Does anxiety increase impulsivity in patients with bipolar disorder or major depressive disorder?

Psycho-biological mechanisms involved in suicidal risk, suicide attempts, and aggression: A replication and extension in bipolar disorder

BACKGROUND

Despite studies showing the individual roles of childhood maltreatment, alexithymia, impulsivity, and biological markers in suicide and aggression in bipolar disorder (BD), combined influence of these factors has not been studied yet.

METHODS

This study aimed to explore this issue in 353 individuals with BD completing self-report and clinician-rated measures. Blood samples were also taken to evaluate biological markers.

RESULTS

Higher C-reactive protein (CRP) and triglycerides (TG) and lower total cholesterol (TC) were observed in alexithymic people. Individuals with childhood maltreatment showed elevated CRP and lower TC and high-density lipoprotein cholesterol (HDLC). Those with both alexithymia and maltreatment displayed the most adverse profile regarding CRP and lipids. Depressive and manic symptoms, suicidal ideation, and low TC and HDL-C were associated with suicide attempts, while age, depressive and manic symptoms, childhood maltreatment, alexithymia, impulsivity, CRP, and low HDL-C accounted for suicidal risk. Aggression was linked to gender, impulsivity, and reduced low-density lipoprotein cholesterol (LDL-C).

LIMITATIONS

A cross-sectional design is a limitation of the study.

CONCLUSION

The study underscores the relationships between psychological and altered biomarkers, particularly elevated CRP and decreased lipid levels, and their roles in contributing to suicide and aggression, proposing a psychobiological model in BD.

Effects of Impulsivity on Competitive Anxiety in Female Athletes: The Mediating Role of Mindfulness Trait

It has been demonstrated that athletes in competitive sports suffer from high levels of competitive anxiety, especially in the case of females. In this sense, it is necessary to identify possible risk and protective factors of those athletes in this collective who suffer from this type of anxiety. However, few studies analyze the relationship between Physical Activity (PA) and anxiety, identifying the possible mediation effect of trait variables such as impulsivity and mindfulness in female athletes. Hence, the aims of this study were: to determine differences between PA levels with anxiety, mindfulness, and impulsiveness; to identify the predictive value of sociodemographic factors and physical activity, impulsivity, and mindfulness on anxiety factors; and to analyze the possible mediating effects of mindfulness on the relationship between impulsivity and anxiety. A total of 242 female athletes underwent an assessment of physical activity, anxiety, mindfulness traits, and impulsivity using validated questionnaires. Data were analyzed according to (1) individual or collective sport, and (2) PA levels according to energy expended (METs min/day). Participants were grouped by light, moderate, and vigorous PA levels. There were 30.5% elite athletes and 73.2% collective sports athletes. Mean age was 22.1 years and mean light, moderate, and vigorous PA were 86.1 ± 136.2, 114.4 ± 159.8, and 370.1 ± 336.3 METs min/day, respectively. Those athletes performing vigorous PA exhibited lower levels of impulsiveness and higher mindfulness traits. As expected, the mindfulness trait was a mediating factor in the relationship between impulsiveness and each factor of competitive anxiety (cognitive, somatic, and self-efficacy). Female athletes could suffer competitive anxiety, especially those who present higher levels of impulsivity. However, higher levels of mindfulness traits seem to be a protective factor in the effects of impulsivity on anxiety in this population and have demonstrated to be significant mediators in this association. Further studies are needed with other female athletes to replicate these results and to determine the specific protective mechanisms of mindfulness traits in preventing competitive anxiety.

History of suicide attempts in patients with bipolar disorder type I: socio-demographic and clinical factors, quality of life and functioning

INTRODUCTION

This study aims to evaluate sociodemographic and clinical factors, quality of life (QoL) and functioning associated with history of suicide attempts (SA) in a sample of bipolar disorder (BD) type I patients.

METHODS

A total of 417 BD type I patients, with and without history of SA were recruited from two Brazilian specialized Mood Disorder Centers. They were assessed with a sociodemographic and clinical questionnaire, the Young Mania Rating Scale, the Hamilton Depression Rating Scale, the Structured Clinical Interviews for DSM-IV Axis I Disorders, the World Health Organization Quality of Life-BREF, and the Sheehan Disability Scale.

RESULTS

One hundred and seventy-nine (42.9%) patients had a history of SA. There were no statistically significant sociodemographic differences between BD patients with and without a history of SA. Logistic regression found that lifetime hospitalization, comorbid anxiety disorders, depressive polarity in the first episode, current intensity of depressive symptoms, history of rapid cycling, family history of suicide and age at onset were significantly associated with SA in BD. Multiple linear regression showed that SA had no effect on QoL and functioning, which were affected mainly by comorbid anxiety disorders and current intensity of depressive symptoms, even in patients considered euthymic.

