Life stress and kindling in bipolar disorder: review of the evidence and integration with emerging biopsychosocial theories

Dialectical Behavior and Social Rhythm Therapy for Comorbid Bipolar Disorder and Borderline Personality Disorder

Bipolar disorder and borderline personality disorder commonly co-occur. Each disorder is associated with substantial morbidity and mortality, which are worsened by co-occurrence of the disorders. Emotional dysregulation, suicidality, and disrupted circadian rhythm are key aspects of psychopathology associated with both conditions. A novel psychotherapy combining elements of two evidence-based treatments (i.e., dialectical behavior therapy [DBT] for borderline personality disorder and social rhythm therapy [SRT] for bipolar disorder) is described. Unlike either treatment alone, the new therapy, called dialectical behavior and social rhythm therapy (DBSRT), targets all three disease-relevant processes and therefore may represent a promising new approach to treatment for individuals with these two conditions. DBSRT may also have utility for individuals with overlapping characteristics of bipolar disorder and borderline personality disorder or for those whose illness manifestation includes a mix of bipolar and borderline personality disorder traits. Strategies associated with DBSRT are described, and a brief case vignette illustrates its application.

De-Salazar P, Alegría M. Association of sociocultural stressors with bipolar disorder onset in Puerto Rican youth growing up as members of a minoritized ethnic group: results from the Boricua Youth Longitudinal Study

Background

The development of bipolar disorder is currently explained by a complex interaction of genetic and environmental factors. Less is known regarding the influence of sociocultural factors. This study aims to evaluate the incidence and impact of sociocultural factors on bipolar disorder onset in two comparable samples of youth growing up in different social settings.

Methods

We leveraged data from two urban population-based cohorts representative of Puerto Rican children growing up in either San Juan (Puerto Rico) or the South Bronx (NYC) and followed up for 17 years. Bipolar disorder diagnoses were based on retrospective self-reports on the World Health Organization Composite International Diagnostic Interview. We used a causal inference approach to estimate associations of sociocultural factors with bipolar disorder onset after adjusting for potential confounders.

Findings

We found that South Bronx children, who grew up as a minoritized group, had twice the risk of bipolar disorder onset as young adults, with an incidence rate of 2.22 new cases per 1000 person-years compared to 1.08 new cases in San Juan (incidence rate difference, 1.13; 95% CI, 0.09-1.20). After adjusting for potential confounders, South Bronx children had the same lifetime hazard of bipolar disorder onset compared to San Juan children. However, our analysis demonstrated that caregivers' exposure to societal cultural stress partially explained the increased risk of bipolar disorder onset in the South Bronx, in addition to the potential contribution of genetics.

Interpretation

Our results provide evidence that societal cultural stress can increase the risk of lifetime bipolar disorder onset in youth growing up as a minoritized group. Addressing stress in minoritized groups might reduce the risk of bipolar disorder onset.

Funding

The Boricua Youth Study has been supported by the National Institutes of HealthMH56401, MH098374, DA033172, and AA020191. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the article.

Effects of a Novel, Transdiagnostic Ecological Momentary Intervention for Prevention, and Early Intervention of Severe Mental Disorder in Youth (EMIcompass): Findings From an Exploratory Randomized Controlled Trial

BACKGROUND/HYPOTHESIS

Digital interventions targeting transdiagnostic mechanisms in daily life may be a promising translational strategy for prevention and early intervention of psychotic and other severe mental disorders. We aimed to investigate the feasibility and initial signals of efficacy of a transdiagnostic, compassion-focused, hybrid ecological momentary intervention for improving resilience (ie, EMIcompass) in youth with early mental health problems.

STUDY DESIGN

In an exploratory, assessor-blind randomized controlled trial, youth aged 14-25 with current distress, broad at-risk mental state, or first episode of severe mental disorder were randomly allocated to experimental (EMIcompass+treatment as usual [TAU]) or control condition (TAU). Data on primary (stress reactivity) and secondary candidate mechanisms as well as candidate primary (psychological distress) and secondary outcomes were collected.

STUDY RESULTS

Criteria for the feasibility of trial methodology and intervention delivery were met (n = 92 randomized participants). No serious adverse events were observed. Initial outcome signals were evident for reduced momentary stress reactivity (stress×time×condition, B = -0.10 95%CI -0.16--0.03, d = -0.10), aberrant salience (condition, B = -0.38, 95%CI -0.57--0.18, d = -0.56) as well as enhanced momentary resilience (condition, B = 0.55, 95%CI 0.18-0.92, d = 0.33) and quality of life (condition, B = 0.82, 95%CI 0.10-1.55, d = 0.60) across post-intervention and 4-week follow-up. No outcome signals were observed for self-reported psychological distress (condition, B = 0.57, 95%CI -1.59-2.72, d = 0.09), but there was suggestive evidence of reduced observer-rated symptoms at the 4-week follow-up (B = -1.41, 95%CI -2.85-0.02, d = -0.41).

CONCLUSIONS

Our findings provide evidence of feasibility and initial signals that EMIcompass may reduce stress reactivity and improve quality of life. A definitive trial is now warranted.

Triggers for acute mood episodes in bipolar disorder: A systematic review

OBJECTIVES

To identify triggers of acute mood episodes in bipolar disorder (BD).

METHODS

We performed a systematic review in the following databases: Pubmed, Embase, and PsycInfo following the preferred reporting items for systematic reviews and meta-analysis guidelines. The systematic search encompassed all relevant studies published until May 23rd, 2022.

RESULTS

A total of 108 studies (case reports/case series, interventional, prospective and retrospective studies) were included in the systematic review. While several decompensation triggers were identified, pharmacotherapy was the one with the largest body of evidence, particularly the use of antidepressants as triggers of manic/hypomanic episodes. Other identified triggers for mania were brain stimulation, energy drinks, acetyl-l-carnitine, St. John's wort, seasonal changes, hormonal changes and viral infections. There is a relative paucity of evidence concerning triggers for depressive relapses in BD, with possible triggers including fasting, decreased sleep and stressful life events.

CONCLUSIONS

This is the first systematic review about triggers/precipitants of relapse in BD. Despite the importance of identification and management of potential triggers for BD decompensation, there is a lack of large observational studies addressing this topic, with most of the included studies being case reports/case series. Notwithstanding these limitations, antidepressant use is the trigger with the strongest evidence for manic relapse. More studies are needed to identify and manage triggers for relapse in BD.

Effects of a Novel, Transdiagnostic, Hybrid Ecological Momentary Intervention for Improving Resilience in Youth (EMIcompass): Protocol for an Exploratory Randomized Controlled Trial

BACKGROUND

Most mental disorders first emerge in youth and, in their early stages, surface as subthreshold expressions of symptoms comprising a transdiagnostic phenotype of psychosis, mania, depression, and anxiety. Elevated stress reactivity is one of the most widely studied mechanisms underlying psychotic and affective mental health problems. Thus, targeting stress reactivity in youth is a promising indicated and translational preventive strategy for adverse mental health outcomes that could develop later in life and for improving resilience. Compassion-focused interventions offer a wide range of innovative therapeutic techniques that are particularly amenable to being implemented as ecological momentary interventions (EMIs), a specific type of mobile health intervention, to enable youth to access interventions in a given moment and context in daily life. This approach may bridge the current gap in youth mental health care.

OBJECTIVE

This study aims to investigate the clinical feasibility, candidate underlying mechanisms, and initial signals of the efficacy of a novel, transdiagnostic, hybrid EMI for improving resilience to stress in youth-EMIcompass.

