Impulsivity and functional impairment in bipolar disorder

The Relationship of Functioning and Life Satisfaction with Illness Management and Recovery in Patients with Bipolar Disorder: A Cross-Sectional Study

The aim of this study was to determine relationship between functioning and life satisfaction with illness management and recovery, and determinants of illness management and recovery in patients with bipolar disorder. This descriptive and correlational study was conducted with 152 participants between August 2022 and February 2023. "Personal Information Form", "Illness Management and Recovery Scale", "Functioning Assessment Short Test" and "Adult Life Satisfaction Scale" were used to collecting data. In study, a positive relationship was found between illness management and recovery and total functionality, autonomy, cognitive functionality, interpersonal relationships, and life satisfaction. Gender, marital status, educational status, employment status, total functioning, autonomy, cognitive functioning, interpersonal relationships, and life satisfaction were found to be effective in illness management and recovery. Being female, single, primary school graduate, unemployed, having low functioning (autonomy, cognitive functioning, interpersonal relationships) and having low life satisfaction were found to be determinants of illness management and recovery.

Proposition of a transdiagnostic processual approach of emotion dysregulation based on core triggers and interpersonal styles

Emotion dysregulation (ED) has primarily been described in patients suffering from borderline personality disorder (BPD) and is an integral part of this diagnosis, but it is also a transdiagnostic construct that can be found in several other psychiatric disorders. The strong relationships between ED and BPD may lead clinicians to underestimate ED associated to other clinical contexts. This can lead to difficulties in diagnostic and treatment orientation, especially in the context of comorbidities. In this article, after reviewing the literature on the development and functioning of emotion dysregulation, and on the evidence for emotion dysregulation in eight disorders (borderline personality disorder, pathological narcissism with/without narcissistic personality disorder, obsessive-compulsive personality disorder, antisocial personality disorder, bipolar disorder, autism spectrum disorder, complex post-traumatic stress disorder, and adult attention deficit hyperactivity disorder), we present a transdiagnostic processual model of emotion dysregulation based on core triggers and interpersonal styles to try to address this issue and to provide a simple but technical tool to help clinicians in their diagnostic assessment and treatment orientation. By focusing more on typical patterns and interpersonal dynamics than only on categories, we believe that this model may contribute to the actual need for improvement of our current psychiatric classifications, alongside other well-studied and under-used dimensional models of psychopathology (e.g., HiTOP, AMPD), and may be useful to build more specific treatment frameworks for patients suffering from ED.

The interplay of daily affect and impulsivity measured by mobile surveys in bipolar disorder

Background

Impulsivity is a prominent feature of bipolar disorder associated with various negative sequelae; moreover, it may be a precursor to shifts in affect or mood, but little is known about its association with affect on a day-to-day timescale. Ecological momentary assessments (a method that captures moment-to-moment ratings of psychological states by repeatedly sampling the same individual) of impulsivity and affect using mobile surveys allow for more nuanced examination of mechanisms of mood and behavior dysregulation. However, few existing studies have validated an ecological momentary assessment of impulsivity in bipolar disorder and examined its time-lagged associations with positive and negative affect. 70 participants with bipolar disorder and 102 healthy comparisons participated in an intensive longitudinal study: they underwent 14 days of ecological momentary assessment data collection annually for 1–4 years. Multiple measures of impulsivity and affect were collected using self-report, behavioral, and ecological momentary assessment modalities; these measures were compared, and levels of impulsivity were compared between bipolar disorder and healthy comparison groups. Time-lagged analyses using daily means explored the next-day predictive relationship of impulsivity on positive/negative affect, and vice versa.

Results

The ecological momentary measure of impulsivity was moderately correlated with the self-report but not behavioral impulsivity measure. Bipolar disorder participants evinced higher self-report, behavioral, and daily impulsivity than healthy comparison participants. Time-lagged analyses revealed a bi-directional association between high impulsivity and high next-day negative (but not positive) affect. Post hoc analyses showed that impulsivity specifically predicted next-day anger and anxiety.

Conclusions

Our multimodal assessment of impulsivity allowed for an examination of the day-to-day course of impulsivity and affect, crucial steps toward understanding the mechanisms of mood symptom and episode onset in bipolar disorder.

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.

Rethinking "aggression" and impulsivity in bipolar disorder: Risk, clinical and brain circuitry features

BACKGROUND

Elevated aggression and impulsivity are implicated in Bipolar Disorder (BD); however, relationships between these behavioral constructs have not been clarified, which can lead to misconceptions with negative consequences including stigma and adverse outcomes including suicide. The study aimed to clarify brain-based distinctions between the two constructs and their associations to risk factors, symptoms and suicide thoughts and behaviors.

METHODS

Self-rated Brown-Goodwin Aggression (BGA) and Barratt Impulsiveness Scale (BIS) scores were compared between adults with BD (n = 38, 74% female) and healthy controls (HC, n = 29, 64% female). Relationships were examined between BGA and BIS with childhood trauma questionnaire (CTQ), mood, comorbidities, and magnetic resonance imaging gray matter volume (GMV) assessments.

RESULTS

In BD, BGA and BIS total scores were both elevated and associated with childhood maltreatment (CM), particularly emotional CM, depression, substance use disorders (SUDs) and suicide attempts (SAs). BGA scores were increased by items corresponding to dysregulation of emotional and social behavior and associated with elevated mood states and suicide ideation and GMV decreases in bilateral orbitofrontal cortex and left posterior insula brain regions, previously associated with these behaviors and clinical features. BIS motor impulsiveness scores were associated with GMV decreases in anterior cingulate cortex implicated in mood and behavioral dyscontrol.

LIMITATIONS

modest sample size, self-reports CONCLUSIONS: The findings suggest separable brain-based domains of dysfunction in BD of motor impulsiveness versus emotionally dysregulated feelings that are primarily self-directed. Both domains are associated with suicide behavior and modifiable risk factors of CM, depression and SUDs that could be targeted for prevention.

The relations between executive functions and occupational functioning in individuals with bipolar disorder: a scoping review

Background

Patients with bipolar disorder experience impairments in their occupational functioning, despite remission of symptoms. Previous research has shown that neurocognitive deficits, especially deficits in executive functions, may persist during euthymia and are associated with diminished occupational functioning.

Objectives

The aim of this scoping review was to identify published studies that report on the relationships between executive functions and occupational functioning in BD to review current knowledge and identify knowledge gaps. In addition to traditional neuropsychological approaches, we aimed to describe executive functioning from a self-regulation perspective, including emotion regulation.

Methods

We applied the methodological framework as described by Arksey and O’Malley (Int J Soc Res Methodol Theory Pract 8:19–32, 2005) and Levac et al. (Implement Sci 5:1–9, 2010). We searched PubMed and psycINFO for literature up to November 2021, after which we screened papers based on inclusion criteria. Two reviewers independently performed the screening process, data charting process, and synthesis of results.

Results

The search yielded 1202 references after deduplication, of which 222 remained after initial screening. The screening and inclusion process yielded 82 eligible papers in which relationships between executive functions and occupational functioning are examined.

Conclusion

Neurocognitive deficits, including in executive functions and self-regulation, are associated with and predictive of diminished occupational functioning. Definitions and measurements for neurocognitive functions and occupational functioning differ greatly between studies, which complicates comparisons. Studies on functional remediation show promising results for improving occupational functioning in patients with BD. In research and clinical practice more attention is needed towards the quality of work functioning and the various contexts in which patients with BD experience deficits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00255-7.

