Mortality and secular trend in the incidence of bipolar disorder

Case identification and healthcare utilization in the years prior to a first mania diagnosis

BACKGROUND

There is limited evaluation of approaches to identify patients with new onset bipolar affective disorder (BPAD) when using administrative datasets.

METHODS

Using the Massachusetts All-Payer Claims Database (APCD), we identified individuals with a 2016 diagnosis of bipolar disorder with mania and examined patterns of psychiatric and medical care over the preceding 48 months.

RESULTS

Among 4806 individuals aged 15-35 years with a 2016 BPAD with mania diagnosis, 3066 had 48 months of historical APCD data, and of those, 75 % involved information from ≥2 payors. After excluding individuals with historical BPAD or mania diagnoses, there were 583 individuals whose 2016 BPAD with mania diagnosis appeared to be new (i.e., 34 new diagnoses per 100,000 individuals aged 15-35 years). Most individuals received medical care, e.g., 98 % had outpatient visits, 76 % had Emergency Department (ED) visits, and 50 % had mental health-related ED visits during the 48 months prior to their first mania diagnosis. One-third (37.2 %) had a depressive episode before their initial BPAD with mania diagnosis.

LIMITATIONS

Study was conducted in one state among insured individuals. We used administrative data, which permits evaluation of large populations but lacks rigorous, well-validated claims-based definitions for BPAD. There could be diagnostic uncertainty during illness course, and clinicians may differ in their diagnostic thresholds.

CONCLUSIONS

Careful examination of multiple years of patient history spanning all payors is essential for identifying new onset BPAD diagnoses presenting with mania, which in turn is critical to estimating population rates of new disease and understanding the early course of disease.

Adaption and validation of the Rwandese version of the Mood Disorder Questionnaire for the screening of bipolar disorder

BACKGROUND

Bipolar disorder is challenging to diagnose. In Rwanda, a sub-Saharan country with a limited number of psychiatrists, the number of people with an undetected diagnosis of bipolar disorder could be high. Still, no screening tool for the disorder is available in the country. This study aimed to adapt and validate the Mood Disorder Questionnaire in the Rwandan population.

METHODS

The Mood Disorder Questionnaire was translated into Kinyarwanda. The process involved back-translation, cross-cultural adaptation, field testing of the pre-final version, and final adjustments. A total of 331 patients with either bipolar disorder or unipolar major depression from two psychiatric outpatient hospitals were included. The statistical analysis included reliability and validity analyses and receiver operating characteristic curve (ROC) analysis. The optimal cut-off was chosen by maximizing Younden's index.

RESULTS

The Rwandese version of The Mood Disorder Questionnaire had adequate internal consistency (Cronbach's alpha =0.91). The optimal threshold value was at least six positive items, which yielded excellent sensitivity (94.7%), and specificity (97.3%). The ROC area under the curve (AUC) was 0.99.

CONCLUSION

The adapted tool showed good psychometric properties in terms of reliability and validity for the screening of bipolar disorder, with a recommended cutoff value of six items on the symptom checklist for a positive score and an exclusion of items 14 and 15. The tool has the potential to be a crucial instrument to identify otherwise undetected cases of bipolar disorder in Rwanda, improving access to mental health treatment, thus enhancing the living conditions of people with bipolar disorder.

Chronic exposure to imipramine induces a switch from depression-like to mania-like behavior in female serotonin transporter knockout rats: Role of BDNF signaling in the infralimbic cortex

BACKGROUND

Bipolar disorder (BD) is a highly burdensome psychiatric disorder characterized by alternating states of mania and depression. A major challenge in the clinic is the switch from depression to mania, which is often observed in female BD patients during antidepressant treatment such as imipramine. However, the underlying neural basis is unclear.

METHODS

To investigate the potential neuronal pathways, serotonin transporter knockout (SERT KO) rats, an experimental model of female BD patients, were subjected to a battery of behavioral tests under chronic treatment of the antidepressant imipramine. In addition, the expression of brain-derived neurotrophic factor (BDNF) and its downstream signaling was examined in the prefrontal cortex.

RESULTS

Chronic exposure to imipramine reduced anxiety and sociability and problem-solving capacity, and increased thigmotaxis and day/night activity in all animals, but specifically in female SERT KO rats, compared to female wild-type (WT) rats. Further, we found an activation of BDNF-TrkB-Akt pathway signaling in the infralimbic, but not prelimbic, cortex after chronic imipramine treatment in SERT KO, but not WT, rats.

LIMITATIONS

Repeated testing behaviors could potentially affect the results. Additionally, the imipramine induced changes in behavior and in the BDNF system were measured in separate animals.

CONCLUSIONS

Our study indicates that female SERT KO rats, which mirror the female BD patients with the 5-HTTLPR s-allele, are at higher risk of a switch to mania-like behaviors under imipramine treatment. Activation of the BDNF-TrkB-Akt pathway in the infralimbic cortex might contribute to this phenotype, but causal evidence remains to be provided.

White matter integrity in bipolar disorder investigated with diffusion tensor magnetic resonance imaging and fractal geometry

BACKGROUND

Growing evidence suggests the presence of white matter (WM) alterations in bipolar disorder (BD). In this study we aimed to investigate the state of WM structures, in terms of tissue integrity and morphological complexity, in BD patients compared to healthy controls (HC), in an attempt to better elucidate the microstructural changes associated with BD.

METHODS

We collected a dataset of 399 Diffusion Tensor Magnetic Resonance Imaging (167 BD and 232 healthy controls) images, acquired at five different sites, which was processed with Tract-Based Spatial Statistics (TBSS) and fractal analysis.

