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

Associations between dietary habits and bipolar disorder: a diet-wide mendelian randomization study

Background

Diet/nutrition is critically important in the pathogenesis, progression, and treatment outcomes of various mental disorders. Current research predominantly focuses on the role of diet in the development and treatment of depression, with less attention given to the relationship between diet and Bipolar Disorder (BD).

Method

We employed Mendelian Randomization (MR) to investigate the relationship between 28 dietary habits and BD. An analysis was conducted using publicly available genome-wide association study data from the UK Biobank dataset. Various dietary habits were analyzed as exposures with BD as the outcome, mainly using the Inverse Variance Weighted (IVW) method.

Results

Intake of non-oily fish and sponge pudding both have a positive association with BD. Oily fish, dried fruit, apples, salt, and cooked vegetables intake also appeared potentially risky for BD, although the possibility of false positives cannot be ruled out. Sensitivity analysis further confirmed the robustness of these findings.

Conclusion

Our research provides evidence of a relationship between various dietary habits and BD. It underscores the need for careful dietary management and balance to reduce the risk of BD, suggesting caution with dietary preferences for fish and sponge pudding. Furthermore, more detailed studies are needed to further understand the potential impacts of high-sugar and high-protein diets on BD development.

AUD in perspective

Alcohol is a major cause of pre-mature death and individual suffering worldwide, and the importance of diagnosing and treating AUD cannot be overstated. Given the global burden and the high attributable factor of alcohol in a vast number of diseases, the need for additional interventions and the development of new medicines is considered a priority by the World Health Organization (WHO). As of today, AUD is severely under-treated with a treatment gap nearing 90%, strikingly higher than that for other psychiatric disorders. Patients often seek treatment late in the progress of the disease and even among those who seek treatment only a minority receive medication, mirroring the still-prevailing stigma of the disease, and a lack of access to effective treatments, as well as a reluctance to total abstinence. To increase adherence, treatment goals should focus not only on maintaining abstinence, but also on harm reduction and psychosocial functioning. A personalised approach to AUD treatment, with a holistic view, and tailored therapy has the potential to improve AUD treatment outcomes by targeting the heterogeneity in genetics and pathophysiology, as well as reason for, and reaction to drinking. Also, the psychiatric co-morbidity rates are high in AUD and dual diagnosis can worsen symptoms and influence treatment response and should be considered in the treatment strategies.

Could reasons for admission help to screen unhealthy alcohol use in emergency departments? A multicenter French study

Background

Many patients admitted to general emergency departments (EDs) have a pattern of drinking that could lead to future alcohol-related complications. However, it is often difficult to screen these patients in the context of emergency. The aim of this study is to analyze whether reasons for admission could help to screen patients who have an unhealthy alcohol use.

Method

Patients were recruited among six public hospital ED in France, between 2012 and 2014. During a one-month period in each hospital, anonymous questionnaires including sociodemographic questions, AUDIT-C and RAPS4-QF were administered to each patients visiting the ED. The reason for admission of each patient was noted at the end of their questionnaire by the ED practitioner.

Results

Ten thousand Four hundred twenty-one patients were included in the analysis. Patients who came to the ED for injuries and mental disorders were more likely to report unhealthy alcohol use than non-harmful use or no use. Among male patients under 65 years old admitted to the ED for a mental disorder, 24.2% drank more than four drinks (40 g ethanol) in typical day at least four time a week in the last 12 months. Among these patients, 79.7% reported daily or almost daily heavy episodic drinking (HED, 60 g ethanol), and all were positive on the RAPS4-QF.

Conclusion

This study highlights that unhealthy alcohol use is frequent among ED patients and particularly among those who come for injuries or mental disorders. Men under 65 years old with a mental disorder require special attention because of their increased prevalence of daily or almost daily HED.

Bipolar II Disorder: Understudied and Underdiagnosed

Despite its inclusion as a distinct entity in APA's Diagnostic and Statistical Manual of Mental Disorders since 1994, bipolar II disorder remains a surprisingly neglected psychiatric condition. Understudied and underrecognized, bipolar II disorder is often misdiagnosed and misunderstood, even by experienced clinicians. As a result, patients typically experience symptoms for more than 10 years before receiving the correct diagnosis. Incorrect diagnosis leads to incorrect treatment, including overuse of monoaminergic antidepressant medications, with resultant declines in functioning and worse quality of life. Perhaps because of its underrecognition, treatment studies of bipolar II disorder are limited, and, too often, results of bipolar I disorder studies are applied to bipolar II disorder, with no direct evidence supporting this practice. Bipolar II disorder is an understudied and unmet treatment challenge in psychiatry. In this review, the authors provide a broad overview of bipolar II disorder, including differential diagnosis, course of illness, comorbid conditions, and suicide risk. The authors summarize treatment studies specific to bipolar II disorder, identifying gaps in the literature. This review reveals similarities between bipolar I and bipolar II disorders, including risks of suicide and predominance of depression over the course of illness, but also differences between the phenotypes in treatment response, for example, to antidepressant medications.

The hidden borderline patient: patients with borderline personality disorder who do not engage in recurrent suicidal or self-injurious behavior

BACKGROUND

Despite the significant psychosocial morbidity associated with borderline personality disorder (BPD), its underrecognition is a significant clinical problem. BPD is likely underdiagnosed, in part, because patients with BPD usually present with chief complaints associated with mood, anxiety, and substance use disorders. When patients with BPD do not exhibit self-harm behavior, we suspect that BPD is less likely to recognized. An important question is whether the absence of this criterion, which might attenuate the likelihood of recognizing and diagnosing the disorder, identifies a subgroup of patients with BPD who are 'less borderline' than patients with BPD who do not manifest this criterion.

METHODS

Psychiatric outpatients were evaluated with a semi-structured diagnostic interview for DSM-IV BPD, 390 of whom were diagnosed with BPD. We compared the demographic and clinical characteristics of patients with BPD who do and do not engage in repeated suicidal and self-harm behavior.

RESULTS

Approximately half of the patients with BPD did not meet the suicidality/self-injury diagnostic criterion for the disorder. There were no differences between the patients who did and did not meet this criterion in occupational impairment, likelihood of receiving disability payments, impairment in social functioning, level of educational achievement, comorbid psychiatric disorders, history of childhood trauma, or severity of depression, anxiety, or anger upon presentation for treatment.

CONCLUSIONS

Repeated self-injurious and suicidal behavior is not synonymous with BPD. It is critical for clinicians to be aware that the absence of repeated self-injury and suicide threats/gestures or attempts does not rule out the diagnosis of BPD.

