Insight in bipolar mania: evaluation of its heterogeneity and correlation with clinical symptoms

Sex differences in cognitive function of first-diagnosed and drug-naïve patients with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is a severe mental illness that affects more than 1% the world's population with high recurrence rates and a series of comorbidities. Cognitive dysfunction is an endophenotype of BD, but sex influences in cognitive impairment remains unclear.

METHOD

We evaluated the performance of 139 patients with first-diagnosed, drug-naïve BD (44 males and 95 females) and 92 healthy controls (24 males and 68 females) using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) scale and the Stroop color-word test.

RESULT

Immediate memory, visuospatial/constructional ability, language, attention, delayed memory, total RBANS score, and Stroop color-word scores were significantly lower in patients with first-diagnosed, drug-naïve BD than healthy participants. Thus, male patients had worse attention and delayed memory scores compared with female patients with BD. Importantly, a worse performance in visuospatial/constructional ability was negatively associated with the Young Mania Rating Scale score in male patients only.

CONCLUSION

Male patients with first-diagnosed, drug-naïve bipolar disorder had worse cognitive dysfunction than female patients in attention and delayed memory. Cognitive deficits were correlated with mania severity only in male patients. These findings reveal the sexual dimorphism in the cognitive deficits of early BD patients with mild and moderated symptoms for further pathophysiological exploration.

Voice analyses using smartphone-based data in patients with bipolar disorder, unaffected relatives and healthy control individuals, and during different affective states

BACKGROUND

Voice features have been suggested as objective markers of bipolar disorder (BD).

AIMS

To investigate whether voice features from naturalistic phone calls could discriminate between (1) BD, unaffected first-degree relatives (UR) and healthy control individuals (HC); (2) affective states within BD.

METHODS

Voice features were collected daily during naturalistic phone calls for up to 972 days. A total of 121 patients with BD, 21 UR and 38 HC were included. A total of 107.033 voice data entries were collected [BD (n  = 78.733), UR (n  = 8004), and HC (n  =  20.296)]. Daily, patients evaluated symptoms using a smartphone-based system. Affective states were defined according to these evaluations. Data were analyzed using random forest machine learning algorithms.

RESULTS

Compared to HC, BD was classified with a sensitivity of 0.79 (SD 0.11)/AUC  = 0.76 (SD 0.11) and UR with a sensitivity of 0.53 (SD 0.21)/AUC of 0.72 (SD 0.12). Within BD, compared to euthymia, mania was classified with a specificity of 0.75 (SD 0.16)/AUC  =  0.66 (SD 0.11). Compared to euthymia, depression was classified with a specificity of 0.70 (SD 0.16)/AUC  =  0.66 (SD 0.12). In all models the user dependent models outperformed the user independent models. Models combining increased mood, increased activity and insomnia compared to periods without performed best with a specificity of 0.78 (SD 0.16)/AUC  =  0.67 (SD 0.11).

CONCLUSIONS

Voice features from naturalistic phone calls may represent a supplementary objective marker discriminating BD from HC and a state marker within BD.

Investigating racing thoughts in insomnia: A neglected piece of the mood-sleep puzzle?

BACKGROUND

Cognitive arousal is thought to play a key role in insomnia disorder. However, although patients frequently complain about racing thoughts appearing at bedtime, studies have considered 'cognitive arousal' as a synonym of rumination and worry, but not as racing thoughts per se. The latter have been mainly linked to hypomanic/manic episodes of bipolar disorder (BD). Here we aimed at investigating self-reported racing thoughts in insomnia disorder, and their specific contribution to insomnia severity, as compared to worry and rumination.

METHODS

72 adults with insomnia disorder, 49 patients with BD in a hypomanic episode and 99 healthy individuals completed the Racing and Crowded Thoughts Questionnaire (RCTQ). Mood symptoms were assessed in patients with insomnia disorder.

RESULTS

RCTQ scores were overall higher in insomnia disorder, especially in sleep-onset insomnia, compared to the hypomanic and healthy groups. Moreover, racing thoughts showed an increase in the evening and at bedtime in sleep-onset insomnia. Importantly, racing thoughts at bedtime, but not rumination and worry, were associated with insomnia severity.

DISCUSSION

Our results are the first to show that racing thoughts is a transdiagnostic symptom in mood and sleep disorders. Racing thoughts, not only rumination and worry, might contribute to the maintenance of sleep difficulties in insomnia. Clinical trials' registration number: NCT04752254.

Mobile App-Based Self-Report Questionnaires for the Assessment and Monitoring of Bipolar Disorder: Systematic Review

Background

Bipolar disorder is a chronic, progressive illness characterized by recurrent episodes of mania and depression. Self-report scales have historically played a significant role in the monitoring of bipolar symptoms. However, these tools rely on episodic memory, which can be unreliable and do not allow the clinician to monitor brief episodic symptoms or the course of symptoms over shorter periods of time. Mobile app–based questionnaires have been suggested as a tool to improve monitoring of patients with bipolar disorder.