Long-term outcome predictors after functional remediation in patients with bipolar disorder

BACKGROUND

Improving functioning in patients with bipolar disorder (BD) is one of the main objectives in clinical practice. Of the few psychosocial interventions that have been specifically developed to enhance the psychosocial outcome in BD, functional remediation (FR) is one which has demonstrated efficacy. The aim of this study was to examine which variables could predict improved functional outcome following the FR intervention in a sample of euthymic or subsyndromal patients with BD.

METHODS

A total of 92 euthymic outpatients were included in this longitudinal study, with 62 completers. Partial correlations controlling for the functional outcome at baseline were calculated between demographic, clinical and neurocognitive variables, and functional outcome at endpoint was assessed by means of the Functioning Assessment Short Test scale. Next, a multiple regression analysis was run in order to identify potential predictors of functional outcome at 2-year follow-up, using the variables found to be statistically significant in the correlation analysis and other variables related to functioning as identified in the previous scientific literature.

RESULTS

The regression model revealed that only two independent variables significantly contributed to the model (F(6,53): 4.003; p = 0.002), namely verbal memory and inhibitory control. The model accounted for 31.2% of the variance. No other demographic or clinical variable contributed to the model.

CONCLUSIONS

Results suggest that patients with better cognitive performance at baseline, especially in terms of verbal memory and executive functions, may present better functional outcomes at long term follow-up after receiving functional remediation.

Predictors of psychosocial functioning in euthymic patients with bipolar disorder: A model selection approach

BACKGROUND

Functional impairment is a major target in the treatment of bipolar disorder (BD), but the magnitude and type of functional difficulties differ across patients. Findings on predictors of overall functioning and specific functional areas are inconsistent. We aimed to characterize functional difficulties and identify factors associated with global functioning and individual domains in euthymic patients.

METHODS

The Functional Assessment Short Test (FAST) was used to assess overall psychosocial functioning and specific functional domains in 80 euthymic participants with BD. Participants also completed a clinical interview and a cognitive assessment. Model selection with elastic net regression was performed to identify predictors of global functioning. We then examined the association of these predictors with individual functional domains using correlation.

RESULTS

FAST scores indicated moderate or severe impairment for 54% of the sample, with occupational functioning showing the highest impairment rate. Elastic net regression selected a model with three variables (higher residual depressive symptoms, lower executive functioning, more perceived cognitive deficits) as predictors of overall functioning. No significant associations were found between these predictors. Depressive symptoms were associated with interpersonal relationships and leisure time, executive skills with occupational functioning, and perceived deficits with cognitive functioning.

CONCLUSIONS

Residual depressive symptoms were the strongest predictor of overall functioning which highlights the importance of assessing and targeting subthreshold symptoms for recovery. Executive difficulties were associated with functioning, particularly occupational skills, independently of depressive symptoms. Interventions targeting these difficulties, such as cognitive and functional remediation, may be key treatment options towards facilitating functional recovery.

Efficacy and safety of topiramate for reducing impulsivity: A transdiagnostic systematic review and meta-analysis of a common clinical use

Impulsivity is an important transdiagnostic feature of many psychiatric disorders, as well as a marker of poorer outcome. Topiramate is broadly used for reducing impulsivity in various neuropsychiatric disorders, but no systematic review or meta-analysis has ever explored whether evidence supports this clinical use. We conducted a systematic review and meta-analysis of the literature, using PubMed, PsycInfo and Cochrane databases. We included all studies assessing the efficacy of topiramate in adults with high levels of impulsivity, based on either psychometric or neuropsychological measures. Seven articles were included, involving 578 participants. Important heterogeneity in designs and quality features was observed. Topiramate lowered impulsivity levels in two of the studies that used the Barratt Impulsiveness Scale (BIS) (401 participants) and in one of the studies that used neuropsychological measures (63 participants). Four other studies found no effect of topiramate on impulsivity. A larger reduction in the BIS-11 overall score, with a mean difference of 2.57 (95% confidence interval -4.12 to -1.02), was found in the topiramate group than the placebo group using a random effects model. However, one study accounted for the major part (85.5%) of it, and most included studies presented a high risk of bias. The use of a self-assessment scale induced an additional risk of self-report bias. No clear-cut evidence was found for a transdiagnostic effectiveness of topiramate in reducing impulsivity levels. However, encouraging results were found in some specific disorders.

Functioning in euthymic patients with bipolar disorder: A systematic review and meta-analysis using the Functioning Assessment Short Test

OBJECTIVES

Systematically review the prevalence of functional impairment (FI) in euthymic patients with bipolar disorder (BD), as assessed only with the Functioning Assessment Short Test (FAST), explore the prevalence of this impairment among all the domains, identify the most compromised of them and the clinical variables associated with low functioning in this population.

METHODS

Meta-analyses were performed, searching for relevant papers published from 2007 to 2019 in Medline, Embase, Cochrane, PsycINFO databases and via hand-searching, without language restrictions. 1128 studies were initially identified, 13 of which were ultimately chosen based on the eligibility criteria. A two-step meta-analysis was performed using the mean difference with a 95% confidence interval for continuous variables and proportion estimation with a fixed-effects model for categorical variables.

RESULTS

In the first step, all FAST domains showed worse FI in patients than in healthy controls, with significant differences between groups. In the second step, the prevalence of FI domains were as follows: global, 58.6%; occupational, 65.6%; cognitive, 49.2%; autonomy, 42.6%; interpersonal relationships, 42.1%; leisure, 29.2%; and financial issues, 28.8%. Residual depressive symptoms were the most frequently cited variable associated with FI.

CONCLUSIONS

This study reinforces the relevant functional impact of BD in this population and suggests that the occupational domain may be the most impaired. Greater efforts should be directed toward targeting functioning in patient care, as it constitutes the most meaningful endpoint of response to treatment, especially with occupational and cognitive rehabilitation, thus allowing patients to overcome the course of illness and carry fulfilling lives.

Cognitive remediation for the treatment of neuropsychological disturbances in subjects with euthymic bipolar disorder: findings from a controlled study

INTRODUCTION

Individuals with euthymic Bipolar Disorder (BD) can experience deteriorated cognitive functioning, with such deterioration being associated with functional impairment. Cognitive remediation (CR) is considered an effective add-on intervention for neuropsychological impairments, but relatively few CR controlled studies have been performed on BD. In the present study the efficacy of a CR intervention designed for the improvement of cognition and functioning in patients with euthymic BD was tested.

METHODS

Patients (n = 54) with euthymic BD were assigned to receive active (n = 27) or control (n = 27) intervention. The active intervention (i.e. the Cognitive Remediation in Integrated Treatment - CRIIT - protocol) was made of 20 individual sessions focused on the treatment of attention, memory and executive functioning through the COGPACK software; each session was integrated with psychoeducation and rehabilitation interventions implemented through a metacognitive approach aimed at ameliorating personal agency.

RESULTS

A significant (p ≤ 0.015) time x group interaction at repeated measures MANOVA was observed on Rey Auditory Verbal Learning Test, Rey Complex Figure Test, Wisconsin Card Sorting Test, Trail Making Test, Visual Search, Life Skills Profile, and Barratt Impulsiveness Scale.

LIMITATIONS

A single-blind approach was used.

DISCUSSION

The results showed that patients undergoing active intervention improved in domains related to executive functions, attention, memory, functioning and impulsivity more significantly than patients undergoing control interventions. This study adds to the evidence that CR improves neurocognition in BD, and suggests that CRIIT protocol represents an add-on intervention of potential relevance to increase cognition and functioning in BD euthymic patients.

