The difficult lives of individuals with bipolar disorder: A review of functional outcomes and their implications for treatment

Cognitive reserve and cognition in mood disorders: A systematic review and meta-analysis

Cognitive functioning heterogeneity is a well-recognized phenomenon in individuals diagnosed with mood disorders. Cognitive Reserve (CR) has been linked to multiple positive outcomes, including cognitive performance in these patients. This systematic review and meta-analysis aim to provide a comprehensive analysis of the relationship between CR and cognitive functioning in individuals with mood disorders, including bipolar disorder and depressive disorders. Following PRISMA guidelines, a systematic review and meta-analysis was conducted of original research exploring the relationship between CR and cognitive performance in adult individuals with mood disorders. The literature search was conducted on PubMed, Scopus, and Web of Science, from 2002 to September 2023, and the Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of studies. Overall, 17 studies met the inclusion criteria for the systematic review and 11 for the meta-analysis. Both qualitative and quantitative findings suggested a positive relationship between CR measures and cognitive domains. CR emerges as a possible protective factor for cognitive functioning in adult individuals with mood disorders, potentially helping to mitigate the cognitive impairments associated with the disorder. These findings underscore the importance of the fact that promoting and enhancing CR could help in the cognitive prognosis of this population.

Illness and narrative identity: examining past and future life story chapters in individuals with bipolar disorder, diabetes mellitus or no chronic illness

The purpose of this study was to investigate whether narrative identity challenges are specific to Bipolar Disorder (BD) as a mental illness or a reflection of living with chronic illness. Nineteen individuals diagnosed with BD, 29 individuals diagnosed with Type 1 Diabetes Mellitus (T1DM) and 25 controls without chronic mental or somatic illness identified past and future life story chapters which were self-rated on emotional tone and self-event connections and content-coded for agency and communion themes. Individuals with BD self-rated their past chapters as more negative and less positive, and their chapters were lower on content-coded agency and communion themes compared to T1DM and controls. There were fewer group differences for future chapters, but BD was associated with lower self-rated positive emotional tone and self-stability connections as well as lower content-coded agency and communion themes. The results indicate that narrative identity is affected in individuals with BD above and beyond the consequences of living with chronic illness. This may reflect distinct effects of mental versus somatic illness on narrative identity.

Effectiveness of structured group psychoeducation for people with bipolar disorder in Rwanda: A randomized open-label superiority trial

BACKGROUND

Psychoeducation is a cornerstone as an add-on to pharmacotherapy in standard care for individuals with bipolar disorder. However, evidence of the effectiveness of psychoeducation in low-resource settings is scarce.

AIMS

We aimed to assess the effectiveness of structured group psychoeducation versus waiting list on relapse prevention for individuals with bipolar disorder in Rwanda, a low-income country.

METHODS

This was a randomized open-label superiority trial. Participants aged 18 years or older with bipolar disorder were recruited at the two referral hospitals for mental health in Rwanda and randomly assigned 12 sessions of group psychoeducation or a waiting list. The program was tailored to the setting and co-designed with patients and clinicians. The follow-up period was 12 months, and the primary outcome mean number of psychiatric hospitalizations.

RESULTS

In February and March 2021, 154 participants were randomly assigned to receive group psychoeducation (n = 78) or to a waiting list (n = 76). The retention rate was high, with only three discontinuing the psychoeducation once they had received a session. Despite limited use of first-line pharmacotherapy, the psychoeducation reduced the risk of hospitalization by half during the 12-month follow-up (RR: 0.50(95 % CI 0.26-0.95)). Yet, no change in medical adherence was observed.

LIMITATION

Weekly assessment of clinical status was not feasible.

CONCLUSION

Structured group psychoeducation for bipolar disorder in a low-resource setting has a protective effect against readmission despite limited access to first-line pharmacotherapy. Further studies are needed to assess the effectiveness of the program in more decentralized settings with less highly trained staff.

TRIAL REGISTRATION

NCT04671225.

Clinical and personal predictors of functioning in affective disorders: Exploratory results from baseline and 6-month follow-up of a randomised controlled trial

Comprehensive knowledge of factors causing and sustaining functional impairment in patients with affective disorders is warranted. The aim is to investigate associations between clinical factors (such as affective symptoms) and personal factors (such as personality traits, coping strategies, and childhood trauma experiences) on functioning and improvement of functioning in patients with affective disorders. This exploratory study includes data from 103 patients with bipolar disorder and unipolar depressive disorder. Clinician-rated functioning was assessed at baseline using the Functioning Assessment Short Test (FAST), and performance-based functioning was assessed at baseline and 6-month follow-up using the Assessment of Motor and Process Skills (AMPS). Data on clinical and personal factors were collected at baseline. Personal factors were measured by the Eysenck Personality Inventory (EPQ), Coping Inventory for Stressful Situations (CISS) and Childhood Trauma Questionnaire (CTQ). Pearson correlations and multiple linear regression models were used to analyse the association of clinical and personal factors with baseline functioning (FAST) and to identify predictors of improvement in functioning (AMPS) from baseline to follow-up. At baseline, greater depressive symptom severity, the personality trait neuroticism, emotional coping, and childhood trauma all correlated with poorer functioning (higher FAST scores). In multiple linear regression models, depression severity, emotional coping and childhood trauma were significant predictors of poorer functioning. More childhood trauma was a predictor of less functional improvement measured by AMPS at 6-month follow-up. In conclusion, maladaptive coping styles and depressive symptoms contribute to functional impairment in patients with affective disorders, while childhood trauma has a negative impact on long-term functional outcomes.

Socio-economic status, functioning and cognition in young versus adult patients newly diagnosed with bipolar disorder and their unaffected relatives; results from a cross-sectional study

BACKGROUND

Bipolar disorders (BD) figures on top of the World Health Organization classification of disabling disorders. It is unclear if there are socioeconomic, functioning, and cognition differences in young patients newly diagnosed with BD and whether these are different for young and adult patients newly diagnosed with BD. Understanding these differences is important for tailored treatment and support.

METHODS

Participant groups included 401 patients newly diagnosed with BD, 145 of their unaffected first-degree relatives (UR) and 209 healthy control individuals (HC). First, we compared socio-economic status, functioning and cognition between young patients newly diagnosed with BD (150), UR (61) and HC (92) (15-25 years) and adult patients newly diagnosed with BD (251), UR (84) and HC (117) (>25 years), respectively. Second, within patients, we compared functioning and cognition between young and adult patients newly diagnosed with BD.

RESULTS

In both participant groups, patients newly diagnosed with BD, and to a lesser degree UR, had lower socio-economic status and impaired functioning and cognition compared with HC. Further, young patients newly diagnosed with BD were less functionally impaired, than adults newly diagnosed with BD, whereas cognition did not differ between groups.

LIMITATIONS

Applied tools for assessments of functioning and cognition are not validated below age 18.

CONCLUSIONS

Overall, lower socio-economic status and impaired functioning and cognition were found both in young and adult patients newly diagnosed with BD and their UR compared with young and adult HC, respectively. Young patients were less functionally impaired than adults, but cognition was similarly impaired.

The effect of resilience on bipolar mood during specialty clinic treatment

BACKGROUND

Limitations in mental health resources behoove exploration of factors that may enhance treatment response. One such factor, resilience, has been minimally examined in bipolar disorder.

METHODS

With multi-level modeling of clinical care data, we examined associations among longitudinal measurements of resilience and mood rating trajectories in a sample of 100 individuals with bipolar disorder during 6 weeks of evidence-based pharmacotherapy and psychotherapy.

RESULTS

Individuals with high self-care subscale scores from the Resilience Questionnaire for Bipolar Disorder exhibited an improving rate of depression change -0.18 (SE = 0.04, p < .001) completing treatment with a subthreshold depression rating of 3.1 (SE = 1.39, p < .05). In contrast, treatment recipients who disagreed or were neutral towards self-care experienced worsening or no change in depression, respectively. This subscale also decreased mood elevation. Each one-point increase yielded a -0.27 (SE = 0.13 p < .05) point decrease in mania.

LIMITATIONS

Resilience may develop longitudinally. In this study, it was examined during active treatment which was a relatively brief period of time.

CONCLUSIONS

Higher bipolar resilience could identify individuals more likely to exhibit improvement in mood during bipolar specialty clinic treatment.

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

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

Social cognition and social motivation in schizophrenia and bipolar disorder: are impairments linked to the disorder or to being socially isolated?

BACKGROUND

People with schizophrenia on average are more socially isolated, lonelier, have more social cognitive impairment, and are less socially motivated than healthy individuals. People with bipolar disorder also have social isolation, though typically less than that seen in schizophrenia. We aimed to disentangle whether the social cognitive and social motivation impairments observed in schizophrenia are a specific feature of the clinical condition v. social isolation generally.