RESULTS

The TBSS analysis demonstrated significantly lower FA values in the BD group. Diffusion abnormalities were primarily located in the temporo-parietal network. The Fractal Dimension (FD) analysis did not reveal consistent significant differences in the morphological complexity of WM structures between the groups. When the FD values of patients were considered individually, it is possible to notice some localized significant deviations from the healthy population.

LIMITATIONS

DTI sequences have not been harmonized before acquisition, samples' sizes are heterogeneous.

CONCLUSIONS

This study, by applying both TBSS and FD analyses, allows to evaluate diffusion and structural alterations of WM at the same time. The evaluation of WM integrity from these two different perspectives could be useful to better understand the pathophysiological and morphological changes underpinning bipolar disorder.

Comparative mortality risks in two independent bipolar cohorts

OBJECTIVES

To compare mortality rates in bipolar disorder with common causes of mortality.

METHODS

Observational data from the Prechter Longitudinal Study of Bipolar Disorder (PLS-BD) of 1128 participants including 281 controls was analyzed using logistical regression to quantify mortality rates in comparison with common comorbidities and causes of death. Outcome and treatment measures, including ASRM, GAD-7, PHQ-9 and medication use were used to stratify those with bipolar disorder (BD) that are alive or deceased. A larger cohort of 10,735 existing BD patients with 7,826 controls (no psychiatric diagnosis) from the University of Michigan Health (U-M Health) clinics was used as replication, observational secondary data analysis.

RESULTS

The mortality rates are significantly different between those with BD and controls in both PLS-BD and U-M Health. Those with BD and are deceased have a higher percentage of elevated depression measures but show no difference in mania or anxiety measures nor medication use patterns. In both cohorts, a diagnosis of BD increases the odds of mortality greater than history of smoking or being older than ≥ 60-years of age.

CONCLUSION

BD was found to increase odds of mortality significantly and beyond that of a history of smoking. This finding was replicated in an independent sample.

Preliminary results from the Australian Genetics of Bipolar Disorder Study: A nation-wide cohort

OBJECTIVE

The Australian Genetics of Bipolar Disorder Study is a nation-wide cohort of adults living with bipolar disorder. The study aims to detect the relationships between genetic risk, symptom severity, and the lifetime prevalence of bipolar disorder, treatment response and medication side effects, and patterns and costs of health care usage.

METHODS

A total of 6682 participants (68.3% female; aged 44.8 ± 13.6 years [range = 18-90]) were recruited in three waves: a nation-wide media campaign, a mail-out based on prescriptions for lithium carbonate and through the Australian Genetics of Depression Study. Participants completed a self-report questionnaire. A total of 4706 (70%) participants provided a saliva sample and were genotyped and 5506 (82%) consented to record linkage of their Pharmaceutical and Medicare Benefits Schedule data.

RESULTS

Most participants were living with bipolar I disorder (n = 4068) while 1622 participants were living with bipolar II disorder and 992 with sub-threshold bipolar disorder. The mean age of bipolar disorder diagnosis was 32.7 ± 11.6 years but was younger in bipolar I (p = 2.0E-26) and females (p = 5.7E-23). Excluding depression with onset prior to bipolar disorder diagnosis, 64.5% of participants reported one or more co-occurring psychiatric disorders: most commonly generalised anxiety disorder (43.5%) and posttraumatic stress disorder (20.7%). Adverse drug reactions were common and resulted in discontinuation rates ranging from 33.4% for lithium to 63.0% for carbamazepine.

CONCLUSION

Our findings highlight the high rate of comorbidities and adverse drug reactions among adults living with bipolar disorder in the general Australian population. Future genomic analyses focus on identifying genetic variants influencing pharmacotherapy treatment response and side effects.

All-cause and cause-specific mortality among people with bipolar disorder: a large-scale systematic review and meta-analysis

OBJECTIVE

Bipolar disorder (BD) is associated with premature mortality. All-cause and specific mortality risks in this population remain unclear, and more studies are still needed to further understand this issue and guide individual and public strategies to prevent mortality in bipolar disorder Thus, a systematic review and meta-analysis of studies assessing mortality risk in people with BD versus the general population was conducted. The primary outcome was all-cause mortality, whilst secondary outcomes were mortality due to suicide, natural, unnatural, and specific-causes mortality.

RESULTS

Fifty-seven studies were included (BD; n = 678,353). All-cause mortality was increased in people with BD (RR = 2.02, 95% CI: 1.89-2.16, k = 39). Specific-cause mortality was highest for suicide (RR = 11.69, 95% CI: 9.22-14.81, k = 25). Risk of death due to unnatural causes (RR = 7.29, 95% CI: 6.41-8.28, k = 17) and natural causes (RR = 1.90, 95% CI: 1.75-2.06, k = 17) were also increased. Among specific natural causes analyzed, infectious causes had the higher RR (RR = 4,38, 95%CI: 1.5-12.69, k = 3), but the analysis was limited by the inclusion of few studies. Mortality risk due to respiratory (RR = 3.18, 95% CI: 2.55-3.96, k = 6), cardiovascular (RR = 1.76, 95% CI: 1.53-2.01, k = 27), and cerebrovascular (RR = 1.57, 95% CI: 1.34-1.84, k = 13) causes were increased as well. No difference was identified in mortality by cancer (RR = 0.99, 95% CI: 0.88-1.11, k = 16). Subgroup analyses and meta-regression did not affect the findings.

