Functional impairment in bipolar II disorder: is it as disabling as bipolar I?

Single-Dose Synthetic Psilocybin With Psychotherapy for Treatment-Resistant Bipolar Type II Major Depressive Episodes: A Nonrandomized Open-Label Trial

Importance

Bipolar II disorder (BDII) is a debilitating condition frequently associated with difficult-to-treat depressive episodes. Psilocybin has evidence for rapid-acting antidepressant effects but has not been investigated in bipolar depression.

Objective

To establish the safety and efficacy of psilocybin in patients with BDII in a current depressive episode.

Design, Setting, and Participants

This was a 12-week, open-label nonrandomized open-label trial conducted at Sheppard Pratt Hospital. Participants aged 18 to 65 years with BDII, a current depressive episode longer than 3 months, and documented insufficient benefit with at least 2 pharmacologic treatments during the current episode were invited to participate. Of 70 approached, 19 met inclusion criteria and were enrolled. The trial was conducted between April 14, 2021, and January 5, 2023.

Interventions

A single dose of synthetic psilocybin, 25 mg, was administered. Psychotropic medications were discontinued at least 2 weeks prior to dosing. Therapists met with patients for 3 sessions during pretreatment, during the 8-hour dosing day, and for 3 integration sessions posttreatment.

Main Outcomes and Measures

The primary outcome measure was change in Montgomery-Åsberg Depression Rating scale (MADRS) at 3 weeks posttreatment. Secondary measures included MADRS scores 12 weeks posttreatment, the self-rated Quick Inventory of Depression Symptoms-Self Rating (QIDS-SR), and the self-rated Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF), each completed at baseline and all subsequent visits. Safety measures included the Columbia Suicide Severity Rating Scale (CSSRS) and the Young Mania Rating Scale (YMRS) completed at each visit.

Results

Of the 15 participants in this study (6 male and 9 female; mean [SD] age, 37.8 [11.6] years), all had lower scores at week 3, with a mean (SD) change of -24.00 (9.23) points on the MADRS, (Cohen d = 4.08; 95% CI, -29.11 to -18.89; P < .001). Repeat measures analysis of variance showed lower MADRS scores at all tested posttreatment time points, including the end point (Cohen d = 3.39; 95% CI, -33.19 to -16.95; adjusted P < .001). At week 3, 12 participants met the response criterion (50% decrease in MADRS), and 11 met remission criterion (MADRS score ≤10). At the study end point, 12 patients met both response and remission criteria. QIDS-SR scores and Q-LES-Q-SF scores demonstrated similar improvements. YMRS and CSSRS scores did not change significantly at posttreatment compared to baseline.

Conclusions and Relevance

The findings in this open-label nonrandomized open-label trial suggest efficacy and safety of psilocybin with psychotherapy in BDII depression and supports further study of psychedelics in this population.

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.

Psychosocial Impairment in Older Patients With Bipolar I Disorder

BACKGROUND

The goal of this study was to assess psychosocial functioning in older patients with bipolar I disorder compared with healthy subjects and to identify the psychopathological factors associated with poor functioning in patients.

METHODS

We recruited 68 euthymic patients with bipolar I disorder from the outpatient unit and 89 healthy controls who were older than 50 years of age. In addition to clinical variables, we used other standardized measures, including the Young Mania Rating Scale, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Functional Assessment Short Test, and the Montreal Cognitive Assessment.

RESULTS

Older patients with bipolar I disorder had poorer psychosocial functioning in general and in the domains of occupation, autonomy, and cognition than the healthy controls on the basis of previously defined Functional Assessment Short Test cutoff scores. We found that 35.3% (95% CI: 23%-47%) of the patients did not have clinically significant functional impairment, 38.2% (95% CI: 26%-50%) had mild impairment, and 26.5% (95% CI: 16%-37%) had moderate impairment. Depressive symptoms and impaired cognition were associated with poor overall functioning.

CONCLUSIONS

The level of psychosocial functioning was heterogeneous among the patients. Subsyndromal depressive symptoms, even at low levels, and impaired cognition predicted poor functioning in euthymic middle-aged and older patients with bipolar I disorder.

Differential characteristics of bipolar I and II disorders: a retrospective, cross-sectional evaluation of clinical features, illness course, and response to treatment

BACKGROUND

The distinction between bipolar I and bipolar II disorder and its treatment implications have been a matter of ongoing debate. The aim of this study was to examine differences between patients with bipolar I and II disorders with particular emphasis on the early phases of the disorders.

METHODS

808 subjects diagnosed with bipolar I (N = 587) or bipolar II disorder (N = 221) according to DSM-IV criteria were recruited between April 1994 and March 2022 from tertiary-level mood disorder clinics. Sociodemographic and clinical variables concerning psychiatric and medical comorbidities, family history, illness course, suicidal behavior, and response to treatment were compared between the bipolar disorder types.

RESULTS

Bipolar II disorder patients were more frequently women, older, married or widowed. Bipolar II disorder was associated with later "bipolar" presentation, higher age at first (hypo)mania and treatment, less frequent referral after a single episode, and more episodes before lithium treatment. A higher proportion of first-degree relatives of bipolar II patients were affected by major depression and anxiety disorders. The course of bipolar II disorder was typically characterized by depressive onset, early depressive episodes, multiple depressive recurrences, and depressive predominant polarity; less often by (hypo)mania or (hypo)mania-depression cycles at onset or during the early course. The lifetime clinical course was more frequently rated as chronic fluctuating than episodic. More patients with bipolar II disorder had a history of rapid cycling and/or high number of episodes. Mood stabilizers and antipsychotics were prescribed less frequently during the early course of bipolar II disorder, while antidepressants were more common. We found no differences in global functioning, lifetime suicide attempts, family history of suicide, age at onset of mood disorders and depressive episodes, and lithium response.

CONCLUSIONS

Differences between bipolar I and II disorders are not limited to the severity of (hypo)manic syndromes but include patterns of clinical course and family history. Caution in the use of potentially mood-destabilizing agents is warranted during the early course of bipolar II disorder.

Status of Type II vs. Type I Bipolar Disorder: Systematic Review with Meta-Analyses

LEARNING OBJECTIVES AFTER PARTICIPATING IN THIS CME ACTIVITY, THE PSYCHIATRIST SHOULD BE BETTER ABLE TO

• Analyze and compare the different bipolar disorder (BD) types.• Identify markers that distinguish BD types and explain how the DSM-IV defines the disorder.

ABSTRACT

Since the status of type II bipolar disorder (BD2) as a separate and distinct form of bipolar disorder (BD) remains controversial, we reviewed studies that directly compare BD2 to type I bipolar disorder (BD1). Systematic literature searching yielded 36 reports with head-to-head comparisons involving 52,631 BD1 and 37,363 BD2 patients (total N = 89,994) observed for 14.6 years, regarding 21 factors (with 12 reports/factor). BD2 subjects had significantly more additional psychiatric diagnoses, depressions/year, rapid cycling, family psychiatric history, female sex, and antidepressant treatment, but less treatment with lithium or antipsychotics, fewer hospitalizations or psychotic features, and lower unemployment rates than BD1 subjects. However, the diagnostic groups did not differ significantly in education, onset age, marital status, [hypo]manias/year, risk of suicide attempts, substance use disorders, medical comorbidities, or access to psychotherapy. Heterogeneity in reported comparisons of BD2 and BD1 limits the firmness of some observations, but study findings indicate that the BD types differ substantially by several descriptive and clinical measures and that BD2 remains diagnostically stable over many years. We conclude that BD2 requires better clinical recognition and significantly more research aimed at optimizing its treatment.