Subjective response to alcohol in young adults with bipolar disorder and recent alcohol use: a within-subject randomized placebo-controlled alcohol administration study

Limited data exists on mechanisms contributing to elevated risk for alcohol use disorder (AUD) in bipolar disorder. Variation in subjective response to alcohol may relate to alcohol use and risk for AUD. This study used a randomized, placebo-controlled, cross-over, within-subjects design to investigate differences in subjective response to alcohol in 50 euthymic young adults (n = 24 with and n = 26 without bipolar disorder type I). Eighty-three percent of participants with bipolar disorder were medicated. Participants completed assessments of clinical history, alcohol expectancies, and recent alcohol use. Participants were dosed to a .08 g% breath alcohol concentration. The placebo condition occurred on a separate counter-balanced day. Subjective response to alcohol was investigated at similar time points during both conditions. Group, condition, and group-by-condition interactions were modeled, with condition and time of subjective response assessment as repeated within-subject variables, and subjective response to alcohol as the dependent variable. Greater stimulating effects and liking of alcohol were reported in people with bipolar disorder (group-by-condition interactions, p < .05) than healthy young adults. While young adults with bipolar disorder reported anticipating feeling less "mellow/relaxed" when drinking (p = .02), during both beverage conditions they reported feeling more "mellow/relaxed" (main effect of group, p = .006). Feeling more "mellow/relaxed" during the alcohol condition related to greater recent alcohol use in bipolar disorder (p = .001). Exploratory analyses suggested anticonvulsants and sedatives/antihistamines may relate to differences in subjective response to alcohol in bipolar disorder. Results suggest young adults with bipolar disorder may differ in alcohol expectancies and experience alcohol intoxication differently-with distinct relations between subjective response to alcohol and alcohol use-compared to healthy young adults.

Physical health comorbidities in older adults with bipolar disorder: A systematic review

OBJECTIVE

To ascertain the prevalence and predictors of physical health comorbidities in older adults with bipolar disorder.

METHODS

The authors conducted a systematic review and narrative synthesis of peer-reviewed journal articles reporting on physical health comorbidities in older adults (aged ≥50) with a diagnosis of bipolar disorder. The Mixed Methods Appraisal Tool (MMAT) assessed study quality.

RESULTS

23 papers reporting on 19 studies met the inclusion criteria. The literature on diabetes, obesity and renal disease was inconclusive. There was some tentative evidence to higher rates of cardiovascular disease and some forms of cancer in older adults with bipolar disorder in comparison to the general population, but this requires further investigation. We identified no studies looking at oral health.

LIMITATIONS

The quality ratings of the identified research were generally low. Very few studies included a comparison sample from the general population or controlled for key covariates in their analysis.

CONCLUSION

Existing literature provides tentative evidence that some physical health comorbidities are elevated in older adults with bipolar disorder. Clinicians should consider interventions that improve the physical health of this group, alongside the chronic mental health difficulties they experience.

The maladaptive domains according to the alternative model of personality disorders (AMPD) criterion B in patients with affective disorders and temperamental triads related to these domains: two unique profiles

OBJECTIVES

The study aimed to (i) compare the maladaptive domains and facets according to the Alternative Model of Personality Disorders (AMPD) Criterion B in patients with a type II bipolar disorder (BD-II) or major depressive disorder (MDD) with healthy controls (HCs), and (ii) investigating the relationship between affective temperaments and these domains and facets in the total sample.

METHODS

Outpatients diagnosed with current BD-II (n = 37; female 62.2%) or MDD (n = 17; female 82.4%) based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria and community HCs (n = 177; female 62.1%) in Kermanshah from July to October 2020 included this case-control study. All participants completed the Personality Inventory for DSM-5 (PID-5), the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A), and the second version of the Beck Depression Inventory (BDI-II). Data were analyzed using analysis of variance (ANOVA), Pearson correlation, and multiple regression.

RESULTS

The score of patients with BD-II in all five domains and those with MDD in three domains including negative affectivity, detachment, and disinhibition are significantly higher than the HCs (p < 0.05). Depressive temperament (related to negative affectivity, detachment, and disinhibition) and cyclothymic temperament (related to antagonism and psychoticism) were the most important correlates of the maladaptive domains.

CONCLUSIONS

Two unique profiles are proposed, including three domains of negative affectivity, detachment, and disinhibition associated with the depressive temperament for MDD, and two domains of antagonism and psychoticism related to cyclothymic temperament for BD-II.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Effects of comorbid alcohol use disorder on bipolar disorder: Focusing on neurocognitive function and inflammatory markers

BACKGROUND

Alcohol use disorder (AUD) is a highly prevalent comorbid disorder in patients with bipolar disorder (BD). Both BD and AUD were found to be associated with inflammation and cognitive deficits, but few study has been done on BD comorbid with AUD (BD+AUD). We aimed to investigate the impacts of comorbid AUD and BD on cognitive function, inflammatory and neurotrophic markers.

METHOD

We recruited 641 BD patients, 150 patients with BD+AUD, and 185 healthy controls (HC). Neuropsychological tests [Wisconsin card sorting test (WCST), continuous performance test (CPT), and Wechsler memory scale - third edition (WMS-III)] and cytokine plasma levels [tumor necrosis factor-α (TNF-α), C-reactive protein (CRP), interleukin-8 (IL-8), transforming growth factor-β1 (TGF-β1), and brain-derived neurotrophic factor (BDNF)] were assessed.

RESULTS

BD+AUD patients had worse cognitive performance than those without AUD. There was a significant difference in the plasma levels of TNF-α, IL-8, and BDNF (P < 0.001, <0.001, and 0.01, respectively) between the patients and the HC groups. Post hoc analysis showed that BD+AUD patients had higher levels of TNF-α and IL-8 than BD-only patients (P < 0.001). Additionally, plasma IL-8 levels were negatively associated with number of completed categories in WCST (P = 0.02), and TNF-α levels were negatively associated with visual immediate index in WMS-III (P = 0.05).

CONCLUSION

Our results suggest that comorbid AUD and BD might worsen cognitive impairments and inflammatory processes. Further longitudinal studies on BD+AUD may be needed.

The Relationship between Selected Factors (Temperament, Bipolar Traits, Sleep Quality, Severity of Addiction) and Depressive Symptoms in Alcohol-Dependent Men

Clinical and epidemiological studies have demonstrated a relationship between alcohol addiction and mood disorders. Alcohol-dependent patients with depression tend to demonstrate clinically more severe manic symptoms, which complicates the process of diagnosis and therapy. However, the predictors indicating the risk of mood disorders in addicted patients remain unclear. The aim of the study was to examine the relationship between personal dispositions, bipolar traits, depth of addiction, quality of sleep, and depressive symptoms in alcohol-dependent men. The study group comprised 70 men (age M = 46.06, SD = 11.29) diagnosed with alcohol addiction. The participants completed a battery of questionnaires: BDI, HCL-32, PSQI, EPQ-R and MAST. The results were tested using Pearson's correlation quotient and general linear model. The findings indicate that some of the studied patients are likely to have mood disorders of clinically significant severity. High neuroticism and poor sleep quality are independent predictors of depressive symptoms in alcohol-dependent patients. Among the components of sleep quality, problems with falling asleep and waking up at night appear to be most strongly associated with depressive symptoms. The intensity of depressive symptoms may relate to the intensity of certain bipolar features, such as risk-taking activity and irritability. High neuroticism and poor sleep quality are independent predictors of depressive symptoms in the studied group.

