The clinical implications of cognitive impairment and allostatic load in bipolar disorder

The efficacy of valproate in acute mania, bipolar depression and maintenance therapy for bipolar disorder: an overview of systematic reviews with meta-analyses

OBJECTIVE

This study aims to conduct an overview on the comparative efficacy of valproate in acute mania, bipolar depression and maintenance treatment of bipolar disorder (BD).

METHOD

We performed an overview of systematic reviews with meta-analyses of randomised controlled trials (RCTs), registered in PROSPERO (CRD42024497749). We searched Medline and Cochrane Database of Systematic Reviews. Summary measures comparing valproate with placebo or other active drugs were described.

RESULTS

We included 26 systematic reviews. For acute mania (31 RCTs, n=4376), valproate showed a significantly better response than placebo in two high-quality systematic reviews (RR=1.42; 95% CI: 1.19 to 1.71) (OR=2.05; 95% CI: 1.32 to 3.20). No significant differences with lithium were found in most outcomes. Valproate had similar efficacy to quetiapine and lower efficacy compared with risperidone, with conflicting results when compared with olanzapine. In bipolar depression (7 RCTs, n=399), valproate was more effective than placebo in reducing depressive symptoms (OR=2.80; 95% CI: 1.26 to 6.18) and achieving remission (OR=2.4; 95% CI: 1.09 to 5.29) (OR=2.15; 95% CI: 0.82 to 5.6), considering the results of three high-quality systematic reviews. No significant difference was observed with lithium, lurasidone, quetiapine or olanzapine plus fluoxetine, but valproate showed superior efficacy to aripiprazole, ziprasidone and agomelatine. In maintenance treatment (11 RCTs, n=1063), valproate was superior to placebo in preventing relapse of any mood episode in two high-quality systematic reviews (RR=0.63; 95% CI: 0.48 to 0.83) (RR=0.63; 95% CI: 0.47 to 0.83). No significant difference was found with lithium, olanzapine or lamotrigine.

CONCLUSION

This overview highlights favourable results for valproate compared with placebo in all phases of BD, as well as presenting specific results in comparison with other active drugs. However, these results must be interpreted considering the methodological limitations of our study.

Exosome-associated mitochondrial DNA in late-life depression: Implications for cognitive decline in older adults

BACKGROUND

Disrupted cellular communication, inflammatory responses and mitochondrial dysfunction are consistently observed in late-life depression (LLD). Exosomes (EXs) mediate cellular communication by transporting molecules, including mitochondrial DNA (EX-mtDNA), playing critical role in immunoregulation alongside tumor necrosis factor (TNF). Changes in EX-mtDNA are indicators of impaired mitochondrial function and might increase vulnerability to adverse health outcomes. Our study examined EX-mtDNA levels and integrity, exploring their associations with levels of TNF receptors I and II (TNFRI and TNFRII), and clinical outcomes in LLD.

METHODS

Ninety older adults (50 LLD and 40 controls (HC)) participated in the study. Blood was collected and exosomes were isolated using size-exclusion chromatography. DNA was extracted and EX-mtDNA levels and deletion were assessed using qPCR. Plasma TNFRI and TNFRII levels were quantified by multiplex immunoassay. Correlation analysis explored relationships between EX-mtDNA, clinical outcomes, and inflammatory markers.

RESULTS

Although no differences were observed in EX-mtDNA levels between groups, elevated levels correlated with poorer cognitive performance (r = -0.328, p = 0.002) and increased TNFRII levels (r = 0.367, p = 0.004). LLD exhibited higher deletion rates (F(83,1) = 4.402, p = 0.039), with a trend remaining after adjusting for covariates (p = 0.084). Deletion correlated with poorer cognitive performance (r = -0.335, p = 0.002). No other associations were found.

LIMITATION

Cross-sectional study with a small number of participants from a specialized geriatric psychiatry treatment center.

CONCLUSION

Our findings suggest that EX-mtDNA holds promise as an indicator of cognitive outcomes in LLD. Additional research is needed to further comprehend the role of EX-mtDNA levels/integrity in LLD, paving the way for its clinical application in the future.

Evaluation of changes in carbonyl stress markers with treatment in male patients with bipolar disorder manic episode: A controlled study

BACKGROUND

Carbonyl stress, a metabolic state characterized by elevated production of reactive carbonyl compounds (RCCs), is closely related to oxidative stress and has been implicated in various diseases. This study aims to investigate carbonyl stress parameters in drug-free bipolar disorder (BD) patients compared to healthy controls, explore their relationship with clinical features, and assess the effect of treatment on these parameters.

METHODS

Patients with a primary diagnosis of a manic episode of BD and healthy controls were recruited. Exclusion criteria included intellectual disability, presence of neurological diseases, chronic medical conditions such as diabetes mellitus and metabolic syndrome, and clinical signs of inflammation. Levels of serum carbonyl stress parameters were determined using high-performance liquid chromatography.

RESULTS

Levels of glyoxal (GO) and methylglyoxal (MGO) did not differ between pre- and post-treatment patients, but malondialdehyde (MDA) levels decreased significantly post-treatment. Pre-treatment MGO and MDA levels were higher in patients compared to controls, and these differences persisted post-treatment. After adjusting for BMI and waist circumference, only MDA levels remained significantly higher in patients compared to controls.

LIMITATIONS

The study's limitations include the exclusion of female patients, which precluded any assessment of potential gender differences, and the lack of analysis of the effect of specific mood stabilizers or antipsychotic drugs.

CONCLUSIONS

This study is the first to focus on carbonyl stress markers in BD, specifically GO, MGO, and MDA. MDA levels remained significantly higher in patients, suggesting a potential role in BD pathophysiology. MGO levels were influenced by metabolic parameters, indicating a potential link to neurotoxicity in BD. Further research with larger cohorts is needed to better understand the role of RCCs in BD and their potential as therapeutic targets.

Early intervention in psychosis for first episode psychotic mania: the experience of people diagnosed with bipolar disorder

BACKGROUND

Early intervention for people diagnosed with bipolar disorder has been identified as a priority, but little is known about how existing early intervention services are experienced by this group or could be tailored to their needs.

AIMS

This study examined the experience of early intervention in psychosis (EIP) services for people diagnosed with bipolar disorder, following first episode psychotic mania.

METHOD

Semi-structured interviews were conducted with 11 adults in EIP services and analysed using Interpretative Phenomenological Analysis.

RESULTS

One superordinate theme was formed, Rebuilding within EIP service, consisting of five subthemes: (i) Piecing together episode through talking to staff; (ii) Exploring other perspectives during CBT; (iii) Empowered through shared decision-making; (iv) Reconsidering future and purpose; (v) Service as safety-net. EIP provision was pivotal in helping participants understand their episode, adjust their perspective, build confidence and progress.

CONCLUSIONS

Aspects of the service that were valued, including person-centred relationships with staff, shared decision-making and the development of motivation and opportunities, reflect key principles of mental health care for young people following first episode psychosis. Furthermore, findings point to elements that may be particularly relevant to early intervention following first episode psychotic mania including managing mood escalation and individualised approaches to goals.

The effect of physical exercises program on social functioning, alexithymia, and sense of coherence among patients with bipolar disorders: A randomized control trial

BACKGROUND

Despite evidence that physical exercises have been helpful in the treatment of various psychiatric disorders, it is unclear whether these data can be generalized to bipolar disorder. The use of physical exercises is challenging and hopeful among patients with bipolar disorders. Few studies have examined the efficacy of physical exercise for patients with bipolar disorders.

OBJECTIVE

Investigate the effect of applying physical exercises program on social functioning, alexithymia, and sense of coherence among patients with bipolar disorders.

METHODS

This study followed a randomized control trial design "pre and post-test." Patients were randomly allocated to intervention (n = 25) and control groups (Waiting list) (n = 25). The Social Functioning Scale, Toronto Alexithymia Scale, and Sense of Coherence scales were applied in the study. Pre-test and post-tests were administered to investigate the effect of applying the physical exercises program between December 2022 to March 2023.