CONCLUSION

Results presented in this meta-analysis show that risk of premature death in BD is not only due to suicide and unnatural causes, but somatic comorbidities are also implicated. Not only the prevention of suicide, but also the promotion of physical health and the prevention of physical conditions in individuals with BD may mitigate the premature mortality in this population. Notwithstanding this is to our knowledge the largest synthesis of evidence on BD-related mortality, further well-designed studies are still warranted to inform this field.

Life expectancy and years of potential life lost in bipolar disorder: systematic review and meta-analysis

BACKGROUND

There is increasing research examining excess mortality in people with bipolar disorder using life expectancy and related measures, which quantify the disease impact on survival. However, there has been no meta-analysis to date summarising existing data on life expectancy in those with bipolar disorder.

AIMS

To systematically review and quantitatively synthesise estimates of life expectancy and years of potential life lost (YPLL) in people with bipolar disorder.

METHOD

We searched Embase, Medline, PsycINFO and Web of Science databases up to 31 March 2021. We generated pooled life expectancy using random-effects models, and derived YPLL summary estimate by calculating averaged values weighted by sample size of individual studies. Subgroup analyses were conducted for gender, geographical region, study period, a given age (set-age) for lifespan estimation and causes of death. The study was registered with PROSPERO (CRD42021241705).

RESULTS

Eleven and 13 studies were included in the review for life expectancy (n = 96 601) and YPLL (n = 128 989), respectively. Pooled life expectancy was 66.88 years (95% CI 64.47-69.28; I² = 99.9%, P < 0.001), was higher in women than men (70.51 (95% CI 68.61-72.41) v. 64.59 (95% CI 61.16-68.03); z = 2.00, P = 0.003) and was lowest in Africa. Weighted average YPLL was 12.89 years (95% CI 12.72-13.07), and was greatest in Africa. More YPLL was observed when lifespan was estimated at birth than at other set-age. YPLLs attributable to natural and unnatural deaths were 5.94 years (95% CI 5.81-6.07) and 5.69 years (95% CI 5.59-5.79), respectively.

CONCLUSIONS

Bipolar disorder is associated with substantially shortened life expectancy. Implementation of multilevel, targeted interventions is urgently needed to reduce this mortality gap.

Process and Outcome Evaluations of Smartphone Apps for Bipolar Disorder: Scoping Review

Background

Mental health apps (MHAs) provide opportunities for accessible, immediate, and innovative approaches to better understand and support the treatment of mental health disorders, especially those with a high burden, such as bipolar disorder (BD). Many MHAs have been developed, but few have had their effectiveness evaluated.

Objective

This systematic scoping review explores current process and outcome measures of MHAs for BD with the aim to provide a comprehensive overview of current research. This will identify the best practice for evaluating MHAs for BD and inform future studies.

Methods

A systematic literature search of the health science databases PsycINFO, MEDLINE, Embase, EBSCO, Scopus, and Web of Science was undertaken up to January 2021 (with no start date) to narratively assess how studies had evaluated MHAs for BD.

Results

Of 4051 original search results, 12 articles were included. These 12 studies included 435 participants, and of these, 343 had BD type I or II. Moreover, 11 of the 12 studies provided the ages (mean 37 years) of the participants. One study did not report age data. The male to female ratio of the 343 participants was 137:206. The most widely employed validated outcome measure was the Young Mania Rating Scale, being used 8 times. The Hamilton Depression Rating Scale-17/Hamilton Depression Rating Scale was used thrice; the Altman Self-Rating Mania Scale, Quick Inventory of Depressive Symptomatology, and Functional Assessment Staging Test were used twice; and the Coping Inventory for Stressful Situations, EuroQoL 5-Dimension Health Questionnaire, Generalized Anxiety Disorder Scale-7, Inventory of Depressive Symptomatology, Mindfulness Attention Awareness Scale, Major Depression Index, Morisky-Green 8-item, Perceived Stress Scale, and World Health Organization Quality of Life-BREF were used once. Self-report measures were captured in 9 different studies, 6 of which used MONARCA. Mood and energy levels were the most commonly used self-report measures, being used 4 times each. Furthermore, 11 of the 12 studies discussed the various confounding factors and barriers to the use of MHAs for BD.

Conclusions

Reported low adherence rates, usability challenges, and privacy concerns act as barriers to the use of MHAs for BD. Moreover, as MHA evaluation is itself developing, guidance for clinicians in how to aid patient choices in mobile health needs to develop. These obstacles could be ameliorated by incorporating co-production and co-design using participatory patient approaches during the development and evaluation stages of MHAs for BD. Further, including qualitative aspects in trials that examine patient experience of both mental ill health and the MHA itself could result in a more patient-friendly fit-for-purpose MHA for BD.

Diagnostic Trends and Prescription Patterns in Disruptive Mood Dysregulation Disorder and Bipolar Disorder

OBJECTIVE

Disruptive mood dysregulation disorder (DMDD) was introduced in DSM-5 to distinguish a subset of chronically irritable youth who may be incorrectly diagnosed and/or treated for pediatric bipolar disorder (BPD). This study characterized the rate of new treatment episodes and treated prevalence of BPD and DMDD from a longitudinal electronic health record database and examined the impact of DMDD on prescription trends.

METHOD

A retrospective cohort study using 2008-2018 Optum electronic health record data was conducted. Youth aged 10 to < 18 years with ≥ 183 days of database enrollment before the study cohort entry were included. Annual new treatment episode rates per 1,000 patient-years and treated prevalence (%) were estimated. Prescriptions for medications, concomitant diagnoses, and acute mental health service use for 2016-2018 were evaluated.