Neural correlates of response inhibition in patients with bipolar disorder during acute versus remitted phase

Objectives: Elevated behavioural impulsivity has been shown to be a core feature of bipolar disorder. However, no study has so far investigated impulsivity-related brain activation in patients with BD during acute versus remitted phase. To address the question whether elevated behavioural impulsivity and its differential neural pathways is a state or trait marker of BD, we employed a combined stop signal-go/no-go task in 30 controls, and 37 depressed and 15 remitted patients who were retested.Methods: Frontal brain activation was recorded using near-infrared spectroscopy.Results: Behaviourally, we found increased impulsivity as indexed by higher stop signal reaction time for patients in their depressed phase while remitted patients did not differ from controls in any measure. In contrast, brain activation measurements revealed an opposite pattern: compared to controls, depressed patients did not show significant differences, while the remitted group displayed significantly decreased activation in bilateral prefrontal cortex during successful inhibition. Analysis of the remaining conditions (go, no-go, unsuccessful inhibition) did not reveal significant differences.Conclusions: Therefore, behavioural impulsivity and prefrontal hypoactivation do not seem to be a trait marker of BD. As only successful inhibition differentiated between groups, a specific dysfunction of this inhibitory process and its neural pathway may be postulated in BD.

Functional outcome assessment in bipolar disorder: A systematic literature review

OBJECTIVES

Functional impairment is an important driver of disability in patients with bipolar disorder (BD) and can persist even when symptomatic remission has been achieved. The objectives of this systematic literature review were to identify studies that assessed functioning in patients with BD and describe the functional scales used and their implementation.

METHODS

A systematic literature review of English-language articles published between 2000 and 2017 reporting peer-reviewed, original research related to functional assessment in patients with BD was conducted.

RESULTS

A total of 40 articles met inclusion criteria. Twenty-four different functional scales were identified, including 13 clinician-rated scales, 7 self-reported scales, and 4 indices based on residential and vocational data. The Global Assessment of Functioning (GAF) and the Functional Assessment Short Test (FAST) were the most commonly used global and domain-specific scales, respectively. All other scales were used in ≤2 studies. Most studies used ≥1 domain-specific scale. The most common applications of functional scales in these studies were evaluations of the relationships between global or domain-specific psychosocial functioning and cognitive functioning (eg, executive function, attention, language, learning, memory) or clinical variables (eg, symptoms, duration of illness, number of hospitalizations, number of episodes).

CONCLUSIONS

The results of this review show growing interest in the assessment of functioning in patients with BD, with an emphasis on specific domains such as work/educational, social, family, and cognitive functioning and high utilization of the GAF and FAST scales in published literature.

Validation of the Barratt Impulsiveness Scale- short form among Indian adolescents

BACKGROUND

Impulsivity is widely assessed with a 30 item self-report measure known as the Barrratt Impulsiveness Scale (BIS-11). Further development involved creation of an abbreviated version, called Barratt Impulsiveness Scale- short form (BIS-15; Spinella, 2007) from the original BIS-11. Unlike the original BIS-11, BIS-15 has not undergone sufficient cross cultural validation especially among the adolescent population.

AIM

To evaluate the factor structure and psychometric properties of BIS-15 among school and college attending Indian adolescents.

METHOD

A total of 1806 adolescents (females = 48%, mean age = 17.14 years) completed BIS-15 questionnaire, strengths and difficulties questionnaire (SDQ) and a risk taking questionnaire that assessed adolescents level of involvement in two protypical risky behaviours- substance use and unsafe sexual behaviours.

RESULTS

The results of the principal component analysis of BIS-15 items revealed a three factor structure: attentional, motor and non-planning impulsivity. The internal consistency of BIS-15 was 0.79. The total score on BIS-15 was significantly associated with the externalizing, internalizing and total difficulty score on SDQ. Significant associations were observed between BIS-15 total impulsivity score and the level of risk taking among adolescents. Further, the results also revealed gender variance in impulsivity scores where male adolescents scored higher on attentional and non-planning impulsivity as compared to female adolescents.

CONCLUSION

BIS-15 is a reliable measure of impulsivity that can be used with Indian adolescent population. It would be particularly more suitable for use in settings that require comprehensive assessment of trait impulsivity in shorter time duration and without burdening the participants.

Increased reward-oriented impulsivity in older bipolar patients: A preliminary study

OBJECTIVE

Impulsivity is a well-established trait of bipolar disorder (BD) that persists across mood phases. It is, however, still unknown whether, in BD, impulsivity remains stable or varies in intensity over the lifespan. This cross-sectional study compared impulsive behavior in older euthymic BD patients and healthy individuals using a range of self-rating and behavioral measures of impulsivity.

METHODS

28 BD patients (56.07 ± 4.08 years, 16 women) and 15 healthy controls (HC; 55.1 ± 3.95 years, 6 women) were administered the Barratt Impulsivity Scale (BIS) and selected tasks of the Cambridge Neuropsychological Test Automated Batter (CANTAB) reflecting impulsivity. Multivariate analysis of variance controlled for age compared impulsivity measures across BD and HC.

RESULTS

BD patients displayed poor decision making, risk taking, and increased delay aversion. Other measures of impulsivity such as response inhibition, sustained cognitive control, and BIS scores were, overall, comparable between BD and HC.

CONCLUSIONS

These preliminary findings suggest that, in BD, aspects of impulsivity related to reward-based decision making persist into late adulthood. Large scale, longitudinal studies are needed to evaluate the relationship of age to impulsivity over time, and explore the link between impulsivity and illness progression in elderly individuals with BD.

The Resilience Questionnaire for Bipolar Disorder: Development and validation

The goal of this research project was to develop a new questionnaire to assess resilience in Bipolar Disorder (BD), the Resilience Questionnaire for Bipolar Disorder (RBD). To examine its psychometric properties, a sample of 125 patients diagnosed with BD and a comparison sample of 107 people completed the new RBD and established measures of generic resilience and health-related outcomes. Exploratory factor analysis for the RBD yielded a 23-item 5-factor solution, and confirmatory factor analysis indicated adequate fit indices. Internal consistency, stability, concurrent validation and known-groups' validity were also supported. The RBD obtained higher responsiveness (6-month follow-up) than the generic resilience scale (BD sample). The RBD is a robust measure to monitor resilience in BD.

Mood disorders and biological rhythms in young adults: A large population-based study

BACKGROUND

It is known that sleep disturbance has been considered a trait-marker of mood disorders. However, the role of disruptions in biological rhythms, such as eating, activity, and social patterns, needs to be better understood.

AIM

To assess the differences in biological rhythms in subjects with bipolar disorder, major depressive disorder, and healthy controls. We also tested the association between disruptions of biological rhythms and circadian preferences.

METHODS

A cross-sectional, population-based study with a representative sample of 1023 young adults. Bipolar disorder and depression were diagnosed using The Mini International Neuropsychiatric Interview - PLUS and DSM Structured Clinical Interview. Self-reported biological rhythms and circadian preference were assessed using the Biological Rhythm Interview of Assessment in Neuropsychiatry (BRIAN).

RESULTS

Bipolar disorders and depression subjects presented higher rates of disruption in biological rhythms when compared to healthy controls even after adjusting for sex, socioeconomic status, alcohol, tobacco, illicit drug use, anxiety disorder and psychotropic medication use. Euthymic subjects showed higher biological rhythm disruption when compared to controls. Higher disruption in biological rhythms was observed in subjects with evening preferences.

CONCLUSION

Higher disruption in biological rhythms occurs in individuals with depression and bipolar disorder even on periods of euthymia.

Impulsivity is associated with blood pressure and waist circumference among adolescents with bipolar disorder

OBJECTIVE

Cardiovascular risk factors (CVRFs) and impulsivity are common in bipolar disorder (BD), and CVRFs are also linked with impulsivity through a number of mechanisms, both behavioral and biological. This study examines the association between CVRFs and impulsivity in adolescents with BD.