Efficacy of Functional Remediation on Cognitive and Psychosocial Functioning in Patients with Bipolar Disorder: Study Protocol for a Randomized Controlled Study

BACKGROUND

Neurocognitive impairment is a prominent characteristic of bipolar disorder (BD), linked with poor psychosocial functioning. This study's purpose is to evaluate the effectiveness of functional remediation (FR) in enhancing neurocognitive dysfunctions in a sample of remitted patients with diagnosis of BD in comparison to treatment as usual-TAU. To quantify the neurocognitive damage, the Brief Assessment of Cognition in Affective Disorders (BAC-A) will be used, and the overall psychosocial functioning will be measured with the Functioning Assessment Short Test-FAST.

METHODS

The randomized, rater-blinded, controlled study will include two arms (1:1) encompassing 54 outpatients with diagnosis of BD-I and BD-II, as defined by the DSM-5 criteria. In the experimental phase, remitted patients aged 18-55 years will be involved. At the baseline, at the end of intervention and at the 6-month follow-up, patients will be evaluated using clinical scales (Young Mania Rating Scale (Y-MRS) and Hamilton Depression Rating Scale (HAM-D)). Neurocognitive measurements and psychosocial functioning will be valued, respectively, with BAC-A and FAST.

DISCUSSION

The primary expected outcome is that following FR intervention, patients will exhibit improved cognitive abilities and psychosocial outcomes compared to the participants in the TAU group. It is now recognized that neurocognitive deficits are potential predictors of functional outcome in patients with BD. In recent years, there has been a growing interest in the implementation of interventions that, in addition to symptomatic remission, are also aimed at neurocognitive dysfunctions in order to achieve a recovery of psychosocial functioning.

Bipolar I and bipolar II subtypes in older age: Results from the Global Aging and Geriatric Experiments in Bipolar Disorder (GAGE-BD) project

OBJECTIVES

The distinction between bipolar I disorder (BD-I) and bipolar II disorder (BD-II) has been a topic of long-lasting debate. This study examined differences between BD-I and BD-II in a large, global sample of OABD, focusing on general functioning, cognition and somatic burden as these domains are often affected in OABD.

METHODS

Cross-sectional analyses were conducted with data from the Global Aging and Geriatric Experiments in Bipolar Disorder (GAGE-BD) database. The sample included 963 participants aged ≥50 years (714 BD-I, 249 BD-II). Sociodemographic and clinical factors were compared between BD subtypes including adjustment for study cohort. Multivariable analyses were conducted with generalized linear mixed models (GLMMs) and estimated associations between BD subtype and (1) general functioning (GAF), (2) cognitive performance (g-score) and (3) somatic burden, with study cohort as random intercept.

RESULTS

After adjustment for study cohort, BD-II patients more often had a late onset ≥50 years (p = 0.008) and more current severe depression (p = 0.041). BD-I patients were more likely to have a history of psychiatric hospitalization (p < 0.001) and current use of anti-psychotics (p = 0.003). Multivariable analyses showed that BD subtype was not related to GAF, cognitive g-score or somatic burden.

CONCLUSION

BD-I and BD-II patients did not differ in terms of general functioning, cognitive impairment or somatic burden. Some clinical differences were observed between the groups, which could be the consequence of diagnostic definitions. The distinction between BD-I and BD-II is not the best way to subtype OABD patients. Future research should investigate other disease specifiers in this population.

A Longitudinal Study of the Association between the LEPR Polymorphism and Treatment Response in Patients with Bipolar Disorder

Patients with bipolar disorder (BD) exhibit individual variability in the treatment outcome, and genetic background could contribute to BD itself and the treatment outcome. Leptin levels significantly change in BD patients treated with valproate (VPA), but whether LEPR polymorphisms are associated with treatment response is still unknown. This longitudinal study aimed to investigate the associations between LEPR polymorphisms and VPA treatment response in BD patients who were drug naïve at their first diagnosis of BD. The single-nucleotide polymorphisms (SNPs) of LEPR (rs1137101, rs1137100, rs8179183, and rs12145690) were assayed, and the LEPR polymorphism frequencies of alleles and genotypes were not significantly different between the controls (n = 77) and BD patients (n = 130). In addition, after the 12-week course of VPA treatment in BD patients, the LEPR polymorphisms showed significant effects on changes in disease severity. Moreover, considering the effect of the LEPR haplotype, the frequency of the CAGG haplotype in BD patients was higher than that in the controls (9.3 vs. 2.9%, p = 0.016), and the LEPR CAGG haplotype was associated with a better treatment response than the other haplotypes in BD patients receiving VPA treatment. Therefore, LEPR polymorphisms might serve as mediators involved in the therapeutic action of VPA treatment.

Long-term work disability due to type I and II bipolar disorder: findings of a six-year prospective study

Background

Bipolar disorder (BD) is one of the leading causes of disability worldwide. However, the prevalence and predictors of long-term work disability among patients with type I and II BD have scarcely been studied. We investigated the clinical predictors of long-term work disability among patients with BD.

Methods

The Jorvi Bipolar Study (JoBS) is a naturalistic prospective cohort study (n = 191) of adult psychiatric in- and out-patients with DSM-IV type I and II BD in three Finnish cities. Within JoBS we examined the prevalence and predictors of disability pension being granted during a six-year follow-up of the 152 patients in the labor force at baseline and collected information on granted pensions from national registers. We determined the predictors of disability pension using logistic regression models.

Results

Over the 6 years, 44% of the patients belonging to the labor force at baseline were granted a disability pension. Older age; type I BD; comorbidity with generalized anxiety disorder, post-traumatic stress disorder or avoidant personality disorder; and duration of time with depressive or mixed symptoms predicted disability pensions. Including disability pensions granted before baseline increased their total prevalence to 55.5%. The observed predictors were similar.

Conclusion

This regionally representative long-term prospective study found that about half of patients with type I or II bipolar disorder suffer from persistent work disability that leads to disability pension. In addition to the severity of the clinical course and type I bipolar disorder, the longitudinal accumulation of time depressed, psychiatric comorbidity, and older age predicted pensioning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00264-6.

Manic morbidity and executive function impairment as determinants of long-term psychosocial dysfunction in bipolar disorder

OBJECTIVE

In this study, we aimed to evaluate the role of cognitive performance and measures of clinical course-including both syndromal and subsyndromal symptomatology-as determinants of the functional outcome of patients with Bipolar Disorder (BD) during a mean follow-up period of more than 4 years.

METHODS

Seventy patients with euthymic BD completed a neurocognitive battery at study entry. Clinical course was assessed prospectively for a period longer than 48 months by two measures: time spent ill (documented using a modified life charting technique) and density of affective episodes (defined as the number of depressive and hypo/manic episodes per year of follow-up). Psychosocial functioning was assessed during euthymia using the Functioning Assessment Short Test (FAST) total score at the end of follow-up period.

RESULTS

Baseline deficits in phonological fluency, a measure of executive functions (β = -2.49; 95% CI = -3.98, -0.99), and density of hypo/manic episodes during follow-up (β = 6.54; 95% CI = 0.43, 12.65) were independently associated with FAST total score at the end of study.

CONCLUSIONS

Although interrelated, manic morbidity and executive function impairments independently contribute to long-term psychosocial dysfunction in BD and could be potential targets of intervention.

