Prevalence and distinct correlates of anxiety, substance, and combined comorbidity in a multi-site public sector sample with bipolar disorder

Alcohol Dependence Syndrome With Bipolar Affective Disorder and Hypomanic Current Episode: A Case Report

Studies have revealed that individuals with bipolar I and bipolar II have a past of substance abuse. The co-occurrence of bipolar disorder and alcoholism is frequent. Although various arguments have been put forward to explain the relationship between these disorders, it is still not fully understood. Since substance abuse is prevalent among bipolar patients, it would be beneficial to investigate the impact of substance abuse on clinical characteristics, as well as the progression of the illness. Thus, this study was carried out to investigate a case of alcohol dependence with bipolar disorder. A 49-year-old male visited the psychiatry outpatient department and then was admitted. The patient's chief complaints were alcohol consumption, cigarette smoking, daily drinking for 35 years, irritability/aggressiveness, boastful talk, overspending, and decreased need for sleep from the last 20 days. According to the literature, self-medicating with alcohol is not an effective treatment for alcoholism, unless it is being used to alleviate the psychological and neurochemical effects caused by alcohol. However, there has been limited research on how to treat individuals who have both alcoholism and another medical condition. A few studies have looked at the impact of medications like valproate, lithium, and naltrexone, as well as psychosocial interventions, in treating patients with bipolar disorder and alcoholism. However, more research is necessary to fully understand the best approach.

Mental and Physical Health Conditions Among U.S. Veterans with Cannabis Use and Cannabis Use Disorders

Purpose of Review

Veterans are a large population that is disproportionately affected by various physical and mental health conditions. The primary aim of this review is to provide a concise overview of recent literature on the prevalence of cannabis use and cannabis use disorder (CUD) among US Veterans, and associations with mental and physical health conditions. We also addressed gaps in the literature by investigating associations between CUD and mental and physical health conditions in 2019 data from the Veterans Health Administration (VHA; N=5,657,277).

Recent Findings

In total, 25 studies were reviewed. In 2019, the prevalence of Veteran cannabis use ranged from 11.9%-18.7%. Cannabis use and CUD were associated with bipolar disorders, psychotic disorders, suicidality, pain conditions, and other substance use, but less consistently associated with depressive disorders, anxiety disorders, and posttraumatic stress disorder. Analyses of 2019 VHA data indicated that CUD was strongly associated with a broad array of physical and mental health conditions and mortality.

Summary

Cannabis use and CUD are prevalent and highly comorbid with other conditions among US Veterans. Harm reduction methods tailored to these populations are needed.

Alcohol use disorders in patients with bipolar disorder: a systematic review and meta-analysis

Alcohol consumption has a key role in more than 200 diseases and health injuries, being an important factor for social and public health costs. Studies with clinical populations show an association between alcohol use disorders (AUD) and bipolar disorder. In this meta-analysis we included studies, reports, or summaries identified in Google Scholar, Lilacs, Medline, and MedCaribe that reported original data published up to 31 January 2023. We included cross-sectional and longitudinal observational studies that investigated the prevalence of AUD in patients with bipolar disorder. We calculated the prevalence rates and conducted a meta-analysis using a random effects model. The meta-analysis included 20 unique studies conducted in 12 countries, with a total sample of 32,886 individuals with bipolar disorder, comprising 17,923 women and 13,963 men, all aged 18 years or older. The prevalence of AUD in individuals with bipolar disorder was found to be 29.12%, while the prevalence of Alcohol Dependence (AD) was 15.87% and the prevalence of Alcohol Abuse (AA) was 18.74%. The high prevalence of AUD individuals with bipolar disorder is important because it highlights the need for targeted interventions to prevent and address comorbid conditions, which may improve treatment outcomes, reduce harm, and promote public health.

Treating bipolar depression with esketamine: Safety and effectiveness data from a naturalistic multicentric study on esketamine in bipolar versus unipolar treatment-resistant depression

BACKGROUND

Bipolar depression accounts for most of the disease duration in type I and type II bipolar disorder (BD), with few treatment options, often poorly tolerated. Many individuals do not respond to first-line therapeutic options, resulting in treatment-resistant bipolar depression (B-TRD). Esketamine, the S-enantiomer of ketamine, has recently been approved for treatment-resistant depression (TRD), but no data are available on its use in B-TRD.

OBJECTIVES

To compare the efficacy of esketamine in two samples of unipolar and bipolar TRD, providing preliminary indications of its effectiveness in B-TRD. Secondary outcomes included the evaluation of the safety and tolerability of esketamine in B-TRD, focusing on the average risk of an affective switch.

METHODS

Thirty-five B-TRD subjects treated with esketamine nasal spray were enrolled and compared with 35 TRD patients. Anamnestic data and psychometric assessments (Montgomery-Asberg Depression Rating Scale/MADRS, Hamilton-depression scale/HAM-D, Hamilton-anxiety scale/HAM-A) were collected at baseline (T0), at one month (T1), and three months (T2) follow up.

RESULTS

A significant reduction in depressive symptoms was found at T1 and T2 compared to T0, with no significant differences in response or remission rates between subjects with B-TRD and TRD. Esketamine showed a greater anxiolytic action in subjects with B-TRD than in those with TRD. Improvement in depressive symptoms was not associated with treatment-emergent affective switch.

CONCLUSIONS

Our results supported the effectiveness and tolerability of esketamine in a real-world population of subjects with B-TRD. The low risk of manic switch in B-TRD patients confirmed the safety of this treatment.

Clinical Predictors of Engagement in Teleintegrated Care and Telereferral Care for Complex Psychiatric Disorders in Primary Care: a Randomized Trial

BACKGROUND

Telepsychiatry Collaborative Care (TCC) and Telepsychiatry/Telepsychology Enhanced Referral (TER) expand the reach of specialty mental health services to underserved populations.

OBJECTIVE

Assess clinical predictors of treatment engagement for complex psychiatric conditions in TCC-in which remote specialists consult with primary care teams via an onsite care manager who also provides brief psychotherapy-and TER, in which remote specialists provide direct telehealth treatment.

DESIGN

A randomized pragmatic trial from twenty-four primary care clinics without onsite psychiatrists or psychologists.

PARTICIPANTS

A total of 1,004 adult patients screened positive for posttraumatic stress disorder (PTSD)and/or bipolar disorder were randomized to receive TCC or TER for 1 year.

MAIN MEASURES

Psychotherapy engagement was measured by the number of sessions completed, and pharmacotherapy engagement by the medication adherence item from the Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ).

KEY RESULTS

Engagement in TCC psychotherapy visits was greater compared to TER. There was no association between the PTSD symptom severity and treatment engagement. The internal state scale (ISS) activation subscale, an indicator of mania, was associated with reduced odds of initiating psychotherapy (odds ratio [OR] = 0.70; 95% CI, 0.59 to 0.84) but not the number of sessions attended once psychotherapy started. The Drug Abuse Screening Test-10(DAST-10) score was associated with receipt of fewer psychotherapy sessions (incidence ratio rate [IRR] = 0.88; 95% CI, 0.81 to 0.95). The number of physical health comorbidities was associated with greater engagement in psychotherapy (IRR = 1.11, 95% CI, 1.03 to 1.19) and pharmacotherapy (OR = 1.54; 95% CI, 1.27 to 1.87). None of the findings varied by intervention group.

CONCLUSIONS

Both teleintegrated and telereferral care offer an opportunity to treat patients with complex psychiatric conditions. While there was no difference in clinical characteristics predicting engagement, onsite care managers engaged patients in more psychotherapy sessions than remote therapists.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02738944.

Prevalence and association of comorbid substance dependence on the course and outcome of bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

AIM

To evaluate the prevalence of substance use disorder (SUD) and its association with the course and outcome of bipolar disorder (BD).

MATERIALS AND METHODS

A total of 773 patients with BD were recruited from 14 centers in different parts of India, and they were evaluated for the prevalence of comorbid substance dependence, course and outcome, subjective cognitive functioning, and disability.

RESULTS

About one-fourth (22.9%) of the participants had one or more substance dependence. In terms of specific substance of abuse, 136 (17.6%) had nicotine dependence, 80 (10.3%) patients had alcohol dependence, 13 (1.7%) had cannabis dependence, and nine (1.2%) had opioid dependence. Compared to those without comorbid substance dependence, those with a dual diagnosis (i.e., using at least one substance in a dependent pattern) were less educated, more often males, more often currently single, more often employed, had a lower number of depressive episodes per year of illness, had a higher number of manic and mixed episodes per year of illness in the first 5 years of illness, had a higher level of disability, and more often had a history of hospitalization and a history of receiving electroconvulsive therapy (ECT); also, a higher proportion of them had manic predominant polarity, more often had recurrent mania course, and were more often receiving a combination of lithium and valproate.

CONCLUSION

About one-fourth of BD patients have comorbid SUDs, and presence of SUD has a negative impact on the course and outcome of BD.