METHODS

In an exploratory randomized controlled trial, youth aged between 14 and 25 years with current distress, a broad Clinical High At-Risk Mental State, or the first episode of a severe mental disorder will be randomly allocated to the EMIcompass intervention (ie, EMI plus face-to-face training sessions) in addition to treatment as usual or a control condition of treatment as usual only. Primary (stress reactivity) and secondary candidate mechanisms (resilience, interpersonal sensitivity, threat anticipation, negative affective appraisals, and momentary physiological markers of stress reactivity), as well as primary (psychological distress) and secondary outcomes (primary psychiatric symptoms and general psychopathology), will be assessed at baseline, postintervention, and at the 4-week follow-up.

RESULTS

The first enrollment was in August 2019, and as of May 2021, enrollment and randomization was completed (N=92). We expect data collection to be completed by August 2021.

CONCLUSIONS

This study is the first to establish feasibility, evidence on underlying mechanisms, and preliminary signals of the efficacy of a compassion-focused EMI in youth. If successful, a confirmatory randomized controlled trial will be warranted. Overall, our approach has the potential to significantly advance preventive interventions in youth mental health provision.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00017265; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017265.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27462.

Behavioral mediators of stress-related mood symptoms in adolescence & young adulthood

BACKGROUND

Stress is a risk factor for unipolar and bipolar mood disorders, but the mechanisms linking stress to specific symptoms remain elusive. Behavioral responses to stress, such as impulsivity and social withdrawal, may mediate the associations between stress and particular mood symptoms.

METHODS

This study evaluated behavioral mediators of the relationship between self-reported intensity of daily stress and mood symptoms over up to eight weeks of daily diary surveys. The sample included individuals with unipolar or bipolar disorders, or with no psychiatric history (n = 113, ages 15-25).

RESULTS

Results showed that higher daily stress was related to higher severity of mania, and this pathway was mediated by impulsive behaviors. Higher stress also predicted higher severity of anhedonic depression, and social withdrawal mediated this relationship. A k-means clustering analysis revealed six subgroups with divergent profiles of stress-behavior-symptom pathways.

LIMITATIONS

Given the observational study design, analyses cannot determine causal relationships amongst these variables. Further work is needed to determine how relationships between these variables may vary based on stressor type, at different timescales, and within different populations.

CONCLUSIONS

Findings support a theoretical model in which impulsivity and social withdrawal act as behavioral mediators of the relationship between stress and mood symptoms. Additionally, distinct patterns of reactivity distinguished subgroups of people vulnerable to particular types of mood symptoms. These results provide novel information about how stress-reactive behaviors relate to specific mood symptoms, which may have clinical relevance as targets of intervention.

Advances in the pharmacotherapeutic management of post-traumatic stress disorder

Introduction: Post-traumatic stress disorder (PTSD), a mental disorder, is associated with anxiety, depression, and social awkwardness resulting from past traumatic episodes like natural disasters, accidents, terrorist attacks, war, rape, and sexual violence. It affects primarily the amygdala, cortex, and hippocampus where neurochemical changes result in altered behavior. PTSD patients display impaired fear extinction, and past events keep haunting them. The topic presents relevant sections like PTSD pharmacotherapy, associated challenges, and the novel targets and drugs for future research and therapy.Areas covered: The authors discuss the current pharmacotherapy like SSRIs, NDRIs, SNRIs, anticonvulsants, antidepressants, and benzodiazepines, used to attenuate the associated symptoms. However, the primary focus being the novel and potential targets which can be explored better to understand possible future research and advanced therapy in PTSD. For the same, an account of both preclinical and clinical studies has been covered.Expert opinion: Excessive adverse effects, limited efficacy, and lower patient compliance are some of the major challenges with conventional drugs. Moreover, they correct only fewer symptoms without halting the disease progression. Several agents are investigated in different preclinical and clinical phases, which can potentially overcome the pitfalls and limitations associated with conventional therapies.

Psychological symptoms during and after Austrian first lockdown in individuals with bipolar disorder? A follow-up control-group investigation

BACKGROUND

The coronavirus disease (COVID-19) pandemic, a global health crisis, has resulted in widespread socioeconomic restrictions including lockdown, social distancing, and self-isolation. To date, little is known about the psychological impact of the COVID-19 pandemic and lockdown on patients with bipolar disorder as a particularly vulnerable group.

METHODS

An online survey was conducted in Austria at two points of measurement (T1 April 2020 during the first lockdown vs. T2 May 2020 at post-lockdown). The sample comprises 20 patients with bipolar disorder (mean age = 49.4 ± 15.6 years) and 20 healthy controls (mean age = 32.7 ± 9.6 years). A 2 × 2 factorial design to compare two time points (T1 vs. T2) and two groups (patients vs. healthy controls) was used. Main outcome measures included the Brief Symptom Inventory-18 (BSI-18) and a (non-validated and non-standardized) assessment to determine COVID-19 fears and emotional distress due to social distancing. Multiple linear regression analyses were used to assess the longitudinal association of COVID-19 fears/emotional distress due to social distancing during lockdown (T1) and psychological symptoms after lockdown (T2).

RESULTS

At T1, results demonstrated higher scores in BSI-18 subscales depression, anxiety and global severity index as well as emotional distress due to social distancing in bipolar patients compared to controls. There was a significant time x group interaction in the BSI-18 subscale somatization showing a decreasing trend in patients with BD compared to controls. No time effects in BSI-18 subscales or COVID-19 fears/emotional distress due to social distancing were observed. Regression analyses showed that COVID-19 fears during lockdown predicted somatization, only in patients.

CONCLUSIONS

There was a connection between the lockdown measures and somatization symptoms observed in patients. When the first steps of easing the social restrictions in May 2020 took place, somatization decreased only in the bipolar compared to the control group. Higher COVID-19 fears during lockdown predicted later symptoms at post-lockdown. Long-term impacts of the COVID-19 pandemic need further investigations to improve current therapeutic approaches and prevent fears and distress during lockdown in individuals with bipolar disorder in times of crisis.

Prolonged functional cerebral asymmetry as a consequence of dysfunctional parvocellular paraventricular hypothalamic nucleus signaling: An integrative model for the pathophysiology of bipolar disorder

Approximately 45 million people worldwide are diagnosed with bipolar disorder (BD). While there are many known risk factors and models of the pathologic processes influencing BD, the exact neurologic underpinnings of BD are unknown. We attempt to integrate the existing literature and create a unifying hypothesis regarding the pathophysiology of BD with the hope that a concrete model may potentially facilitate more specific diagnosis, prevention, and treatment of BD in the future. We hypothesize that dysfunctional signaling from the parvocellular neurons of the paraventricular hypothalamic nucleus (PVN) results in the clinical presentation of BD. Functional damage to this nucleus and its signaling pathways may be mediated by myriad factors (e.g. immune dysregulation and auto-immune processes, polygenetic variation, dysfunctional interhemispheric connections, and impaired or overactivated hypothalamic axes) which could help explain the wide variety of clinical presentations along the BD spectrum. The neurons of the PVN regulate ultradian rhythms, which are observed in cyclic variations in healthy individuals, and mediate changes in functional hemispheric lateralization. Theoretically, dysfunctional PVN signaling results in prolonged functional hemispheric dominance. In this model, prolonged right hemispheric dominance leads to depressive symptoms, whereas left hemispheric dominance correlated to the clinical picture of mania. Subsequently, physiologic processes that increase signaling through the PVN (hypothalamic-pituitaryadrenal axis, hypothalamic- pituitary-gonadal axis, and hypothalamic-pituitary-thyroid axis activity, suprachiasmatic nucleus pathways) as well as, neuro-endocrine induced excito-toxicity, auto-immune and inflammatory flairs may induce mood episodes in susceptible individuals. Potentially, ultradian rhythms slowing with age, in combination with changes in hypothalamic axes and maturation of neural circuitry, accounts for BD clinically presenting more frequently in young adulthood than later in life.