METHODS

Subjects were 34 adolescents with BD and 35 healthy control (HC) adolescents. CVRFs were based on International Diabetes Federation metabolic syndrome criteria (triglycerides, high-density lipoprotein cholesterol, waist circumference, blood pressure (BP) and glucose). Impulsivity was measured using the computerized Cambridge Gambling Task (CGT). Analyses controlled for age, IQ, lifetime attention deficit hyperactivity disorder, and current antipsychotic use.

RESULTS

Adolescents with BD had higher diastolic BP (73.36 ± 9.57 mmHg vs. 67.91 ± 8.74 mmHg, U = 401.0, p = 0.03), higher triglycerides (1.13 ± 0.60 mmol/L vs. 0.78 ± 0.38 mmol/L, U = 373.5, p = 0.008), and were more likely to meet high-risk criteria for waist circumference (17.6% vs. 2.9%, p = 0.04) vs. HC. Within the BD group, CGT sub-scores were correlated with CVRFs. For example, overall proportion bet was positively correlated with systolic (r = 0.387, p = 0.026) and diastolic (ρ = 0.404, p = 0.020) BP. Quality of decision-making was negatively correlated with systolic BP (ρ = -0.401, p = 0.021) and waist circumference (ρ = -0.534, p = 0.003). Significant interactions were observed, such that BD diagnosis moderates the relationship between both waist circumference and BP with CGT sub-scores.

CONCLUSION

BP and waist circumference are associated with impulsivity in BD adolescents, but not in HC adolescents. Future studies are warranted to determine temporality and to evaluate whether optimizing CVRFs improves impulsivity among BD adolescents.

Behavioral measures and self-report of impulsivity in bipolar disorder: no association between Stroop test and Barratt Impulsiveness Scale

BACKGROUND

Impulsivity as a tendency to act quickly without considering future consequences has been proposed as a dimensional factor in bipolar disorder. It can be measured using behavioral tasks and self-report questionnaires. Previous findings revealed patients to show worse performance on at least one behavioral measure of impulsivity. Additionally, self-reported impulsivity seems to be higher among bipolar patients, both parameters being possibly associated with a more severe course of illness. In this study, our primary aim was to investigate the relationship between these two constructs of impulsivity among bipolar patients.

METHODS

A total of 40 euthymic patients with bipolar disorder (21 female, 22 Bipolar I) and 30 healthy controls were recruited for comprehensive neuropsychological assessment. To assess inhibition control as a behavioral measure of impulsivity, the Stroop Color and Word Test (Stroop) was used. Additionally, both groups completed the Barratt Impulsiveness Scale (BIS) as a self-report of impulsivity. To compare the groups' performance on the Stroop and ratings on the BIS, the non-parametric Mann-Whitney U test was used. Within the bipolar group, we additionally examined the possibility of an association between Stroop performance and BIS total scores using Pearson's Correlation r.

RESULTS

Patients and controls differed significantly on the Stroop and BIS, with patients performing worse on the Stroop and scoring higher on the BIS. However, there was no association between the Stroop and BIS within the bipolar group. As an exploratory analysis, a positive correlation between Stroop performance and number of episodes was found. Further, we detected a statistical trend in the direction of poorer Stroop performance among patients treated with polypharmacy.

CONCLUSIONS

Both difficulties with behavioral inhibition and self-reported impulsivity were observed to be higher in bipolar patients than controls in the current study. However, within the patient group we did not observe an association between patients' behavioral performance and self-report. This indicates that the parameters likely constitute distinct, dimensional factors of bipolar disorder. In future research, studies with larger samples should investigate which of the two markers constitutes the better marker for the illness and is more suitable to differentiate the most severe patients.

Psychometric properties and validation of a four-item version of the Strauss-Carpenter scale in bipolar disorder

Background

Bipolar disorder is a chronic illness that impairs functioning and affects the quality of life of patients. The onset of this illness usually occurs at an early age, and the risk of relapse remains high for decades. Thus, due to the great clinical relevance of identifying long-term predictors of functioning in bipolar disorder, Strauss and Carpenter developed a scale composed of items known to have prognostic value.

Methods

To determine the clinical usefulness of the four-item Strauss–Carpenter scale in bipolar disorder, a 1-year prospective follow-up study was carried out. The internal consistency, convergent and discriminant validity, and test–retest reliability of the scale were assessed. We also compared the Strauss–Carpenter scale with the reference scales Global Assessment Functioning (GAF), Clinical Global Impression for Bipolar Disorder, the Modified Version (CGI-BIP-M) and the Sheehan Disability Scale (Sheehan). Additionally, a cut-off point for remission was established.

Results

The total sample was composed of 98 patients with a diagnosis of bipolar disorder. The four-item version of the Strauss–Carpenter scale showed to have appropriate psychometric properties, comparable to those of reference scales. The best cut-off point for remission was 14.

Conclusions

The four-item version of the Strauss–Carpenter scale has suitable validity and reliability for the assessment of functioning in patients with bipolar disorder.

[Factors predicting functioning in type 1 bipolar patients during remission period]

INTRODUCTION

Recent studies indicate that bipolar disorder is associated with a profound impairment in almost all areas of functioning. This study aims to evaluate functional recovery in type 1 bipolar patients during remission period.

METHOD

We conducted a cross-sectional study of euthymic type 1 bipolar patients followed up on an ambulatory basis. In the analysis to be reported here we used Hamilton Depression Scale, Young Mania Rating Scale (YMRS), Rosenberg Self-Esteem Scale, and Functioning Assessment Short Test (FAST).

RESULTS

More than half of the study population (53.3%) had overall functional impairment. The overall functioning was associated with age, education level, professional activity, the number of manic and depressive episodes, the number of hospitalizations, a higher HDRS score as well as with the two self-esteem subscores: "self-confidence" and "self-deprecation".

CONCLUSION

Our results suggest that a paradigm shift in the treatment of bipolar disorders should happen and that the goals of therapy should be modified from symptomatic remission to functional remission.

Impulsivity predicts the onset of DSM-IV-TR or RDC hypomanic and manic episodes in adolescents and young adults with high or moderate reward sensitivity

BACKGROUND

A growing body of research suggests that bipolar disorders (BD) are associated with high impulsivity. Using a multi-method approach, the current study provided the first examination of the hypothesis that impulsivity would prospectively predict shorter time to onset of DSM-IV-TR or RDC hypomanic or manic episodes in a sample selected based on reward sensitivity, a biobehavioral trait shown to predict onset and course of BD.

METHODS

163 participants with high reward sensitivity and 114 participants with moderate reward sensitivity were followed every six months for an average of 2.68 years. Participants completed the Barratt Impulsiveness Scale - Version 11 (BIS-11), Balloon Analog Risk Task (BART), Beck Depression Inventory, Altman Self-Rating Mania Scale, and an expanded Schedule for Affective Disorders and Schizophrenia (exp-SADS) - Lifetime Version at baseline and were followed prospectively with the exp-SADS - Change Version to assess onset of hypomanic or manic episodes and treatment seeking for mood problems.

RESULTS

Cox proportional hazard regression analyses indicated that impulsivity as measured by a behavioral task (BART; OR=1.04, p=.03) and a self-report measure (BIS-11 Attentional Impulsiveness subscale; OR=1.16, p=.01) predicted shorter time to hypomania/mania onset, after controlling for baseline depressive and manic symptoms, family history of mood disorder, treatment seeking for mood problems, and reward sensitivity.

LIMITATIONS

The study was limited by non-comprehensive assessment of impulsivity and unknown generalizability to clinical samples.