RESULTS

There were 7,677 youths with DMDD and 6,480 youths with BPD identified. Mean age (13-15 years) and ethnicity were similar for both groups. A rise in new treatment episode rates (0.87-1.75 per 1,000 patient-years, p < .0001) and treated prevalence (0.08%-0.35%, p < .0001) of DMDD diagnoses (2016-2018) following diagnosis inception was paralleled by decreasing new treatment episode rates (1.22-1.14 per 1,000 patient-years, p < .01) and treated prevalence (0.42%-0.36%, p < .0001) of BPD diagnoses (2015-2018). More youth in the DMDD group were prescribed medications compared with the BPD group (81.9% vs 69.4%), including antipsychotics (58.9% vs 51.0%). Higher proportions of youth with DMDD vs youth with BPD had disruptive behavior disorders (eg, 35.9% vs 20.5% had oppositional defiant disorder), and required inpatient hospitalization related to their mental health disorder (45.0% vs 33.0%).

CONCLUSION

Diagnosis of DMDD has had rapid uptake in clinical practice but is associated with increased antipsychotic and polypharmacy prescriptions and higher rates of comorbidity and inpatient hospitalization in youth with a DMDD diagnosis compared with a BPD diagnosis.

Increased Asymmetric Perfusion of the Cerebral Cortices and Thalamus Indicates Individuals at Risk for Bipolar Disorder: A Family Cohort Single Photon Emission Computed Tomography Neuroimaging Study

Bipolar disorder is a significant mental illness affecting over 4 million people in North America and approximately 46 million worldwide. While the onset of bipolar disorder is typically in late adolescence and early adulthood, the correct diagnosis can be delayed for several years. This delay can result in inappropriate pharmaceutical interventions, loss of career or productivity, suicide, family hardship, and unnecessary expense. Moreover, prolonged untreated or inappropriately treated bipolar disorder may cause damage to the brain. Early diagnosis is a critical need to circumvent the damage, suffering, and expense caused by the current delay. Brain perfusion single photon emission computed tomography (SPECT) neuroimaging reveals visual correlates of brain function. Herein, a family cohort all with bipolar disorder is described and their symptoms correlated with findings on the individual SPECT brain scans. The family consisted of two parents and three children (one female). The scans were interpreted by a panel of experts. Then a post hoc region-of-interest (ROI) analysis was conducted on SPECT data normalized to the cerebellum maximum with comparison to similarly normalized data from a normative sample. These findings support two distinct patterns of SPECT perfusion scan changes that can be found in individuals with bipolar disorder. In addition, these findings indicate that SPECT scan findings may be predictive of individual risk for progressing to symptomatic bipolar disorder. While preliminary, the findings in this cohort support the need for larger, diverse cohort studies of bipolar and control subjects to assess the predictive value of these particular SPECT perfusion findings in bipolar disorder.

Excess mortality and life-years lost in people with bipolar disorder: an 11-year population-based cohort study

AIMS

Bipolar disorder is associated with premature mortality, but evidence is mostly derived from Western countries. There has been no research evaluating shortened lifespan in bipolar disorder using life-years lost (LYLs), which is a recently developed mortality metric taking into account illness onset for life expectancy estimation. The current study aimed to examine the extent of premature mortality in bipolar disorder patients relative to the general population in Hong Kong (HK) in terms of standardised mortality ratio (SMR) and excess LYLs, and changes of mortality rate over time.

METHODS

This population-based cohort study investigated excess mortality in 12 556 bipolar disorder patients between 2008 and 2018, by estimating all-cause and cause-specific SMRs, and LYLs. Trends in annual SMRs over the 11-year study period were assessed. Study data were retrieved from a territory-wide medical-record database of HK public healthcare services.

RESULTS

Patients had higher all-cause [SMR: 2.60 (95% CI: 2.45-2.76)], natural-cause [SMR: 1.90 (95% CI: 1.76-2.05)] and unnatural-cause [SMR: 8.63 (95% CI: 7.34-10.03)] mortality rates than the general population. Respiratory diseases, cardiovascular diseases and cancers accounted for the majority of deaths. Men and women with bipolar disorder had 6.78 (95% CI: 6.00-7.84) years and 7.35 (95% CI: 6.75-8.06) years of excess LYLs, respectively. The overall mortality gap remained similar over time, albeit slightly improved in men with bipolar disorder.

CONCLUSIONS

Bipolar disorder is associated with increased premature mortality and substantially reduced lifespan in a predominantly Chinese population, with excess deaths mainly attributed to natural causes. Persistent mortality gap underscores an urgent need for targeted interventions to improve physical health of patients with bipolar disorder.

Suicide mortality and use of psychotropic drugs in patients hospitalized due to bipolar disorder: A Finnish nationwide cohort study

BACKGROUND

Knowledge on the comparative effectiveness of pharmacological treatments to prevent suicide mortality in bipolar disorder is still lacking.

METHODS

We studied the risk of suicide mortality during 1996-2012 among all patients who had been hospitalized due to bipolar disorder in Finland (n = 18,018; mean follow-up time 7.2 years) using nation-wide databases. We used a Cox proportional hazards model. Analyses were adjusted for the effects of time since diagnosis, order of treatments, current use of other treatments, polypharmacy, number of suicidal hospitalizations within 2 year (indicator of inherent risk of relapse), age at index date, sex, and calendar year of index date. In secondary analysis, the first 30 days were omitted from analysis after initiation of a psychopharmacological treatment to control for protopathic bias.