The Impact of Posttraumatic Stress Disorder on Pharmacologic Intervention Outcomes for Adults With Bipolar Disorder: A Systematic Review

BACKGROUND

The prevalence of posttraumatic stress disorder (PTSD) co-occurring in people with bipolar disorder (BD) is high. People with BD and PTSD may experience different outcomes and quality of life after pharmacologic treatment than those with BD alone. This review systematically explores the impact of PTSD on pharmacologic treatment outcomes for adults with BD.

METHODS

We conducted a systematic search up to November 25, 2021, using MEDLINE Complete, Embase, American Psychological Association PsycInfo, and the Cochrane Central Register of Controlled Trials to identify randomized and nonrandomized studies of pharmacologic interventions for adults with BD that assessed for comorbid PTSD. We used the Newcastle-Ottawa Scale and Cochrane Risk of Bias tool to assess the risk of bias.

RESULTS

The search identified 5093 articles, and we reviewed 62 full-text articles. Two articles met inclusion criteria (N = 438). One article was an observational study, and the other was a randomized comparative effectiveness trial. The observational study examined lithium response rates and found higher response rates in BD alone compared with BD plus PTSD over 4 years. The randomized trial reported more severe symptoms in the BD plus PTSD group than in those with BD alone following 6 months of quetiapine treatment. There was no significant difference in the lithium treatment group at follow-up.

CONCLUSIONS

Comorbid PTSD may affect quetiapine and lithium treatment response in those with BD. Because of the high risk of bias and low quality of evidence, however, these results are preliminary. Specific studies exploring comorbid BD and PTSD are required to inform pharmacotherapy selection and guidelines appropriately. (International Prospective Register of Systematic Reviews ID: CRD42020182540).

Comorbidity of adult ADHD and substance use disorder in a sample of inpatients bipolar disorder in Iran

BACKGROUNDS

The study of the relationship between adult Attention deficit hyperactivity disorder (ADHD) and bipolar disorder has received more attention in recent years and there is limited information in this area. On the other hand, there is a significant comorbidity between ADHD and bipolar disorder with substance use disorder. In this study, we investigated the prevalence of comorbidity of adult ADHD and substance use disorder among a group of bipolar patients admitted to a psychiatric hospital.

METHODS

One hundred fifty patients from a total of 200 consecutive patients who were referred to the emergency department of Roozbeh Psychiatric Hospital in Tehran, diagnosed with bipolar disorder based on the initial psychiatric interview and needed hospitalization, were evaluated again by an experienced faculty member psychiatrist by using a subsequent interview based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition(DSM-5). They were evaluated using the Structured Clinical Interview for DSM-5 (SCID-5) questionnaire to confirm the diagnosis of bipolar disorder and the comorbidity of adult ADHD and substance use disorder.

RESULTS

From 150 patients diagnosed with bipolar disorder, 106 patients (70.7%) had adult ADHD. 89 patients (59.3%) had substance use disorder and 58 patients (38.7%) had both of these comorbidities with bipolar disorder. Comorbidity of adult ADHD was associated with the earlier onset of the first mood episode in bipolar disorder (p value = 0.025). There was no statistically significant relationship between substance use disorder and age of onset of the first episode. (P value = 0.57).

CONCLUSIONS

Due to the limitations of studies on adult ADHD comorbidity with bipolar disorder, especially in hospital settings, as well as the increased risk of association with substance use disorder, further multicenter studies in this area with larger sample sizes can increase awareness in this regard.

Comorbidity and Coaggregation of Major Depressive Disorder and Bipolar Disorder and Cannabis Use Disorder in a Controlled Family Study

IMPORTANCE

Cannabis use disorder (CUD) is increasing in the US. Clarification of the potential mechanisms underlying the comorbidity between mood disorders and CUD may help prevent CUD.

OBJECTIVE

To examine co-occurrence and familial aggregation of CUD and mood disorder subtypes.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional, community-based study in the Washington, DC, metropolitan area, semistructured diagnostic interviews and family history reports assessed lifetime DSM-IV disorders in probands and relatives. Familial aggregation and coaggregation of CUD with mood disorders were estimated via mixed-effects models, adjusting for age, sex, recruitment source, and comorbid mood, anxiety, and other substance use disorders. A total of 586 adult probands (186 with bipolar disorder; 55 with CUD) and 698 first-degree relatives (91 with bipolar disorder; 68 with CUD) were recruited from a community screening of the greater Washington, DC, metropolitan area from May 2004 to August 2020. Inclusion criteria were ability to speak English, and availability and consent to contact at least 2 living first-degree relatives.

MAIN OUTCOMES AND MEASURES

Lifetime CUD in first-degree relatives.

RESULTS

Of 586 probands, 395 (67.4%) were female; among 698 relatives, 437 (62.6%) were female. The mean (SD) age was 47.5 (15.2) years for probands and 49.6 (18.0) years for relatives. In the proband group, 82 participants (14.0%) self-identified as African American or Black, 467 (79.7%) as White, and 37 (6.3%) as American Indian or Alaska Native, Asian, more than one race, or another race or ethnicity or declined to respond. In the relative group, 53 participants (7.6%) self-identified as African American or Black, 594 (85.1%) as White, and 51 (7.3%) as American Indian or Alaska Native, Asian, more than one race, or another race or ethnicity or declined to respond. These groups were combined to protect privacy owing to small numbers. CUD in probands (55 [9.4%]) was associated with an increase in CUD in relatives (adjusted odds ratio [aOR], 2.64; 95% CI, 1.20-5.79; P = .02). Bipolar disorder II (BP-II) in probands (72 [12.3%]) was also associated with increased risk of CUD in relatives (aOR, 2.57; 95% CI, 1.06-6.23; P = .04). However, bipolar disorder I (114 [19.5%]) and major depressive disorder (192 [32.8%]) in probands were not significantly associated with CUD in relatives. Among relatives, CUD was associated with BP-II (aOR, 4.50; 95% CI, 1.72-11.77; P = .002), major depressive disorder (aOR, 3.64; 95% CI, 1.78-7.45; P < .001), and mean (SD) age (42.7 [12.8] years with CUD vs 50.3 [18.3] years without CUD; aOR, 0.98; 95% CI, 0.96-1.00; P = .02). Familial coaggregation of BP-II with CUD was attenuated by the inclusion of comorbid anxiety disorders. Further, rates of CUD were highest in relatives with both a familial and individual history of BP-II (no familial or individual history of BP-II: 41 [7.2%]; familial history but no individual history of BP-II: 13 [19.1%]; individual history but no familial history of BP-II: 10 [22.2%]; familial and individual history of BP-II: 4 [28.6%]; Fisher exact test, P < .001). The onset of mood disorder subtypes preceded CUD in probands and relatives in most cases.

CONCLUSIONS AND RELEVANCE

The findings confirmed a familial aggregation of CUD. The increase in risk of CUD among relatives of probands with BP-II suggests that CUD may share a common underlying diathesis with BP-II. Taken together with the temporal precedence of depression and mania with respect to CUD onset, these findings highlight a potential role for BP-II intervention as CUD prevention.

Pilot project for a recovery-oriented, DBT-informed skill-building education course for families of adults with borderline personality, bipolar or major depressive disorders

There are a variety of educational interventions for families who have a relative with a mental health disorder. However, for those with one or more emotion dysregulation disorders, there are limited options. This article reports on the results of a pilot project using a quasi-experimental design with a sample of 270 (intervention = 217, control = 53) to assess an intervention, Getting Off the Emotional Roller Coaster Skill-Building Family Education Course (GOER Family Course), for families coping with and managing emotion regulation disorders in a loved one which are often misdiagnosed or co-occurring. This intervention was effective in reducing caregiver burden [F(1, 120) = 12.25, p = 0.001], while improving attitudes, knowledge, and skills [F(1, 170) = 6.16, p = 0.014]. It fills an important gap in available resources for families faced with challenges and responsibilities that these disorders can present, especially when inaccurately diagnosed or receiving ineffective treatment. While there is a need for further research and adaptation to virtual learning, the preliminary results show positive effects.

Innate immune stimulation prevents the development of anxiety-like behaviors in chronically stressed mice

Anxiety is a common psychological disease which can induce severe social burdens. Searching methods that prevent the onset of anxiety is of great significance for ameliorating the social and individual problems induced by this type of disease. In this study, we investigated how innate immune pre-stimulation influences the anxiety-like behaviors in chronically stressed mice. Our results showed that a single injection of an innate immune stimulant lipopolysaccharide (LPS) at the dose of 50, 100, and 500 μg/kg 1 day before stress exposure prevented chronic social defeat stress (CSDS)-induced anxiety-like behaviors in mice. A single injection of LPS (100 μg/kg) 5 days before stress exposure produced similar preventive effects on CSDS-induced anxiety-like behaviors, while similar effects were not observed at the condition of 10-days interval between LPS injection and stress exposure. A second LPS injection 10 days after the first LPS injection or a 4 × LPS injection 10 days before stress exposure also prevented CSDS-induced anxiety-like behaviors. Moreover, a single injection of LPS (100 μg/kg) 1 day before stress exposure prevented the production of pro-inflammatory cytokines in the hippocampus and prefrontal cortex of CSDS mice. Suppression of innate immune stimulation by minocycline pretreatment simultaneously abrogated the preventive effect of LPS pre-injection (100 μg/kg) on CSDS-induced anxiety-like behaviors and pro-inflammatory cytokine production in the brain. Our results demonstrated that the pre-stimulation of the innate immune system can prevent the development of anxiety-like behaviors and the progression of the neuroinflammatory responses in the brain in chronically stressed mice.