METHODS

We compared four groups (clinically stable patients with schizophrenia or bipolar disorder, individuals drawn from the community with self-described social isolation, and a socially connected community control group) on loneliness, social cognition, and approach and avoidance social motivation.

RESULTS

Individuals with schizophrenia (n = 72) showed intermediate levels of social isolation, loneliness, and social approach motivation between the isolated (n = 96) and connected control (n = 55) groups. However, they showed significant deficits in social cognition compared to both community groups. Individuals with bipolar disorder (n = 48) were intermediate between isolated and control groups for loneliness and social approach. They did not show deficits on social cognition tasks. Both clinical groups had higher social avoidance than both community groups.

CONCLUSIONS

The results suggest that social cognitive deficits in schizophrenia, and high social avoidance motivation in both schizophrenia and bipolar disorder, are distinct features of the clinical conditions and not byproducts of social isolation. In contrast, differences between clinical and control groups on levels of loneliness and social approach motivation were congruent with the groups' degree of social isolation.

KIOS: A smartphone app for self-monitoring for patients with bipolar disorder

OBJECTIVES

This study examined the use of a self-monitoring/self-management smartphone application (app) for patients with bipolar disorder. The app was specifically designed with patient-centered computational software system based on concepts from nonlinear systems (chaos) theory.

METHODS

This was a randomized, active comparator study of use of the KIOS app compared to an existing free app that has high utilization rates known as eMoods, over 52 weeks, and performed in three academic centers. Patients were evaluated monthly utilizing the Bipolar Inventory of Symptoms Schedule (BISS). The primary outcome measure was the persistence of using the app over the year of the study.

RESULTS

Patients assigned to KIOS persisted in the study longer than those assigned to eMoods; 57 patients (87.70%) in the KIOS group versus 42 (73.69%) in the eMoods group completed the study (p = 0.03). By 52 weeks, significantly more of KIOS group (84.4%) versus eMoods group (54%) entered data into their programs (χ2  = 14.2, df = 1, p = 0.0002). Patient satisfaction for KIOS was greater (F = 5.21, df = 1, 108, p = 0.025) with a standardized effect size (Cohen's d) of 0.41. There was no difference in clinical outcome at the end of the study between the two groups.

CONCLUSIONS

This is the first randomized comparison study comparing two apps for the self-monitoring/self-management of bipolar disorder. The study revealed greater patient satisfaction and greater adherence to a patient-centered software program (KIOS) than a monitoring program that does not provide feedback (eMoods).

"What makes you well?" Supports of well-being in bipolar disorder. A qualitative study

OBJECTIVE

Subjective experience of people living with bipolar disorder is gaining attention in the field of research. Improving well-being could be as important as symptom remission, but this constitutes a vague concept. This study aimed at exploring the boundaries and the determinants of the well-being of people living with bipolar disorder in a French context.

METHODS

Individual semi-structured interviews were conducted with 16 patients by three professionals. Interviews were transcribed and analysed using the thematic analysis method.

RESULTS

Various dimensions emerged as contributing to well-being: daily routines, connectedness, regaining a positive identity, and self-awareness for self-management.

CONCLUSIONS

In addition to those common to the general population, this study highlighted specific determinants of well-being: the construction of a positive identity through acceptance of the diagnosis, the importance of self-awareness and self-management. They are highly intertwined with those of personal recovery and could help caregivers design interventions that directly target these goals. This study aimed to identify specific components of well-being for people living with bipolar disorder. Understanding the determinants of well-being enable caregivers to design tailored interventions that directly target quality of life and help improve bipolar disorder outcomes.

Functional Impairment, Attachment, and Affective Temperaments in Euthymic Patients with Bipolar Disorder

Background

Functional impairment in euthymic patients with bipolar disorder is a compelling issue, and revealing unknown related factors with functional impairment is a substantial topic. We aimed to assess the effects of clinical factors, affective temperaments, and attachment on overall functioning in euthymic patients with bipolar disorder.

Methods

Sixty-three patients with bipolar disorder and 61 healthy controls participated in this study. The assessment involved Hamilton Depression Rating Scale; Young Mania Rating Scale; Relationship Scales Questionnaire; Temperament Evaluation of Memphis, Pisa, Paris, and San Diego; and Functioning Assessment Short Test.

Results

Secure attachment scores were significantly higher in the control group than in the bipolar disorder group. Depressive, anxious, and cyclothymic temperament scores were significantly higher in the bipolar disorder group. In the bipolar disordergroup higher occupational, cognitive, autonomy, interpersonal relationships, and leisure subdomain and overall functional impairment scores were found than in the healthy control group. Secure attachment scores were significantly and negatively correlated with anxious and depressive temperaments. Secure attachment scores were positively and significantly correlated with hyperthymic temperament scores. Years of education; subclinical depressive symptoms; secure attachment; and cyclothymic, irritable, depressive, hyperthymic, and anxious temperaments were all significantly correlated with the overall functional impairment in the patient group. The cyclothymic and anxious temperament positively predicted the overall functional impairment in the bipolar group, while the secure attachment negatively predicted the overall functional impairment in the regression analysis.

Conclusion

The results suggest that, when following up the patients with bipolar disorder in relation to functional impairment, secure attachment, cyclothymic, and anxious temperaments should be taken into consideration.

A longitudinal study of cognition, functional outcome and quality of life in bipolar disorder and major depression

OBJECTIVE

Cognitive impairments are known to be a frequent cause of disability in bipolar disorder (BD) and major depression (MDD). Yet there is no consensus regarding the particular cognitive functions whose impairments can lead to disability in each domain of functioning. The aim of this study was to perform a longitudinal evaluation of working memory, inhibition, cognitive flexibility and attention in BD and MDD, investigate the relationship of these cognitive functions to disability and quality of life, and evaluate the impact of variables related to cognitive reserve (education and daily cognitive stimulation) on cognitive performance.

METHOD

31 participants (MDD = 12; BD = 19) were evaluated at baseline and after an average time of 2 years.

RESULTS

the BD group showed improvements in attention while patients with MDD improved on measures of attention and working memory. In BD working memory performance was associated with the cognition and mobility domains of functioning, and with physical and environmental quality of life. In MDD, cognitive flexibility was related to social relationships and environmental quality of life.

CONCLUSION

working memory and cognitive flexibility may be an interesting target for interventions aiming to improve everyday functioning and quality of life in BD and MDD.

Mindfulness-based cognitive therapy versus psychoeducational intervention in bipolar outpatients: Results from a randomized controlled trial

INTRODUCTION

Few controlled trials have assessed the impact of Mindfulness Based Cognitive Therapy (MBCT) on symptoms and functioning in bipolar disorder (BD). This study aims to evaluate the effectiveness of MBCT adjunctive group treatment.

MATERIAL AND METHODS

Randomized, prospective, multicenter, single-blinded trial that included BP-outpatients with subthreshold depressive symptoms. Participants were randomly assigned to three arms: treatment as usual (TAU); TAU plus psychoeducation; and TAU plus MBCT. Primary outcome was change in Hamilton-D score; secondary endpoints were change in anxiety, hypo/mania symptoms and functional improvement. Patients were assessed at baseline (V1), 8 weeks (V2) and 6 months (V3). Main hypothesis was that adjunctive MBCT would improve depressive symptoms more than psychoeducation.

RESULTS

Eighty-four participants were recruited (MBCT=40, Psychoeducation=34, TAU=10). Depressive symptoms improved in the three arms between V1 and V2 (p<0.0001), and between V1 and V3 (p<0.0001), and did not change between V2 and V3. At V3 no significant differences between groups were found. There were no significant differences in other measures either.

CONCLUSIONS

In our BD population we did not find superiority of adjunctive MBCT over adjunctive Psychoeducation or TAU on subsyndromal depressive symptoms; neither on anxiety, hypo/mania, relapses, or functioning.

Efficacy of cognitive remediation in bipolar disorder: systematic review and meta-analysis of randomized controlled trials

A significant percentage of people with bipolar disorder (BD) exhibit suboptimal functional adjustment, even when appropriately treated and after symptomatic recovery is achieved. Given that cognitive impairment is one of the strongest correlates of socio-occupational outcomes and quality of life in BD, cognitive remediation (CR) is currently acknowledged as a promising treatment that could help bridge the gap between symptomatic and full functional recovery. The aim of this review was to explore the efficacy of CR approaches in improving cognitive and functional outcomes in BD patients. PubMed, PsycINFO, and CENTRAL were searched from inception to November 2022. Randomized controlled trials exploring the effects of CR on cognition and/or functional adjustment in adult BD patients were eligible. Ten studies based on seven independent trials (n = 586) were included. Change-score effect sizes (Hedges' g) were obtained for efficacy outcome measures and combined by means of meta-analytic procedures. Small but significant overall effects were observed for working memory (g = 0.32, 95% CI 0.11-0.52), planning (g = 0.30, 95% CI 0.03-0.56), and verbal learning (g = 0.40, 95% CI 0.15-0.66). However, CR was not found to exert any significant effects on functional outcomes at treatment completion or at follow-up assessment. Although CR may modestly enhance the cognitive performance of BD patients, this effect does not translate into an improvement at the functional level. The current data do not support the inclusion of CR as a treatment recommendation in clinical practice guidelines for the management of BD.