CONCLUSION

Suicidal behavior in patients with BD is a complex phenomenon and reflects a more severe course of illness. Patients with history of SA may have worse QoL and functional impairment not because of its direct effect, but because of the greater association with clinical factors related to poor prognosis.

Relationship between impulsivity, comorbid anxiety and neurocognitive functions in bipolar disorder

OBJECTIVE

The aim of the study is to examine the relationship between anxiety and impulsivity and to reveal the correlation of these variables with clinical and sociodemographic features. It is also aimed to investigate the relationship between impulsivity and anxiety with neurocognitive functions in bipolar disorder.

METHODS

The sample of the study comprises of 71 patients with bipolar disorder type I without any comorbidity (BD), 37 patients with anxiety disorder comorbidity with bipolar disorder type I (BDAD), 52 patients with anxiety disorder (AD) and 50 healthy controls (HC). Participants completed Barratt Impulsivity Scale-11, State-Trait Anxiety Inventory 1-2, Panic Disorder Severity Scale (PDSS), brief version of Fear of Negative Evaluation Scale (FNES), Anxiety Sensitivity Index-3 (ASI-3), Trail-Making Test A-B, Digit Span Test, Stroop Test.

RESULTS

PDSS scores, trait anxiety level, hypomanic and mixed episode numbers explain 26% of attention impulsivity. Gender and ASI-3 social dimensions explain 16% of motor impulsivity. Trait anxiety explains non-planning and total impulsivity at 26 and 24%, respectively. When neurocognitive impairment's effect was controlled, it was found AD and BDAD groups had higher impulsivity levels than the BD and HC groups.

CONCLUSION

Anxiety disorder comorbidity increases impulsivity in bipolar disorder.KEYPOINTSIn the presence of anxiety disorder spectrum comorbidity, bipolar disorder patients will have increased impulsivity and the clinical course may be more severe.Trait anxiety levels and anxiety sensitivity may be predictive factors for impulsivity.In the presence of anxiety disorder spectrum comorbidity, it should be taken into consideration that these patients may be more impulsive and should be treated with more care in terms of evaluation of the disorder.

The Association Between Suicide Attempts, Anxiety, and Childhood Maltreatment Among Adolescents and Young Adults With First Depressive Episodes

Objective: Adolescents and young adults are susceptible to high-risk behaviors such as self-harm and suicide. However, the impact of childhood maltreatment on suicide attempts in adolescents and young adults with first episode of depression remains unclear. This study examined the association between suicide attempts and childhood maltreatment among adolescents and young adults with first depressive episodes. Methods: A total of 181 adolescents and young adults with first depressive episodes were included. The Child Trauma Questionnaire (CTQ), Beck Anxiety Inventory (BAI), and Patient Health Questionnaire-2 (PHQ-2) were used to assess childhood maltreatment and the severity of anxiety and depressive symptoms, respectively. The suicide item in the MINI-International Neuropsychiatric Interview (M.I.N.I.) 5.0 was used to assess the suicide attempts. Logistic regression analyses were used to explore the associated factors of suicide attempts. Results: The prevalence of SA in the total sample was 31.5% (95% CI = 24.9-38.1%). Multivariate logistic regression analyses revealed that the diagnosis of bipolar disorder (OR = 2.18, 95% CI = 1.07-4.40), smoking (OR = 2.64, 95% CI = 1.10-6.37), anxiety symptoms (OR = 1.05, 95% CI = 1.02-1.08), and childhood maltreatment (OR = 1.04, 95% CI = 1.01-1.07) were potential associated factors of SA. In addition, anxiety symptoms had a mediating effect on the relationship between childhood maltreatment and SA. Conclusion: Adolescents and young adults with first depressive episodes and having experiences of childhood maltreatment are at a high risk of suicide. The severity of anxiety symptoms may mediate the relation between childhood maltreatment and suicide attempts in this group of patients.

Cortical Volumetric Correlates of Childhood Trauma, Anxiety, and Impulsivity in Bipolar Disorder

OBJECTIVE

More recently, attention has turned to the linkage between childhood trauma and emotional dysregulation, but the evidence in bipolar disorder (BD) is limited. To determine neurobiological relationships between childhood trauma, current anxiety, and impulsivity, we investigated cortical volumetric correlates of these clinical factors in BD.

METHODS

We studied 36 patients with DSM-5 BD and 29 healthy controls. Childhood trauma, coexisting anxiety, and impulsivity were evaluated with the Korean version-Childhood Trauma Questionnaire (CTQ), the Korean version-Beck Anxiety Inventory (BAI), and the Korean version-Barratt Impulsiveness Scale (BIS). Voxel-based morphometry (VBM) was used to assess gray matter volume (GMV) alterations on the brain magnetic resonance imaging (MRI). Partial correlation analyses were conducted to examine associations between the GMV and each scale in the BD group.