Objective

This paper aims to determine the feasibility and validity of mobile app–based self-report questionnaires.

Methods

We performed a systematic review of the literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed, PsycInfo, Web of Science, Ovid MEDLINE, and EMBASE databases were searched for papers published in English that assessed adherence to and the validity of mobile app–based self-report questionnaires. Relevant studies published from database creation to May 22, 2020, were identified, and results examining the validity of and rates of adherence to app-based self-report questionnaires are reported.

Results

A total of 13 records were identified for inclusion in this review. Of these studies, 4 assessed the concurrent validity of mobile app–based self-report tools, with the majority of findings indicating significant associations between data collected using these tools and the Young Mania Rating Scale, Hamilton Depression Rating Scale-17, or Montgomery-Åsberg Depression Rating Scale (P<.001 to P=.24). Three studies comparing the variability or range of symptoms between patients with bipolar disorder and healthy controls suggested that these data are capable of differentiating between known groups. Two studies demonstrated statistically significant associations between data collected via mobile app–based self-report tools and instruments assessing other clinically important factors. Adherence rates varied across the studies examined. However, good adherence rates (>70%) were observed in all but 1 study using a once-daily assessment. There was a wide range of adherence rates observed in studies using twice-daily assessments (42%-95%).

Conclusions

These findings suggest that mobile app–based self-report tools are valid in the assessment of symptoms of mania and depression in euthymic patients with bipolar disorder. Data collected using these tools appear to differ between patients with bipolar disorder and healthy controls and are significantly associated with other clinically important measures. It is unclear at this time whether these tools can be used to detect acute episodes of mania or depression in patients with bipolar disorder. Adherence data indicate that patients with bipolar disorder show good adherence to self-report assessments administered daily for the duration of the study periods evaluated.

Daily estimates of clinical severity of symptoms in bipolar disorder from smartphone-based self-assessments

Currently, the golden standard for assessing the severity of depressive and manic symptoms in patients with bipolar disorder (BD) is clinical evaluations using validated rating scales such as the Hamilton Depression Rating Scale 17-items (HDRS) and the Young Mania Rating Scale (YMRS). Frequent automatic estimation of symptom severity could potentially help support monitoring of illness activity and allow for early treatment intervention between outpatient visits. The present study aimed (1) to assess the feasibility of producing daily estimates of clinical rating scores based on smartphone-based self-assessments of symptoms collected from a group of patients with BD; (2) to demonstrate how these estimates can be utilized to compute individual daily risk of relapse scores. Based on a total of 280 clinical ratings collected from 84 patients with BD along with daily smartphone-based self-assessments, we applied a hierarchical Bayesian modelling approach capable of providing individual estimates while learning characteristics of the patient population. The proposed method was compared to common baseline methods. The model concerning depression severity achieved a mean predicted R2 of 0.57 (SD = 0.10) and RMSE of 3.85 (SD = 0.47) on the HDRS, while the model concerning mania severity achieved a mean predicted R2 of 0.16 (SD = 0.25) and RMSE of 3.68 (SD = 0.54) on the YMRS. In both cases, smartphone-based self-reported mood was the most important predictor variable. The present study shows that daily smartphone-based self-assessments can be utilized to automatically estimate clinical ratings of severity of depression and mania in patients with BD and assist in identifying individuals with high risk of relapse.

The Influence of Current Mood States on Screening Accuracy of the Mood Disorder Questionnaire

Objective

In this study we investigated whether current mood states of patients with bipolar disorder have an influence on the screening accuracy of the Mood Disorder Questionnaire (MDQ).

Methods

A total of 452 patients with mood disorder (including 192 with major depressive disorder and 260 with bipolar disorder completed the Korean version of the MDQ. Patients with bipolar disorder were subdivided into three groups (bipolar depressed only, bipolar euthymic only, bipolar manic/hypomanic only) according to current mood states. The screening accuracy of the MDQ including sensitivity, specificity and area under the curve (AUC) of receiver operating characteristic (ROC) curves were evaluated according to current mood states.

Results

The optimal cutoff of MDQ was 5 in this study sample. Sensitivity and specificity were not significantly different according to current mood states. Significant differences in AUCs of four independent ROC curves were not found (ROC 1st curve included all bipolar patients; ROC 2nd curve included only bipolar depressed patients; ROC 3rd curve included only bipolar manic/hypomanic patients; ROC 4th curve included only bipolar euthymic patients).

Conclusion

The study results showed that current mood states (either euthymic state, depressed or manic/hypomanic) did not significantly influence the screening accuracy of the MDQ suggesting that the MDQ could be a useful screening instrument for detecting bipolar disorder in clinical practice regardless of the current mood symptoms of subjects.

Impulsivity issues in borderline personality disorder and it's links with insight: the role of urgency

Objective

Impulsivity plays a major role in a wide range of disorders including Borderline Personality Disorder. Another crucial clinical dimension is insight. This clinical dimension is linked with symptomatology and treatment issue. The present study aims to investigate the impact of positive and negative urgency on insight in Borderline Personality Disorder.