Risk of childhood trauma exposure and severity of bipolar disorder in Colombia

BACKGROUND

Bipolar disorder (BD) is higher in developing countries. Childhood trauma exposure is a common environmental risk factor in Colombia and might be associated with a more severe course of bipolar disorder in Low-Middle Income-Countries. We carried out the first case-control study in Colombia using a structural clinical interview and the Childhood Trauma Questionnaire-Short Form (CTQ-SF) to describe the prevalence and association between trauma exposure during childhood with a severe course of illness (early age onset, rapid cycling, ideation or suicide attempt, or ≥ 3 hospitalization) in a sample of BD patients.

RESULTS

A total of 114 cases and 191 controls evaluated showed the following results. Cases included 61.4% BD type I and 38.6% BD type II. The median age was 31.5 years (IQR, 75-24) for BD patients and 31 years old (IQR, 38-24) for healthy controls. A higher prevalence of childhood trauma was evidenced in cases compared to controls. Emotional abuse, physical abuse, sexual abuse, physical neglect and emotional neglect evidenced a strong association with severe bipolar disorder (OR = 3.42, p < .001; OR = 4.68, p < .001; OR = 4.30, p = .003; OR = 5.10, p < .001; OR = 5.64, p < .001, respectively).

CONCLUSIONS

This is the first association study between childhood trauma exposure as a higher risk for a severe course of illness in BD patients in Colombian. Our findings highlight the higher prevalence of childhood trauma in bipolar patients and the strong association of childhood trauma with severe bipolar disorder. These findings are relevant for screening and evaluating childhood trauma exposure during the course of BD patients.

Alcohol use is associated with affective and interoceptive network alterations in bipolar disorder

INTRODUCTION

Alcohol use in bipolar disorder (BD) is associated with mood lability and negative illness trajectory, while also impacting functional networks related to emotion, cognition, and introspection. The adverse impact of alcohol use in BD may be explained by its additive effects on these networks, thereby contributing to a poorer clinical outcome.

METHODS

Forty BD-I (DSM-IV-TR) and 46 psychiatrically healthy controls underwent T1 and resting state functional MRI scanning and the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) to assess alcohol use. Functional images were decomposed using spatial independent component analysis into 14 resting state networks (RSN), which were examined for effect of alcohol use and diagnosis-by-alcohol use accounting for age, sex, and diagnosis.

RESULTS

Despite the groups consuming similar amounts of alcohol (BD: mean score ± SD 3.63 ± 3; HC 4.72 ± 3, U = 713, p = .07), for BD participants, greater alcohol use was associated with increased connectivity of the paracingulate gyrus within a default mode network (DMN) and reduced connectivity within an executive control network (ECN) relative to controls. Independently, greater alcohol use was associated with increased connectivity within an ECN and reduced connectivity within a DMN. A diagnosis of BD was associated with increased connectivity of a DMN and reduced connectivity of an ECN.

CONCLUSION

Affective symptomatology in BD is suggested to arise from the aberrant functionality of networks subserving emotive, cognitive, and introspective processes. Taken together, our results suggest that during euthymic periods, alcohol can contribute to the weakening of emotional regulation and response, potentially explaining the increased lability of mood and vulnerability to relapse within the disorder.

MM, Villanueva-Silvestre V, Vázquez-Martínez A. Relationship Between Depression and Risky Alcohol Consumption in Women: the Mediating Role of Coping Styles and Age

Women are more likely to use alcohol as a coping strategy for psychological distress, with higher rates of comorbidity with depression being found in those with an alcohol use disorder. The objective of this study was to analyze changes in problematic alcohol consumption and depression during the COVID-19 lockdown, and to establish a predictive model based on age. A total of 1889 women aged 18-64 years (M = 36.14) participated. The Patient Health Questionnaire was applied for depression, the Alcohol Use Disorders Identification Test-Short Version for alcohol, and active and avoidant coping were considered. In the period prior to the pandemic, depression and avoidant coping were good predictors of alcohol consumption in women, regardless of age. During lockdown, this predictive capacity was only maintained in women aged 35-64 years. In the mediational models, differences were observed according to age. For women aged 18-34 years, depression was the predictor variable of problematic alcohol consumption, but for women aged 35-64 years it was the avoidant coping style, which is the predominant style in women of this age with clinical depression. The relevance of age in the combined treatments of depression and problematic alcohol consumption is highlighted, and training in active coping strategies is suggested.

Coping drinking motives, neural functional coupling during emotion processing, and alcohol use in young adults with bipolar disorder

BACKGROUND

Rates of alcohol use disorders in individuals with bipolar disorder are 3 to 5 times greater than in the general population and exceed rates of alcohol use disorders reported in other affective and anxiety disorders. Despite this high rate of comorbidity, our understanding of the psychosocial and neural mechanisms that underlie the initiation of alcohol misuse in young adults with bipolar disorder remains limited. Prior work suggests that individuals with bipolar disorder may misuse alcohol as a coping mechanism, yet the neural correlates of coping drinking motives and associated alcohol use have not been previously investigated in this population.

METHODS

Forty-eight young adults (22 bipolar disorder type I, 26 typically developing; 71% women; average age ± standard deviation = 22 ± 2 years) completed the Drinking Motives and Daily Drinking Questionnaires, and a Continuous Performance Functional magnetic resonance imaging (fMRI) Task with Emotional and Neutral Distracters. We calculated the relative difference in anterior cingulate cortex (ACC) functional coupling with the anterior insula and amygdala in response to emotional distracters compared with neutral stimuli and investigated the relations with coping drinking motives and alcohol use.

RESULTS

Across all participants, coping drinking motives were associated with greater quantity of recent alcohol use. In individuals with bipolar disorder, greater ACC-anterior insula functional coupling was associated with greater coping drinking motives, and greater quantity and frequency of recent alcohol use. The relative difference in ACC-anterior insula functional coupling was not associated with coping drinking motives or alcohol use in the typically developing group. Greater ACC-anterior insula functional coupling in individuals with bipolar disorder was also associated with greater anxiety symptoms and recent perceived psychological stress. Exploratory analyses suggest that the relations between ACC-anterior insula functional coupling and coping drinking motives may be confounded by anticonvulsant use.