RESULTS

Childhood trauma, anxiety, and impulsivity were interrelated in BD. BD patients revealed significant inverse correlations between the GMV in the right precentral gyrus and CTQ scores (r=-0.609, p<0.0003); between the GMV in the left middle frontal gyrus and BAI scores (r=-0.363, p=0.044). Moreover, patients showed similar tendency of negative correlations between the GMV in the right precentral gyrus and BIS scores; between the GMV in the left middle frontal gyrus and CTQ scores.

CONCLUSION

The present study provides evidence for a neural basis between childhood trauma and affect regulations in BD. The GMV alterations in multiple frontal lobe areas may represent neurobiological markers for anticipating the course of BD.

Fronto-temporal galanin modulates impulse control

RATIONALE

The neuropeptide galanin has been implicated in a wide range of pathological conditions in which frontal and temporal structures are compromised. It works through three subtypes of G-protein-coupled receptors. One of these, the galanin receptor 1 (Gal-R1) subtype, is densely expressed in the ventral hippocampus (vHC) and ventral prefrontal cortex (vPFC); two brain structures that have similar actions on behavioral control. We hypothesize that Gal-R1 contributes to cognitive-control mechanisms that require hippocampal-prefrontal cortical circuitry.

OBJECTIVE

To examine the effect of local vHC and vPFC infusions of M617, a Gal-R1 agonist, on inhibitory mechanisms of response control.

METHODS

Different cohorts of rats were implanted with bilateral guide cannulae targeting the vPFC or the vHC. Following infusion of the Gal-R1 agonist, we examined the animals' behavior using a touchscreen version of the 5-choice reaction time task (5-choice task).

RESULTS

The Gal-R1 agonist produced opposing behaviors in the vPFC and vHC, leading to disruption of impulse control when infused in the vPFC but high impulse control when infused into the vHC. This contrast between areas was accentuated when we added variability to the timing of the stimulus, which led to long decision times and reduced accuracy in the vPFC group but a general improvement in performance accuracy in the vHC group.

CONCLUSIONS

These results provide the first evidence of a selective mechanism of Gal-R1-mediated modulation of impulse control in prefrontal-hippocampal circuitry.

Interrelationship of Opioid Dependence, Impaired Impulse Control, and Depressive Symptoms: An Open-Label Cross-Sectional Study of Patients in Maintenance Therapy

OBJECTIVE

A growing number of studies indicate increased impulsivity in patients with opioid dependence (OD). However, few studies exclude concomitant drug use and consider depression as a comorbidity, both of which can bias results.

AIM

We aimed to compare impulsivity in patients with OD enrolled in maintenance therapy (ICD code F11.22) and well-matched healthy controls taking psychopathological impairments into account. Furthermore, we compared the result to risky behavioral patterns in patients.

METHODS

This cross-sectional study included 50 patients with OD enrolled in either methadone or buprenorphine maintenance therapy and 50 healthy controls matched for gender, age, education, marital status, and premorbid intelligence. Abstinence from benzodiazepines, amphetamines, and cocaine was verified by urine analysis. We used the Barratt Impulsiveness Scale 11 (BIS-11), Beck's Depression Inventory (BDI), the Symptom Checklist 90 Revised (SCL-90R), and the European version of the Addiction Severity Index (EuropASI).

RESULTS

Patients exhibited significantly worse impulse control than healthy individuals. We found no correlation between impulsiveness and reported risky behavior patterns but found a significant correlation between depressive symptoms and psychopathological impairment.

CONCLUSIONS

Patients with OD showed a higher impulsivity than healthy individuals. Impulsivity could be a cause or a consequence of a substance use disorder; further research is warranted to explain this relationship. Impulsivity was associated with depression, an important confounder; future research needs to take this into account.

Self-reported inhibition predicts history of suicide attempts in bipolar disorder and major depression

BACKGROUND

Studies have reliably identified an association between suicide attempts and executive functions such as decision making (DM) and inhibitory control (IC) in patients with mood disorders. As such, the present study aimed to investigate the association between inhibition, DM, impulsivity and the history of suicide attempts in individuals with bipolar (BD) or major depressive disorder (MDD), identifying which assessment instruments may be most strongly associated with suicide in clinical samples.

METHODS

The sample included 80 control subjects and two groups of patients with BD and MDD, matched by age and education (26 with a history of suicide attempts [MD+], and 26 with no such history [MD-]). Participants completed behavioral and self-report measures of DM and IC, which were compared between groups using ANCOVA, followed by logistic regression for patients with mood disorders only, and the presence or absence of a history of suicide as the outcome.

RESULTS

Cognitive performance did not differ between groups. The MD+ group showed significantly higher motor and attentional impulsivity on the BIS-11 than the MD- and control groups. A regression analysis containing these scores showed that motor impulsivity was the only significant predictor of a history of suicide (OR = 1.14; 95%CI 1.00-1.30).