Defining Heterogeneous Cognitive Trajectories in Bipolar Disorder: A Perspective

Bipolar disorder (BD) is a highly disabling mental illness that affects approximately 1% of the global population. Cognitive capacity is a strong predictor of "everyday" functional outcome in BD and should thus be considered a key treatment target. Interventions to improve cognition have been largely unsuccessful, likely due to the substantial heterogeneity inherent to the illness. It is known that 40%-60% of people with BD have cognitive impairment, yet impairment is not "one size fits all"; in fact, the literature supports discrete cognitive subtypes in BD (e.g., intact, globally impaired, and selectively impaired). Gaining a better understanding of these cognitive subtypes, their longitudinal trajectories, and their biological underpinnings will be essential for improving patient outcomes. The prevailing hypothesis for the development of cognitive impairment in BD postulates a stepwise cumulative effect of repeated mood episodes causing wear-and-tear on the brain. However, a paucity of data supports this idea at the group level. We propose that studying heterogeneity longitudinally will allow for clearer delineation of the natural history of cognitive trajectories in BD. In sum, parsing heterogeneity in BD will allow us to identify causal mechanisms and optimize treatment at the level of the individual.

[Cognitive impairment in remitted patients with bipolar disorder]

OBJECTIVE

To assess the frequency and severity of cognitive impairment as well as its correlations with clinical characteristics in remitted patients with bipolar disorder (BD).

MATERIAL AND METHODS

Eighty-five patients with BD type I (64 patients) and BD type II (21 patients) in remission were examined (average age 36.6±5.7). Affective symptoms were assessed using the Hamilton Depression Rating Scale (HDRS) and Young's Mania Rating Scale (YMRS). Cognitive impairment was assessed using the Brief Neuropsychological Cognitive Examination (BNCE).

RESULTS

Cognitive impairment was revealed in 43.5% of the patients. The frequency and structure of cognitive impairment in patients with BD type I and type II did not differ. The patients with cognitive impairment were characterized by decreased speed of mental processes, decreased working memory and attention deficit. The correlation of the total BNCE score with the age of the patients, duration of the disease, total HDRS and YMRS scores was revealed.

CONCLUSION

The results demonstrate the affective nature of cognitive deficit in the patients. Cognitive impairment in remitted patients with BD is a significant therapeutic target.

Social cognition in first-degree relatives of bipolar disorder: Theory of Mind and nonverbal sensitivity

Social cognition might be impaired in first degree relatives (FDR) of BD but existing research shows controversial results about social cognitive impairments in this population. The aim of this study was to assess Theory of Mind (ToM) and nonverbal sensitivity in FDR of BD and compare the results with those of two groups of persons with remitted bipolar disorder (BD), type I and II, and a control group. Social cognitive ability was examined in first degree relatives of BD, with a biological parent, offspring or sibling diagnosed with the disorder. For this study, 37 FDRs of bipolar patients, 37 BD I, 40 BD II and 40 control participants were recruited. Social cognition was explored by means of the Reading the Mind in the Eyes Test and the MiniPONS. Results showed a significant impairment in FDR of BD in the ToM task, but not in nonverbal sensitivity. Performance of FDRs in social cognition is better than that of BDs (either type I or type II) but worse when compared with that of healthy individuals without a family history of psychiatric disorders. Nevertheless, no differences were found between BD I and BD II groups. Males and older participants showed a worse performance in all groups. Group family therapy with FDRs of BD might include training in the recognition of nonverbal cues, which might increase the understanding of their familiars with BD, in order to modify communication abilities.

Clinical correlates of seasonality in bipolar disorder: A specifier that needs specification?

OBJECTIVE

Seasonal pattern (SP) is a bipolar disorder (BD) specifier that indicates a tendency towards affective relapses during specific moments of the year. SP affects 15%-25% of BD patients. In the past, SP was applied only to depressive relapses while, in DSM-5, SP may be applied to both depressive and (hypo)manic episodes. We examined the association between different clinical correlates of BD and SP according to its current definition in a cohort of patients with BD type I (BDI) and II (BDII).

METHODS

Patients were recruited from a specialized unit and assessed according to the season of relapse and type of episode per season. SP and non-SP patients were compared looking into sociodemographic and clinical correlates. Significant variables at univariate comparisons were included in multivariate logistic regression with SP as the dependent variable.

RESULTS

708 patients were enrolled (503 BDI, 205 BDII), and 117 (16.5%) fulfilled DSM-5 criteria for SP. The mean age was 45.3 years (SD = 14.18), and 389 were female (54.9%). The logistic regression model included a significant contribution of BDII (OR = 2.23, CI 1.4-3.55), family history of mood disorder (OR = 1.97, CI 1.29-3.01), undetermined predominant polarity (OR = 0.44, CI 0.28-0.70), and aggressive behavior (OR = 0.42, CI 0.23-0.75).

CONCLUSION

Our results outline a novel positive association of SP with undetermined predominant polarity, BDII, family history of mood disorder, and with fewer aggressiveness-related symptoms. Seasonality is associated with a biphasic pattern with similar dominance of (hypo)mania and depression and is more frequent in BDII as compared to BDI. Seasonal episodes may be easier to predict, but difficult to prevent.

Predictors of High Psychosocial Functioning in Bipolar Disorder

The aim of this study was to identify predictors of high psychosocial functioning in patients with bipolar disorder (BD). One hundred forty-five outpatients with BD and 50 healthy controls were included. Patients were categorized as having high psychosocial functioning if they concomitantly met three conditions: a) General Assessment of Functioning greater than 90, b) full-time employment, and c) full functional recovery. Clinical, demographical, and neurocognitive variables were assessed and considered as potential predictors of high functioning in regression models. We found that 22.8% (n = 33) of patients exhibited high psychosocial functioning. BD type II, higher educational level, and better performance in verbal memory, attention, and executive functions were independent predictors of high psychosocial functioning. Our results provide evidence that functional outcomes are heterogeneous in BD, including a percentage of patients who maintain good to excellent psychosocial functioning despite their illness. Neurocognitive functioning could be one of the most influential factors to explain this heterogeneity.

Reward sensitivity and the course of bipolar disorder: A survival analysis in a treatment seeking sample

OBJECTIVES

Reward sensitivity is suggested to be an influence on the onset and reoccurrence of bipolar disorder (BD) in observational longitudinal studies. The current study examined whether reward sensitivity predicted the recurrence of mood episodes in a treatment seeking sample. We also explored if reward sensitivity moderated treatment outcomes of psychosocial treatment.

METHODS

Seventy-six euthymic adult patients with BD were randomly assigned to either Cognitive Behavioral Therapy (CBT) or Supportive Therapy (ST) and followed up for 2 years after completing therapy (Meyer and Hautzinger, 2012). The primary outcome measure was recurrence of mood episodes. The final multivariate Cox regression models included potential covariates, therapy conditions, BAS reward sensitivity, and the interaction between BAS and therapy conditions.

RESULTS

BAS emerged as the only significant predictor of time till recurrence of mania, but not depression, but the overall model did not reach significance. There was no interaction between treatment and BAS reward sensitivity. Interestingly, a diagnosis of BD II predicted time till recurrence of depression.

CONCLUSION

The main result regarding BAS partially confirms prior studies linking BAS and mania, but power and the specific sample seeking psychosocial treatment might have reduced the effect.

Visual event-related potentials in external emotional conditions in bipolar disorders I and II

OBJECTIVES

Mutual influences of cognitive and emotional functions occur in bipolar disorder, but specific alterations in relation to external emotional stimuli in bipolar I (BD I) and II (BD II) subtypes remain unknown. This study aimed to explore the effects of external emotional stimuli on cerebral attentional function in BD I and BD II.

METHODS

We tested visual oddball event-related potentials (ERPs) during various external emotional stimuli (Disgust, Fear, Erotica, Happiness, Neutral and Sadness) in 31 patients with BD I, 19 BD II and 47 healthy volunteers. Participants' concurrent affective states were also evaluated.