The Vestiges of Childhood Interparental Conflict: Adolescent Sensitization to Recent Interparental Conflict

This study examined whether childhood interparental conflict moderated the mediational pathway involving adolescent exposure to interparental conflict, their negative emotional reactivity to family conflict, and their psychological problems in a sample of 235 children (M_age  = 6 years). Significant moderated-mediation findings indicated that the mediational path among Wave 4 interparental conflict during adolescence, change in youth negative reactivity (Waves 4-5), and their psychological problems (Waves 4-6) was significant for teens who experienced low, rather than high, levels of childhood interparental conflict (Waves 1-3). Supporting the stress sensitization model, analyses showed that adolescents exposed to high interparental conflict during childhood evidenced greater increases in negative reactivity than their peers when recent parental conflicts were mild.

Sleep and Parasympathetic Activity During Rest and Stress in Healthy Adolescents and Adolescents With Bipolar Disorder

OBJECTIVE

Sleep disruption contributes to the pathophysiology of mental disorders, particularly bipolar illness, but the biobehavioral mechanisms of this relationship are insufficiently understood. This study evaluated sleep duration, timing, and variability as prospective predictors of parasympathetic nervous system activity during rest and social stress in adolescents with bipolar disorder, reflecting sleep-related interference in stress regulatory systems that may confer vulnerability to mood episodes.

METHOD

Participants were adolescents with bipolar disorder (n = 22) and healthy adolescents (n = 27). Sleep duration and timing were measured by actigraphy for 1 week before a laboratory social stress task, during which high-frequency heart rate variability (HF-HRV) was indexed using electrocardiography. Multilevel models were used to evaluate group, sleep characteristics, and their interactions as predictors of initial HF-HRV and change in HF-HRV during rest and stress.

RESULTS

Associations between group and changes in HF-HRV during stress were moderated by sleep duration mean (z = 2.24, p = .025) and variability (z = -2.78, p = .006). There were also main effects of mean sleep duration on initial HF-HRV during rest (z = -5.37, p < .001) and stress (z = -2.69, p = .007). Follow-up analyses indicated that, in bipolar adolescents during stress, shorter and longer sleep durations were associated with lower initial HF-HRV (z = -5.44, p < .001), and greater variability in sleep duration was associated with less change in HF-HRV (z = -2.18, p = .029).

CONCLUSIONS

Sleep durations that are relatively short or long, which are characteristic of mood episodes, are associated with parasympathetic vulnerability to social stress in adolescents with bipolar disorder. Obtaining regular sleep of moderate duration may favorably affect responses to stress in bipolar youth.

Considering a Potential Role of Linalool as a Mood Stabilizer for Bipolar Disorder

Epidemiologic studies suggest that the lifetime prevalence of bipolar spectrum disorders ranges from 2.8 to 6.5 percent of the population. To decrease morbidity and mortality associated with disease progression, pharmacologic intervention is indicated for the majority of these patients. While a number of effective treatment regimens exist, many conventional medications have significant side effect profiles that adversely impact patients' short and long-term well-being. It is thus important to continue advancing and improving therapeutic options available to patients. This paper reviews the limitations of current treatments and examines the chemical compound Linalool, an alcohol found in many plant species, that may serve as an effective mood stabilizer. While relatively little is known about Linalool and bipolar disorder, the compound has been shown to have antiepileptic, anti-inflammatory, anxiolytic, anti-depressive, and neurotrophic effects, with mechanisms that are comparable to current bipolar disorder treatment options.

Sleep and physical activity in patients with newly diagnosed bipolar disorder in remission, their first-degree unaffected relatives and healthy controls

Background

Sleep disturbances are a central feature in bipolar disorder (BD) that often persist in remission and seem to be present also in unaffected first-degree relatives (UR) of patients with BD, presenting a possible risk factor for later onset of BD. However, it is unknown if these disturbances are associated with unhealthy life-style as reflected in low levels of physical activity. We investigated sleep disturbances and physical activity levels in patients with newly diagnosed BD in full or partial remission, their UR and healthy controls (HC).

Methods

Sleep patterns and physical activity were compared in 227 patients with newly diagnosed BD, 76 UR and 148 HC. The Pittsburgh Sleep Quality Index (PSQI) and the International Physical Activity Questionnaire (IPAQ) were used to assess sleep disturbances and physical activity, respectively.

Results

In sex- and age-adjusted analyses, patients with BD exhibited more sleep disturbances and lower physical activity compared with UR and HC, respectively. Unaffected relatives reported significantly longer sleep latency and a non-significant trend towards more overall sleep disturbances compared with HC.

Conclusions

Sleep disturbances and less physical activity are present in patients with newly diagnosed BD in partial or full remission. Individuals at familiar risk of BD reported longer sleep latency and similar physical activity compared with HC. Further prospective studies are needed to clarify whether these discrete sleep disturbances act as risk factor for later onset of BD and whether increased physical activity in high-risk individuals may act as a protective factor against development of psychiatric illness.

Reporting trigger factors for (hypo)manic episodes in bipolar disorder: association with personality and prognosis

OBJECTIVE

To investigate external factors that trigger manic and hypomanic relapses and how this is associated with personality and clinical outcome measured as number of affective episodes over a 7-year period.

METHOD

This is a prospective cohort study of 204 meticulously characterized Swedish bipolar disorder patients. Personality was evaluated at baseline using the Swedish universities Scales of Personality in 170 patients, and 90 patients were followed up after approximately 7 years in order to evaluate clinical outcomes.

RESULTS

We found that 44% of the patients reported trigger factors, including sleep disturbance, work- or family-related issues, medication, and illicit drug use. There were no significant differences in any of the personality traits when comparing the 74 patients that reported triggers with the 90 patients that did not. At 7-year follow-up, there was no difference between the groups in number of affective episodes (depressive, hypomanic, manic, or mixed), involuntary commitments, suicide attempts, or self-harm incidents since baseline.

CONCLUSIONS

Around 40% of the patients reported external triggers for manic and hypomanic episodes. However, this was neither associated with personality traits nor number of affective episodes at 7-year follow-up.

The role of environmental stress and DNA methylation in the longitudinal course of bipolar disorder

BACKGROUND

Stressful life events influence the course of affective disorders, however, the mechanisms by which they bring about phenotypic change are not entirely known.

METHODS

We explored the role of DNA methylation in response to recent stressful life events in a cohort of bipolar patients from the longitudinal PsyCourse study (n = 96). Peripheral blood DNA methylomes were profiled at two time points for over 850,000 methylation sites. The association between impact ratings of stressful life events and DNA methylation was assessed, first by interrogating methylation sites in the vicinity of candidate genes previously implicated in the stress response and, second, by conducting an exploratory epigenome-wide association analysis. Third, the association between epigenetic aging and change in stress and symptom measures over time was investigated.

RESULTS

Investigation of methylation signatures over time revealed just over half of the CpG sites tested had an absolute difference in methylation of at least 1% over a 1-year period. Although not a single CpG site withstood correction for multiple testing, methylation at one site (cg15212455) was suggestively associated with stressful life events (p < 1.0 × 10^-5). Epigenetic aging over a 1-year period was not associated with changes in stress or symptom measures.

CONCLUSIONS

To the best of our knowledge, our study is the first to investigate epigenome-wide methylation across time in bipolar patients and in relation to recent, non-traumatic stressful life events. Limited and inconclusive evidence warrants future longitudinal investigations in larger samples of well-characterized bipolar patients to give a complete picture regarding the role of DNA methylation in the course of bipolar disorder.

