherence and other psychiatric outcomes in a series of cases treated as part of our initial development work. Results suggest that the intervention is feasible and acceptable to patients and could be helpful in enhancing the effects of existing treatments. Given these promising results, we plan to test the intervention further in a randomized clinical trial.

Terapêutica medicamentosa: conhecimento e dificuldades de familiares de pessoas idosas com transtorno afetivo bipolar

Este estudo descritivo quali-quantitativo teve como objetivo verificar o grau de conhecimento e dificuldades do familiar do idoso com Transtorno Afetivo Bipolar referentes ao tratamento medicamentoso prescrito para o paciente. Participaram do estudo 17 familiares de idosos com Transtorno Afetivo Bipolar atendidos em um Núcleo de Saúde Mental. Para coleta de dados empregou-se a entrevista semiestruturada e aplicação de escala. Identificou-se baixo nível de conhecimento dos familiares, especialmente sobre doses e frequência dos medicamentos prescritos. Dentre as dificuldades relacionadas ao tratamento medicamentoso dos pacientes, relatadas pelos familiares, destacaram-se a ambiguidade em relação à avaliação dos benefícios do medicamento, não aderência dos pacientes ao medicamento, sobrecarga relacionada aos cuidados referentes aos medicamentos, tratamento inadequado, preocupação com o acesso ao medicamento e utilização de bebida alcoólica pelo paciente. É imperativa a necessidade de ações educativas junto à família e sua inclusão na assistência oferecida ao paciente, como colaboradora e alvo das intervenções.

Cognitive functioning in patients with bipolar disorder: association with depressive symptoms and alcohol use

BACKGROUND

Cognitive dysfunction is clearly recognized in bipolar patients, but the degree of impairment varies due to methodological factors as well as heterogeneity in patient populations. The goal of this study was to evaluate cognitive functioning in bipolar patients and to assess its association with depressive symptoms. Post hoc the relationship with lifetime alcohol use disorder was explored.

METHODOLOGY/PRINCIPAL FINDINGS

The study included 110 bipolar patients and 75 healthy controls. Patients with severe depressive symptoms, (hypo)manic symptoms and current severe alcohol use disorder were excluded. Diagnoses were evaluated via the Mini-International Neuropsychiatric Interview. Cognitive functioning was measured in domains of psychomotor speed, speed of information processing, attentional switching, verbal memory, visual memory, executive functioning and an overall mean score. Severity of depression was assessed by the Inventory of Depressive Symptomatology-self rating. Patients were euthymic (n = 46) or with current mild (n = 38) or moderate (n = 26) depressive symptoms. Cognitive impairment was found in 26% (z-score 2 or more above reference control group for at least one domain) of patients, most prominent in executive functioning (effect size; ES 0.49) and speed of information processing (ES 0.47). Depressive symptoms were associated with dysfunction in psychomotor speed (adjusted beta 0.43; R(2) 7%), speed of information processing (adjusted beta 0.36; R(2) 20%), attentional switching (adjusted beta 0.24; R(2) 16%) and the mean score (adjusted beta 0.23; R(2) 24%), but not with verbal and visual memory and executive functioning. Depressive symptoms explained 24% of the variance in the mean z-score of all 6 cognitive domains. Comorbid lifetime alcohol use (n = 21) was not associated with cognitive dysfunction.

CONCLUSIONS/SIGNIFICANCE

Cognitive dysfunction in bipolar disorder is more severe in patients with depressive symptoms, especially regarding speed and attention. Therefore, interpretation of cognitive functioning in patients with depressive symptoms should be cautious. No association was found between cognitive functioning and lifetime comorbid alcohol use disorder.

History of manic and hypomanic episodes and risk of incident cardiovascular disease: 11.5 year follow-up from the Baltimore Epidemiologic Catchment Area Study

BACKGROUND

While several studies have suggested that bipolar disorder may elevate risk of cardiovascular disease, few studies have examined the relationship between mania or hypomania and cardiovascular disease. The purpose of this study is to examine history of manic and hypomanic episodes as an independent risk factor for cardiovascular disease (CVD) during an 11.5 year follow-up of the Baltimore Epidemiologic Catchment Area Follow-up Study.

METHODS

All participants were psychiatrically assessed face-to-face based on Diagnostic Interview Schedule in 1981 and 1982 and were categorized as having either history of manic or hypomanic episode (MHE; n=58), major depressive episode only (MDE; n=71) or no mood episode (NME; n=1339). Incident cardiovascular disease (CVD; n=67) was determined by self-report of either myocardial infarction (MI) or congestive heart failure (CHF) in 1993-6.

