Cognitive Impairment in Euthymic Pediatric Bipolar Disorder: A Systematic Review and Meta-Analysis

Structural and functional disruption of subcortical limbic structures related with executive function in pediatric bipolar disorder

BACKGROUND

Impaired cognition has been demonstrated in pediatric bipolar disorder (PBD). The subcortical limbic structures play a key role in PBD. However, alternations of anatomical and functional characteristics of subcortical limbic structures and their relationship with neurocognition of PBD remain unclear.

METHODS

Thirty-six PBD type I (PBD-I) (15.36 ± 0.32 years old), twenty PBD type II (PBD-II) (14.80 ± 0.32 years old) and nineteen age-gender matched healthy controls (HCs) (14.16 ± 0.36 years old) were enlisted. Primarily, the volumes of the subcortical limbic structures were obtained and differences in the volumes were evaluated. Then, these structures served as seeds of regions of interest to calculate the voxel-wised functional connectivity (FC). After that, correlation analysis was completed between volumes and FC of brain regions showing significant differences and neuropsychological tests.

RESULTS

Compared to HCs, both PBD-I and PBD-II patients showed a decrease in the Stroop color word test (SCWT) and digit span backward test scores. Compared with HCs, PBD-II patients exhibited a significantly increased volume of right septal nuclei, and PBD-I patients presented increased FC of right nucleus accumbens and bilateral pallidum, of right basal forebrain with right putamen and left pallidum. Both the significantly altered volumes and FC were negatively correlated with SCWT scores.

SIGNIFICANCE

The study revealed the role of subcortical limbic structural and functional abnormalities on cognitive impairments in PBD patients. These may have far-reaching significance for the etiology of PBD and provide neuroimaging clues for the differential diagnosis of PBD subtypes.

CONCLUSIONS

Distinctive features of neural structure and function in PBD subtypes may contribute to better comprehending the potential mechanisms of PBD.

Functioning and neurocognition in very early and early-life onset bipolar disorders: the moderating role of bipolar disorder type

Defining homogeneous subgroups of bipolar disorder (BD) is a major goal in personalized psychiatry and research. According to the neurodevelopmental theory, age at onset may be a key variable. As potential trait markers of neurodevelopment, cognitive and functional impairment should be greater in the early form of the disease, particularly type 1 BD (BD I). The age at onset was assessed in a multicenter, observational sample of 4190 outpatients with BD. We used a battery of neuropsychological tests to assess six domains of cognition. Functioning was measured using the Functioning Assessment Short Test (FAST). We studied the potential moderation of the type of BD on the associations between the age at onset and cognitive and functioning in a subsample of 2072 euthymic participants, controlling for potential clinical and socio-demographic covariates. Multivariable analyses showed cognition to not be impaired in individuals with early (21-30 years) and very early-life (before 14 years) onset of BD. Functioning was equivalent between individuals with early and midlife-onset of BD II and NOS but better for individuals with early onset of BD I. In contrast, functioning was not worse in individuals with very early-onset BD I but worse in those with very early-onset BD II and NOS. Early-life onset BDs were not characterized by poorer cognition and functioning. Our results do not support the neurodevelopmental view that a worse cognitive prognosis characterizes early-life onset BD. This study suggests that functional remediation may be prioritized for individuals with midlife-onset BD I and very early life onset BD 2 and NOS.

A bibliometric and visual analysis of cognitive function in bipolar disorder from 2012 to 2022

INTRODUCTION

Bipolar disorder (BD) is a chronic psychiatric disorder that combines hypomania or mania and depression. The study aims to investigate the research areas associated with cognitive function in bipolar disorder and identify current research hotspots and frontier areas in this field.

METHODOLOGY

Publications related to cognitive function in BD from 2012 to 2022 were searched on the Web of Science Core Collection (WoSCC) database. VOSviewer, CiteSpace, and Scimago Graphica were used to conduct this bibliometric analysis.

RESULTS

A total of 989 articles on cognitive function in BD were included in this review. These articles were mainly from the United States, China, Canada, Spain and the United Kingdom. Our results showed that the journal "Journal of Affective Disorders" published the most articles. Apart from "Biploar disorder" and "cognitive function", the terms "Schizophrenia", "Meta analysis", "Rating scale" were also the most frequently used keywords. The research on cognitive function in bipolar disorder primarily focused on the following aspects: subgroup, individual, validation and pathophysiology.

CONCLUSIONS

The current concerns and hotspots in the filed are: "neurocognitive impairment", "subgroup", "1st degree relative", "mania", "individual" and "validation". Future research is likely to focus on the following four themes: "Studies of the bipolar disorder and cognitive subgroups", "intra-individual variability", "Validation of cognitive function tool" and "Combined with pathology or other fields".

Differences in clinical presentation between newly diagnosed bipolar I and II disorders: A naturalistic study

AIM

This naturalistic clinical study aims to investigate differences between newly diagnosed patients with bipolar type I (BDI) and bipolar type II (BDII) disorders in socio-demographic and clinical characteristics, affective symptoms, cognition, functioning and comorbidity with personality disorders.

METHODS

The BD diagnosis and type were confirmed using the Schedules for Clinical Assessment in Neuropsychiatry. Affective symptoms were assessed with the Young Mania Rating Scale, the Hamilton Depression Rating Scale, the Major Depressive Index, and the Altman Self-Rating Mania Scale. Functional impairment was assessed with the Functional Assessment Short Test. Cognitive impairment was evaluated by the Screen for Cognitive Impairment in Psychiatry and the Cognitive Complaints in Bipolar Disorder Rating Assessment. Finally, comorbid personality disorders were assessed with the Standardized Assessment of Personality-Abbreviated Scale and structured interview Structured Clinical Interview for DSM-disorders.

RESULTS

383 newly diagnosed patients were included (BDI: n = 125; BDII: n = 258). Against expectations, we found no more depressive symptoms in BDII compared with BDI nor any differences in cognitive, childhood trauma or overall functional impairment. The only difference was lower occupational impairment in the BDII group.

LIMITATIONS

The self-reported measures of cognitive difficulties and childhood trauma involved potential bias (recall or other). Despite BD being newly diagnosed a diagnostic delay was observed.

CONCLUSION

Patients newly diagnosed with BDII and BDI had similar burdens of depressive symptoms and cognitive and overall functional impairment, however patients with BDI had lower occupational functioning. No statistically significant difference was found in prevalence of comorbid personality disorders between patients with BDI and BDII.

Socio-economic status, functioning and cognition in young versus adult patients newly diagnosed with bipolar disorder and their unaffected relatives; results from a cross-sectional study

BACKGROUND

Bipolar disorders (BD) figures on top of the World Health Organization classification of disabling disorders. It is unclear if there are socioeconomic, functioning, and cognition differences in young patients newly diagnosed with BD and whether these are different for young and adult patients newly diagnosed with BD. Understanding these differences is important for tailored treatment and support.

METHODS

Participant groups included 401 patients newly diagnosed with BD, 145 of their unaffected first-degree relatives (UR) and 209 healthy control individuals (HC). First, we compared socio-economic status, functioning and cognition between young patients newly diagnosed with BD (150), UR (61) and HC (92) (15-25 years) and adult patients newly diagnosed with BD (251), UR (84) and HC (117) (>25 years), respectively. Second, within patients, we compared functioning and cognition between young and adult patients newly diagnosed with BD.

RESULTS

In both participant groups, patients newly diagnosed with BD, and to a lesser degree UR, had lower socio-economic status and impaired functioning and cognition compared with HC. Further, young patients newly diagnosed with BD were less functionally impaired, than adults newly diagnosed with BD, whereas cognition did not differ between groups.

LIMITATIONS

Applied tools for assessments of functioning and cognition are not validated below age 18.

CONCLUSIONS

Overall, lower socio-economic status and impaired functioning and cognition were found both in young and adult patients newly diagnosed with BD and their UR compared with young and adult HC, respectively. Young patients were less functionally impaired than adults, but cognition was similarly impaired.

Childhood cumulative trauma, social support and stress as predictors of illness outcomes and quality of life in bipolar disorder

OBJECTIVE

Trauma, social support and stress have been identified as factors which may be associated with the bipolar disorder illness course. However, these are yet to be examined in prospective studies as predictors of illness outcomes and overall quality of life in bipolar disorder.

METHOD

One hundred and fourteen participants (N = 97; 85.1% female) living with bipolar disorder I (41.2%) or II (58.8%) completed a semi-structured interview and a range of self-report measures assessing trauma history, social support, perceived stress, depression, anxiety, mania, suicidality, number of mood episodes and quality of life, at baseline and 6-month follow-up.

RESULTS

Childhood cumulative trauma, social support and perceived stress accounted for a substantial and significant portion of the variance in quality of life (62%; 23.6%), anxiety severity (34.6%; 24.5%) and depression severity (49.6%; 26.7%), at both baseline and 6-month follow-up. Perceived stress made significant unique contributions to the prediction of all outcomes, and social support made significant unique contributions to depression and quality of life in bipolar disorder.