CONCLUSIONS

Impulsivity confers vulnerability to hypomania or mania. Future studies would benefit from considering how impulsivity can be integrated into existing biopsychosocial models of BD.

Assessing personal financial management in patients with bipolar disorder and its relation to impulsivity and response inhibition

INTRODUCTION

Impulsivity and risk-taking behaviours are reported in bipolar disorder (BD). We examined whether financial management skills are related to impulsivity in patients with BD.

METHODS

We assessed financial management skills using the Executive Personal Finance Scale (EPFS), impulsivity using the Barratt Impulsiveness Scale (BIS) and response inhibition using an emotional go/no-go task in bipolar individuals (N = 21) and healthy controls (HC; N = 23).

RESULTS

Patients had fewer financial management skills and higher levels of impulsivity than HC. In patients and controls, increased impulsivity was associated with poorer personal financial management. Patients and HC performed equally on the emotional go/no-go task. Higher BIS scores were associated with faster reaction times in HC. In patients, however, higher BIS scores were associated with slower reaction times, possibly indicating compensatory cognitive strategies to counter increased impulsivity.

CONCLUSIONS

Patients with BD may have reduced abilities to manage personal finances, when compared against healthy participants. Difficulty with personal finance management may arise in part as a result of increased levels of impulsivity. Patients may learn to compensate for increased impulsivity by modulating response times in our experimental situations although whether such compensatory strategies generalize to real-world situations is unknown.

Low compliance to pharmacological treatment is linked to cognitive impairment in euthymic phase of bipolar disorder

BACKGROUND

Cognitive impairment and low compliance to pharmacological treatment are frequent complications in bipolar disorder. Moreover, low compliance in patients with bipolar disorder is one of the main reasons for relapse. This in turn, is associated with an increase in neurocognitive symptoms. The current study aimed to determine whether attention, memory, and executive function are related to the level of compliance to pharmacological treatment in individuals with bipolar disorder in euthymic phase.

METHOD

We examined 34 patients with bipolar disorder (12 with low compliance to the treatment and 22 with high compliance to the treatment) according to the DSM-IV criteria, in the range of 18-55 years. All patients were assessed through a neuropsychological battery in one single session. Analysis of covariance (ANCOVA) was used to compare neuropsychological test scores between low and high compliance patients. Clinical and sociodemographic characteristics were included as covariates in the study.

RESULTS

Patients with low level of compliance performed significantly worse than high treatment compliance on verbal memory immediate free recall (F (1)=12.14, p=.002), verbal memory immediate cued recall (F (1)=10.45, p=.003), verbal memory delayed free recall (F (1)=5.52, p=.027), and verbal memory delayed cued recall (F (1)=6.11, p=.021). Covariates such as number of manic episodes, history of psychosis and years of education were found significant for executive functions and processing speed.

CONCLUSION

We found that low compliance to pharmacological treatment is consistently linked to immediate and delayed verbal memory. In addition, executive function and processing speed were associated with clinical and demographic characteristics. Limitations of this study include the small sample size, a cross-sectional design that cannot address causality, and inability to account for pharmacologic effects.

Clinical features, impulsivity, temperament and functioning and their role in suicidality in patients with bipolar disorder

OBJECTIVE

Our aim was to analyse sociodemographic and clinical differences between non-suicidal (NS) bipolar patients (BP), BP reporting only suicidal ideation (SI) and BP suicide attempters according to Columbia-Suicide Severity Rating Scale (C-SRSS) criteria. Secondarily, we also investigated whether the C-SRSS Intensity Scale was associated with emergence of suicidal behaviour (SB).

METHOD

A total of 215 euthymic bipolar out-patients were recruited. Semistructured interviews including the C-SRSS were used to assess sociodemographic and clinical data. Patients were grouped according to C-SRSS criteria: patients who scored ≤1 on the Severity Scale were classified as NS. The remaining patients were grouped into two groups: 'patients with history of SI' and 'patients with history of SI and SB' according to whether they did or did not have a past actual suicide attempt respectively.

RESULTS

Patients from the three groups differed in illness onset, diagnosis, number of episodes and admissions, family history, comorbidities, rapid cycling and medication, as well as level of education, functioning, impulsivity and temperamental profile.

CONCLUSION

Our results suggest that increased impulsivity, higher rates of psychiatric admissions and a reported poor controllability of SI significantly increased the risk for suicidal acts among patients presenting SI.

Predictors of long-term work disability among patients with type I and II bipolar disorder: a prospective 18-month follow-up study

OBJECTIVES

Bipolar disorder (BD) is one of the leading causes of disability worldwide. However, vocational ability and predictors of long-term work disability have rarely been studied among patients with BD. We investigated clinical predictors of work disability among patients with BD in psychiatric care.

METHODS

The Jorvi Bipolar Study (JoBS) is a naturalistic prospective cohort study (N = 191) representing adult (18-59 years) psychiatric inpatients and outpatients with DSM-IV bipolar I disorder (BD-I) and bipolar II disorder (BD-II) in three Finnish cities. Within the JoBS, we investigated the prevalence of disability pensions at baseline, and predictors for being granted a disability pension during an 18-month follow-up of the 151 patients in the labor force at baseline. Cox models were used to determine predictors for onset of disability pension.

RESULTS

At baseline, 21% (40/191) of the patients already had a disability pension. During the follow-up, a further 38 patients (25% of the 151 followed) were granted a new disability pension. The predictors included older age, male gender, depressive index episode, higher number of psychiatric hospitalizations, generalized anxiety disorder, avoidant personality disorder, and depressive burden during follow-up. However, the predictors differed depending on bipolar subtype, age, and gender.

CONCLUSIONS

BD-I and BD-II are associated with a major risk of long-term work disability, the proportion of patients with a disability pension rising to 41% in the medium-term follow-up of the Finnish cohort investigated in the present study. Severe clinical course, depression, comorbidities, age, and gender are likely to be the main predictors but predictors may vary depending on the subgroup.

Suicide attempts in major depressive episode: evidence from the BRIDGE-II-Mix study

OBJECTIVES

The Bipolar Disorders: Improving Diagnosis, Guidance, and Education (BRIDGE-II-Mix) study aimed to estimate the frequency of mixed states in patients with a major depressive episode (MDE) according to different definitions and to compare their clinical validity, looking into specific features such as suicidality.

METHODS

A total of 2,811 subjects were enrolled in this multicenter cross-sectional study. Psychiatric symptoms, and sociodemographic and clinical variables were collected. The analysis compared the characteristics of patients with MDE with (MDE-SA group) and without (MDE-NSA) a history of suicide attempts.

RESULTS

The history of suicide attempts was registered in 628 patients (22.34%). In the MDE-SA group, women (72.5%, p = 0.028), (hypo)mania in first-degree relatives (20.5%, p < 0.0001), psychotic features (15.1%, p < 0.0001), and atypical features (9.2%, p = 0.009) were more prevalent. MDE-SA patients' previous responses to treatment with antidepressants included more (hypo)manic switches [odds ratio (OR) = 1.97, 95% confidence interval (CI): 1.58-2.44, p < 0.0001], treatment resistance (OR = 2.07, 95% CI: 1.72-2.49, p < 0.0001), mood lability (OR = 1.98, 95% CI: 1.65-2.39, p < 0.0001), and irritability (OR = 1.80, 95% CI: 1.48-2.17, p < 0.0001). Multivariate analysis evidenced that risky behavior, psychomotor agitation and impulsivity, and borderline personality and substance use disorders were the variables most frequently associated with previous suicide attempts. In the MDE-SA group, 75 patients (11.9%) fulfilled Diagnostic and Statistical Manual (DSM)-5 criteria for MDE with mixed features, and 250 patients (39.8%) fulfilled research-based diagnostic criteria for a mixed depressive episode.