CONCLUSION

Results suggest that a difference in ACC-anterior insula functional coupling during emotion processing may underlie alcohol use as a maladaptive coping mechanism in young adults with bipolar disorder.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Behavioral Interventions to Reduce Cardiovascular Risk Among People with Severe Mental Disorder

Cardiovascular disease (CVD) is the leading cause of death among people with severe mental disorder (SMD). CVD risk factors occur at the individual, health system, and socio-environmental levels and contribute not only to high rates of CVD but also to worsening mental health. While acknowledging this wider context, this review focuses on behavioral interventions for seven CVD risk behaviors-smoking, physical inactivity, excessive alcohol consumption, low fruit and vegetable intake, inadequate sleep, poor social participation, and poor medication adherence-that are common among people with SMD. We survey recent meta-reviews of the literature and then review additional key studies to provide clinical recommendations for behavioral interventions to reduce CVD risk among people with SMD. A transdiagnostic psychological approach from the start of mental health treatment, drawing upon multidisciplinary expertise to address multiple risk behaviors, is recommended. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Auditory mismatch negativity in bipolar disorder: a focused review

The auditory mismatch negativity, a component of the event-related potential elicited by an unexpected stimulus in a sequence of acoustic stimuli, provides an objective measure of the accuracy of the echoic information processing of the human brain in vivo. Auditory mismatch negativity is also a useful probe of cortical glutamatergic N-methyl-d-aspartate receptor activity and disturbance. Notably, auditory mismatch negativity is consistently impaired in schizophrenia. Because of the wide spectrum extending from bipolar affective illness and schizoaffective psychosis to typical schizophrenia, we examined the literature on auditory mismatch negativity in bipolar disorder with the aim to find any neurophysiological dysfunction concerning pre-attentive information processing shared by these clinical conditions. This focused review includes 26 original articles published in peer-reviewed journals and indexed in the National Institutes of Health National Library of Medicine (PubMed) search system. Overall, evidence is consistent with the finding that auditory mismatch negativity is impaired in bipolar disorder with psychotic features, even though to a lesser extent than in schizophrenia. It must be acknowledged that, in a few twin and family studies, mismatch negativity abnormalities were not specifically associated with bipolar disorder. In conclusion, auditory mismatch negativity research supports the involvement of the N-methyl-d-aspartate system in the pathophysiology of bipolar disorder, as previously assessed for schizophrenia, thus creating an intriguing trait d'union between these two mental illnesses and stimulating the development of novel therapeutic agents. With additional replication and validation, auditory mismatch negativity may be further considered as a correlate of a common psychopathology of schizophrenia and bipolar spectrum illnesses.

Influence of childhood maltreatment on prevalence, onset and persistence of psychiatric comorbidities and suicide attempts in bipolar disorders

Background

Methods

Results

Conclusions

Age-related changes in physiology in individuals with bipolar disorder

BACKGROUND

Individuals with bipolar disorder have a reduced life expectancy and may experience accelerated biological ageing. In individuals with bipolar disorder and healthy controls, we examined differences in age-related changes in physiology.

METHODS

UK Biobank recruited more than 500,000 participants, aged 37-73, between 2006 and 2010. Generalised additive models were used to examine associations between age and grip strength, cardiovascular function, body composition, lung function and heel bone mineral density.

RESULTS

The main dataset included 271,118 adults (mean age = 56.04 years; 49.60% females). We found statistically significant differences between cases and controls for grip strength, blood pressure, pulse rate and body composition, with standardised mean differences of up to -0.24 (95% CI -0.28 to -0.19). Evidence of differences in lung function, heel bone mineral density or arterial stiffness was limited. Case-control differences were most evident for age-related changes in cardiovascular function (both sexes) and body composition (females). Differences did not uniformly narrow or widen with age and differed by sex. For example, the difference in systolic blood pressure between male cases and controls was -1.3 mmHg at age 50 and widened to -4.7 mmHg at age 65. Diastolic blood pressure in female cases was 1.2 mmHg higher at age 40 and -1.2 mmHg lower at age 65.

LIMITATIONS

Analyses did not distinguish between bipolar disorder subtypes. Results may not generalise to other age groups.

CONCLUSIONS

Differences between bipolar disorder cases and controls were most evident for cardiovascular and body composition measures. Targeted screening for cardiovascular and metabolic health in middle age is warranted to potentially mitigate excess mortality.

Cancer care for people with mental disorders: A qualitative survey among cancer care and psychiatric care professionals in Japan

OBJECTIVE

It is widely assumed that there are multiple levels (from individual to policy level) of problems involving disparities in cancer care for people with mental disorders. However, few studies have comprehensively investigated issues as perceived by medical professionals. The purpose of the present study was to identify a wide range of issues in cancer care for people with mental disorders and offer corresponding solutions for both cancer care professionals and psychiatric care professionals.

METHODS

We distributed open-ended questionnaires to 754 healthcare professionals in various medical facilities, including designated cancer hospitals, psychiatric hospitals, and other local healthcare/welfare facilities. Participants were asked to describe issues in cancer care for people with mental disorders.

RESULTS

Of the 754 recruited professionals, 439 (58.2%) responded to the questionnaire. Sixty-one issues were extracted and categorized into 10 categories: patient factors; isolation and lack of support; obstacles to transport; socioeconomic factors; attitudes of psychiatric professionals; medical system of psychiatric hospitals; attitudes of cancer care professionals; medical system of designated cancer hospitals; regional cancer medical systems; and lack of coordination among multidisciplinary healthcare professionals. Forty-eight specific solutions were summarized into 12 goals.

CONCLUSIONS

The present study widely identified issues causing disparities in cancer care for patients with mental disorders. We found that the issues extended from the patient level to the public-policy level. Our findings suggest the need for a multidisciplinary approach that includes both cancer and psychiatric care professionals to address the gap in cancer care for people with mental disorders.

Patients with borderline personality disorder and bipolar disorder: a descriptive and comparative study

BACKGROUND

Bipolar disorder and borderline personality disorder (BPD) are each significant public health problems. It has been frequently noted that distinguishing BPD from bipolar disorder is challenging. Consequently, reviews and commentaries have focused on differential diagnosis and identifying clinical features to distinguish the two disorders. While there is a burgeoning literature comparing patients with BPD and bipolar disorder, much less research has characterized patients with both disorders. In the current report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compare psychiatric outpatients with both BPD and bipolar disorder to patients with BPD without bipolar disorder and patients with bipolar disorder without BPD.

METHODS

Psychiatric outpatients presenting for treatment were evaluated with semi-structured interviews. The focus of the current study is the 517 patients with both BPD and bipolar disorder (n = 59), BPD without bipolar disorder (n = 330), and bipolar disorder without BPD (n = 128).

RESULTS

Compared to patients with bipolar disorder, the patients with bipolar disorder and BPD had more comorbid disorders, psychopathology in their first-degree relatives, childhood trauma, suicidality, hospitalizations, time unemployed, and likelihood of receiving disability payments. The added presence of bipolar disorder in patients with BPD was associated with more posttraumatic stress disorder in the patients as well as their family, more bipolar disorder and substance use disorders in their relatives, more childhood trauma, unemployment, disability, suicide attempts, and hospitalizations.

CONCLUSIONS

Patients with both bipolar disorder and BPD have more severe psychosocial morbidity than patients with only one of these disorders.