CONCLUSIONS

Self-reported motor impulsivity was a significant predictor of suicide. These findings underscore the importance of self-report measures in neuropsychological assessment, and their contributions to the management and prognosis of patients with mood disorders. Lastly, they point to the role of impulsivity as a target for interventions and public policy on suicide prevention.

Is the Higher Number of Suicide Attempts in Bipolar Disorder vs. Major Depressive Disorder Attributable to Illness Severity?

The present study represents an early stage investigation into the phenomenon whereby those with bipolar disorder attempt suicide more frequently than those with unipolar depression, but do not tend to attempt suicide during mania. Data for this study were obtained from baseline measurements collected in a randomized treatment study at a major southwestern United States military medical center. We demonstrated the rarity of suicide attempts during mania, the higher frequency of suicide attempts in those with bipolar disorder compared to those with depression, and the persistence of effects after accounting for severity of illness. These results provide the impetus for the development and testing of theoretical explanations.

Prevalence and Associated Features of Anxiety Disorder Comorbidity in Bipolar Disorder: A Meta-Analysis and Meta-Regression Study

Objective: Bipolar disorder is highly comorbid with anxiety disorders, however current and lifetime comorbidity patterns of each anxiety disorder and their associated features are not well studied. Here, we aimed to conduct a meta-analysis and meta-regression study of current evidence. Method: We searched PubMed to access relevant articles published until September 2015, using the keywords "Bipolar disorder" or "Affective Psychosis" or "manic depressive" separately with "generalized anxiety," "panic disorder," "social phobia," "obsessive compulsive," and "anxiety." Variables for associated features and prevalence of anxiety disorders were carefully extracted. Results: Lifetime any anxiety disorder comorbidity in BD was 40.5%; panic disorder (PD) 18.1%, generalized anxiety disorder (GAD) 13.3%, social anxiety disorder (SAD) 13.5% and obsessive compulsive disorder (OCD) 9.7%. Current any anxiety disorder comorbidity in BD is 38.2%; GAD is 15.2%, PD 13.3%, SAD 11.7%, and OCD 9.9%. When studies reporting data about comorbidities in BDI or BDII were analyzed separately, lifetime any anxiety disorder comorbidity in BDI and BDII were 38% and 34%, PD was 15% and 15%, GAD was 14% and 16.6%, SAD was 8% and 13%, OCD was 8% and 10%, respectively. Current any DSM anxiety disorder comorbidity in BDI or BDII were 31% and 37%, PD was 9% and 13%, GAD was 8% and 12%, SAD was 7% and 11%, and OCD was 8% and 7%, respectively. The percentage of manic patients and age of onset of BD tended to have a significant impact on anxiety disorders. Percentage of BD I patients significantly decreased the prevalence of panic disorder and social anxiety disorder. A higher rate of substance use disorder was associated with greater BD-SAD comorbidity. History of psychotic features significantly affected current PD and GAD. Conclusions: Anxiety disorder comorbidity is high in BD with somewhat lower rates in BDI vs BDII. Age of onset, substance use disorders, and percentage of patients in a manic episode or with psychotic features influences anxiety disorder comorbidity.

Clinical and socio-demographic correlates of anxious distress in Asian outpatients with major depressive disorder

BACKGROUND

Anxious distress in major depressive disorder (MDD) is common and associated with poor outcomes and management difficulties.

AIMS

This post hoc analysis aimed to examine the socio-demographic and clinical correlates of anxiety distress in Asian outpatients with MDD.

METHODS

Instead of two out of five specifiers defined by the Diagnostic and Statistical Manual Version-5, anxious distress defined in this study was operationalized as the presence of at least two out of four proxy items drawn from the 90-item Symptom Checklist, Revised (SCL-90-R). Other measures included the Montgomery-Asberg Depression Rating Scale (MADRS), the Fatigue Severity Scale, the Sheehan Disability Scale and the Multidimensional Scale of Perceived Social Support.

RESULTS

The data of 496 patients with MDD were included. Anxious distress was found in 371 participants (74.8%). The binary logistic regression analysis found that anxious distress was independently and significantly correlated with working status, higher MADRS scores, severe insomnia and functional impairment.

CONCLUSIONS

Three-fourths of Asian patients with MDD in tertiary care settings may have DSM-5 anxious distress of at least moderate distress. Its prevalence may vary among working groups. The specifier was associated with greater depressive symptom severity, severe insomnia and functional impairment.