The big five model in bipolar disorder: a latent profile analysis and its impact on longterm illness severity

Background

Using a personality typing approach, we investigated the relationship between personality profiles and the prediction of longterm illness severity in patients with bipolar disorder (BD). While previous research suggests associations between BD and traits from the NEO-FFI profiles, the current study firstly aimed to identify latent classes of NEO-FFI profiles, and, secondly, to examine their impact on the longterm prognosis of BD.

Methods

Based on the NEO-FFI profiles of 134 euthymic patients diagnosed with BD (64.2% female, mean age = 44.3 years), successive latent profile analyses were conducted. Subsequently, a subsample (n = 80) was examined prospectively by performing multiple regression analysis of the latent classes to evaluate the longitudinal course of the disease (mean: 54.7 weeks) measured using a modified Morbidity Index.

Results

The latent profile analyses suggested a 3-class model typifying in a resilient (n = 68, 51%), vulnerable (n = 55, 41%) and highly vulnerable (n = 11, 8%) class. In the regression analysis, higher vulnerability predicted a higher longterm Morbidity Index (R² = 0.28).

Conclusions

Subgroups of patients with BD share a number of discrete personality features and their illness is characterized by a similar clinical course. This knowledge is valuable in a variety of clinical contexts including early detection, intervention planning and treatment process.

Psychological predictors of bipolarity in panic disorder

BACKGROUND

Panic disorders frequently occur with affective disorders, particularly bipolar disorder. Patients with panic disorder and bipolar disorder are more likely to present with severe symptoms, such as high rates of suicidal behavior, poor symptomatic and functional recovery, and poor drug responses.

AIM

To investigate the psychological characteristics of panic disorder patients related to bipolarity.

METHODS

A total of 254 patients (136 men and 118 women, mean age = 33.48 ± 3.2 years) who were diagnosed with panic disorder were included in the study. Panic disorder with bipolarity (BP+) was defined as a score of ≥ 7 on the Korean version of the Mood Disorder Questionnaire (K-MDQ), and a score lower than 7 was considered as a panic disorder without bipolarity (BP-). Self-report questionnaires were analyzed to examine their association with bipolarity. Psychological tests used in the study were the Mood Disorder Questionnaire (MDQ), Panic Disorder Severity Scale, Beck Depression Inventory, State-Trait Anxiety Inventory (STAI), Temperament and Character Inventory (TCI), and Minnesota Multiphasic Personality Inventory (MMPI). Statistical analyses were performed to evaluate the correlation between bipolarity of panic disorder patients and various psychological test results indicative of psychological characteristics.

RESULTS

Patients with a K-MDQ score of 7 or more were considered to have a history of manic or hypomanic episodes (BP+ group, n = 128), while patients with K-MDQ scores below 7 were defined as those without bipolarity (BP- group, n = 126). The BP+ group were more likely to be unmarried (single 56.2% vs 44.4%, P = 0.008) and younger (30.78 ± 0.59 vs 37.11 ± 3.21, P < 0.001). Additionally, the BP+ group had significantly higher scores on psychological assessment scales, such as the hypochondriasis, psychopathic deviate, masculinity-femininity, psychasthenia, schizophrenia, and hypomania (Ma) in MMPI, and novelty seeking, harm avoidance and self-transcendence in TCI, and STAI (state and trait) compared to the BP- group. In logistic regression analysis, depression in MMPI, self-directedness in TCI, and age were negatively associated with MDQ score, meanwhile, Ma in MMPI and STAI (trait) were positively associated with MDQ score.

CONCLUSION

The result of this study suggests that almost 50% of patients with panic disorder are likely to have hypomanic or manic symptoms, and certain psychological factors are associated bipolarity in panic disorder.

The impact of generalized anxiety disorder in obsessive-compulsive disorder patients

Despite generalized anxiety disorder (GAD) being one of the most prevalent comorbidities in obsessive-compulsive disorder (OCD), few studies have researched its impact on the OCD phenotype. The present study investigated how the sociodemographic and clinical profile of people with OCD with comorbid GAD differs from people with OCD without comorbid GAD. We hypothesised that the phenotype of the comorbid group would be closely related to GAD, in that it would more likely be female, have an earlier age at onset of OCD, and show an increased severity of fear-related OCD symptoms (aggressive, sexual/religious, and contamination dimensions), more avoidant behaviours, greater suicidality, more severe anxiety symptoms, and increased rates of comorbid anxiety and mood disorders. The study included 867 participants with OCD, with GAD being comorbid in 33.56%. Mann-Whitney U tests, chi-square tests with continuity correction, and logistic regressions were performed. Results showed that comorbid GAD was uniquely associated with an increased number of avoidant behaviours, greater anxiety severity, panic disorder without agoraphobia, social phobia, specific phobia, and type II bipolar disorder. These results illustrate the clinical severity associated with this comorbidity and highlight markers that can aid diagnosis of GAD in OCD. Future studies should investigate whether this comorbidity has an impact on the treatment of OCD.

Cannabis use among military veterans: A great deal to gain or lose?

Policy changes have resulted in dramatic increases in access to cannabis for medical purposes. Veterans are disproportionately affected by conditions for which medical cannabis is often pursued, making an evidence-based perspective on risks versus benefits of high priority. The current review sought to examine the state of the evidence on the correlates and consequences of cannabis use among veterans. Using a comprehensive search strategy, 501 articles were identified and 86 studies met criteria for inclusion. The literature was predominated by cross-sectional studies (67%) of male veterans (71.4%-100% male) from the United States (93.0%). Three overarching themes emerged, comprising cannabis associations with other substance use, mental health, and physical health outcomes. The balance of the evidence associated cannabis use with negative health outcomes, with consistent positive associations with other substance use, psychiatric disorders, and self-harm/suicidality. Few studies examined the therapeutic effects of cannabis, thus limiting the potential to evaluate evidence of efficacy. Priority areas for future research are studies using designs that can examine the directionality of links between cannabis and health in veterans more conclusively, and studies directly examining therapeutic efficacy of cannabis-based therapies in veterans. Methodologically rigorous design will be essential to inform clinical recommendations and practices guidelines in an era of burgeoning access to cannabis.

Valproate Reverses Mania-Like Behavior of Clock delta19 Mouse and Alters Monoamine Neurotransmitters Metabolism in the Hippocampus

BACKGROUND

Mice with a deletion at exon 19 of the circadian locomotor output cycles Kaput gene (Clock ^delta19) exhibit mania-like behavior and have been one of the most common animal models for bipolar disorder (BD). The predictive validity of the Clock ^delta19 was investigated via studies using lithium previously. Determination of effects of other mood stabilizers on Clock ^delta19 mouse would be helpful for better understanding of the mechanism underlined.

METHODS

Wildtype (WT) and Clock ^delta19 mice were treated with saline (n = 10 for WT and n=10 for Clock ^delta19) or valproate (VPA) (n = 10 for WT and n=10 for Clock ^delta19) for 10 days. The hyperactivity, anxiety-like behaviors and depression-like behaviors were tested. The concentration of monoamine neurotransmitters and their metabolites in the hippocampus of saline or VPA treated WT and Clock ^delta19 mouse (n = 8 for each) were also determined.

RESULTS

VPA can reverse hyperactivity, lower level of anxiety-like and depression-like behaviors of the Clock ^delta19 mouse. Clock ^delta19 mouse exhibited lower levels of serotonin (5-HT) and dopamine (DA) in right hippocampus compared to WT mouse. Chronic VPA treatment did not affect the levels of 5-HT and DA, but can reduce the level of levodopa (L-DOPA) in the right hippocampus of Clock ^delta19 mouse.

CONCLUSION

Our results indicated that chronic VPA treatment can reverse the mania-like behaviors of the Clock ^delta19 mouse and further consolidate the validity of the Clock ^delta19 mouse as a model of BD. Monoamine neurotransmitters and their metabolites in the hippocampus are partly regulated by mutation of the Clock gene or VPA treatment.

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

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

Cost-effectiveness of the Adaptive Implementation of Effective Programs Trial (ADEPT): approaches to adopting implementation strategies

BACKGROUND

Theory-based methods to support the uptake of evidence-based practices (EBPs) are critical to improving mental health outcomes. Implementation strategy costs can be substantial, and few have been rigorously evaluated. The purpose of this study is to conduct a cost-effectiveness analysis to identify the most cost-effective approach to deploying implementation strategies to enhance the uptake of Life Goals, a mental health EBP.