CONCLUSION

Stress and social support play an important role in bipolar disorder and in quality of life for people living with this condition. Given that stress and social support are modifiable risk factors, this provides a promising direction for future intervention-based research.

Decreased dynamic variability of the cerebellum in the euthymic patients with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is a complex mental illness characterized by different mood states, including depression, mania/hypomania, and euthymia. This study aimed to comprehensively evaluate dynamic changes in intrinsic brain activity by using dynamic fractional amplitude of low-frequency fluctuations (dfALFF) and dynamic degree centrality (dDC) in patients with BD euthymia or depression and healthy individuals.

METHODS

The resting-state functional magnetic resonance imaging data were analyzed from 37 euthymic and 28 depressed patients with BD, as well as 85 healthy individuals. Using the sliding-window method, the dfALFF and dDC were calculated for each participant. These values were compared between the 3 groups using one-way analysis of variance (ANOVA). Additional analyses were conducted using different window lengths, step width, and window type to ensure the reliability of the results.

RESULTS

The euthymic group showed significantly lower dfALFF and dDC values of the left and right cerebellum posterior lobe compared with the depressed and control groups (cluster level PFWE < 0.05), while the latter two groups were comparable. Brain regions showing significant group differences in the dfALFF analysis overlapped with those with significant differences in the dDC analysis. These results were consistent across different window lengths, step width, and window type.

CONCLUSIONS

These findings suggested that patients with euthymic BD exhibit less flexibility of temporal functional activities in the cerebellum posterior lobes compared to either depressed patients or healthy individuals. These results could contribute to the development of neuropathological models of BD, ultimately leading to improved diagnosis and treatment of this complex illness.

Frequency-dependent alterations of global signal topography in patients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is associated not only with disorders in multiple brain networks but also with frequency-specific brain activities. The abnormality of spatiotemporal networks in patients with MDD remains largely unclear.

METHODS

We investigated the alterations of the global spatiotemporal network in MDD patients using a large-sample multicenter resting-state functional magnetic resonance imaging dataset. The spatiotemporal characteristics were measured by the variability of global signal (GS) and its correlation with local signals (GSCORR) at multiple frequency bands. The association between these indicators and clinical scores was further assessed.

RESULTS

The GS fluctuations were reduced in patients with MDD across the full frequency range (0-0.1852 Hz). The GSCORR was also reduced in the MDD group, especially in the relatively higher frequency range (0.0728-0.1852 Hz). Interestingly, these indicators showed positive correlations with depressive scores in the MDD group and relative negative correlations in the control group.

CONCLUSION

The GS and its spatiotemporal effects on local signals were weakened in patients with MDD, which may impair inter-regional synchronization and related functions. Patients with severe depression may use the compensatory mechanism to make up for the functional impairments.

Association of polygenic risk for bipolar disorder with grey matter structure and white matter integrity in youth

There is a gap in knowledge regarding the polygenic underpinnings of brain anomalies observed in youth bipolar disorder (BD). This study examined the association of a polygenic risk score for BD (BD-PRS) with grey matter structure and white matter integrity in youth with and without BD. 113 participants were included in the analyses, including 78 participants with both T1-weighted and diffusion-weighted MRI images, 32 participants with T1-weighted images only, and 3 participants with diffusion-weighted images only. BD-PRS was calculated using PRS-CS-auto and was based on independent adult genome-wide summary statistics. Vertex- and voxel-wise analyses examined the associations of BD-PRS with grey matter metrics (cortical volume [CV], cortical surface area [CSA], cortical thickness [CTh]) and fractional anisotropy [FA] in the combined sample, and separately in BD and HC. In the combined sample of participants with T1-weighted images (n = 110, 66 BD, 44 HC), higher BD-PRS was associated with smaller grey matter metrics in frontal and temporal regions. In within-group analyses, higher BD-PRS was associated with lower CTh of frontal, temporal, and fusiform gyrus in BD, and with lower CV and CSA of superior frontal gyrus in HC. In the combined sample of participants with diffusion-weighted images (n = 81, 49 BD, 32 HC), higher BD-PRS was associated with lower FA in widespread white matter regions. In summary, BD-PRS calculated based on adult genetic data was negatively associated with grey matter structure and FA in youth in regions implicated in BD, which may suggest neuroimaging markers of vulnerability to BD. Future longitudinal studies are needed to examine whether BD-PRS predicts neurodevelopmental changes in BD vs. HC and its interaction with course of illness and long-term medication use.

Psychomotor agitation and irritability in adolescents with manic episode: Clinical data from three inpatient units

OBJECTIVES

We aimed to investigate the characteristics of adolescents with Bipolar disorder-I with irritability and agitation (Mania+IA) compared to those without irritability and agitation (Mania-IA) in a multi-center representative sample.

METHODS

Data of 145 patients from three tertiary-care inpatient units between 2016 and 2021 were obtained. Psychomotor agitation was defined as a score of ≥3 on the YMRS "Increased Motor Activity--Energy" item, irritability as a score of ≥4 on the YMRS 'irritability' item, and severity anchors of speech and thought disturbance on the YMRS '6 and 7' items.

RESULTS

Previous manic episodes (p = 0.013), involuntary hospitalization (p = 0.006), psychotic features (p = 0.001), formal thought disorder (p = 0.010) and aggressive/disruptive behavior (p = 0.021) were more frequent in the Mania+IA group. Conversely, depressive episodes (p = 0.006) and family history of depression (p = 0.024) were more frequent in the Mania-IA group. The Mania+IA had poorer functioning at the time of discharge.

CONCLUSIONS

Irritability and agitation were closely related to complications, psychotic symptoms and thought disorder. Assessment and monitoring of psychomotor agitation and irritability may help child and adolescent psychiatrists to predict clinical difficulties and appropriate interventions.

The Influence of Vitamin D Status on Cognitive Ability in Patients with Bipolar Disorder and Healthy Controls

Recent evidence on the association between vitamin D and cognition in mentally healthy individuals is inconsistent. Furthermore, the link between vitamin D and cognitive ability in individuals with bipolar disorder has not been studied yet. Thus, we aimed to investigate the association between 25-hydroxyvitamin D (25(OH)D), 24,25 dihydroxyvitamin D (24,25(OH)2D, the vitamin D metabolite ratio (VMR) and cognition in a cohort of euthymic patients with bipolar disorder. Vitamin D metabolites were measured simultaneously by liquid-chromatography tandem mass-spectrometry in serum samples from 86 outpatients with bipolar disorder and 93 healthy controls. Neither the inactive precursor 25(OH)D, nor the primary vitamin D catabolite 24,25(OH)2D, or the vitamin D metabolite ratio were significantly associated with the domains "attention", "memory", or "executive function" in individuals with bipolar disorder and healthy controls. Further, no vitamin D deficiency effect or interaction group × vitamin D deficiency was found in the cognitive domain scores. In summary, the present study does not support vitamin D metabolism as a modulating factor of cognitive function in euthymic BD patients. Considering the current study's cross-sectional design, future research should expand these results in a longitudinal setting and include additional aspects of mental health, such as manic or depressive symptoms, long-term illness course and psychopharmacological treatment.

Association of cannabis use with neurocognition in adolescents with bipolar disorder

BACKGROUND

Bipolar disorder (BD) and cannabis use are each associated with neurocognitive deficits in adolescents. However, little is known regarding the association of neurocognition with cannabis use among adolescents with BD. Therefore, we examined this topic in a sample of adolescents with BD and healthy control (HC) adolescents.

METHODS

Participants included 121 adolescents (n = 32 with BD and lifetime cannabis use (BDCB+), n = 31 with BD and no lifetime cannabis use (BDCB-), n = 58 HC with no lifetime cannabis use), aged 14-20 years. Five neurocognitive subtests of the computerized CANTAB battery were assessed. Groups were compared using an analysis of covariance (ANCOVA) covarying for age, sex, and intelligence quotient.

RESULTS

The three groups differed significantly on tests of visuospatial working memory (F = 4.41, p = 0.014, η p 2 = 0 . 07 ) and sustained attention (F = 5.15, p = 0.007, η p 2 = 0 . 08 ). Post hoc analyses revealed working memory scores were significantly worse in BDCB+ versus HC (p = 0.04, d = 0.59), and sustained attention was significantly worse in BDCB- versus HC (p = 0.006, d = 0.70).

CONCLUSION

These preliminary findings suggest that cannabis use among adolescents with BD is associated with working memory deficits. Future studies in larger samples are warranted to evaluate causation versus predisposition to cannabis use, and to evaluate duration, quantity, and potency of cannabis on neurocognition among adolescents with BD.