RESULTS

A statistically significant increase in the mean sense of coherence and social functioning scores among the study group. Mean alexithymia scores were significantly decreased among the study group between pre, immediately after, and after a three-month follow-up period.

CONCLUSION

Physical exercises are an adjunctive treatment modality that is helpful for patients with bipolar disorders. Nurse educators and service providers should reconsider the physical health care requirements for patients with bipolar disorders to equip them to manage the common comorbidities in people with mental illness.

Dissecting clinical and biological heterogeneity in clinical states of bipolar disorder: a 10-year retrospective study from China

Objectives

To dissect clinical and biological heterogeneity in clinical states of bipolar disorder (BD), and investigate if neuropsychological symptomatology, comorbidity, vital signs, and blood laboratory indicators are predictors of distinct BD states.

Methods

A retrospective BD cohort was established with data extracted from a Chinese hospital's electronic medical records (EMR) between 2009 and 2018. Subjects were inpatients with a main discharge diagnosis of BD and were assessed for clinical state at hospitalization. We categorized all subjects into manic state, depressive state, and mixed state. Four machine learning classifiers were utilized to classify the subjects. A Shapley additive explanations (SHAP) algorithm was applied to the classifiers to aid in quantifying and visualizing the contributions of each feature that drive patient-specific classifications.

Results

A sample of 3,085 records was included (38.54% as manic, 56.69% as depressive, and 4.77% as mixed state). Mixed state showed more severe suicidal ideation and psychomotor abnormalities, while depressive state showed more common anxiety, sleep, and somatic-related symptoms and more comorbid conditions. Higher levels of body temperature, pulse, and systolic and diastolic blood pressures were present during manic episodes. Xgboost achieved the best AUC of 88.54% in manic/depressive states classification; Logistic regression and Random forest achieved the best AUCs of 75.5 and 75% in manic/mixed states and depressive/mixed states classifications, respectively. Myocardial enzymes and the non-enzymatic antioxidant uric acid and bilirubin contributed significantly to distinguish BD clinical states.

Conclusion

The observed novel biological associations with BD clinical states confirm that biological heterogeneity contributes to clinical heterogeneity of BD.

Recovering from first episode psychotic mania: The experience of people diagnosed with bipolar disorder

AIM

Early intervention for people diagnosed with bipolar disorder is a priority, but little is known about how recovery from first episode psychotic mania is experienced by this group. This study aimed to explore the experience of recovery from first episode psychotic mania for people diagnosed with bipolar disorder.

METHODS

Semi-structured interviews were conducted with 11 young adults during recovery from first episode psychotic mania and were analysed using Interpretative Phenomenological Analysis.

RESULTS

Three themes were identified: (i) 'Possession of purpose and staying well', (ii) 'Coping with compromise' and (iii) 'Manic relapse: pressure and proving self'. On becoming well, the participants experienced a sense of purpose through engaging with activities and goals that also drove their efforts to engage in strategies to stay well. However, these strategies created feelings of compromise that not all were prepared to accept. Though having purpose and goals created a positive sense of direction, for a minority of the participants they also created additional pressure, contributing to manic relapse.

CONCLUSIONS

The purpose created by engaging with aspirations and career-related activities during early intervention was found to be important for a meaningful recovery from first episode bipolar disorder. This instilled positivity and purpose, motivating efforts to maintain wellness. The feelings of compromise that some participants experienced point to the need for individually tailored interventions. Findings suggest a delicate relationship between the positivity of engaging in goals and the risk of manic relapse during recovery from first episode psychotic mania.

Epigenetic age deacceleration in youth at familial risk for schizophrenia and bipolar disorder

Epigenetic modifications occur sequentially during the lifespan, but their pace can be altered by external stimuli. The onset of schizophrenia and bipolar disorder is critically modulated by stressors that may alter the epigenetic pattern, a putative signature marker of exposure to environmental risk factors. In this study, we estimated the age-related epigenetic modifications to assess the differences between young individuals at familial high risk (FHR) and controls and their association with environmental stressors. The sample included 117 individuals (6-17 years) at FHR (45%) and a control group (55%). Blood and saliva samples were used estimate the epigenetic age with six epigenetic clocks through methylation data. Environmental risk was measured with obstetric complications, socioeconomic statuses and recent stressful life events data. Epigenetic age was correlated with chronological age. FHR individuals showed epigenetic age deacceleration of Horvath and Hannum epigenetic clocks compared to controls. No effect of the environmental risk factors on the epigenetic age acceleration could be detected. Epigenetic age acceleration adjusted by cell counts showed that the FHR group was deaccelerated also with the PedBE epigenetic clock. Epigenetic age asynchronicities were found in the young at high risk, suggesting that offspring of affected parents follow a slower pace of biological aging than the control group. It still remains unclear which environmental stressors orchestrate the changes in the methylation pattern. Further studies are needed to better characterize the molecular impact of environmental stressors before illness onset, which could be critical in the development of tools for personalized psychiatry.

Data-driven cognitive phenotypes in subjects with bipolar disorder and their clinical markers of severity

BACKGROUND

Subjects with bipolar disorder (BD) show heterogeneous cognitive profile and that not necessarily the disease will lead to unfavorable clinical outcomes. We aimed to identify clinical markers of severity among cognitive clusters in individuals with BD through data-driven methods.

METHODS

We recruited 167 outpatients with BD and 100 unaffected volunteers from Brazil and Spain that underwent a neuropsychological assessment. Cognitive functions assessed were inhibitory control, processing speed, cognitive flexibility, verbal fluency, working memory, short- and long-term verbal memory. We performed hierarchical cluster analysis and discriminant function analysis to determine and confirm cognitive clusters, respectively. Then, we used classification and regression tree (CART) algorithm to determine clinical and sociodemographic variables of the previously defined cognitive clusters.

RESULTS

We identified three neuropsychological subgroups in individuals with BD: intact (35.3%), selectively impaired (34.7%), and severely impaired individuals (29.9%). The most important predictors of cognitive subgroups were years of education, the number of hospitalizations, and age, respectively. The model with CART algorithm showed sensitivity 45.8%, specificity 78.4%, balanced accuracy 62.1%, and the area under the ROC curve was 0.61. Of 10 attributes included in the model, only three variables were able to separate cognitive clusters in BD individuals: years of education, number of hospitalizations, and age.

CONCLUSION

These results corroborate with recent findings of neuropsychological heterogeneity in BD, and suggest an overlapping between premorbid and morbid aspects that influence distinct cognitive courses of the disease.

Bipolar spectrum disorders in neurologic disorders

Psychiatric symptoms frequently predate or complicate neurological disorders, such as neurodegenerative diseases. Symptoms of bipolar spectrum disorders (BSD), like mood, behavioral, and psychotic alterations, are known to occur - individually or as a syndromic cluster - in Parkinson's disease and in the behavioral variant of frontotemporal dementia (FTD). Nonetheless, due to shared pathophysiological mechanisms, or genetic predisposition, several other neurological disorders show significant, yet neglected, clinical and biological overlaps with BSD like neuroinflammation, ion channel dysfunctions, neurotransmission imbalance, or neurodegeneration. BSD pathophysiology is still largely unclear, but large-scale network dysfunctions are known to participate in the onset of mood disorders and psychotic symptoms. Thus, functional alterations can unleash BSD symptoms years before the evidence of an organic disease of the central nervous system. The aim of our narrative review was to illustrate the numerous intersections between BSD and neurological disorders from a clinical-biological point of view and the underlying predisposing factors, to guide future diagnostic and therapeutical research in the field.

Heterogeneity of psychosocial functioning in patients with bipolar disorder: Associations with sociodemographic, clinical, neurocognitive and biochemical variables

OBJECTIVE

This study aims to identify the functional heterogeneity in fully or partially remitted patients with bipolar disorder and explore the correlations between psychosocial functioning and sociodemographic, clinical, neurocognitive and biochemical variables.