CONCLUSIONS

Important differences between MDE-SA and MDE-NSA patients have emerged. Early identification of symptoms such as risky behavior, psychomotor agitation, and impulsivity in patients with MDE, and treatment of mixed depressive states could represent a major step in suicide prevention.

Bipolar disorder with comorbid attention-deficit and hyperactivity disorder. Main clinical features and clues for an accurate diagnosis

OBJECTIVE

To study the prevalence of attention-deficit and hyperactivity disorder (ADHD) in adult patients with bipolar disorder (BD) and identify differential clinical features for a better diagnosis.

METHOD

A total of 163 euthymic bipolar out-patients were screened for ADHD with the ASRS.V1 and the WURS at a BD Unit. Patients with a positive screening were assessed with the CAADID, at an ADHD unit. Sociodemographic and clinical features of the groups with and without ADHD were compared.

RESULTS

Lifetime prevalence of comorbid ADHD was 17.9% (10.5% for adult ADHD and 7.4% for childhood ADHD). The BD + ADHD group showed more suicidal behaviour although less severe. Comorbidity was also more common, especially regarding substance use disorders. Nevertheless, these patients did not show more affective episodes or hospitalizations and suffered more atypical but less melancholic depression. However, they required more treatment with psychotherapy and valproate. One-third of positive screenings at the ASRS were false; a severe course of BD was the hallmark of this subgroup.

CONCLUSION

Adult patients with BD and ADHD show differential clinical features, but not a more severe course of BD. Comorbidity with substance abuse is a big issue, deserving special clinical attention. Better screening tools are necessary to avoid overdiagnosis of comorbid ADHD in BD.

Increased impulsivity as a vulnerability marker for bipolar disorder: evidence from self-report and experimental measures in two high-risk populations

BACKGROUND

Heightened impulsivity has been suggested as a possible risk factor for bipolar disorder (BD). However, studies on high-risk populations are scarce and have mainly focused on individuals with a genetic risk. The present study investigated two high-risk samples for BD with regard to several aspects of the impulsivity construct.

METHODS

Unaffected relatives of BD patients (genetically defined high-risk group, N=29) and participants scoring high on the Hypomanic Personality Scale (psychometrically defined high-risk sample, N=25) were being compared to respective control groups (N=27 and N=25) using a multi-method approach. Participants were accessed on the Barratt Impulsiveness Scale-11 (BIS-11, trait impulsivity), the Stop Signal Task (response inhibition), and the Cambridge Gambling Task (impulsive behavior in decision-making processes).

RESULTS

Both high-risk groups reported heightened impulsivity on the BIS-11, as well as impulsive decision-making, whereas no significant group differences in response inhibition were observed.

LIMITATIONS

Limitations were the lack in specificity of the results for BD and the cross-sectional study design, which does not allow conclusions about the influence of impulsivity on the development of or resilience for BD in risk groups.

CONCLUSIONS

Our findings support the assumption that increased trait impulsivity and impulsive decision-making are a vulnerability marker for and an endophenotype of BD.

Which aspects of long-term outcome are predicted by positive and negative symptoms in early-onset psychosis? An exploratory eight-year follow-up study

BACKGROUND

Early-onset psychoses show substantial variability of diagnostic and functional outcome. Finding reliable prognostic factors may allow to allocate resources to those with the worst prognosis. The aim of the study was to gain new insights regarding the potential value of baseline negative and positive symptoms as predictors of outcome in psychoses of early onset.

METHOD

Sixty-three patients with early-onset schizophrenia spectrum psychosis hospitalized in an adolescent psychiatry unit were assessed with the Positive and Negative Syndrome Scale during the index admission. Associations with diagnosis, illness course and functional outcome were analysed in mean 8 years of follow-up (range 3.4-13.5 years).

RESULTS

The mean age at the index admission and the follow-up was 16.6 ± 1.2 and 24.5 ± 3.0 years, respectively. A significant majority of subjects continued psychiatric treatment (95%) and had been readmitted (71%). The mortality rate was 3% (suicide and accident). Negative symptoms were related to mental health service utilization during the follow-up. General severity of symptoms, specifically positive and cognitive factors were associated with the diagnosis of schizophrenia and inversely with diagnostic shift outside the schizophrenia spectrum at the catamnesis. Poor impulse control at baseline was associated with worse functional outcome. The drug-free subgroup with no occupational/educational activity compared with the drug-treated subjects showed lower levels of baseline negative symptomatology.

CONCLUSION

The study findings suggest that in patients with early-onset psychosis negative and positive symptoms show a differential prognostic value. Pharmacotherapy may attenuate the effect of symptoms on functional outcome. These hypotheses need to be tested in future studies using confirmatory approaches.

Resilience and impulsivity in euthymic patients with bipolar disorder

BACKGROUND

Stress plays an important role in the onset and recurrence of bipolar disorder (BD). Resilience is the ability to cope with stress or adversity. Few studies have examined resilience in BD, and this study aimed to investigate the clinical correlates of resilience in euthymic patients with BD.

METHODS

A total of 62 outpatients with BD type I, II, and not otherwise specified (NOS) who were in remission and 62 healthy individuals matched with the BD group in terms of age and sex were recruited. All participants completed the Connor-Davidson Resilience Scale and Barratt Impulsiveness Scale. A psychiatrist interviewed the subjects to assess clinical characteristics. Multiple linear regression analysis was used to determine factors associated with resilience.

RESULTS

The BD group had significantly higher levels of impulsivity and lower levels of resilience compared with the control group. Degree of impulsivity, number of depressive episodes, Clinical Global Impression (CGI) scores, and length of education were significantly correlated with resilience. Attention impulsivity, non-planning impulsivity, and number of depressive episodes were associated with low levels of resilience, even when age, sex, length of education, and CGI scores were controlled.

LIMITATIONS

Because tertiary hospital patients were recruited, the generalizability of the findings is limited.

CONCLUSIONS

This study shows that low levels of resilience are related to high levels of impulsivity and to an increased number of depressive episodes in euthymic patients with BD. Given the reciprocal relationship between resilience and impulsivity, efforts to enhance resilience and reduce impulsivity may make important contributions to the treatment of patients with BD.

Impulsivity predicts time to reach euthymia in adults with bipolar disorder

OBJECTIVES

Specific demographic and illness characteristics have been identified as predictors of overall morbidity and treatment course among individuals with bipolar disorder. However, the role of specific cognitive limitations on disease severity and treatment response is unclear. The present study evaluated whether impulsiveness during acute mania was a significant predictor of achieving euthymia within one year following psychiatric hospitalization.

METHODS

Participants were 94 adult inpatients (60 manic) with bipolar I disorder. Baseline symptom severity was assessed using the Young Mania Rating Scale and the Montgomery-Åsberg Depression Rating Scale. Impulsivity was measured with the Stop Signal Task, Degraded Stimulus Continuous Performance Task, Delayed Response Task, and Barratt Impulsiveness Scale-11.

RESULTS

Individual predictors of time to reach euthymia included fewer depressive symptoms and better impulse control at baseline, later age at illness onset, shorter illness duration, and the absence of comorbid attention-deficit hyperactivity disorder. Self-reported impulsivity was a significant independent predictor of time to euthymia, even after accounting for relevant clinical variables.

CONCLUSIONS

Better trait impulse control may be associated with better treatment responsiveness among adults with bipolar disorder.

Bipolar I and II versus unipolar depression: clinical differences and impulsivity/aggression traits

OBJECTIVE

To investigate distinguishing features between bipolar I, II and unipolar depression, and impulsivity/aggression traits in particular.