The disruption of functional connectome gradient revealing networks imbalance in pediatric bipolar disorder

OBJECTIVE

Pediatric bipolar disorder (PBD) is a psychiatric disorder marked by alteration of brain networks. However, the understanding of these alterations in topological organization still unclear. This study aims to leverage the functional connectome gradient to examine changes in functional network hierarchy in PBD.

METHOD

Connectome gradients were used to scrutinize the differences between functional gradient map in PBD patients (n = 68, aged 11 to 18) and healthy controls (HC, n = 37, aged 11 to 18). The association between regional altered gradient scores and clinical factors was examined. We further used Neurosynth to determine the correlation of the cognitive terms with the PBD principal gradient changes.

RESULTS

Global topographic alterations were exhibited in the connectome gradient in PBD patients, involving gradient variance, explanation ratio, gradient range, and gradient dispersion in the principal gradient. Regionally, PBD patients revealed that the default mode network (DMN) held the most majority of the brain areas with higher gradient scores, whereas a higher proportion of brain regions with lower gradient scores in the sensorimotor network (SMN). These regional gradient differences exhibited significant correlation with clinical features and meta-analysis terms including cognitive behavior and sensory processing.

CONCLUSION

Functional connectome gradient presents a thorough investigation of large-scale networks hierarchy in PBD patients. This exhibited excessive segregation between DMN and SMN supports the theory of imbalance in top-down control and bottom-up in PBD and provides a possible biomarker for diagnostic assessment.

Pediatric Bipolar Disorder: A Practical Guide for Clinicians

Pediatric bipolar disorder (PBD) is a controversial clinical entity and it still needs to be satisfactorily defined. Having a polymorphous presentation and associated with numerous symptoms of comorbid psychiatric illnesses often diagnosed during childhood and adolescence, including attention deficit hyperactivity disorder, its symptoms do not completely parallel those of bipolar disorder in adults. The clinician must be able to reach a diagnosis of PBD in the presence of fluctuating and atypical symptoms, especially in children, who tend to experience mixed episodes and very rapid cycles. Historically a key symptom for diagnosing PBD is episodic irritability. Proper diagnosis is critical due to the gravity of its prognosis. Clinicians may find supporting evidence for a diagnosis through careful study of the medical and developmental history of the young patient in addition to psychometric data. Treatment prioritizes psychotherapeutic intervention and assigns important roles to family involvement and a healthy lifestyle.

Paediatric bipolar disorder and its controversy

OBJECTIVES

Paediatric bipolar disorder - bipolar disorder occurring in prepubertal children - is a diagnosis subject to considerable controversy. Whilst historically considered to be very rare, proponents since the 1990s have argued that mania can present differently in children and, as such, is much more common than previously thought. Such proposals raise questions about the validity of proposed phenotypes and potential risks of iatrogenic harm.

METHODS

I critically examine the construct of paediatric bipolar disorder using Robins and Guze's (1970, American Journal of Psychiatry126, 983-987) influential criteria for the validity of a psychiatric diagnosis. I review, in turn, evidence relating to its clinical description, delimitation from other conditions, follow-up studies, family studies, laboratory studies, and treatment response.

RESULTS

Across domains, existing research highlights significant challenges establishing the diagnosis. This includes significant heterogeneity in operationalising criteria for children; variable or poor inter-rater reliability; difficulty distinguishing paediatric bipolar disorder from other conditions; large differences in rates of diagnosis between the United States of America and other countries; limited evidence of continuity with adult forms; and a lack of evidence for proposed paediatric phenotypes in children at genetic high-risk of the condition. Laboratory and treatment studies are limited, but also do not provide support for the construct.

CONCLUSIONS

Evidence for the more widespread existence of paediatric bipolar disorder and its various proposed phenotypes remains weak. The ongoing popularity of the diagnosis, most evident in America, may reflect social pressures and broader limitations in psychiatric nosology. The uncertainty around the diagnosis highlights the need for careful longitudinal assessment of children potentially affected.

Neurostructural and neurocognitive correlates of APOE ε4 in youth bipolar disorder

BACKGROUND

Bipolar disorder (BD) is a clinical risk factor for Alzheimer's disease (AD). Apolipoprotein E ε4 (APOE ε4), a genetic risk factor for AD, has been associated with brain structure and neurocognition in healthy youth.

AIMS

We evaluated whether there was an association between APOE ε4 with neurostructure and neurocognition in youth with BD.

METHODS

Participants included 150 youth (78 BD:19 ε4-carriers, 72 controls:17 ε4-carriers). 3T-magnetic resonance imaging yielded measures of cortical thickness, surface area, and volume. Regions-of-interest (ROI) and vertex-wise analyses of the cortex were conducted. Neurocognitive tests of attention and working memory were examined.

RESULTS

Vertex-wise analyses revealed clusters with a diagnosis-by-APOE ε4 interaction effect for surface area (p = 0.002) and volume (p = 0.046) in pars triangularis (BD ε4-carriers > BD noncarriers), and surface area (p = 0.03) in superior frontal gyrus (controls ε4-carriers > other groups). ROI analyses were not significant. A significant interaction effect for working memory (p = 0.001) appeared to be driven by nominally poorer performance in BD ε4-carriers but not control ε4-carriers; however, post hoc contrasts were not significant.

CONCLUSIONS

APOE ε4 was associated with larger neurostructural metrics in BD and controls, however, the regional association of APOE ε4 with neurostructure differed between groups. The role of APOE ε4 on neurodevelopmental processes is a plausible explanation for the observed differences. Future studies should evaluate the association of APOE ε4 with pars triangularis and its neurofunctional implications among youth with BD.

Perceived cognitive impairment in high school students in the United States

Introduction

Some youth experience cognitive difficulties that interfere with their ability to learn and function well in a school environment. We examined correlates of perceived cognitive impairment among high school students who completed a national survey conducted by the United States Centers for Disease Control and Prevention (CDC) in 2019.

Methods

Participants were high school students (grades 9–12) who completed the Youth Risk Behavior Survey (YRBS) in 2019. The CDC uses this survey to monitor risk behaviors. Students answered the following question ‘Because of a physical, mental, or emotional problem, do you have serious difficulty concentrating, remembering, or making decisions?’ as either ‘yes’ or ‘no.’ Student responses to this question were analyzed in relation to demographic variables and variables pertaining to adversity, mental health problems, and drug use.

Results

The sample included 8,349 students between the ages of 14 and 18, with 4,093 boys (49%) and 4,256 girls (51%). A large proportion reported having serious difficulty concentrating, remembering, or making decisions due to physical, mental, or emotional problems (38%). A significantly larger proportion of girls (45%) than boys (30%) reported experiencing cognitive impairment [χ²(1) = 212.23, p < 0.001; Odds Ratio = 1.95, 95% confidence interval = 1.78–2.13]. Youth who exercised regularly were significantly less likely to report cognitive impairment. Binary logistic regression was used to examine the associations between perceived cognitive impairment and adversity, mental health, and lifestyle variables separately for boys [χ²(11) = 569.158, p < 0.001; Nagelkerke R² = 0.212] and girls [χ²(11) = 1,026.189, p < 0.001; Nagelkerke R² = 0.321]. Being bullied, feeling unsafe or threatened at school, getting very low grades, insufficient sleep, and using illicit drugs were independently associated with perceived cognitive impairment in both boys and girls—after controlling for associations with depression and suicidality. Youth who denied mental health problems, psychosocial adversities, and using illicit drugs reported much lower rates of perceived cognitive impairment (boys = 13%, girls = 15%).

Conclusion

A remarkably large proportion of high school students in the United States reported experiencing serious difficulty with their cognitive functioning over the past year. Girls were significantly more likely to endorse perceived cognitive difficulties compared to boys. There was a strong association between perceived cognitive impairment and the experience of psychosocial adversity.

The prevalence and characteristics of MCCB cognitive impairment in unmedicated patients with bipolar II depression and major depressive disorder

BACKGROUND

Cognitive impairment has been acknowledged as a core clinical manifestation of bipolar disorder (BD) as well as major depressive disorder (MDD). Determining the prevalence and characteristics of cognitive impairment is important for clinical interventions. This study investigated the prevalence and characteristics of cognitive impairment based on the Measurement and Treatment Research to Improve Cognition Schizophrenia Consensus Cognitive Battery (MCCB) in both BD and MDD.

METHOD

One hundred and forty-nine BD II depression, 147 MDD, and 124 demographically matched healthy controls (HC) underwent MCCB cognitive assessment. The prevalence of MCCB cognitive impairment and group difference comparisons were performed. Additionally, association analysis was performed to investigate the relationship between cognitive performance and clinical variables.

RESULTS

Compared to the HC group, both BD II depression and MDD groups had a significantly reduced performance for all MCCB cognitive domains (all p < 0.05). The numerical scores for visual learning were lower in the BD II depression group compared to the MDD group. 32.89% of the BD II depression patients had clinically significant impairment (>1.5 SD below the normal mean) in two or more MCCB domains compared to 23.13% for MDD patients.

