Trends in the incidence and DALYs of bipolar disorder at global, regional, and national levels: Results from the global burden of Disease Study 2017

Evaluating Oxidative Stress Markers in At-Risk Individuals for Bipolar Disorder: A Systematic Review and Meta-Analysis

INTRODUCTION

Bipolar disorder (BD), a mood disorder with recurrent affective episodes and a strong genetic basis is frequently associated with significant comorbidities, both physical and psychiatric, yet its neurobiology remains unclear. Recent evidence underscores oxidative stress as a pivotal factor linking BD to its comorbidities, prompting an investigation into whether this is a sign of a genetic vulnerability or a consequence of the disease. In this study, we systematically reviewed oxidative stress studies conducted on individuals at risk for BD. We performed a meta-analysis on studies examining oxidative DNA damage in these individuals.

METHODS

The literature was searched across the databases PubMed, Web of Science, Scopus, Ovid MEDLINE, and Cochrane to locate studies of oxidative stress markers in relatives of patients with BD compared with healthy controls (from 1946 to March 2024). Studies were considered for inclusion based on the following criteria: (i) involvement of first- or second-degree relatives of individuals diagnosed with BD, (ii) presence of a healthy control group, (iii) reporting of oxidative stress parameters for relatives, including mean and standard deviation or median and interquartile range (25-75%) values, and (iv) publication in the English language. Studies comparing the levels of 8-hydroxy-2'-deoxyguanosine (8-OH-dG) or its tautomer 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxo-dG) in individuals at risk for BD with healthy controls were evaluated using a meta-analysis with the random-effects method. The risk of bias was evaluated using the Risk of Bias in Non-Randomized Studies of Exposure (ROBINS-E) tool.

RESULTS

Eleven studies were included in the systematic review and four studies for the meta-analysis. The meta-analysis included 543 individuals (first-degree relatives of individuals with BD = 238, control = 305). 8-OH-dG levels were found to be increased in first-degree relatives of individuals with BD compared to healthy controls (random effects: Hedges's g = 0.53, 95% CI = 0.36-0.71, p < 0.001). Findings of oxidative stress markers other than oxidative DNA damage in relatives of individuals with BD are limited and scarce.

CONCLUSION

In this meta-analysis, which consists of a limited number of studies, oxidative DNA damage seems to be a trait marker for BD. This finding could be associated with increased comorbidity and a higher risk of premature aging in individuals at risk for BD. However, further studies with larger sample sizes and longitudinal designs are warranted to confirm findings. Clarifying the changes in these markers from individuals at risk for the disorder throughout the course of the illness would help bridge the gap in understanding the role of oxidative pathways in the risk of BD.

Machine learning-based discrimination of unipolar depression and bipolar disorder with streamlined shortlist in adolescents of different ages

BACKGROUND

Variations in symptoms and indistinguishable depression episodes of unipolar depression (UD) and bipolar disorder (BD) make the discrimination difficult and time-consuming. For adolescents with high disease prevalence, an efficient diagnostic tool is important for the discrimination and treatment of BU and UD.

METHODS

This multi-center cross-sectional study involved 1587 UD and 246 BD adolescents aged 12-18. A combination of standard questionnaires and demographic information was collected for the construction of a full-item list. The unequal patient number was balanced with three data balancing algorithms, and 4 machine learning algorithms were compared for the discrimination ability of UD and BD in three age groups: all ages, 12-15 and 16-18. Random forest (RF) with the highest accuracy were used to rank the importance of features/items and construct the 25-item shortlist. A separate dataset was used for the final performance evaluation with the shortlist, and the discrimination ability for UD and BD was investigated.

RESULTS

RF performed the best for UD and BD discrimination in all 3 age groups (AUC 0.88-0.90). The most important features that differentiate UD from BD belong to Parental Bonding Instrument (PBI) and Loneliness Scale of the University of California at Los Angeles (UCLA). With RF and the 25-item shortlist, the diagnostic accuracy can still reach around 80 %, achieving 95 % of the accuracy levels obtained with all features.

CONCLUSIONS

Through machine learning algorithms, the most influencing factors for UD and BD classification were recombined and applied for rapid diagnosis. This highly feasible method holds the potential for convenient and accurate diagnosis of young patients in research and clinical practice.

The global burden of disease attributable to high body mass index in 204 countries and territories: Findings from 1990 to 2019 and predictions to 2035

AIM

Our study aims to provide an updated estimate of age- and sex-specific deaths and disability-adjusted life years (DALYs) associated with high body mass index (BMI) from 1990 to 2019 at the global, regional and national levels, and to forecast the global burden of disease attributed to high BMI from 2020 to 2035.