METHODS

We used data from a previously conducted randomized trial to compare the cost-effectiveness of Replicating Effective Programs (REP) combined with external and/or internal facilitation among sites non-responsive to REP. REP is a low-level strategy that includes EBP packaging, training, and technical assistance. External facilitation (EF) involves external expert support, and internal facilitation (IF) augments EF with protected time for internal staff to support EBP implementation. We developed a decision tree to assess 1-year costs and outcomes for four implementation strategies: (1) REP only, (2) REP+EF, (3) REP+EF add IF if needed, (4) REP+EF/IF. The analysis used a 1-year time horizon and assumed a health payer perspective. Our outcome was quality-adjusted life years (QALYs). The economic outcome was the incremental cost-effectiveness ratio (ICER). We conducted deterministic and probabilistic sensitivity analysis (PSA).

RESULTS

Our results indicate that REP+EF add IF is the most cost-effective option with an ICER of $593/QALY. The REP+EF/IF and REP+EF only conditions are dominated (i.e., more expensive and less effective than comparators). One-way sensitivity analyses indicate that results are sensitive to utilities for REP+EF and REP+EF add IF. The PSA results indicate that REP+EF, add IF is the optimal strategy in 30% of iterations at the threshold of $100,000/QALY.

CONCLUSIONS

Our results suggest that the most cost-effective implementation support begins with a less intensive, less costly strategy initially and increases as needed to enhance EBP uptake. Using this approach, implementation support resources can be judiciously allocated to those clinics that would most benefit. Our results were not robust to changes in the utility measure. Research is needed that incorporates robust and relevant utilities in implementation studies to determine the most cost-effective strategies. This study advances economic evaluation of implementation by assessing costs and utilities across multiple implementation strategy combinations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02151331 , 05/30/2014.

Effects of mood episodes and comorbid anxiety on neuropsychological impairment in patients with bipolar spectrum disorder

OBJECTIVES

Cases of patients with bipolar disorder (BD) having neuropsychological impairment have been reported, although inconsistently. The possibility of comorbidity with anxiety disorder (AD) has been suggested. The association between mood episodes and AD comorbidity on neuropsychological performance is unclear and thus was investigated in the current study.

METHODS

All participants were informed about and agreed to participate in this study. Patients with BD were recruited from outpatient and inpatient settings, and healthy controls (HCs) were recruited as a comparison group. Six hundred and twenty-eight participants (175 HCs and 453 BD-56 BDI and 397 BDII) were studied based on their current mood episode, namely, depressive (BD_d ), manic/hypomanic (BDm), mixed (BDmix), and euthymic (BDeu), compared with/without AD comorbidity (164 with AD).

RESULTS

Compared to HCs, all BD groups had significantly more impaired neuropsychological profiles, but the BDeu group was found to have less impairment in memory and executive function than the episodic BD groups. The percentage of AD comorbidity in BDd, BDm, BDmix, and BDeu was 33.9%, 40.3%, 33.0%, and 35.6%, respectively (χ²  = 1.61, p > .05). The results show that AD plays a different role in neuropsychological impairment across various mood episodes in BD.

CONCLUSION

Memory impairment and executive dysfunction may be state-like cognitive phenotypes and are affected by AD comorbidity during mixed and depressive episodes in BD, while sustained attention deficiencies are more like trait markers, regardless of mood episodes, and persist beyond the course of the illness. The AD comorbidity effect on attentional deficit is greater when suffering from a manic episode.

Post-traumatic stress burden in a sample of hospitalized patients with Bipolar Disorder: Which impact on clinical correlates and suicidal risk?

BACKGROUND

Increasing evidence suggests Bipolar Disorder (BD) to be frequently associated to a history of traumatic experiences and Post-traumatic Stress Disorder (PTSD), with consequent greater symptoms severity, number of hospitalizations and worsening in quality of life. The aim of the present study was to investigate the lifetime exposure to traumatic events and PTSD rates in-patients with BD and to analyze the relationships between PTSD symptoms, clinical characteristics and severity of the mood disorder.

METHODS

A consecutive sample of 212 in-patients with a DSM-5 diagnosis of BD was enrolled at the psychiatric unit of a major University hospital in Italy and assessed by the SCID-5 and MOOD Spectrum-Self Report lifetime version (MOODS-SR). Socio-demographic characteristics, clinical features, substance or alcohol abuse, history of suicide related behaviors were also collected.

RESULTS

Lifetime trauma exposure emerged in 72.3% subjects, with a DSM-5 PTSD diagnosis reported by 35.6%. Patients with PTSD showed more frequently a (hypo)manic episode at onset, alcohol or substance abuse, psychotic features, suicide behaviors, higher scores in almost all the MOODS-SR domains, compared to those without PTSD.

LIMITATIONS

Cross sectional study. Lack of data about the time since trauma exposure or PTSD onset.

CONCLUSIONS

Our findings show a history of multiple traumatic experiences in hospitalized patients with BD besides high rates of PTSD, with the co-occurrence of these conditions appearing to be related to a more severe BD. Detailed investigation of post-traumatic stress symptoms is recommended for the relevant implications on the choice of a tailored treatment and the prognosis assessment.

Prevalence of Comorbid Anxiety Disorders and Their Associated Factors in Patients with Bipolar Disorder or Major Depressive Disorder

OBJECTIVE

Comorbid anxiety disorders in patients with mood disorders have a negative impact on outcomes, such as persistence of depressive symptoms, deterioration of quality of life (QoL), increased suicide risk, mood instability with antidepressant treatment, but often go underrecognized in clinical practice. To identify features useful for supporting the confirmation of comorbid anxiety disorders, we investigated the prevalence of comorbid anxiety disorders and their associated factors in Japanese patients with mood disorders using data from our previously reported JET-LMBP study.

PATIENTS AND METHODS

Patients with bipolar disorder (BD; n=114) and patients with major depressive disorder (MDD; n=334), all with major depressive episodes (DSM-IV-TR) were analyzed. Comorbid anxiety disorders were confirmed using the Mini-International Neuropsychiatric Interview. Demographic and clinical features were assessed using patient background forms, including the Quick Inventory of Depressive Symptomatology-Self Report Japanese version, 36-Item Short-Form Health Survey (SF-36), and Child Abuse and Trauma Scale (CATS). Multivariate logistic regression analysis adjusted for age, sex, and severity of depressive symptoms was used to identify factors associated with comorbid anxiety disorders (post hoc analysis).

RESULTS

The prevalence of comorbid anxiety disorders was significantly higher in patients with BD (53.2%) than in patients with MDD (37.2%). Factors associated with comorbid anxiety disorders in BD included no spouse, interpersonal rejection sensitivity, higher CATS sexual abuse scores, and lower SF-36 mental component summary scores. In MDD, factors included hypersomnia, pathological guilt feelings, higher CATS neglect scores, and lower SF-36 physical component summary scores.

CONCLUSION

Comorbid anxiety disorders were commonly seen in Japanese patients with mood disorders. Childhood abuse, atypical depression symptoms, and deterioration of health-related QoL were commonly associated with comorbid anxiety disorders in BD and MDD, suggesting that the presence of these features may be useful to support the confirmation of comorbid anxiety disorders in these patients.

Effects of a mental stress challenge on brain function in coronary artery disease patients with and without depression

OBJECTIVE

Coronary artery disease (CAD) patients with comorbid depression show an increase in mortality compared to cardiac patients without depression, but the mechanisms mediating this effect remain obscure. One possible explanation for this finding is that depressed patients with CAD exhibit an increased vulnerability to stress. The purpose of this study was to assess the effects of stress and depression on brain function and to explore its relationship with myocardial ischemia in CAD patients.

METHODS

Patients with CAD and depression (N = 13) and CAD without depression (N = 15) underwent imaging of the brain with positron emission tomography and [O-15] water and imaging of the heart with single photon emission computed tomography (SPECT) and [Tc-99m] sestamibi under mental stress task and control conditions.

RESULTS

CAD patients with depression compared to nondepressed showed decreased function with mental stress in the rostral anterior cingulate, the hippocampus, parts of the dorsolateral temporal and parietal cortex, the cerebellum, and the uncus, with increased blood flow in the parahippocampus, visual association cortex, and posterior cingulate. Depressed CAD patients who became ischemic during a mental stress task had relative decreases in the caudal and posterior cingulate, orbitofrontal cortex, and cerebellum, and increased activation in the parietal cortex and precuneus/visual association cortex compared to nonischemic depressed CAD patients.

CONCLUSIONS

These findings are consistent with dysfunction in a network of brain regions involved in the stress response in patients with comorbid CAD and depression that has direct and indirect links to the heart, suggesting a pathway by which stress and depression could lead to increased risk of heart disease related morbidity and mortality. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Coadministration of lithium and celecoxib attenuates the behavioral alterations and inflammatory processes induced by amphetamine in an animal model of mania

The present study evaluated the effects of the coadministration of lithium (Li) and Cel on inflammatory parameters in an animal model of mania induced by dextroamphetamine (D-amph). It was used Wistar rats 60 days old (250-350 g). The animals (n = 10 per group) received D-amph (2 mg/kg) or saline solution of NaCl 0.9% (Sal) intraperitoneally once a day for 14 days. From day eight until 14, the animals from the D-amph and Sal groups received Li (24 mg/kg), Cel (20 mg/kg), Li + Cel or water via gavage. Behavioral analyses were performed using the open-field test. The levels of IL-1β, IL-4, IL-10, and TNF-α were evaluated. The administration of D-amph induced hyperactivity in the rats, as well increased the IL-4, IL-10, and TNF-α levels in the serum, frontal cortex, and striatum of rats compared to those of the controls, and treatment with Li plus Cel reversed these alterations. In general, the administration of Li or Cel per se did not have effects on the behavioral and biochemical parameters. However, the treatment with Cel per se decreased only the IL-10 levels in the serum of animals. Besides, the treatment with Li or Cel decreased the IL-4 levels in the serum and reversed the effects of D-amph on this parameter in the frontal cortex. The treatment with Li reversed the effects of D-amph on the TNF-α levels in all tissues evaluated, and the administration of Cel reversed this alteration only in the striatum. It can be observed that treatment with Li plus Cel was more effective against damages caused by D-amph when compared to the administration of both treatments per se, suggesting that the coadministration can be more effective to treat BD rather than Li or Cel itself. The treatment with Li plus Cel was effective against the inflammation induced by D-amph.