METHODS

One hundred and forty fully or partially remitted patients with bipolar disorder (BD) and seventy healthy controls were recruited. The patients were grouped into different profiles based on the Functioning Assessment Short Test (FAST) domain scores by hierarchical cluster analysis. The characteristics of subgroups and the correlations between psychosocial functioning and sociodemographic, clinical, neurocognitive and biochemical variables in each cluster were then analyzed.

RESULTS

There were three subgroups in fully or partially remitted patients with BD: the lower functioning group (LF), performed global functioning impairments; the moderate functioning group (MF), presented selective impairments in functional domains; and the good functioning subgroup (GF), performed almost intact functioning. Among the three subgroups, there were differences in FAST domains, sociodemographic variables, clinical variables, some neurocognitive domains and several biochemical indexes.

CONCLUSIONS

The study successfully identified three functional subgroups. The characteristics of discrete subgroups and the specific clinical factors, neurocognitive domains and biochemical indexes that are correlated with functional subgroups will allow for making tailored interventions to promote functional recovery and improve the quality of life.

Allostatic load and mental health: a latent class analysis of physiological dysregulation

This study explored the associations between specific profiles of biological dysregulation and mental health outcomes in a national, community sample of healthy adults in the United States. A latent class analysis of data from the Midlife Development in the United States study (n = 1,757) was conducted to determine classes of biological dysregulation. Multinomial logistic regressions of class membership were employed to determine associations with measures related to depression, including whether or not individuals had sought treatment, Center for Epidemiological Studies Depression Scale, and both the generalized distress and anhedonia subscales of the Mood and Anxiety Symptoms Questionnaire. Four classes of dysregulation emerged: baseline/low dysregulation, metabolic and inflammatory dysregulation, parasympathetic dysregulation, and SAM pathway dysregulation. Individuals who met the criteria for depression measures were more likely to be in the metabolic and immune dysregulation and parasympathetic dysregulation groups as compared to the baseline group. The results suggest that mental health outcomes, such as depression, are differentially associated with specific profiles of biological dysregulation. A more nuanced approach to profiles of dysregulation could better inform treatment decisions.Lay summaryHigher levels of allostatic load, which represents the cumulative wear and tear of exposure to stress, are associated with increased rates of depression and anhedonia. Specifically, parasympathetic dysregulation and immunometabolic dysregulation are associated with negative mental health outcomes.

Efficacy of an integrative approach for bipolar disorder: preliminary results from a randomized controlled trial

BACKGROUND

Bipolar disorder (BD) represents one of the most therapeutically complex psychiatric disorders. The development of a feasible comprehensive psychological approach to complement pharmacotherapy to improve its clinical management is required. The main objective of the present randomized controlled trial (RCT) was to test the efficacy of a novel adjunctive treatment entitled integrative approach in patients with BD, including: psychoeducation, mindfulness training, and functional remediation.

METHODS

This is a parallel two-armed, rater-blind RCT of an integrative approach plus treatment as usual (TAU), v. TAU alone. Participants were recruited at the Hospital Clinic of Barcelona and randomized to one of the two conditions. They were assessed at baseline and after finishing the intervention. The main outcome variable included changes in psychosocial functioning assessed through the Functioning Assessment Short Test (FAST).

RESULTS

After finishing the treatment, the repeated-measures analyses revealed a significant group × time interaction in favor of the patients who received the integrative approach (n = 28) compared to the TAU group (n = 37) (Pillai's trace = 0.10; F(1,57) = 6.9; p = 0.01), improving the functional outcome. Significant effects were also found in two out of the six domains of the FAST, including the cognitive domain (Pillai's trace = 0.25; F(1,57) = 19.1; p < 0.001) and leisure time (Pillai's trace = 0.11; F(1,57) = 7.15; p = 0.01). Regarding the secondary outcomes, a significant group × time interaction in Hamilton Depression Rating Scale changes was detected (Pillai's trace = 0.08; F(1,62) = 5.6; p = 0.02).

CONCLUSION

This preliminary study suggests that the integrative approach represents a promising cost-effective therapy to improve psychosocial functioning and residual depressive symptoms in patients suffering from BD.

Repurposing Immunomodulatory Imide Drugs (IMiDs) in Neuropsychiatric and Neurodegenerative Disorders

Neuroinflammation represents a common trait in the pathology and progression of the major psychiatric and neurodegenerative disorders. Neuropsychiatric disorders have emerged as a global crisis, affecting 1 in 4 people, while neurological disorders are the second leading cause of death in the elderly population worldwide (WHO, 2001; GBD 2016 Neurology Collaborators, 2019). However, there remains an immense deficit in availability of effective drug treatments for most neurological disorders. In fact, for disorders such as depression, placebos and behavioral therapies have equal effectiveness as antidepressants. For neurodegenerative diseases such as Parkinson's disease and Alzheimer's disease, drugs that can prevent, slow, or cure the disease have yet to be found. Several non-traditional avenues of drug target identification have emerged with ongoing neurological disease research to meet the need for novel and efficacious treatments. Of these novel avenues is that of neuroinflammation, which has been found to be involved in the progression and pathology of many of the leading neurological disorders. Neuroinflammation is characterized by glial inflammatory factors in certain stages of neurological disorders. Although the meta-analyses have provided evidence of genetic/proteomic upregulation of inflammatory factors in certain stages of neurological disorders. Although the mechanisms underpinning the connections between neuroinflammation and neurological disorders are unclear, and meta-analysis results have shown high sensitivity to factors such as disorder severity and sample type, there is significant evidence of neuroinflammation associations across neurological disorders. In this review, we summarize the role of neuroinflammation in psychiatric disorders such as major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and bipolar disorder, as well as in neurodegenerative disorders, such as Parkinson's disease and Alzheimer's disease, and introduce current research on the potential of immunomodulatory imide drugs (IMiDs) as a new treatment strategy for these disorders.

Concepts of Neuroinflammation and Their Relationship With Impaired Mitochondrial Functions in Bipolar Disorder

Bipolar disorder (BD) is a chronic psychiatric disease, characterized by frequent behavioral episodes of depression and mania, and neurologically by dysregulated neurotransmission, neuroplasticity, growth factor signaling, and metabolism, as well as oxidative stress, and neuronal apoptosis, contributing to chronic neuroinflammation. These abnormalities result from complex interactions between multiple susceptibility genes and environmental factors such as stress. The neurocellular abnormalities of BD can result in gross morphological changes, such as reduced prefrontal and hippocampal volume, and circuit reorganization resulting in cognitive and emotional deficits. The term "neuroprogression" is used to denote the progressive changes from early to late stages, as BD severity and loss of treatment response correlate with the number of past episodes. In addition to circuit and cellular abnormalities, BD is associated with dysfunctional mitochondria, leading to severe metabolic disruption in high energy-demanding neurons and glia. Indeed, mitochondrial dysfunction involving electron transport chain (ETC) disruption is considered the primary cause of chronic oxidative stress in BD. The ensuing damage to membrane lipids, proteins, and DNA further perpetuates oxidative stress and neuroinflammation, creating a perpetuating pathogenic cycle. A deeper understanding of BD pathophysiology and identification of associated biomarkers of neuroinflammation are needed to facilitate early diagnosis and treatment of this debilitating disorder.

