Verbal learning impairment in euthymic bipolar disorder: BDI v BDII

Neurocognitive effects of six ketamine infusions and the association with antidepressant effects in treatment-resistant bipolar depression: a preliminary study

Objective

The N-methyl-D-aspartate subtype glutamate receptor antagonist ketamine has rapid antidepressant and antisuicidal effects in treating treatment-resistant bipolar depression (TRBD). The neurocognitive effects of repeated ketamine infusions in TRBD are not known.

Methods

Six intravenous infusions of ketamine (0.5 mg/kg over 40 min) were administered on a Monday–Wednesday–Friday schedule during a 12-day period on 16 patients with TRBD followed by a 2-week observational period. The assessment of neurocognitive function was conducted using the MATRICS Consensus Cognitive Battery at baseline, 13 and 26 days. Tasks were designed to test speed of processing, working memory, visual learning and verbal learning.

Results

A significant improvement was found only in scores of speed of processing (F = 9.9, p = 0.001) after a 2-week observational period, which was accounted for by the improvement of depression symptoms. There were no significant changes over time in terms of working memory, visual learning and verbal learning. Pearson correlation analysis showed that the improvement of depression symptoms through six ketamine infusions was greater among TRBD patients with lower working memory at baseline (r = 0.54, p = 0.03). In multiple regression analysis, the significant correlation was still maintained (beta = 0.67, t = 2.2, p = 0.04).

Conclusion

This preliminary study indicated that six ketamine infusions were not harmful but were slightly beneficial for speed of processing in TRBD. However, this change was mainly accounted for the improvement of depression symptoms over time. Lower baseline working memory appears to be associated with greater antidepressant response after completion of six ketamine infusions in patients with TRBD.

Neurocognitive impairment and evidence-based treatment options in Bipolar disorder

BACKGROUND

The current paper briefly summarizes the literature on the neurocognitive deficit and its treatment in BD patients.

METHODS

The material was chosen on the basis of previous systematic reviews the author has taken part in.

RESULTS

The data so far suggest that the deficit is qualitatively similar but quantitatively milder in comparison to schizophrenia, it is present already since the first episode, is weakly related to mood symptoms and somewhat stronger to psychotic symptoms, it probably determines much of the disability and treatment is problematic. This deficit is also present during periods of euthymia. The possible adverse effect of psychotropic medication is rather small if any at all and is confounded by the specific clinical symptoms, for which medication is used for their treatment. This is especially true concerning antipsychotics and psychotic symptoms. The origin and the etiopathogenesis of the core neurocognitive impairment remain elusive. The presence of a neurodegenerative and of a neurodevelopmental component has both data in favor and against and they are both the focus of debate.

CONCLUSIONS

Treatment of the neurocognitive deficit and restoration of functioning is problematic. The data are limited and treatment options are few and with a weak overall effect. Pharmacological treatments, ECT and rTMS present some hard data, while the literature is inconclusive concerning psychotherapeutic interventions.

A systematic review on neuropsychological function in bipolar disorders type I and II and subthreshold bipolar disorders-something to think about

Neuropsychological dysfunction is a well-established finding in individuals with bipolar disorder type I (BP-I), even during euthymic periods; however, it is less clear whether this also pertains to bipolar disorder type II (BP-II) or those with subthreshold states (SBP; subthreshold bipolar disorder), such as bipolar not otherwise specified (BP-NOS). Herein, we compare the literature regarding neuropsychological performance in BP-II vs BP-I to determine the extent of relative impairment, and we present and review all related studies on cognition in SBP. After systematically searching PubMed, Medline, PsycINFO, and The Cochrane Library, we found 17 papers that comprise all the published studies relevant for this review. The areas that are consistently found to be impaired in BP are executive function, verbal memory, visual spatial working memory, and attention. More studies than not show no significant difference between BP-I and BP-II, particularly in euthymic samples. Preliminary evidence suggests that patients experiencing major depressive episodes who also meet criteria for SBP show similar profiles to BP-II; however, these results pertain only to a depressed sample. SBP were found to perform significantly better than both MDD and healthy controls in a euthymic sample. A consensus on mood state, patient selection, and neuropsychological testing needs to be agreed on for future research. Furthermore, no studies have used the most recent DSM-5 criteria for SBP; future studies should address this. Finally, the underlying bases of cognitive dysfunction in these diagnostic groups need to be further investigated. We suggest recommendations on all of the above current research challenges.