Methods

We recruited eighty-one women with Borderline Personality Disorder and assessed insight level and impulsivity scores using the Beck Cognitive insight scale and the UPPS-short form scale.

Results

Our results showed interesting links between positive urgency and insight quality.

Conclusion

Negative emotions play a fundamental role for the insight quality, but positive emotions are surprisingly related to clinical insight. We discuss the possible therapeutical impact of this results on treatment adaptation.

Thought and language disturbance in bipolar disorder quantified via process-oriented verbal fluency measures

Bipolar disorder (BD) is characterized by speech abnormalities, reflected by symptoms such as pressure of speech in mania and poverty of speech in depression. Here we aimed at investigating speech abnormalities in different episodes of BD, including mixed episodes, via process-oriented measures of verbal fluency performance - i.e., word and error count, semantic and phonological clustering measures, and number of switches-, and their relation to neurocognitive mechanisms and clinical symptoms. 93 patients with BD - i.e., 25 manic, 12 mixed manic, 19 mixed depression, 17 depressed, and 20 euthymic-and 31 healthy controls were administered three verbal fluency tasks - free, letter, semantic-and a clinical and neuropsychological assessment. Compared to depression and euthymia, switching and clustering abnormalities were found in manic and mixed states, mimicking symptoms like flight of ideas. Moreover, the neuropsychological results, as well as the fact that error count did not increase whereas phonological associations did, showed that impaired inhibition abilities and distractibility could not account for the results in patients with manic symptoms. Rather, semantic overactivation in patients with manic symptoms, including mixed depression, may compensate for trait-like deficient semantic retrieval/access found in euthymia. "For those who are manic, or those who have a history of mania, words move about in all directions possible, in a three-dimensional 'soup', making retrieval more fluid, less predictable." Kay Redfield Jamison (2017, p. 279).

Clinical correlates of loss of insight in bipolar depression

INTRODUCTION

Affective state may influence insight, especially regarding mania. Nevertheless, studies have so far suggested that depression seems not to significantly impair insight. To the best of our knowledge, this study pioneers the evaluation of how insight variations in bipolar depression correlate with clinical variables.

METHOD

A group of 165 bipolar patients, 52 of whom had depressive episodes according to DSM-5 criteria, were followed during a year. All patients underwent clinical assessment, and insight was evaluated through the Insight Scale for Affective Disorders (ISAD). Repeated-measures ANOVA was calculated comparing scores on the four ISAD factors (insight into symptoms, the condition itself, self-esteem and social relationships) in order to investigate differences in insight according to different objects. Correlational analysis explored which clinical symptoms were linked to reduced insight.

RESULTS

Worse total insight correlated with suicide attempt/ideation and fewer subsyndromal manic symptoms such as mood elevation, increased energy and sexual interest. Worse self-esteem insight was associated with not only suicide ideation/attempt but also with activity reduction and psychomotor retardation. Worse symptom insight also correlated with psychomotor retardation. Better insight into having an affective disorder was associated with more intense hypochondria symptoms. Finally, worse insight into having an illness was associated with psychotic episodes.

CONCLUSION

Our study found that symptoms other than psychosis - suicide ideation, psychomotor retardation and reduction of activity and work - correlate with insight impairment in bipolar depression.

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.

Behavioral and Psychological Symptoms Impact Clinical Competence in Alzheimer's Disease

Decision-making is considered a fundamental aspect of personal autonomy and can be affected in psychiatric and neurologic diseases. It has been shown that cognitive deficits in dementia impact negatively on decision-making. Moreover, studies highlighted impaired clinical competence in neuropsychiatric disorders, such as schizophrenia and bipolar disorder. In this context, the current study explored the relationship between behavioral and psychological symptoms of dementia (BPSD) and clinical competence, especially the capacity to consent to treatment, in Alzheimer's disease (AD). Seventy-one patients with mild to moderate AD participated, completing assessments for capacity to consent to treatment, general cognition and neuropsychiatric disturbances. For each neuropsychiatric symptom, patients with and without the particular disturbance were compared on the different subscales of the MacArthur Competence Tool for Treatment (MacCAT-T; Understanding, Appreciation, Reasoning and Expression). The results showed that patients presenting delusions, as well as apathetic patients, had a lower ability to express a clear treatment choice compared to patients without these symptoms. By contrast, patients with dysphoria/depression had higher scores on this variable. Additionally, AD patients with euphoria had more difficulties discussing consequences of treatment alternatives compared to patients without this disturbance. None of the differences were confounded by global cognition. There were no between-group differences in clinical decision-making for patients with hallucinations, agitation/aggression, anxiety, irritability, disinhibition and aberrant motor behavior. These findings highlight the importance of taking BPSD into account when assessing decision-making capacity, especially clinical competence, in AD. Furthermore, reducing BPSD may lead to better clinical competence in patients with AD, as well as to improvements in patients and caregivers' quality of life.