Disability and its correlates among persons with bipolar disorder: Exploratory findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

Aim

This study aimed to evaluate the disability and its correlates in persons with Bipolar Disorder during the remission phase.

Materials and Methods

As part of the multicentric study, 773 patients with bipolar disorder, currently in clinical remission, were evaluated for disability on the Indian Disability Assessment Evaluation Scale.

Results

About one-fifth of the participants had some level of disability in the domain of self-care, one-third had some level of disability in the interpersonal domain, one-fourth had some level of disability in communication and understanding, and a maximum proportion (43.7%) had some disability in the domain of work. Overall, about one-fifth (18.4%) were considered to have a benchmark disability (i.e., disability >40%). In terms of correlates, those with a disability had a short duration of current remission, a higher number of manic and mixed episodes, a higher mean number of total episodes, spent more time in the episodes, had lower severity of the depressive episodes, higher residual depressive and manic symptoms, had overall higher manic affective morbidity, had a higher level of cognitive deficits, and had poorer insight.

Conclusion

A significant proportion of patients with bipolar disorder have disability in work domain, and the presence of residual symptoms of either polarity are associated with higher level of disability.

Variation in self and familiar facial recognition in bipolar disorder patients at different clinical stages

Previous studies suggest a close relationship between self-disorders and schizophrenia or unipolar depression. However, few studies have explored the characteristics of self-processing in bipolar disorder (BD) during different clinical states. This study compared the differences in self-face recognition (SFR) among patients with bipolar mania (BPM), bipolar depression (BPD), bipolar remission (RM), and healthy controls (HC). Images of subject's own face, a familiar face, and an unfamiliar face were combined in pairs at a certain proportion to obtain three types of blended images. We then compared the tendency between BD and HC while judging two kinds of blended faces emerging from presentation software. The results showed that the BPM and BPD groups seemed to lack an advantage in self-recognition. Self-processing and familiarity processing were significantly enhanced in BPM patients, while only familiarity processing was enhanced in BPD. The severity of clinical symptoms was not significantly correlated with self-bias or familiarity bias in BD.

Experiences that matter in bipolar disorder: a qualitative study using the capability, comfort and calm framework

BACKGROUND

When assessing the value of an intervention in bipolar disorder, researchers and clinicians often focus on metrics that quantify improvements to core diagnostic symptoms (e.g., mania). Providers often overlook or misunderstand the impact of treatment on life quality and function. We wanted to better characterize the shared experiences and obstacles of bipolar disorder within the United States from the patient's perspective.

METHODS

We recruited 24 individuals diagnosed with bipolar disorder and six caretakers supporting someone with the condition. Participants were involved in treatment or support services for bipolar disorder in central Texas. As part of this qualitative study, participants discussed their everyday successes and obstacles related to living with bipolar disorder during personalized, open-ended interviews. Audio files were transcribed, and Nvivo software processed an initial thematic analysis. We then categorized themes into bipolar disorder-related obstacles that limit the patient's capability (i.e., function), comfort (i.e., relief from suffering) and calm (i.e., life disruption) (Liu et al., FebClin Orthop 475:315-317, 2017; Teisberg et al., MayAcad Med 95:682-685, 2020). We then discuss themes and suggest practical strategies that might improve the value of care for patients and their families.

RESULTS

Issues regarding capability included the struggle to maintain identity, disruptions to meaningful employment, relationship loss and the unpredictable nature of bipolar disorder. Comfort related themes included the personal perception of diagnosis, social stigma and medication issues. Calm themes included managing dismissive doctors, finding the right psychotherapist and navigating financial burdens.

CONCLUSIONS

Qualitative data from patients with bipolar disorder helps identify gaps in care or practical limitations to treatment. When we listen to these individuals, it is clear that treatments must also address the unmet psychosocial impacts of the condition to improve patient care, capability and calm.

Assessments of functional outcomes and its determinants among bipolar disorder patients in Northwest Ethiopia comprehensive specialized hospitals: a multicenter hospital-based study

INTRODUCTION

Bipolar disorder is a severe and chronic mental illness that could continue for a lifetime. Although it is a leading cause of disability and impairments for significant numbers of patients, the levels of functional outcomes have not been studied in Ethiopia. Therefore, this study aimed to assess the functional outcome levels and associated factors among bipolar disorder patients in Northwest Ethiopia.

METHOD

Hospital-based cross-sectional study was employed among bipolar disorder patients attending psychiatric clinics, in Northwest Ethiopia, from April to June 2021. Systematic random sampling was used to get respondents. Descriptive and inferential statistics were done. Data were entered into EpiData version 4.6.02 and exported to SPSS Version 22 for analysis. Bivariable and multivariable binary logistic regression analysis was used to identify the factors associated with functional outcome levels, and p value < 0.05 was considered significant with 95% CI.

RESULT

Of the total 423 study participants approached, only 411 completed the questionnaire, with a response rate of 97.2%. The median (IQR) level of functional outcome was 6 (0-22) and 40% of the study subjects were impaired. Leisure time was the most normal functioning domain (92.2%), whereas cognitive (43.5%) and occupational (41.6%) domains were the most impaired domains. Unemployment (AOR (95%CI) = 3.9 (1.46-10.49), obesity (AOR (95% CI) = 6.5 (1.22-34.58), depressed and manic mood phases (AOR (95%CI) = 5.2 (2.84-9.35) and (AOR (95%CI) = 7.8 (3.31-18.34) respectively, medication non-adherence (AOR (95% CI) = 3.2 (1.71-6.05), and relapsed once or ≥ twice (AOR (95%CI) = 2.2 (1.25-3.98) and (AOR (95%CI) = 8.3 (2.73-25.30), respectively, were some of the important predictor variables that were significantly associated to the functional impairments levels.

CONCLUSION

The median of functional outcomes levels was found in an acceptable range; however, significant numbers of bipolar patients were functionally impaired. Moreover, patients still need unrestricted interventions in the cognitive and occupational functional domains. Socio-demographic, clinical, medication, and psychosocial variables were significantly associated with functional outcomes. Bipolar patients need to be followed and managed to improve their functional outcome and all stakeholders should be involved to achieve the recommended levels.

The financial situation before and after first-time psychiatric in-patient diagnosis of schizophrenia spectrum, bipolar, and major depressive disorder

Schizophrenia spectrum, bipolar, and major depressive disorders are severe mental illnesses (SMIs) that not only entail great suffering for those affected but also major societal costs. In this study, I use administrative register data to provide a detailed picture of the financial situation of people with SMI in Sweden during a period of ±10 years around first-time psychiatric in-patient diagnosis of schizophrenia spectrum, bipolar, and major depressive disorders. Receiving a diagnosis was associated with a considerable drop in earnings, which was largely compensated for by social transfers: mainly sickness and disability insurance. However, there were also large and increasing pre-diagnosis earnings gaps, relative to matched comparison groups, especially among those with schizophrenia spectrum disorders. These gaps were to a lesser extent compensated for by social transfers. Consequently, there were permanent and increasing - due to lost earnings growth - income differentials. Hence, findings in previous studies are confirmed: even in an advanced welfare state, people with SMI - especially those with schizophrenia - have an extremely weak position on the labour market and an equally difficult financial situation.

The experience of caregivers providing therapeutic patient education for people living with bipolar disorder: a qualitative study

BACKGROUND

Therapeutic patient education (TPE) programs are psycho-educational treatments suggested for all chronic diseases. For several years, these programs have been developing for people living with bipolar disorder. However, to date, only few qualitative studies have explored the experience of caregivers. We wanted to explore the experience of caregivers working in psychiatry as facilitators of a therapeutic education program for people living with bipolar disorder.

METHOD

A single-center qualitative study was carried out. We conducted an inductive exploration, examining the content of the discourse produced in a focus group of eight caregivers in therapeutic education. The corpus was transcribed manually and a thematic analysis was conducted by two authors in a blinded fashion before combining.