Impulsivity and its relationship with anxiety, depression and stress

We aimed to assess the association between depression, anxiety, stress and impulsivity with respect to age. The Depression, Anxiety and Stress Scale (DASS-42) and the Barratt Impulsiveness Scale (BIS-11) were administered to 145 individuals. Due to a negative correlation between age, BIS-11 and DASS-42 subscales, participants were divided into three groups: young-aged (18-30years), middle-aged (31-49years) and old-aged (≥50years). Subjects from old-aged group had significantly lower scores of depression, anxiety, stress and impulsivity compared to those from younger groups. Anxiety, followed by stress and depression, was the strongest predictor of BIS-11 total score in young-aged and middle-aged individuals. There were no significant differences in the correlations between BIS-11 total score, depression, anxiety and stress in old-aged individuals. Our results indicate that the levels of depression, anxiety, stress and impulsivity decrease with age. Additionally, age might moderate the effect of depression, anxiety and stress on impulsivity.

Switching from Inadequate Adjunctive or Combination Treatment Options to Brexpiprazole Adjunctive to Antidepressant: An Open-Label Study on the Effects on Depressive Symptoms and Cognitive and Physical Functioning

BACKGROUND

Approximately 50% of patients with major depressive disorder do not respond adequately to their antidepressant treatment, underscoring the need for more effective treatment options. The objective of this study was to investigate the effect of adjunctive brexpiprazole on depressive symptoms in patients with major depressive disorder who were not responding to adjunctive or combination therapy of their current antidepressant treatments with several different classes of agents (NCT02012218).

METHODS

In this 6-week, open-label, phase 3b study, patients with major depressive disorder who had an inadequate response to ≥1 adjunctive or combination therapy, in addition to history of ≥1 failure to monotherapy antidepressant treatment, were switched to adjunctive brexpiprazole. Efficacy was assessed by change from baseline to week 6 in Montgomery-Åsberg Depression Rating Scale total score. Patient functioning was assessed using the Sheehan Disability Scale and the Cognitive and Physical Functioning Questionnaire. Safety and tolerability were also assessed.

RESULTS

A total of 51/61 (83.6%) patients completed 6 weeks of treatment with adjunctive brexpiprazole. Improvements in depressive symptoms were observed (least squares mean change from baseline to week 6 in Montgomery-Åsberg Depression Rating Scale total score, -17.3 [P < .0001]) as well as improvements in general and cognitive functioning (mean changes from baseline to week 6: Sheehan Disability Scale, -3.1 [P < .0001]; Massachusetts General Hospital-Cognitive and Physical Functioning Questionnaire, -9.2 [P < .0001]). The most common adverse event was fatigue (14.8%); akathisia was reported by 8.2% of patients.

CONCLUSIONS

In patients with major depressive disorder who had switched to open-label adjunctive brexpiprazole following inadequate response to previous adjunctive or combination therapy, improvements were observed in depressive symptoms, general functioning, cognitive function, and energy/alertness.

Prevalence, impact and treatment of generalised anxiety disorder in bipolar disorder: a systematic review and meta-analysis

QUESTION

Recent data suggest that anxiety disorders are as often comorbid with bipolar disorder (BD) as with unipolar depression; however, less attention has been paid to comorbidity of anxiety disorders with BD. Generalised anxiety disorder (GAD) is one of the most prevalent anxiety disorders that is highly comorbid with other mental disorders. We carried out a systematic review and meta-analysis to assess the degree of comorbidity between GAD and BD.

STUDY SELECTION AND ANALYSIS

We searched for all studies, which included primary data concerning the existence of GAD in patients with BD. The literature search strategy, selection of publications and the reporting of results have been conducted with PRISMA guidelines. The meta-analysis calculated prevalence estimates using the variance-stabilising Freeman-Tukey double arcsine transformation. We applied the inverse variance method using both fixed-effects and random-effects models to estimate summary effects for all combined studies. Heterogeneity was assessed and measured with Cochran's Q and I(2) statistics, respectively.

FINDINGS

The current meta-analysis analysed data from 28 independent studies and a total of 2975 patients from point prevalence studies and 4919 patients from lifetime studies. The overall random-effects point prevalence of GAD in patients with BD was 12.2% (95% CI 10.9% to 13.5%) and the overall random-effects lifetime estimate was 15.1% (95% CI 9.7% to 21.5%). Both estimates reported significant heterogeneity (94.0% and 94.7%, respectively).

CONCLUSIONS

Published studies report prevalence rates with high heterogeneity and consistently higher than those typically reported in the general population. It is believed that comorbid GAD might be associated with a more severe BD course and increased suicidality, and it is unknown how best to treat such conditions. The current meta-analysis confirms that GAD is highly prevalent in BD and the rate is higher in comparison to those in the general population.

The temporal course and clinical correlates of subjective impulsivity in bipolar disorder as revealed through ecological momentary assessment

BACKGROUND

Impulsivity is frequently linked with bipolar disorder and is associated with mania and negative outcomes. The temporal dynamics of subjective impulsivity are unclear, in particular whether impulsivity precedes or follows changes in positive or negative affect.