CONCLUSIONS

A high percent of patients in the BD II depression and MDD group exhibited MCCB cognitive impairments with clinical significance. Cognitive impairments were more common in BD II depression patients compared to MDD patients, particularly for visual learning. These findings suggest that clinicians should be aware of the severe cognitive impairment in mood disorders and establish effective cognitive screening and intervention strategies.

Association of Lithium and Second-Generation Antipsychotics with Neurocognition in Youth with Bipolar Disorder

Objective: Numerous studies have examined the association of antimanic medications with neurocognition in adults with bipolar disorder (BD). However, few studies have examined this topic in youth. Thus, we aimed to examine the association of lithium and second-generation antipsychotics (SGAs), the first-line antimanic medications for youth with BD, with neurocognition in a relatively large sample of youth with BD. Methods: Participants included 91 youth with BD-I, -II, or -Not Otherwise Specified, aged 13-20 years (n = 14 current lithium use, n = 51 current SGA use). We examined four tests from the Cambridge Neuropsychological Test Automated Battery: Intra/Extra Dimensional Set-Shifting Task (IED), Rapid Visual Information Processing Task (RVP), Stockings of Cambridge Test (SOC), and Affective Go/No-Go (AGN). Within-sample Z-scores were computed, and a global neurocognitive composite score and g factor derived from these tests comprised the primary outcomes. Multivariable analyses controlled for age, sex, and IQ. Results: Current lithium use was significantly associated with poorer cognitive flexibility/set-shifting (IED). After further controlling for lifetime comorbid attention-deficit/hyperactivity disorder and current depression symptoms in sensitivity analyses, the lithium finding was no longer significant. Current SGA use was significantly associated with greater affective processing bias (AGN). No significant findings survived correction for multiple comparisons. All other cognitive outcomes were not significantly associated with current lithium use, current SGA use, or total number of current medications. Conclusions: Treatment with lithium or SGAs was associated with minimal neurocognitive impairments, with small effect sizes in primary multivariable analyses. This study adds to the limited body of literature examining medication use in relation to neurocognition in youth with BD. While the current study cannot rule out associations of smaller effect size, present findings suggest that leading mood-stabilizing medications are not associated with frank neurocognitive impairments in youth with BD.

Research Status in Clinical Practice Regarding Pediatric and Adolescent Bipolar Disorders

Bipolar disorders (BDs) have high morbidity. The first onset of 27.7% of BDs occurs in children under 13 years and of 37.6% occurs in adolescents between 13 and 18 years. However, not all of the pediatric and adolescent patients with BD receive therapy in time. Therefore, studies about pediatric and adolescent patients with disorders have aroused increased attention in the scientific community. Pediatric and adolescent patients with BD present with a high prevalence rate (0.9-3.9%), and the pathogenic factors are mostly due to genetics and the environment; however, the pathological mechanisms remain unclear. Pediatric and adolescent patients with BD manifest differently from adults with BDs and the use of scales can be helpful for diagnosis and treatment evaluation. Pediatric and adolescent patients with BDs have been confirmed to have a high comorbidity rate with many other kinds of disorders. Both medication and psychological therapies have been shown to be safe and efficient methods for the treatment of BD. This review summarizes the research status related to the epidemiology, pathogenic factors, clinical manifestations, comorbidities, diagnostic and treatment scales, medications, and psychological therapies associated with BDs.

Effect of medication therapy combined with transcranial direct current stimulation on depression and response inhibition of patients with bipolar disorder type I: a clinical trial

OBJECTIVE

Bipolar Disorder (BD) is one of the most common mental disorders associated with depressive symptoms and impairment in executive functions such as response inhibition. This study aimed to investigate the effectiveness of medication therapy combined with Transcranial Direct Current Stimulation (tDCS) on depression and response inhibition of patients with BD.

METHOD

This is a double-blinded randomized clinical trial with pretest, posttest, and follow-up design. Participants were 30 patients with BD randomly assigned to two groups of Medication+tDCS (n = 15, receiving medications plus tDCS with 2 mA intensity over dorsolateral prefrontal cortex for 10 days, two sessions per day each for 20 min) and Medication (n = 15, receiving mood stabilizers including 2-5 tables of 300 mg (mg) lithium, 200 mg sodium valproate, and 200 mg carbamazepine two times per day). Pretest, posttest and 3-month follow-up assessments were the 21-item Hamilton Depression Rating Scale (HDRS) and a Go/No-Go test. Collected data were analyzed in SPSS v.20 software.

RESULTS

The mean HDRS score in both groups was reduced after both interventional techniques, where the group received combined therapy showed more reduction (P < 0.01), although their effects were not maintained after 3 months. In examining response inhibition variable, only the combined therapy could reduce the commission error of patients under a go/no-go task (p < 0.05), but its effect was not maintained after 3 months. There was no significant difference in the group received medication therapy alone.

CONCLUSION

Medication in combination with tDCS can reduce the depressive symptoms and improve the response inhibition ability of people with BD.

TRIAL REGISTRATION

This study was registred by Iranian Registry of Clinical Trials (Parallel, ID: IRCT20191229045931N1 , Registration date: 24/08/2020).

Altered spatiotemporal consistency of corticolimbic circuitry in euthymic pediatric bipolar disorder

Bipolar disorder (BD) is a life-threatening illness which clinically defined by an alternating pattern of depressive and manic episodes with a separated period of euthymia. It remains unknown about the consistency of temporal-spatial spontaneous brain activity in euthymic patients, especially in pediatric BD (PBD) patients.Resting-state fMRI signals of sixteen euthymic PBD patients and 16 healthy controls were processed and FOur-dimensional (spatiotemporal) Consistency of local neural Activities (FOCA) and functional connectivity were calculated in the present study. Voxel-wised correlation between clinical and cognitive indices and FOCA in PBD was calculated.Compared with healthy subjects, euthymic PBD patients showed worse performance in tests of Stroop Color-Word Test, Digit Span Test and Trail Making Test. Euthymic PBD patients demonstrated increased FOCA in left inferior frontal gyrus, left anterior cingulate cortex and left superior frontal gyrus and decreased FOCA in right orbital frontal gyrus, bilateral precuneus, right superior occipital gyrus and bilateral superior parietal gyrus. Decreased functional connectivities were found between right orbital frontal gyrus and left amygdala, between left superior frontal gyrus and left putamen, and between left superior frontal gyrus and left insula. And increased functional connectivity was found between right superior occipital gyrus and right hippocampus. FOCA of parahippocampal gyrus was negatively correlated with the SCWT-B score in PBD patients.Abnormal spatiotemporal consistency of brain regions of corticolimbic circuitry is possible to contribute to an imbalance between emotional processing and cognitive control in euthymic PBD. The measurement of FOCA measure may provide important clues of understanding PBD.

Impaired theory of mind and emotion recognition in pediatric bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Social cognition is impaired in patients with severe mental disorders. We aimed to investigate impairments in social cognition in youth with pediatric bipolar disorder (PBD) through a systematic review of the literature and the meta-analysis.

METHOD

Following the PRISMA guidelines, we searched in PubMed, Scopus, and Cochrane CENTRAL for studies reporting on the theory of mind (ToM) and emotion recognition (ER) abilities of patients with PBD compared to healthy controls (HC). We conducted a random-effects model meta-analysis for the contrast between PBD and HC. Subgroup and meta-regression analyses were conducted for demographic and clinical variables as appropriate.

RESULTS

A total of thirteen studies involving 429 patients with PBD and 394 HC were included. Patients with PBD had significantly poorer social cognitive abilities (Hedges' g for ER, g = -0.74, CI = -0.91, -0.57; and for ToM, g = -0.98, CI = -1.41 to -0.55). Subgroup analysis also revealed significant impairment in ER for patients in a euthymic state (g = -0.75). Age, gender, sample size, the severity of mood symptoms, estimated IQ, the frequencies of bipolar-I disorder, attention-deficit hyperactivity disorder, medications, study quality and euthymia did not moderate the difference in meta-regression. Heterogeneity was low in all analyses and there was no evidence for publication bias.

CONCLUSION

The results of this meta-analysis supported the notion that PBD is associated with a deficit in social cognitive abilities at a medium to a large level. Impairments in social cognition could be an illness-related trait of PBD. Meta-regression results did not find a moderator of the deficits in social cognition.

Cognitive complaints in individuals recently diagnosed with bipolar disorder: A cross-sectional study

AIM

To assess the differences in subjective cognitive dysfunction between major depressive disorder (MDD) and recently diagnosed Bipolar Disorder (BD) across euthymia and mood episodes.

METHODS

This is a cross-sectional study corresponding to the second wave of a longitudinal study. The first wave consisted of subjects aged between 18 and 60 diagnosed with MDD. In the follow up after three years (second wave), conversion from MDD to BD diagnosis was assessed by qualified psychologists using the Mini International Neuropsychiatric Interview (MINI-Plus). Subjects were categorized in four diagnostic groups: euthymic MDD, MDD in a current mood episode, euthymic BD, and BD in a current mood episode. All subjects completed the Cognitive Complaints in Bipolar Disorder Rating Assessment (COBRA), an instrument specifically designed for detecting subjective cognitive deficits in BD.