An evaluation of the impact of co-occurring anxiety and substance use disorder on bipolar disorder illness outcomes in STEP-BD

BACKGROUND

Anxiety disorder (AD) and substance use disorder (SUD) highly co-occur with bipolar disorder (BD). AD and/or SUD co-occurrence is associated with poorer clinical outcomes in BD. However, respective associations between AD and/or SUD diagnoses and BD outcomes require clarification. Baseline data from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) were therefore utilized to investigate independent and simultaneous contributions of ADs and SUDs on clinical variables in BD.

METHODS

Two latent factors, "pathological anxiety" and "substance use problems," were derived from presence/absence of lifetime AD and SUD diagnoses. Latent dimensions' associations with clinical variables, obtained from the Affective Disorders Evaluation, Mini-International Neuropsychiatric Interview and Range of Impaired Functioning, were estimated via structural equation modeling (SEM).

RESULTS

Modeled independently, pathological anxiety and substance use problems were significantly associated with several variables. Yet when modeled simultaneously, pathological anxiety's associations with functional impairment, past-year rapid cycling, and past-year %time spent anxious and depressed remained while most variables' associations with substance use problems became non-significant. The only significant latent-factor interaction evidenced was for age of BD onset.

LIMITATIONS

Analyses were limited to lifetime diagnoses and causality may not be inferred given cross-sectional data.

CONCLUSIONS

ADs and SUDs impact on BD was mostly additive rather than synergistic. Findings highlight the potentially understated importance of treating inter-episodic anxiety in BD as it may exacerbate mood symptoms, increasing functional impairment and risk for subsequent mood episodes.

Comorbidity of bipolar and anxiety disorders: An overview of trends in research

Over the last three decades burgeoning research has shown that anxiety disorder comorbidity is not only highly prevalent in bipolar disorder (BD), but it also adversely impacts the course, outcome, and treatment of BD. The present review provides an overview of the current trends in research on comorbid anxiety and BDs based on prior reviews and meta-analyses (n = 103), epidemiological surveys, and large-scale clinical studies. The results reiterated the fact that at least half of those with BD are likely to develop an anxiety disorder in their lifetimes and a third of them will manifest an anxiety disorder at any point of time. All types of anxiety disorders were equally common in BD. However, there was a wide variation in rates across different sources, with most of this discrepancy being accounted for by methodological differences between reports. Comorbid anxiety disorders negatively impacted the presentation and course of BD. This unfavourable clinical profile led to poorer outcome and functioning and impeded treatment of BD. Despite the extensive body of research there was paucity of data on aetiology and treatment of anxiety disorder comorbidity in BD. Nevertheless, the substantial burden and unique characteristics of this comorbidity has important clinical and research implications.

The Association of Lifetime Suicide Attempts With Anxiety Disorders in Patients With Bipolar Disorder

The association of lifetime suicidal behaviors with anxiety disorders (ADs) in patients with bipolar disorder (BD) has been controversial. In this study, we hypothesized that certain types of ADs were related to the occurrence of past suicide attempts (SAs) independent of the severity of the BD, including the presence of past affective episodes. Lifetime diagnoses of BD and ADs were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders (SCID-I). Of the total sample of 200 patients with BD, 32.0% had at least 1 past SA. The mean number of previous hospitalizations, a history of social AD, and a history of posttraumatic stress disorder were strongly associated with past SAs in patients with bipolar I disorder. The presence of lifetime social AD was associated with lifetime SAs independent of previous depressive episodes. Therefore, we suggest that social AD itself is associated with a greater risk for SAs in patients with BD independent of the presence of depression.

Using a randomized controlled trial to test whether modifications to contingency management improve outcomes for heavy drinkers with serious mental illness

BACKGROUND

In contingency management (CM), individuals receive rewards for alcohol abstinence. CM is associated with reduced alcohol use in adults with co-occurring serious mental illnesses (SMI). Pre-treatment urine ethyl glucuronide (uEtG) levels equivalent to daily heavy drinking (uEtG >349ng/mL) are associated with poor response to CM. Modifications to CM are needed to improve outcomes for non-responders.

AIMS

To determine if pre-treatment heavy drinkers, defined by uEtG, with SMI achieve higher levels of alcohol abstinence when they receive an increased magnitude of reinforcement for abstinence (High-Magnitude CM) or reinforcers for reduced drinking, prior to receiving reinforcers for abstinence (Shaping CM), relative to those who receive typical low-magnitude abstinence based CM (Usual CM). Additionally, variables in the Addictions Neuroclinical Assessment model will be examined as treatment response moderators.

METHODS

Participants (N=400) will be recruited from two urban mental health organizations and complete a 4-week induction period where they will be reinforced for submitting samples for uEtG testing. Participants who attain a mean uEtG >349mg/mL will be randomized to receive either Usual CM, High-Magnitude CM, or Shaping CM for 16weeks. Differences in abstinence, assessed by uEtG, will be examined during treatment and during a 12-month follow-up. Measures of negative emotionality, alcohol reinforcer salience, and executive functioning will be gathered at study intake and used to predict treatment outcomes.

DISCUSSION

This novel approach to CM will use an alcohol biomarker to identify those at risk for treatment non-response and determine if adaptations to CM might improve outcomes for this group.

Are affective temperaments determinants of quality of life in euthymic patients with bipolar disorder?

BACKGROUND

Bipolar disorder (BD) is a disabling illness that is associated with low quality of life (QoL). This low QoL goes further than mood episodes, which suggests that stable traits, such as affective temperaments, can cause functional impairment.

OBJECTIVE

Our study analyses the impact of affective temperaments on the Physical Component Summary (PCS) and Mental Component Summary (MCS) of QoL in euthymic BD patients.

METHODS

A multicentre study was conducted in 180 euthymic BD patients and 95 healthy controls. Firstly, statistical analyses were performed to compare QoL and affective temperaments between the two groups. Secondly, Adaptive Lasso Analysis was carried out to identify the potential confounding variables and select the affective temperaments as potential predictors on the PCS and MCS of QoL in BD patients, as well as the control group.

RESULTS

QoL scores in terms of PCS and MCS in BD patients were significantly lower than in healthy individuals. Whereas anxious temperament, anxiety disorder comorbidity, and age were the best predictors of PCS impairment in BD patients, anxious temperament, subclinical depressive symptoms, and age were the best predictors of MCS impairment.

LIMITATIONS

Further longitudinal studies with unaffected high-risk relatives are needed to examine the potential interaction between affective temperament and psychopathology.

CONCLUSIONS

Anxious temperament has an impact on QoL in BD in terms of both the physical component and the mental component. Systematic screening of temperament in BD would give clinicians better knowledge of QoL predictors. Further research should allow more individualized treatment of BD patients based on temperamental factors.

The aldehyde dehydrogenase 2 polymorphisms on neuropsychological performance in bipolar II disorder with or without comorbid anxiety disorder

Anxiety disorders (ADs), the most common comorbid illnesses with bipolar disorder (BP) has been reported to associate with dopamine system. Dopamine, metabolized to 3,4-dihydroxyphenylacetic acid (DOPAC) by aldehyde dehydrogenase 2 (ALDH2), and the distribution of the ALDH2*1/*1, and ALDH2*1/*2+ALDH*2/*2 alleles in the Han Chinese general population is relatively equal. The association between dopamine metabolic enzymes and cognitive performance in patients with bipolar II disorder (BP-II) comorbid with AD is unclear. This study proposed to explore the role of ALDH2 polymorphisms on neuropsychological performance between BP-II comorbid with or without AD. One hundred ninety-seven BP-II patients with and without a comorbid AD were recruited and compared with 130 healthy controls (HCs). A polymerase chain reaction and a restriction fragment length polymorphism analysis were used to determine genotypes for ALDH2, and study participants underwent neuropsychological tests. An interaction between AD comorbidity and the ALDH2 polymorphisms was found in different domain of cognitive dysfunction in the BP-II patients. The ALDH2 polymorphisms might have different effects on the neuropsychological performance of BP-II patients with and without comorbid AD.

