Predominant polarity as a course specifier for bipolar disorder: a systematic review

The progression trajectory of Bipolar Disorder: results from the application of a staging model over a ten-year observation

BACKGROUND

Trying to better define Bipolar Disorder (BD) progression, different staging models have been conceptualized, each one emphasizing different aspects of illness. In a previous article we retrospectively applied the main staging models to a sample of 100 bipolar patients at four time points over a ten-year observation. In the present study, focusing on Kupka & Hillegers's model, we aimed to assess the transition of the same sample through the different stages of illness and to explore the potential role of clinical variables on the risk of progression.

METHODS

Multistate Model using the mstate package in R and Markov model with stratified hazards were used for statistical analysis.

RESULTS

A high hazard of transition from stage 2 to 3 emerged, with a probability of staying in stage 2 decreasing to 14 % after 3 years. BD II was significantly associated with transition from stage 1 to 2, whereas the number of lifetime episodes >3 and the elevated predominant polarity with transition from stage 3 to 4.

CONCLUSION

Our results corroborated the evidence on BD progression and contributed to outline its trajectory over time. Further effort may help to define a standardized staging approach towards ever increasing tailored interventions.

Prevalence and correlates of manic/hypomanic and depressive predominant polarity in bipolar disorder: systematic review and meta-analysis

BACKGROUND

Identification of the predominant polarity, i.e. hypomanic/manic (mPP) or depressive predominant polarity (dPP), might help clinicians to improve personalised management of bipolar disorder.

AIMS

We performed a systematic review and meta-analysis to estimate prevalence and correlates of mPP and dPP in bipolar disorder.

METHOD

The protocol was registered in the Open Science Framework Registries (https://doi.org/10.17605/OSF.IO/8S2HU). We searched main electronic databases up to December 2023 and performed random-effects meta-analyses of weighted prevalence of mPP and dPP. Odds ratios and weighted mean differences (WMDs) were used for relevant correlates.

RESULTS

We included 28 studies, providing information on rates and/or correlates of mPP and dPP. We estimated similar rates of mPP (weighted prevalence = 30.0%, 95% CI: 23.1 to 37.4%) and dPP (weighted prevalence = 28.5%, 95% CI: 23.7 to 33.7%) in bipolar disorder. Younger age (WMD = -3.19, 95% CI: -5.30 to -1.08 years), male gender (odds ratio = 1.39, 95% CI: 1.10 to 1.76), bipolar-I disorder (odds ratio = 4.82, 95% CI: 2.27 to 10.24), psychotic features (odds ratio = 1.56, 95% CI: 1.01 to 2.41), earlier onset (WMD = -1.57, 95% CI: -2.88 to -0.26 years) and manic onset (odds ratio = 13.54, 95% CI: 5.83 to 31.46) were associated with mPP (P < 0.05). Depressive onset (odds ratio = 12.09, 95% CI: 6.38 to 22.90), number of mood episodes (WMD = 0.99, 95% CI: 0.28 to 1.70 episodes), history of suicide attempts (odds ratio = 2.09, 95% CI: 1.49 to 2.93) and being in a relationship (odds ratio = 1.98, 95% CI: 1.22 to 3.22) were associated with dPP (P < 0.05). No differences were estimated for other variables.

CONCLUSIONS

Despite some limitations, our findings support the hypothesis that predominant polarity might be a useful specifier of bipolar disorder. Evidence quality was mixed, considering effects magnitude, consistency, precision and publication bias. Different predominant polarities may identify subgroups of patients with specific clinical characteristics.

Combining predominant polarity and affective spectrum concepts in bipolar disorder: towards a novel theoretical and clinical perspective

This is an overview of recent advances on predominant polarity conceptualization in bipolar disorder (BD). Current evidence on its operationalized definitions, possible contextualization within the affective spectrum, along with its epidemiological impact, and treatment implications, are summarized. Predominant polarity identifies three subgroups of patients with BD according to their mood recurrencies: (i) those with depressive or (ii) manic predominance as well as (iii) patients without any preponderance ('nuclear' type). A predominant polarity can be identified in approximately half of patients, with similar rates for depressive and manic predominance. Different factors may influence the predominant polarity, including affective temperaments. More generally, affective disorders should be considered as existing on a spectrum ranging from depressive to manic features, also accounting for disorders with 'ultrapredominant' polarity, i.e., unipolar depression and mania. While mixed findings emerge on its utility in clinical practice, it is likely that the construct of predominant polarity, in place of conventional differentiation between BD-I and BD-II, may be useful to clarify the natural history of the disorder and select the most appropriate interventions. The conceptualization of predominant polarity seems to reconcile previous theoretical views of both BD and affective spectrum into a novel perspective. It may provide useful information to clinicians for the early identification of possible trajectories of BD and thus guide them when selecting interventions for maintenance treatment. However, further research is needed to clarify the specific role of predominant polarity as a key determinant of BD course, outcome, and treatment response.

Development and validation of a nomogram to predict suicidal behavior in female patients with mood disorder

Introduction

This study aims to explore the risk factors associated with suicidal behavior and establish predictive models in female patients with mood disorders, specifically using a nomogram of the least absolute shrinkage and selection operator (LASSO) regression.

Methods

A cross-sectional survey was conducted among 396 female individuals diagnosed with mood disorders (F30-F39) according to the International Classification of Diseases and Related Health Problems 10th Revision (ICD-10). The study utilized the Chi-Squared Test, t-test, and the Wilcoxon Rank-Sum Test to assess differences in demographic information and clinical characteristics between the two groups. Logistic LASSO Regression Analyses were utilized to identify the risk factors associated with suicidal behavior. A nomogram was constructed to develop a prediction model. The accuracy of the prediction model was evaluated using a Receiver Operating Characteristic (ROC) curve.

Result

The LASSO regression analysis showed that psychotic symptoms at first-episode (β = 0.27), social dysfunction (β = 1.82), and somatic disease (β = 1.03) increased the risk of suicidal behavior. Conversely, BMI (β = -0.03), age of onset (β = -0.02), polarity at onset (β = -1.21), and number of hospitalizations (β = -0.18) decreased the risk of suicidal behavior. The area under ROC curve (AUC) of the nomogram predicting SB was 0.778 (95%CI: 0.730-0.827, p < 0.001).

Conclusion

The nomogram based on demographic and clinical characteristics can predict suicidal behavior risk in Chinese female patients with mood disorders.

Predominant polarity in bipolar affective disorder and its impact on cognition and quality of life

Background

Bipolar mood disorder or bipolar affective disorder (BPAD) is a chronic illness characterized by phases of mania/hypomania, depression, or mixed episodes. The course of bipolar mood disorder is relapsing in nature. It is associated with high comorbidity rates, a large number of premature deaths due to suicide, and a worse social and work performance. All of those characteristics entail a significant economic impact due to both direct and indirect costs and require an effective diagnostic and therapeutic approach. Lifetime prevalence of BPAD is approximately 4% worldwide. Various attempts have been made to define "predominance" of polarity in BPAD.

Need for this Study

Our study tries to highlight the existence of predominant polarity by comparing effects of the same on substance consumption, cognitive abilities, quality of life, and preponderance of specific polarity to specific gender.

Method

After Institutional Ethics Committee Approval and written informed consent, patients who were diagnosed with BPAD attending out-patient department of a tertiary care hospital in Mumbai were recruited. A total of 57 participants were enrolled. The World Health Organization Quality of Life - Brief Scale (WHOQOL BREF) and the Montréal Cognitive Assessment (MoCA) were both used to evaluate the patients' quality of life and cognitive ability, respectively.

Discussion and Results

Men exhibited manic predominant polarity, while women had depressive predominant polarity, with P value of. 003. Regarding age, illness length, education, substance abuse, family history, and suicide attempts, there was no discernible difference in the polarities. The outcome of female bipolar patients may be improved if the clinician is mindful of the burden of depression, risk of misdiagnosis, and variable therapy response. Interestingly, our study found no significant difference between MoCA scores of those with depressive and manic polarity. Substantial MoCA score differences were found between the groups with depressive polarity and no polarity.

Conclusion

Men were observed to experience more manic episodes. More women in the study experienced predominantly depressive polarity, highlighting the need to probe for a past history of hypomania or mixed episodes to avoid misdiagnosis as unipolar depression in them. Manic predominate polarity performed better in the physical and psychological domains of the post hoc test for quality-of-life BREF scale. There were substantial MoCA score differences between the groups with depressive polarity and no polarity, with the depressive polarity showing more cognitive decline.