Increased Global-Brain Functional Connectivity Is Associated with Dyslipidemia and Cognitive Impairment in First-Episode, Drug-Naive Patients with Bipolar Disorder

Objectives

Previous researches have demonstrated that abnormal functional connectivity (FC) is associated with the pathophysiology of bipolar disorder (BD). However, inconsistent results were obtained due to different selections of regions of interest in previous researches. This study is aimed at examining voxel-wise brain-wide functional connectivity (FC) alterations in the first-episode, drug-naive patient with BD in an unbiased way.

Methods

A total of 35 patients with BD and 37 age-, sex-, and education-matched healthy controls underwent resting-state functional magnetic resonance imaging (rs-fMRI). Global-brain FC (GFC) was applied to analyze the image data. Support vector machine (SVM) was adopted to probe whether GFC abnormalities could be used to identify the patients from the controls.

Results

Patients with BD exhibited increased GFC in the left inferior frontal gyrus (LIFG), pars triangularis and left precuneus (PCu)/superior occipital gyrus (SOG). The left PCu belongs to the default mode network (DMN). Furthermore, increased GFC in the LIFG, pars triangularis was positively correlated with the triglycerides (TG) and low-density lipoprotein cholesterol (LDL-C) and negatively correlated with the scores of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) coding test and Stroop color. Increased GFC values in the left PCu/SOG can be applied to discriminate patients from controls with preferable sensitivity (80.00%), specificity (75.68%), and accuracy (77.78%).

Conclusions

This study found increased GFC in the brain regions of DMN; LIFG, pars triangularis; and LSOG, which was associated with dyslipidemia and cognitive impairment in patients with BD. Moreover, increased GFC values in the left PCu/SOG may be utilized as a potential biomarker to differentiate patients with BD from controls.

Substance use among patients in specialized mental health services in Norway: prevalence and patient characteristics based on a national census

PURPOSE

The aim of this study was to investigate the clinical and demographic variation in the prevalence of substance use among the general psychiatric population in Norway.

METHODS

A national census in psychiatric institutions and outpatient clinics was conducted. Data were returned for 2358 inpatients (response rate, 65%) and 23,167 outpatients (response rate, 60%). Substance use was measured based on substance use disorder diagnosis or reported substance use in the last 4 weeks (alcohol 2-4 days a week or more frequently/illicit drug use). Regression analyses controlling for demographic and sociodemographic characteristics were carried out.

RESULTS

Substance use was identified in 32.4% of inpatients and 13.9% of outpatients. The most frequently reported substances used were alcohol, sedatives and cannabis. Among inpatients, the prevalence of substance use was highest in patients with schizophrenia, personality disorders and anxiety disorders. Among outpatients, the prevalence was highest in patients with schizophrenia and other psychoses. Inpatients with anxiety disorders and outpatients with schizophrenia and other psychoses had a significantly higher risk of substance use than other patients. In both samples, the prevalence of substance use was higher among males, 24 to 29-year-olds and the most socially deprived.

CONCLUSIONS

This study provides further knowledge about patients at risk for co-morbid substance abuse and poor treatment outcomes. Clinicians may consider targeting patients with schizophrenia and other psychoses, young males and those who are socially deprived in efforts to prevent emerging substance abuse and improve outcomes.

Antisocial Personality Disorder in Bipolar Disorder: A Systematic Review

Background and Objectives: Bipolar Disorder (BD) is a severe psychiatric disorder that worsens quality of life and functional impairment. Personality disorders (PDs), in particular Cluster B personality, have a high incidence among BD patients and is considered a poor prognostic factor. The study of this co-morbidity represents an important clinical and diagnostic challenge in psychiatry. Particularly, clinical overlap has been shown between antisocial personality disorder (ASPD) and BD that could worsen the course of both disorders. We aimed to detect the frequency of ASPD in bipolar patients with greater accuracy and the impact of ASPD on the clinical course of BD. Materials and Methods: A systematic literature search was conducted in PubMed, Embase, MEDLINE and the Cochrane Library through December 2020 without language or time restriction, according to PRISMA statement guidelines. Results: Initially, 3203 items were identified. After duplicates or irrelevant paper deletion, 17 studies met the inclusion criteria and were included in this review. ASPD was more frequent among BD patients, especially in BD type I. BD patients with ASPD as a comorbidity seemed to have early onset, higher number and more severe affective episodes, higher levels of aggressive and impulsive behaviors, suicidality and poor clinical outcome. ASPD symptoms in BD seem to be associated with a frequent comorbidity with addictive disorders (cocaine and alcohol) and criminal behaviors, probably due to a shared impulsivity core feature. Conclusions: Considering the shared symptoms such as impulsive and dangerous behaviors, in patients with only one disease, misdiagnosis is a common phenomenon due to the overlapping symptoms of ASPD and BD. It may be useful to recognize the co-occurrence of the disorders and better characterize the patient with ASPD and BD evaluating all dysfunctional aspects and their influence on core symptoms.

Smoking and drinking among patients with mental disorders: Evidence from a nationally representative Japanese survey

BACKGROUND

No studies to date have addressed the association of mental disorder with smoking and drinking behaviors independent of anxiety and depressive symptoms. We therefore examined this association, stratified by age and sex, to determine the target population for behavioral modification in Japan.

METHODS

We analyzed data from participants aged 20-79 years without hospitalized or institutionalized status who participated in the nationwide Comprehensive Survey of Living Conditions conducted in 2016. Prevalence ratios (PRs) for current smoking, heavy daily smoking (>20 cigarettes per day), at-risk drinking (>100 g alcohol per week), and heavy drinking (>350 g) were calculated with adjustment for potential confounders. After stratification by age (20-39, 40-64, and 65-79 years) and sex, prevalence and PRs were calculated using propensity scores.

RESULTS

From among 340,194 participants, 8275 (2.4%) had mental disorder. Presence of mental disorder was significantly associated with current smoking (PR=1.18, 95%CI=1.12-1.23) and heavy daily smoking (PR=1.35, 95%CI=1.21-1.50) and inversely associated with at-risk drinking (PR=0.70, 95%CI=0.66-0.75). PRs for smoking behavior were higher in women than in men and in younger adults than in the other age groups. They were particularly high in younger women (PR=1.67 for current smokers and PR=2.17 for heavy daily smokers).

LIMITATIONS

Our findings were obtained from a cross-sectional study.

CONCLUSION

This is the first evidence that the association of mental disorder with smoking behavior is independent of anxiety and depressive symptoms. Our results indicate the need for tailored behavioral modification interventions for young people with mental disorders in Japan, particularly young women.

Subjective response to alcohol: Associated alcohol use and orbitofrontal gray matter volume in bipolar disorder

BACKGROUND

Alcohol use disorders (AUDs) are highly prevalent in bipolar disorder, however the developmental etiology of this comorbidity remains unknown. Structural differences in the orbitofrontal cortex (OFC) have been linked to problematic drinking in bipolar disorder and typically developing youth, with evidence implicating variations in OFC in differential subjective response to alcohol in typical development.