RESULTS

In comparison between use and no use among specific agents, only lithium (HR 0.33, 95%CI 0.24-0.47, p<0.0001) and valproic acid (HR 0.61, 95%CI 0.48-0.79, p=0.0002) were associated with a significantly decreased risk of suicide in bipolar disorder. Lithium showed a 42% lower risk for suicide mortality compared to valproic acid (HR 0.58, 95% CI 0.39-0.86, p = 0.007). Hypnotics were associated with a significantly (HR 1.52, 95%CI 1.22-1.90, p=0.0002) higher risk of suicide.

LIMITATIONS

Only hospitalized patients were included.

CONCLUSIONS

Lithium should be considered as treatment of choice for patients with bipolar disorder who are at high risk for suicide. Hypnotic use among suicidal patients indicates need for close monitoring of these patients.

All-Cause Mortality of Hospital-Treated Borderline Personality Disorder: A Nationwide Cohort Study

Patients with borderline personality disorder (BPD) are known to present frequently in emergency rooms, and they have a high rate of suicide. The mortality rate of patients with BPD is still unclear. The Danish Psychiatric Central Research Register and The Danish Register for Causes of Death were used to identify patients with a first-ever diagnosis of BPD (ICD-10: F60.31) from 1995 through 2011 together with time and cause of death. A total of 10,545 patients with a BPD diagnosis were followed for a mean time of 7.98 years. A total of 547 deaths were registered. The standardized mortality ratio of patients with BPD compared to the general population was 8.3 (95% CI [7.6, 9.1]). More than three inpatient admissions per year or a comorbid diagnosis of substance use disorder correlated with a higher mortality rate. The increased mortality rate in patients with BPD treated in secondary care emphasizes that it is a severe mental disorder.

Is cesarean section a cause of affective disorders?-A national cohort study using sibling designs

BACKGROUND

The gut microbiota of children delivered by cesarean section differs from that of children delivered vaginally. In light of the gut-brain axis hypothesis, cesarean section may influence risk of affective disorders.

METHODS

Population based prospective cohort study included Danish children born 1982 through 2001, with follow-up until 2015. The effect of delivery mode on the risk of affective disorders was assessed using a standard Cox model and two types of Cox sibling models. Diagnostic codes or prescriptions for antidepressants and lithium were used to define cases of affective disorders.

RESULTS

1,009,444 children were followed for 8,880,794 person-years from the age of 13 years, with relevant covariates available from birth. There are strong calendar time trends in the occurrence of affective disorders with an increasingly younger age at first diagnosis and with a hotspot between the years 2007-2012. Fully adjusted standard Cox models showed an increased risk of affective disorders for both pre-labor (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.08-1.15) and intrapartum (HR, 1.07; 95% CI, 1.05-1.10) cesarean section, compared to vaginal delivery. This effect disappeared in the between-within sibling model for pre-labor (HR, 1.00; 95% CI, 0.94-1.07) but not intrapartum (HR, 1.05; 95% CI, 1.00-1.12) cesarean section.

LIMITATIONS

Interpretation of results from sibling models may not be relevant to children without siblings.

CONCLUSIONS

These results do not support the hypothesis that a delivery-mode dependent change in gut microbiota is a cause of subsequent affective disorders, despite an apparent association with delivery mode.

Exploring factors of diagnostic delay for patients with bipolar disorder: a population-based cohort study

BACKGROUND

Bipolar disorder if untreated, has severe consequences: severe role impairment, higher health care costs, mortality and morbidity. Although effective treatment is available, the delay in diagnosis might be as long as 10-15 years. In this study, we aim at documenting the length of the diagnostic delay in Hungary and identifying factors associated with it.

METHODS

Kaplan-Meier survival analysis and Cox proportional hazards model was employed to examine factors associated with the time to diagnosis of bipolar disorder measured from the date of the first presentation to any specialist mental healthcare institution. We investigated three types of factors associated with delays to diagnosis: demographic characteristics, clinical predictors and patient pathways (temporal sequence of key clinical milestones). Administrative data were retrieved from specialist care; the population-based cohort includes 8935 patients from Hungary.

RESULTS

In the sample, diagnostic delay was 6.46 years on average. The mean age of patients at the time of the first bipolar diagnosis was 43.59 years. 11.85% of patients were diagnosed with bipolar disorder without any delay, and slightly more than one-third of the patients (35.10%) were never hospitalized with mental health problems. 88.80% of the patients contacted psychiatric care for the first time in outpatient settings, while 11% in inpatient care. Diagnostic delay was shorter, if patients were diagnosed with bipolar disorder by non-specialist mental health professionals before. In contrast, diagnoses of many psychiatric disorders received after the first contact were coupled with a delayed bipolar diagnosis. We found empirical evidence that in both outpatient and inpatient care prior diagnoses of schizophrenia, unipolar depression without psychotic symptoms, and several disorders of adult personality were associated with increased diagnostic delay. Patient pathways played an important role as well: the hazard of delayed diagnosis increased if patients consulted mental healthcare specialists in outpatient care first or they were hospitalized.

CONCLUSIONS

We systematically described and analysed the diagnosis of bipolar patients in Hungary controlling for possible confounders. Our focus was more on clinical variables as opposed to factors controllable by policy-makers. To formulate policy-relevant recommendations, a more detailed analysis of care pathways and continuity is needed.