Predominant polarity as a neurobiological specifier in bipolar disorder: Evidence from a multimodal neuroimaging study

BACKGROUND

While predominant (PP) and onset polarity (OP) have considerable clinical and treatment implications in bipolar disorder (BD), the neurobiological underpinnings of PP and OP from a radiological perspective remain largely unknown. The main objective of this study is to investigate the neuroanatomical profile of polarity subphenotypes (PP and OP) in euthymic BD patients, using a standardized multimodal neuroimaging protocol to evaluate regional gray matter (GM) volumes, cortical thickness, as well as white matter (WM) integrity of major projection, commissural and association tracts.

METHODS

Forty-two euthymic BD patients stratified for PP and OP and 42 healthy controls (HC) were included in this computational neuroimaging study to comprehensively characterize gray and white matter alterations. Univariate analyses of covariance (ANCOVAs) were conducted with Bonferroni corrections for each MRI modality and Cohen's d effect sizes were calculated for group comparisons.

RESULTS

Phenotype-associated cortical thickness abnormalities and volumetric alterations were identified, but no WM changes ascertained. Specifically, we found a main effect of OP on GM volume of left middle frontal gyrus and of OP and PP (either or both) on cortical thickness of various regions previously implicated in BD, i.e. inferior frontal gyrus-pars opercularis (left) and pars orbitalis (bilateral), left lateral orbitofrontal gyrus, bilateral medial segment of the superior frontal gyrus, left planum polare, right anterior cingulate gyrus, left anterior and posterior insula, bilateral frontal operculum (both OP and PP); left anterior and posterior orbitofrontal gyrus, left transverse temporal gyrus, right posterior insula (only OP); and right medial frontal cortex (only PP). Based on the magnitude of differences on pairwise comparisons, we found a large effect of OP on cortical thickness in a single region (left anterior orbitofrontal gyrus) (OP-M > OP-D), while PP subgroups showed large or medium effect size differences in cortical thickness (PP-M > PP-D) in a wider array of regions (right medial frontal cortex, left frontal operculum, left inferior frontal gyrus-pars opercularis, bilateral medial segment of the superior frontal gyrus). For most regions, PP-D patients showed the greatest decreases in cortical thickness compared to HC while PP-M showed the smallest, with PP-U showing an "unspecified" pattern mostly lying in-between PP-D and PP-M.

CONCLUSIONS

Our multimodal imaging findings suggest specific polarity BD subgroups with compromised cortical thickness; we recorded a greater impact of PP on brain structure compared to OP, which provides additional evidence that PP can be considered as a neurobiological specifier in BD.

Polygenic Risk and Episode Polarity Among Individuals With Bipolar Disorder

OBJECTIVE

The authors investigated associations between polygenic liabilities for bipolar disorder, major depression, and schizophrenia and episode polarity among individuals with bipolar disorder.

METHODS

The sample consisted of 2,705 individuals diagnosed with bipolar disorder at Danish psychiatric hospitals between January 1995 and March 2017. DNA was obtained from dried blood spots collected at birth as part of routine screening. Polygenic risk scores (PRSs) for bipolar disorder, major depression, and schizophrenia were generated using a meta-PRS method combining internally and externally trained components. Associations between PRS and polarity at first episode, polarity at any episode, and number of episodes with a given polarity were evaluated for each disorder-specific PRS using logistic and negative binominal regressions adjusted for the other two PRSs, age, sex, genotype platform, and five ancestral principal components.

RESULTS

PRS for bipolar disorder was positively associated with any manic episodes (odds ratio=1.23, 95% CI=1.09-1.38). PRS for depression was positively associated with any depressive (odds ratio=1.11, 95% CI=1.01-1.23) and mixed (odds ratio=1.15, 95% CI=1.03-1.28) episodes and negatively associated with any manic episodes (odds ratio=0.76, 95% CI=0.69-0.84). PRS for schizophrenia was positively associated with any manic episodes (odds ratio=1.13, 95% CI=1.01-1.27), but only when psychotic symptoms were present (odds ratio for psychotic mania: 1.27, 95% CI=1.05-1.54; odds ratio for nonpsychotic mania: 1.06, 95% CI=0.93-1.20). These patterns were similar for first-episode polarity and for the number of episodes within each pole.

CONCLUSIONS

PRSs for bipolar disorder, major depression, and schizophrenia are associated with episode polarity and psychotic symptoms in a congruent manner among individuals with bipolar disorder.

Effect of long-acting injectable antipsychotics on emergency department visits and hospital admissions in people with bipolar disorder: A retrospective mirror-image analysis from the Northern Milan Area Cohort (NOMIAC) study

BACKGROUND

Mood recurrences in bipolar disorder (BD) are often associated with poor treatment adherence. Despite long-acting injectable antipsychotics (LAIs) may favor treatment compliance, their use in BD is still poorly explored.

METHODS

This mirror-image study investigated the effect of LAIs initiation on the number of emergency department (ED) visits and days of hospitalization, among individuals with BD from the mental health services of a large area of the Metropolitan City of Milan. The mirror periods were 365 days either side of the LAI initiation. Individual medical records were retrospectively reviewed.

RESULTS

Sixty-eight individuals with BD initiating a LAI over the index period were included. We estimated that LAI initiation overall reduced both ED visits (p = 0.002) and days of hospitalization (p < 0.001). This remained true only for those participants who i) continued LAI for the entire 12-month period of observation and ii) were treated with a second-generation antipsychotic LAI. In addition, LAI initiation reduced number of hospitalization days during hypo/manic (p = 0.013), but not depressive (p = 0.641) episodes, as well as compulsory admission days (p = 0.002).

LIMITATIONS

Due to the retrospective design, we could not collect systematic information on symptom severity and reasons of LAI discontinuation. Moreover, the limited sample size did not allow us to estimate effectiveness of single LAI agents.

CONCLUSIONS

Our study provides additional insight on the effectiveness of LAIs in BD, supporting their clinical utility for pragmatic outcomes such as ED visits and hospitalizations. Further longitudinal research is needed to clarify the real-world effectiveness of LAIs for BD clinical management.

Euthymic patients with predominantly manic polarity avoid happy faces in a dot probe task

BACKGROUND

Some studies suggest a mood-congruent attentional bias in bipolar patients. However, for euthymic patients, especially in dependence on the predominant polarity, there is little and inconsistent data. A clearer understanding of emotion-related attentional biases and their relationship to dysfunctional emotion regulation could help improving the diagnostics and treatment of bipolar disorder (BD). Twenty bipolar patients in a depressive state (BP-acute-D), 32 euthymic patients with manic (BP-euth-M) or depressive (BP-euth-D) predominant polarity, and 20 healthy control participants (HC) performed a dot-probe task (DPT) with happy and sad faces presented for 250 ms or 1250 ms in two different runs. Emotion regulation strategies were assessed with two questionnaires.

RESULTS

In the short presentation condition of the DPT, BP-euth-M showed less attention for happy faces than HC (p = .03, r = - 0.48). BP-acute-D scored lower in cognitive reappraisal and putting into perspective and higher in suppression, catastrophizing, and rumination than HC. BP-euth-M scored higher in rumination and BP-euth-D lower in putting into perspective and higher in catastrophizing than HC. In BP-euth-D and HC, bias scores for sad faces in the longer presentation condition and reappraisal scores correlated positively.

CONCLUSIONS

Results of the DPT suggest an avoidance of happy faces for BP-euth-M which we interpret as a protection mechanism for triggers of mania. That individuals who apply more reappraisal show more selective attention to sad faces could on the one hand reflect a mental effort in reevaluating the sad emotional input and on the other hand a greater tolerance for it.

Differences in the prophylactic effect of serum lithium levels on depression and mania in bipolar disorder: A dose-response meta-analysis

The optimal serum lithium levels for preventing the recurrence of mood episodes in bipolar disorder are controversial, especially when polarity is considered. The present study aimed to comprehensively examine the dose-response relationship between lithium concentration and risk of recurrence of mood episodes. We conducted a systematic search of major databases before January 2021 (PROSPERO: CRD42021235812). A one-stage, random-effects, restricted cubic splines model was used to estimate the dose-response relationship between lithium concentration and risk of recurrence of any or specific mood episodes (depression or mania). The effect size is shown as odds ratio (OR). Our meta-analysis included six randomised controlled trials with a total of 975 participants. The dose-response curve showed that increased serum concentrations were associated with a gradual decrease in the risk of any mood episodes (OR 0.50 at 0.60 mmol/l, OR 0.15 at 1.20 mmol/l). The risk of depression decreased slightly with a concentration of 0.60 mmol/l (OR 0.83) but dropped rapidly as the concentration increased to 1.20 mmol/l (OR 0.39). By contrast, the risk for mania initially decreased steadily (OR 0.44), but decreased only marginally (OR 0.30) as the concentration increased. To reduce the recurrence risk to 56%, prevention of depression required a higher concentration than that required for mania (1.13 mmol/l vs. 0.60 mmol/l). Our results suggest a negative dose-response relationship between serum lithium levels and risk of recurrence. In particular, the different preventive effects of serum concentration on depression and mania will be an important clinical reference.