RESULTS

The total sample (n = 468) included 410 subjects with MDD and 58 individuals recently diagnosed with BD. We subdivided the 2 groups based on their current mood state, and found a significant difference in COBRA total scores between euthymic BD individuals (median 17.00 [IQR: 8.75 - 20.75]) and euthymic MDD subjects (median 8.00 [IRQ: 5.00 - 14.00], p = 0.002), showing higher subjective cognitive dysfunction in individuals recently diagnosed with BD. The differences remained significant after adjusting for the presence of lifetime psychotic symptoms. We found no differences between MDD and BD during an acute mood episode.

LIMITATION

The small sample size of individuals with BD.

CONCLUSION

The findings suggest a higher presence of subjective cognitive complaints among individuals recently diagnosed with BD in comparison to individuals with MDD during euthymia.

Cognitive correlates of impulsive aggression in youth with pediatric bipolar disorder and bipolar offspring

BACKGROUND

Youth with bipolar disorder (BD) and offspring of individuals with BD (BD-OFF) are characterized by higher levels of impulsive and overt aggression. The cognitive basis underlying these aggressive behaviors are not clarified in this population. The aim of this study was to investigate the relationship between cognitive alterations and aggressive behavior in youth with BD and BD-OFF.

METHODS

Forty-two youth with BD, 17 BD-OFF and 57 healthy controls (HCs) were administered the Modified Overt Aggression Scale (MOAS), the Cambridge Neuropsychological Test Automated Battery (CANTAB), the Young Mania Rating Scale (YMRS) and the Children's Depression Rating Scale (CDRS). Multiple linear regression analyses were performed in the three groups separately. In each group, tests scores from the CANTAB were predictors. MOAS subscale scores and MOAS total scores were dependent variables. Results are corrected for age, IQ and mood state.

RESULTS

Both youth with BD and BD-OFF showed positive correlations between impairment in executive functions and levels of verbal aggression. In youth with BD, altered processing of either positive and negative stimuli positively correlated with MOAS total scores, whereas in BD-OFF, such relationship was negative.

CONCLUSIONS

Impulsive aggressive behaviors in youth with BD arise from a combination of altered affective processing and executive dysfunction. The negative relationship between affective processing and aggression in BD-OFF suggested the presence of possible mechanisms of resilience in this population.

Emotion regulation in pediatric bipolar disorder: A meta-analysis of published studies

BACKGROUND

Emotion regulation is a relatively recent topic in psychiatry, and has only recently begun to be tested across Pediatric Bipolar Disorder (PBD). To date, no meta-analysis has investigated the presence of emotion regulation deficits in PBD patients.

OBJECTIVES

The aim of this study is to understand where the literature stands on this topic, as well as how different researchers are measuring and grasping the concept of emotion regulation in pediatric bipolar disorders.

METHODS

A systematic search of trials using the terms ("Pediatric Bipolar Disorder") AND ("Emotion Regulation" OR "Affect Regulation" OR "Mood Lability" OR "Mood Instability" OR "Irritability") was conducted using PubMed, Google Scholar, ResearchGate, Web of Science and Psych Info databases. Of the initial 366 articles identified, 8 met eligibility criteria for the meta-analysis and were included in this study.

RESULTS

There is a statistically significant difference in Accuracy in Emotion Regulation tasks, with a tendency for lower accuracy in PBD patients; however, both groups did not differ statistically regarding Response Time.

CONCLUSION

Our data suggests that PBD patients do present emotion regulation deficits, particularly regarding facial emotion recognition and affective language interference tasks mediated by cognitive assignments. These results have important implications in developing novel psychotherapeutic interventions for this population.

Akt-mTOR hypoactivity in bipolar disorder gives rise to cognitive impairments associated with altered neuronal structure and function

The Akt family of kinases exerts many of its cellular effects via the activation of the mammalian target of rapamycin (mTOR) kinase through a series of intermediary proteins. Multiple lines of evidence have identified Akt-family kinases as candidate schizophrenia and bipolar disorder genes. Although dysfunction of the prefrontal cortex (PFC) is a key feature of both schizophrenia and bipolar disorder, no studies have comprehensively assessed potential alterations in Akt-mTOR pathway activity in the PFC of either disorder. Here, we examined the activity and expression profile of key proteins in the Akt-mTOR pathway in bipolar disorder and schizophrenia homogenates from two different PFC subregions. Our findings identify reduced Akt-mTOR PFC signaling in a subset of bipolar disorder subjects. Using a reverse-translational approach, we demonstrated that Akt hypofunction in the PFC is sufficient to give rise to key cognitive phenotypes that are paralleled by alterations in synaptic connectivity and function.

Degenerative dementias: Alterations of emotions and mood disorders

Degenerative dementias such as Alzheimer's disease and frontotemporal dementia result in distinct alterations in emotional processing, emotional experiences, and mood. The neuropathology of these dementias extends to structures involved in emotional processing, including the basolateral limbic network (orbitofrontal cortex, anterior temporal lobe, amygdala, and thalamus), the insula, and ventromedial frontal lobe. Depression is the most common emotion and mood disorder affecting patients with Alzheimer's disease. The onset of depression can be a prodromal sign of this dementia. Anxiety can also be present early in the course of Alzheimer's disease and especially among patients with early-onset forms of the disease. In contrast, patients with behavioral variant frontotemporal dementia demonstrate hypoemotionality, deficits in the recognition of emotion, and decreased psychophysiological reactivity to emotional stimuli. They typically have a disproportionate impairment in emotional and cognitive empathy. One other unique feature of behavioral variant frontotemporal dementia is the frequent occurrence of bipolar disorder. The management strategies for these alterations of emotion and mood in degenerative dementias primarily involve the judicious use of the psychiatric armamentarium of medications.

Neurocognitive functioning in bipolar disorder: What we know and what we don’t

Introduction: This narrative review of systematic reviews and meta-analyses aims at compiling available evidence in various aspects of neurocognitive functioning in Bipolar Disorder (BD).

Methods: We conducted a MEDLINE literature search and identified 38 relevant systematic reviews and metaanalyses.

Results: Current evidence suggests that BD is associated with cognitive impairment across multiple domains and during all clinical states. However, there is a considerable cognitive heterogeneity within BD, which cannot be explained by clinical subtypes, and the pattern of neurocognitive impairment in BD overlaps with other psychiatric conditions such as major depression and schizophrenia. Residual depressive symptoms, poor clinical course and higher number of manic episodes may negatively impact cognitive performance, which is a major predictor of general functioning in BD. Evidence from available prospective studies does not support the notion of progressive cognitive decline in BD while some evidence exists to suggest patients may show some improvements in cognitive functioning following the first manic episode. Furthermore, a subset of patients may show premorbid cognitive abnormalities that could signal an early neurodevelopmental aetiology. Preliminary findings from small studies identify potential pro-cognitive effects of Cognitive Remediation, erythropoietin, intranasal insulin, lurasidone, mifepristone, repetitive Transcranial Magnetic Stimulation and transcranial Direct Current Stimulation in BD.

Discussion: Longitudinal studies in high-risk individuals can provide a better understanding of the development and progression of neurocognitive impairment in BD. Largescale randomised control trials are needed to compare the pro-cognitive efficacy of various pharmacological and non-pharmacological interventions in different cognitive subgroups of patients at different stages of BD.

The Greater Houston Area Bipolar Registry-Clinical and Neurobiological Trajectories of Children and Adolescents With Bipolar Disorders and High-Risk Unaffected Offspring

The aims of this article are to discuss the rationale, design, and procedures of the Greater Houston Area Bipolar Registry (HBR), which aims at contributing to the effort involved in the investigation of neurobiological mechanisms underlying bipolar disorder (BD) as well as to identify clinical and neurobiological markers able to predict BD clinical course. The article will also briefly discuss examples of other initiatives that have made fundamental contributions to the field. This will be a longitudinal study with participants aged 6-17 at the time of enrollment. Participants will be required to meet diagnostic criteria for BD, or to be offspring of a parent with BD. We will also enroll healthy controls. Besides clinical information, which includes neurocognitive performance, participants will be asked to provide blood and saliva samples as well as to perform neuroimaging exams at baseline and follow-ups. Several studies point to the existence of genetic, inflammatory, and brain imaging alterations between individuals at higher genetic risk for BD compared with healthy controls. Longitudinal designs have shown high conversion rates to BD among high-risk offspring, with attempts to identify clinical predictors of disease onset, as well as clarifying the burden associated with environmental stressors. The HBR will help in the worldwide effort investigating the clinical course and neurobiological mechanisms of affected and high-risk children and adolescents with BD.