METHODS

A total of 41 outpatients with bipolar disorder (I or II) were provided with mobile devices for 11 weeks and completed twice-daily surveys about affective states and subjective impulsivity. We examined the association between aggregate subjective impulsivity with baseline global cognitive function, suicide risk ratings, and medication adherence, as well as concurrent and lagged associations with momentary positive and negative affect ratings.

RESULTS

A total of 2902 ratings were available across study subjects. Higher aggregate mean ratings of impulsivity were associated with worse baseline global cognitive function, prior suicide attempts, and self-reported problems with medication adherence, as well as more severe manic (but not depressive) symptoms. Time-lagged models indicated that greater negative affect, but not positive affect, predicted subsequent increases in subjective impulsivity, which, in turn, predicted diminished positive affect.

LIMITATIONS

Other measures of impulsivity with which to validate subjective ratings were unavailable and the sample was restricted to generally clinically stable outpatients.

CONCLUSIONS

Subjective impulsivity as measured by daily monitoring was associated with worse cognitive function and self-rated medication adherence, and higher suicide risk ratings. Impulsivity may be a maladaptive strategy to regulate negative affect in bipolar disorder.

A Lifetime Prevalence of Comorbidity Between Bipolar Affective Disorder and Anxiety Disorders: A Meta-analysis of 52 Interview-based Studies of Psychiatric Population

BACKGROUND

Bipolar affective disorder has a high rate of comorbidity with a multitude of psychiatric disorders and medical conditions. Among all the potential comorbidities, co-existing anxiety disorders stand out due to their high prevalence.

AIMS

To determine the lifetime prevalence of comorbid anxiety disorders in bipolar affective disorder under the care of psychiatric services through systematic review and meta-analysis.

METHOD

Random effects meta-analyses were used to calculate the lifetime prevalence of comorbid generalised anxiety disorder, panic disorder, social anxiety disorder, specific phobia, agoraphobia, obsessive compulsive disorder and posttraumatic stress disorder in bipolar affective disorder.

RESULTS

52 studies were included in the meta-analysis. The rate of lifetime comorbidity was as follows: panic disorder 16.8% (95% CI 13.7-20.1), generalised anxiety disorder 14.4% (95% CI 10.8-18.3), social anxiety disorder13.3% (95% CI 10.1-16.9), post-traumatic stress disorder 10.8% (95% CI 7.3-14.9), specific phobia 10.8% (95% CI 8.2-13.7), obsessive compulsive disorder 10.7% (95% CI 8.7-13.0) and agoraphobia 7.8% (95% CI 5.2-11.0). The lifetime prevalence of any anxiety disorders in bipolar disorder was 42.7%.

CONCLUSIONS

Our results suggest a high rate of lifetime concurrent anxiety disorders in bipolar disorder. The diagnostic issues at the interface are particularly difficult because of the substantial symptom overlap. The treatment of co-existing conditions has clinically remained challenging.

Shared clinical associations between obesity and impulsivity in rapid cycling bipolar disorder: a systematic review

BACKGROUND

Obesity seems to show a two-way relationship with bipolar disorder (BD), representing not only a possible vulnerability factor but also a consequence of chronic mood dysregulation associated with an overall poor prognosis. Increased impulsivity has been described across all stages and phases of BD as being also associated with a worse prognosis. Although obesity and impulsivity are common features among rapid cycling bipolar disorder (RC-BD) patients, there is a lack of understanding about the clinical implications of these conditions combined in BD.

METHODS

To explore and integrate available evidence on shared clinical associations between obesity and impulsivity in RC-BD a systematic search of the literature in the electronic database of the National Library of Medicine (PubMed) has been conducted.

RESULTS

One hundred and fourteen articles were included in our systematic review. Among RC-BD patients, substance abuse disorders (SUDs), anxiety disorders (ADs), predominantly depressive polarity, chronic exposure to antidepressants, psychotic symptoms, suicidality, and comorbid medical conditions are strongly associated with both obesity and impulsivity.

LIMITATIONS

Heterogeneity of published data, inconsistent measurements of both obesity and impulsivity in RC-BD and an absence of control for RC-BD in epidemiological surveys. Consequently, their combined impact on the severity of RC-BD is yet to be recognized and remains to be poorly understood.

CONCLUSION

In RC-BD patients the co-occurrence of obesity and impulsivity is associated with an unfavorable course of illness, specific shared clinical correlates, negative psychosocial impact, and overall worse prognosis. There is a need to examine obesity and impulsivity as modulating factors and markers of severity in RC-BD.