Undetermined predominant polarity in a cohort of bipolar disorder patients: Prevalent, severe, and overlooked

OBJECTIVES

Predominant polarity (PP) is a concept used to define patients with bipolar disorder (BD) as presenting a tendency to manifest depressive (DPP) or manic (MPP) episodes. Still, the high percentage of patients with an undetermined PP (UPP), has been overlooked in most studies. Thus, we aimed to study UPP and outline its socio-demographic, clinical, and treatment-related features.

METHODS

Patients were recruited from a BD specialized unit. The sample was divided into three groups according to PP and socio-demographic and clinical variables were compared. Significant variables at univariate comparisons were included in multivariate logistic regression with UPP as the dependent variable.

RESULTS

A total of 708 BD patients were included, of which 437 with UPP (61.7%). UPP was associated with a higher number of affective relapses, when compared with DPP or MPP (χ2= 28.704, p<0.001). Mixed episodes (OR=1.398; CI=1.118-1.749), aggressive behaviour (OR=1.861; CI=1.190-2.913), seasonality (OR=2.025; CI= 1.289-3.501) and treatment with lamotrigine (OR= 2.101; CI=1.244-3.550) were significantly associated with UPP at the logistic regression.

LIMITATIONS

Recall bias may have occurred due to mixed episode diagnostic criteria change over the years. No data on the patients' follow-up has been reported on predominant polarity changes.

CONCLUSIONS

UPP is associated with a higher number of relapses, and different clinical variables related to a severe course of illness. Considering PP in patients with BD may guide the choice for differential treatment approaches having an impact on BD course of illness and patients' prognosis and recovery.

Structural neuroimaging and predominant polarity in patients with type 1 bipolar disorder from Antioquia

INTRODUCTION

Predominant polarity (PP) has been proposed as a specifier of bipolar disorder (BD) due to its relationship with clinical and prognostic variables. It is possible that this is due to a different underlying neurobiology, in such a way that the changes found by structural nuclear magnetic resonance imaging (sMRI) in BD are different and specific.

OBJECTIVES

To explore findings of structural neuroimaging in patients with BD type I (BD-I) according to PP.

METHODS

Cross-sectional study that evaluated 77 patients with BD-I using the DIGS interview. PP was established using the operative definition of two-thirds of all affective episodes throughout life to classify PP as manic (MPP), depressive (DPP) or indeterminate (IPP). MRI was performed during the euthymia phase to measure intracranial structures. The data obtained was analysed using a linear regression model adjusted for confounding variables (drug use, alcohol use, psychoactive substance use) and were compared between the three groups finding the standardised mean difference (SMD).

RESULTS

Differences with adequate effect size were found in three brain structures after adjusting for confounding variables, specifically in the right fusiform gyrus and the left lingual gyrus, which were greater in the DPP group than in the MPP group (SMD = 0.92; 95% CI = 0.34-1.49 and SMD = 0.78; 95% CI = 0.21-1.35). Likewise, in the right thalamus, it was shown to be greater in the IPP group compared to MPP group (SMD 0.89, 95% CI = 0.31-1.46).

CONCLUSIONS

A reduction in the thickness of the right fusiform gyrus and the left lingual gyrus, as well as the right thalamic volume was observed in patients with BD-I with PPM, which supports the hypothesis that PP has a plausible neurobiological correlate and could have potential utility as a BD specifier.

Clinical and demographic factors associated with delayed diagnosis of bipolar disorder: Data from Health Outcomes and Patient Evaluations in Bipolar Disorder (HOPE-BD) study

BACKGROUND

The diagnosis of Bipolar Disorder (BD) is frequently delayed. In this study, we aimed to examine the clinical and demographic factors associated with delayed diagnosis of BD, defined as the difference between the age at first mood episode (depressive, manic, or hypomanic) and the age at the correct diagnosis of BD, using data from a Canadian multicentre naturalistic study.

METHODS

The sample included 192 patients with Bipolar I Disorder (BD-I) and 127 with Bipolar II Disorder (BP-II) who participated in the Health Outcomes and Patient Evaluations in Bipolar Disorder (HOPE-BD) study. Sociodemographic characteristics and clinical features that had been previously associated with delayed diagnosis of BD were included in the analysis.

RESULTS

The median delay in diagnosis was 5.0 years in BD-I and 11.0 years in BD-II. Clinical factors such as earlier age of onset, lifetime suicide attempts and comorbid anxiety disorders were associated with a longer delay, whereas the presence of lifetime psychotic symptoms and psychiatric hospitalizations were associated with a shorter delay. Quantile regression analysis showed older age at which professional help was first sought and younger age of onset as predictors of increased delay in diagnosis of BD-I and BD-II. Depression as first episode predicted longer delay in diagnosis of BD-I but not BD-II.

CONCLUSION

Our findings identified the ongoing lag in identification of a BD diagnosis and the clinical markers most associated with this delay, highlighting the need for implementation of strategies for early identification and interventions in BD.

Treatment of Symptom Clusters in Schizophrenia, Bipolar Disorder and Major Depressive Disorder With the Dopamine D3/D2 Preferring Partial Agonist Cariprazine

Cariprazine is currently approved for the treatment of patients with schizophrenia (USA and EU), and for manic, depressive, and episodes with mixed features in bipolar I disorder (USA): several randomized controlled studies have also explored its efficacy in patients with major depressive disorder. This review summarizes its current therapeutic uses and potential advantages for treating the main symptoms of schizophrenia, bipolar I and major depressive disorder, considering its pharmacodynamic properties, efficacy, and tolerability. Its predominantly D3 receptor preferring affinity, with functional selectivity according to the prevailing neuronal environment, contributes to its efficacy across a wide array of psychopathological symptoms (including reality distortion, disorganized thought, negative symptoms, mood disturbance, anhedonia, and cognitive impairment), and to a favorable side effect profile. Cariprazine may be a "drug of choice" in patients with predominant negative and cognitive symptoms of schizophrenia, as well as those with metabolic syndrome. Further investigation of its relative efficacy when compared to aripiprazole or other active comparators is warranted. Its effectiveness in the treatment of bipolar mania, bipolar I depression and bipolar I episodes with mixed features, with minimal accompanying metabolic changes is well-established. The longer half-life and delayed time to relapse in patients diagnosed with schizophrenia when compared to other second-generation antipsychotics represent other advantages, given the high rates of non-adherence and frequent relapses seen in clinical practice. Its efficacy in overlapping symptom domains in other major psychiatric disorders appears promising.

Ten-year course of treated bipolar I disorder: The role of polarity at onset

INTRODUCTION

Early-stage predictors of illness course are needed in bipolar disorder (BD). Differences among patients with a first depressive versus maniac/hypomanic episode have been stated, although in most studies, memory bias and time from onset to start of specialized treatment might interfere. The aim was to compare the first 10 years of illness course according to polarity at onset.

METHODS

49 type I BD patients admitted for treatment for a first-time affective episode and a following 10-year attendance to the institution were included. A retrospective year by year comparison according to polarity at onset (depressive (DPO) or maniac (MPO)) was performed. Cramer's V and Cohen d were computed to determine effect size.

RESULTS

59.2% (n = 29) started with MPO. Both groups were similar in demographic and social outcome characteristics, clinical features, and treatment variables. Patients with DPO reported more depressive episodes than MPO patients (U = 149.0 p < .001, Cohen's d = 0.87); both groups had a similar number of manic episodes. Only during the first year of follow-up, suicide attempts (SA) were more frequent in patients with DPO while the presence of a psychotic episode and psychiatric hospitalizations were more frequent in the MPO group.

CONCLUSION

According to these findings, it can be concluded that illness onset is only indicative of depressive predominant polarity but is not related to other poor prognostic variables after the first year of illness onset, in treated BD. SA in the first year of an affective disorder could represent a marker of BD.

A clinical approach to treatment resistance in depressed patients: What to do when the usual treatments don't work well enough?

BACKGROUND

Major depressive disorder is a common, recurrent, disabling and costly disorder that is often severe and/or chronic, and for which non-remission on guideline concordant first-line antidepressant treatment is the norm. A sizeable percentage of patients diagnosed with MDD do not achieve full remission after receiving antidepressant treatment. How to understand or approach these 'refractory', 'TRD' or 'difficult to treat' patients need to be revisited. Treatment resistant depression (TRD) has been described elsewhere as failure to respond to adequate treatment by two different antidepressants. This definition is problematic as it suggests that TRD is a subtype of major depressive disorder (MDD), inferring a boundary between TRD and depression that is not treatment resistant. However, there is scant evidence to suggest that a discrete TRD entity exists as a distinct subtype of MDD, which itself is not a discrete or homogeneous entity. Similarly, the boundary between TRD and other forms of depression is predicated at least in part on regulatory and research requirements rather than biological evidence or clinical utility.