RESULTS

The ERP N2 latencies during Fear and Happiness were prolonged, P3 amplitudes during Disgust and Erotica were decreased in BD I; P3 amplitudes during Disgust, Erotica, Happiness and Neutral conditions were decreased in BD II. Increased frontal and parietal and decreased temporal and occipital activations were found in BD I, while increased occipital and parietal and decreased frontal and limbic activations in BD II in relation to different external emotions. ERP components were not correlated with concurrent affective states in patients.

CONCLUSIONS

Automatic attention during Happiness and Fear, and voluntary attention during Disgust and Erotica conditions were impaired in BD I; and voluntary attention during Disgust, Happiness, Erotica and Neutral conditions was impaired in BD II. Our study illustrates different patterns of visual attentional deficits associated with different external emotional stimuli in BD I and BD II.

Psychosocial Interventions for Bipolar II Disorder

Bipolar II disorder causes significant suffering among patients and their families, some of which may be alleviated by psychotherapy alone or as an adjunct to pharmacotherapy. Psychotherapies may be more effective if modified to meet the specific needs of patients with bipolar II disorder.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Use of the Functioning Assessment Short Test (FAST) in defining functional recovery in bipolar I disorder. Post-hoc analyses of long-term studies of aripiprazole once monthly as maintenance treatment

PURPOSE

There is growing agreement that definitions of "recovery" in bipolar-I disorder (BP-I) should include functional outcomes beyond sustained symptomatic remission. In this post-hoc analysis, we assessed functional recovery rates according to the validated Functioning Assessment Short Test (FAST) in participants with BP-I after 52 weeks of maintenance treatment with aripiprazole once monthly (AOM).

PATIENTS AND METHODS

Rates of functional recovery with AOM 400 were investigated in two 52-week studies. NCT01567527 was a placebo-controlled, double-blind, randomized-withdrawal study and NCT01710709 was an open-label study. Functional recovery, assessed at the end of the respective maintenance phases, was defined as a total FAST score of ≤11 for 8 consecutive weeks.

RESULTS

Post-hoc analyses included 229 patients from the randomized-withdrawal study (AOM 400 n=116; placebo n=113). The open-label study included 402 patients (including 321 de novo patients and 81 rollover patients who had completed the randomized-withdrawal study). In the randomized-withdrawal study, functional recovery was achieved by 30.2% (n=35) of the AOM 400 group compared with 24.8% (n=28) in the placebo group. The difference was not statistically significant (p=0.39). In the open-label study, 36% (n=116) of de novo patients and 43% (n=35) of rollover patients had functionally recovered after 52 weeks of AOM 400 treatment.

CONCLUSION

These data highlight the utility of a sustained FAST total score of ≤11 as a definition of recovery and emphasize the possibility of achieving this ambitious treatment goal with effective long-term treatment.

Coping with amplified emotionality among people with bipolar disorder: A longitudinal study

BACKGROUND

The amplified emotionality characteristics of bipolar disorder (BD) may interfere with goal pursuit in the recovery process. This is the first study to test the coping flexibility model empirically among people with BD. Finding ways to cope with goal-striving life events should shed light on managing elevated mood states.

METHODS

Using a 12-month longitudinal follow-up design, this study examined the stability in coping flexibility with experimentally-devised Behavioral Approach System (BAS) activating life events and mood states at 6- and 12-month time points for individuals with BD (n = 83) and healthy controls (n = 89). Hierarchical linear modeling tested the individual growth model by studying the longitudinal data.

RESULTS

The findings showed fluctuations in different components of coping flexibility and mood states across time. They confirmed the amplified emotionality characteristics of BD. Moreover, coping flexibility took precedence over BAS sensitivity and psychosocial functioning levels in predicting mood states.

LIMITATIONS

Measurements of BAS sensitivity may focus on trait nature only and prone to subjective bias. The assessment of mood or coping flexibility may not accurately capture actual experience in daily life. Lack of respective data on bipolar subtypes and significant differences in some dimensions between the BD and control groups are further limitations of the study.

CONCLUSIONS

The study's findings have implications for coping with amplified emotionality within the personal recovery process for people with BD. Judicious application of coping strategies and adjustment of perceived controllability are crucial for individuals to reach goals pertinent to personal recovery and manage potential manic mood symptoms.

Cerebral processing of facial emotions in bipolar I and II disorders: An event-related potential study

BACKGROUND

Behavioral results have shown that bipolar disorder patients have impaired recognition of facial emotions, but the detailed information processing of facial emotions in patients with bipolar I (BD I) and II (BD II) disorders remain unknown.

METHODS

We tested the cerebral event-related potentials to the static facial expressions of Neutral, Happiness, Anger and Sadness in 39 adult patients with BD I, 22 BD II, and 54 healthy volunteers. Participants' affective states were measured with the Mood Disorder Questionnaire, the Hypomania Checklist-32, and the Plutchik-van Praag Depression Inventory.

RESULTS

Over-processed right occipitotemporal cortex during N1 time window to Neutral and Happiness, and during P3b window to Sadness were found in BD I; prolonged N1 latencies to Neutral and Happiness, declined P3b amplitude to Sadness, negative correlation between P3b latency to Sadness and depression, and attenuated superior frontal activity during P3b window to Sadness were found in BD II; and the right-side dominance during facial emotion processing were found in both BD I and BD II.

LIMITATIONS

We didn't record the personality traits or medication used in patients, nor included other facial emotions such as fear and disgust.

CONCLUSIONS

When responding to facial emotions, both BD I and BD II showed a right-side processing dominance; BD I displayed enhanced processing in the right occipitotemporal cortex during structural encoding and categorical processing of facial emotions; while BD II displayed generalized impairments, less involvement of superior frontal cortex to negative emotions, and reduced ability to process negative emotions which was associated with depression.

Factors associated with poor functional outcome in bipolar disorder: sociodemographic, clinical, and neurocognitive variables

OBJECTIVE

The current investigation aimed at studying the sociodemographic, clinical, and neuropsychological variables related to functional outcome in a sample of euthymic patients with bipolar disorder(BD) presenting moderate-severe levels of functional impairment.

METHODS

Two-hundred and thirty-nine participants with BD disorders and with Functioning Assessment Short Test(FAST) scores equal or above 18 were administered a clinical and diagnostic interview, and the administration of mood measure scales and a comprehensive neuropsychological battery. Analyses involved preliminary Pearson bivariate correlations to identify sociodemographic and clinical variables associated with the FAST total score. Regarding neuropsychological variables, a principal component analysis (PCA) was performed to group the variables in orthogonal factors. Finally, a hierarchical multiple regression was run.

RESULTS

The best fitting model for the variables associated with functioning was a linear combination of gender, age, estimated IQ, Hamilton Depression Rating Scale (HAM-D), number of previous manic episodes, Factor 1 and Factor 2 extracted from the PCA. The model, including all these previous variables, explained up to 29.4% of the observed variance.

CONCLUSIONS

Male gender, older age, lower premorbid IQ, subdepressive symptoms, higher number of manic episodes, and lower performance in verbal memory, working memory, verbal fluency, and processing speed were associated with lower functioning in patients with BD.

Functional outcome and social cognition in bipolar disorder: Is there a connection?

BACKGROUND

Interest in social cognition in bipolar disorder (BD) has increased considerably over the past decade, with studies highlighting major impairments, especially in mental state reasoning, even during euthymia. A causal relationship between social cognition deficits and social functioning has already been established in individuals with schizophrenia, but there is still little information about links between social cognition and social functioning in BD. Our aim was therefore to review the relationship between functional outcome and social cognition in patients with BD.