RESULTS

Four dimensions and twenty themes were identified: i) facilitators' pleasant experiences of the TPE sessions with a secure climate and a sense of belonging to a group, ii) being a TPE facilitator with a new horizontal and collaborative posture valuing the experiential knowledge, iii) the role of the TPE sessions with knowledge provision, empowerment and destigmatization, and iv) perceived changes in patients with an appeasement, the awareness of a shared experience, openness to others, a phenomenon of identification to peers and a new commitment.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The observations noted overlap with the elements of the personal recovery well known CHIME framework (Connectedness, Hope, positive Identity, Meaning in life and Empowerment). Therapeutic education is a developing form of psychosocial rehabilitation care: through the mobilization of a new attitude of caring, the facilitation of TPE programs could be a lever for changing the posture of caregivers in favor of supporting the personal recovery of people with bipolar disorder. These results would need to be confirmed by further studies.

The economic and humanistic burden of bipolar disorder in adults in the United States

BACKGROUND

Bipolar disorder is associated with functional impairment and diminished health-related quality of life (HRQoL). The purpose of this study was to estimate the annual per patient direct healthcare costs, indirect costs, and HRQoL of patients with bipolar disorder by depressive symptom severity and overall compared to the general population in the US.

METHODS

This cross-sectional study used self-reported data from the 2020 US National Health and Wellness Survey. Adult respondents who reported bipolar disorder symptoms in the past 12 months and/or a diagnosis of bipolar disorder were identified (bipolar disorder cohort) and were further classified by depressive symptom severity based on Patient Health Questionnaire (PHQ-9) scores (none/mild = 0-9, moderate = 10-14, severe = 15-27). Annualized direct healthcare costs and indirect costs were calculated from 6-month healthcare resource utilization and work productivity, respectively. A general population cohort was constructed using 2:1 propensity score matching. Multivariate regression models of all-cause hospitalizations in the past 6 months, annualized direct healthcare costs, annualized indirect costs, and HRQoL (eg, EuroQol 5-Dimension Health Questionnaire (EQ-5D)) controlled for confounders (demographic and clinical characteristics).

RESULTS

Of 3583 adults meeting pre-specified criteria for bipolar disorder, 1401 (39.1%) reported none/mild, 889 (24.8%) moderate, and 1293 (36.1%) severe depressive symptom severity. Additionally, 3285 (91.7%) were matched to 6570 adults in the general population. Compared to the general population, adjusted mean hospitalizations (0.53 vs. 0.30), annualized per patient direct healthcare costs ($20,846 vs. $11,391), and indirect costs ($14,795 vs. $9274) were significantly greater for the bipolar disorder cohort (all p < 0.001); adjusted HRQoL (EQ-5D: 0.69 vs. 0.79) was significantly worse (p < 0.001). By depressive symptom severity, adjusted mean hospitalizations (none/mild = 0.30, moderate = 0.50, severe = 0.46), direct healthcare costs ($14,389, $22,302, $21,341), and indirect costs ($10,799, $17,109, $18,470) were significantly greater for moderate and severe compared to none/mild depressive symptom severity (all p < 0.01); adjusted HRQoL (EQ-5D: 0.77, 0.67, 0.59) was significantly worse (p < 0.001).

CONCLUSIONS

Among respondents with bipolar disorder, those with moderate to severe depression had greater direct healthcare costs and indirect costs as well as worse HRQoL than those with mild or no depressive symptoms. Treatment targeting reduction in depressive symptoms may reduce the economic and humanistic burden of bipolar disorder.

Role of DSM5 anxious distress specifier interview in acute manic episode: sociodemographic characteristics, clinical presentation and quality of life

Background

DSM 5 anxious distress specifier is one of the newly added specifiers for bipolar and related disorders. It may have impacts on the symptoms severity, insight, impulsivity, and different domains of quality of life of acute manic episodes of bipolar disorders. The current study aimed to study the effects of DSM 5 anxious distress specifier in acute manic episodes and its relation to sociodemographic data, clinical characteristics, and quality of life. 380 patients with the diagnosis of acute manic episode were recruited in the study, sociodemographic data, clinical features, DSM 5 anxious distress specifier interview, attitude and insight of the disorder, impulsivity and different aspects of quality of life were also evaluated in those patients.

Results

The studied patients were divided into 2 subgroups according to the presence of high DSM5 anxious distress specifier interview score. The duration of a manic episode (P < 0.001), the severity of the manic episode (P < 0.001), and the presence of psychotic features (P = 0.002) were more common in the subgroup with high DSM 5 anxious distress. DSM 5 anxious distress specifier was severe (P < 0.001) and more frequent (P < 0.001) in the 1st subgroup than the 2nd one. There was a statistically significant difference regarding the attentional facet of the Barratt impulsiveness scale between the studied groups (P = 0.002). In addition, there was a statistically significant difference regarding the mean score (P < 0.001) and severe impairment (P < 0.001) domains of work and social adjustment scale between the 2 subgroups.

Conclusions

DSM 5 anxious distress specifier interview is a very crucial parameter of evaluation the patients with acute manic episodes which may have implications on the clinical presentations, symptoms severity, impulsivity, and variable aspects of quality of life in those patients. All these implications might change the course, prognosis, and outcomes of an acute manic episode of bipolar disorder.

Inflammation and cognition in severe mental illness: patterns of covariation and subgroups

A potential relationship between dysregulation of immune/inflammatory pathways and cognitive impairment has been suggested in severe mental illnesses (SMI), such as schizophrenia (SZ) and bipolar (BD) spectrum disorders. However, multivariate relationships between peripheral inflammatory/immune-related markers and cognitive domains are unclear, and many studies do not account for inter-individual variance in both cognitive functioning and inflammatory/immune status. This study aimed to investigate covariance patterns between inflammatory/immune-related markers and cognitive domains and further elucidate heterogeneity in a large SMI and healthy control (HC) cohort (SZ = 343, BD = 289, HC = 770). We applied canonical correlation analysis (CCA) to identify modes of maximum covariation between a comprehensive selection of cognitive domains and inflammatory/immune markers. We found that poor verbal learning and psychomotor processing speed was associated with higher levels of interleukin-18 system cytokines and beta defensin 2, reflecting enhanced activation of innate immunity, a pattern augmented in SMI compared to HC. Applying hierarchical clustering on covariance patterns identified by the CCA revealed a high cognition-low immune dysregulation subgroup with predominantly HC (24% SZ, 45% BD, 74% HC) and a low cognition-high immune dysregulation subgroup predominantly consisting of SMI patients (76% SZ, 55% BD, 26% HC). These subgroups differed in IQ, years of education, age, CRP, BMI (all groups), level of functioning, symptoms and defined daily dose (DDD) of antipsychotics (SMI cohort). Our findings suggest a link between cognitive impairment and innate immune dysregulation in a subset of individuals with severe mental illness.

Psychiatric comorbidity in individuals with bipolar disorder: relation with clinical outcomes and functioning

The aim was to assess the lifetime prevalence of psychiatric comorbidity (PC) in Brazilian euthymic individuals with bipolar disorder type I, and investigate its effects on clinical outcomes and functioning. A group of 179 outpatients with BD-I in the recuperation phase were assessed, of whom 75 (41.9%) had PC and 104 (58.1%) had not. Both groups were compared using sociodemographic/clinical questionnaire, Structured Clinical Interview for DSM-IV axis I and II, Sheehan Disability and Barratt Impulsiveness Scales. Patients with PC presented less religious affiliation, more history of lifetime psychotic symptoms, rapid cycling, suicide attempts, worse scores of functioning, and higher prevalence of personality disorders. Ordinal logistic regression indicated that PC was associated with increased odds of worse levels of disability. Therefore, it could be observed that patients with BD evaluated only in euthymia presented a high mental disorders comorbidity. Considering their burdensome impact, appropriate management is a challenging reality and a crucial factor in reducing morbidity and mortality associated with BD. Further longitudinal studies on their relationship may broaden interventions to reduce patient's suffering.

The relationship between cognition and functioning in Bipolar Disorder: An investigation using functional imaging during working memory performance

The psychosocial functioning of individuals suffering from bipolar disorder (BD) has a significant impact on prognosis and quality of life. The aim of this study was to assess brain functional correlates of psychosocial functioning in BD individuals during the performance of a working memory task. Sixty-two subjects (31 euthymic BD individuals and 31 matched healthy controls) underwent structural and functional magnetic resonance imaging scanning while performing the 1- and 2-back versions of the n-back task (1-back and 2-back). The Functional Assessment Short Test (FAST) and its subdomains were used to assess functioning. Whole brain analysis revealed only overall activation differences between BD patients and healthy controls, but the patients showed failure of de-activation in the medial frontal cortex. Six clusters of significant inverse correlation with the FAST scores were found in the dorsolateral prefrontal cortex, the superior parietal cortex, and temporo-occipital regions bilaterally, and in the left inferior frontal cortex. Cognitive and occupational functioning were the subdomains most significantly associated with brain activation in these clusters. The results suggest that poor psychosocial functioning in BD individuals is associated with hypoactivation in a range of cortical regions, including the fronto-parietal working memory network and inferior temporo-occipital regions.