AIM

This paper aims to investigate the notion of treatment failure in order to understand (i) what is TRD in the context of a broader formulation based on the understanding of depression, (ii) what factors make an individual patient difficult to treat, and (iii) what is the appropriate and individualised treatment strategy, predicated on an individual with refractory forms of depression?

METHOD

Expert contributors to this paper were sought internationally by contacting representatives of key professional societies in the treatment of MDD - World Federation of Societies for Biological Psychiatry, Australasian Society for Bipolar and Depressive Disorders, International Society for Affective Disorders, Collegium Internationale Neuro-Psychopharmacologium and the Canadian Network for Mood and Anxiety Treatments. The manuscript was prepared through iterative editing.

OUTCOMES

The concept of TRD as a discrete subtype of MDD, defined by failure to respond to pharmacotherapy, is not supported by evidence. Between 15 and 30% of depressive episodes fail to respond to adequate trials of 2 antidepressants, and 68% of individuals do not achieve remission from depression after a first-line course of antidepressant treatment. Failure to respond to antidepressant treatment, somatic therapies or psychotherapies may often reflect other factors including; biological resistance, diagnostic error, limitations of current therapies, psychosocial variables, a past history of exposure to childhood maltreatment or abuse, job satisfaction, personality disorders, co-morbid mental and physical disorders, substance use or non-adherence to treatment. Only a subset of patients not responding to antidepressant treatment can be explained through pharmacokinetic or pharmacodynamics mechanisms. We propose that non remitting MDD should be personalised, and propose a strategy of 'deconstructing depression'. By this approach, the clinician considers which factors contribute to making this individual both depressed and 'resistant' to previous therapeutic approaches. Clinical formulation is required to understand the nature of the depression. Many predictors of response are not biological, and reflect a confluence of biological, psychological, and sociocultural factors, which may influence the illness in a particular individual. After deconstructing depression at a personalised level, a personalised treatment plan can be constructed. The treatment plan needs to address the factors that have contributed to the individual's hard to treat depression. In addition, an individual with a history of illness may have a lot of accumulated life issues due to consequences of their illness, and these should be addressed in a recovery plan.

LIMITATIONS

A 'deconstructing depression' qualitative rubric does not easily provide clear inclusion and exclusion criteria for researchers wanting to investigate TRD.

CONCLUSIONS

MDD is a polymorphic disorder and many individuals who fail to respond to standard pharmacotherapy and are considered hard to treat. These patients are best served by personalised approaches that deconstruct the factors that have contributed to the patient's depression and implementing a treatment plan that adequately addresses these factors. The existence of TRD as a discrete and distinct subtype of MDD, defined by two treatment failures, is not supported by evidence.

Predominant polarity in bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

AIM

This cross-sectional study aimed to assess the predominant polarity (PP) in patients with bipolar disorder (BD) and the factors associated with PP.

METHODOLOGY

For this study, 773 participants with at least 10 years of illness, were recruited from 14 centres, were evaluated using the National Institute of Mental Health- Retrospective Life Charts to assess the course of illness and PP was determined by both Barcelona proposal and the Harvard Index.

RESULTS

According to Barcelona proposal for PP, 20.6% of the patients belonged to depressive PP, 45.8% belonged to manic PP and 33.6% belonged to indeterminate polarity. According to Harvard index of PP, 31.6% of the patients belonged to depressive PP, 56.1% belonged to manic polarity and 12.3% of the patients could not be categorized into any of these categories and hence, were considered to have indeterminate polarity. Those with depressive PP were more often having BD-II, had later age of onset, spent more time in episodes, had higher residual depressive symptoms, had lower residual manic symptoms, more often had depression as the first lifetime episode, and less often had at least one psychotic episode.

CONCLUSION

In the Indian subcontinent, although the prevalence of PP is influenced by the definition used, the most common PP is that of mania.

Predominant Polarity and Polarity Index of Maintenance Treatments for Bipolar Disorder: A Validation Study in a Large Naturalistic Sample in Italy

Background and Objectives: Predominant polarity (PP) may be a useful course specifier in at least a significant proportion of patients with Bipolar Disorder (BD), being associated with several clinically relevant correlates. Emerging evidence suggests that the concept of PP might influence the selection of maintenance treatments, based on a drug polarity index (PI) which measures the greater antidepressive vs. antimanic preventive efficacy of mood stabilizers over long-term maintenance treatment. In this study, we aimed to validate the PI in a large sample of Italian BD patients with accurate longitudinal characterization of the clinical course, which ensured a robust definition of the PP. Materials and Methods: Our sample is comprised of 653 patients with BD, divided into groups based on the predominant polarity (manic/hypomanic predominant polarity—MPP, depressive predominant polarity—DPP and no predominant polarity). Subsequently we calculated the mean total polarity index for each group, and we compared the groups. Results: When we examined the mean PI of treatments prescribed to individuals with DPP, MPP and no predominant polarity, calculated using two different methods, we failed to find significant differences, with the exception of the PI calculated with the Popovic method and using the less stringent criterion for predominant polarity (PP_50%). Conclusions: Future prospective studies are needed in order to determine whether the predominant polarity is indeed one clinical factor that might guide the clinician in choosing the right mood stabilizer for BD maintenance treatment.

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.

Bipolar Disorder Course and Outcome Study from India (BiD-CoIN study): Sample Description & Methods

OBJECTIVES

This multicentric study from India aimed to evaluate the long term course and outcome of bipolar disorder (BD).

METHOD

Seven hundred and seventy-three participants diagnosed with BD, attending 14 outpatient clinic centers across the country, were evaluated using the National Institute of Mental Health- Retrospective Life Charts to assess the long term course of BD.

RESULTS

The mean age of onset of the first episode of illness of the study sample was 26.3 (8.54) years, and mean duration of illness at the time of assessment was 233.05 (94.55) months. In terms of the total number of lifetime episodes, the mean number of manic episodes (mean: 3.68; SD: 4.75) exceeded the mean number of depressive episodes (mean: 3.36; SD: 5.51). The mean numbers of total lifetime episodes were 8.58 (10.6%). When the number of episodes per year was computed, the mean number of manic episodes per year exceeded that of the mean number of depressive episodes. Compared to females, a higher proportion of males had a history of comorbid substance dependence.

LIMITATIONS

The course was assessed retrospectively and the study was limited to participants attending the outpatient clinics.

CONCLUSIONS

The course of BD in India differs from that described from developed countries in the form of a number of manic episodes exceeding the depressive episodes.

Cerebro-cerebellar white matter connectivity in bipolar disorder and associated polarity subphenotypes

BACKGROUND

The cerebellum has a crucial role in mood regulation. While cerebellar grey matter (GM) alterations have been previously reported in bipolar disorder (BD), cerebro-cerebellar white matter (WM) connectivity alterations and cerebellar GM profiles have not been characterised in the context of predominant polarity (PP) and onset polarity (OP) subphenotypes of BD patients which is the aim of the present study.

METHODS

Forty-two euthymic BD patients stratified for PP and OP and 42 healthy controls (HC) were included in this quantitative neuroimaging study to evaluate cerebellar GM patterns and cerebro-cerebellar WM connections. Diffusion tensor tractography was used to characterise afferent and efferent cerebro-cerebellar tract integrity. False discovery rate corrections were applied in post-hoc comparisons.

RESULTS

BD patients exhibited higher fractional anisotropy (FA) in fronto-ponto-cerebellar tracts bilaterally compared to HC. Subphenotype-specific FA profiles were identified within the BD cohort. Regarding PP subgroups, we found FA changes in a) left contralateral fronto-ponto-cerebellar tract (depressive-PP > HC) and b) contralateral/ipsilateral fronto-ponto-cerebellar tracts bilaterally (manic-PP > HC). Regarding OP subgroups, we observed FA changes in a) left/right contralateral fronto-ponto-cerebellar tracts (depressive-OP > HC) and b) all fronto-ponto-cerebellar, most parieto-ponto-cerebellar and right contralateral occipito-ponto-cerebellar tracts (manic-OP>HC). In general, greater and more widespread cerebro-cerebellar changes were observed in manic-OP patients than in depressive-OP patients compared to HC. Manic-OP showed higher FA compared to depressive-OP patients in several afferent WM tracts. No GM differences were identified between BD and HC and across BD subgroups.

CONCLUSIONS

Our findings highlight fronto-ponto-cerebellar connectivity alterations in euthymic BD. Polarity-related subphenotypes have distinctive cerebro-cerebellar WM signatures with potential clinical and pathobiological implications.