Cognitive emotional processing across mood disorders

While impairments in cognitive emotional processing are key to the experience of mood disorders, little is understood of their shared and distinct features across major depressive disorder (MDD) and bipolar disorder (BD). In this review, we discuss the similarities and differences in abnormal emotional processing associated with mood disorders across the cognitive domains of perception, attention, memory, and reward processing, with a particular focus on how these impairments relate to the clinical profile of the disorders. We consider behavioral and neuroimaging evidence, especially that of the growing consensus surrounding mood-congruent biases in cognition, in combination with state- and trait-related characteristics in an attempt to provide a more comprehensive and translational overview of mood disorders. Special consideration is given to the shared phenomenon of mood instability and its role as a potential transdiagnostic marker across the prodrome and maintenance of mood disorders.

Neuropsychological Functioning in Euthymic Phase of Bipolar Affective Disorder

BACKGROUND

A substantial proportion of euthymic bipolar disorder patients have neuropsychological impairment which can have a significant impact on the overall functional recovery.

MATERIALS AND METHODS

A total of 60 bipolar disorder patients, currently in euthymic phase for the last 3 months with minimum duration of illness 2 years and current Young Mania Rating Scale <7 and Hamilton Depression Rating Scale <6, currently on medications were administrated various neuropsychological tests.

RESULTS

Approximately half of the patients have neuropsychological impairments in the areas of mental speed, sustained attention, verbal fluency, working memory, set shifting, verbal and visual memory, and visual-constructional ability.

CONCLUSION

Findings of the current study provides evidence of neuropsychological impairment in euthymic bipolar disorder patients, and type of medications also has an impact on neuropsychological functions.

Neurocognitive features in clinical subgroups of bipolar disorder: A meta-analysis

OBJECTIVE

There is a significant cognitive heterogeneity in bipolar disorder (BD). The aim of this systematic review was to examine the potential distinctive neuropsychological of features of clinical subgroups of BD. A literature search investigating cognitive differences between potential subtypes of BD was conducted.

METHODS

It was possible to conduct a meta-analysis of studies investigating the relationship between cognitive deficits and subgroups of DSM-IV BD (type I (BD-I) and type II (BD-II)), subgroups based on history of psychosis (PBD and NPBD). The cognitive domains investigated in this meta-analysis included verbal memory, visual memory, processing speed, executive functions speed (EF-speed), EF-accuracy, attention, working memory, social cognition. Current meta-analysis included 48 reports and compared cognitive performances of 1211 BD-I and 836 BD-II patients. It also compared cognitive functioning in 1017 PBD and 744 NPBD patients.

RESULTS

Both history of psychosis (d = 0.19) and BD-I (d = 0.17) diagnosis were associated with modestly more pronounced global cognitive impairment. In specific domains, BD-I significantly underperformed BD-II in verbal memory, processing speed, EF-speed, EF-accuracy (d = 0.15-0.26). PBD was associated with significantly impaired cognition compared to NPBD in verbal memory, processing speed, EF-speed, EF-accuracy, working memory and social cognition (d = 0.12-0.28).

CONCLUSION

In BD, history of psychosis and full-manic episode are modestly associated with increased cognitive deficits. Neurocognitive differences between clinical subtypes of BD are quite subtle and are not distinctive. Furthermore, other factors reflecting differences in illness severity can explain observed between-group differences. Most of the cognitive heterogeneity in BD cannot be explained by proposed subtypes of BD.

The Compelling and Persistent Problem of Bipolar Disorder Disguised as Major Depression Disorder: An Integrative Review [Formula: see text]

BACKGROUND

Up to 40% of patients with bipolar disorder are misdiagnosed, usually with major depression disorder.