METHODS

We used the data for the number of deaths, DALYs, age-standardized rate (per 100 000 population), percentage change and population attributable fraction from the Global Burden of Disease Study 2019 (GBD 2019) to examine the disease burden attributable to high BMI. We further applied an autoregressive integrated moving average (ARIMA) model to predict the disease burden for the period 2020-2035.

RESULTS

From 1990 to 2019, the deaths and DALYs attributable to high BMI increased by 148% and 155.86% for men, and by 111.67% and 121.78% for women, respectively. In 2019, high BMI directly accounted for 8.52% [95% uncertainty intervals (UI) 0.05, 0.12] of all-cause deaths and 5.89% (95% UI 0.04, 0.08) of global DALYs. The highest death rates were observed in men aged 65-69 and women aged 75-79. The highest DALY rates were observed in the age group of 60-64 for both sexes. In 2019, the highest age-standardized deaths and DALY rates were observed in the Central Asia region [163.15 (95% UI 107.72, 223.58) per 100 000 people] and the Oceania region [4643.33 (95% UI 2835.66, 6902.6) per 100 000 people], respectively. Fiji [319.08 (95% UI 213.77, 444.96) per 100 000 people] and Kiribati [10 000.58 (95% UI 6266.55, 14159.2) per 100 000 people] had the highest age-standardized deaths and DALY rates, respectively. In 2019, the highest age-standardized rates of high BMI-related deaths and DALYs were observed in the middle-high socio-demographic index quintile and in the middle socio-demographic index quintile. The age-standardized deaths and DALY rates attributable to high BMI are projected to increase in both sexes from 2020 to 2035. The death rates are projected to rise from 62.79 to 64.31 per 100 000 people, while the DALY rates are projected to rise from 1946 to 2099.54 per 100 000 people.

CONCLUSIONS

High BMIs significantly contribute to the global disease burden. The projected rise in deaths and DALY rates attributable to high BMI by 2035 highlights the critical need to address the impact of obesity on public health. Our study provides policymakers with up-to-date and comprehensive information.

Clinical and genetic contributions to medical comorbidity in bipolar disorder: a study using electronic health records-linked biobank data

Bipolar disorder is a chronic and complex polygenic disease with high rates of comorbidity. However, the independent contribution of either diagnosis or genetic risk of bipolar disorder to the medical comorbidity profile of individuals with the disease remains unresolved. Here, we conducted a multi-step phenome-wide association study (PheWAS) of bipolar disorder using phenomes derived from the electronic health records of participants enrolled in the Mayo Clinic Biobank and the Mayo Clinic Bipolar Disorder Biobank. First, we explored the conditions associated with a diagnosis of bipolar disorder by conducting a phenotype-based PheWAS followed by LASSO-penalized regression to account for correlations within the phenome. Then, we explored the conditions associated with bipolar disorder polygenic risk score (BD-PRS) using a PRS-based PheWAS with a sequential exclusion approach to account for the possibility that diagnosis, instead of genetic risk, may drive such associations. 53,386 participants (58.7% women) with a mean age at analysis of 67.8 years (SD = 15.6) were included. A bipolar disorder diagnosis (n = 1479) was associated with higher rates of psychiatric conditions, injuries and poisonings, endocrine/metabolic and neurological conditions, viral hepatitis C, and asthma. BD-PRS was associated with psychiatric comorbidities but, in contrast, had no positive associations with general medical conditions. While our findings warrant confirmation with longitudinal-prospective studies, the limited associations between bipolar disorder genetics and medical conditions suggest that shared environmental effects or environmental consequences of diagnosis may have a greater impact on the general medical comorbidity profile of individuals with bipolar disorder than its genetic risk.

Rash caused by lurasidone in old chinese patient with bipolar disorder: case-based review

BACKGROUND

Rash is one of common adverse drug reaction and which have been reported in typical and atypical antipsychotics. Reports of lurasidone induced skin reactions are sparse. In this study, we report a case of rash caused by lurasidone.

CASE PRESENTATION

A 63-year-old man with bipolar disorder (BD) who is treated by lurasidone. However, the patient presents a rash all over after lurasidone dose increasing from 40 mg/day to 60 mg/day. With the diagnosis of drug induced rash, lurasidone was discontinued, and the rash complete disappears within 2 weeks. In addition, all case reports about antipsychotics associated rash were reviewed by searching English and Chinese database including Pubmed, Embase, Cochrane Library, CNKI and Wanfang database. A total of 139 articles contained 172 patients were included in our study. The literature review and our case suggest that the cutaneous adverse events caused by antipsychotic drugs should not be ignored, particularly for the patient who was first use or at dose increasing of antipsychotic.