The Role of Stress and Mineralocorticoid Receptor Haplotypes in the Development of Symptoms of Depression and Anxiety During Adolescence

Adolescence is a critical developmental period characterized by heightened levels of depressive and anxiety symptoms. Experiencing chronic or environmental stress, for example, as a result of traumatic events or insensitive parenting, increases the risk for depression and anxiety. However, not all adolescents develop depressive or anxiety symptoms following environmental stressors, due to differences in stress resilience. One of the factors involved in stress resilience is enhanced functionality of the mineralocorticoid receptor (MR), one of the two brain receptors for the stress hormone cortisol. High levels of MR functionality result in relatively lower rates of depression, particularly in women that experienced stress. However, much less is known about MR functionality in relation to the development of adolescent depression and to other internalizing behavior problems such as anxiety. We therefore examined whether the effects of a functional MR haplotype (i.e., the MR CA haplotype) on the development of depressive and anxiety symptoms are sex-dependent, as well as interact with environmental stressors. In a community sample of adolescents (N = 343, 9 waves between age 13 and 24), environmental stressors were operationalized as parental psychological control and childhood trauma. Results showed a sex-dependent effect of MR CA haplotype on the development of depressive symptoms but not for anxiety symptoms. MR CA haplotypes were protective for girls but not for boys. This study sheds more light on the sex-dependent effects of MR functionality related to the development of depressive and anxiety symptoms during adolescence.

A Hybrid Feature Pool-Based Emotional Stress State Detection Algorithm Using EEG Signals

Human stress analysis using electroencephalogram (EEG) signals requires a detailed and domain-specific information pool to develop an effective machine learning model. In this study, a multi-domain hybrid feature pool is designed to identify most of the important information from the signal. The hybrid feature pool contains features from two types of analysis: (a) statistical parametric analysis from the time domain, and (b) wavelet-based bandwidth specific feature analysis from the time-frequency domain. Then, a wrapper-based feature selector, Boruta, is applied for ranking all the relevant features from that feature pool instead of considering only the non-redundant features. Finally, the k-nearest neighbor (k-NN) algorithm is used for final classification. The proposed model yields an overall accuracy of 73.38% for the total considered dataset. To validate the performance of the proposed model and highlight the necessity of designing a hybrid feature pool, the model was compared to non-linear dimensionality reduction techniques, as well as those without feature ranking.

The case for improved care and provision of treatment for people with first-episode mania

The care of people with first-episode mania has been overlooked in comparison with the care of patients with other non-affective psychoses, despite evidence suggesting targeted treatments might be of benefit for this patient group. In this Personal View, we outline the general epidemiology of first-episode mania in the context of bipolar disorder, the natural history of mania (with an emphasis on its recurrent nature), current evidence for pharmacological, psychological, and service-level interventions, current guidelines for the treatment of first-episode mania, and provide a patient's point of view of the care pathway (appendix). We note the paucity of high-quality evidence for interventions in first-episode mania and the lack of agreement among treatment guidelines in relation to treatment, especially maintenance treatment. We suggest that, based on high morbidity and clinical need, research evidence to inform guideline development is necessary, and in the interim, clearer guidance on treatment and diagnosis should be given; specifically, we have suggested that patients should be cared for within a first-episode psychosis service, when such a service exists.

Multi-Lag Analysis of Symbolic Entropies on EEG Recordings for Distress Recognition

Distress is a critical problem in developed societies given its long-term negative effects on physical and mental health. The interest in studying this emotion has notably increased during last years, being electroencephalography (EEG) signals preferred over other physiological variables in this research field. In addition, the non-stationary nature of brain dynamics has impulsed the use of non-linear metrics, such as symbolic entropies in brain signal analysis. Thus, the influence of time-lag on brain patterns assessment has not been tested. Hence, in the present study two permutation entropies denominated Delayed Permutation Entropy and Permutation Min-Entropy have been computed for the first time at different time-lags to discern between emotional states of calmness and distress from EEG signals. Moreover, a number of curve-related features were also calculated to assess brain dynamics across different temporal intervals. Complementary information among these variables was studied through sequential forward selection and 10-fold cross-validation approaches. According to the results obtained, the multi-lag entropy analysis has been able to reveal new significant insights so far undiscovered, thus notably improving the process of distress recognition from EEG recordings.

Emotional Stress State Detection Using Genetic Algorithm-Based Feature Selection on EEG Signals

In recent years, stress analysis by using electro-encephalography (EEG) signals incorporating machine learning techniques has emerged as an important area of research. EEG signals are one of the most important means of indirectly measuring the state of the brain. The existing stress algorithms lack efficient feature selection techniques to improve the performance of a subsequent classifier. In this paper, genetic algorithm (GA)-based feature selection and k-nearest neighbor (k-NN) classifier are used to identify stress in human beings by analyzing electro-encephalography (EEG) signals. GA is incorporated in the stress analysis pipeline to effectively select subset of features that are suitable to enhance the performance of the k-NN classifier. The performance of the proposed method is evaluated using the Database for Emotion Analysis using Physiological Signals (DEAP), which is a public EEG dataset. A feature set is extracted in 32 EEG channels, which consists of statistical features, Hjorth parameters, band power, and frontal alpha asymmetry. The selected features through GA are used as input to the k-NN classifier to distinguish whether each EEG datapoint represents a stress state. To further consolidate, the effectiveness of the proposed method is compared with that of a state-of-the-art principle component analysis (PCA) method. Experimental results show that the proposed GA-based method outperforms PCA, with GA demonstrating 71.76% classification accuracy compared with 65.3% for PCA. Thus, it can be concluded that the proposed method can be effectively used for stress analysis with high classification accuracy.

Serotonin depletion causes valproate-responsive manic-like condition and increased hippocampal neuroplasticity that are reversed by stress

Abnormal hippocampal neural plasticity has been implicated in behavioural abnormalities and complex neuropsychiatric conditions, including bipolar disorder (BD). However, the determinants of this neural alteration remain unknown. This work tests the hypothesis that the neurotransmitter serotonin (5-HT) is a key determinant of hippocampal neuroplasticity, and its absence leads to maladaptive behaviour relevant for BD. Depletion of brain 5-HT in Tph2 mutant mice resulted in reduced behavioural despair, reduced anxiety, marked aggression and lower habituation in novel environments, reminiscent of bipolar-associated manic behaviour. Treatment with valproate produced a substantial improvement of the mania-like behavioural phenotypes displayed by Tph2 mutants. Brain-wide fMRI mapping in mutants revealed functional hippocampal hyperactivity in which we also observed dramatically increased neuroplasticity. Importantly, remarkable correspondence between the transcriptomic profile of the Tph2 mutant hippocampus and neurons from bipolar disorder patients was observed. Chronic stress reversed the emotional phenotype and the hippocampal transcriptional landscape of Tph2 mutants. These changes were associated with inappropriate activation of transcriptional adaptive response to stress as assessed by gene set enrichment analyses in the hippocampus of Tph2 mutant mice. These findings delineate 5-HT as a critical determinant in BD associated maladaptive emotional responses and aberrant hippocampal neuroplasticity, and support the use of Tph2−/− mice as a new research tool for mechanistic and therapeutic research in bipolar disorder.