Anxiety in bipolar disorder: A review of publication trends

BACKGROUND

Although anxiety is highly prevalent in people with bipolar disorders and has deleterious impact on the course of the illness, past reviews have shown that many aspects of the topic remain under-researched. This scoping review aims to provide a comprehensive overview of the literature addressing anxiety in bipolar disorder (A-BD) between 2011 and 2020, assess if the interest in the topic has increased over the period and map the publication trends.

METHODS

Three databases were systematically searched, and all articles were screened at the title/abstract and full text level based on inclusion and exclusion criteria. Of these, 1099 articles were included in the study. The annual number of articles on A-BD published between 2011 and 2020 was calculated and articles addressing it as a primary topic (n = 310) were classified into 4 categories and 11 subcategories to identify gaps in the knowledge.

RESULTS

The results show no clear increase in the number of annual publications during the period and much of the available literature is of a descriptive nature. Less is known about the processes underlying the comorbidity and about treatment approaches.

LIMITATIONS

Given the large scope of the research question, no quality assessment of the evidence was made. Only articles in English or French were considered.

CONCLUSIONS

These results highlight the need to change the focus of research efforts to better understand and address this unique set of conditions in clinical settings.

Social and environmental variables as predictors of mania: a review of longitudinal research findings

Considerable evidence suggests that psychosocial variables can shape the course of bipolar disorder. Here, though, we focus on the more specific idea that the social environment can predict the course of mania. We systematically review evidence from longitudinal studies concerning how social support, family interactions, traumatic life events, and recent life events relate to the age of onset, the frequency of episode recurrence, and the severity of manic symptoms. Although we find some evidence that the course of mania can be worsened by social environmental factors, the links are specific. Among social variables, some studies indicate that conflict and hostility are predictive, but more general social relationship qualities have not been found to predict mania. Some research indicates that childhood trauma, and recent life events involving goal attainment or sleep disruption can predict mania. Taken together, the profile of variables involving recent exposure that are most predictive include those that are activating, reward-related, or sleep-disrupting, which fits with general psychological hypotheses of behavioral activation and sleep disruption as important for mania. We discuss gaps in the literature, and we note future directions for research, including the need for more integrative, longitudinal research on a fuller range of social and biological risk variables.

The mental health of China and Pakistan, mental health laws and COVID-19 mental health policies: a comparative review

Mental health is one of the major causes of disability worldwide, and mental health problems such as depression and anxiety are ranked among the top 25 leading causes of disease burden in the world. This burden is considerable over the lifetime of both men and women and in various settings and ages. This study aims to compare the mental health status of people in China and Pakistan and to highlight the mental health laws and policies during COVID-19 and afterwards. According to the literature on mental health, before the COVID-19 pandemic, mental health problems increased gradually, but during and after the COVID-19 pandemic, an abrupt surge occurred in mental health problems. To overcome mental health disorders, most (but not all) countries have mental health laws, but some countries ignore mental health disorders. China is one such country that has mental health laws and policies and, during the COVID-19 pandemic, China made beneficial and robust policies and laws, thereby succeeding in defeating the COVID-19 pandemic. The mortality rate and financial loss were also lower than in other countries. While Pakistan has mental health laws and general health policies, the law is only limited to paperwork and books. When it came to COVID-19, Pakistan did not make any specific laws to overcome the virus. Mental health problems are greater in Pakistan than in China, and China's mental health laws and policies are more robust and more widely implemented than those in Pakistan. We conclude that there are fewer mental health issues in China than in Pakistan both before and since the COVID-19 pandemic. China has strong mental health laws and these are robustly implemented, while the mental health law in Pakistan is not applied in practice.

Cognitive profiles in bipolar I disorder and associated risk factors: Using Wechsler adult intelligence scale—IV

Background

Despite the growing evidence of cognitive impairments in bipolar disorder (BD), little work has evaluated cognitive performances utilizing the latest version of the Wechsler Intelligence Scale-IV (WAIS-IV), which is one of the most widely used neurocognitive assessments in clinical settings. Furthermore, clinical characteristics or demographic features that negatively affect the cognitive functioning of BD were not systematically compared or evaluated. Accordingly, the present study aimed to examine the cognitive profile of bipolar I disorder (BD-I) patients and associated risk factors.

Methods

Participants included 45 patients, diagnosed with BD-I, current or most recent episode manic, and matching 46 healthy controls (HC). Cognitive performance was evaluated via WAIS-IV, and clinical characteristics of the BD-I group were examined via multiple self- and clinician-report questionnaires.

Results

Multivariate analysis of covariance (MANCOVA) results indicated that the BD-I group demonstrated significantly poorer performance compared to the HC group in subtests and indexes that reflect working memory and processing speed abilities. Redundancy analysis revealed that overall symptom severity, manic symptom severity, and anxiety were significant predictors of cognitive performance in BD-I, while age of onset, past mood disorder history, depression severity, and impulsiveness showed comparatively smaller predictive values.

Conclusion

The current study suggests cognitive deterioration in the cognitive proficiency area while generalized ability, including verbal comprehension and most of the perceptual reasoning skills, remain intact in BD-I. The identified risk factors of cognitive performance provide specific clinical recommendations for intervention and clinical decision-making.

Predictive models for social functioning in healthy young adults: A machine learning study integrating neuroanatomical, cognitive, and behavioral data

Poor social functioning is an emerging public health problem associated with physical and mental health consequences. Developing prognostic tools is critical to identify individuals at risk for poor social functioning and guide interventions. We aimed to inform prediction models of social functioning by evaluating models relying on bio-behavioral data using machine learning. With data from the Human Connectome Project Healthy Young Adult sample (age 22-35, N = 1,101), we built Support Vector Regression models to estimate social functioning from variable sets of brain morphology to behavior with increasing complexity: 1) brain-only model, 2) brain-cognition model, 3) cognition-behavioral model, and 4) combined brain-cognition-behavioral model. Predictive accuracy of each model was assessed and the importance of individual variables for model performance was determined. The combined and cognition-behavioral models significantly predicted social functioning, whereas the brain-only and brain-cognition models did not. Negative affect, psychological wellbeing, extraversion, withdrawal, and cortical thickness of the rostral middle-frontal and superior-temporal regions were the most important predictors in the combined model. Results demonstrate that social functioning can be accurately predicted using machine learning methods. Behavioral markers may be more significant predictors of social functioning than brain measures for healthy young adults and may represent important leverage points for preventative intervention.

Patients' perspectives of the effects of a group-based therapeutic patient education program for bipolar disorder: a qualitative analysis

BACKGROUND

Few qualitative studies have explored the impact of group-based psychoeducation programs from the perspective of patients with bipolar disorder, and no studies to date have examined the effects of such programs on patients' personal recovery. The aim of this study was to explore the effects of a group therapeutic education program on the personal recovery of people with bipolar disorder and its determinants.

METHODS

Three professionals conducted semistructured interviews with 16 patients who participated in 9 weekly sessions of four separate bipolar therapeutic education programs. The interviews were transcribed verbatim and analyzed inductively by two of the professionals using the thematic analysis method.

RESULTS

Three main themes emerged from the interviews: the elements of therapeutic education, the experience of therapeutic education and the changes facilitated by therapeutic education. The changes reported by the participants included the evolution of the patient's relationship with the disorder, improvement in the patient's knowledge of the disorder, improvement in disorder management throughout daily life in general, and development of psycho-social skills and social relationships.

CONCLUSIONS

This study provides support for the beneficial impact of group therapeutic education programs on the personal recovery of people with bipolar disorder. These programs improve all dimensions of recovery according to the CHIME model, with connectedness, hope and empowerment being the main dimensions impacted. Our results indicate that therapeutic group education programs can be beneficial for people with bipolar disorder at any point during their experience of the disorder, with the potential exception of periods of thymic decompensation.

Strategies and foundations for scientific discovery in longitudinal studies of bipolar disorder

Bipolar disorder (BD) is a complex and dynamic condition with a typical onset in late adolescence or early adulthood followed by an episodic course with intervening periods of subthreshold symptoms or euthymia. It is complicated by the accumulation of comorbid medical and psychiatric disorders. The etiology of BD remains unknown and no reliable biological markers have yet been identified. This is likely due to lack of comprehensive ontological framework and, most importantly, the fact that most studies have been based on small nonrepresentative clinical samples with cross-sectional designs. We propose to establish large, global longitudinal cohorts of BD studied consistently in a multidimensional and multidisciplinary manner to determine etiology and help improve treatment. Herein we propose collection of a broad range of data that reflect the heterogenic phenotypic manifestations of BD that include dimensional and categorical measures of mood, neurocognitive, personality, behavior, sleep and circadian, life-story, and outcomes domains. In combination with genetic and biological information such an approach promotes the integrating and harmonizing of data within and across current ontology systems while supporting a paradigm shift that will facilitate discovery and become the basis for novel hypotheses.