Neuroprogression as an Illness Trajectory in Bipolar Disorder: A Selective Review of the Current Literature

Bipolar disorder (BD) is a chronic and disabling psychiatric condition that is linked to significant disability and psychosocial impairment. Although current neuropsychological, molecular, and neuroimaging evidence support the existence of neuroprogression and its effects on the course and outcome of this condition, whether and to what extent neuroprogressive changes may impact the illness trajectory is still poorly understood. Thus, this selective review was aimed toward comprehensively and critically investigating the link between BD and neurodegeneration based on the currently available evidence. According to the most relevant findings of the present review, most of the existing neuropsychological, neuroimaging, and molecular evidence demonstrates the existence of neuroprogression, at least in a subgroup of BD patients. These studies mainly focused on the most relevant effects of neuroprogression on the course and outcome of BD. The main implications of this assumption are discussed in light of specific shortcomings/limitations, such as the inability to carry out a meta-analysis, the inclusion of studies with small sample sizes, retrospective study designs, and different longitudinal investigations at various time points.

Allostatic load, emotional hyper-reactivity, and functioning in individuals with bipolar disorder

OBJECTIVES

Diagnosis and management of bipolar disorder (BD) are limited by the absence of available biomarkers. Allostatic load (AL) represents the strain that stress, including the effects of acute phases and inter-episode chronic mood instability, exerts on interconnected biological systems. This study aimed to operationalize an AL index and explore whether it could be relevant to better characterize BD patients with and without emotional hyper-reactivity particularly those at higher risk of immune-cardiometabolic dysregulation and functional impairment.

METHODS

Levels of biomarkers of chronic inflammation (hsCRP and albumin), cardiovascular (systolic/diastolic blood pressure) and metabolic functions (fasting glucose, glycosylated hemoglobin, total cholesterol, LDL, HDL, and triglycerides) were measured in 1072 adult BD outpatients. Patients were classified in two groups (with/without emotional hyper-reactivity) assessed by the Multidimensional Assessment of Thymic States scale. An Allostatic Load Index for BD (BALLI), comprising six biomarkers, was constructed using data-driven biomarker selection.

RESULTS

BALLI showed 81.1% accuracy with good sensitivity (81%) and specificity (81.2%) for characterizing BD patients presenting emotional hyper-reactivity, elevated risk of inflammation (increased hsCRP, hypoalbuminemia) and cardiometabolic disturbances (hypertension, hyperglycemia, and hypertriglyceridemia). Patients classified by the BALLI as presenting emotional hyper-reactivity had significantly lower global and cognitive functioning than those without emotional hyper-reactivity (P < .0001).

CONCLUSIONS

A multidimensional approach based on a simple AL score (eg, BALLI) and dimensions of behavior (eg, emotional hyper-reactivity) alongside mood is clinically relevant. AL index could be a useful tool to detect multisystemic physiological dysregulations in BD patients with/without emotional hyper-reactivity particularly those at higher risk of immune-cardiometabolic disturbances and functional impairment.

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

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

Exercise is medicine: a new perspective for health promotion in bipolar disorder

INTRODUCTION

Similar effects in reducing the symptoms of the mood disorder are reported in the literature compared the action of drugs and aerobic exercise sessions, demonstrating the potential of exercise in the control and mood stabilization. Therefore, there are many reasons to believe that the increased cardiorespiratory fitness (VO_2max) can be an important means of protection and a reducing potential of physical and mental damage in bipolar disorders (BD). This review will highlight the current pattern of response of exercise on the pathophysiology of BD, relating the possible mechanisms, and hypotheses based on exercises.

AREAS COVERED

The mechanism of monoaminergic action and its relationship with exercise, role of physical conditioning and increased VO_2Max on neurotrophin release, and new perspectives on long-term exercise will be reviewed.

EXPERT OPINION

The adaptations to training, although little explored in the context of BD, can induce the expression of substances that co-regulate several processes related to the pathophysiology of BD. Furthermore, high intensity interval training (HIIT) can also be adjusted to improve the physical fitness and health in patients with BD. Future research is needed to adopt a training strategy that is both time efficient and adequate for the population in question.

The black sheep of the family- whole-exome sequencing in family of lithium response discordant bipolar monozygotic twins

Twin studies are among the most promising strategies for studying heritable disorders, including bipolar disorder (BD). The aim of the present study was to identify distinguishing genes between monozygotic (MZ) twins with different BD phenotype and compare them to their non-affected siblings. Whole-exome sequencing (WES) can identify rare and structural variants that could detect the polygenetic burden of complex disorders. WES was performed on a family composed of two MZ twins with BD, their unaffected brother and unaffected parents. The twins have a discordant response to lithium and distinct course of illness. Following WES, six genes of particular interest emerged: Neurofibromin type 1 (NF1), Biorientation of chromosomes in cell division 1 (BOD1), Golgi-associated gamma adaptin ear-containing ARF binding protein 3 (GGA3), Disrupted in schizophrenia 1 (DISC1), Neuromedin U receptor 2 (NMUR2), and Huntingtin interacting protein 1-related (HIP1R). Interestingly, many of these influence glutamatergic pathways and thus the findings may have therapeutical implications. These results may provide important insights to unveil genetic underpinnings of BD and the response to lithium.

The CINP Guidelines on the Definition and Evidence-Based Interventions for Treatment-Resistant Bipolar Disorder

BACKGROUND

Resistant bipolar disorder is a major mental health problem related to significant disability and overall cost. The aim of the current study was to perform a systematic review of the literature concerning (1) the definition of treatment resistance in bipolar disorder, (2) its clinical and (3) neurobiological correlates, and (4) the evidence-based treatment options for treatment-resistant bipolar disorder and for eventually developing guidelines for the treatment of this condition.

MATERIALS AND METHODS

The PRISMA method was used to identify all published papers relevant to the definition of treatment resistance in bipolar disorder and the associated evidence-based treatment options. The MEDLINE was searched to April 22, 2018.

RESULTS

Criteria were developed for the identification of resistance in bipolar disorder concerning all phases. The search of the literature identified all published studies concerning treatment options. The data were classified according to strength, and separate guidelines regarding resistant acute mania, acute bipolar depression, and the maintenance phase were developed.

DISCUSSION

The definition of resistance in bipolar disorder is by itself difficult due to the complexity of the clinical picture, course, and treatment options. The current guidelines are the first, to our knowledge, developed specifically for the treatment of resistant bipolar disorder patients, and they also include an operationalized definition of treatment resistance. They were based on a thorough and deep search of the literature and utilize as much as possible an evidence-based approach.

Targeting Inflammatory-Mitochondrial Response in Major Depression: Current Evidence and Further Challenges

The prevalence of psychiatric disorders has increased in recent years. Among existing mental disorders, major depressive disorder (MDD) has emerged as one of the leading causes of disability worldwide, affecting individuals throughout their lives. Currently, MDD affects 15% of adults in the Americas. Over the past 50 years, pharmacotherapy, psychotherapy, and brain stimulation have been used to treat MDD. The most common approach is still pharmacotherapy; however, studies show that about 40% of patients are refractory to existing treatments. Although the monoamine hypothesis has been widely accepted as a molecular mechanism to explain the etiology of depression, its relationship with other biochemical phenomena remains only partially understood. This is the case of the link between MDD and inflammation, mitochondrial dysfunction, and oxidative stress. Studies have found that depressive patients usually exhibit altered inflammatory markers, mitochondrial membrane depolarization, oxidized mitochondrial DNA, and thus high levels of both central and peripheral reactive oxygen species (ROS). The effect of antidepressants on these events remains unclear. Nevertheless, the effects of ROS on the brain are well known, including lipid peroxidation of neuronal membranes, accumulation of peroxidation products in neurons, protein and DNA damage, reduced antioxidant defenses, apoptosis induction, and neuroinflammation. Antioxidants such as ascorbic acid, tocopherols, and coenzyme Q have shown promise in some depressive patients, but without consensus on their efficacy. Hence, this paper provides a review of MDD and its association with inflammation, mitochondrial dysfunction, and oxidative stress and is aimed at thoroughly discussing the putative links between these events, which may contribute to the design and development of new therapeutic approaches for patients.

Current understandings of the trajectory and emerging correlates of cognitive impairment in bipolar disorder: An overview of evidence

OBJECTIVES

Cognitive dysfunction affects a significant proportion of people with bipolar disorder (BD), but the cause, trajectory and correlates of such dysfunction remains unclear. Increased understanding of these factors is required to progress treatment development for this symptom dimension.