Mice with reduced DAT levels recreate seasonal-induced switching between states in bipolar disorder

Developing novel therapeutics for bipolar disorder (BD) has been hampered by limited mechanistic knowledge how sufferers switch between mania and depression-how the same brain can switch between extreme states-described as the "holy grail" of BD research. Strong evidence implicates seasonally-induced switching between states, with mania associated with summer-onset, depression with winter-onset. Determining mechanisms of and sensitivity to such switching is required. C57BL/6J and dopamine transporter hypomorphic (DAT-HY 50% expression) mice performed a battery of psychiatry-relevant behavioral tasks following 2-week housing in chambers under seasonally relevant photoperiod extremes. Summer-like and winter-like photoperiod exposure induced mania-relevant and depression-relevant behaviors respectively in mice. This behavioral switch paralleled neurotransmitter switching from dopamine to somatostatin in hypothalamic neurons (receiving direct input from the photoperiod-processing center, the suprachiasmatic nucleus). Mice with reduced DAT expression exhibited hypersensitivity to these summer-like and winter-like photoperiods, including more extreme mania-relevant (including reward sensitivity during reinforcement learning), and depression-relevant (including punishment-sensitivity and loss-sensitivity during reinforcement learning) behaviors. DAT mRNA levels switched in wildtype littermate mice across photoperiods, an effect not replicated in DAT hypomorphic mice. This inability to adjust DAT levels to match photoperiod-induced neurotransmitter switching as a homeostatic control likely contributes to the susceptibility of DAT hypormophic mice to these switching photoperiods. These data reveal the potential contribution of photoperiod-induced neuroplasticity within an identified circuit of the hypothalamus, linked with reduced DAT function, underlying switching between states in BD. Further investigations of the circuit will likely identify novel therapeutic targets to block switching between states.

Testing frameworks for personalizing bipolar disorder

The hallmark of bipolar disorder is a clinical course of recurrent manic and depressive symptoms of varying severity and duration. Mathematical modeling of bipolar disorder holds the promise of an ability to personalize diagnoses, to predict future mood episodes, to directly compare diverse datasets, and to link basic mechanisms to behavioral data. Several modeling frameworks have been proposed for bipolar disorder, which represent competing hypothesis about the basic framework of the disorder. Here, we test these hypotheses with self-report assessments of mania and depression symptoms from 178 bipolar patients followed prospectively for 4 or more years. Statistical analysis of the data did not support the hypotheses that mood arises from a rhythmic process or multiple stable states (e.g., mania or depression) or that manic and depressive symptoms are highly anti-correlated. Alternatively, it is shown that bipolar disorder could arise from an inability for mood to quickly return to normal when perturbed. This latter concept is embodied by an affective instability model that can be personalized to the clinical course of any individual with chronic disorders that have an affective component.

Forebrain-specific ablation of phospholipase Cγ1 causes manic-like behavior

Manic episodes are one of the major diagnostic symptoms in a spectrum of neuropsychiatric disorders that include schizophrenia, obsessive-compulsive disorder and bipolar disorder (BD). Despite a possible association between BD and the gene encoding phospholipase Cγ1 (PLCG1), its etiological basis remains unclear. Here, we report that mice lacking phospholipase Cγ1 (PLCγ1) in the forebrain (Plcg1^f/f; CaMKII) exhibit hyperactivity, decreased anxiety-like behavior, reduced depressive-related behavior, hyperhedonia, hyperphagia, impaired learning and memory and exaggerated startle responses. Inhibitory transmission in hippocampal pyramidal neurons and striatal dopamine receptor D1-expressing neurons of Plcg1-deficient mice was significantly reduced. The decrease in inhibitory transmission is likely due to a reduced number of γ-aminobutyric acid (GABA)-ergic boutons, which may result from impaired localization and/or stabilization of postsynaptic CaMKII (Ca²⁺/calmodulin-dependent protein kinase II) at inhibitory synapses. Moreover, mutant mice display impaired brain-derived neurotrophic factor-tropomyosin receptor kinase B-dependent synaptic plasticity in the hippocampus, which could account for deficits of spatial memory. Lithium and valproate, the drugs presently used to treat mania associated with BD, rescued the hyperactive phenotypes of Plcg1^f/f; CaMKII mice. These findings provide evidence that PLCγ1 is critical for synaptic function and plasticity and that the loss of PLCγ1 from the forebrain results in manic-like behavior.

Circuits Regulating Pleasure and Happiness in Bipolar Disorder

According to our model, the motivation for appetitive-searching vs. distress-avoiding behaviors is regulated by two parallel cortico-striato-thalamo-cortical (CSTC) re-entry circuits that include the core and the shell parts of the nucleus accumbens, respectively. An entire series of basal ganglia, running from the caudate nucleus on one side to the centromedial amygdala on the other side, control the intensity of these reward-seeking and misery-fleeing behaviors by stimulating the activity of the (pre)frontal and limbic cortices. Hyperactive motivation to display behavior that potentially results in reward induces feelings of hankering (relief leads to pleasure); while, hyperactive motivation to exhibit behavior related to avoidance of aversive states results in dysphoria (relief leads to happiness). These two systems collaborate in a reciprocal fashion. We hypothesized that the mechanism inducing the switch from bipolar depression to mania is the most essential characteristic of bipolar disorder. This switch is attributed to a dysfunction of the lateral habenula, which regulates the activity of midbrain centers, including the dopaminergic ventral tegmental area (VTA). From an evolutionary perspective, the activity of the lateral habenula should be regulated by the human homolog of the habenula-projecting globus pallidus, which in turn might be directed by the amygdaloid complex and the phylogenetically old part of the limbic cortex. In bipolar disorder, it is possible that the system regulating the activity of this reward-driven behavior is damaged or the interaction between the medial and lateral habenula may be dysfunctional. This may lead to an adverse coupling between the activities of the misery-fleeing and reward-seeking circuits, which results in independently varying activities.

Kindling of Life Stress in Bipolar Disorder: Effects of Early Adversity

Most theoretical frameworks regarding the role of life stress in bipolar disorders (BD) do not incorporate the possibility of a changing relationship between psychosocial context and episode initiation across the course of the disorder. The kindling hypothesis theorizes that over the longitudinal course of recurrent affective disorders, the relationship between major life stressors and episode initiation declines (Post, 1992). The present study aimed to test an extension of the kindling hypothesis in BD by examining the effect of early life adversity on the relationship between proximal life events and prospectively assessed mood episodes. Data from 145 bipolar participants (59.3% female, 75.2% Caucasian, and mean age of 20.19 years; SD = 1.75 years) were collected as part of the Temple-Wisconsin Longitudinal Investigation of Bipolar Spectrum Project (112 Bipolar II; 33 Cyclothymic disorder). Participants completed a self-report measure of early adversity at baseline and interview-assessed mood episodes and life events at regular 4-month follow-ups. Results indicate that early childhood adversity sensitized bipolar participants to the effects of recent stressors only for depressive episodes and not hypomanic episodes within BD. This was particularly the case with minor negative events. The current study extends prior research examining the kindling model in BD using a methodologically rigorous assessment of life stressors and mood episode occurrence. Clinicians should assess experiences of early adversity in individuals with BD as it may impact reactivity to developing depressive episodes in response to future stressors.

Symbolic Analysis of Brain Dynamics Detects Negative Stress

The electroencephalogram (EEG) is the most common tool used to study mental disorders. In the last years, the use of this recording for recognition of negative stress has been receiving growing attention. However, precise identification of this emotional state is still an interesting unsolved challenge. Nowadays, stress presents a high prevalence in developed countries and, moreover, its chronic condition often leads to concomitant physical and mental health problems. Recently, a measure of time series irregularity, such as quadratic sample entropy (QSEn), has been suggested as a promising single index for discerning between emotions of calm and stress. Unfortunately, this index only considers repetitiveness of similar patterns and, hence, it is unable to quantify successfully dynamics associated with the data temporal structure. With the aim of extending QSEn ability for identification of stress from the EEG signal, permutation entropy (PEn) and its modification to be amplitude-aware (AAPEn) have been analyzed in the present work. These metrics assess repetitiveness of ordinal patterns, thus considering causal information within each one of them and obtaining improved estimates of predictability. Results have shown that PEn and AAPEn present a discriminant power between emotional states of calm and stress similar to QSEn, i.e., around 65%. Additionally, they have also revealed complementary dynamics to those quantified by QSEn, thus suggesting a synchronized behavior between frontal and parietal counterparts from both hemispheres of the brain. More precisely, increased stress levels have resulted in activation of the left frontal and right parietal regions and, simultaneously, in relaxing of the right frontal and left parietal areas. Taking advantage of this brain behavior, a discriminant model only based on AAPEn and QSEn computed from the EEG channels P3 and P4 has reached a diagnostic accuracy greater than 80%, which improves slightly the current state of the art. Moreover, because this classification system is notably easier than others previously proposed, it could be used for continuous monitoring of negative stress, as well as for its regulation towards more positive moods in controlled environments.