Predictors and outcomes of somatization in bipolar I disorder: A latent class mixture modeling approach

BACKGROUND

Mood disorders are often associated with somatic symptoms. The role of somatic symptoms on disease progression in unipolar depression is substantially better characterized than that role in bipolar disorder. Moreover, the contribution of comorbid anxiety disorders and medical illness is not well understood.

METHOD

We investigated 527 patients with bipolar I disorder clustered within 102 families using a latent class approach. Predictors were added stepwise into the model. Anxiety and commonly associated medical illnesses were added as covariates.

RESULTS

The rate of somatic symptoms in this sample was 73% (mean 1.7 symptoms), and 27.3% had a comorbid anxiety disorder. A two-class model, with a subgroup at high-risk for somatization, gave the best fit to the data. Multilevel mixture modeling accounted for family clusters. Somatic symptoms were independently associated with disease severity, defined as earlier age of first seeking psychiatric help (x = 21.7 vs x = 24.7, p = 0.005) and first psychiatric hospitalization (x = 25.7 vs x = 28.2, p = 0.03), greater probability of attempting suicide (x = 0.41 vs x = 0.32, p = 0.047), and rapid-cycling disease course (x = 0.57 vs x = 0.36, p < 0.001). Persons with few or no somatic symptoms were more likely to be hospitalized for severe mania (x = 0.63 vs x = 0.51; p = 0.013), but did not significantly differ in hospitalization for severe depression.

LIMITATIONS

The study is correlational. Information on pharmacologic interventions and comorbid diseases was limited.

CONCLUSIONS

Somatic symptoms in bipolar disorder could be an independent indicator for disease severity, suicidality, and rapid-cycling disease course. In severe mental illness, somatic and psychological symptoms must be jointly addressed.

Prevalence and Associated Features of Anxiety Disorder Comorbidity in Bipolar Disorder: A Meta-Analysis and Meta-Regression Study

Objective: Bipolar disorder is highly comorbid with anxiety disorders, however current and lifetime comorbidity patterns of each anxiety disorder and their associated features are not well studied. Here, we aimed to conduct a meta-analysis and meta-regression study of current evidence. Method: We searched PubMed to access relevant articles published until September 2015, using the keywords "Bipolar disorder" or "Affective Psychosis" or "manic depressive" separately with "generalized anxiety," "panic disorder," "social phobia," "obsessive compulsive," and "anxiety." Variables for associated features and prevalence of anxiety disorders were carefully extracted. Results: Lifetime any anxiety disorder comorbidity in BD was 40.5%; panic disorder (PD) 18.1%, generalized anxiety disorder (GAD) 13.3%, social anxiety disorder (SAD) 13.5% and obsessive compulsive disorder (OCD) 9.7%. Current any anxiety disorder comorbidity in BD is 38.2%; GAD is 15.2%, PD 13.3%, SAD 11.7%, and OCD 9.9%. When studies reporting data about comorbidities in BDI or BDII were analyzed separately, lifetime any anxiety disorder comorbidity in BDI and BDII were 38% and 34%, PD was 15% and 15%, GAD was 14% and 16.6%, SAD was 8% and 13%, OCD was 8% and 10%, respectively. Current any DSM anxiety disorder comorbidity in BDI or BDII were 31% and 37%, PD was 9% and 13%, GAD was 8% and 12%, SAD was 7% and 11%, and OCD was 8% and 7%, respectively. The percentage of manic patients and age of onset of BD tended to have a significant impact on anxiety disorders. Percentage of BD I patients significantly decreased the prevalence of panic disorder and social anxiety disorder. A higher rate of substance use disorder was associated with greater BD-SAD comorbidity. History of psychotic features significantly affected current PD and GAD. Conclusions: Anxiety disorder comorbidity is high in BD with somewhat lower rates in BDI vs BDII. Age of onset, substance use disorders, and percentage of patients in a manic episode or with psychotic features influences anxiety disorder comorbidity.

Irritable temperament and lifetime psychotic symptoms as predictors of anxiety symptoms in bipolar disorder

PURPOSE

Affective temperaments, hopelessness, alexithymia, and anxiety/agitation symptoms may play a significant role in the psychopathological characteristics of bipolar disorder (BD). Here, we aimed to investigate the eventual association between the mentioned explanatory variables and anxiety/agitation symptoms in BD.

MATERIALS AND METHODS

We recruited at the Section of Psychiatry, Department of Neuroscience, University of Genoa (Italy), 92 BD inpatients having a mean age of 52 (±13.8) years. Participants were assessed using specific psychometric instruments. Anxiety/agitation symptoms have been evaluated using the 11-item of the Beck Depression Inventory II (BDI-II).

RESULTS

Overall, 53.8% of participants presented with anxiety/agitation symptoms and 46.2% without. The two groups significantly differed about socio-economic status, lifetime psychotic symptoms, and residual depressive symptoms between episodes. Anxiety/agitation symptoms significantly correlated with irritable affective temperament (r = 0.407; p = .01), hopelessness (r = 0.541; p ≤ .001), difficulty identifying feelings (r = 0.440; p ≤ .001), difficulty describing feelings (r = 0.437; p ≤ .001), and externally oriented-thinking (r = 0.393; p ≤ .001). After multivariate analyses, irritable affective temperament (OR = 2.457, p ≤ .01) and less lifetime psychotic symptoms (OR = 0.007, p ≤ .05) remained the only significant variables associated with anxiety/agitation symptoms.

CONCLUSIONS

The generalization of the main findings is limited by the small sample size and cross-sectional study design. Nevertheless, our results suggest that the careful assessment of affective temperaments and psychotic symptoms may help to early identify BD patients suffering from anxiety/agitation symptoms and may allow to perform targeted interventions in the clinical practice.

Does perfectionism in bipolar disorder pedigrees mediate associations between anxiety/stress and mood symptoms?

Background

Bipolar disorder (BD) and the anxiety disorders are highly comorbid. The present study sought to examine perfectionism and goal attainment values as potential mechanisms of known associations between anxiety, stress and BD symptomatology. Measures of perfectionism and goal attainment values were administered to 269 members of BD pedigrees, alongside measures of anxiety and stress, and BD mood symptoms. Regression analyses were used to determine whether perfectionism and goal attainment values were related to depressive and (hypo)manic symptoms; planned mediation models were then used to test the potential for perfectionism to mediate associations between anxiety/stress and BD symptoms.

Results

Self-oriented perfectionism was associated with chronic depressive symptoms; socially-prescribed perfectionism was associated with chronic (hypo)manic symptoms. Self-oriented perfectionism mediated relationships between anxiety/stress and chronic depressive symptoms even after controlling for chronic hypomanic symptoms. Similarly, socially-prescribed perfectionism mediated associations between anxiety/stress and chronic hypomanic symptoms after controlling for chronic depressive symptoms. Goal attainment beliefs were not uniquely associated with chronic depressive or (hypo)manic symptoms.

Conclusions

Cognitive styles of perfectionism may explain the co-occurrence of anxiety and stress symptoms and BD symptoms. Psychological interventions for anxiety and stress symptoms in BD might therefore address perfectionism in attempt to reduce depression and (hypo)manic symptoms in addition to appropriate pharmacotherapy.

Electronic supplementary material

The online version of this article (doi:10.1186/s40345-017-0102-8) contains supplementary material, which is available to authorized users.

Simplifying profiles of comorbidity in bipolar disorder

BACKGROUND

Comorbid psychiatric symptoms in bipolar disorder (BD) predict poorer course of illness and treatment outcome. The sheer number of comorbid symptoms has thwarted developing treatments to address these comorbid concerns. The goal of this study was to develop a more parsimonious approach to understanding clusters of comorbid symptoms within BD.

METHOD

Data were collected as part of the National Epidemiologic Survey on Alcohol and Related Conditions. Structured diagnostic interviews were conducted with 43,093 participants using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV (AUDADIS-IV). Analyses were conducted on lifetime symptom counts for the most common 14 comorbid disorders among the 1411 persons who met lifetime criteria for bipolar I disorder.

RESULTS

An exploratory factor analysis with promax rotation as well as confirmatory factor analyses revealed a three-factor solution of Externalizing, Anxiety, and Mood syndromes, with a higher order Internalizing factor comprised of the Mood and Anxiety factors.

LIMITATIONS

Further research is needed in a clinical sample.

CONCLUSIONS

Comorbid symptoms in BD tend to cohere into Internalizing and Externalizing disorders, which could simplify research and treatment on comorbidity in BD.

Molecular and Cellular Effects of Traumatic Stress: Implications for PTSD

PURPOSE OF REVIEW

Posttraumatic stress disorder (PTSD) is characterized by hyperarousal and recurrent stressful memories after an emotionally traumatic event. Extensive research has been conducted to identify the neurobiological determinants that underlie the pathophysiology of PTSD. In this review, we examine evidence regarding the molecular and cellular pathophysiology of PTSD focusing on two primary brain regions: the vmPFC and the amygdala.