METHODS

We conducted a systematic review of the literature. Relevant articles were identified through literature searches in the MEDLINE/PubMed, EBSCOHost and Google Scholar databases for the years 2000-2017, using the keywords bipolar, social cognition, theory of mind, mentalizing, emotion recognition, emotion processing, and functioning. A total of 20 studies met our inclusion/exclusion criteria.

RESULTS

We found that functioning was significantly correlated with three domains of social cognition (ToM, emotion processing, and attribution bias). Twelve of 13 studies reported a correlation with emotion processing, but a correlation with ToM was only found in three of the 11 studies that assessed it. Six studies found an effect of depressive symptoms on emotion processing and no significant association was found with manic symptomatology.

CONCLUSIONS

To the best of our knowledge, the present review is the first to specifically explore the relationship between social cognition and social functioning in patients with BD. This exploration is of interest, as it enhances current understanding of this disorder and, by so doing, should improve patient outcomes.

Functional impairment in adult bipolar disorder with ADHD

BACKGROUND

It is well established that patients with either bipolar disorder (BD) or attention-deficit/hyperactivity disorder (ADHD) present functional impairment even when in remission. Nevertheless, research on functional impairment with adult patients with bipolar disorder comorbid to ADHD (BD+ADHD) is very scarce. The main objective of the current report was to evaluate the overall and specific domains of functioning, in patients with BD+ADHD compared to patients with pure bipolar disorder (pBD) and healthy controls (HCs).

METHOD

162 subjects from 3 groups were compared: 63 pBD, 23 BD+ADHD and 76 HCs. All the patients with BD had been euthymic for at least 6 months and they were recruited at the Hospital Clinic of Barcelona. All the participants were assessed with the 17-item Hamilton Depression Rating Scale (HAM-D), the Young Mania Rating Scale (YMRS) and the Functioning Assessment Short Test (FAST). Clinical, and sociodemographic data were also recorded.

RESULTS

Clinical groups, pBD and BD+ADHD, showed lower overall functioning (p < 0.001) in each domain of the FAST scale compared to the HCs. Moreover, the Tukey post hoc test revealed that the BD+ADHD group showed a worse score than pBD in the cognitive domain of the FAST. However, after controlling for potential confounding variables, only the HDRS scores (p < 0.026) remained significant for the cognitive domain of the FAST.

LIMITATIONS

The small sample size of the comorbid BD+ADHD group.

CONCLUSIONS

Adult patients with BD+ADHD showed the worst scores in functioning compared with the HCs, but did not show more severe functional impairment than the pBD group except for the cognitive domain. Therefore our findings suggest that depressive symptoms in adults with BD+ADHD may negatively influence cognitive functioning. Further studies are needed to confirm our findings for the management of BD+ADHD.

Staging, Neurocognition and Social Functioning in Bipolar Disorder

Introduction: Bipolar disorder (BD) is associated with significant neurocognitive and functional impairment, which may progress across stages. The 'latent stage' of BD remains understudied. This cross-sectional study assessed staging, neurocognition and social functioning among BD patients and their healthy siblings. Methods: Four groups were included: euthymic type I BD patients in the early (n = 25) and late (n = 23) stages, their healthy siblings (latent stage; n = 23) and healthy controls (n = 21). All 92 subjects underwent a comprehensive neuropsychological battery of processing speed, verbal learning/memory, visual memory, working memory, verbal fluency, executive cognition, and motor speed. Social functioning was assessed using the FAST scale. Results: Siblings' social functioning was identical to that of controls, and significantly better than both early- (p < 0.005) and late- (p < 0.001) stage patients. Although all patients were strictly euthymic, those at late stages had a significantly worse social functioning than early-stage patients (p < 0.001). Compared to controls, increasingly greater neurocognitive dysfunction was observed across stages of BD (F = 1.59; p = 0.005). Healthy siblings' performance lied between those of controls and patients, with deficits in tasks of processing speed, executive attention, verbal memory/learning, and visual memory. Both early- and late-stage patients had a more severe and widespread dysfunction than siblings, with no significant differences between them. Conclusions: Genetic vulnerability to BD-I seems to be associated with neurocognitive impairments, whereas social dysfunction would be the result of the clinical phenotype. Staging models of BD should take into account these divergent findings in the latent stage.

Investigating gaze processing in euthymic bipolar disorder: Impaired ability to infer mental state and intention, but preservation of social attentional orienting

Euthymic bipolar disorder (BD) has been associated with subtle impairment in face processing. However, it is not known whether their difficulties extend to the processing of gaze. In the present study, two tasks, both of which rely on the ability to make use of the eye region of a pictured face, were used: the Reading the Mind in the Eyes test and the Eye-gaze cueing task. Compared to healthy controls, BD patients were impaired at judging mental state from images of the face but showed normal susceptibility to the direction of gaze as an attentional cue. These findings suggest that BD patients present selective gaze processing impairment, limited to the sensitivity to intention and emotion. This impairment could account at least partially for the higher levels of interpersonal problems generally observed in BD.

Effects of venlafaxine versus lithium monotherapy on quality of life in bipolar II major depressive disorder: Findings from a double-blind randomized controlled trial

Bipolar disorder is associated with decreased quality of life, especially during depressive episodes. There are few studies that have examined whether quality of life improves following pharmacological treatments of bipolar depression. In this exploratory study, we examined the effects of antidepressant versus mood stabilizer monotherapy on quality of life ratings in bipolar II subjects during acute (12 week) treatment. Data were derived from a randomized double-blind comparison of venlafaxine (n = 65) versus lithium (n = 64) monotherapy. The Quality of Life Index (QLI) was administered at baseline (n = 126; 98%) and again at the end of treatment. We explored treatment differences in continuous changes on the QLI using last-observation carried forward. Additionally, we explored the likelihood of experiencing clinically-significant improvements as well as baseline correlates of QLI and changes in QLIe. Venlafaxine was superior to lithium in reducing symptoms of depression during acute treatment. However, there were no significant differences between treatments in QLI ratings. Changes in symptoms of depression were correlated to, but not redundant, with improvements in QLI ratings. These findings suggest that quality of life may be an important secondary outcome to target and measure as a part of comparative clinical trials of pharmacotherapy for bipolar II depression.

Italian Bipolar II vs I patients have better individual functioning, in spite of overall similar illness severity

Introduction Bipolar disorders (BDs) comprise different variants of chronic, comorbid, and disabling conditions, with relevant suicide and suicide attempt rates. The hypothesis that BD types I (BDI) and II (BDII) represent more and less severe forms of illness, respectively, has been increasingly questioned over recent years, justifying additional investigation to better characterize related sociodemographic and clinical profiles.

METHODS

A sample of 217 outpatients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)-described BD (141 BDI, 76 BDII), without a current syndromal mood episode, was recruited, and sociodemographic and clinical characteristics of BDI and II patients were compared.

RESULTS

BDII patients had significantly more favorable sociodemographics, in relation to occupational stability, cohabitation, and marital status. However, BDII compared with BDI patients had significantly longer duration of untreated illness, more frequent lifetime anxiety disorders comorbidity, longer most recent episode duration, higher rate of depressive first/most recent episode, and more current antidepressant use. In contrast, BDI compared with BDII patients had significantly more severe illness in terms of earlier age at onset; higher rate of elevated first/most recent episode, lifetime hospitalizations, and involuntary commitments; lower Global Assessment of Functioning score; and more current antipsychotic use. BDI and II patients had similar duration of illness, psychiatric family history, lifetime number of suicide attempts, current subthreshold symptoms, history of stressful life events, and overall psychiatric/medical comorbidity.