Familial aggregation analysis of cognitive performance in early-onset bipolar disorder

We analysed the familial aggregation (familiality) of cognitive dimensions and explored their role as liability markers for early-onset bipolar disorder (EOBD). The sample comprised 99 subjects from 26 families, each with an offspring diagnosed with EOBD. Four cognitive dimensions were assessed: reasoning skills; attention and working memory; memory; and executive functions. Their familiality was investigated in the total sample and in a subset of healthy relatives. The intra-family resemblance score (IRS), a family-based index of the similarity of cognitive performance among family members, was calculated. Familiality was detected for the attention and working memory (AW) dimension in the total sample (ICC = 0.37, p = 0.0004) and in the subsample of healthy relatives (ICC = 0.37, p = 0.016). The IRS reflected that there are families with similar AW mean scores (either high or low) and families with heterogeneous scores. Families with the most common background for the AW dimension (IRS > 0) were selected and dichotomized in two groups according to the mean family AW score. This allowed differentiating families whose members had similar high scores than those with similar low scores: both patients (t = - 4.82, p = 0.0005) and relatives (t = - 5.04, p < 0.0001) of the two groups differed in their AW scores. AW dimension showed familial aggregation, suggesting its putative role as a familial vulnerability marker for EOBD. The IRS estimation allowed the identification of families with homogeneous scores for this dimension. This represents a first step towards the investigation of the underlying mechanisms of AW dimension and the identification of etiological subgroups.

Altered Functional Integration in the Salience and Default Mode Networks in Euthymic Pediatric Bipolar Disorder

Accumulating studies demonstrate emotional and cognitive dysregulation in the euthymic period of pediatric bipolar disorder (PBD). However, the relative contribution of functional integration in human brain to disturbed emotion and cognitive function in the euthymic PBD patients remains unclear. In this study, 16 euthymic PBD patients and 16 healthy controls underwent resting-state functional magnetic resonance imaging. A data-driven functional connectivity analysis was used to investigate functional connectivity changes of the euthymic PBD. Compared with healthy controls, the euthymic PBD exhibited greater global functional connectivity density in the left anterior insula and lower global functional connectivity density in the right temporoparietal junction, the left angular gyrus, and the bilateral occipital lobule. A distant functional connectivity analysis demonstrated altered integration within the salience and default mode networks in euthymic PBD. Correlation analysis found that altered functional connectivity of the salience network was related to the reduced performance in the backward digit span test, and altered functional connectivity of the default mode network was related to the Young Mania Rating Scale in euthymic PBD patients. Our findings indicated that disturbed functional integration in salience and default mode networks might shed light on the physiopathology associated with emotional and cognitive dysregulation in PBD.

Associations among childhood parenting, affective temperaments, depressive symptoms, and cognitive complaints in adult community volunteers

BACKGROUND

Correlations between depressive symptoms and affective temperaments or quality of childhood parenting have been investigated previously; however, how childhood parenting and affective temperaments affect cognitive complaints remains unknown. Thus, we evaluated correlations among childhood parenting, affective temperaments, depressive symptoms, and cognitive complaints in adults.

METHODS

Participants (N = 490) completed the Parental Bonding Instrument (PBI), Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Auto-questionnaire version (TEMPS-A), the Patient Health Questionnaire-9 (PHQ-9), and the Cognitive Complaints in Bipolar Disorder Rating Assessment (COBRA). Multiple regression analyses and structural equation modeling were performed to evaluate scale correlations.

RESULTS

As per structural equation modeling, the direct effect of PHQ-9 and four subscales (cyclothymic, depressive, irritable, and anxious temperament) of TEMPS-A on COBRA were significant; the indirect effect of the four subscales of TEMPS-A on COBRA via PHQ-9 was significant; the direct effect of the three subscales (paternal care, maternal care, and maternal overprotection) of PBI on PHQ-9 and four subscales of TEMPS-A were significant; the indirect effect of the three subscales of PBI on PHQ-9 via the four subscales of TEMPS-A was significant.

LIMITATIONS

Cross-sectional designs cannot identify causal relationships between parameters. As participants were adult volunteers from the community, results may not be generalizable to individuals with psychiatric disorders.

CONCLUSIONS

Childhood parenting affects cognitive complaints indirectly via affective temperaments and depressive symptoms in adult community volunteers. An important role of affective temperaments and depressive symptoms in the effects of childhood parenting on cognitive complaints is suggested.

Mismatch Negativity and Loudness Dependence of Auditory Evoked Potentials among Patients with Major Depressive Disorder, Bipolar II Disorder, and Bipolar I Disorder

Mismatch negativity (MMN) and loudness dependence of auditory evoked potentials (LDAEP), which are event-related potentials, have been investigated as biomarkers. MMN indicates the pre-attentive function, while LDAEP may be an index of central serotonergic activity. This study aimed to test whether MMN and LDAEP are useful biological markers for distinguishing patients with bipolar disorder (BD) and major depressive disorder (MDD), as well as the relationship between MMN and LDAEP. Fifty-five patients with major depressive episodes, aged 20 to 65 years, who had MDD (n = 17), BD type II (BIID) (n = 27), and BD type I (BID) (n = 11), were included based on medical records. Patients with MDD had a higher MMN amplitude than those with BID. In addition, the MMN amplitude in F4 positively correlated with the Korean version of mood disorder questionnaire scores (r = 0.37, p = 0.014), while the MMN amplitude in F3 correlated negatively with LDAEP (r = −0.30, p = 0.024). The odds ratios for the BID group and some variables were compared with those for the MDD group using multinomial logistic regression analysis. As a result, a significant reduction of MMN amplitude was found under BID diagnosis compared to MDD diagnosis (p = 0.015). This study supported the hypothesis that MMN amplitude differed according to MDD, BIID, and BID, and there was a relationship between MMN amplitude and LDAEP. These findings also suggested that BID patients had a reduced automatic and pre-attentive processing associated with serotonergic activity or N-methyl-D-aspartate receptor.

A Preliminary Study of the Effects of Treatment with Lithium Versus Quetiapine on Attention of Adolescents with Bipolar Disorder

Objectives: Despite attentional deficits being a prominent feature of bipolar disorder, there are limited data on the effects of common treatments for bipolar disorder on attention. Thus, we sought to compare the effects of lithium versus quetiapine on attention in adolescents with bipolar disorder. Methods: Adolescents ages 10-17 with bipolar disorder, type I, who were experiencing a manic or mixed episode, were recruited from outpatient settings and the inpatient psychiatric units at Cincinnati Children's Hospital Medical Center during their first manic episode. Healthy comparison subjects were recruited from outreach programs in the community. Patients were randomized to lithium or quetiapine, administered in a double-dummy, double-blinded manner for 6 weeks. Attentional deficits were assessed in all groups using the Identical Pairs Continuous Performance Task at baseline and at week 6. Results: Patients with bipolar disorder (n = 79) had impaired attention relative to the healthy group (n = 57) at both baseline and after 6 weeks of treatment. The lithium-treated group (n = 30) had poorer attentional performance than the healthy group at week 6. There was a difference in change in performance between lithium- and quetiapine-treated (n = 49) groups. Conclusion: Youth with bipolar disorder may have impaired attention relative to their healthy peers. Conclusions are limited by the high dropout rate in the lithium-treated group.

Exercise as Medicine for Mental and Substance Use Disorders: A Meta-review of the Benefits for Neuropsychiatric and Cognitive Outcomes

BACKGROUND

Exercise may improve neuropsychiatric and cognitive symptoms in people with mental disorders, but the totality of the evidence is unclear. We conducted a meta-review of exercise in (1) serious mental illness (schizophrenia spectrum, bipolar disorder and major depression (MDD)); (2) anxiety and stress disorders; (3) alcohol and substance use disorders; (4) eating disorders (anorexia nervosa bulimia nervosa, binge eating disorders, and (5) other mental disorders (including ADHD, pre/post-natal depression).

METHODS

Systematic searches of major databases from inception until 1/10/2018 were undertaken to identify meta-analyses of randomised controlled trials (RCTs) of exercise in people with clinically diagnosed mental disorders. In the absence of available meta-analyses for a mental disorder, we identified systematic reviews of exercise interventions in people with elevated mental health symptoms that included non-RCTs. Meta-analysis quality was assessed with the AMSTAR/+.

RESULTS

Overall, we identified 27 systematic reviews (including 16 meta-analyses representing 152 RCTs). Among those with MDD, we found consistent evidence (meta-analyses = 8) that exercise reduced depression in children, adults and older adults. Evidence also indicates that exercise was more effective than control conditions in reducing anxiety symptoms (meta-analyses = 3), and as an adjunctive treatment for reducing positive and negative symptoms of schizophrenia (meta-analyses = 2). Regarding neurocognitive effects, exercise improved global cognition in schizophrenia (meta-analyses = 1), children with ADHD (meta-analyses = 1), but not in MDD (meta-analyses = 1). Among those with elevated symptoms, positive mental health benefits were observed for exercise in people with pre/post-natal depression, anorexia nervosa/bulimia nervosa, binge eating disorder, post-traumatic stress disorder and alcohol use disorders/substance use disorders. Adverse events were sparsely reported.