The case for improved care and provision of treatment for people with first-episode mania

The care of people with first-episode mania has been overlooked in comparison with the care of patients with other non-affective psychoses, despite evidence suggesting targeted treatments might be of benefit for this patient group. In this Personal View, we outline the general epidemiology of first-episode mania in the context of bipolar disorder, the natural history of mania (with an emphasis on its recurrent nature), current evidence for pharmacological, psychological, and service-level interventions, current guidelines for the treatment of first-episode mania, and provide a patient's point of view of the care pathway (appendix). We note the paucity of high-quality evidence for interventions in first-episode mania and the lack of agreement among treatment guidelines in relation to treatment, especially maintenance treatment. We suggest that, based on high morbidity and clinical need, research evidence to inform guideline development is necessary, and in the interim, clearer guidance on treatment and diagnosis should be given; specifically, we have suggested that patients should be cared for within a first-episode psychosis service, when such a service exists.

Increasing mortality gap for patients diagnosed with bipolar disorder-A nationwide study with 20 years of follow-up

OBJECTIVES

The primary aim of this study was to examine whether the mortality of patients with bipolar disorder has increased over the past two decades as compared with the background population.

METHODS

All patients registered with a bipolar disorder diagnosis in the Danish Psychiatric Research Registry from 1965 until the end of 2014, living in Denmark, alive and below the age of 65 years in the study period from 1995 to 2014 were included. Included patients reaching the age of 65 years during the study period were censored at that time point. Overall standardized mortality ratios (SMRs) were calculated for each calendar year over the study period, and trends in SMR over the study period were examined using linear regression. In addition, the SMRs were stratified according to age groups.

RESULTS

Patients with bipolar disorder had an overall elevated mortality rate relative to the general population with an SMR of 2.8, 95% confidence interval (CI): 2.8-2.9. The highest SMR was found among the youngest (15-29 years: 8.2, 95% CI: 6.7-10.1; 30-34 years: 7.7, 95% CI: 6.4-9.3; 35-39 years: 6.2, 95% CI: 5.4-7.2; 40-44 years: 4.6, 95% CI: 4.1-5.1; 45-49 years: 3.5, 95% CI: 3.3-3.8; 50-54 years: 3.2, 95% CI: 3.0-3.4; 55-59 years: 2.7, 95% CI: 2.6-2.8; and 60-64 years: 2.2, 95% CI: 2.1-2.3). An increase in SMR of 0.03 per year in patients diagnosed with bipolar disorder (P < 0.01) was found.

CONCLUSIONS

The mortality gap between patients with bipolar disorder and the general Danish population has widened over the past two decades, which is a cause for concern, although reasons for the increasing mortality gap are unknown.

No apparent association between bipolar disorder and cancer in a large epidemiological study of outpatients in a managed care population

An association between bipolar disorder (BD) and cancer risk has been reported. The purpose of this study was to investigate this association through linkage analysis of a national HMO database and a national cancer registry. All members of the Leumit Health Services (LHS) HMO of Israel from 2000 to 2012 were included. Members with a recorded diagnosis of BD and a record of at least one written or dispensed prescription for pharmacotherapy for treatment of BD were classified as patients with BD. We linked the LHS population with the Israel National Cancer Registry database to capture all cases of cancer reported. Standardized incidence ratios (SIRs) for cancer in the BD population as compared with non-BD LHS members were calculated. A total of 870 323 LHS members were included in the analysis; 3304 of whom met the criteria for inclusion in the BD arm. We identified 24 515 and 110 cancer cases among members without BD and with BD, respectively. Persons with BD were no more likely than other HMO members to be diagnosed with cancer during the follow-up period [SIR, males=0.91, 95% confidence interval (CI): 0.66-1.22; SIR, females=1.15, 95% CI: 0.89-1.47]. Sensitivity analysis using different criteria for positive BD classification (lithium treatment alone or registered physician diagnosis) had no effect on the estimate of cancer risk. A nonstatistically significant association between breast cancer and BD among women was observed (SIR=1.24, 95% CI: 0.79-1.86). These findings do not corroborate previously reported associations between BD and elevated cancer risk.

Anxiety disorders and childhood maltreatment as predictors of outcome in bipolar disorder

BACKGROUND

Comorbid anxiety disorders and childhood maltreatment have each been linked with unfavourable outcomes in people with bipolar disorder. Because childhood maltreatment is associated with anxiety disorders in this population, their respective predictive value remains to be determined.

METHODS

In 174 adults with bipolar disorder, we assessed childhood maltreatment using the Childhood Trauma Questionnaire and lifetime anxiety disorders with the MINI International Neuropsychiatric Interview. We constructed an overall index of severity of bipolar disorder as a sum of six indicators (unemployment, psychotic symptoms, more than five manic episodes, more than five depressive episodes, suicide attempt, and hospital admission). We tested the relationship between childhood maltreatment, the number of anxiety disorders and the overall severity index using ordered logistic regression.

RESULTS

The number of lifetime anxiety disorders was associated with the overall severity index (OR = 1.43, 95%CI = 1.01-2.04, p = 0.047). This relationship was only slightly attenuated when controlled for childhood maltreatment (OR = 1.39, 95%CI = 0.97-2.00, p = 0.069). The relationship between childhood maltreatment and the overall severity index was not statistically significant (OR = 1.26, 95%CI = 0.92-1.74, p = 0.151). Secondary analyses revealed that childhood maltreatment was associated with suicide attempts (OR = 1.70, 95%CI = 1.15-2.51, p = 0.008) and obsessive compulsive disorder was associated with the overall severity index (OR = 9.56, 95%CI = 2.20-41.47, p = 0.003).