Real-World Functioning in Psychiatric Outpatients: Predictive Factors

Introduction: Investigations on predictors of real-world functioning were mainly performed in patients with schizophrenia, while fewer studies have been conducted in other psychiatric disorders. Objective: Our objective was to identify clinical, socio-demographic, and illness-related predictors of real-world functioning during 12 months of standard treatments in outpatients with different diagnoses. Methods: Outpatients (n = 1019) with schizophrenia (SZ), major depressive disorder (MDD), bipolar disorder (BD), and borderline personality disorder (BPD) were evaluated with the following tools: SCID-5-CV and SCID-5-PD, CGI-S, SAT-P, DAI-10, and PSP. Change of PSP (ΔPSP) between baseline and 12 months was used as the dependent variable in multiple regression analysis. Results: Higher PSP score at baseline and the achievement of main milestones predicted better functioning after follow-up in all subgroups of patients, with the exception of BD. In the total sample, ΔPSP was related to age of onset, treatments, and quality of life, and inversely related to psychiatric anamnesis, antidepressants, and global symptoms. In SZ, ΔPSP was related to adherence and quality of life. In MDD, ΔPSP was related to psychotherapy and quality of life, and inversely related to antidepressants and global symptoms. In BD, ΔPSP was related to age of onset, antipsychotics, and quality of life, while it was inversely related to psychiatric anamnesis. In BPD, antipsychotics, mood stabilizers, psychotherapy, and quality of life were directly related to ΔPSP, while suicidal attempts and global symptoms had an inverse relation. Conclusions: Several socio-demographic and illness-related variables predicted improvement of real-world functioning, besides psychopathology and severity of the disease.

Long-term work disability due to type I and II bipolar disorder: findings of a six-year prospective study

Background

Bipolar disorder (BD) is one of the leading causes of disability worldwide. However, the prevalence and predictors of long-term work disability among patients with type I and II BD have scarcely been studied. We investigated the clinical predictors of long-term work disability among patients with BD.

Methods

The Jorvi Bipolar Study (JoBS) is a naturalistic prospective cohort study (n = 191) of adult psychiatric in- and out-patients with DSM-IV type I and II BD in three Finnish cities. Within JoBS we examined the prevalence and predictors of disability pension being granted during a six-year follow-up of the 152 patients in the labor force at baseline and collected information on granted pensions from national registers. We determined the predictors of disability pension using logistic regression models.

Results

Over the 6 years, 44% of the patients belonging to the labor force at baseline were granted a disability pension. Older age; type I BD; comorbidity with generalized anxiety disorder, post-traumatic stress disorder or avoidant personality disorder; and duration of time with depressive or mixed symptoms predicted disability pensions. Including disability pensions granted before baseline increased their total prevalence to 55.5%. The observed predictors were similar.

Conclusion

This regionally representative long-term prospective study found that about half of patients with type I or II bipolar disorder suffer from persistent work disability that leads to disability pension. In addition to the severity of the clinical course and type I bipolar disorder, the longitudinal accumulation of time depressed, psychiatric comorbidity, and older age predicted pensioning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00264-6.

Determinants of three-year clinical outcomes in real-world outpatients with bipolar disorder: The multicenter treatment survey for bipolar disorder in psychiatric outpatient clinics (MUSUBI)

BACKGROUND

There is limited evidence regarding predictors of long-term clinical outcomes in patients with bipolar disorder (BD). The objective of this study was to describe 3-year clinical outcomes and identify their predictors from participants in the multicenter treatment survey for BD in psychiatric outpatient clinics (MUSUBI).

METHODS

The MUSUBI was a naturalistic study investigating patients with BD in real-world clinical practice. Our study extracted data regarding 1647 outpatients with BD from 2016, 2017, and 2019 as baseline, 1-year, and 3-year assessments. As clinical outcomes, we assessed the presence of time ill (depressive and manic) during the 1 year prior to the 3-year assessment and durable remission (53 weeks or more) prior to the 3-year assessment.

RESULTS

Participants with durable remission prior to the 3-year assessment had significant associations with diagnosis of a personality disorder and duration of continuous remission at baseline. Regarding the presence of depressive symptoms during the 1 year prior to the 3-year assessment, work status, Global Assessment of Functioning (GAF) scores, suicidal ideation, and duration of continuous remission at baseline had significant associations with this outcome.

CONCLUSIONS

At the 3-year assessment, 19.3% of participants (318/1647) achieved durable remission, while 47.5% of them (782/1647) were not remitted. Our findings can help clinicians predict the illness course of BD by understanding demographic and clinical characteristics.

Gut Microbial Dysbiosis and Cognitive Impairment in Bipolar Disorder: Current Evidence

Recent studies have reported that the gut microbiota influences mood and cognitive function through the gut-brain axis, which is involved in the pathophysiology of neurocognitive and mental disorders, including Parkinson’s disease, Alzheimer’s disease, and schizophrenia. These disorders have similar pathophysiology to that of cognitive dysfunction in bipolar disorder (BD), including neuroinflammation and dysregulation of various neurotransmitters (i.e., serotonin and dopamine). There is also emerging evidence of alterations in the gut microbial composition of patients with BD, suggesting that gut microbial dysbiosis contributes to disease progression and cognitive impairment in BD. Therefore, microbiota-centered treatment might be an effective adjuvant therapy for BD-related cognitive impairment. Given that studies focusing on connections between the gut microbiota and BD-related cognitive impairment are lagging behind those on other neurocognitive disorders, this review sought to explore the potential mechanisms of how gut microbial dysbiosis affects cognitive function in BD and identify potential microbiota-centered treatment.

Affective disorders: eliminate WArning signs and REstore functioning-AWARE-a randomised controlled multimodule intervention study, presentation of design and intervention

INTRODUCTION

Affective disorders are associated with impaired overall functioning and quality of life (QoL). Despite different medical and psychological treatment options, the prognosis remains largely unchanged. Consequently, the field needs new intervention strategies especially targeting patient groups with impaired functioning. This study aims to improve functioning and QoL in patients with affective disorders using a comprehensive 360° intervention.

METHODS AND ANALYSIS

Affective disorders: eliminate WArning signs And REstore (AWARE) functioning is a randomised, controlled, parallel-group design study. Participants will be 120 outpatients, men or women, aged 18-65 years, with a diagnosis of bipolar disorder or major depressive disorder. Inclusion requires an objectively rated impaired functioning defined as a score ≥11 according to the Functioning Assessment Short Test. Participants will be randomised to 6-month AWARE intervention or treatment as usual (TAU). The AWARE intervention is a 360° multimodal intervention based on the International Classification of Functioning Brief Core Set for bipolar and unipolar disorder targeting functioning.The primary outcome is improvement of observation-based activities of daily living (ADL) ability using Assessment of Motor and Process Skills. Secondary outcomes are changes from baseline to endpoint in functioning, QoL, stress, cognition and physical health.Our hypothesis is that the AWARE treatment in comparison with TAU will improve observed ability to perform ADL, patients self-perceived level of functioning and QoL.Status: currently recruiting patients.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from The Regional Ethics Committee in the Capital Region of Denmark. All patients will be provided oral and written information about the trial before informed consent is obtained. The study results will be disseminated by peer-review publications. If the present AWARE intervention shows beneficial effects, the goal is to use it as a template for future interventions addressing disability in patients with affective disorders as well as for patients within other diagnostic categories.

TRIAL REGISTRATION NUMBER

NCT04701827; Clinicaltrials.gov.

Developing a profile of activities of daily living for bipolar disorder: a systematic review protocol and meta-analysis

INTRODUCTION

Bipolar disorder (BD) is a severe mental health disorder that affects 2% of the adult population. Individuals with this disorder are at a higher risk for morbidity and functional difficulties. They may also experience significant challenges in their activities of daily living (ADLs). This systematic review will identify all available studies that examine subsets of ADLs that impact individuals with BD.

METHODS AND ANALYSIS

MEDLINE, Embase, CINAHL and APA PsycINFO will be searched to identify observational studies that examined functioning, independence or performance across a variety of ADLs. Title and abstract, full-text screening and a risk of bias assessment will be conducted in duplicate. An overarching table that summarises the level of functioning across different ADLs or an 'ADL profile' will be developed, and if there are sufficient data, these will be separated based on the phases of BD, such as manic/hypomanic, depressed and euthymic.