CONCLUSIONS

In conclusion, we report a case of lurasidone related rash and review rash caused by antipsychotics. Psychiatrists should be alert to the possibility of the rash caused by antipsychotics, especially the patient was first use of antipsychotics or the antipsychotic dose was increasing.

The clinical significance of emotional urgency in bipolar disorder: a scoping review

BACKGROUND

Emotional urgency, defined as a trait concept of emotion-based impulsivity, is at least moderately associated with general psychopathology. However, its clinical significance and associations with clinically relevant features of bipolar disorder remain unclear. This scoping review aims address this gap by determining the extent of evidence in this niche scope of study.

METHODS

Evidence of between-group differences of positive and negative urgency, its associations with mood severity, and all peripheral associations related to illness and psychosocial outcomes were synthesized based on PRISMA checklists and guidelines for scoping reviews (PRISMA-ScR).

DESIGN

Electronic databases were searched for articles published between January 2001 and January 2024. A total of 1013 entries were gathered, and a total of 10 articles were included in the final selection after the removal of duplicates and ineligible articles.

RESULTS

Differences in urgency scores between bipolar disorder and healthy controls were large (Cohen's d ranged from 1.77 to 2.20). Negative urgency was at least moderately associated with overall trauma, emotional abuse, neglect, suicide ideation, neuroticism, and irritable/cyclothymic temperament, whereas positive urgency was at least moderately associated with various aspects of aggression and quality of life. Positive but not negative urgency was associated with quality of life in bipolar disorder.

CONCLUSION

Large between-group differences found for emotional urgency in bipolar disorder imply large clinical significance. Emotional urgency was associated with worse clinical features and outcomes. Given the high clinical heterogeneity of the disorder, emotional urgency may be an important phenotype indicative of greater disorder severity.

Risk of periodontitis in adolescents with bipolar disorder: a cohort study of 21,255 subjects

Although a growing number of studies have investigated the relationship between psychosocial factors and periodontitis, studies investigating the association between bipolar disorder (BD) and periodontitis are lacking. Using the Taiwan National Health Insurance Research Database, 4251 adolescents with BD and 17,004 age- and sex-matched controls were included. They were followed up from enrollment to the end of 2011 or death. Periodontitis was diagnosed during the follow-up. Cox regression analysis indicated that adolescents with BD had a higher risk of periodontitis (hazard ratio [HR]: 2.96, 95% confidence interval [CI] 2.77-3.17) than did controls. Subanalyses stratified by sex revealed a higher risk of periodontitis in male (HR: 2.83, 95% CI 2.56-3.14) and female (HR: 3.01, 95% CI 2.74-3.30) adolescents with BD than their respective controls. The long-term use of mood stabilizers was associated with a higher risk of periodontitis (HR: 1.19, 95% CI 1.06-1.35) in the BD cohort. Our study highlighted an increased risk of periodontitis in adolescents with BD compared with controls during the follow-up. We recommend that more attention should be paid to the prevention of periodontitis in adolescents with BD, especially those who are female or receiving mood stabilizers.

Cluster analysis exploring the impact of childhood neglect on cognitive function in patients with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is a severe mental disorder related to neurocognitive deficits. Exposure to childhood trauma is associated with worse cognitive performance. Different compositions of childhood trauma in BD and their impacts on cognition are rarely reported.

METHODS

We used the Brief Assessment of Cognition in Affective Disorders (BAC-A) to assess cognitive performance and the Chinese version of the Short Form of the Childhood Trauma Questionnaire (C-CTQ-SF) to assess childhood trauma experience among 55 euthymic BD patients. Cluster analysis was applied to dissect their childhood trauma experiences, which revealed three distinct clusters: a low trauma group, neglect-focus group, and multiple-trauma-experience group. We compared the cognitive function between the three clusters and used a generalized linear model to evaluate the impact of childhood neglect on cognitive domains.

RESULTS

The neglect-focus cluster showed prominent exposures to physical and emotional neglect (41.8%). BD patients in this cluster performed worse in BAC-A compared with patients in the multiple trauma cluster, especially in working memory and processing speed. The neglect-focus group revealed a significant negative effect on the composite score (ß = -0.904, p = 0.025) and working memory (ß = -1.150, p = 0.002) after adjusting sex, age, education year, BMI and total psychotropic defined daily dose.

CONCLUSIONS

Distinct patterns of childhood trauma experience are seen in BD patients and are related with different cognitive profiles. Early exposure of neglect-focus trauma was associated with the worst cognitive performance in current study. Further studies investigating the intensity of the neglect, as well as individual resilience and coping mechanisms in BD, are warranted.