METHODS

This paper provides a critical overview of the literature concerning the trajectories and emerging correlates of cognitive functioning in BD. It is a narrative review in which we provide a qualitative synthesis of current evidence concerning clinical, molecular, neural and lifestyle correlates of cognitive impairment in BD across the lifespan (in premorbid, prodromal, early onset, post-onset, elderly cohorts).

RESULTS

There is emerging evidence of empirical links between cognitive impairment and an increased inflammatory state, brain structural abnormalities and reduced neuroprotection in BD. However, evidence regarding the progressive nature of cognitive impairment is mixed, since consensus between different cross-sectional data is lacking and does not align to the outcomes of the limited longitudinal studies available. Increased recognition of cognitive heterogeneity in BD may help to explain some inconsistencies in the extant literature.

CONCLUSIONS

Large, longitudinally focussed studies of cognition and its covariation alongside biological and lifestyle factors are required to better define cognitive trajectories in BD, and eventually pave the way for the application of a precision medicine approach for individual patients in clinical practice.

Disturbance of Oxidative Stress Parameters in Treatment-Resistant Bipolar Disorder and Their Association With Electroconvulsive Therapy Response

OBJECTIVE

Electroconvulsive therapy (ECT) is an effective option for treatment-resistant bipolar disorder (trBD). However, the mechanisms of its effect are unknown. Oxidative stress is thought to be involved in the underpinnings of BD. Our study is the first, to our knowledge, to report the association between notable oxidative stress parameters (superoxide dismutase [SOD], glutathione peroxidase [GSH-Px], catalase [CAT], and malondialdehyde [MDA]) levels and ECT response in trBD patients.

METHODS

A total 28 trBD patients and 49 controls were recruited. Six-week ECT and naturalistic follow-up were conducted. SOD, GSH-Px, CAT, and MDA levels were measured by enzyme-linked immunosorbent assay, and the 17-item Hamilton Depression Rating Scale and Young Mania Rating Scale were administered at baseline and the end of the 6th week. MANCOVA, ANCOVA, 2 × 2 ANCOVA, and a multiple regression model were conducted.

RESULTS

SOD levels were lower in both trBD mania and depression (P = .001; P = .001), while GSH-Px (P = .01; P = .001) and MDA (P = .001; P = .001) were higher in both trBD mania and depression compared with controls. CAT levels were positively associated with 17-item Hamilton Depression Rating Scale scores in trBD depression (radjusted  = 0.83, P = .005). MDA levels in trBD decreased after 6 weeks of ECT (P = .001). Interestingly, MDA levels decreased in responders (P = .001) but not in nonresponders (P > .05).

CONCLUSIONS

Our study indicates that decreased SOD could be a trait rather than a state in trBD. Oxidative stress levels are associated with illness severity and ECT response. This suggests that the mechanism of oxidative stress plays a crucial role in the pathophysiology of trBD.

Association between CANCA1C gene rs1034936 polymorphism and alcohol dependence in bipolar disorder

INTRODUCTION

Bipolar disorder (BD) is a highly heritable and disabling mental illness, commonly associated with substance abuse, being alcohol abuse the most frequent. Comorbid BD and substance abuse disorders are often associated with high levels of health service utilization and destabilization of the course of illness resulting in poor treatment outcomes. Although recent genome-wide association studies have detected a number of risk genes for BD, the data is still sparse and inconclusive for those genes that may contribute to the increased risk of comorbid alcohol abuse (AA) in BD. The primary aim of the present study was to investigate the effects of 46 single-nucleotide polymorphisms (SNPs) within eight genes on different phenotypes of BD patients, such as comorbid alcohol abuse. We further assessed clinical variables associated with AA.

METHODS

One-hundred fifty-eight BD I and II patients were enrolled in a naturalistic cohort study. Genomic DNA of 92 patients was extracted from whole blood using standard procedures and 46 tag SNPs in eight genes of interest (ANK, CACNA1C, CACNB2, FKBP5, GRM7, ITIH3, SYNE1 and TCF4) were genotyped.

RESULTS

Seventy-one patients out of 158 (45%) satisfied diagnostic criteria for comorbid AA. Among 46 SNPs analyzed, the only SNP associated with comorbid AA was rs1034936 polymorphism in the CANCA1C gene. This polymorphism was also associated with lifetime cocaine abuse, manic switch and current atypical antipsychotics.

CONCLUSIONS

Our findings suggest a role of rs1034936 CACNA1C gene variant in BD-AA group. Despite their preliminary nature, the present results may provide new insight on mechanisms underlying AA in BD.

Depression as is Seen by Molecular Spectroscopy. Phospholipid- Protein Balance in Affective Disorders and Dementia

There is an expanding field of research investigating the instrumental methods to measure the development of affective disorders. The goal of the commentary is to turn the attention of medical practitioners at the molecular spectroscopy techniques (FTIR, Raman and UV-Vis) that can be applied for monitoring and quantification of the phospholipid-protein balance in human blood serum of depressed patients. Even facial overview of cited original research strongly suggests that disturbed phospholipid-protein balance could be one of the biomarkers of affective disorders. The blood serum monitoring of depressed patients would serve as a tool for more effective holistic therapy.

Predicting individual responses to lithium with oxidative stress markers in drug-free bipolar disorder

Objectives: This is the first study to investigate the oxidative stress (OxS) levels in drug-free bipolar disorder (BD) patients and their association with lithium response.Methods: A total of 61 drug-free BD patients and 49 controls were included. Patients treated with lithium were followed-up for 6 weeks. The levels of superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), catalase (CAT) and malondialdehyde (MDA) were measured at baseline and at the end of the sixth week.Results: Compared to controls, the SOD levels were lower, whereas the MDA were higher in the BD-depression (BD-D) group (both P < 0.001). GSH-Px levels were higher in both the BD-D and the BD-mania (BD-M) group (both P < 0.001). Both GSH-Px and MDA levels in the BD (P = 0.009, P < 0.001) and the BD-D subgroup (P = 0.006, P = 0.001) decreased significantly after the 6-week treatment with lithium. Interestingly, both GSH-Px and MDA levels decreased in responders (P = 0.03, P = 0.002) but not in the non-responders of BD-D (both p > 0.05). Moreover, the reduction in the MDA levels were associated with lithium response (B = 1.47, Wald statistic = 5.94, P = 0.015, odds ratio = 4.35, 95% confidence interval 1.33-14.20).Conclusions: Our study demonstrates an imbalance of OxS in drug-free BD, especially BD-D. Lithium reduces the GSH-Px and MDA levels in BD patients. The reduction in MDA levels may predict individual responsiveness to lithium.

A review on shared clinical and molecular mechanisms between bipolar disorder and frontotemporal dementia

Mental disorders are highly prevalent and important causes of medical burden worldwide. Co-occurrence of neurological and psychiatric symptoms are observed among mental disorders, representing a challenge for their differential diagnosis. Psychiatrists and neurologists have faced challenges in diagnosing old adults presenting behavioral changes. This is the case for early frontotemporal dementia (FTD) and bipolar disorder. In its initial stages, FTD is characterized by behavioral or language disturbances in the absence of cognitive symptoms. Consequently, patients with the behavioral subtype of FTD (bv-FTD) can be initially misdiagnosed as having a psychiatric disorder, typically major depression disorder (MDD) or bipolar disorder (BD). Bipolar disorder is associated with a higher risk of dementia in older adults and with cognitive impairment, with a subset of patients presents a neuroprogressive pattern during the disease course. No mendelian mutations were identified in BD, whereas three major genetic causes of FTD have been identified. Clinical similarities between BD and bv-FTD raise the question whether common molecular pathways might explain shared clinical symptoms. Here, we reviewed existing data on clinical and molecular similarities between BD and FTD to propose biological pathways that can be further investigated as common or specific markers of BD and FTD.