METHODS

Six hundred and eighty-five (n=685) patients in a major depressive episode with lifetime Unipolar (UP) depression (n=455), Bipolar I (BP-I) disorder (n=151), and Bipolar II (BP-II) (n=79) disorder were compared in terms of their socio-demographic and clinical characteristics.

RESULTS

Compared to unipolar patients, BP-I and BP-II depressed patients were significantly younger at onset of their first depressive episode, and were more likely to experience their first depressive episode before/at age of 15. They also had more previous affective episodes, more first- and second-degree relatives with history of mania, more current psychotic and subsyndromal manic symptoms, and received psychopharmacological and psychotherapy treatment at an earlier age. Furthermore, BP-I and BP-II depressed patients had higher lifetime impulsivity, aggression, and hostility scores. With regard to bipolar subtypes, BP-I patients had more trait-impulsivity and lifetime aggression than BP-II patients whereas the latter had more hostility than BP-I patients. As for co-morbid disorders, Cluster A and B Personality Disorders, alcohol and substance abuse/dependence and anxiety disorders were more prevalent in BP-I and BP-II than in unipolar patients. Whereas the three groups did not differ on other socio-demographic variables, BP-I patients were significantly more often unemployed that UP patients.

CONCLUSION

Our findings comport with major previous findings on differences between bipolar and unipolar depression. As for trait characteristics, bipolar I and II depressed patients had more life-time impulsivity and aggression/hostility than unipolar patients. In addition, bipolar I and II patients also differed on these trait characteristics.

Lipid correlates of attentional impulsivity in first episode mania: results from an Indian population

BACKGROUND

Attentional/cognitive impulsivity has been demonstrated as being associated with an increased risk for suicide and other self-harming behaviors, along with a more severe course in patients with bipolar disorder. That an alteration of the various serum lipid fractions might be associated with increased impulsivity has been proposed in the past, but evidences are ambiguous and mainly based on western population data.

OBJECTIVE

The present study was aimed to analyze the attentional impulsivity and various serum lipid fractions in bipolar patients, from an Indian perspective.

MATERIALS AND METHODS

At presentation, 60 drug free/naïve first episode Mania patients were rated on the Barratt impulsiveness scale-version 11 and Young Mania Rating Scale; body mass index (BMI) was calculated and blood samples were analyzed for total cholesterol (TC), high density lipoproteins, low density lipoproteins and very low density lipoproteins (VLDL), triglycerides (TG) and apolipoproteins A1 and B.

RESULTS

The analysis revealed statistically significant negative correlation and inverse linear relationship between TC, TG, VLDL and BMI with attentional impulsivity.

CONCLUSION

The present study adds to the growing literature on a complex relationship between lipid fractions and attentional impulsivity. The findings present interesting insights into the possible substrates of human behavior at biochemical levels. The implications are many, including a need to introspect regarding the promotion of weight loss and cholesterol reduction programs in constitutionally vulnerable population.

Shared clinical associations between obesity and impulsivity in rapid cycling bipolar disorder: a systematic review

BACKGROUND

Obesity seems to show a two-way relationship with bipolar disorder (BD), representing not only a possible vulnerability factor but also a consequence of chronic mood dysregulation associated with an overall poor prognosis. Increased impulsivity has been described across all stages and phases of BD as being also associated with a worse prognosis. Although obesity and impulsivity are common features among rapid cycling bipolar disorder (RC-BD) patients, there is a lack of understanding about the clinical implications of these conditions combined in BD.

METHODS

To explore and integrate available evidence on shared clinical associations between obesity and impulsivity in RC-BD a systematic search of the literature in the electronic database of the National Library of Medicine (PubMed) has been conducted.

RESULTS

One hundred and fourteen articles were included in our systematic review. Among RC-BD patients, substance abuse disorders (SUDs), anxiety disorders (ADs), predominantly depressive polarity, chronic exposure to antidepressants, psychotic symptoms, suicidality, and comorbid medical conditions are strongly associated with both obesity and impulsivity.

LIMITATIONS

Heterogeneity of published data, inconsistent measurements of both obesity and impulsivity in RC-BD and an absence of control for RC-BD in epidemiological surveys. Consequently, their combined impact on the severity of RC-BD is yet to be recognized and remains to be poorly understood.

CONCLUSION

In RC-BD patients the co-occurrence of obesity and impulsivity is associated with an unfavorable course of illness, specific shared clinical correlates, negative psychosocial impact, and overall worse prognosis. There is a need to examine obesity and impulsivity as modulating factors and markers of severity in RC-BD.

Behavioral approach system sensitivity and risk taking interact to predict left-frontal EEG asymmetry

The Behavioral Approach System (BAS) hypersensitivity theory of bipolar disorder (BD; Alloy & Abramson, 2010; Depue & Iacono, 1989) suggests that hyperreactivity in the BAS results in the extreme fluctuations of mood characteristic of BD. In addition to risk conferred by BAS hypersensitivity, cognitive and personality variables may play a role in determining risk. We evaluated relationships among BAS sensitivity, risk taking, and an electrophysiological correlate of approach motivation, relative left-frontal electroencephalography (EEG) asymmetry. BAS sensitivity moderated the relationship between risk taking and EEG asymmetry. More specifically, individuals who were high in BAS sensitivity showed left-frontal EEG asymmetry regardless of their level of risk-taking behavior. However, among individuals who were moderate in BAS sensitivity, risk taking was positively associated with asymmetry. These findings suggest that cognitive and personality correlates of bipolar risk may evidence unique contributions to a neural measure of trait-approach motivation. Clinical implications of these findings are discussed.

Characteristics of stress-coping behaviors in patients with bipolar disorders

Appropriate stress-coping strategies are needed to improve the outcome in the treatment of bipolar disorders, as stressful life events may aggravate the course of the illness. The aim of this study was to compare stress-coping behaviors between bipolar patients and healthy controls. A total of 206 participants comprising 103 bipolar patients fulfilling the Diagnostic and Statistical Manual for Axis I disorder fourth edition (DSM-IV) diagnostic criteria for bipolar I and II disorders and controls matched by age and sex were included in this study. Stress-coping behaviors were assessed using a 53-item survey on a newly-designed behavioral checklist. The characteristics of stress-coping behaviors between the two groups were compared by using t-test and factor analysis. Social stress-coping behaviors such as 'journey', 'socializing with friends', and 'talking something over' were significantly less frequent in bipolar patients than controls. On the other hand, pleasurable-seeking behaviors such as 'smoking', 'masturbation', and 'stealing' were significantly more frequent in bipolar patients than controls. These results suggest that bipolar patients may have more maladaptive stress-coping strategies than normal controls. It is recommended to develop and apply psychosocial programs to reduce maladaptive stress-coping behaviors of bipolar patients.

Meta-analysis of predictors of favorable employment outcomes among individuals with bipolar disorder

OBJECTIVES

Although several studies have reported on predictors of employment in individuals with bipolar disorder (BD), the magnitude of the impact of these variables is unclear as no previous studies have estimated the collective effect sizes (ESs). The present meta-analysis estimated ESs and explored which of these variables are associated with positive employment outcomes.

METHODS

We searched for articles published between 2000 and 2011 that reported associations between sociodemographic, clinical, psychosocial, and/or cognitive variables with employment outcomes in BD. Of the 781 articles identified, 22 met the inclusion criteria and were included in the final analysis (n = 6,301). Weighted correlation coefficients (r-index) were computed as ESs for each of the predictor variables, which were grouped into six categories: cognitive performance, symptomatology, sociodemographic factors, course of illness, clinical variables, and other personal factors. The overall ES (Rw) was estimated by assuming random-effect models. Sensitivity analyses were also performed to determine the robustness of the findings.