Impact of comorbid anxiety disorders and obsessive-compulsive disorder on 24-month clinical outcomes of bipolar I disorder

BACKGROUND

This study investigated the impact of comorbid obsessive-compulsive disorder (OCD) and four anxiety disorders [panic disorder (PD), agoraphobia, social anxiety disorder (SAD), and generalized anxiety disorder (GAD)] on the clinical outcomes of bipolar disorder.

METHODS

This study analysed data of 174 patients with bipolar I disorder who participated in the prospective observational study. Participants were assessed every 3 months for 24 months. The primary outcome measure was the achievement of symptomatic remission, defined by a total score on the Young Mania Rating Scale (YMRS) of ≤12 and a total score on the 21-item Hamilton Depression Rating Scale (HAMD-21) of ≤8.

RESULTS

Comorbidity was associated with decreased likelihood of remission. However, the impact of individual disorders on outcome differed according to clinical and treatment situations. Most comorbid anxiety disorders and OCD had a negative effect on remission during the first year of evaluation, as measured by the HAMD-21, and in patients taking a conventional mood stabilizer alone. However, the association with poorer outcome was observed only for a few specific comorbid disorders in the second year (GAD and OCD), as measured by YMRS-defined remission (OCD), and in patients with olanzapine therapy (GAD and OCD).

LIMITATIONS

Follow-up evaluation of comorbid disorders was lacking.

CONCLUSIONS

Comorbid anxiety disorders and OCD negatively influenced the clinical course of bipolar disorder. Specifically, OCD had a consistently negative impact on the outcome of bipolar I disorder regardless of clinical situation. Effective strategies for the control of these comorbidities are required to achieve better treatment outcomes.

Response inhibition in alcohol-dependent patients and patients with depression/anxiety: a functional magnetic resonance imaging study

BACKGROUND

The inability to inhibit certain behaviors is a key feature of impulsivity, which is often present in people with a substance use disorder. However, the findings on impulsivity in people with alcohol dependence (AD) are inconsistent, possibly because of the frequent co-occurrence of depression/anxiety (D/A) and its influence on impulsivity. In the current study, we aimed to distinguish response inhibition impairments in AD from possible response inhibition effects associated with D/A.

METHOD

AD patients (n = 31) with high D/A co-morbidity were compared to patients with D/A only (n = 18) and healthy controls (HCs; n = 16) using the Stop Signal Task (SST) during functional magnetic resonance imaging (fMRI). Correlation analyses were performed between activated brain areas, behavioral data and addiction and D/A characteristics.

RESULTS

The three groups did not differ on response inhibition performance. However, AD severity, but not D/A severity, was positively associated with decreased response inhibition. During the SST, AD patients showed hyperactivity in the putamen and thalamus compared with D/A patients and HCs. Thalamus activation was negatively associated with AD duration. In addition, AD patients showed hypoactivity in the supplementary motor area (SMA) compared with HCs. SMA activity within HCs was negatively correlated with depressive symptom severity. Discussion In general, AD patients were not more impulsive than D/A patients or HCs but they did reveal inhibition impairments with increasing AD severity. A shift from cortical to subcortical engagement in AD patients during response inhibition may represent an alternative strategy, which decreased with longer drinking history, suggesting the presence of an AD-specific endophenotype.

Association between family history of mood disorders and clinical characteristics of bipolar disorder: results from the Brazilian bipolar research network

OBJECTIVES

To compare clinical characteristics of bipolar disorder (BD) in patients with and without a family history of mood disorders (FHMD) in a large sample from the Brazilian Research Network of Bipolar Disorders.

METHODS

Four-hundred eighty-eight DSM-IV BD patients participating in the Brazilian Research Network of Bipolar Disorders were included. Participants were divided between those with FHMD (n=230) and without FHMD (n=258). We compared these two groups on demographic and clinical variables and performed a logistic regression to identify which variables were most strongly associated with positive family history of mood disorders.

RESULTS

BD patients with FHMD presented with significantly higher lifetime prevalence of any anxiety disorder, obsessive-compulsive disorder, social phobia, substance abuse, and were more likely to present history of suicide attempts, family history of suicide attempts and suicide, and more psychiatric hospitalizations than BD patients without FHMD. Logistic regression showed that the variables most strongly associated with a positive FHMD were any comorbid anxiety disorder, comorbid substance abuse, and family history of suicide.

LIMITATIONS

Cross-sectional study and verification of FHMD by indirect information.

CONCLUSION

BD patients with FHMD differ from BD patients without FHMD in rates of comorbid anxiety disorder and substance abuse, number of hospitalizations and suicide attempts. As FHMD is routinely assessed in clinical practice, these findings may help to identify patients at risk for particular manifestations of BD and may point to a common, genetically determined neurobiological substrate that increases the risk of conditions such as comorbidities and suicidality in BD patients.