RECENT FINDINGS

This discussion includes a review of the molecular alterations related to PTSD, focusing mainly on changes to glucocorticoid receptor signaling. We also examine postmortem gene expression studies that have been conducted to date and the molecular changes that have been observed in peripheral blood studies of PTSD patients. Causal, mechanistic evidence is difficult to obtain in human studies, so we also review preclinical models of PTSD. Integration of peripheral blood and postmortem studies with preclinical models of PTSD has begun to reveal the molecular changes occurring in patients with PTSD. These findings indicate that the pathophysiology of PTSD includes disruption of glucocorticoid signaling and inflammatory systems and occurs at the level of altered gene expression. We will assess the impact of these findings on the future of PTSD molecular research.

Lifetime anxiety disorder and current anxiety symptoms associated with hastened depressive recurrence in bipolar disorder

AIMS

To assess differential relationships between lifetime anxiety disorder/current anxiety symptoms and longitudinal depressive severity in bipolar disorder (BD).

METHODS

Stanford BD Clinic outpatients enrolled during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation and followed with the STEP-BD Clinical Monitoring Form while receiving naturalistic treatment for up to two years. Baseline unfavorable illness characteristics/current mood symptoms and times to depressive recurrence/recovery were compared in patients with versus without lifetime anxiety disorder/current anxiety symptoms.

RESULTS

Among 105 currently recovered patients, lifetime anxiety disorder was significantly associated with 10/27 (37.0%) demographic/other unfavorable illness characteristics/current mood symptoms/current psychotropics, hastened depressive recurrence (driven by earlier onset age), and a significantly (> two-fold) higher Kaplan-Meier estimated depressive recurrence rate, whereas current anxiety symptoms were significantly associated with 10/27 (37.0%) demographic/other unfavorable illness characteristics/current mood symptoms/current psychotropics and hastened depressive recurrence (driven by lifetime anxiety disorder), but only a numerically higher Kaplan-Meier estimated depressive recurrence rate. In contrast, among 153 currently depressed patients, lifetime anxiety disorder/current anxiety symptoms were not significantly associated with time to depressive recovery or depressive recovery rate.

LIMITATIONS

American tertiary BD clinic referral sample, open naturalistic treatment.

CONCLUSIONS

Research is needed regarding differential relationships between lifetime anxiety disorder and current anxiety symptoms and hastened/delayed depressive recurrence/recovery - specifically whether lifetime anxiety disorder versus current anxiety symptoms has marginally more robust association with hastened depressive recurrence, and whether both have marginally more robust associations with hastened depressive recurrence versus delayed depressive recovery, and related clinical implications.

A placebo controlled study of quetiapine-XR in bipolar depression accompanied by generalized anxiety with and without a recent history of alcohol and cannabis use

OBJECTIVE

This study aims to compare treatment response in bipolar I or II depression and generalized anxiety disorder (GAD) with and without recent alcohol and/or cannabis use disorder (ALC/CAN) to quetiapine-XR (extended release) or placebo.

METHODS

A randomized, double-blind, 8-week study of quetiapine-XR versus placebo in patients with bipolar I or II depression and GAD with or without a recent ALC/CAN was used to compare changes in Hamilton Depression Rating Scale-17, Hamilton Anxiety Rating Scale, the 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR-16), Clinical Global Impression for Bipolar Disorder-Severity (CGI-BP-S), and Timeline Follow Back within and between groups.

RESULTS

In the quetiapine-XR group, patients with a recent ALC/CAN (n = 22) had significant decreases in QIDS-SR-16 (-9.6 ± 1.6 vs. -3.7 ± 1.7) and CGI-BP-S (-1.6 ± 0.4 vs. -0.8 ± 0.03) than those without a recent ALC/CAN (n = 24). In the placebo group, both patients with a recent ALC/CAN (n = 23) and those without (n = 21) had similar reductions in these measures. The reduction of QIDS-SR-16 scores in patients with a recent ALC/CAN was also significantly different from that of their counterparts in the placebo group. Patients who received quetiapine-XR had larger decreases in the number of drinking days/week (p = 0.17) and number of cannabis joints/week (p = 0.09) compared to those who received placebo.

CONCLUSION

Quetiapine-XR was superior to placebo in reducing QIDS-SR-16 total score in patients with a recent ALC/CAN. Patients taking quetiapine-XR used less alcohol and cannabis than patients on placebo, suggesting that quetiapine-XR may be of use in patients with bipolar disorder accompanied by GAD and other comorbidities.

Mood symptoms in pregnant and postpartum women with bipolar disorder: a naturalistic study

OBJECTIVE

We conducted a prospective naturalistic study of pregnant women with bipolar disorder (BD) to evaluate symptoms of BD across childbearing and assess whether pharmacotherapy reduced their severity.

METHODS

Assessments were scheduled at 20, 30, and 36 weeks' gestation and 2, 12, 26, and 52 weeks postpartum. Symptoms were assessed using the Structured Interview Guide for the Hamilton Depression Rating Scale-Atypical Depression Supplement (SIGH-ADS) and Mania Rating Scale (MRS).

RESULTS

Pregnant women (N=152) with BD were evaluated; 88 women (58%) were treated and 64 untreated (42%) with psychotropic drugs during pregnancy. Among the 88 women treated, 23 (26%) discontinued their medication in the first trimester and the remaining 65 (74%) were exposed throughout pregnancy or in the second and third trimesters. More than two-thirds (73%) of the women who remained in the study took psychotropic agents postpartum. The mean scores on the SIGH-ADS were in the mild range of depressive symptoms in both the psychotropic-treated and untreated groups in both pregnancy and postpartum. The majority of women had no or few symptoms of mania. Of the pregnant women treated with psychotropic agents, 66% received a guideline-concordant drug, and 34% received either antidepressant monotherapy (for BD I) or mono- or polypharmacy with a variety of other agents.

CONCLUSIONS

This sample of perinatal women with BD was characterized by mild residual symptoms of depression independent of pharmacotherapy, which poses a risk for recurrence and impaired parenting. The treatment of childbearing women with BD deserves urgent clinical and research attention to improve psychiatric outcomes.

The Effects of Histone Deacetylase Inhibition on the Levels of Cerebral Cytokines in an Animal Model of Mania Induced by Dextroamphetamine

Studies have suggested the involvement of inflammatory processes in the physiopathology of bipolar disorder. Preclinical evidences have shown that histone deacetylase inhibitors may act as mood-stabilizing agents and protect the brain in models of mania and depression. The aim of the present study was to evaluate the effects of sodium butyrate (SB) and valproate (VPA) on behavioral changes, histone deacetylase activity, and the levels of cytokines in an animal model of mania induced by dextroamphetamine (d-AMPH). Wistar rats were first given d-AMPH or saline (Sal) for a period of 14 days, and then, between the 8th and 14th days, the rats were treated with SB, VPA, or Sal. The activity of histone deacetylase and the levels of cytokines (interleukin (IL) IL-4, IL-6, and IL-10 and tumor necrosis factor-alpha (TNF-α)) were evaluated in the frontal cortex and striatum of the rats. The administration of d-AMPH increased the activity of histone deacetylase in the frontal cortex. Administration of SB or VPA decreased the levels of histone deacetylase activity in the frontal cortex and striatum of rats. SB per se increased the levels of cytokines in both of the brain structures evaluated. AMPH increased the levels of cytokines in both of the brain structures evaluated, and VPA reversed this alteration. The effects of SB on d-AMPH-induced cytokine alterations were dependent on the brain structure and the cytokine evaluated. Despite VPA and SB having a similar mechanism of action, both being histone deacetylase inhibitors, they showed different effects on the levels of cytokines. The present study reinforces the need for more research into histone deacetylase inhibitors being used as a possible target for new medications in the treatment of bipolar disorder.

An Open Effectiveness Trial of a Multimodal Inpatient Treatment for Depression and Anxiety Among Adults With Serious Mental Illness

OBJECTIVE

This prospective open effectiveness trial examined symptom change trajectories and rates of remission from depression and anxiety in an intensive multimodal inpatient treatment for adults with serious mental illness (SMI). Patient baseline characteristics were examined as mediators/moderators of treatment response.

METHODS

Adult inpatients with SMI (N = 994) completed an average of 39 days of inpatient treatment. Latent growth curve (LGC) methods were used to model symptom trajectories, estimating expected remission based on individual patterns of change observed across the sample.

RESULTS

Absolute reductions in symptoms were substantial, with large effect size improvements for both depression (d = 1.21, 95% CI [1.13, 1.29]) and anxiety (d = 1.13, 95% CI [1.05, 1.21]). For those presenting with elevated depressive symptoms (Patient Health Questionnaire-Depression ≥ 5.0; 87.5% of the sample), 46.9% evidenced remission from admission to discharge. Among patients presenting with significant anxiety (Patient Health Questionnaire-Generalized Anxiety Disorder Screener ≥ 5.0; 84.5% of the sample), 50.0% evidenced remission from admission to discharge. Mediation analyses revealed that depression and anxiety severity decreased more rapidly with increasing age and initial levels of experiential avoidance.

CONCLUSIONS

Rates of remission of depression and anxiety were greater than anticipated in this large cohort of adult SMI inpatients and may be related to intensity and length of hospitalization.