CONCLUSION

BDII compared with BDI patients had more favorable sociodemographic features, but a mixture of specific unfavorable illness characteristics, confirming that BDII is not just a milder form of BD and requires further investigation in the field.

Onset polarity in bipolar disorder: A strong association between first depressive episode and suicide attempts

BACKGROUND

The role of onset polarity (OP) in patients with bipolar disorder (BD) has been increasingly investigated over the last few years, for its clinical, prognostic, and therapeutic implications. The present study sought to assess whether OP was associated with specific correlates, in particular with a differential suicidal risk in BD patients.

METHODS

A sample of 362 recovered BD patients was dichotomized by OP: depressed (DO) or elevated onset (EO: hypomanic/manic/mixed). Socio-demographic and clinical variables were compared between the subgroups. Additionally, binary logistic regression was performed to assess features associated with OP.

RESULTS

DO compared with EO patients had older current age and were more often female, but less often single and unemployed. Clinically, DO versus EO had a more than doubled rate of suicide attempts, as well as significantly higher rates of BD II diagnosis, lifetime stressful events, current psychotropics and antidepressants use, longer duration of the most recent episode (more often depressive), but lower rates of psychosis and involuntary commitments.

LIMITATIONS

Retrospective design limiting the accurate assessment of total number of prior episodes of each polarity.

CONCLUSIONS

Our results support the influence of OP on BD course and outcome. Moreover, in light of the relationship between DO and a higher rate of suicide attempts, further investigation may help clinicians in identifying patients at higher risk of suicide attempts.

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

BACKGROUND

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

METHOD

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Differences in clinical presentation between bipolar I and II disorders in the early stages of bipolar disorder: A naturalistic study

AIM

In a naturalistic clinical study of patients in the early stages of bipolar disorders the aim was to assess differences between patients with bipolar I (BD I) and bipolar II (BD II) disorders on clinical characteristics including affective symptoms, subjective cognitive complaints, functional level, the presence of comorbid personality disorders and coping strategies.

METHODS

Diagnoses were confirmed using the Structured Clinical Interview for DSM-IV Disorders. Clinical symptoms were rated with the Young Mania Rating Scale and the Hamilton Depression Rating Scale, and functional status using the Functional Assessment Short Test. Cognitive complaints were assessed using the Massachusetts General Hospital Cognitive and Physical Functioning Questionnaire, the presence of comorbid personality disorders using the Standardized Assessment of Personality - Abbreviated Scale and coping style using the Coping Inventory for Stressful Situations.

RESULTS

In total, 344 patients were included (BD I (n=163) and BD II (n=181). Patients with BD II presented with significantly more depressive symptoms, more cognitive complaints, lower overall functioning, and a higher prevalence of comorbid personality disorders. Finally, they exhibited a trend towards using less adaptive coping styles.

LIMITATION

It cannot be omitted that some patients may have progressed from BD II to BD I. Most measures were based on patient self report.

CONCLUSIONS

Overall, BD II was associated with a higher disease burden. Clinically, it is important to differentiate BD II from BD I and research wise, there is a need for tailoring and testing specific interventions towards BD II.

The correlation between plasma brain-derived neurotrophic factor and cognitive function in bipolar disorder is modulated by the BDNF Val66Met polymorphism

We explored the effect of the Brain-derived neurotrophic factor (BDNF) Val66Met polymorphism (rs6265) on correlation between changes in plasma BDNF levels with cognitive function and quality of life (QoL) after 12 weeks of treatment in bipolar disorder (BD). Symptom severity and plasma BDNF levels were assessed upon recruitment and during weeks 1, 2, 4, 8 and 12. QoL, the Wisconsin Card Sorting Test (WCST), and the Conners’ Continuous Performance Test (CPT) were assessed at baseline and endpoint. The BDNF Val66Met polymorphism was genotyped. Changes in cognitive function and QoL over 12 weeks were reduced using factor analysis for the evaluation of their correlations with changes in plasma BDNF. Five hundred forty-one BD patients were recruited and 65.6% of them completed the 12-week follow-up. Changes in plasma BDNF levels with factor 1 (WCST) were significantly negatively correlated (r = −0.25, p = 0.00037). After stratification of BD subtypes and BDNF genotypes, this correlation was significant only in BP-I and the Val/Met genotype (r = −0.54, p = 0.008). We concluded that changes in plasma BDNF levels significantly correlated with changes in WCST scores in BD and is moderated by the BDNF Val66Met polymorphism and the subtype of BD.

Quality of life, functioning and cognition in bipolar disorder and major depression: A latent profile analysis

This study aimed to identify profiles of functioning and quality of life (QOL) in depression (MDD), bipolar disorder (BD) and healthy adults, as well as the clinical, demographic and cognitive variables associated with each of these profiles. Participants completed the WHODAS 2.0 and WHOQOL-BREF, which were submitted to latent profile analysis. The four cluster solution provided the best fit for our data. Cluster 1 consisted mostly of healthy adults, and had the highest functioning and QOL. Clusters 2 contained older patients with subclinical depressive symptoms and psychiatric comorbidities, whose impairments in QOL and functioning were associated with mood symptoms and several cognitive abilities. Patients with MDD, BDI or BDII with mild to moderate depression, such as those in cluster 3, may benefit more significantly from interventions in cognitive flexibility, inhibition, planning, and sustained attention. Lastly, patients with mood disorders and clinically significant levels of depression, as well as a history of suicide attempts, like those in cluster 4, may benefit from interventions aimed at working memory, inhibitory control, and cognitive flexibility; that is, the three core executive functions. These findings should be further investigated, and used to guide treatments for patients with mood disorders and different patterns of functional impairment.

Cognitive variability in bipolar II disorder: who is cognitively impaired and who is preserved

OBJECTIVES

Although it is well established that euthymic patients with bipolar disorder can have cognitive impairment, substantial heterogeneity exists and little is known about the extent and severity of impairment within the bipolar II disorder subtype. Therefore, the main aim of this study was to analyze cognitive variability in a sample of patients with bipolar II disorder.

METHODS

The neuropsychological performance of 116 subjects, including 64 euthymic patients with bipolar II disorder and 52 healthy control subjects, was examined and compared by means of a comprehensive neurocognitive battery. Neurocognitive data were analyzed using a cluster analysis to examine whether there were specific groups based on neurocognitive patterns. Subsequently, subjects from each cluster were compared on demographic, clinical, and functional variables.

RESULTS

A three-cluster solution was identified with an intact neurocognitive group (n = 29, 48.3%), an intermediate or selectively impaired group (n = 24, 40.0%), and a globally impaired group (n = 7, 11.6%). Among the three clusters, statistically significant differences were observed in premorbid intelligence quotient (p = 0.002), global functional outcome (p = 0.021), and leisure activities (p = 0.001), with patients in the globally impaired cluster showing the lowest attainments. No differences in other clinical characteristics were found among the groups.

CONCLUSIONS

These results confirm that neurocognitive variability is also present among patients with bipolar II disorder. Approximately one-half of the patients with bipolar II disorder were cognitively impaired, and among them 12% were severely and globally impaired. The identification of different cognitive profiles may help to develop cognitive remediation programs specifically tailored for each cognitive profile.

The association between biological rhythms, depression, and functioning in bipolar disorder: a large multi-center study

OBJECTIVE

We examined the relationship between biological rhythms and severity of depressive symptoms in subjects with bipolar disorder and the effects of biological rhythms alterations on functional impairment.