Impulsivity in patients with panic disorder-agoraphobia: the role of cyclothymia

The relationship between Panic Disorder (PD) and impulsivity is not well explored. The present investigation aims to compare impulsivity, measured by different rating tools, in PD patients vs. healthy controls and to explore the influence of co-morbid Cyclothymic Disorder (CD) on the relationship between PD and impulsivity. Sixty-four subjects with PD and 44 matched controls underwent a diagnostic and symptomatological evaluations by the Mini Neuropsychiatric Interview (M.I.N.I) Plus 5.0; the Bech-Rafaelsen Depression and Mania Scale (BRDMS), the State-Trait Anxiety Inventory (STAI), the Hypomania Check List (HCL-32) and the Clinical Global Impression (CGI); the Questionnaire for the Affective and Anxious Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Modified (TEMPS-M), the Separation Anxiety Sensitivity Index (SASI), the Interpersonal Sensitivity Symptoms Inventory (ISSI). Finally, psychometric and neurocognitive evaluations of impulsivity was carried out using the Barratt Impulsiveness Scale (BIS-11) and the Immediate and Delayed Memory Task (IMT/DMT). Subjects with PD were more impulsive than the controls in all the explored measures, reporting higher scores in symptomatological and temperamental scales. The comparison between PD patients with (Cyclo+) and without (Cyclo-) comorbid CD and controls showed that Cyclo+ are the most impulsive subjects in all the investigated measures and are characterized by the greatest symptomatological impairment, the highest scores in temperamental scales, and the highest levels of interpersonal sensitivity and separation anxiety. In our patients with PD, without lifetime comorbidity with major mood episodes, trait and state impulsivity may be related to the presence of comorbid cyclothymic mood instability.

The Effects of Acupuncture Treatment on Sleep Quality and on Emotional Measures among Individuals Living with Schizophrenia: A Pilot Study

Purpose. To examine the effects of acupuncture on sleep quality and on emotional measures among patients with schizophrenia. Methods. Twenty patients with schizophrenia participated in the study. The study comprised a seven-day running-in no-treatment period, followed by an eight-week experimental period. During the experimental period, participants were treated with acupuncture twice a week. During the first week (no-treatment period) and the last week of the experimental period, participants filled out a broad spectrum of questionnaires and their sleep was continuously monitored by wrist actigraph. Results. A paired-sample t-test was conducted comparing objective and subjective sleep parameters manifested by participants before and after sequential acupuncture treatment. A significant effect of acupuncture treatment was observed for seven objective sleep variables: sleep onset latency, sleep percentage, mean activity level, wake time after sleep onset, mean number of wake episodes, mean wake episode and longest wake episode. However, no significant effects of acupuncture treatment were found for subjective sleep measures. Likewise, the results indicate that acupuncture treatment improved psychopathology levels and emotional measures, that is, depression level and anxiety level. Conclusions. Overall, the findings of this pilot study suggest that acupuncture has beneficial effects as a treatment for insomnia and psychopathology symptoms among patients with schizophrenia.

Activated depression: mixed bipolar disorder or agitated unipolar depression?

The combination of depression and activation presents clinical and diagnostic challenges. It can occur, in either bipolar disorder or major depressive disorder, as increased agitation as a dimension of depression. What is called agitation can consist of expressions of painful inner tension or as disinhibited goal-directed behavior and thought. In bipolar disorder, elements of depression can be combined with those of mania. In this case, the agitation, in addition to increased motor activity and painful inner tension, must include symptoms of mania that are related to goal-directed behavior or manic cognition. These diagnostic considerations are important, as activated depression potentially carries increased behavioral risk, especially for suicidal behavior, and optimal treatments for depressive episodes differ between bipolar disorder and major depressive disorder.

Anxiety as a marker of severity in acute mania

OBJECTIVE

Anxiety has scarcely been studied in acute mania. The aim of this study was to assess anxiety symptoms during manic episodes and their impact on clinical outcomes.

METHOD

Observational, cross-sectional multicentre study. Anxiety was measured using the Hamilton Anxiety Rating Scale (HARS). Bivariate and multiple linear regression analyses were performed using the HARS score as the dependent variable.

RESULTS

Two hundred and forty-two patients admitted with a diagnosis of acute manic episode according to DSM-IV TR criteria and a Young Mania Rating Scale>20 were analysed. Mean age was 43 years (SD=11.9) and 57% were women. Forty-six per cent of patients (n=104) presented moderate to severe anxiety symptoms (HARS score>14). Anxiety was significantly associated with severity of manic symptoms (P<0.0001). Patients with anxiety had 20% longer hospitalizations (mean 21 days, CI95% 19.7-23.7).

CONCLUSION

An association of anxiety symptoms with greater severity in acute mania was demonstrated. The close relationship between anxiety and manic symptoms highlights the need for greater clinical attention to anxiety in this population. Further studies are necessary to determine whether effective treatment of anxiety symptoms could improve clinical and care outcomes.