OBJECTIVE

The purpose was to describe the current state of the science of the misdiagnosis of bipolar disorder, with the ultimate goal of improving psychiatric diagnostic workups including screening.

DESIGN

An integrative review was conducted using standard criteria for evaluating research articles.

RESULTS

Forty-nine articles met the eligibility criteria. Articles explored patient-related and health care provider-related factors contributing to the misdiagnosis of bipolar disorder as well as consequences of misdiagnosis. Clinically oriented, reliable, and valid screening tools for bipolar disorder also were reviewed.

CONCLUSIONS

Awareness of multiple, challenging patient-related factors and more comprehensive assessment and screening by health care providers may reduce misdiagnosis.

Associations between residual depressive symptoms, cognition, and functioning in patients with euthymic bipolar disorder: results from the FACE-BD cohort

BackgroundThe relationship between residual depressive symptoms, cognition and functioning in patients with euthymic bipolar disorder is a subject of debate.AimsTo assess whether cognition mediates the association between residual depressive symptoms and functioning in patients with bipolar disorder who were euthymic.MethodWe included 241 adults with euthymic bipolar disorder in a multicentre cross-sectional study. We used a battery of tests to assess six cognition domains. A path analysis was then used to perform a mediation analysis of the relationship between residual depressive symptoms, cognitive components and functioning.ResultsOnly verbal and working memory were significantly associated with better functioning. Residual depressive symptoms were associated with poorer functioning. No significant relationship was found between residual depressive symptoms and any cognitive component.ConclusionsCognition and residual depressive symptoms appear to be two independent sources of variation in the functioning of people with euthymic bipolar disorder.

The effects of medication and current mood upon facial emotion recognition: findings from a large bipolar disorder cohort study

OBJECTIVES

Emotional processing abnormalities have been implicated in bipolar disorder (BD) but studies are typically small and uncontrolled. Here, facial expression recognition was explored in a large and naturalistically recruited cohort of BD patients.

METHODS

271 patients with BD completed the facial expression recognition task. The effects of current medication together with the influence of current mood state and diagnostic subtype were assessed whilst controlling for the effects of demographic variables.

RESULTS

Patients who were currently receiving treatment with lithium demonstrated significantly poorer accuracy in recognising angry faces, an effect that held in a monotherapy sub-analysis comparing those participants on lithium only and those who were medication-free. Accuracy in recognising angry faces was also lower amongst participants currently taking dopamine antagonists (antipsychotics). Higher levels of current depressive symptoms were linked to poorer accuracy at identifying happy faces.

CONCLUSION

Use of lithium and possibly dopamine antagonists may be associated with reduced processing of anger cues in BD. Findings support the existence of mood-congruent negative biases associated with depressive symptoms in BD. Observational cohort studies provide opportunities to explore the substantial effects of demographic, psychometric and clinical variables on cognitive performance and emotional processing.

Neurocognitive performance, psychopathology and social functioning in individuals at high risk for schizophrenia or psychotic bipolar disorder

INTRODUCTION

Although cognitive deficits are consistent endophenotypes of schizophrenia and bipolar disorder, findings in psychotic bipolar disorder (BDP) are inconsistent. In this study we compared adult unaffected first-degree relatives of schizophrenia and BDP patients on cognition, psychopathology, social functioning and quality of life.

METHODS

Sixty-six unaffected first-degree relatives of schizophrenia patients (SUnR), 36 unaffected first-degree relatives of BDP patients (BDPUnR) and 102 controls participated in the study. Between-group differences were examined and Discriminant Function Analysis (DFA) predicted group membership.

RESULTS

Visual memory, control inhibition, working memory, cognitive flexibility and abstract reasoning were linearly impaired in the relatives' groups. Poorer verbal fluency and processing speed were evident only in the SUnR group. The SUnR group had higher depressive and somatization symptoms while the BDPUnR group had higher anxiety and lower social functioning compared with the controls. Individuals with superior cognition were more likely to be classified as controls; those with higher social functioning, prolonged processing speed and lower anxiety were more likely to be classified as SUnR.