ETHICS AND DISSEMINATION

As this systematic review uses information from previous literature, this review does not require ethics approval. This review will help identify the trends in daily activities that individuals struggle with and can help healthcare practitioners identify specific areas of need for support. We plan to disseminate the results in a peer-reviewed journal and conferences targeting occupational therapists and mental health clinicians.

PROSPERO REGISTRATION NUMBER

CRD42021255089.

The Influence of Growth Mindset on the Mental Health and Life Events of College Students

Growth mindset refers to our core belief that our talents can be developed through practice, which may influence our thoughts and behaviors. Growth mindset has been studied in a variety of fields, including education, sports, and management. However, few studies have explored whether differences in individuals' growth mindsets influence college students' self-reported mental health. Using the Growth Mindset Scale, Adolescent Self-rating Life Events Checklist, and SCL-90 Scale, data was collected from 2,505 freshmen in a University in China. Findings revealed that the students within the growth mindset group scored significantly lower on "mental health issues" and "stress due to life events" than the students in the fixed mindset group. Our findings suggest that individuals with a growth mindset are less prone to mental health problems than individuals with a fixed mindset.

Difficulties in emotion regulation in bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Bipolar disorder (BD) is a severe mental disorder characterized by mood swings and functional impairment. Although alterations in emotional regulation (ER) are a key feature, a comprehensive meta-analysis on abnormalities in emotion regulation in BD is still lacking.

METHODS

We performed a random-effects meta-analysis on studies comparing the ER measured with the Difficulties in Emotion Regulation Scale (DERS) in BD and healthy controls (HC) or borderline personality disorder (BPD) and calculated the standardized mean difference (SMD) of the total DERS score between those with BD and HC (primary outcome). Secondary outcomes were the SMD of the DERS subscales between BD and HC, as well as the SMD of the total score of DERS and the subscales between BD and BPD.

RESULTS

Twelve studies (858 BD, 540 BPD, 285 HC) were included. Compared to HC, BD showed significantly higher total DERS score (k=8, SMD 0.962, p<0.001) and subscale scores, including non-acceptance (k=6, SMD=0.85, p<0.001), goal-directed behavior (k=6, SMD=0.894, p<0.001), impulse control (k=6, SMD=1.08, p<0.001), strategies (k=6, SMD=1.25, p<0.001) and emotional clarity (k=6, SMD=0.694, p=0.001). Relative to BPD, BD presented significantly lower scores in all the DERS subscales. Sensitivity analyses confirmed the main analyses. The age of the participants and sample size moderated the primary outcome.

LIMITATIONS

The small number of studies and the cross-sectional design limit the generalizability of the results.

CONCLUSIONS

Our findings suggest that alterations of specific ER abilities are present in BD and their magnitude is smaller relative to BPD. Future therapeutic interventions should target ER strategies.

Perceived criticism and family attitudes as predictors of recurrence in bipolar disorder

Background

Bipolar disorder (BD) is a highly recurrent psychiatric condition. While combined pharmacological and psychosocial treatments improve outcomes, not much is known about potential moderators that could affect these treatments. One potential moderator might be the quality of interpersonal relations in families, for example, familial attitudes and perceived criticism.

Method

To explore this question we conducted a post-hoc analysis that used an existing data set from a previous study by our group that compared cognitive behavioral therapy (CBT) and supporting therapy (ST) in remitted BD. In the present study, we used Cox proportional hazard models.

Results

We found that the relatives’ ratings of criticism predicted the likelihood of depressive recurrences, especially in the ST condition. The patients’ ratings of negative familial attitudes predicted the risk of recurrences in general, irrespective of the therapy condition.

Conclusion

These results suggest that it might be important to assess perceived criticism and familial attitudes as potential moderators of treatment outcome in BD.

Relationship between cognitive flexibility and subsequent course of mood symptoms and suicidal ideation in young adults with childhood-onset bipolar disorder

Neurocognitive deficits, such as cognitive flexibility impairments, are common in bipolar disorder (BD) and predict poor academic, occupational, and functional outcomes. However, the association between neurocognition and illness trajectory is not well understood, especially across developmental transitions. This study examined cognitive flexibility and subsequent mood symptom and suicidal ideation (SI) course in young adults with childhood-onset BD-I (with distinct mood episodes) vs. BD-not otherwise specified (BD-NOS) vs. typically-developing controls (TDCs). Sample included 93 young adults (ages 18-30) with prospectively verified childhood-onset DSM-IV BD-I (n = 34) or BD-NOS (n = 15) and TDCs (n = 44). Participants completed cross-sectional neuropsychological tasks and clinical measures. Then participants with BD completed longitudinal assessments of mood symptoms and SI at 6-month intervals (M = 39.18 ± 16.57 months of follow-up data). Analyses included ANOVAs, independent-samples t tests, chi-square analyses, and multiple linear regressions. Participants with BD-I had significant deficits in cognitive flexibility and executive functioning vs. BD-NOS and TDCs, and impaired spatial working memory vs. TDCs only. Two significant BD subtype-by-cognitive flexibility interactions revealed that cognitive flexibility deficits were associated with subsequent percentage of time depressed and with SI in BD-I but not BD-NOS, regardless of other neurocognitive factors (full-scale IQ, executive functioning, spatial working memory) and clinical factors (current and prior mood and SI symptoms, age of BD onset, global functioning, psychiatric medications, comorbidity). Thus, cognitive flexibility may be an important etiological brain/behavior mechanism, prognostic indicator, and intervention target for childhood-onset BD-I, as this deficit appears to endure into young adulthood and is associated with worse prognosis for subsequent depression and SI.

Repetitive transcranial magnetic stimulation (rTMS) in bipolar disorder: A systematic review

OBJECTIVES

Repetitive transcranial magnetic stimulation (rTMS) is commonly used in unipolar depression; yet, its evidence in bipolar disorder (BD) is limited. We sought to review the evidence on the use of rTMS across the different stages of BD.

METHODS

MEDLINE database was systematically searched using the PubMed interface following the PRISMA guidelines. Inclusion criteria were as follows: (i) randomized clinical trials (RCTs), open-label studies, and case series; (ii) specific evaluation of the treatment outcomes using psychometric scales; (iii) clinical studies in adults; and (iv) articles in the English language. The systematic review has been registered on PROSPERO (CRD42020192788).

RESULTS

Thirty-one papers were included in the review. Most studies included participants diagnosed with a bipolar depressive episode (N = 24), have yielded mixed findings, and have yet to reach a consensus on the most effective rTMS protocol. Few studies examined the effect of rTMS during manic (N = 5) or mixed episode (N = 1), or as maintenance treatment (N = 1). The limited data thus far suggest rTMS to be relatively safe and well tolerated. Small sample sizes, heterogeneity among study designs, patients and control groups recruited, rTMS parameters, and outcome measures are among the most significant limitations to these studies.

CONCLUSION

The current data regarding the application of rTMS in BD patients remain limited. More adequately powered sham-controlled studies are required to verify its efficacy. Large-scale clinical trials are needed to also determine whether its effects extend to manic and mixed episodes, as well as its role in mood stabilization and amelioration of suicidal behavior.

Domain-Based Functional Improvements in Bipolar Disorder After Interpersonal and Social Rhythm Therapy

BACKGROUND

Studies typically report overall change in function when assessing bipolar disorder (BD) interventions, but individual domains are not analyzed. Which aspects of functioning are impacted is clearly important and may differ between treatments.

METHODS

Data were analyzed from two previous clinical trials of Interpersonal and Social Rhythm Therapy (IPSRT) for BD patients. Change in total and subscale scores on the Social Adjustment Scale Self-Report (SAS-SR) from 0 to 78 weeks, were analyzed.

RESULTS

152 BD patients took part in randomized controlled trials of IPSRT (n = 38) vs. Specialist Supportive Care (SSC) (n = 43), and of IPSRT (n = 41) vs. treatment as usual (TAU) which was discharge to primary care (n = 30). IPSRT was superior to TAU on change in the social and leisure activities and extended family subscales, and SAS-SR total score over 18 months.

LIMITATIONS

Studies were not designed to be pooled. Patients in study 1 were younger and symptomatic at baseline. Patients assigned to TAU were more likely to drop-out. Patients did not respond to subscales that were not personally applicable (work, marital, children).

CONCLUSION

IPSRT had a positive impact on two SAS-SR subscales compared to TAU over 18 months. Other subscales were limited by the lack of respondents due to individual applicability. Different psychotherapy may have differential effects on different domains of function. Measures of function and research into functioning in BD should include domain-based measures, and report the numbers of participants who respond to questions in each domain.

The impact of lurasidone on functioning and indirect costs in adults with bipolar depression: a post-hoc analysis

OBJECTIVE

The aim of this post-hoc analysis was to assess the impact of lurasidone monotherapy on functional impairment, productivity, and associated indirect costs in patients with bipolar depression.