Personalized and precision medicine as informants for treatment management of bipolar disorder

DSM-5 diagnostic categories, defined by a set of psychopathological symptoms are heterogeneous conditions that may include different biological entities, with distinct etiopathogenesis, different courses and requiring different treatment management. For bipolar disorder the major evidences for this lack of validity are the long paths before a proper diagnosis, the inconsistence of treatment guidelines, the long phases of pharmacological adjustment and the low average of long-term treatment response rates. Personalized medicine for mental disorders aims to couple established clinical-pathological indexes with new molecular profiling to create diagnostic, prognostic and therapeutic strategies precisely tailored to each patient. Regarding bipolar disorder, the clinical history and presentation are still the most reliable markers in stratifying patients and guiding therapeutic management, despite the research goes to great lengths to develop new neuropsychological or biological markers that can reliably predict individual therapy effectiveness. We provide an overview of the advancements in personalized medicine in bipolar disorder, with particular attention to how psychopathology, age at onset, comorbidity, course and staging, genetic and epigenetic, imaging and biomarkers can influence treatment management and provide an integration to the conventional treatment guidelines. This approach may offer a new and rational path for the development of treatments for targeted subgroups of patients with bipolar disorder.

Functional remediation improves bipolar disorder functioning with no effects on brain-derived neurotrophic factor levels

The main aim of this study is to evaluate the impact of functional remediation (FR) in serum brain derived neurotrophic factor (BDNF) levels in euthymic adult patients with Bipolar Disorder (BD). A total of 128 participants were recruited at the Hospital Clinic of Barcelona. They were assessed at baseline and at the end of follow-up by the means of Hamilton Depression Scale (HAM-D), Young Mania Rating Scale (YMRS) and Functioning Assessment Short Test (FAST), as well as a clinical structured interview to collect clinical and demographic variables of interest. Blood samples were also collected to assess BDNF levels. After baseline assessment, patients received FR, Psychoeducation or treatment as usual (TAU). One hundred and two out of 126 participants finished the study distributed as follows: FR group (n = 39); Psychoeducation group (n = 47) and TAU group (n = 16). Longitudinal repeated-measures analyses addressing the treatment effect on BDNF levels showed non-significant differences between the three groups (Pillai's trace = 0.06; F_(2,97)= 0.28; p = 0.75), suggesting no interaction between treatment allocation and time on BDNF levels. The results of this study suggest that FR has no effect on peripheral BDNF levels in euthymic patients with BD, despite the improvement in psychosocial functioning.

The associations between subjective and objective cognitive functioning across manic or hypomanic, depressed, and euthymic states in Chinese bipolar patients

BACKGROUND

Patients may present cognitive deficits during all stages of bipolar disorder (BD). Few studies have examined self-reported cognitive difficulties and its relation to neurocognitive dysfunction during symptomatic periods of BD. This study aimed to compare subjective cognitive functioning and explore associations between subjective and objective cognitive functioning across different BD clinical states, and investigate the predicting and moderating roles of mood symptoms.

METHODS

Subjective cognitive functioning (measured by Cognitive Complaints in Bipolar Disorder Rating Assessment, COBRA) and several domains of cognitive functioning (assessed by a neuropsychological battery), including executive functions, attention and processing speed, and visual memory, were examined in 48 hypomanic or manic patients, 42 depressed bipolar patients, 50 euthymic bipolar patients and 60 healthy comparisons.

RESULTS

All patients exhibited subjective and objective cognitive deficits in relation to healthy comparisons. There was a significant association between subjective and objective cognitive functioning in euthymic group, but the association was not significant in acute symptomatic groups, which could be moderated by depressive or manic symptoms in depressive or manic group, respectively. Subjective cognitive functioning was significantly correlated with mood symptoms, and the best predictor of subjective cognitive functioning was depressive symptoms.

LIMITATIONS

This was a cross-sectional study with a mixed sample of inpatients and outpatients. The medication effect was not adjusted.

CONCLUSIONS

The associations between subjective and objective cognitive dysfunction varied in clinical states, and mood symptoms moderated the associations. A neuropsychological test battery is required to substantiate actual cognitive dysfunction in clinical settings, irrespective of subjective cognitive deficits.

Peripheral Oxidative Stress Markers in Patients with Bipolar Disorder during Euthymia and in Siblings

AIMS

Oxidative stress is increased during the acute phases of bipolar disorder (BD). Our aim here was to analyze oxidative stress biomarkers in patients with BD during euthymia and their siblings.

METHOD

A cross-sectional study was performed in euthymic patients with BD-I (n=48), unaffected siblings (n=23) and genetically unrelated healthy controls (n=21). Protein carbonyl content (PCC), total antioxidant capacity (TRAP), lipid peroxidation (TBARS) and uric acid were measured as biomarkers of oxidative stress in blood.

RESULTS

The antioxidant capacity (TRAP) was lower (p<0.001) in patients with BD compared to their siblings and controls, whereas no differences were observed in PCC, TBARS or uric acid. In patients, the concentrations of TRAP and TBARS were positively associated with the dose of valproic acid (p<0.05 and p<0.001, respectively). The concentrations of these biomarkers were not significantly associated with any of socio-demographic and clinical variables.

CONCLUSION

A selective reduction in antioxidant capacity is present in BD during euthymia state, whereas other markers of oxidative stress are unaltered during euthymia. Siblings did not show any alterations in oxidative stress biomarkers. Oxidative stress might represent a state-dependent marker in BD. The association between treatment with valproic acid and oxidative stress markers in euthymia deserves further studies.

Subjective neurocognition and quality of life in patients with bipolar disorder and siblings

BACKGROUND

Bipolar disorder (BD) is associated with significant neurocognitive and functional impairment, which may progress across stages. However, the potential progression of subjective cognitive complaints and quality of life (QoL) has not been addressed. Our main objective was to assess subjective cognitive complaints and QoL on euthymic patients with BD and their healthy siblings.

METHODS

Four groups were compared: euthymic patients with type I BD in the early (n = 25) and late (n = 23) stages, their healthy siblings (latent stage; n = 23) and healthy controls (n = 21). Cognitive complaints and QoL were assessed using the COBRA and WHO-QoLBREF questionnaires, respectively.

RESULTS

Late-stage patients had greater number of subjective cognitive complaints and reported a worse QoL compared to the other groups. Early-stage patients also had more cognitive complaints than controls and siblings, although differences were not significant. Siblings and controls reported similar QoL.

LIMITATIONS

the most important limitation of this study is the criterion used to define the early and late stages of BD, as currently there is no consensus and previous studies have used different criteria.

CONCLUSIONS

This is the first study to examine subjective cognition and QoL in patients with BD and siblings. Our results raise the possibility that burden of cognitive complaints increase with disorder progression, in tandem with deterioration in subjective QoL. That would support a clinical staging model of BD. This hypothesis remains to be confirmed by a longitudinal analysis.

Classification of patients with bipolar disorder using k-means clustering

Introduction

Bipolar disorder (BD) is a heterogeneous disorder needing personalized and shared decisions. We aimed to empirically develop a cluster-based classification that allocates patients according to their severity for helping clinicians in these processes.

Methods

Naturalistic, cross-sectional, multicenter study. We included 224 subjects with BD (DSM-IV-TR) under outpatient treatment from 4 sites in Spain. We obtained information on socio-demography, clinical course, psychopathology, cognition, functioning, vital signs, anthropometry and lab analysis. Statistical analysis: k-means clustering, comparisons of between-group variables, and expert criteria.

Results and discussion

We obtained 12 profilers from 5 life domains that classified patients in five clusters. The profilers were: Number of hospitalizations and of suicide attempts, comorbid personality disorder, body mass index, metabolic syndrome, the number of comorbid physical illnesses, cognitive functioning, being permanently disabled due to BD, global and leisure time functioning, and patients’ perception of their functioning and mental health. We obtained preliminary evidence on the construct validity of the classification: (1) all the profilers behaved correctly, significantly increasing in severity as the severity of the clusters increased, and (2) more severe clusters needed more complex pharmacological treatment.