Factor analysis of temperament and personality traits in bipolar patients: Correlates with comorbidity and disorder severity

BACKGROUND

Temperament and personality traits have been suggested as endophenotypes for bipolar disorder based on several lines of evidence, including heritability. Previous work suggested an anxious-reactive factor identified across temperament and personality inventories that produced significant group discrimination and could potentially be useful in genetic analyses. We have attempted to further characterize this factor structure in a sample of bipolar patients.

METHODS

A sample of 1195 subjects with bipolar I disorder was evaluated, all with complete data available. Dimension reduction across two inventories identified 18 factors explaining 39% of the variance.

RESULTS

The two largest factors reflected affective instability and general anxiety/worry, respectively. Subsequent analyses of the clinical features associated with bipolar disorder revealed specificity for the factors in a predictable pattern. Cluster analysis of the factors identified a subgroup defined by a strong lack of general anxiety and low affective instability represented by the first two factors. The remaining subjects could be distinguished into two clusters by the presence of either more positive characteristics, including persistence/drive, spirituality, expressivity, and humor, or more negative characteristics of depression and anxiety.

LIMITATIONS

These analyses involved bipolar I subjects only and must be extended to other bipolar spectrum diagnoses, unaffected relatives, and individuals at risk.

CONCLUSIONS

These results suggest that temperament and personality measures access latent traits associated with important clinical features of bipolar disorder. By translating clinical variables into quantitative traits, we may identify subgroups of bipolar patients with distinct clinical profiles, thereby facilitating both individual treatment strategies and genetic analyses.

Threat sensitivity in bipolar disorder

Life stress is a major predictor of the course of bipolar disorder. Few studies have used laboratory paradigms to examine stress reactivity in bipolar disorder, and none have assessed autonomic reactivity to laboratory stressors. In the present investigation we sought to address this gap in the literature. Participants, 27 diagnosed with bipolar I disorder and 24 controls with no history of mood disorder, were asked to complete a complex working memory task presented as "a test of general intelligence." Self-reported emotions were assessed at baseline and after participants were given task instructions; autonomic physiology was assessed at baseline and continuously during the stressor task. Compared to controls, individuals with bipolar disorder reported greater increases in pretask anxiety from baseline and showed greater cardiovascular threat reactivity during the task. Group differences in cardiovascular threat reactivity were significantly correlated with comorbid anxiety in the bipolar group. Our results suggest that a multimethod approach to assessing stress reactivity-including the use of physiological parameters that differentiate between maladaptive and adaptive profiles of stress responding-can yield valuable information regarding stress sensitivity and its associations with negative affectivity in bipolar disorder. (PsycINFO Database Record (c) 2015 APA, all rights reserved).

Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990-2015: Systematic review and meta-analysis

BACKGROUND

Comorbidity between substance use disorders (SUDs) and bipolar disorder (BD) is highly prevalent to the extent it may almost be regarded the norm. This systematic review and meta-analysis aimed to estimate the prevalence rates of SUDs in treatment seeking patients diagnosed with BD in both inpatient and outpatient settings.

METHODS

A comprehensive literature search of Medline, EMBASE, psychINFO and CINAHL databases was conducted from 1990 to 2015. Prevalence of co-morbid SUDs and BD were extracted and odds ratios (ORs) were calculated using random effects meta-analysis.

RESULTS

There were 151 articles identified by electronic searches that yielded 22 large, multi-site studies and 56 individual studies describing comorbid rates of SUDs amongst community dwelling, BD inpatients or outpatients. The SUDs with the highest prevalence in BD were alcohol use (42%) followed by cannabis use (20%) and other illicit drug use (17%). Meta-analysis showed males had higher lifetime risks of SUDs compared to females. BD and comorbid SUDS were associated with earlier age of onset and slightly more hospitalisations than non-users.

LIMITATIONS

The results do not take into account the possibility that individuals may have more than one comorbid disorder, such as having more than one SUD, anxiety disorder, or other combination. Some of the meta-analyses were based on relatively few studies with high rates of heterogeneity. Most included studies were cross-sectional and therefore causality cannot be inferred.

CONCLUSIONS

This systematic review shows comorbidity between SUDs and bipolar illness is highly prevalent in hospital and community-based samples. The prevalence of SUDs was similar in patients with bipolar I and bipolar II disorders. This study adds to the literature demonstrating that SUDs are common in BD and reinforces the need to provide better interventions and properly conducted treatment trials to reduce the burden conferred by comorbid SUD and BD.

Current irritability robustly related to current and prior anxiety in bipolar disorder

BACKGROUND

Although current irritability and current/prior anxiety have been associated in unipolar depression, these relationships are less well understood in bipolar disorder (BD). We investigated relationships between current irritability and current/prior anxiety as well as other current emotions and BD illness characteristics.

METHODS

Outpatients referred to the Stanford Bipolar Disorders Clinic during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation. Prevalence and clinical correlates of current irritability and current/prior anxiety and other illness characteristics were examined.

RESULTS

Among 497 BD outpatients (239 Type I, 258 Type II; 58.1% female; mean ± SD age 35.6 ± 13.1 years), 301 (60.6%) had baseline current irritability. Patients with versus without current irritability had significantly higher rates of current anxiety (77.1% versus 42.9%, p < 0.0001) and history of anxiety disorder (73.1% versus 52.6%, p < 0.0001). Current irritability was more robustly related to current anxiety than to current anhedonia, sadness, or euphoria (all p < 0.001), and current irritability-current anxiety associations persisted across current predominant mood states. Current irritability was more robustly related to past anxiety than to all other assessed illness characteristics, including 1° family history of mood disorder, history of alcohol/substance use disorder, bipolar subtype, and current syndromal/subsyndromal depression (all p < 0.05).

LIMITATIONS

Limited generalizability beyond our predominately white, female, educated, insured American BD specialty clinic sample.

CONCLUSIONS

In BD, current irritability was robustly related to current/prior anxiety. Further studies are warranted to assess longitudinal clinical implications of relationships between irritability and anxiety in BD.

Prevalence, impact and treatment of generalised anxiety disorder in bipolar disorder: a systematic review and meta-analysis

QUESTION

Recent data suggest that anxiety disorders are as often comorbid with bipolar disorder (BD) as with unipolar depression; however, less attention has been paid to comorbidity of anxiety disorders with BD. Generalised anxiety disorder (GAD) is one of the most prevalent anxiety disorders that is highly comorbid with other mental disorders. We carried out a systematic review and meta-analysis to assess the degree of comorbidity between GAD and BD.

STUDY SELECTION AND ANALYSIS

We searched for all studies, which included primary data concerning the existence of GAD in patients with BD. The literature search strategy, selection of publications and the reporting of results have been conducted with PRISMA guidelines. The meta-analysis calculated prevalence estimates using the variance-stabilising Freeman-Tukey double arcsine transformation. We applied the inverse variance method using both fixed-effects and random-effects models to estimate summary effects for all combined studies. Heterogeneity was assessed and measured with Cochran's Q and I(2) statistics, respectively.

FINDINGS

The current meta-analysis analysed data from 28 independent studies and a total of 2975 patients from point prevalence studies and 4919 patients from lifetime studies. The overall random-effects point prevalence of GAD in patients with BD was 12.2% (95% CI 10.9% to 13.5%) and the overall random-effects lifetime estimate was 15.1% (95% CI 9.7% to 21.5%). Both estimates reported significant heterogeneity (94.0% and 94.7%, respectively).

CONCLUSIONS

Published studies report prevalence rates with high heterogeneity and consistently higher than those typically reported in the general population. It is believed that comorbid GAD might be associated with a more severe BD course and increased suicidality, and it is unknown how best to treat such conditions. The current meta-analysis confirms that GAD is highly prevalent in BD and the rate is higher in comparison to those in the general population.

Clinical and genetic factors associated with suicide in mood disorder patients

Suicidality is a continuum ranging from ideation to attempted and completed suicide, with a complex etiology involving both genetic heritability and environmental factors. The majority of suicide events occur in the context of psychiatric conditions, preeminently major depression and bipolar disorder. The present study investigates clinical factors associated with suicide in a sample of 553 mood disorder patients, recruited within the 'Psy Pluriel' center, Centre Européen de Psychologie Médicale, and the Department of Psychiatry of Erasme Hospital (Brussels). Furthermore, genetic association analyses examining polymorphisms within COMT, BDNF, MAPK1 and CREB1 genes were performed in a subsample of 259 bipolar patients. The presence or absence of a previous suicide attempt and of current suicide risk were assessed. A positive association with suicide attempt was reported for younger patients, females, lower educated, smokers, those with higher scores on depressive symptoms and higher functional disability and those with anxiety comorbidity and familial history of suicidality in first- and second-degree relatives. Anxiety disorder comorbidity was the stronger predictor of current suicide risk. No associations were found with polymorphisms within COMT and BDNF genes, whereas significant associations were found with variations in rs13515 (MAPK1) and rs6740584 (CREB1) polymorphisms. From a clinical perspective, our study proposes several clinical characteristics, such as increased depressive symptomatology, anxiety comorbidity, functional disability and family history of suicidality, as correlates associated with suicide. Genetic risk variants in MAPK1 and CREB1 genes might be involved in a dysregulation of inflammatory and neuroplasticity pathways and are worthy of future investigation.