CONCLUSION

Our panoramic meta-overview suggests that exercise can be an effective adjunctive treatment for improving symptoms across a broad range of mental disorders.

Welfare consequences for people diagnosed with attention deficit hyperactivity disorder (ADHD): A matched nationwide study in Denmark

There is insufficient data regarding the excess direct and indirect costs associated with attention deficit hyperactivity disorder (ADHD). Using the Danish National Patient Registry (2002-2016), we identified 83,613 people of any age with a diagnosis of ADHD or who were using central-acting medication against ADHD (primarily methylphenidate, with at least two prescriptions) and matched them to 334,446 control individuals. Additionally, 18,959 partners of patients aged ≥18 years with ADHD were identified, and compared with 74,032 control partners. Direct costs were based on data from the Danish Ministry of Health. Information about the use and costs of drugs were obtained from the Danish Medicines Agency. The frequencies of visits and hospitalizations, and costs of general practice were derived from data from the National Health Security. Indirect costs were obtained from Coherent Social Statistics. The average annual health care costs for people with ADHD and their partners were, respectively, €2636 and €477 higher than those of the matched controls. A greater percentage of people with ADHD and their partners compared with respective control subjects received social services (sick pay or disability pension). Those with ADHD had a lower income from employment than did controls for equivalent periods up to five years before the first diagnosis of ADHD. The additional direct and indirect annual costs (for those aged ≥18 years) including transfers of ADHD compared with controls were €23,072 for people with ADHD and €7,997 for their partners. ADHD has substantial socioeconomic consequences for individual patients, their partners and society.

Bipolar Disorder Among Patients Diagnosed With Frontotemporal Dementia

OBJECTIVE

Previous studies have documented manic and hypomanic symptoms in behavioral variant frontotemporal dementia (bvFTD), suggesting a relationship between bipolar disorder and bvFTD.

METHODS

The investigators conducted a literature review as well as a review of the psychiatric histories of 137 patients with bvFTD, and patients with a prior diagnosis of bipolar disorder were identified. The clinical characteristics of patients' bipolar disorder diagnosis, family history, features of bvFTD, and results from fluorodeoxyglucose positron emission tomography (FDG-PET), as well as autopsy findings, were evaluated.

RESULTS

Among the 137 patients, 14 (10.2%) had a psychiatric diagnosis of bipolar disorder, eight of whom met criteria for bipolar disorder (type I, N=6; type II, N=2) 6-12 years preceding onset of classic symptoms of progressive bvFTD. Seven of the eight patients with bipolar disorder had a family history of mood disorders, four had bitemporal predominant hypometabolism on FDG-PET, and two had a tauopathy involving temporal lobes on autopsy. Three additional patients with late-onset bipolar I disorder proved to have a nonprogressive disorder mimicking bvFTD. The remaining three patients with bvFTD had prior psychiatric symptoms that did not meet criteria for a diagnosis of bipolar disorder. The literature review and the findings for one patient further suggested a shared genetic mutation in some patients.

CONCLUSIONS

Manic or hypomanic episodes years before other symptoms of bvFTD may be a prodrome of this dementia, possibly indicating anterior temporal involvement in bvFTD. Other patients with late-onset bipolar disorder exhibit the nonprogressive frontotemporal dementia phenocopy syndrome. Finally, a few patients with bvFTD have a genetic predisposition for both disorders.

What is bipolar disorder? A disease model of dysregulated energy expenditure

Advances in the understanding and management of bipolar disorder (BD) have been slow to emerge. Despite notable recent developments in neurosciences, our conceptualization of the nature of this mental disorder has not meaningfully progressed. One of the key reasons for this scenario is the continuing lack of a comprehensive disease model. Within the increasing complexity of modern research methods, there is a clear need for an overarching theoretical framework, in which findings are assimilated and predictions are generated. In this review and hypothesis article, we propose such a framework, one in which dysregulated energy expenditure is a primary, sufficient cause for BD. Our proposed model is centered on the disruption of the molecular and cellular network regulating energy production and expenditure, as well its potential secondary adaptations and compensatory mechanisms. We also focus on the putative longitudinal progression of this pathological process, considering its most likely periods for onset, such as critical periods that challenges energy homeostasis (e.g. neurodevelopment, social isolation), and the resulting short and long-term phenotypical manifestations.

A proof of concept machine learning analysis using multimodal neuroimaging and neurocognitive measures as predictive biomarker in bipolar disorder

BACKGROUND

Concomitant use of complementary, multimodal imaging measures and neurocognitive measures is reported to have higher accuracy as a biomarker in Alzheimer's dementia. However, such an approach has not been examined to differentiate healthy individuals from Bipolar disorder. In this study, we examined the utility of support vector machine (SVM) technique to differentiate bipolar disorder patients and healthy using structural, functional and diffusion tensor images of brain and neurocognitive measures.

METHODS

30 patients with Bipolar disorder-I and 30 age, sex matched individuals participated in the study. Structural MRI, resting state functional MRI and diffusion tensor images were obtained using a 1.5 T scanner. All participants were administered neuropsychological tests to measure executive functions. SVM, a supervised machine learning technique was applied to differentiate patients and healthy individuals with k-fold cross validation over 10 trials.

RESULTS

The composite marker consisting of both neuroimaging and neuropsychological measures, had an accuracy of 87.60 %, sensitivity of 82.3 % and specificity of 92.7 %. The performance of composite marker was better compared to that of individual markers on classificatory.

CONCLUSIONS

We were able to achieve a high accuracy for machine learning technique in distinguishing BD from HV using a combination of multimodal neuroimaging and neurocognitive measures. Findings of this proof of concept study, if replicated in larger samples, could have potential clinical applications.

Anxiety disorders comorbidity in pediatric bipolar disorder: a meta-analysis and meta-regression study

OBJECTIVE

Anxiety disorders (AD) are known for its comorbidity and negative impact on the course of adult bipolar disorder (BD). However, there is limited research on AD comorbidity in pediatric BD (PBD). Here, we aimed to conduct a meta-analysis and meta-regression study about the comorbidity and covariates of AD and PBD.

METHOD

We systematically searched relevant articles published until May 2019, as defined in PRISMA guidelines. Variables for associated features and prevalence of AD were extracted.

RESULTS

Thirty-seven articles represented data for the analysis. Lifetime any AD comorbidity was 44.7%; panic disorder (PD) was 12.7%; generalized anxiety disorder (GAD) was 27.4%; social phobia was 20.1%; separation anxiety disorder (SAD) was 26.1%; and obsessive-compulsive disorder (OCD) was 16.7%. Childhood-onset studies reported higher GAD and SAD comorbidity, while adolescent-onset studies reported higher PD, OCD, and social phobia. Age of onset, gender, comorbidity of ADHD, substance use, oppositional defiant disorder and conduct disorder affected each anxiety disorders' comorbidity with PBD differently.

CONCLUSION

Anxiety disorders are highly comorbid with PBD. Early-onset PBD increases the risk of AD. Biopsychosocial aspects of this comorbidity and its course needs to be evaluated further.

Neurodevelopmental pathways in bipolar disorder

Aberrations in neurodevelopmental trajectories have been implicated in the neurobiology of several mental disorders and evidence indicates a pathophysiological and genetic overlap of schizophrenia and bipolar disorder (BD). In this narrative review, we summarize findings related to developmental and perinatal factors as well as epidemiological, clinical, neuropsychological, brain imaging, postmortem brain and genomic studies that provide evidence for a putative neurodevelopmental pathogenesis and etiology of BD. Overall, aberrations in neurodevelopmental pathways have been more consistently implicated in the pathophysiology of schizophrenia compared to BD. Nevertheless, an accumulating body of evidence indicates that dysfunctional neurodevelopmental pathways may be implicated in the underlying pathophysiology of at least a subset of individuals with BD particularly those with an early age of illness onset and those exhibiting psychotic symptoms. A heuristic neurodevelopmental model for the pathophysiology of BD based on the findings of this review is proposed. Furthermore, we critically discuss clinical and research implications of this model. Finally, further research directions for this emerging field are provided.

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.