LIMITATIONS

This was a cross-sectional study with a moderate-sized sample recruited from a specialist program.

CONCLUSIONS

While comorbid anxiety disorders are associated with the overall severity of bipolar disorder, childhood maltreatment is specifically associated with suicide attempts. Clinicians should systematically assess both factors. Interventions to improve outcomes of people with bipolar disorder with comorbid anxiety disorders and history of childhood maltreatment are needed.

Annual Research Review: Quality of life and childhood mental and behavioural disorders - a critical review of the research

BACKGROUND

An individual's subjective perception of well-being is increasingly recognized as an essential complement to clinical symptomatology and functional impairment in children's mental health. Measurement of quality of life (QoL) has the potential to give due weight to the child's perspective.

SCOPE AND METHODOLOGY

Our aim was to critically review the current evidence on how childhood mental disorders affect QoL. First, the major challenges in this research field are outlined. Then we present a systematic review of QoL in children and adolescents aged 0-18 years formally diagnosed with a mental and behavioural disorder, as compared to healthy or typically developing children or children with other health conditions. Finally, we discuss limitations of the current evidence base and future directions based on the results of the systematic review and other relevant literature.

FINDINGS AND CONCLUSIONS

The systematic review identified 41 eligible studies. All were published after the year 2000 and 21 originated in Europe. The majority examined QoL in neurodevelopmental disorders, including attention-deficit hyperactivity disorder (k = 17), autism spectrum disorder (k = 6), motor disorders (k = 5) and intellectual disability (k = 4). Despite substantial heterogeneity, studies demonstrate that self-reported global QoL is significantly reduced compared to typical/healthy controls across several disorders and QoL dimensions. Parents' ratings were on average substantially lower, casting doubt on the validity of proxy-report. Studies for large diagnostic groups such as depressive disorders, anxiety disorders, (early onset) schizophrenia and eating disorders are largely lacking. We conclude that representative, well-characterized normative and clinical samples as well as longitudinal and qualitative designs are needed to further clarify the construct of QoL, to derive measures of high ecological validity, and to examine how QoL fluctuates over time and is attributable to specific conditions or contextual factors.

Molecular Mechanisms of Bipolar Disorder: Progress Made and Future Challenges

Bipolar disorder (BD) is a chronic and progressive psychiatric illness characterized by mood oscillations, with episodes of mania and depression. The impact of BD on patients can be devastating, with up to 15% of patients committing suicide. This disorder is associated with psychiatric and medical comorbidities and patients with a high risk of drug abuse, metabolic and endocrine disorders and vascular disease. Current knowledge of the pathophysiology and molecular mechanisms causing BD is still modest. With no clear biological markers available, early diagnosis is a great challenge to clinicians without previous knowledge of the longitudinal progress of illness. Moreover, despite recommendations from evidence-based guidelines, polypharmacy is still common in clinical treatment of BD, reflecting the gap between research and clinical practice. A major challenge in BD is the development of effective drugs with low toxicity for the patients. In this review article, we focus on the progress made and future challenges we face in determining the pathophysiology and molecular pathways involved in BD, such as circadian and metabolic perturbations, mitochondrial and endoplasmic reticulum (ER) dysfunction, autophagy and glutamatergic neurotransmission; which may lead to the development of new drugs.

Building a genetic risk model for bipolar disorder from genome-wide association data with random forest algorithm

A genetic risk score could be beneficial in assisting clinical diagnosis for complex diseases with high heritability. With large-scale genome-wide association (GWA) data, the current study constructed a genetic risk model with a machine learning approach for bipolar disorder (BPD). The GWA dataset of BPD from the Genetic Association Information Network was used as the training data for model construction, and the Systematic Treatment Enhancement Program (STEP) GWA data were used as the validation dataset. A random forest algorithm was applied for pre-filtered markers, and variable importance indices were assessed. 289 candidate markers were selected by random forest procedures with good discriminability; the area under the receiver operating characteristic curve was 0.944 (0.935–0.953) in the training set and 0.702 (0.681–0.723) in the STEP dataset. Using a score with the cutoff of 184, the sensitivity and specificity for BPD was 0.777 and 0.854, respectively. Pathway analyses revealed important biological pathways for identified genes. In conclusion, the present study identified informative genetic markers to differentiate BPD from healthy controls with acceptable discriminability in the validation dataset. In the future, diagnosis classification can be further improved by assessing more comprehensive clinical risk factors and jointly analysing them with genetic data in large samples.

Sleep and circadian alterations in people at risk for bipolar disorder: A systematic review

BACKGROUND

Sleep and circadian abnormalities have been mostly demonstrated in bipolar patients. However, it is not clear whether these alterations are present in population at high risk for bipolar disorder (BD), indicating a possible risk factor for this condition.

OBJECTIVE

This systematic review aims to define current evidence about sleep and rhythm alterations in people at risk for BD and to evaluate sleep and circadian disorders as risk factor for BD.

METHODS

The systematic review included all articles about the topic until February 2016. Two researchers performed an electronic search of PubMed and Cochrane Library. Keywords used were 'sleep' or 'rhythm' or 'circadian' AND 'bipolar disorder' or 'mania' or 'bipolar depression' AND 'high-risk' or 'risk'.