A narrative review of cross-sectional and prospective associations between self-schemas and bipolar disorder

The role of self-concept in bipolar disorder (BD) has not been well understood. The present review utilizes the notion of self-schema and interrogates existing research concerning evidence for cross-sectional and prospective associations between four schema-like constructs (i.e. trait self-esteem, dysfunctional beliefs concerning contingent self-worth, early maladaptive schemas and implicit self-esteem) and various facets of BD. Existing findings demonstrate various types of involvement of self-schemas in BD. Of particular clinical relevance, the present review suggests that low trait self-esteem and dysfunctional beliefs concerning contingent self-worth are risk factors for ongoing BD symptoms and mood episodes. The present review also yields important yet unaddressed questions with respect to the evaluative content of self-schemas associated with the hypo/manic phase of BD.

Differences in Demographic and Clinical Characteristics of Patients With Depressive vs. Manic First Episode of Bipolar Disorder

Background: Bipolar disorder is a serious mental disease marked by episodes of depression, mania, hypomania, or mixed states. Patients with bipolar disorder may present with different symptoms at first onset. The aim of this study is to compare demographic and clinical variables based on a patient's first episode of bipolar disorder, including risk of recurrence over a 2-year period. Methods: A large cohort (N = 742) of patients with bipolar disorder in China was analyzed. Patients were divided into two groups according to their first episode of bipolar disorder, either depression or mania. Patients in mixed state first episode were classified based on predominant symptoms. Three hundred eighteen patients of the cohort had a first episode of mania and 424 patients had initial symptoms of depression. Demographic and clinical data were collected. All patients were followed up for 24 months. Data on compliance with follow-up appointments and recurrence of symptoms after 6, 12, 18, and 24 months were collected. Clinical characteristics (course of disease, age of onset, psychiatric family history, etc.) were compared between the mania group and depression groups. Results: More patients with bipolar disorder had a first episode of depression than mania (57.14 vs. 42.86%). Compared with the depression group, the mania group had later age of diagnosis of bipolar disorder [(38.64 ± 13.50) vs. (36.34 ± 14.94), P = 0.028], lower education level [(9.37 ± 4.34) vs. (10.17 ± 4.81), P = 0.017] and longer latency between an initial episode of psychiatric symptoms and formal bipolar diagnosis [(10.80 ± 10.76) vs. (8.85 ± 9.90), P = 0.012]. More patients in the mania group were male and without psychotic symptoms (all P < 0.05). In comparison with the mania group, more patients in the depression group were female, with higher frequency of a reported precipitating event before first mood episode (all P < 0.05). Compared with the depression group, the mania group had more recurrences of illness at the end of 12 months (Z =-2.156, P = 0.031), 18 months (Z =-2.192, P = 0.028), and 24 months (Z = -2.364, P = 0.018). Conclusions: In our study, there are a number of differences in demographic and clinical characteristics of patients with different onset syndromes of bipolar disorder. These differences include gender, education level, diagnosis age, the rate of recurrences, and others. These data of a cohort of Chinese patients add to the growing international literature on the relationship between index episode of bipolar disorder and clinical variables and outcomes. These results and further study may allow clinicians to offer patients and families more reliable prognostic information at the onset of disease.

Structural Neuroimaging and Predominant Polarity in Patients with Type 1 Bipolar Disorder from Antioquia

INTRODUCTION

Predominant polarity (PP) has been proposed as a specifier of bipolar disorder (BD) due to its relationship with clinical and prognostic variables. It is possible that this is due to a different underlying neurobiology, in such a way that the changes found by structural nuclear magnetic resonance imaging (sMRI) in BD are different and specific.

OBJECTIVES

To explore findings of structural neuroimaging in patients with BD type I (BD-I) according to PP.

METHODS

Cross-sectional study that evaluated 77 patients with BD-I using the DIGS interview. PP was established using the operative definition of two-thirds of all affective episodes throughout life to classify PP as manic (MPP), depressive (DPP) or indeterminate (IPP). MRIwas performed during the euthymia phase to measure intracranial structures. The data obtained was analysed using a linear regression model adjusted for confounding variables (drug use, alcohol use, psychoactive substance use) and were compared between the three groups finding the standardised mean difference (SMD).

RESULTS

Differences with adequate effect size were found in three brain structures after adjusting for confounding variables, specifically in the right fusiform gyrus and the left lingual gyrus, which were greater in the DPP group than in the MPP group (SMD = 0.92; 95% CI = 0.34 to 1.49 and SMD = 0.78; 95% CI = 0.21 to 1.35). Likewise, in the right thalamus, it was shown to be greater in the IPP group compared to MPP group (SMD 0.89, 95% CI = 0.31 to 1.46).

CONCLUSIONS

A reduction in the thickness of the right fusiform gyrus and the left lingual gyrus, as well as the right thalamic volume was observed in patients with BD-I with PPM, which supports the hypothesis that PP has a plausible neurobiological correlate and could have potential utility as a BD specifier.

How to treat mania

OBJECTIVE

In this paper, we aimed at reviewing evidence-based treatment options for bipolar mania and proposed tentative evidence-based clinical suggestions regarding the management of a manic episode, especially regarding the choice of the proper mood stabilizer and antipsychotic medication.

METHOD

A narrative review was undertaken addressing 'treatment of bipolar mania'. Findings have been synthesized and incorporated with clinical experience into a model to support different treatment choices.

RESULTS

To date, there is solid evidence supporting the use of several medications, such as lithium, divalproex, and carbamazepine, and antipsychotics, such as chlorpromazine, haloperidol, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, inhaled loxapine, asenapine, and cariprazine in acute mania, and some evidence supporting the use of clozapine or electroconvulsive therapy in treatment-refractory cases. However, in clinical practice, when making decisions about treatment, personalized treatment is needed, according to the different clinical presentations and more complex clinical situations within the manic episode and considering a long-term view and with the objective of not only a symptomatic but also functional recovery. After remission from acute mania, psychoeducation strategies are useful to ensure adherence.

DISCUSSION

Despite the evidence forefficacy of many currently available treatments for mania, the majority of RCTs provide little direction for the clinician as to what steps might be optimal in different presentations of mania as well as in the presence of specific patient characteristics. Manic episodes should be managed on a personalized basis considering the clinical course and patient criteria and with the expectation of maintaining that treatment in the long-term.

Predominant polarity and hippocampal subfield volumes in Bipolar disorders

OBJECTIVES

Predominant polarity (PP) is a proposed course specifier for bipolar disorders (BD) based on patient lifetime mood episodes. Hippocampal subfield volumetric changes have been proposed as a neurobiological marker for BD and could be influenced by mood episodes. Our study aimed to test the hypothesis that patients with BD differ in hippocampal subfield volumes according to their PP.

METHODS

We assessed 172 outpatients, diagnosed with BD according to DSM-IV-TR criteria, and 150 healthy control (HC) participants. High-resolution magnetic resonance imaging was performed on all subjects and volumes of all hippocampal subfields were measured using FreeSurfer.

RESULTS

Patients with depressive PP (BD-DP) and with uncertain PP (BD-UP) but not with manic/hypomanic PP (BD-MP) showed a global reduction on all hippocampal subfield volumes with respect to HCs. When directly compared, BD-DP presented with smaller bilateral presubiculum/subiculum volumes than BD-MP.

CONCLUSIONS

Results support the potential utility of PP not only as a clinical but also as a neurobiological specifier of BD.

Comorbid personality disorders in manic bipolar I disorder patients is associated with increased use of long-acting injectable antipsychotic treatment and higher rates of rehospitalization

Personality disorder comorbidity is considered a poor prognostic factor among bipolar disorder patients. However, an evidence-based pharmacological treatment for this sub-population is lacking, and only few studies investigated the impact of personality disorder on bipolar disorder-I course. Here, we studied the effect of comorbid personality disorder on the administrated psychopharmacotherapy and rehospitalization risk among manic bipolar disorder-I patients. A sample of 340 patients with bipolar disorder-I, who were hospitalized with acute manic episode between 2005 and 2013, were retrospectively followed for a mean duration of 1129 days. Drug treatment at discharge and rehospitalization rates during follow-up time were compared between bipolar disorder-I patients with (n = 55) or without (n = 285) personality disorder comorbidity. Multivariate survival analyses adjusted for covariates were conducted. During the study period, 39.4% of bipolar disorder-I patients were rehospitalized due to a mood episode. Comorbid personality disorder was significantly associated with higher rates of long-acting injectable antipsychotics administration at discharge from hospitalization (adjusted odds ratio 2.66, 95% confidence interval: 1.19-5.94, P = 0.017). Comorbid personality disorder significantly increased the adjusted risk of rehospitalization due to a mood episode (hazard ratio = 2.04, 95% confidence interval: 1.29-3.23, P = 0.002). In conclusion, comorbid personality disorder in manic bipolar disorder-I patients is associated with increased use of long-acting injectable antipsychotics and higher rates of rehospitalization.