RESULTS

Significant predictors of favorable employment outcomes included: cognitive performance (e.g., verbal memory, Rw = 0.33; executive function, Rw = 0.26), sociodemographic factors (e.g., years of education, Rw = 0.23), course of illness (e.g., number of lifetime psychiatric hospitalizations, Rw = -0.35), symptomatology (e.g., depression, Rw = -0.25), and other personal factors (e.g., personality disorder, Rw = -0.49).

CONCLUSIONS

Overall, the cognitive performance and course of illness had larger average ESs than symptomatology or sociodemographic factors on favorable employment outcomes. These findings may help to guide the design of more effective work interventions for people with BD.

Association between GSK3β gene and increased impulsivity in bipolar disorder

Bipolar patients present increased levels of impulsivity even during remission periods. It is known that this dimensional trait negatively impacts on the course of illness and worsens their prognosis and outcome. Evidence from both basic and clinical researches supports that Lithium (Li) may decrease impulsivity. Owing to the fact that Li inhibits both glycogen synthetase kinase-3 (GSK3) isoenzimes, our aim was to analyze the potential impact of genetic variants located at the GSK3 α and β genes on impulsivity levels in a bipolar sample. Our sample consisted of 199 unrelated Caucasian bipolar outpatients who were recruited from the Bipolar Disorder Unit of the Hospital Clinic of Barcelona and from primary care settings from Oviedo. Four polymorphisms at the GSK3 α and β genes were genotyped in order to analyze the impact of genetic variability on impulsivity as measured by the BIS-11 scale. Single SNP analysis showed that patients carrying T and G alleles at the rs1732170-GSK3β and the rs334558-GSK3β, respectively, presented increased levels of attentional impulsivity compared to non-carriers. These results were also confirmed by haplotype analysis. Our results suggest that genetic variability at GSK3β gene is associated to increased impulsivity in bipolar patients.

Relationship between anhedonia and impulsivity in schizophrenia, major depression and schizoaffective disorder

BACKGROUND

Anhedonia and impulsivity are prominent symptoms of many psychiatric disorders and may indicate worse prognosis, notably in schizophrenia and major depression. Despite the convergence of negative outcomes from both dimensions, the relationship between anhedonia and impulsivity in psychiatric disorders has been seldom directly assessed. The objective of the present study is to examine the correlations between anhedonia and impulsivity in three diagnostic groups: major depression, schizophrenia and schizoaffective disorder.

SAMPLING AND METHODS

121 outpatients (Mansoura University Hospital, Egypt) with major depressive disorder (N=29), schizophrenia (N=59), and schizoaffective disorder (N=33), were assessed and responded to the Beck Depression Inventory, Barrat's Impulsivity Scale-11, and Chapman's Social and Physical Anhedonia Scales.

RESULTS

Physical and social anhedonia scores were negatively correlated to impulsivity scores in major depression patients. Conversely, higher scores in physical and social anhedonia predicted higher impulsivity scores in schizophrenia. No correlations between impulsivity and anhedonia were evidenced among schizoaffectives.

CONCLUSION

The relationship between self-reported physical and social anhedonia and impulsivity is diagnosis-specific.

The Relationship between Impulsivity and Quality of Life in Euthymic Patients with Bipolar Disorder

OBJECTIVE

Bipolar disorder (BD) is characterized by elevated impulsivity, even during periods of remission. Many recovered BD patients have functional impairments, which can lead to poor quality of life (QoL). The aim of this study was to investigate the association between impulsivity and QoL in euthymic BD patients.

METHODS

A total of 56 remitted or recovered patients with type I or II BD, diagnosed based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, were recruited. Psychiatrists administered the Clinical Global Impression (CGI) for BD and the Global Assessment of Functioning (GAF) scales and then interviewed the subjects to assess clinical variables. Patients completed the Barratt Impulsiveness Scale (BIS-11) and the World Health Organization Quality of Life Assessment Instrument-Brief Form (WHOQoL-BREF). Pearson correlations, univariate regression analyses, and multiple linear regression analyses were performed.

RESULTS

The BIS-11 total score was significantly correlated with the WHOQoL-BREF total score (r=-0.55, p<0.01) and with the WHOQoL-BREF subscales. After controlling for GAF score and other clinical variables, the BIS-11 total score (β=-0.43, p=0.001) was independently associated with overall QoL. Additionally, the BIS-11 total score was particularly strongly associated with the physical, psychological, and social domains of the multi-dimensional QoL scale.

CONCLUSION

Our results suggest that high impulsivity is related to low QoL in euthymic BD patients. Further studies are needed to examine whether interventions for high impulsivity effectively improve QoL in patients with BD.

Clinical features associated with trait-impulsiveness in euthymic bipolar disorder patients

BACKGROUND

A strong association has been reported between trait-impulsiveness and bipolar disorder (BD). Much attention has been focused on this association, but subgroup analysis has generated conflicting results, raising questions about the role of trait-impulsiveness in suicidal behavior and substance misuse in bipolar patients.

METHOD

We compared Barratt Impulsiveness Scale-10 scores between 385 euthymic bipolar patients and 185 healthy controls. We then investigated possible association between impulsiveness scores and the following clinical characteristics: suicide attempt (SA), lifetime alcohol/cannabis misuse, rapid cycling and mixed episodes.

RESULTS

Bipolar patients and healthy controls had significantly different BIS-10 total score and subscores (motor, attentional and nonplanning impulsiveness) (all p values <0.0001). No association was observed between BIS-10 total score, personal history of SA, number of SA, age at first SA and history of violent SA. Higher BIS-10 total scores were associated with alcohol misuse (p=0.005), cannabis misuse (p<0.0001), with an additive effect for these two substances (p=0.005). Higher BIS-10 total scores were also associated with rapid cycling (p=0.006) and history of mixed episodes (p=0.002), with an additive effect of these two variables (p=0.0006).

LIMITATIONS

We used only one clinical measurement of impulsiveness and did not carry out cognitive assessment.

CONCLUSION

This study demonstrates that trait-impulsiveness may be considered as a dimensional feature associated with BD and with a more severe clinical expression of the disease, characterized by a history of substance misuse, rapid cycling and mixed episodes. We found no association between impulsiveness and SA characteristics in bipolar patients, confirming some previous negative results.

Validity and Reliability of the Italian Version of the Functioning Assessment Short Test (FAST) in Bipolar Disorder

BACKGROUND

Functioning Assessment Short Test (FAST) is a brief instrument designed to assess the main functioning problems experienced by psychiatric patients, specifically bipolar patients. It includes 24 items assessing impairment or disability in six domains of functioning: autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships and leisure time. The aim of this study is to measure the validity and reliability of the Italian version of this instrument.

METHODS

Twenty-four patients with DSM-IV TR bipolar disorder and 20 healthy controls were recruited and evaluated in three private clinics in Cagliari (Sardinia, Italy). The psychometric properties of FAST (feasibility, internal consistency, concurrent validity, discriminant validity (patients vs controls and eutimic patients vs manic and depressed), and test-retest reliability were analyzed.

RESULTS

The internal consistency obtained was very high with a Cronbach's alpha of 0.955. A highly significant negative correlation with GAF was obtained (r = -0.9; p < 0.001) pointing to a reasonable degree of concurrent validity. FAST show a good test-retest reliability between two independent evaluation differing of one week (mean K =0.73). The total FAST scores were lower in controls as compared with Bipolar Patients and in Euthimic patients compared with Depressed or Manic.

CONCLUSION

The Italian version of the FAST showed similar psychometrics properties as far as regard internal consistency and discriminant validity of the original version and show a good test retest reliability measure by means of K statistics.