Personality disorder symptom severity predicts onset of mood episodes and conversion to bipolar I disorder in individuals with bipolar spectrum disorder

Although personality disorders (PDs) are highly comorbid with bipolar spectrum disorders (BSDs), little longitudinal research has been conducted to examine the prospective impact of PD symptoms on the course of BSDs. The aim of this study is to examine whether PD symptom severity predicts shorter time to onset of bipolar mood episodes and conversion to bipolar I disorder over time among individuals with less severe BSDs. Participants (n = 166) with bipolar II disorder, cyclothymia, or bipolar disorder not otherwise specified completed diagnostic interview assessments of PD symptoms and self-report measures of mood symptoms at baseline. They were followed prospectively with diagnostic interviews every 4 months for an average of 3.02 years. Cox proportional hazard regression analyses indicated that overall PD symptom severity significantly predicted shorter time to onset of hypomanic (hazard ratio [HR] = 1.42; p < .001) and major depressive episodes (HR = 1.51; p < .001) and conversion to bipolar I disorder (HR = 2.51; p < .001), after controlling for mood symptoms. Results also suggested that cluster B severity predicted shorter time to onset of hypomanic episodes (HR = 1.38; p = .002) and major depressive episodes (HR = 1.35; p = .01) and conversion to bipolar I disorder (HR = 2.77; p < .001), whereas cluster C severity (HR = 1.56; p < .001) predicted shorter time to onset of major depressive episodes. These results support predisposition models in suggesting that PD symptoms may act as a risk factor for a more severe course of BSDs. (PsycINFO Database Record

Prevention of recurrent affective episodes using extinction training in the reconsolidation window: A testable psychotherapeutic strategy

Stressors may initially precipitate affective episodes, but with sufficient numbers of recurrences, episodes can occur more autonomously. It is postulated the memory engram for these recurrent depressions moves from the conscious representational memory system to the unconscious habit memory system encoded in the striatum. If this were the case, cognitive behavior therapy targeted toward extinction of habit memories could be an effective maneuver for helping reverse the automaticity of affective episode recurrence. Extinction training in the reconsolidation window (which opens about 5min to 1h after active memory recall) can revise, reverse, or eliminate the long term memories associated with PTSD and other anxiety disorders and with drug abuse craving. We hypothesize that similar cognitive behavioral work in the reconsolidation window could inhibit stress-induced and spontaneous affective episodes. Some initial formulations of possible therapeutic strategies are presented and discussed, as well as caveats. It is hoped that preliminary exposition of this theoretical approach to recurrences in the affective disorders based on principles dependent on work in the reconsolidation window will lead to more detailed elaboration of the therapeutic maneuvers most likely to be successful and ones that can be specifically tested for their clinical efficacy.

Biological hypotheses and biomarkers of bipolar disorder

The most common mood disorders are major depressive disorders and bipolar disorders (BD). The pathophysiology of BD is complex, multifactorial, and not fully understood. Creation of new hypotheses in the field gives impetus for studies and for finding new biomarkers for BD. Conversely, new biomarkers facilitate not only diagnosis of a disorder and monitoring of biological effects of treatment, but also formulation of new hypotheses about the causes and pathophysiology of the BD. BD is characterized by multiple associations between disturbed brain development, neuroplasticity, and chronobiology, caused by: genetic and environmental factors; defects in apoptotic, immune-inflammatory, neurotransmitter, neurotrophin, and calcium-signaling pathways; oxidative and nitrosative stress; cellular bioenergetics; and membrane or vesicular transport. Current biological hypotheses of BD are summarized, including related pathophysiological processes and key biomarkers, which have been associated with changes in genetics, systems of neurotransmitter and neurotrophic factors, neuroinflammation, autoimmunity, cytokines, stress axis activity, chronobiology, oxidative stress, and mitochondrial dysfunctions. Here we also discuss the therapeutic hypotheses and mechanisms of the switch between depressive and manic state.

Does stress play a significant role in bipolar disorder? A meta-analysis

BACKGROUND

There is evidence that stressful life events (LE) play a crucial role in the etiology of bipolar affective disorder (BD). However, primary studies, as well as narrative reviews, have provided mixed results. The present meta-analysis combined and analyzed previous data in order to address these inconsistencies.

METHOD

Forty-two studies published in 53 records were identified by systematically searching MEDLINE, PsychINFO, and PSYCHINDEX using the terms "bipolar disorder" OR "manic-depressive" OR "bipolar affective disorder" OR "mania" AND "stress" OR "life event" OR "daily hassles" OR "goal attainment". Then, meta-analyses were conducted.

RESULTS

Individuals diagnosed with BD reported more LE before relapse when compared to euthymic phases. They also experienced more LE relative to healthy individuals and to physically ill patients. No significant difference in the number of LE was found when BD was compared to unipolar depression and schizophrenia.

LIMITATIONS

When interpreting the present meta-analytic findings one should keep in mind that most included studies were retrospective and often did not specify relevant information, e.g., if the LE were chronic or acute or if the individuals were diagnosed with BD I or II. We could not entirely rule out a publication bias.

CONCLUSION

The present meta-analyses found that individuals with BD were sensitive to LE, which corroborates recent theoretical models and psychosocial treatment approaches of BD. Childbirth, as a specific LE, affected individuals with BD more than individuals with unipolar depression. Future studies that investigate specific LE are warranted.

Neurobiology of Chronic Stress-Related Psychiatric Disorders: Evidence from Molecular Imaging Studies

Chronic stress accounts for billions of dollars of economic loss annually in the United States alone, and is recognized as a major source of disability and mortality worldwide. Robust evidence suggests that chronic stress plays a significant role in the onset of severe and impairing psychiatric conditions, including major depressive disorder, bipolar disorder, and posttraumatic stress disorder. Application of molecular imaging techniques such as positron emission tomography and single photon emission computed tomography in recent years has begun to provide insight into the molecular mechanisms by which chronic stress confers risk for these disorders. The present paper provides a comprehensive review and synthesis of all positron emission tomography and single photon emission computed tomography imaging publications focused on the examination of molecular targets in individuals with major depressive disorder, posttraumatic stress disorder, or bipolar disorder to date. Critical discussion of discrepant findings and broad strengths and weaknesses of the current body of literature is provided. Recommended future directions for the field of molecular imaging to further elucidate the neurobiological substrates of chronic stress-related disorders are also discussed. This article is part of the inaugural issue for the journal focused on various aspects of chronic stress.

Environmental factors, life events, and trauma in the course of bipolar disorder

The etiology and clinical course of bipolar disorder are considered to be determined by genetic and environmental factors. Although the kindling hypothesis emphasizes the impact of environmental factors on initial onset, their connection to the outcome and clinical course have been poorly established. Hence, there have been numerous research efforts to investigate the impact of environmental factors on the clinical course of illness. Our aim is to outline recent research on the impact of environmental determinants on the clinical course of bipolar disorder. We carried out a computer-aided search to find publications on an association between environmental factors, life events, and the clinical course of bipolar disorder. Publications in the reference lists of suitable papers have also been taken into consideration. We performed a narrative overview on all eligible publications. The available body of data supports an association between environmental factors and the clinical course of bipolar disorder. These factors comprise prenatal, early-life, and entire lifespan aspects. Given varying sample sizes and several methodological limitations, the reported quality and extent of the association between environmental factors and the clinical course of bipolar disorder should be interpreted with utmost caution. Systematic longitudinal long-term follow-up trials are needed to obtain a clearer and more robust picture.