Conclusions

We propose a new, easy-to-use, cluster-based severity classification for BD that may help clinicians in the processes of personalized medicine and shared decision-making.

Modifiable and non-modifiable factors associated with functional impairment during the inter-episodic periods of bipolar disorder

The chronic, long-term evolution of bipolar disorder (BD) requires a careful clinical characterization with prognostic implications in terms of symptom and functional control. The OPTHYMUM multicenter study was conducted in France with the objective of evaluating residual symptoms on overall functioning of BD patients during inter-episodic period. The aims of the present study were to identify the potentially modifiable (e.g., treatable) and non-modifiable variables associated with functional impairment during the inter-episodic periods of BD. Sample was divided into two groups according to level of functioning (adequate vs. impaired), based on the FAST scale total score. FAST cut-off for functional impairment is a score >11. The two subgroups were compared as per sociodemographic and clinical variables with standard univariate analyses, and a logistic regression model was created. The model as a whole contained independent non-modifiable factors (age, gender, BD type, illness duration) and modifiable factors (illness severity, predominant polarity, depressive and manic residual symptoms, comorbidities). The final model was statistically significant (χ ² = 53.89, df = 5, p < 0.001). Modifiable factors most strongly associated with functional impairment were manic predominant polarity (OR = 1.79, CI 95% 1.09-2.96, p = 0.022), residual depressive symptoms (OR = 1.30, CI 95% 1.18-1.43, p < 0.001) and illness severity (OR = 1.24, CI 95% 1.01-1.52, p = 0.037), whilst non-modifiable factor was illness duration (OR = 1.03, CI 95% 1.01-1.05, p = 0.017). Despite intrinsic and non-modifiable illness characteristics, a clinical-wise choice of treatment may help to improve control of manic relapses. Potential improvement of residual depressive symptoms may alleviate the functional burden associated with bipolar disorder.

Psychometric properties and cross-cultural comparison of the cognitive complaints in bipolar disorder rating assessment (COBRA) in Mexican patients with bipolar disorder

Bipolar Disorder (BD) is a serious and frequent mental health condition that is sometimes fatal. Several longitudinal studies have found an important correlation between cognition and functionality in BD. Despite the known importance of cognitive symptoms in BD, evaluation of cognitive deficits is not routinely done in clinical settings, as assessment is time-consuming and requires neuropsychological testing. The aim was to evaluate the psychometric properties of the subjective cognitive deficits in bipolar disorder (COBRA) rating scale in a Mexican sample of patients with BD and perform a cross-cultural comparison with the results obtained in other cultures. Ninety-two Healthy Subjects and 80 euthymic patients with BD were asked to complete the COBRA rating scale. The psychometric properties found in Mexican population show a good internal consistency and good discriminant validity with control subjects. Adequate congruence coefficients were obtained between the COBRA analyses in Mexican population and Spanish population and acceptable when compared to Japanese population. The COBRA scale is a brief and valid measure of cognitive complaints in BD for use in Mexican population.

Clinical staging in severe mental disorders; bipolar disorder, depression and schizophrenia

Clinical staging is a diagnostic tool used in other medical specialties, which has resulted from the combination of a categorical and dimensional approach. In the last 2decades, the usefulness of its application in the field of psychiatry has been suggested, mainly as a tool for diagnostic help, and therapeutic and prognostic orientation. In this paper we review the clinical staging models that have been proposed to date for bipolar disorder, depression and schizophrenia. A literature search was performed in PubMed and Medline databases. A total of 15 studies were selected according to inclusion and exclusion criteria. Models were grouped according to the type of disorder for which staging was proposed (bipolar disorder: 4, depression: 5, schizophrenia: 6), and their characteristics were described. As a conclusion, we identify the need to empirically validate these models to demonstrate that staging is a useful tool for clinical practice.

The Staging of Major Mood Disorders: Clinical and Neurobiological Correlates

OBJECTIVE

Staging of psychiatric disorders is gaining momentum and the purpose of this review is to examine whether major mood disorders can be defined according to stages.

METHODS

In April 2018 the PubMed electronic data base was scrutinized by a combination of various search terms like "major depressive disorder and staging," "bipolar disorder and neuroprogression," etc. To incorporate the latest findings the search was limited to the last 10 years. Both original and review articles were examined by reading the abstracts, and papers which were found to be particularly applicable were read in full and their reference lists were also consulted.

RESULTS

A significant increase occurred in the number of papers published on the topic of staging of mood disorders. Staging formats were found for both major mood disorders, with the caveat that many more articles were discovered for bipolar disorder. Current evidence points to allostatic load and neuroprogression as the basis for staging of mood disorders.

CONCLUSION

Principal affective illnesses may be characterized by distinct stages, for instance early, intermediate and late. These phases inform the management so that clinicians should incorporate the staging schema into everyday practice and implement treatment strategies according to the phase of the illness.

Oxidative stress markers imbalance in late-life depression

BACKGROUND

Oxidative stress has been implicated in the pathophysiology of mood disorders in young adults. However, there is few data to support its role in the elderly. The primary aim of this study was to evaluate whether subjects with late-life depression (LLD) presented with changes in oxidative stress response in comparison with the non-depressed control group. We then explored how oxidative stress markers associated with specific features of LLD, in particular cognitive performance and age of onset of major depressive disorder in these individuals.

METHODS

We included a convenience sample of 124 individuals, 77 with LLD and 47 non-depressed subjects (Controls). We measure the plasma levels of 6 oxidative stress markers: thiobarbituric acid reactive substances (TBARS), protein carbonil content (PCC), free 8-isoprostane, glutathione peroxidase (GPx) activity, glutathione reductase (GR) activity, and glutathione S-transferase (GST) activity.

RESULTS

We found that participants with LLD had significantly higher free 8-isoprostane levels (p = 0.003) and lower glutathione peroxidase activity (p = 0.006) compared to controls. Free 8-isoprostane levels were also significantly correlated with worse scores in the initiation/perseverance (r = -0.24, p = 0.01), conceptualization (r = -0.22, p = 0.02) sub-scores, and the total scores (r = -0.21, p = 0.04) on the DRS.

CONCLUSIONS

Our study provides robust evidence of the imbalance between oxidative stress damage, in particular lipid peroxidation, and anti-oxidative defenses as a mechanism related to LLD, and cognitive impairment in this population. Interventions aiming to reduce oxidative stress damage can have a potential neuroprotective effect for LLD subjects.

Systematic genetic analyses of genome-wide association study data reveal an association between the key nucleosome remodeling and deacetylase complex and bipolar disorder development

BACKGROUND

Genome-wide association studies (GWASs) are used to identify genetic variants for association with bipolar disorder (BD) risk; however, each GWAS can only reveal a small fraction of this association. This study systematically analyzed multiple GWAS data sets to provide further insights into potential causal BD processes by integrating the results of Psychiatric Genomics Consortium Phase I (PGC-I) for BD with core human pathways and functional networks.

METHODS

The i-Gsea4GwasV2 program was used to analyze data from the PGC-I GWAS for BD (the pathways came from Reactome), as well as the nominally significant pathways. We established a gene network of the significant pathways and performed a gene set analysis for each gene cluster of the Enhancing Neuroimaging Genetics through Meta-Analysis (ENIGMA) GWAS data for the volumes of the intracranial region and seven subcortical regions.