The existential crisis of bipolar II disorder

The issue of categorical vs. dimensional classification of bipolar disorder continues to generate controversy as it has for generations. Despite the evidence that no psychiatric disorder has discrete boundaries separating pathological and nonpathological states, and within a disorder, no clear differences separate subtypes-which would suggest a more dimensional approach-there are valid reasons to continue with our current categorical system, which distinguishes bipolar I from bipolar II disorder. Complicating the issue, a number of interested constituencies, including patients and their families, clinicians, scientists/researchers, and governmental agencies and insurance companies have different interests and needs in this controversy. This paper reviews both the advantages and disadvantages of continuing the bipolar I/bipolar II split vs. redefining bipolar disorder as one unified diagnosis. Even with one unified diagnosis, other aspects of psychopathology can be used to further describe and classify the disorder. These include both predominant polarity and categorizing symptoms by ACE-activity, cognition and energy. As a field, we must decide whether changing our current classification before we have a defining biology and genetic profile of bipolar disorder is worth the disruption in our current diagnostic system.

Common and distinct global functional connectivity density alterations in drug-naïve patients with first-episode major depressive disorder with and without auditory verbal hallucination

Auditory verbal hallucination (AVH), defined as the auditory perception of speech in the absence of a real external stimulus, occurs in individuals with and without mental illness. The distribution of functional abnormalities in patients with AVH suggests aberrant brain network connectivity. However, no study has measured the global functional connectivity density (gFCD) associated with AVH in patients with major depressive disorder (MDD); gFCD is used widely to examine the density distribution of whole-brain resting-state functional connectivity and can serve as an index reflecting brain metabolism disturbance. In this study, we involved drug-naïve patients with first-episode MDD with (n = 35) and without (n = 40) AVH and healthy controls (n = 50).Whole-brain resting-state functional magnetic resonance imaging data were acquired and gFCD was calculated and compared among groups. We found the following gFCD alterations that were shared by both MDD groups: (1) decreased gFCD in the bilateral postcentral gyrus, precentral gyrus, insular cortices and occipital lobe; and (2) increased gFCD in the left middle cingulate cortex. More importantly, we found AVH-specific gFCD changes in patients with MDD: increased gFCD in the left Wernicke's brain regions and bilateral hippocampus and thalamus, and decreased gFCD in the bilateral lateral prefrontal lobule. These findings reflect the disturbance of brain information communication and metabolism in patients with MDD and AVH, related mainly to the language and memory processing circuits, and to some extent provide further support for the "VOICE" model of AVH.

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

BACKGROUND

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

RESULTS

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

LIMITATIONS

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

sVCAM-1, sICAM-1, TNF-α and IL-6 levels in bipolar disorder type I: Acute, longitudinal and therapeutic implications

OBJECTIVES

To explore the serum levels of soluble vascular cell adhesion molecule-1 (sVCAM-1), soluble intercellular cell adhesion molecule-1 (sICAM-1), tumour necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in patients with bipolar disorder (BD), with regard to acute episode characteristics, course of the disorder and treatment.

METHODS

The study group consisted of 83 patients diagnosed with BD type I. The control group consisted of 73 healthy individuals, matched with the study group according to age, gender and body mass index. The serum levels of sVCAM-1, sICAM-1, TNF-α and IL-6 were measured by ELISA.

RESULTS

Compared with healthy controls, significantly elevated levels of IL-6 and sICAM-1 and significantly lower levels of TNF-α and sVCAM-1 were identified in acute and remission phases of BD. The acute serum levels of sVCAM-1 were associated with the type and severity of acute mood symptoms as well as with course of illness characteristics. TNF-α was associated with duration of untreated disorder and type of treatment.

CONCLUSIONS

BD is related to both acute and long-term alterations of immune mediators, including adhesion molecules. The potential immunomodulatory role of pharmacotherapeutic treatment is also to be considered in BD.

Predominant polarity in bipolar disorder patients: The COPE bipolar sample

BACKGROUND

The concept of predominant polarity (PP) is defined as presenting more symptoms of one polarity. Previous studies have defined PP as one polarity (either a depression or mania episode) occurring during at least two-thirds of the lifetime.

METHODS

We conducted an observational study with the COPE-BD (Clinical Outcome and Psycho-Education for Bipolar Disorder, Clinical Outcome Measures Section) dataset to identify the diagnostic and treatment differences between bipolar disorder (BD) patients with and without PP.

RESULTS

The final sample included 210 BD-I (59.0%) and 146 BD-II (41.0%) patients. Of these, 28.9% patients presented predominant polarity (PP): 62 (17.4%) of those patients were depressed polarity predominant (DPP), 41 (11.5%) were manic polarity predominant (MPP), and 253 (71.1%) met criteria for bipolar disorders but did not present with PP. In comparison to this group of BD patients with undetermined polarity, the group of BD patients with PP presented more rapid cycling. Furthermore, in the undetermined polarity group, the onset of illness occurred earlier, and the duration of the illness was longer, with more hypomanic/manic and depressive episodes than patients who met the PP criteria.

LIMITATIONS

This study has a naturalistic and retrospective design and does not allow a specific follow-up of polarity over time.

CONCLUSIONS

These different clinical characteristics underline the importance of considering PP in patients with BD, and justify the need for differential treatment approach which could have an impact on patients' prognosis. Yet, more independent and prospective research is needed to confirm these findings, especially with the new classification of DSM-5 concerning mixed states.

Examining Patterns of Polypharmacy in Bipolar Disorder: Findings from the REAP-BD, Korea

Based on Korean data from the Research on Asian Psychotropic Prescription Pattern for Bipolar Disorder, this study tried to present prescription patterns in biopolar disorder (BD) and its associated clinical features. Based on the information obtained from the study with structured questions, the tendency of prescription pattern was studied and analyzed. Polypharmacy was predominant, including simple polypharmacy in 51.1% and complex polypharmacy in 34.2% of patients. Subjects associated with simple or complex polypharmacy were significantly younger, had higher inpatient settings, a larger portion of onset with manic episode, a shorter duration of untreated illness, a shorter duration of current episode, were more overweight, used less antidepressants and used more anxiolytics. These findings can suggest higher polypharmacy rate in more severe BD and highlight the necessity of monitoring the weight of subjects with polypharmacy.

Predominant polarity in bipolar I and II disorders: A five-year follow-up study

BACKGROUND

Patients with bipolar disorder (BD) differ in their relative predominance of types of episodes, yielding predominant polarity, which has important treatment implications. However, few prospective studies of predominant polarity exist.

METHODS

In the Jorvi Bipolar Study (JoBS), a regionally representative cohort of 191 BD I and BD II in- and outpatients was followed for five years using life-chart methodology. Differences between depressive (DP), manic (MP), and no predominant polarity (NP) groups were examined regarding time ill, incidence of suicide attempts, and comorbidity.

RESULTS

At baseline, 16% of patients had MP, 36% DP, and 48% NP. During the follow-up the MP group spent significantly more time euthymic, less time in major depressive episodes, and more time in manic states than the DP and NP groups. The MP group had significantly lower incidence of suicide attempts than the DP and NP group, lower prevalence of comorbid anxiety disorders but more psychotic symptoms lifetime and more often (hypo)manic first phase of the illness than the DP group. Classification of predominant polarity was influenced by the timeframe used.

LIMITATIONS

The retrospective counting of former phases is vulnerable to recall bias. Assignment of dominant polarity may necessitate a sufficient number of illness phases.

CONCLUSIONS

Predominant polarity has predictive value in predicting group differences in course of illness, but individual patients' classification may change over time. Patients with manic polarity may represent a more distinct subgroup than the two others regarding illness course, suicide attempts, and psychiatric comorbidity.

Duration of euthymia and predominant polarity in bipolar disorder

BACKGROUND

The concept of Predominant Polarity (PP) provides relevant information for clinical practice and has been widely described as course specifier for Bipolar Disorder (BD), however it has not been incorporated in DSM-5 yet. A descriptive study was conducted to identify clinical patterns associated with PP in outpatients attending a Mental Health Unit.

METHODS

Clinical and socio-demographic characteristics were assessed from a sample of 118 euthymic outpatients fulfilling DSM 5 criteria for BDI or II recruited at a catchment area. According to their PP, patients were divided into three subgroups: depressive (DPP; 39.0%), manic (MPP; 32.2%) or indeterminate (IPP; 28.8%). Subgroups of PP were compared regarding a comprehensive set of demographic and clinical features.