METHODS

Data were analyzed from a 6-week randomized, double-blind (DB; NCT00868699), placebo-controlled trial of lurasidone monotherapy and a 6-month open label extension (OLE; NCT00868959) study. Patients with bipolar depression who completed the 6-week DB trial were subsequently enrolled in the OLE. Analysis of the OLE was limited to patients who either continued lurasidone (LUR-LUR) or switched from placebo to lurasidone monotherapy (PBO-LUR). The Sheehan Disability Scale (SDS), which measures functional impairment and productivity, was collected at DB baseline, DB week 6/OLE baseline, OLE month 3, and OLE month 6. Annual indirect costs were calculated based on days lost or unproductive from work/school due to symptoms. Effect sizes (ES) in functioning and days lost/unproductive were reported for the DB trial and mean changes for the OLE.

RESULTS

A total of 485 patients were enrolled in the DB trial (lurasidone: n = 323; placebo: n = 162) and 316 were in the lurasidone monotherapy group during the OLE (LUR-LUR: n = 210; PBO-LUR: n = 106). In the DB trial, improvements in functioning (work: ES = 0.36, p = .0071; social: ES = 0.55, p < .0001; family: ES = 0.50, p < .0001) were significantly greater for lurasidone compared to placebo. Reductions in days lost (ES = 0.33, p = .0050) and unproductive (ES = 0.45, p = .0001) were significantly higher for lurasidone vs. placebo. This resulted in a greater reduction in indirect costs for lurasidone vs. placebo (least squares mean (standard error) = -$32,322 ($2,100) vs. -$20,091 ($2,838)). Improvements in functioning and productivity were sustained during the 6-month OLE for both LUR-LUR and PBO-LUR.

CONCLUSIONS

Lurasidone monotherapy for the treatment of bipolar depression significantly improved functioning and reduced indirect costs vs. placebo at week 6. Significant improvements in functioning and productivity were sustained for 6 months for both LUR-LUR and PBO-LUR.

Bipolar disorders and retinal electrophysiological markers (BiMAR): Study protocol for a comparison of electroretinogram measurements between subjects with bipolar disorder and a healthy control group

BACKGROUND

Bipolar disorders (BD) is a common, chronic and disabling psychiatric condition. In addition to being characterized by significant clinical heterogeneity, notable disturbances of sleep and cognitive function are frequently observed in all phases of the disease. Currently, there is no readily available biomarker in current clinical practice to help diagnose or predict the disease course. Thus, identification of biomarkers in BD is today a major challenge. In this context, the study of electrophysiological biomarkers based on electroretinogram (ERG) measurements in BD seems highly promising. The BiMAR study aims to compare electrophysiological data measured with ERG between a group of euthymic patients with BD and a group of healthy control subjects. Secondarily, we will also describe the existing potential relationship between clinical, sleep and neuropsychological phenotypes of patients and electrophysiological data.

METHODS

The BiMAR study is a comparative and monocentric study carried out at the Expert Center for BD in Nancy, France. In total, 70 euthymic adult patients with BD and 70 healthy control subjects will be recruited. Electrophysiological recordings with ERG and electroencephalogram (EEG) will be performed with a virtual reality headset after a standardized clinical evaluation to all participants. Then, an actigraphic monitoring of 21 consecutive days will be carried out. At the end of this period a neuropsychological evaluation will be performed during a second visit. The primary outcome will be electrophysiological measurements with ERG flash and pattern. Secondary outcomes will be EEG data, sleep settings, clinical and neuropsychological assessments. For patients only, a complementary ancillary study, carried out at the University Hospital of Nancy, will be proposed to assess the retinal structure and microvascularization using Optical Coherence Tomography. Recruitment started in January 2022 and will continue until the end of July 2023.

DISCUSSION

The BiMAR study will contribute to identifying candidate ERG electrophysiological markers for helping the diagnosis of BD and identify subgroups of patients with different clinical profiles. Eventually, this would allow earlier diagnosis and personalized therapeutic interventions.

CLINICAL TRIAL REGISTRATION

The study is registered at Clinicaltrials.gov, NCT05161546, on 17 December 2021 (https://clinicaltrials.gov/ct2/show/NCT05161546).

The long-term course of cognition in bipolar disorder: a systematic review and meta-analysis of patient-control differences in test-score changes

Neuropsychological impairment represents a key aspect of bipolar disorder (BD) that is evident even in early-course patients and is a strong predictor of functional outcomes among those affected. Previous meta-analyses of longitudinal studies suggest that BD-related cognitive deficits may not progress along the course of the disorder. However, short test-retest periods were used in most primary studies and comparisons with healthy controls were limited. The aim of this review was to synthesize the findings of research reports comparing long-term neurocognitive trajectories between BD patients and healthy individuals. PubMed, PsycINFO, and Scopus databases were searched from inception through July 2021. Publications were considered for inclusion if they reported cognitive test scores of BD patients and healthy controls at two different time points, with a minimum test-retest interval of 5 years. Fifteen studies compared the long-term course of cognition in BD patients with that of healthy controls. Ten of these were included in the quantitative analysis and involved 540 BD patients and 644 healthy individuals (mean follow-up period: 8.9 years). Patient-control effect sizes (standardized mean differences) were calculated for test-score changes in 24 neuropsychological variables and combined by means of meta-analytic procedures. No significant differences were found between patients and controls regarding long-term cognitive outcomes. These findings are consistent with previous shorter-term longitudinal meta-analyses and do not provide evidence for progressive cognitive deterioration in most bipolar individuals. Future studies should address the longitudinal course of cognition in different subgroups of BD patients and its prognostic and therapeutic value.

Heterogeneity of psychosocial functioning in patients with bipolar disorder: Associations with sociodemographic, clinical, neurocognitive and biochemical variables

OBJECTIVE

This study aims to identify the functional heterogeneity in fully or partially remitted patients with bipolar disorder and explore the correlations between psychosocial functioning and sociodemographic, clinical, neurocognitive and biochemical variables.

METHODS

One hundred and forty fully or partially remitted patients with bipolar disorder (BD) and seventy healthy controls were recruited. The patients were grouped into different profiles based on the Functioning Assessment Short Test (FAST) domain scores by hierarchical cluster analysis. The characteristics of subgroups and the correlations between psychosocial functioning and sociodemographic, clinical, neurocognitive and biochemical variables in each cluster were then analyzed.

RESULTS

There were three subgroups in fully or partially remitted patients with BD: the lower functioning group (LF), performed global functioning impairments; the moderate functioning group (MF), presented selective impairments in functional domains; and the good functioning subgroup (GF), performed almost intact functioning. Among the three subgroups, there were differences in FAST domains, sociodemographic variables, clinical variables, some neurocognitive domains and several biochemical indexes.

CONCLUSIONS

The study successfully identified three functional subgroups. The characteristics of discrete subgroups and the specific clinical factors, neurocognitive domains and biochemical indexes that are correlated with functional subgroups will allow for making tailored interventions to promote functional recovery and improve the quality of life.

Affective episodes in recently diagnosed patients with bipolar disorder associated with altered working memory-related prefrontal cortex activity: A longitudinal fMRI study

INTRODUCTION

Bipolar disorder (BD) is often accompanied by trait-related cognitive impairments, but it is unclear which neurocircuitry abnormalities give rise to these impairments and whether neurocircuitry differences are exacerbated with illness progression. This longitudinal fMRI study of recently diagnosed BD patients investigates whether aberrant working memory (WM) related activity in the cognitive control network is accentuated by new affective episodes.

METHODS

Forty-seven recently diagnosed BD patients in full or partial remission and 38 healthy controls were assessed with neurocognitive tests and fMRI during the performance of a verbal n-back WM task at baseline and follow-up (15.4 months in average).

RESULTS

Patients showed WM-related hypo-activity in dorsal prefrontal cortex (dPFC) and impaired cognitive function within attention and psychomotor speed, WM and executive function, and verbal learning and memory compared to controls at baseline. During the follow-up period, 26 patients experienced at least one affective episode (BD+), while 21 remained in remission (BD-). There was no deterioration in cognitive performance in BD+ compared to BD- patients. Nevertheless, BD+ displayed increased WM-related dPFC activity at follow-up compared with BD- patients. This change in dPFC response was independent of mood symptoms and medication.

LIMITATIONS

The study did not account for type or frequency of affective episodes.

CONCLUSION

The study identifies cognitive impairment and WM-related hypo-activity in dPFC early during the course of BD. Increased high-load WM related dPFC activity over the follow-up period in BD+ versus BD- patients in the absence of changes in cognitive performance may reflect an episode-related reduction in PFC efficiency.