METHOD

Bipolar patients (n = 260) and healthy controls (n = 191) were recruited from mood disorders programs in three sites (Spain, Brazil, and Canada). Parameters of biological rhythms were measured using the Biological Rhythms Assessment in Neuropsychiatry (BRIAN), an interviewer administered questionnaire that assesses disruptions in sleep, eating patterns, social rhythms, and general activity.

RESULTS

Multivariate analyses of covariance showed significant intergroup differences after controlling for potential confounders (Pillai's F = 49.367; df = 2, P < 0.001). Depressed patients had the greatest biological rhythms disturbance, followed by patients with subsyndromal symptoms, euthymic patients, and healthy controls. Biological rhythms and HAMD scores were independent predictors of poor functioning (F = 12.841, df = 6, P < 0.001, R²  = 0.443).

CONCLUSION

Our study shows a dose-dependent association between the severity of depressive symptoms and degree of biological rhythms disturbance. Biological rhythms disturbance was also an independent predictor of functional impairment. Although the directionality of this relationship remains unknown, our results suggest that stability of biological rhythms should be an important target of acute and long-term management of bipolar disorder and may aid in the improvement of functioning.

Assessing cognitive function in bipolar disorder: challenges and recommendations for clinical trial design

OBJECTIVE

Neurocognitive impairment in schizophrenia has been recognized for more than a century. In contrast, only recently have significant neurocognitive deficits been recognized in bipolar disorder. Converging data suggest the importance of cognitive problems in relation to quality of life in bipolar disorder, highlighting the need for treatment and prevention efforts targeting cognition in bipolar patients. Future treatment trials targeting cognitive deficits will be met with methodological challenges due to the inherent complexity and heterogeneity of the disorder, including significant diagnostic comorbidities, the episodic nature of the illness, frequent use of polypharmacy, cognitive heterogeneity, and a lack of consensus regarding measurement of cognition and outcome in bipolar patients. Guidelines for use in designing future trials are needed.

PARTICIPANTS

The members of the consensus panel (each of the bylined authors) were selected based upon their expertise in bipolar disorder. Dr Burdick is a neuropsychologist who has studied cognition in this illness for 15 years; Drs Ketter, Calabrese, and Goldberg each bring considerable expertise in the treatment of bipolar disorder, both within and outside of controlled clinical trials. This consensus statement was derived from work together at scientific meetings (eg, symposium presentation at the 2014 Annual Meeting of the American Society of Clinical Psychopharmacology, among others) and ongoing discussions by conference call. With the exception of the public presentations on this topic, these meetings were closed to outside participants.

EVIDENCE

A literature review was undertaken by the authors to identify illness-specific challenges relevant to the design and conduct of treatment trials targeting neurocognition in bipolar disorder. Expert opinion from each of the authors guided the consensus recommendations.

CONSENSUS PROCESS

Consensus recommendations, reached by unanimous opinion of the authors, are provided here as a preliminary guide for future trial design. Recommendations comprise exclusion of certain syndromal-level comorbid diagnoses and current affective instability, restrictions on numbers and types of medications, and use of prescreening assessment to ensure enrollment of subjects with adequate objective evidence of baseline cognitive impairment.

CONCLUSIONS

Clinical trials to address cognitive deficits in bipolar disorder face distinctive design challenges. As such trials move from proof-of-concept to confirmation of clinical efficacy, it will be important to incorporate distinctive design modifications to adequately address these challenges and increase the likelihood of demonstrating cognitive remediation effects. The field is now primed to address these challenges, and a comprehensive effort to formalize best practice guidelines will be a critically important next step.

Functional remediation for patients with bipolar II disorder: improvement of functioning and subsyndromal symptoms

Recently, Functional Remediation (FR) has proven to be effective in improving the functional outcome of euthymic bipolar patients. The aim of this study was to test the efficacy of the FR program in a subsample of euthymic bipolar II patients (BPII). A post-hoc analyses were undertaken using data of 53 BPII outpatients who had participated in a multicenter, rater-blind, randomized, controlled trial exploring the efficacy of FR (n=17) as compared with a Psychoeducation group (PSY) (n=19) and a treatment as usual control group (TAU n=17). The primary outcome variable was the functional improvement defined as the mean change in the Functioning Assessment Short Test (FAST) from baseline to endpoint after the intervention. Regarding the treatment effect, data reveal a significant functional improvement from baseline to endpoint, suggestive for an interaction between program pertinence and time (pre-post). Nevertheless, Tukey׳s post-hoc test only revealed a trend in favor of a better outcome for FR when compared to the other two groups. We also found an interaction between program pertinence and time when analysing the subdepressive symptoms, with BPII patients in FR showing a significant reduction when compared to the PSY group. Our results suggest that the FR appears to be effective in improving the overall functional outcome in BPII, as well as in reducing subdepressive symptoms.

e-HCL-32: a useful, valid and user friendly tool in the screening of bipolar II disorder

BACKGROUND AND OBJECTIVES

Bipolar type II (BDII) is a frequent disorder with high morbidity and mortality, characterized by depressive and hypomanic episodes. Early diagnosis can be effective in improving long-term prognosis. However, diagnosing BDII is challenging due to the difficulty in detecting past hypomanic episodes. The HCL-32 is a widely used and reliable screening instrument for the detection of past hypomanic episodes. Making this tool available to more patients could help diagnose and treat undetected cases of BDII earlier. New technologies such as the Internet have been previously used for this purpose with favorable outcomes. Accordingly, the objective of this study is to evaluate the acceptability, validity, reliability and equivalence of an online version of this questionnaire.

METHODS

From May 2012 to March 2013, 52 participants attending an outpatient mental health clinic completed a paper version of the HCL-32 (HCL-32) and its online version (e-HCL-32) within two weeks. After its completion, they were asked to answer a brief satisfaction survey.

RESULTS

No differences were found (HCL-32 mean total score=17.73 (SD=7.37), e-HCL-32 mean total score=18.28 (SD=7.09). T=-1.720, p=0.092, 95% CI=-1.21 to 0.09) between the results of the paper and pencil HCL-32 compared to its online version (e-HCL-32). The psychometric properties of the online version of the hypomania checklist (e-HCL-32) were good and comparable to the paper and pencil version. 80% of participants found online questionnaires to be easier to answer and more user-friendly.

CONCLUSION

The results of this study support the use of an online screening tool for the detection of previous hypomanic episodes (necessary for BDII diagnosis) as it showed to have a similar validity and reliability to the traditional paper and pencil method.

Empirical evidence for discrete neurocognitive subgroups in bipolar disorder: clinical implications

BACKGROUND

Recent data suggest trait-like neurocognitive impairments in bipolar disorder (BPD), with deficits about 1 s.d. below average, less severe than deficits noted in schizophrenia. The frequency of significant impairment in BPD is approximately 60%, with 40% of patients characterized as cognitively spared. This contrasts with a more homogeneous presentation in schizophrenia. It is not understood why some BPD patients develop deficits while others do not.

METHOD

A total of 136 patients with BPD completed the MATRICS Consensus Cognitive Battery and data were entered into hierarchical cluster analyses to: (1) determine the optimal number of clusters (subgroups) that fit the sample; and (2) assign subjects to a specific cluster based on individual profiles. We then compared subgroups on several clinical factors and real-world community functioning.

RESULTS

Three distinct neurocognitive subgroups were found: (1) an intact group with performance comparable with healthy controls on all domains but with superior social cognition; (2) a selective impairment group with moderate deficits on processing speed, attention, verbal learning and social cognition and normal functioning in other domains; and (3) a global impairment group with severe deficits across all cognitive domains comparable with deficits in schizophrenia.