RESULTS

PP subgroups significantly differed in duration of euthymia, measured in months since the last episode (p < 0.04), with MMP patients showing longer periods (42.4 months) than those with DPP and IPP (18.6 and 18.1 months, respectively). Moreover, history of seasonal pattern was significantly higher in the DPP group compared with the PPM group (p < 0.001). There were no significant correlations between PP and type of last episode, length of illness, number of previous admissions, history of psychotic symptoms, or number of suicide attempts.

LIMITATIONS

Cross sectional design, relatively modest sample size.

CONCLUSIONS

Our study showed similar results to previous literature regarding distribution of predominant polarity. The association found between PP and duration of euthymia represents a novel finding which awaits confirmation and adds further support to the usefulness of PP in clinical practice.

Impact of predominant polarity on long-term outcome in bipolar disorder: A 7-year longitudinal cohort study

INTRODUCTION

Recent studies suggest that Predominant Polarity (PP) may be an important specifier of Bipolar Disorder (BD), establishing distinct groups of patients and providing a potential tool for tailored treatment. PP has been associated to various clinical variables present in the course of the disorder, including deficits in cognitive functioning, suicide attempts, hospitalizations and response to pharmacological treatment. However, most published studies are retrospective and cross-sectional, frequently relying on patients´ ability to recall past information, which may often be inaccurate.

METHODS

Participants were recruited from the outpatient clinic of the Bipolar Disorder Research Program at the Institute of Psychiatry of the University of São Paulo. Baseline clinical and demographic variables were collected using a semi-structured questionnaire and the SCID-CV. Longitudinal data were collected through medical records, mood charts, and mood symptom scales conducted throughout a 7-year follow-up period.

RESULTS

Manic Predominant Polarity (MPP) was associated with a significantly higher number of hospitalizations, suicide attempts, and episodes with psychotic symptoms throughout the 7-year observed period in comparison to Depressive Predominant Polarity (DPP) and Indefinite Predominant Polarity (IPP) patients. Moreover, baseline PP was significantly associated with 7-year PP, with 67% of patients maintaining their PP both at baseline and after the 7-year follow-up period.

LIMITATIONS

The present study is limited due to the statistically small sample size, although, to our knowledge, it is the largest longitudinal study conducted in this topic, and the unequally distributed frequency of patients´ visitations, which may have created intervals of unobserved periods within the follow-up period.

DISCUSSION

The results revealed PP to be an important specifier for predicting the course of the disorder. Overall, MPP was significantly associated with variables indicative of a worse outcome, suggesting that greater attention to preventive treatment should be addressed to this subgroup. Lastly, baseline PP was significantly associated with 7-year observed PP, suggesting that patients tend to remain within the same PP throughout the course of the disorder.

Does Blood Flow Change according to Mood? Blood Rheology in Bipolar Disorder

Objective

Bipolar disorder (BD) is associated with increased rates of cardiovascular diseases. There is growing evidence that blood viscosity may have a common role, correlated with well-known major risk factors that promote cardiovascular disease. In this study we aimed to investigate the whole blood viscosity (WBV) in different stages of BD.

Methods

A total of 121 bipolar patients and 41 age-gender matched healthy controls were included. Forty-four of bipolar patients were in manic, 35 were depressed and 42 were in euthymic state. WBV was calculated from hematocrit and total plasma protein according to Simone's formula at low and high shear rates (LSR and HSR).

Results

WBV at HSR of manic group was 16.91±1.01, depressive group was 17.23±0.80, euthymic group was 17.63±0.95, and control group was 17.52±0.71 (p =0.001). WBV at LSR of manic depressive, euthymic and control group were 53.10±20.58, 60.30±17.02, 8.91±20.33, and 62.01±19.28, respectively (p =0.001). Both WBV at HSR and LSR of manic group was significantly lower than that of the euthymic and control groups (p =0.001 and 0.010 respectively for HSR, p =0.001 and 0.011 respectively for LSR). WBV was significantly positively correlated with lipid profile except high density lipoprotein (HDL).

Conclusion

Our results demonstrate a decrement in blood viscosity in manic episode compared with euthymics and controls. Positive correlation of blood viscosity with lipid parameters (except HDL), and negative correlation with number of previous manic episodes suggest that manic episode has favorable effect on cardiovascular risk regarding to blood viscosity.

The association between school exam grades and subsequent development of bipolar disorder

OBJECTIVE

Prior studies have indicated that both high and low school grades are associated with development of bipolar disorder (BD), but these studies have not adjusted for parental history of mental disorder, which is a likely confounder. Furthermore, the association between school grades and bipolar I disorder (BD-I) has not been studied. Therefore, we aimed to study the association between school exam grades and subsequent development of BD and BD-I while adjusting for parental history of mental disorder.

METHODS

We conducted a register-based nationwide cohort study following 505 688 individuals born in Denmark between 1987 and 1995. We investigated the association between school exam grades and development of BD or BD-I with a Cox model adjusting for family history of mental disorder and other potential confounders.

RESULTS

During follow-up, 900 individuals were diagnosed with BD and 277 of these with BD-I. The risk for BD and BD-I was significantly increased for individuals not having completed the exams at term [adjusted hazard ratio (aHR) for BD (aHR=1.71, 95% CI: 1.43-2.04) and for BD-I (aHR=1.57, 95% CI: 1.13-2.19)]. Also, having low exam grades in mathematics was associated with increased risk of both BD (aHR=2.41, 95% CI: 1.27-4.59) and BD-I (aHR=2.71, 95% CI: 1.41-5.21). Females with very high exam grades in Danish (percentile group>97.7) had a significantly increased risk of BD-I (aHR=2.49, 95% CI: 1.19-5.23).

CONCLUSIONS

The potential to develop BD seems to affect the school results of individuals negatively even before BD is diagnosed - with females having the potential to develop BD-I as a possible exception.

Clinical characterization of Italian suicide attempters with bipolar disorder

IntroductionBipolar disorder (BD) is a chronic, highly disabling condition associated with psychiatric/medical comorbidity and substantive morbidity, mortality, and suicide risks. In prior reports, varying parameters have been associated with suicide risk.

OBJECTIVES

To evaluate sociodemographic and clinical variables characterizing Italian individuals with BD with versus without prior suicide attempt (PSA).

METHODS

A sample of 362 Italian patients categorized as BD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) was assessed and divided in 2 subgroups: with and without PSA. Sociodemographic and clinical variables were compared between prior attempters and non-attempters using corrected multivariate analysis of variance (MANOVA).

RESULTS

More than one-fourth of BD patients (26.2%) had a PSA, with approximately one-third (31%) of these having>1 PSA. Depressive polarity at onset, higher number of psychiatric hospitalizations, comorbid alcohol abuse, comorbid eating disorders, and psychiatric poly-comorbidity were significantly more frequent (p<.05) in patients with versus without PSA. Additionally, treatment with lithium, polypharmacotherapy (≥4 current drugs) and previous psychosocial rehabilitation were significantly more often present in patients with versus without PSA.

CONCLUSIONS

We found several clinical variables associated with PSA in BD patients. Even though these retrospective findings did not address causality, they could be clinically relevant to better understanding suicidal behavior in BD and adopting proper strategies to prevent suicide in higher risk patients.

Prevalence and treatment of panic disorder in bipolar disorder: systematic review and meta-analysis

QUESTION

Recent data suggest that anxiety disorders are as often comorbid with bipolar disorder (BD) as with unipolar depression. The literature on panic disorder (PD) comorbid with BD has been systematically reviewed and subject to meta-analysis.

STUDY SELECTION AND ANALYSIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were thoroughly followed for literature search, selection and reporting of available evidence. The variance-stabilising Freeman-Tukey double arcsine transformation was used in the meta-analysis of prevalence estimates. Both fixed-effect and random-effects models with inverse variance method were applied to estimate summary effects for all combined studies. Heterogeneity was assessed and measured with Cochran's Q and I2 statistics.

FINDINGS

Overall, 15 studies (n=3391) on cross-sectional prevalence and 25 independent lifetime studies (n=8226) were used to calculate pooled estimates. The overall random-effects point prevalence of PD in patients with BD, after exclusion of one potential outlier study, was 13.0% (95% CI 7.0% to 20.3%), and the overall random-effects lifetime estimate, after exclusion of one potential outlier study, was 15.5% (95% CI 11.6% to 19.9%). There were no differences in rates between BD-I and BD-II. Significant heterogeneity (I2 >95%) was found in both estimates.

CONCLUSIONS

Estimates that can be drawn from published studies indicate that the prevalence of PD in patients with BD is higher than the prevalence in the general population. Comorbid PD is reportedly associated with increased risk of suicidal acts and a more severe course. There is no clear indication on how to treat comorbid PD in BD. Findings from the current meta-analysis confirm the highly prevalent comorbidity of PD with BD, implicating that in patients with BD, PD might run a more chronic course.