RESULTS

Thirty articles were analyzed (7451 participants at risk for BD). Sleep disturbances are frequent in studies using both subjective measures and actigraphy. High-risk individuals reported irregularity of sleep/wake times, poor sleep and circadian rhythm disruption. Poor sleep quality, nighttime awakenings, and inadequate sleep are possible predictive factors for BD. A unique study suggested that irregular rhythms increase risk of conversion. People at risk for BD showed high cortisol levels in different times of day. Studies about anatomopathology, melatonin levels, inflammatory cytokines and oxidative stress were not identified. The most important limitations were differences in sleep and rhythm measures, heterogeneity of study designs, and lack of consistency in the definition of population at risk.

CONCLUSION

Sleep and circadian disturbances are common in people at risk for BD. However, the pathophysiology of these alterations and the impact on BD onset are still unclear.

Seasonal variations in hospital admissions for mania: Examining for associations with weather variables over time

BACKGROUND

Bipolar disorder is characterized by a seasonal pattern with emerging evidence that weather conditions may trigger symptoms. Thus, our aims were to investigate if year-to-year variations in admissions with mania correlated with year-to-year variations in key meteorological variables, if there was a secular trend in light of climate change and if gender or admission status influenced the seasonal pattern.

METHODS

We undertook a Danish register-based nationwide historical cohort study. We included all adults hospitalized to psychiatric care from 1995 to 2012 with mania using the Danish Psychiatric Central Research Register. The Danish Meteorological Institute provided the meteorological variables. The association between weather and admissions was tested using linear regression.

RESULTS

Our database comprised 24,313 admissions with mania. There was a seasonal pattern with admission rates peaking in summer. Higher admission rates were associated with more sunshine, more ultraviolet radiation, higher temperature and less snow but were unassociated with rainfall. We did not find a secular trend in the seasonal pattern. Finally, neither gender nor admission status impacted on the overall seasonal pattern of admissions with mania.

LIMITATIONS

Only patients in psychiatric care were included. We could not subdivide by type of bipolar disorder.

CONCLUSION

This cohort study based on more than 24,000 admissions identified a distinct seasonal pattern in hospital admissions for those with mania. We found no secular trend. This could indicate that the climate change is not impacting on seasonal patterns, that there is no link between the proposed variables or that change is currently not sufficiently distinctive.

Trends in the psychopharmacological treatment of bipolar disorder: a nationwide register-based study

OBJECTIVE

In bipolar disorder, treatment with antidepressants without concomitant use of mood stabilisers (antidepressant monotherapy) is associated with development of mania and rapid cycling and is therefore not recommended. The present study aimed to investigate the psychopharmacological treatment patterns in bipolar disorder over time, with a focus on antidepressant monotherapy.

METHODS

Cohort study with annual cross-sectional assessment of the use of psychotropic medications between 1995 and 2012 for all Danish residents aged 10 years or older with a diagnosis of bipolar disorder registered in the Danish Psychiatric Central Research Register. Users of a given psychotropic medication were defined as individuals having filled at least one prescription for that particular medication in the year of interest.

RESULTS

We identified 20 618 individuals with bipolar disorder. The proportion of patients with bipolar disorder using antidepressants, atypical antipsychotics and anticonvulsants increased over the study period, while the proportion of patients using lithium, typical antipsychotics and benzodiazepines/sedatives decreased. The proportion of patients treated with antidepressant monotherapy decreased from 20.5% in 1997 to 12.1% in 2012, and among antidepressant users, the proportion in monotherapy decreased from 47.7% to 23.9%, primarily driven by a decrease in the use of tricyclic antidepressants.

CONCLUSION

The results show an increase in the proportion of patients with bipolar disorder being treated with antidepressants in the period from 1997 to 2012. However, in accordance with international treatment guidelines, the extent of antidepressant monotherapy decreased during the same period.

Atypical Antipsychotics in the Treatment of Acute Bipolar Depression with Mixed Features: A Systematic Review and Exploratory Meta-Analysis of Placebo-Controlled Clinical Trials

Evidence supporting the use of second generation antipsychotics (SGAs) in the treatment of acute depression with mixed features (MFs) associated with bipolar disorder (BD) is scarce and equivocal. Therefore, we conducted a systematic review and preliminary meta-analysis investigating SGAs in the treatment of acute BD depression with MFs. Two authors independently searched major electronic databases from 1990 until September 2015 for randomized (placebo-) controlled trials (RCTs) or open-label clinical trials investigating the efficacy of SGAs in the treatment of acute bipolar depression with MFs. A random-effect meta-analysis calculating the standardized mean difference (SMD) between SGA and placebo for the mean baseline to endpoint change in depression as well as manic symptoms score was computed based on 95% confidence intervals (CI). Six RCTs and one open-label placebo-controlled studies (including post-hoc reports) representing 1023 patients were included. Participants received either ziprasidone, olanzapine, lurasidone, quetiapine or asenapine for an average of 6.5 weeks across the included studies. Meta-analysis with Duval and Tweedie adjustment for publication bias demonstrated that SGA resulted in significant improvements of (hypo-)manic symptoms of bipolar mixed depression as assessed by the means of the total scores of the Young Mania Rating Scale (YMRS) (SMD −0.74, 95% CI −1.20 to −0.28, n SGA = 907, control = 652). Meta-analysis demonstrated that participants in receipt of SGA (n = 979) experienced a large improvement in the Montgomery–Åsberg Depression Rating Scale (MADRS) scores (SMD −1.08, 95% CI −1.35 to −0.81, p < 0.001) vs. placebo (n = 678). Publication and measurement biases and relative paucity of studies. Overall, SGAs appear to offer favorable improvements in MADRS and YMRS scores vs. placebo. Nevertheless, given the preliminary nature of the present report, additional original studies are required to allow more reliable and clinically definitive conclusions.