RESULTS

A total of 30 of 1816 Reactome pathways were identified and showed associations with BD risk. We further revealed 22 interconnected functional and topologically interacting clusters (Clusters 0-21) that were associated with BD risk. Moreover, we obtained brain transcriptome data from BrainSpan and found significant associations between common variants of the genes in Cluster 1 with the hippocampus (HIP; P = .026; family-wise error [FWE] correction) and amygdala (AMY; P = .016; FEW correction) in Cluster 8 with HIP (P = .022; FWE correction). The genes in Cluster 1  were  enriched  for the transcriptional co-expression profile in the prenatal AMY, and core genes (CDH4, MTA2, RBBP4, and HDAC2) were identified to be involved in regulating early brain development.

CONCLUSION

This study demonstrated that the HIP and AMY play a central role in neurodevelopment and BD risk.

Accelerated aging in schizophrenia and related disorders: Future research

Several lines of evidence suggest schizophrenia is a segmental progeria, that is, some but not all aspects of accelerated aging may be present. However, the evidence has not been consistent. Problems with matching and confounding may account for some of these discrepancies. Given the etiopathophysiological heterogeneity of schizophrenia, it is possible that only a specific pathophysiological group within schizophrenia is associated with progeroid features, while others are not, or that one group is associated with a particular segment of aging features, while other progeroid features are found in another pathophysiological subgroup. In the aging research field, significant progress has been made in identifying the molecular pathways that confer aging: epigenetic changes, inflammation, proteostasis, adult stem cell function, metabolic changes, and adaptation to stress, and macromolecular damage. In addition to replication and clarification of existing kinds of evidence, examining these aging pathways would improve our understanding of progeria in schizophrenia.

Allostatic load but not medical burden predicts memory performance in late-life bipolar disorder

OBJECTIVE

Older patients with bipolar disorder (BD) present with variable degrees of cognitive impairment. Over time, stress, mood episodes, and comorbidities increase the body's allostatic load. We assessed the extent to which allostatic load vs more traditional measures of medical burden account for the heterogeneity in cognition in this population.

METHODS

Thirty-five older euthymic patients with BD and 30 age-equated, gender-equated, and education-equated comparison participants were administered a comprehensive assessment including a neuropsychological battery, and 9 physiological measures to determine allostatic load. The relationship among allostatic load, medical burden, and cognition was assessed.

RESULTS

Compared with the mentally healthy comparators, patients were impaired globally, and in 4 cognitive domains-information-processing speed / executive functioning, delayed memory, language, and visuomotor ability, and presented with greater medical burden but not a different allostatic load. Allostatic load, but not medical burden, was associated with delayed memory performance both in a correlational analysis and in a multivariate regression analysis.

CONCLUSION

Euthymic older patients with BD are impaired on several cognitive domains and have high medical burden. Their memory performance is more strongly associated with allostatic load than with traditional measures of medical burden. These findings need to be replicated and extended longitudinally.

Depression and Mania Induce Pro-inflammatory Activation of Macrophages Following Application of Serum from Individuals with Bipolar Disorder

Objective

Evidence has suggested that immune imbalance is involved with bipolar disorder (BD); however, its precise mechanism is poorly understood. This study investigated whether biochemical changes in the serum from BD patients could modulate the phenotype of cultured macrophages.

Methods

Eighteen subjects with BD and five healthy individuals were included in this study. The human monocyte cell line U-937 was activated with phorbol 12-myristate 13-acetate (PMA) and polarization was induced with RPMI-1640 media supplemented with 10% serum from each patient for 24 hours. Gene expression of selected M1 and M2 markers was assessed by quantitative PCR.

Results

Macrophages exposed to serum of manic and depressive BD patients displayed an increase of interleukin-1β (6.40±3.47 and 9.04±5.84 vs. 0.23±0.11; p<0.05) and tumor necrosis factor-α (2.23±0.91 and 2.03±0.45 vs. 0.62±0.24; p=0.002 and p=0.004, respectively) compared to euthymic group (there was no difference between euthymic and controls). In parallel, U-937 macrophages treated with serum of patients in acute episode displayed a down-regulation of CXCL9 (0.29±0.20 vs. 1.86±1.61; p=0.006) and CXCL10 expression (0.36±0.15 and 0.86±0.24 vs. 1.83±0.88; p<0.000 and p=0.04) compared to the euthymia group.

Conclusion

Our results are consistent with previous studies showing that changes in peripheral blood markers could modulate M1/M2 polarization in BD. The evidence of macrophages as source of inflammatory cytokines might be helpful to unravel how the mononuclear phagocyte system is involved in the etiology of BD.

How Well Do We Understand the Long-Term Health Implications of Childhood Bullying?

Once dismissed as an innocuous experience of childhood, bullying is now recognized as having significant psychological effects, particularly with chronic exposure. Victims of bullying are at risk for a number of psychiatric disturbances, and growing evidence suggests that the pathophysiological effects of bullying, as with other forms of trauma and chronic stress, create additional health risks. We review the literature on the known sequelae of bullying, including psychiatric and physiological health effects, with a focus on implications for the victim. In addition, since it is now well established that early and chronic exposure to stress has a significant negative impact on health outcomes, we explore the implications of this research in relation to bullying and victimization in childhood. In particular, we examine how aspects of the stress response, via epigenetic, inflammatory, and metabolic mediators, have the capacity to compromise mental and physical health, and to increase the risk of disease. Research on the relevant mechanisms associated with bullying and on potential interventions to decrease morbidity is urgently needed.

Episode accumulation associated with hastened recurrence and delayed recovery in bipolar disorder

AIMS

Assess episode accumulation (≥ 10 prior mood episodes) associations with demographic/baseline clinical characteristics and mood episode recurrence/recovery in bipolar disorder (BD).

METHODS

Stanford BD Clinic outpatients enrolled during 2000-2011 were assessed with Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation. Among recovered and syndromal mood episode patients, we assessed episode accumulation associations with demographic/baseline clinical characteristics and with recurrence/recovery (by Kaplan-Meier survival analyses, with mediators assessed with Cox Proportional Hazard Ratio (HR) analyses).

RESULTS

Among all 450 BD outpatients, almost twice as many had versus lacked episode accumulation (65.8% versus 34.2%), which was less common among 92 recovered versus 193 syndromal mood episode patients (51.1% versus 69.9%). Among recovered patients, episode accumulation was associated with 14/18 (77.7%) demographic/other baseline clinical characteristics, and hastened mood episode recurrence. Among syndromal mood episode patients, episode accumulation was associated with 13/18 (72.2%) demographic/other baseline clinical characteristics, and delayed mood episode recovery.

LIMITATIONS

American tertiary BD clinic referral sample.

CONCLUSION

Studies are needed to confirm episode accumulation is associated with hastened mood episode recurrence and delayed mood episode recovery in BD, and to further explore its' associations with hastened mood elevation recurrence and delayed recovery from depressive and mood elevation episodes, considered separately.

Episode forecasting in bipolar disorder: Is energy better than mood?

OBJECTIVE

Bipolar disorder is a severe mood disorder characterized by alternating episodes of mania and depression. Several interventions have been developed to decrease high admission rates and high suicides rates associated with the illness, including psychoeducation and early episode detection, with mixed results. More recently, machine learning approaches have been used to aid clinical diagnosis or to detect a particular clinical state; however, contradictory results arise from confusion around which of the several automatically generated data are the most contributory and useful to detect a particular clinical state. Our aim for this study was to apply machine learning techniques and nonlinear analyses to a physiological time series dataset in order to find the best predictor for forecasting episodes in mood disorders.

METHODS

We employed three different techniques: entropy calculations and two different machine learning approaches (genetic programming and Markov Brains as classifiers) to determine whether mood, energy or sleep was the best predictor to forecast a mood episode in a physiological time series.

RESULTS

Evening energy was the best predictor for both manic and depressive episodes in each of the three aforementioned techniques. This suggests that energy might be a better predictor than mood for forecasting mood episodes in bipolar disorder and that these particular machine learning approaches are valuable tools to be used clinically.

CONCLUSIONS

Energy should be considered as an important factor for episode prediction. Machine learning approaches provide better tools to forecast episodes and to increase our understanding of the processes that underlie mood regulation.