LIMITATIONS

The relatives' sample is quite heterogeneous; the effects of genetic or environmental risk-factors were not examined.

CONCLUSIONS

Cognitive functions mediated by a fronto-parietal network, show linear impairments in unaffected relatives of BDP and schizophrenia patients; processing speed and verbal fluency impairments were evident only in schizophrenia relatives. Self-perceived symptomatology and social functioning also differ between schizophrenia and BDP relatives. The continuum seen in patients in several indices was also seen in the cognitive impairments in unaffected relatives of schizophrenia and BDP patients.

Psychoeducation and online mood tracking for patients with bipolar disorder: A randomised controlled trial

BACKGROUND

Psychoeducation is an effective adjunct to medications in bipolar disorder (BD). Brief psychoeducational approaches have been shown to improve early identification of relapse. However, the optimal method of delivery of psychoeducation remains uncertain. Here, our objective was to compare a short therapist-facilitated vs. self-directed psychoeducational intervention for BD.

METHODS

BD outpatients who were receiving medication-based treatment were randomly assigned to 5 psychoeducation sessions administered by a therapist (Facilitated Integrated Mood Management; FIMM; n=60), or self-administered psychoeducation (Manualized Integrated Mood Management; MIMM; n=61). Follow-up was based on patients' weekly responses to an electronic mood monitoring programme over 12 months.

RESULTS

Over follow-up, there were no group differences in weekly self-rated depression symptoms or relapse/readmission rates. However, knowledge of BD (assessed with the Oxford Bipolar Knowledge questionnaire (OBQ)) was greater in the FIMM than the MIMM group at 3 months. Greater illness knowledge at 3 months was related to a higher proportion of weeks well over 12 months.

LIMITATIONS

Features of the trial may have reduced the sensitivity to our psychoeducation approach, including that BD participants had been previously engaged in self-monitoring.

CONCLUSIONS

Improved OBQ score, while accelerated by a short course of therapist-administered psychoeducation (FIMM), was seen after both treatments. It was associated with better outcome assessed as weeks well. When developing and testing a new psychosocial intervention, studies should consider proximal outcomes (e.g., acquired knowledge) and their short-term impact on illness course in bipolar disorder.

Associations between mood instability and emotional processing in a large cohort of bipolar patients

BACKGROUND

Aberrant emotional biases have been reported in bipolar disorder (BD), but results are inconsistent. Despite the clinical relevance of chronic mood variability in BD, there is no previous research investigating how the extent of symptom fluctuations in bipolar disorder might relate to emotional biases. This exploratory study investigated, in a large cohort of bipolar patients, whether instability in weekly mood episode symptoms and other clinical and demographic factors were related to emotional bias as measured in a simple laboratory task.

METHOD

Participants (N = 271, BDI = 206, BDII = 121) completed an 'emotional categorization and memory' task. Weekly self-reported symptoms of depression and mania were collected prospectively. In linear regression analyses, associations between cognitive bias and mood variability were explored together with the influence of demographic and clinical factors, including current medication.

RESULTS

Greater accuracy in the classification of negative words relative to positive words was associated with greater instability in depressive symptoms. Furthermore, greater negative bias in free recall was associated with higher instability in manic symptoms. Participants diagnosed with BDII, compared with BDI, showed overall better word recognition and recall. Current antipsychotic use was associated with reduced instability in manic symptoms but this did not impact on emotional processing performance.

CONCLUSIONS

Emotional processing biases in bipolar disorder are related to instability in mood. These findings prompt further investigation into the underpinnings as well as clinical significance of mood instability.

Effect of alcohol and illicit substance use on verbal memory among individuals with bipolar disorder

BACKGROUND

Cognitive impairment is a well-established feature of bipolar disorder (BD). Comorbid BD and substance use leads to poor psychosocial and clinical outcomes. However, knowledge on the neurocognitive functioning of individuals with dual diagnosis is limited. The aim of this study is to assess the cognitive performance of subjects with BD, BD with comorbid alcohol use disorder (AUD), and BD with comorbid illicit substance use disorders (SUD) as compared to healthy individuals.