Kindling of life stress in bipolar disorder: comparison of sensitization and autonomy models

Research on life stress in bipolar disorder largely fails to account for the possibility of a dynamic relationship between psychosocial stress and episode initiation. The kindling hypothesis (Post, 1992) states that over the course of recurrent affective disorders, there is a weakening temporal relationship between major life stress and episode initiation that could reflect either a progressive sensitization or progressive autonomy to life stress. The present study involved a comprehensive and precise examination of the kindling hypothesis in 102 participants with bipolar II disorder that allowed for a direct comparison of sensitization and autonomy models. Polarity-specific tests were conducted across the continuum of event severity with respect to impact and frequency of life events. Hypotheses were polarity- and event-valence specific and were based on the stress sensitization model. Results were only partially consistent with the sensitization model: Individuals with more prior mood episodes had an increased frequency of minor negative events before depression and of minor positive events before hypomania. However, the number of past episodes did not moderate relationships between life events and time until prospective onset of mood episodes. These results are more consistent with a sensitization than an autonomy model, but several predictions of the sensitization model were not supported. Methodological strengths, limitations, and implications are discussed regarding putative changes in stress reactivity that may occur with repeated exposure to mood episodes in bipolar II disorder.

Childhood adverse life events and parental psychopathology as risk factors for bipolar disorder

Childhood adverse events are risk factors for later bipolar disorder. We quantified the risks for a later diagnosis of bipolar disorder after exposure to adverse life events in children with and without parental psychopathology. This register-based population cohort study included all persons born in Denmark from 1980 to 1998 (980 554 persons). Adversities before age 15 years were: familial disruption; parental somatic illness; any parental psychopathology; parental labour market exclusion; parental imprisonment; placement in out-of-home care; and parental natural and unnatural death. We calculated risk estimates of each of these eight life events as single exposure and risk estimates for exposure to multiple life events. Main outcome variable was a diagnosis of bipolar disorder after the age of 15 years, analysed with Cox proportional hazard regression. Single exposure to most of the investigated adversities were associated with increased risk for bipolar disorder, exceptions were parental somatic illness and parental natural death. By far the strongest risk factor for bipolar disorder in our study was any mental disorder in the parent (hazard ratio 3.53; 95% confidence interval 2.73-4.53) and the additional effects of life events on bipolar risk were limited. An effect of early adverse life events on bipolar risk later in life was mainly observed in children without parental psychopathology. Our findings do not exclude early-life events as possible risk factors, but challenge the concept of adversities as important independent determinants of bipolar disorder in genetically vulnerable individuals.

Medical burden, body mass index and the outcome of psychosocial interventions for bipolar depression

OBJECTIVE

Individuals with bipolar disorder experience a disproportionately high incidence of medical co-morbidity and obesity. These health-related problems are a barrier to recovery from mood episodes and have been linked with unfavorable responses to pharmacological treatment. However, little is known about whether and how these characteristics affect responses to adjunctive psychotherapy.

METHOD

Embedded in the Systematic Treatment Enhancement Program for Bipolar Disorder was a randomized controlled trial of psychotherapy for bipolar depression comparing the efficacy of intensive psychotherapy plus pharmacotherapy with collaborative care (a three-session psycho-educational intervention) plus pharmacotherapy. We conducted a post-hoc analysis to evaluate whether medical burden and body mass index predicted and/or moderated the likelihood of recovery and time until recovery from a depressive episode among patients in the two treatments.

RESULTS

Participants who had medical co-morbidity and body mass index data constituted 199 of the 293 patients in the original Systematic Treatment Enhancement Program for Bipolar Disorder trial. Higher medical burden predicted a lower likelihood of recovery from depression in both treatment conditions (odds ratio = 0.89), but did not moderate responses to intensive psychotherapy vs collaborative care. Intensive psychotherapy yielded superior recovery rates for individuals of normal body mass index (odds ratio= 2.39) compared with collaborative care, but not among individuals who were overweight or obese.

CONCLUSION

Medical co-morbidity and body weight impacts symptom improvement and attention to this co-morbidity may inform the development of more personalized treatments for bipolar disorder.

DNA Damage in Major Psychiatric Diseases

Human cells are exposed to exogenous insults and continuous production of different metabolites. These insults and unwanted metabolic products might interfere with the stability of genomic DNA. Recently, many studies have demonstrated that different psychiatric disorders show substantially high levels of oxidative DNA damage in the brain accompanied with morphological and functional alterations. It reveals that damaged genomic DNA may contribute to the pathophysiology of these mental illnesses. In this article, we review the roles of oxidative damage and reduced antioxidant ability in some vastly studied psychiatric disorders and emphasize the inclusion of treatment options involving DNA repair. In addition, while most currently used antidepressants are based on the manipulation of the neurotransmitter regulation in managing different mental abnormalities, they are able to prevent or reverse neurotoxin-induced DNA damage. Therefore, it may be plausible to target on genomic DNA alterations for psychiatric therapies, which is of pivotal importance for future antipsychiatric drug development.

The Influence of Trauma, Life Events, and Social Relationships on Bipolar Depression

A growing body of research suggests that the social environment exerts a powerful influence on the course of bipolar depression. This article reviews longitudinal research to suggest that trauma, negative life events, social support deficits, and family difficulties are common and predict a more severe course of depression when present among those diagnosed with bipolar disorder. The triggers of bipolar depression overlap with those documented for unipolar depression, suggesting that many of the treatment targets for unipolar depression may be applicable for bipolar depression.

Dysregulation of the NF-κB pathway as a potential inducer of bipolar disorder

A century of investigations enhanced our understanding of bipolar disorder although it remains a complex multifactorial disorder with a mostly unknown pathophysiology and etiology. The role of the immune system in this disorder is one of the most controversial topics in genetic psychiatry. Though inflammation has been consistently reported in bipolar patients, it remains unclear how the immunologic process influences the disorder. One of the core components of the immune system is the NF-κB pathway, which plays an essential role in the development of innate and adaptive immunity. Remarkably, the NF-κB pathway received only little attention in bipolar studies, as opposed to studies of related psychiatric disorders where immune dysregulation has been proposed to explain the neurodegeneration in patient conditions. If immune dysregulation can also explains the neurodegeneration in bipolar disorder, it will underscore the role of the immune system in the chronicity and pathophysiology of the disorder and may promote personalized therapeutic strategies. This is the first review to summarize the current knowledge of the pathophysiological functions of NF-κB in bipolar disorder.

Childhood-compared to adolescent-onset bipolar disorder has more statistically significant clinical correlates

BACKGROUND

The strengths and limitations of considering childhood-and adolescent-onset bipolar disorder (BD) separately versus together remain to be established. We assessed this issue.

METHODS

BD patients referred to the Stanford Bipolar Disorder Clinic during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD Affective Disorders Evaluation. Patients with childhood- and adolescent-onset were compared to those with adult-onset for 7 unfavorable bipolar illness characteristics with replicated associations with early-onset patients.

RESULTS

Among 502 BD outpatients, those with childhood- (<13 years, N=110) and adolescent- (13-18 years, N=218) onset had significantly higher rates for 4/7 unfavorable illness characteristics, including lifetime comorbid anxiety disorder, at least ten lifetime mood episodes, lifetime alcohol use disorder, and prior suicide attempt, than those with adult-onset (>18 years, N=174). Childhood- but not adolescent-onset BD patients also had significantly higher rates of first-degree relative with mood disorder, lifetime substance use disorder, and rapid cycling in the prior year. Patients with pooled childhood/adolescent - compared to adult-onset had significantly higher rates for 5/7 of these unfavorable illness characteristics, while patients with childhood- compared to adolescent-onset had significantly higher rates for 4/7 of these unfavorable illness characteristics.