RESULTS

Compared with NME subjects, the odds ratio for incident CVD among MHE subjects was 2.97 (95% confidence interval: 1.40, 6.34) after adjusting for putative risk factors.

CONCLUSIONS

These data suggest that a history of MHE increase the risk of incident CVD among community residents. Recognition of manic symptoms and addressing related CVD risk factors could have long term preventative implications in the development of cardiovascular disease in the community.

[Cannabis and mood]

OBJECTIVE

Evaluate the relationship between acute and chronic use of cannabis and mood changes.

METHOD

Articles were selected by electronic search in PubMed. Chapters in books and reference lists of selected articles were also reviewed. As the research did not involve humans, there was no evaluation by a Research Ethics Committee.

RESULTS

High rates of comorbidity between use/abuse/dependence of cannabis and affective disorders in longitudinal studies and in clinical samples were observed. Longitudinal studies indicate that, in long-term, the higher use of cannabis is associated with an increased risk of developing bipolar disorder, and probably, major depression in subjects initially without affective disorder, but was not found increased risk of cannabis use among those initially only with mania or depression. Another important observation is that substance abuse in bipolar patients may be associated with a number of negative characteristics, such as difficulty in recovering the affective symptoms, more hospitalizations, poor compliance with treatment, increased risk of suicide, aggression and a poor response to lithium. Psychosocial and pharmacological treatments are indicated for the management of comorbidity between cannabis and affective disorders.

CONCLUSION

The relationship between cannabis use and mood changes are observed both in the epidemiological research and in the clinical settings.

Bipolar disorder as a risk factor for repeat DUI behavior

BACKGROUND

Bipolar disorder (BD) is more prevalent among people with substance use disorders (SUD) than the general population. SUD among recidivist driving under the influence (DUI) populations are extremely prevalent; not surprisingly, recent evidence suggests that rates of BD also are elevated among DUI offenders. Studies of BD patients with SUD have found high prevalence of other psychiatric disorders and relatively low rate of treatment engagement. This study examines both the prevalence of other mental disorders and treatment status among a cohort of DUI offenders with BD and SUD.

METHODS

A consecutively selected cohort (N=729) of repeat DUI offenders attending a two-week inpatient treatment program completed a standardized diagnostic interview (the Composite International Diagnostic Interview: CIDI). The CIDI generated DSM-IV diagnoses.

RESULTS

This study yielded three main results for this repeat DUI offender sample: (1) BD is associated with significantly higher lifetime prevalence of alcohol, drug, and non-substance psychiatric disorders (e.g., PTSD); (2) approximately one quarter of BD participants have not discussed their mania with a professional; and (3) only half of the BD participants in this cohort have had mania treatment they consider effective and even fewer have had any treatment during the past twelve months.

LIMITATIONS

Participants were predominantly Caucasian males attending treatment as a sentencing option in a single Massachusetts DUI program.

CONCLUSION

These findings suggest that clinicians in DUI treatment settings should consider both evaluating for BD and initiating therapy.

Cortical and sub-cortical effects in primate models of cocaine use: implications for addiction and the increased risk of psychiatric illness

Drug abuse is a serious risk factor for the incidence and severity of multiple psychiatric illnesses. Understanding the neurobiological consequences of repeated exposure to abused drugs can help to inform how those risks are manifested in terms of specific neurochemical mechanisms and brain networks. This review examines selective studies in non-human primates that employed a cocaine self-administration model. Neurochemical consequences of chronic exposure appear to differ from observations in rodent studies. Whereas chronic intermittent exposure in the rodent is usually associated with a dose-dependent increase in dopaminergic response to a cocaine challenge, in the rhesus monkey, high cumulative exposure was not observed to cause a sensitized dopamine response. These non-human primate observations are concordant with clinical findings in human users. The results of cue exposure studies on dopaminergic transmission are also reviewed. Direct microdialysis measurements indicate that there is not a sustained increase in dopamine associated with cocaine-linked cues. As an alternative to striatal dopaminergic mechanisms mediating cue effects, single unit studies in prefrontal cortex during self-administration in monkeys suggests the orbitofrontal and anterior cingulate cortex are strongly engaged by cocaine cues. Based on the strong clinical imaging literature on cortical and cognitive dysfunction associated with addiction, it is proposed that the strong engagement of cortical systems during repeated cocaine reinforcement results in maladaptive changes that contribute to the risks of drug use for exacerbation of other psychiatric disorders.