METHODS

We included 270 inpatients and outpatients with BD and 211 healthy controls. The diagnostic of BD and substance use disorder was assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders Axis I. Demographic and clinical information were also collected. The cognitive assessment included the Wechsler Test of Adult Reading (WTAR), and a revised version of the California Verbal Learning Test (CVLT) as part of the South Texas Assessment of Neurocognition (STAN).

RESULTS

The STAN was administered to 134 BD patients (100 female, M±SD: 37.37±12.74 years), 72 BD patients with AUD (40 female, M±SD: 38.42±11.82), 64 BD patients with SUD (39 female, M±SD: 34.50±10.57), and 211 healthy controls with no lifetime history of mental illness and substance use (127 female, M±SD: 34.80±12.57 years). In terms of clinical characteristics, BD+SUD showed a marginally earlier onset of illness compared to BD. Compared to HC, BD performed poorly in the immediate recall and short-delay free tests of the CVLT, while BD patients with AUD and SUD showed significant memory deficits in both the immediate recall and recognition components of the CVLT. There were no differences in memory performance between BD and BD with either AUD or SUD.

CONCLUSIONS

A history of substance use disorders is associated with an earlier onset of BD. BD has marked effects on processes underlying the encoding of new information, while comorbid substance use in BD impairs more specifically the recognition of previously presented information. Future longitudinal studies should evaluate the effects of AUD and SUD on illness progression and therapeutic outcomes.

Reduced hippocampus volume and memory performance in bipolar disorder patients carrying the BDNF val66met met allele

BACKGROUND

Previous studies investigated the impact of brain-derived neurotrophic factor (BDNF) val66met (rs6265) on hippocampus volumes and neurocognition in bipolar disorders (BD), but the results were not consistent. This study aimed to investigate the effect of BDNF polymorphism on hippocampus volumes and memory performance in well-characterized adult populations diagnosed with type I BD (BD-I) and major depressive disorder (MDD) compared with healthy controls (HC).

METHODS

48 BD-I patients, 33 MDD patients and 60 HC were genotyped for BDNF rs6265 using DNA isolated from white blood cells. Individuals with val/met and met/met genotypes were grouped as met carriers and compared to those with the val/val. Brain segmentations were obtained from structural magnetic resonance imaging (MRI) using the Freesurfer. Memory performance was assessed with the California Verbal Learning Task (CVLT).

RESULTS

We found a significant diagnosis effect and marginal interaction between diagnosis and BDNF genotype group for both hippocampus volumes and memory performance. BDNF met allele carrier BD patients had smaller hippocampus volumes and reduced performance on multiple CVLT scores compared to MDD patients and HC.

CONCLUSIONS

We provide strong evidence for the BDNF val66met polymorphism as a putative biological signature for the neuroanatomical and cognitive abnormalities commonly observed in BD patients.

Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

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.

The neurocognitive functioning in bipolar disorder: a systematic review of data

BACKGROUND

During the last decades, there have been many different opinions concerning the neurocognitive function in Bipolar disorder (BD). The aim of the current study was to perform a systematic review of the literature and to synthesize the data in a comprehensive picture of the neurocognitive dysfunction in BD.

METHODS

Papers were located with searches in PubMed/MEDLINE, through June 1st 2015. The review followed a modified version of the recommendations of the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses statement.

RESULTS

The initial search returned 110,403 papers. After the deletion of duplicates, 11,771 papers remained for further evaluation. Eventually, 250 were included in the analysis.

CONCLUSION

The current review supports the presence of a neurocognitive deficit in BD, in almost all neurocognitive domains. This deficit is qualitative similar to that observed in schizophrenia but it is less severe. There are no differences between BD subtypes. Its origin is unclear. It seems it is an enduring component and represents a core primary characteristic of the illness, rather than being secondary to the mood state or medication. This core deficit is confounded (either increased or attenuated) by the disease phase, specific personal characteristics of the patients (age, gender, education, etc.), current symptomatology and its treatment (especially psychotic features) and long-term course and long-term exposure to medication, psychiatric and somatic comorbidity and alcohol and/or substance abuse.