LIMITATIONS

Caucasian, insured, suburban, low substance abuse, American specialty clinic-referred sample limits generalizability. Onset age is based on retrospective recall.

CONCLUSIONS

Childhood- compared to adolescent-onset BD was more robustly related to unfavorable bipolar illness characteristics, so pooling these groups attenuated such relationships. Further study is warranted to determine the extent to which adolescent-onset BD represents an intermediate phenotype between childhood- and adult-onset BD.

The role of life events and psychological factors in the onset of first and recurrent mood episodes in bipolar offspring: results from the Dutch Bipolar Offspring Study

BACKGROUND

Life events are an established risk factor for the onset and recurrence of unipolar and bipolar mood episodes, especially in the presence of genetic vulnerability. The dynamic interplay between life events and psychological context, however, is less studied. In this study, we investigated the impact of life events on the onset and recurrence of mood episodes in bipolar offspring, as well as the effects of temperament, coping and parenting style on this association.

METHOD

Bipolar offspring (n = 108) were followed longitudinally from adolescence to adulthood. Mood disorders were assessed with: the Kiddie Schedule of Affective Disorders and Schizophrenia - Present and Lifetime Version or the Structured Clinical Interview for DSM-IV Axis I disorders; life events with the Life Events and Difficulties Schedule; and psychological measures using the Utrecht Coping List, Temperament and Character Inventory and short-EMBU (memories of upbringing instrument). Anderson-Gill models (an extension of the Cox proportional hazard model) were utilized.

RESULTS

Life events were associated with an increased risk for first and, although less pronounced, subsequent mood episodes. There was a large confounding effect for the number of previous mood episodes; findings suggest a possible kindling effect. Passive coping style increased the risk of mood episode onset and recurrent episodes, but also altered the effect of life events on mood disorders. Harm avoidance temperament was associated with mood episode recurrence.

CONCLUSIONS

Life events are especially a risk factor in the onset of mood disorders, though less so in recurrent episodes. Psychological features (passive coping and harm-avoidant temperament) contribute to the risk of an episode occurring, and also have a moderating effect on the association between life events and mood episodes. These findings create potential early intervention strategies for bipolar offspring.

Investigating the mechanism(s) underlying switching between states in bipolar disorder

Bipolar disorder (BD) is a unique disorder that transcends domains of function since the same patient can exhibit depression or mania, states with polar opposite mood symptoms. During depression, people feel helplessness, reduced energy, and risk aversion, while with mania behaviors include grandiosity, increased energy, less sleep, and risk preference. The neural mechanism(s) underlying each state are gaining clarity, with catecholaminergic disruption seen during mania, and cholinergic dysfunction during depression. The fact that the same patient cycles/switches between these states is the defining characteristic of BD however. Of greater importance therefore, is the mechanism(s) underlying cycling from one state - and its associated neural changes - to another, considered the 'holy grail' of BD research. Herein, we review studies investigating triggers that induce switching to these states. By identifying such triggers, researchers can study neural mechanisms underlying each state and importantly how such mechanistic changes can occur in the same subject. Current animal models of this switch are also discussed, from submissive- and dominant-behaviors to kindling effects. Focus however, is placed on how seasonal changes can induce manic and depressive states in BD sufferers. Importantly, changing photoperiod lengths can induce local switches in neurotransmitter expression in normal animals, from increased catecholaminergic expression during periods of high activity, to increased somatostatin and corticotrophin releasing factor during periods of low activity. Identifying susceptibilities to this switch would enable the development of targeted animal models. From animal models, targeted treatments could be developed and tested that would minimize the likelihood of switching.

Contributions of the social environment to first-onset and recurrent mania

In treated cohorts, individuals with bipolar disorder are more likely to report childhood adversities and recent stressors than individuals without bipolar disorder; similarly, in registry-based studies, childhood adversities are more common among individuals who later become hospitalized for bipolar disorder. Because these types of studies rely on treatment-seeking samples or hospital diagnoses, they leave unresolved the question of whether or not social experiences are involved in the etiology of bipolar disorder. We investigated the role of childhood adversities and adulthood stressors in liability for bipolar disorder using data from the National Epidemiologic Survey on Alcohol and Related Conditions (n=33 375). We analyzed risk for initial-onset and recurrent DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) manic episodes during the study's 3-year follow-up period. Childhood physical abuse and sexual maltreatment were associated with significantly higher risks of both first-onset mania (odds ratio (OR) for abuse: 2.23; 95% confidence interval (CI)=1.71, 2.91; OR for maltreatment: 2.10; CI=1.55, 2.83) and recurrent mania (OR for abuse: 1.55; CI=1.00, 2.40; OR for maltreatment: 1.60; CI=1.00, 2.55). In addition, past-year stressors in the domains of interpersonal instability and financial hardship were associated with a significantly higher risk of incident and recurrent mania. Exposure to childhood adversity potentiated the effects of recent stressors on adult mania. Our findings demonstrate a role of social experiences in the initial onset of bipolar disorder, as well as in its prospective course, and are consistent with etiologic models of bipolar disorder that implicate deficits in developmentally established stress-response pathways.

The influence of life events on first and recurrent admissions in bipolar disorder

Background

Life events play an important role in the onset and course of bipolar disorder. We will test the influence of life events on first and recurrent admissions in bipolar disorder and their interaction to test the kindling hypothesis.

Methods

We collected information about life events and admissions across the life span in 51 bipolar patients. We constructed four models to explore the decay of life event effects on admissions. To test their interaction, we used the Andersen-Gill model.

Results

The relationship between life events and admissions was best described with a model in which the effects of life events gradually decayed by 25% per year. Both life event load and recurrent admissions significantly increased the risk of both first and subsequent admissions. No significant interaction between life event load and number of admissions was found.

Conclusions

Life events increase the risk of both first and recurrent admissions in bipolar disorder. We found no significant interaction between life events and admissions, but the effect of life events on admissions decreases after the first admission which is in line with the kindling hypothesis.

Suicide attempts in a longitudinal sample of adolescents followed through adulthood: Evidence of escalation

OBJECTIVES

This study was designed to examine escalation in repeat suicide attempts from adolescence through adulthood, as predicted by sensitization models (and reflected in increasing intent and lethality with repeat attempts, decreasing amount of time between attempts, and decreasing stress to trigger attempts).

METHOD

In a prospective study of 180 adolescents followed through adulthood after a psychiatric hospitalization, suicide attempts, and antecedent life events were repeatedly assessed (M = 12.6 assessments, SD = 5.1) over an average of 13 years 6 months (SD = 4 years 5 months). Multivariate logistic, multiple linear, and negative binomial regression models were used to examine patterns over time.

RESULTS

After age 17-18, the majority of suicide attempts were repeat attempts (i.e., made by individuals with prior suicidal behavior). Intent increased both with increasing age, and with number of prior attempts. Medical lethality increased as a function of age but not recurrent attempts. The time between successive suicide attempts decreased as a function of number of attempts. The amount of precipitating life stress was not related to attempts.

CONCLUSIONS

Adolescents and young adults show evidence of escalation of recurrent suicidal behavior, with increasing suicidal intent and decreasing time between successive attempts. However, evidence that sensitization processes account for this escalation was inconclusive. Effective prevention programs that reduce the likelihood of individuals attempting suicide for the first time (and entering this cycle of escalation), and relapse prevention interventions that interrupt the cycle of escalating suicidal behavior among individuals who already have made attempts are critically needed. (PsycINFO Database Record