The clinical course of late-life bipolar disorder, looking back and forward

OBJECTIVES

Little is known about the course of late-life bipolar disorder (LLBD). First, we studied patients with LLBD retrospectively with regard to age at first mood episode, onset polarity, predominant polarity and episode density and its associations with other clinical variables. Next, we examined prospectively the clinical course and its associated factors.

METHODS

Data were used from a dynamic cohort (Dutch Older Bipolars [DOBi]) including 101 patients with LLBD (mean age of 68.9 years) at baseline in 2012, with 3-year follow-up measurements available for 64 of these patients. Retrospective course was assessed by diagnostic interviews, and at follow-up polarity and duration for each consecutive episode were noted. Linear and logistic analyses were performed to assess associations between relevant factors and outcome.

RESULTS

The mean age at the first episode was 33.0 years. Onset polarity was depression in 44.6% of patients, with a predominant polarity of depression in 47.5%. At 3-year follow-up, 37.5% of patients reported at least one mood episode, mainly depression. Life events, somatic illness, use of lithium and other factors were not associated with recurrence during the 3-year follow-up.

DISCUSSION

A relapse rate of 37.5% in 3 years is high, considering that LLBD patients generally have a longer history of disease and were receiving care and medication. The course of LLBD can provide important information on which clinical factors are associated with recurrence. Further phenotyping may reveal unique predictors for outcome, and both course specifiers and clinical variables should be included.

MicroRNA-Mediated Regulation of ITGB3 and CHL1 Is Implicated in SSRI Action

Background: Selective serotonin reuptake inhibitor (SSRI) antidepressant drugs are the first-line of treatment for major depressive disorder (MDD) but are effective in <70% of patients. Our earlier genome-wide studies indicated that two genes encoding for cell adhesion proteins, close homolog of L1 (CHL1) and integrin beta-3 (ITGB3), and microRNAs, miR-151a-3p and miR-221/222, are implicated in the variable sensitivity and response of human lymphoblastoid cell lines (LCL) from unrelated individuals to SSRI drugs.

Methods: The microRNAs miR-221, miR-222, and miR-151-a-3p, along with their target gene binding sites, were explored in silico using miRBase, TargetScan, microRNAviewer, and the UCSC Genome Browser. Luciferase reporter assays were conducted for demonstrating the direct functional regulation of ITGB3 and CHL1 expression by miR-221/222 and miR-151a-3p, respectively. A human LCL exhibiting low sensitivity to paroxetine was utilized for studying the phenotypic effect of CHL1 regulation by miR-151a-3p on SSRI response.

Results: By showing direct regulation of CHL1 and ITGB3 by miR-151a-3p and miR-221/222, respectively, we link these microRNAs and genes with cellular SSRI sensitivity phenotypes. We report that miR-151a-3p increases cell sensitivity to paroxetine via down-regulating CHL1 expression.

Conclusions: miR-151a-3p, miR-221/222 and their (here confirmed) respective target-genes, CHL1 and ITGB3, are implicated in SSRI responsiveness, and possibly in the clinical response to antidepressant drugs.

The influence of current mood state, number of previous affective episodes and predominant polarity on insight in bipolar disorder

BACKGROUND

Although many studies have explored the effect of current affective episodes on insight into bipolar disorder, the potential interaction between current mood state and previous affective episodes has not been consistently investigated.

OBJECTIVE

To explore the influence of dominant polarity, number of previous affective episodes and current affective state on insight in bipolar disorder patients in euthymia or mania.

METHODS

A total of 101 patients with bipolar disorder were recruited for the study, including 58 patients in euthymia (30 with no defined predominant polarity and 28 with manic predominant polarity) and 43 in mania (26 with no defined predominant polarity and 17 with manic predominant polarity). Patients underwent a clinical assessment and insight was evaluated through the Insight Scale for Affective Disorders.

RESULTS

Bipolar disorder patients in mania had worse insight than those in euthymia, with no effect of dominant polarity. In addition, positive psychotic symptoms showed a significant effect on insight and its inclusion as a covariate eliminated differences related to mood state. Finally, the number of previous manic or depressive episodes did not correlate with insight level.

CONCLUSIONS

Mania is a predictor of loss of insight into bipolar disorder. However, it is possible that its contribution is linked to the more frequent presence of psychotic symptoms in this state. Dominant polarity and number/type of previous affective episodes have a limited impact on insight.

Bipolar disorder in Asia: Illness course and contributing factors

BACKGROUND

Epidemiological studies analysing the course of Bipolar Disorder (BD) are relatively rare in the Asian context, contributing to the uncertainty regarding the prevalent course patterns and factors influencing such patterns. The current review identifies the regional characteristics of BD course patterns and the associated factors.

METHODS

A review of the existing literature was done using 'PubMed' and 'Cochrane' databases which yielded 145 studies including those from all 48 Asian countries. Relevant discussions from the Western literature were incorporated.

RESULTS

Regional and cross-national studies reveal a mania-predominant course in BD in Asian countries. Prolonged depressive episodes and comorbid anxiety disorders worsen the course of BD-II. Certain risk factors such as the young age of onset and greater episode frequency are useful predictors of bipolar diatheses. Substance use disorder comorbidity is more prevalent in males whereas depression and suicidal behaviours are more frequent in females with BD. Comorbid anxiety and personality disorders also encumber the illness course. Logistic reasons and ignorance of side-effects were specifically associated with poor adherence. An 'eveningness' chronotype and poor sleep quality were associated with frequent recurrences. Seasonal patterns vary among men and women, especially for depressive episodes.

LIMITATIONS

The effects of treatment and childhood BD course features were not discussed.

CONCLUSIONS

There are region-specific characteristics in bipolar illness course and factors influencing such course patterns compared to the rest of the World. Future research from Asia shall attempt to study the neurobiological underpinnings of such characteristics and plan appropriate strategies to address the same.

A study on the bioequivalence of lithium and valproate salivary and blood levels in the treatment of bipolar disorder

Lithium (Li) and valproate (VPA) are used in the treatment of bipolar disorder (BD), with narrow therapeutic window requiring periodic control of serum levels. This prevents intoxication, lack of efficacy due to low serum concentrations, and allows monitoring adherence. We aimed at evaluating the bioequivalence of salivary and blood levels of LI or VPA in a sample of adult BD patients. Secondarily, lithium bioequivalence was evaluated across different patients' lifespans. BD patients treated with either Li or VPA underwent contemporary standard serum and salivary measurements. Blood levels of both drugs were taken according to standard procedures. Li salivary levels were performed by an adapted potentiometric method on the AVL9180 electrolyte analyzer. VPA salivary levels were taken with an immune-assay method with turbidimetric inhibition. A total of 50 patients (38 on Li, 12 on VPA) were enrolled. Blood-saliva bioequivalence for VPA was not found due to a high variability in salivary measures. Li measures resulted in a high correlation (r=0.767, p<0.001), showing no partial correlation with age (r=0.147, p=0.380). Li salivary test is a reliable method of measuring Li availability and is equivalent to serum levels. Potential advantages of Li salivary testing are its non-invasive nature and the possibility of doing the test during the usual appointment with the psychiatrist.

Cognitive impairments and predominant polarity in bipolar disorder: a cross-sectional study

Background

Bipolar disorder (BD) patients exhibit cognitive impairments during euthymic states. Studies suggest that manic episodes may be correlated to cognitive impairments. The present study investigated the relationship between predominant polarity and the cognitive deficits frequently detected in bipolar patients. We hypothesize that mania predominant polarity (MPP) patients should exhibit greater cognitive impairments in comparison to depressive (DPP) and indefinite predominant polarity (IPP) patients and healthy control (HC) individuals.

Methods

The study evaluated 55 euthymic BD patients, type I and II, and 31 HCs. Patients were divided into 3 groups: MPP (n = 17), DPP (n = 22), and IPP (n = 16), and compared regarding demographic and clinical variables, and performance on a 7-test neuropsychological battery.

Results

MPP patients demonstrated greater cognitive impairments in alternating attention, verbal fluency, and delayed memory in comparison to DPP, IPP, and HC. Compared to HC, IPP patients exhibit cognitive deficits in verbal fluency and alternating attention and DPP patients solely in verbal fluency. Furthermore, DPP patients did not exhibit, in none of the seven neuropsychological tests, significant poorer performances than MPP or IPP patients, although having significant more episodes than MPP patients.

Conclusion

MPP patients exhibit increased cognitive impairments in comparison to DPP, IPP, and HC subjects. Manic episodes may play an important role in the development of cognitive deficits and thus, in potential neuroprogression. Predominant polarity may be an important specifier for predicting future cognitive impairments.