Alterations of Cognition and Cerebral Ventricle Volume in Manic and Euthymic Pediatric Bipolar Disorder

Introduction: It remains unknown whether volumetric alterations of ventricles are similar or not in pediatric bipolar disorder (PBD) among different mood states. The present study aims to estimate ventricular volumetric alteration of PBD patients in manic and euthymic status, as well as the relationship between this alteration and cognitive changes. Methods: T1 magnetic resonance images were obtained from 20 manic PBD patients, 21 euthymic PBD patients, and 19 healthy controls (HCs). Ventricular volumes were automatically obtained via FreeSurfer 6.0 software. Ventricular volumes and cognitive indices were compared among the three groups, and the relationship between ventricular volumes and cognitive/clinical indices was analyzed. Results: In contrast to HCs, manic and euthymic PBD patients exhibited decreased cognitive scores of the Stroop color-word test and the digit span subtest. Manic PBD subjects presented enlarged volumes in the bilateral ventricles, third ventricle, and whole ventricles, and euthymic PBD participants displayed increased volumes in the third ventricle, fourth ventricle, and whole ventricles. No significant differences in cognitive performance and ventricular volumes were found between PBD groups. No significant correlation was discovered between ventricular volumes and cognitive/clinical indices in both manic and euthymic PBD patients. Conclusions: No significant differences in cognitive performance and ventricle volume were observed between euthymic and manic PBD groups, which may imply that the alterations are not specific to mood state. It may indicate structural and functional damage of corresponding brain circuits in euthymic PBD patients similar with that of manic PBD, which may provide clues to the diagnosis and treatment of euthymic PBD.

Inflammation, brain structure and cognition interrelations among individuals with differential risks for bipolar disorder

Neuro-inflammation might impact on clinical manifestations and cognition function via changing the volumes of key brain structures such as the anterior cingulate cortex (ACC) in bipolar disorder (BD). In this study, we investigated the interrelations among interleukin (IL)-6 cytokine level, grey matter (GM) volume of the anterior cingulated cortex (ACC), and attention function among offspring of parents diagnosed with BD. The offspring were categorized as being either asymptomatic or symptomatic based on whether they manifested pre-defined sub-threshold mood symptoms. We found that the symptomatic offspring showed significantly higher serum levels of IL-6 than the asymptomatic offspring (F_{(1, 59)} = 67.65, p < 0.001). On the brain level, we obtained significant interactive effect of group and IL6 level on the ACC GM (P_FWE = 0.017). Specifically, the GM volume of the rostral ACC was negatively associated with the levels of IL-6 in the asymptomatic offspring (P_FWE = 0.021), but not the symptomatic offspring (P_FWE > 0.05). Mediation analyses revealed that the GM volume of the rostral ACC significantly mediated the negative association between the IL-6 levels and attention performance in the asymptomatic offspring (bootstrapping Confidence Interval (CI) = -6.0432 to -0.0731) but not the symptomatic offspring (bootstrapping CI = -0.3197 to 1.3423). Our data suggest that the asymptomatic and symptomatic bipolar offspring may exhibit different neurocognitive-inflammatory profiles, which could be further validated as viable biosignatures for BD risk and resilience.

Correlation Between Decreased Amygdala Subnuclei Volumes and Impaired Cognitive Functions in Pediatric Bipolar Disorder

BACKGROUND

The amygdala has been proposed to be involved in the pathophysiology of pediatric and adult bipolar disorder (BD). The goal of this structural magnetic resonance imaging (sMRI) study was to investigate the morphometric characteristics of amygdala subnuclei in patients with pediatric bipolar disorder (PBD) compared to healthy controls (HCs). Simultaneously, we examined correlation between amygdala subnuclei volumes and cognitive dysfunction.

MATERIALS AND METHODS

We assessed 40 adolescent outpatients, diagnosed with manic or euthymic PBD according to the DSM-5 criteria for BD and 19 HCs. Cognitive functions were evaluated using a Stroop color-word test (SCWT), trail making test (TMT), visual reproduction immediate recall subtest (VR I), and digit span subtest (DST). Amygdala and its subnuclei structures were automated segmented using FreeSurfer software and the volumes of them were compared between groups and correlation with clinical and cognitive outcomes was conducted.

RESULTS

Manic patients exhibited significantly decreased volumes in the bilateral whole amygdala and its basal nucleus, cortico-amygdaloid transition (CAT), and accessory basal nucleus (ABN) compared with HCs. Euthymic patients had decreased volume in the bilateral ABN and left CAT. In addition, we found significant positive associations between VR I scores and the right whole amygdala and its bilateral basal, right lateral, and ABN volumes in the manic group.

CONCLUSION

These findings support previous reports of smaller amygdala volumes and cognitive dysfunctions in PBD, and further mapping abnormalities to specific amygdala subnuclei. Correlation between basolateral volume and VR I of PBD may expand our understanding of neural abnormalities that could be targeted by treatment.

The effects of cognitive reserve on predicting and moderating the cognitive and psychosocial functioning of patients with bipolar disorder

BACKGROUND

Cognitive reserve (CR) reflects the resilience of the brain to cope with neuropathological changes and minimize clinical manifestations. In the present study, we explore the association between CR and cognitive and psychosocial functioning, and examined the potential moderating role of CR in patients with bipolar disorder (BD).

METHODS

One hundred and twenty-five outpatients with BD type I and sixty healthy individuals were recruited. All participants were assessed with a neuropsychological battery examining attention and processing speed, working memory, visual memory and executive functioning, the Global Assessment of Functioning scale and the Cognitive Complaints in Bipolar Disorder Rating Assessment. Proxies for cognitive reserve included premorbid intelligence and educational level.

RESULTS

Patients with bipolar disorder presented with worse cognitive performance and psychosocial functioning than healthy controls. Multiple regression models revealed that educational level negatively associated with all assessed domain-specific cognition scores and premorbid intelligence predicted attention and processing speed and psychosocial functioning. Notably, premorbid intelligence significantly moderated the associations between the number of episodes (total, hypo/manic and depressed) and neurocognitive functioning, and the educational level also moderated the relationships between the numbers of hypo/manic and total episodes and subjective cognitive functioning.

CONCLUSIONS

Cognitive reserve contributes to functional outcomes in patients with BD and may emerge as a key factor contributing to the course and prognosis of patients with BD. In the future, cognitive reserve must be considered in both research and clinical interventions related to bipolar disorder.

Cognitive impairment in late life bipolar disorder: Risk factors and clinical outcomes

BACKGROUND

Late Life Bipolar Disorder (LLBD) is associated with a high prevalence of cognitive impairments, but few studies have examined their risk factors and clinical correlates METHODS: Participants with bipolar disorder older than 60 (n = 86) were recruited from psychiatric outpatient and inpatients units. Patients were assessed with various instruments, including the Clinical Dementia Rating scale, the Montreal Cognitive Assessment and the Cumulative Illness Rating Scale. The distribution of disorder-specific and general risk factors was compared between patients with LLBD plus cognitive impairments (mild cognitive impairment or dementia) and those with LLBD but no cognitive impairment. Analyses were first conducted at the bivariate level, then using multiple regression. The association with disability, aggressive behavior and suicidal ideation was also explored.

RESULTS

Cognitive impairments in LLBD were associated with a diagnosis of type 1 bipolar disorder (OR = 6.40, 95%CI: 1.84 - 22.31, p = 0.004), fewer years of education (OR = 0.79, 95%CI: 0.69 - 0.91, p = 0.001) and higher severity of physical diseases (OR 26.54, 95%CI: 2.07 - 340.37, p = 0.01). Moreover, cognitive impairments were associated with an increased likelihood of disability and recent aggressive behavior, but not suicidal ideation.

LIMITATIONS

retrospective design, conflation of MCI and dementia, not all subjects were in euthymia CONCLUSIONS: In LLBD, the presence of cognitive impairments was associated with a diagnosis of type I bipolar disorder, lower education and more severe physical comorbidities. In turn, MCI or dementia were associated with increased disability and aggressive behavior. These findings may aid the identification of patients at risk for cognitive deterioration in everyday clinical practice.

Clinical differences between patients with pediatric bipolar disorder with and without a parental history of bipolar disorder

Pediatric Bipolar Disorder (PBD) is a highly heritable condition responsible for 18% of all pediatric mental health hospitalizations. Despite the heritability of this disorder, few studies have assessed potential differences in the clinical manifestation of PBD among patients with a clear parental history of BD. Additionally, while recent studies suggest that attentional deficits are a potential endophenotypic marker of PBD, it is unclear whether heritability is a relevant contributor to these symptoms. In order to address this gap, the present study assessed 61 youth with PBD (6-17 years old), corresponding to 27 offspring of BD patients, and 31 PBD patients without a parental history of the disorder. All standardized assessments, including the K-SADS-PL-W were performed by trained child and adolescent psychiatrists. We performed a logistic multivariate model using the variables of ADHD, rapid cycling, and lifetime psychosis. Rates of ADHD comorbidity were significantly higher among PBD patients who had a parent with BD. Furthermore, PBD patients who had a parent with BD showed a trend toward significance of earlier symptom onset. PBD offspring did not show increased rates of suicide attempts, rapid cycling, or psychosis. Given these findings, it appears that PBD patients who have a parent with BD may represent a distinct endophenotype of the disorder. Future longitudinal and larger studies are required to confirm our findings.