METHODS

Subjective response to alcohol, recent alcohol use, impulsivity, and variation in OFC gray matter volume were investigated in 48 emerging adults (24 with bipolar disorder, 24 typically developing). On average 1.5 years later, drinking patterns were reassessed and relations between subjective response and changes in alcohol use were explored.

RESULTS

Groups did not differ in baseline alcohol use or subjective response. At baseline, decreased subjective response to alcohol was associated with increased alcohol use in both groups. Lower gray matter volume in medial OFC in bipolar disorder was associated with increased subjective response to alcohol, whereas lower gray matter volume in OFC in typically developing participants was associated with decreased subjective response to alcohol. Increase in alcohol use (baseline to follow-up) was associated with increased baseline subjective response to alcohol in bipolar disorder, and decreased baseline subjective response in the typically developing group.

LIMITATIONS

Preliminary study with a small sample size.

CONCLUSION

Underlying OFC biology may contribute to differences in alcohol sensitivity in bipolar disorder which may also relate to prospective changes in alcohol use patterns. Future studies are needed to examine how these factors prospectively relate to development of AUDs in bipolar disorder.

Comorbid Premenstrual Dysphoric Disorder and Bipolar Disorder: A Review

Bipolar disorder (BD) differs in its clinical presentation in females compared to males. A number of clinical characteristics have been associated with BD in females: more rapid cycling and mixed features; higher number of depressive episodes; and a higher prevalence of BD type II. There is a strong link between BD and risk for postpartum mood episodes, and a substantial percentage of females with BD experience premenstrual mood worsening of varying degrees of severity. Females with premenstrual dysphoric disorder (PMDD)-the most severe form of premenstrual disturbances-comorbid with BD appear to have a more complex course of illness, including increased psychiatric comorbidities, earlier onset of BD, and greater number of mood episodes. Importantly, there may be a link between puberty and the onset of BD in females with comorbid PMDD and BD, marked by a shortened gap between the onset of BD and menarche. In terms of neurobiology, comorbid BD and PMDD may have unique structural and functional neural correlates. Treatment of BD comorbid with PMDD poses challenges, as the first line treatment of PMDD in the general population is selective serotonin reuptake inhibitors, which produce risk of treatment-emergent manic symptoms. Here, we review current literature concerning the clinical presentation, illness burden, and unique neurobiology of BD comorbid with PMDD. We additionally discuss obstacles faced in symptom tracking, and management of these comorbid disorders.

A Multimethod Examination of Sensitivity to Reward and Sensitivity to Punishment in Bipolar Disorder and Alcohol Dependence: Results from a 2 × 2 Factorial Design

INTRODUCTION

Shared neurobehavioral characteristics of bipolar disorder (BD) and alcohol dependence (AD), including heightened sensitivity to reward (SR), may account for high rates of BD and AD co-occurrence (BD + AD). However, empirical research is lacking. The present multimethod investigation examined SR and sensitivity to punishment (SP) among these patient groups using a reliable and well-validated self-report questionnaire of SR and SP along with a laboratory task specifically designed to distinguish SR and SP activation.

METHODS

One-hundred participants formed 4 groups: BD + AD (n = 40), BD (n = 18), AD (n = 25), and healthy controls (n = 17). Clinical interviews were administered, and participants completed the Sensitivity to Punishment and Sensitivity to Reward Questionnaire (SPSR-Q) and the Point Score Reaction Test behavioral task. Pearson correlations, hierarchical linear regression, and 2 × 2 factorial general linear modeling with Bonferroni-corrected pairwise comparisons were performed.

RESULTS

BD and AD main effects were significant on self-reported SR and SP; however, BD × AD interactions were not. BD + AD individuals were significantly higher on self-reported SR than BD and AD individuals, yet all clinical groups were similar on SP. Behavioral response times did not distinguish groups nor did they associate with self-report data.

DISCUSSION/CONCLUSION

BD and AD had additive, rather than interactive, effects on self-reported SR and SP. The methods employed, paired with their application to the present sample, may account for a lack of positive findings with behavioral data.

Associations Between Psychiatric Disorders and Alcohol Consumption Levels in an Adult Primary Care Population

Background

Unhealthy alcohol use frequently co‐occurs with psychiatric disorders; however, little is known about the relationship between psychiatric disorders and alcohol consumption levels. Understanding varying levels of unhealthy alcohol use among individuals with a variety of psychiatric disorders in primary care would provide valuable insight for tailoring interventions.

Methods

We conducted a cross‐sectional study of 2,720,231 adult primary care patients screened for unhealthy alcohol use between 2014 and 2017 at Kaiser Permanente Northern California, using electronic health record data. Alcohol consumption level was classified as no reported use, low‐risk use, and unhealthy use, per National Institute on Alcohol Abuse and Alcoholism guidelines. Unhealthy use was further differentiated into mutually exclusive groups: exceeding only daily limits, exceeding only weekly limits, or exceeding both daily and weekly limits. Multivariable multinomial logistic regression models were fit to examine associations between 8 past‐year psychiatric disorders (depression, bipolar disorder, anxiety disorder, obsessive–compulsive disorder, schizophrenia, schizoaffective disorder, anorexia nervosa, and bulimia nervosa) and alcohol consumption levels, adjusting for sociodemographic and health characteristics.

Results

In the full sample [53% female, 48% White, mean (SD) age = 46 (18) years], patients with psychiatric disorders (except eating disorders), compared to those without, had lower odds of reporting low‐risk and unhealthy alcohol use relative to no use. Among patients who reported any alcohol use (n = 861,427), patients with depression and anxiety disorder, compared to those without, had higher odds of exceeding only weekly limits and both limits; patients with bulimia nervosa were also more likely to exceed both limits.

Conclusions

Findings suggest that patients with anxiety disorder, depression, and bulimia nervosa who drink alcohol are more likely to exceed recommended limits, increasing risk of developing more serious problems. Health systems and clinicians may wish to consider implementing more robust screening, assessment, and intervention approaches to support these vulnerable subgroups in limiting their drinking.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Screening for alcohol use disorder among individuals with comorbid psychiatric disorders: Diagnostic accuracy in a sample of young Swiss men

Alcohol use disorder (AUD) is frequently comorbid with other psychiatric disorders. However, few studies investigated the psychometric properties of AUD screening tools in presence of co-occurring disorders. This study examined the diagnostic accuracy of a short AUD screening tool among young adults, in the presence of high vs. low or moderate symptomatology of other common psychiatric disorders. Data were collected among young Swiss men (n = 233) between 2016 and 2018. Measures included a diagnostic interview for AUD and screening tools for AUD and other psychiatric disorders (attention deficit hyperactivity disorder, antisocial personality disorder, bipolar disorder, borderline personality disorder, major depressive disorder, and social anxiety disorder). We computed receiver operating characteristic curves to test whether the AUD screening tool was an accurate indicator of AUD for groups with high vs. low or moderate symptomatology of each psychiatric disorder. The results showed that the optimal cut-off score was ≥3 (the original cut-off of the scale) for participants with a low or moderate symptomatology and ≥4 for participants with a high symptomatology. Our findings highlighted the urgent need for an integrated approach to screening. Psychiatric comorbidities should be included in the screen for AUD to obtain accurate results.

Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness

BACKGROUND

People with severe mental disorders (SMD) experience premature mortality mostly from preventable physical causes. The World Health Organization (WHO) have recently produced guidelines on the management of physical health conditions in SMD. This paper presents the evidence which led to the recommendations for tobacco cessation and management of substance use disorders in SMD.

METHODS

Scoping reviews informed 2 PICO (Population Intervention, Comparator, Outcome) questions relating to tobacco cessation and management of substance use disorders in SMD. Systematic searches led to the identification of systematic reviews with relevant evidence to address these questions. Retrieved evidence was assessed using GRADE methodology, informing the development of guidelines.

RESULTS

One thousand four hundred thirty-four records were identified through systematic searches for SMD and tobacco cessation, of which 4 reviews were included in GRADE tables and 18 reviews in narrative synthesis. For SMD and substance use disorders, 4268 records were identified, of which 4 studies from reviews were included in GRADE tables and 16 studies in narrative synthesis. People with SMD who use tobacco should be offered combined pharmacological (Varenicline, Bupropion or Nicotine Replacement Therapy) and non-pharmacological interventions such as tailored directive and supportive behavioural interventions. For people with SMD and substance use disorders (drug and/or alcohol), interventions should be considered in accordance with WHO mhGAP guidelines. Prescribers should note potential drug-drug interactions. Recommendation were conditional and based on low/very low certainty of evidence with a scarcity of evidence from low- and middle-income settings.

CONCLUSIONS

These guidelines mark an important step towards addressing premature mortality in people with SMD. The dearth of high-quality evidence and evidence from LMIC settings must inform the future research agenda.

GUIDELINES

https://www.who.int/mental_health/evidence/guidelines_physical_health_and_severe_mental_disorders/en https://www.who.int/publications-detail/mhgap-intervention-guide%2D%2D-version-2.0.

Psychiatric comorbidities in bipolar disorders: An examination of the prevalence and chronology of onset according to sex and bipolar subtype

OBJECTIVES

Bipolar Disorder (BD) is frequently comorbid with other psychiatric disorders. However, few studies systematically examine which disorders are more likely to occur pre- or post-BD onset. We examine the prevalence and Age At Onset (AAO) of psychiatric conditions in adults with BD.

METHODS

A structured clinical interview was used to assess lifetime history and AAO of alcohol and cannabis misuse, suicide attempts, anxiety and eating disorders in a French sample of euthymic patients with BD (n = 739). Regression analyses were used to test for statistically significant associations between rates and AAO of comorbidities in BD groups stratified by sex or subtype.

RESULTS

Prevalence of alcohol and cannabis misuse was associated with male sex and BD-I subtype; whilst most anxiety and eating disorders were associated with female sex. The AAO of most comorbid conditions preceded that of BD, except for panic disorder, agoraphobia and alcohol misuse. Few variations were observed in AAO of comorbidities according to groups.

LIMITATIONS

All assessments were retrospective, so estimates of prevalence rates and especially exact AAO of some comorbidities are at risk of recall bias.

CONCLUSIONS

Sex and BD subtype are associated with different rates of comorbid disorders. However, there were minimal between group differences in median AAO of comorbidities. By describing the chronological sequence of comorbidities in BD we were able to demonstrate that a minority of comorbidities typically occurred post-onset of BD. This is noteworthy as these disorders might be amenable to interventions aimed at early secondary prevention.

Evaluation of 2D:4D digit ratio in bipolar 1 disorder patients and its relationship with treatment response

BACKGROUND

The role of sex steroids in bipolar disorder (BD) has been demonstrated in adults. We aimed to evaluate the 2D:4D ratio, which indirectly reflects prenatal sex steroids, in BD. Another purpose of this study was to determine the relationship between clinical features, especially lithium response, and digit ratio.

METHODS

The study included 74 patients with bipolar 1 disorder and 74 healthy individuals matched according to age, gender, and educational status. The digit ratio was calculated by dividing the index finger (2D) length by the ring finger (4D) length in both hands. A lithium response scale was used to evaluate the lithium response history.

RESULTS

There was no difference in 2D:4D ratio between the patients and controls in either right or left hands. The digit ratio was not different between groups with and without suicide attempts. The 2D:4D ratio in the patient group was lower in individuals unresponsive to lithium therapy than in partial and good responders for both right and left hands.

DISCUSSION

According to the results of our study, the 2D:4D ratio in the BD group was not different from healthy controls but was lower in patients unresponsive to lithium. In this respect, the 2D:4D ratio can be considered as a biomarker for lithium response in BD. In large-sample studies, the 2D:4D ratio should be investigated for pathophysiology and treatment response of BD.

Is cesarean section a cause of affective disorders?-A national cohort study using sibling designs

BACKGROUND

The gut microbiota of children delivered by cesarean section differs from that of children delivered vaginally. In light of the gut-brain axis hypothesis, cesarean section may influence risk of affective disorders.

METHODS

Population based prospective cohort study included Danish children born 1982 through 2001, with follow-up until 2015. The effect of delivery mode on the risk of affective disorders was assessed using a standard Cox model and two types of Cox sibling models. Diagnostic codes or prescriptions for antidepressants and lithium were used to define cases of affective disorders.

RESULTS

1,009,444 children were followed for 8,880,794 person-years from the age of 13 years, with relevant covariates available from birth. There are strong calendar time trends in the occurrence of affective disorders with an increasingly younger age at first diagnosis and with a hotspot between the years 2007-2012. Fully adjusted standard Cox models showed an increased risk of affective disorders for both pre-labor (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.08-1.15) and intrapartum (HR, 1.07; 95% CI, 1.05-1.10) cesarean section, compared to vaginal delivery. This effect disappeared in the between-within sibling model for pre-labor (HR, 1.00; 95% CI, 0.94-1.07) but not intrapartum (HR, 1.05; 95% CI, 1.00-1.12) cesarean section.

LIMITATIONS

Interpretation of results from sibling models may not be relevant to children without siblings.

CONCLUSIONS

These results do not support the hypothesis that a delivery-mode dependent change in gut microbiota is a cause of subsequent affective disorders, despite an apparent association with delivery mode.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reconsidering the associations between self-reported alcohol use disorder and mental health problems in the light of co-occurring addictions in young Swiss men

BACKGROUND

Alcohol use disorder (AUD) is known to co-occur with other addictions, as well as with mental health problems. However, the effects of other addictions co-occurring with AUD on mental health problems were rarely studied and not considering them may bias estimates of the association between AUD and mental health problems. This study investigated which role co-occurring addictions play for the cross-sectional associations between self-reported AUD and mental health problems.