CONCLUSIONS

These results suggest the presence of multiple cognitive subgroups in BPD with unique profiles and begin to address the relationships between these subgroups, several clinical factors and functional outcome. Next steps will include using these data to help guide future efforts to target these disabling symptoms with treatment.

Differentiating bipolar I and II disorders and the likely contribution of DSM-5 classification to their cleavage

Current diagnostic criteria define bipolar I (BP I) and bipolar II (BP II) disorders as distinct conditions, differing only slightly by clinical features. This review seeks to identify commonalities and differentiating features across the two sub-types, and emphasize that differences in causes and treatments are likely to be highly dependent on the diagnostic criteria used to define and differentiate the two conditions. We undertake a literature review of candidate clinical features that might be anticipated to vary or be shared across BP I and BP II disorders, and consider the impact of DSM definition on such applied findings. Studies respecting DSM-IV differentiation of BP I and BP II disorders have generated relatively few differences across the conditions, which may reflect definitional similarity or commonalities across the two conditions. As DSM-5 decision rules are similar to those used by DSM-IV to differentiate BP I and BP II disorders, we argue for application studies employing DSM-5 decisions to examine the differential impact of three features that weight BP I assignment (i.e. psychosis, hospitalization and/or impairment) and examine other sets of differentiating criteria.

Structural brain alterations in bipolar disorder II: a combined voxel-based morphometry (VBM) and diffusion tensor imaging (DTI) study

BACKGROUND

Brain structural changes have been described in bipolar disorder (BP), but usually studies focused on both I and II subtypes indiscriminately and investigated changes in either brain volume or white matter (WM) integrity. We used combined voxel-based morphometry (VBM) and diffusion tensor imaging (DTI) analysis to track changes in the grey matter (GM) and WM in the brains of patients affected by BPII, as compared to healthy controls.

METHODS

Using VBM and DTI, we scanned 20 DSM-IV-TR BPII patients in their euthymic phase and 21 healthy, age- and gender-matched volunteers with no psychiatric history.

RESULTS

VBM showed decreases in GM of BPII patients, compared to controls, which were diffuse in nature and most prominent in the right middle frontal gyrus and in the right superior temporal gurus. DTI showed significant and widespread FA reduction in BPII patients in all major WM tracts, including cortico-cortical association tracts.

LIMITATIONS

The small sample size limits the generalisability of our findings.

CONCLUSIONS

Reduced GM volumes and WM integrity changes in BPII patients are not prominent like those previously reported in bipolar disorder type-I and involve cortical structures and their related association tracts.

Overview of antidepressant treatment of bipolar depression

Bipolar depression remains a major unresolved challenge for psychiatric therapeutics. It is associated with significant disability and mortality and represents the major proportion of the approximately half of follow-up time spent in morbid states despite use of available treatments. Evidence regarding effectiveness of standard treatments, particularly with antidepressants, remains limited and inconsistent. We reviewed available clinical and research literature concerning treatment with antidepressants in bipolar depression and its comparison with unipolar depression. Research evidence concerning efficacy and safety of commonly used antidepressant treatments for acute bipolar depression is very limited. Nevertheless, an updated meta-analysis indicated that overall efficacy was significantly greater with antidepressants than with placebo-treatment and not less than was found in trials for unipolar major depression. Moreover, risks of non-spontaneous mood-switching specifically associated with antidepressant treatment are less than appears to be widely believed. The findings encourage additional efforts to test antidepressants adequately in bipolar depression, and to consider options for depression in types I vs. II bipolar disorder, depression with subsyndromal hypomania and optimal treatment of mixed agitated-dysphoric states--both short- and long-term. Many therapeutic trials considered were small, varied in design, often involved co-treatments, or lacked adequate controls.

P50 sensory gating is a trait marker of the bipolar spectrum

Sensory gating deficit, assessed by a paired auditory stimulus paradigm (P50), has been reported as a stable marker of schizophrenia. The aim of this study was to explore if this neurophysiological disturbance also fulfilled stability criteria in the bipolar disorder (BD) spectrum bipolar, as state independence is one of the main points to be considered as a potential endophenotype of the illness. The P50 evoked potential was studied in 95 healthy controls and 126 bipolar euthymic patients. Euthymia was established according to Van Gorp's criteria. Bipolar I and II subtypes were analyzed separately. The influence of a lifetime history of psychoses was also evaluated in the clinical sample. P50 gating was deficitary in all the subsamples of patients relative to healthy comparison subjects. Bipolar I patients with and without a history of psychosis showed higher P50 ratios than the other subgroups of patients, although these differences were not significant. P50 alterations were mainly due to a deficit in the inhibition of the second wave (test wave or S2) amplitude.

CONCLUSIONS

The findings suggest that this inhibitory deficit can be considered characteristic of the illness and that the intensity of the gating abnormality varies according to the severity of BD.

Persistence of cognitive impairment and its negative impact on psychosocial functioning in lithium-treated, euthymic bipolar patients: a 6-year follow-up study

BACKGROUND

Previous cross-sectional studies report that cognitive impairment is associated with poor psychosocial functioning in euthymic bipolar patients. There is a lack of long-term studies to determine the course of cognitive impairment and its impact on functional outcome. Method A total of 54 subjects were assessed at baseline and 6 years later; 28 had DSM-IV TR bipolar I or II disorder (recruited, at baseline, from a Lithium Clinic Program) and 26 were healthy matched controls. They were all assessed with a cognitive battery tapping into the main cognitive domains (executive function, attention, processing speed, verbal memory and visual memory) twice over a 6-year follow-up period. All patients were euthymic (Hamilton Rating Scale for Depression score lower than 8 and Young mania rating scale score lower than 6) for at least 3 months before both evaluations. At the end of follow-up, psychosocial functioning was also evaluated by means of the Functioning Assessment Short Test.

RESULTS

Repeated-measures multivariate analysis of covariance showed that there were main effects of group in the executive domain, in the inhibition domain, in the processing speed domain, and in the verbal memory domain (p<0.04). Among the clinical factors, only longer illness duration was significantly related to slow processing (p=0.01), whereas strong relationships were observed between impoverished cognition along time and poorer psychosocial functioning (p<0.05).

CONCLUSIONS

Executive functioning, inhibition, processing speed and verbal memory were impaired in euthymic bipolar out-patients. Although cognitive deficits remained stable on average throughout the follow-up, they had enduring negative effects on psychosocial adaptation of patients.

Neurocognitive features in subgroups of bipolar disorder

OBJECTIVE

To examine which subgroups of DSM-IV bipolar disorder (BD) [BD type I (BD-I) or BD type II (BD-II), and subgroups based on history of psychosis, presenting polarity, and age at onset] differentiate best regarding neurocognitive measures.

METHODS

A total of 199 patients with BD were characterized by clinical and neurocognitive features. The distribution of subgroups in this sample was: BD-I, 64% and BD-II, 36%; 60% had a history of psychosis; 57% had depression as the presenting polarity; 61% had an early onset of BD, 25% had a mid onset, and 14% had a late onset. We used multivariate regression analyses to assess relationships between neurocognitive variables and clinical subgroups.

RESULTS

Both BD-I diagnosis and elevated presenting polarity were related to impairments in verbal memory, with elevated presenting polarity explaining more of the variance in this cognitive domain (22.5%). History of psychosis and BD-I diagnosis were both related to impairment in semantic fluency, with history of psychosis explaining more of the variance (11.6%).

CONCLUSION

Poor performance in verbal memory appears to be associated with an elevated presenting polarity, and poor performance in semantic fluency appears to be associated with a lifetime history of psychosis.