METHOD

Participants were 5516 young Swiss men (73.0% of those that gave written informed consent) who completed a self-report questionnaire. Using short screening questionnaires, we assessed three substance use disorders (alcohol, cannabis and tobacco), seven behavioural addictions (internet, gaming, smartphone, internet sex, gambling, work, exercise) and four mental health problems (major depression, bipolar disorder, attention deficit hyperactivity disorder (ADHD) and social anxiety disorder). Differences in the proportions of mental health problems were tested using logistic regressions between (1) participants with no AUD and AUD, (2) participants with no AUD and AUD alone and (3) participants with no AUD and AUD plus at least one co-occurring addiction.

RESULTS

Overall, (1) participants with AUD had higher proportions of major depression (Odds ratio (OR [95% confidence interval]) = 3.51 [2.73, 4.52]; ADHD (OR = 3.12 [2.41, 4.03]); bipolar disorder (OR = 4.94 [3.38, 7.21]) and social anxiety (OR = 2.21 [1.79, 2.73])) compared to participants with no AUD. Considering only participants with AUD alone compared to participants with no AUD (2), differences in proportions were no longer significant for major depression (OR = 0.83 [0.42, 1.64]), bipolar disorder (OR = 1.69 [0.67, 4.22]), social anxiety (OR = 1.15 [0.77, 1.73]) and ADHD (OR = 1.65 [1.00, 2.72]) compared to participants with no AUD. In contrast, (3) proportions of mental health problems were considerably higher for participants with AUD plus at least one other addiction when compared to participants with no AUD, with OR's ranging from 2.90 [2.27, 3.70] for social anxiety, 4.03 [3.02, 5.38] for ADHD, 5.29 [4.02, 6.97] for major depression to 6.64 [4.44, 9.94] for bipolar disorder.

CONCLUSIONS

AUD was associated with all four measured mental health problems. However, these associations were mainly due to the high proportions of these mental health problems in participants with AUD plus at least one co-occurring addiction and only to a lesser degree due to participants with AUD alone (i.e. without any other co-occurring addictions). Hence, estimates of the association between AUD and mental health problems that do not consider other addictions may be biased (i.e. overestimated). These findings imply that considering addictions co-occurring with AUD, including behavioural addictions, is important when investigating associations between AUD and mental health problems, and for the treatment of AUD and co-morbid disorders.

Delay discounting and reward sensitivity in a 2 × 2 study of bipolar disorder and alcohol dependence

BACKGROUND AND AIMS

Separate studies have shown increased delay discounting in people with bipolar disorder (BD) and people with alcohol dependence (AD) relative to people without mental health problems. Delay discounting was compared in people with no mental health problems, AD, BD and AD plus BD. Associations of delay discounting with self-reported impulsivity and reward sensitivity were also assessed.

DESIGN

The study was a two-by-two factorial comparative observational design.

SETTING

Data were collected at baseline diagnostic visits as part of a neuroimaging study at a medical university in South Carolina, USA.

PARTICIPANTS

Twenty-two BD + AD, 33 BD, 28 AD and 27 people without mental health problems participated.

MEASUREMENTS

Diagnostic and clinician-rated symptom measures, self-report questionnaires and a computerized delay discounting task were administered. Two-by-two general linear univariate models were tested to examine between-group differences on discounting rates, and bivariate correlations and hierarchical regression analyses were performed to examine associations between discounting rates and self-reported reward sensitivity and impulsivity.

FINDINGS

There was a significant main effect of AD (P = 0.006, η2  = 0.068). The main effect of BD and the BD × AD interaction terms were non-significant (P ≥ 0.293, η2  ≤ 0.010). Reward sensitivity and impulsivity were not significantly associated with discounting rates after adjustment for the other (P ≥ 0.089).

CONCLUSIONS

People with alcohol dependence appear to have higher delay discounting, while previously found associations between bipolar disorder and delay discounting may be secondary to alcohol use disorder.

Positive screening rates for bipolar disorder in pregnant and postpartum women and associated risk factors

OBJECTIVE

Bipolar disorder affects 2-8% of pregnant and postpartum women; untreated illness is associated with poor outcomes. This study aimed to describe bipolar disorder screening rates in obstetric settings and associated characteristics.

METHOD

Women were recruited during pregnancy through three months postpartum from 14 obstetric clinics in Massachusetts. The Mood Disorder Questionnaire (MDQ) was used to screen for bipolar disorder; a subset previously diagnosed with bipolar was also examined. Differences in characteristics by screening outcome were tested using chi-square and t-tests.

RESULTS

Of 574 participating women, 18.8% screened positive for bipolar disorder. Compared to those with negative, those with positive bipolar screens had 18.5-times the prevalence of positive substance use screens (11.1% vs. 0.6%, p < 0.001) and 3.4-times reported feeling they were not receiving adequate psychiatric help (24.0 vs. 7.0%, p < 0.001). Less than half of those with positive bipolar screens (42.0%) and 61.3% with pre-existing bipolar reported receiving current psychiatric care.

CONCLUSIONS

Almost one in five perinatal women screened positive for bipolar disorder. Positive screenings were associated with comorbid substance use and low treatment rates. This study highlights the importance of screening for bipolar disorder during the perinatal period and the need for systematic approaches to ensure adequate assessment and follow-up.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT02760004.

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

Background

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

Objectives

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

Design

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

Setting

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

Participants

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

Interventions

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

Main outcome measures

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

Results

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

Limitations

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

Conclusion

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

Future work

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

Trial registration

Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583.

Funding

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

Sodium valproate in pregnancy: what are the risks and should we use a shared decision-making approach?

BACKGROUND

Despite significant teratogenic risks, sodium valproate is still widely prescribed in many countries to women of childbearing age, as a mood stabiliser in bipolar disorder and also in epilepsy. The UK has recently banned valproate use in women who are not in a pregnancy prevention programme. Whilst this ruling reflects prevailing clinical practice, it also highlights an ongoing debate about when (if ever) a woman who is or could become pregnant should be allowed to choose to take valproate.

MAIN BODY

We review the benefits and harms of drugs available for bipolar disorder and epilepsy in women of childbearing age, with a particular focus on teratogenic risk. We speculate on hypothetical rare situations in which potential benefits of valproate may outweigh potential harms in such women. We also review the literature on shared decision-making - on which there is now a NICE guideline and numerous evidence-based decision tools. Drawing on previous work by experts in shared decision-making, we offer a list of 'frequently asked questions' and a matrix of options to support conversations with women about continuing or discontinuing the drug in (or in anticipation of) pregnancy. We also consider whether shared decision-making is an appropriate paradigm when considering whether to continue a teratogenic drug.

CONCLUSION

We conclude that because valproate in pregnancy remains the subject of such debate, there is scope for further research - not only into the relative efficacy and safety of alternatives to it - but also into the dynamics of communication and shared decision-making in this situation.