Global burden of stroke attributable to high systolic blood pressure in 204 countries and territories, 1990-2019

Background

High systolic blood pressure (HSBP) is severely related to stroke, although the global burden of stroke associated with HSBP needs to be understood.

Materials and methods

Data derived from the Global Burden of Disease, Injuries, and Risk Factors Study were used to analyze deaths, disability-adjusted life years (DALYs), age-standardized rates of mortality (ASMR), age-standardized rates of DALY (ASDR), and estimated annual percentage change (EAPC).

Results

Globally, 52.57% of deaths and 55.54% of DALYs from stroke were attributable to HSBP in 2019, with higher levels in men; the ASMRs and ASDRs in 1990-2019 experienced a decline of 34.89% and 31.71%, respectively, with the highest ASMR- and ASDR-related EAPCs in women. The middle socio-demographic index (SDI) regions showed the most numbers of deaths and DALYs in 2019 and 1990, with a decline in ASMR and ASDR; East Asia shared over 33% of global deaths and DALYs; Central Asia shared the highest ASMR and ASDR; high-income Asia Pacific experienced the highest decline in the ASMR- and ASDR-related EAPCs. Central and Southeast Asia had the highest percentages for deaths and DALYs, respectively, with more ASMR in high-middle SDI; the SDI and human development index were negatively associated with ASMR/ASDR and ASMR/ASDR-related EAPCs in 2019.

Conclusion

Global deaths and DALYs of stroke attributable to HSBP but none of their age-standardized rates have been on the rise over the past three decades; its disease burden focused especially on men aged 70 years and older in East, Central, and Southeast Asia, and the middle to high SDI regions.

Differences in clinical presentation between newly diagnosed bipolar I and II disorders: A naturalistic study

AIM

This naturalistic clinical study aims to investigate differences between newly diagnosed patients with bipolar type I (BDI) and bipolar type II (BDII) disorders in socio-demographic and clinical characteristics, affective symptoms, cognition, functioning and comorbidity with personality disorders.

METHODS

The BD diagnosis and type were confirmed using the Schedules for Clinical Assessment in Neuropsychiatry. Affective symptoms were assessed with the Young Mania Rating Scale, the Hamilton Depression Rating Scale, the Major Depressive Index, and the Altman Self-Rating Mania Scale. Functional impairment was assessed with the Functional Assessment Short Test. Cognitive impairment was evaluated by the Screen for Cognitive Impairment in Psychiatry and the Cognitive Complaints in Bipolar Disorder Rating Assessment. Finally, comorbid personality disorders were assessed with the Standardized Assessment of Personality-Abbreviated Scale and structured interview Structured Clinical Interview for DSM-disorders.

RESULTS

383 newly diagnosed patients were included (BDI: n = 125; BDII: n = 258). Against expectations, we found no more depressive symptoms in BDII compared with BDI nor any differences in cognitive, childhood trauma or overall functional impairment. The only difference was lower occupational impairment in the BDII group.

LIMITATIONS

The self-reported measures of cognitive difficulties and childhood trauma involved potential bias (recall or other). Despite BD being newly diagnosed a diagnostic delay was observed.

CONCLUSION

Patients newly diagnosed with BDII and BDI had similar burdens of depressive symptoms and cognitive and overall functional impairment, however patients with BDI had lower occupational functioning. No statistically significant difference was found in prevalence of comorbid personality disorders between patients with BDI and BDII.

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.

Global, regional and national burdens of bipolar disorders in adolescents and young adults: a trend analysis from 1990 to 2019

Background

Bipolar disorder is identified as a cause of severe damage to the physical, psychological and social functioning of adolescents and young adults.

Aims

The aim of this study is to ascertain the trends in the burden of bipolar disorder among individuals aged 10-24 years at global, regional and national levels from 1990 to 2019.

Methods

The data analysed in this study were from the Global Burden of Diseases 2019. The numbers, rates per 100 000 population, average annual percentage changes (AAPCs) of incidence, prevalence and years lived with disability (YLDs) of bipolar disorder are reported at the global, regional and national levels among individuals aged 10-24 years. Global trends by age, sex and Social Development Index (SDI) were further analysed.

Results

Globally, the incidence of bipolar disorder among adolescents and young adults increased from 79.21 per 100 000 population (95% uncertainty interval (UI): 58.13 to 105.15) in 1990 to 84.97 per 100 000 population (95% UI: 61.73 to 113.46) in 2019, AAPC 0.24 (95% confidence interval (CI): 0.22 to 0.26). In the past three decades, there has been an increase in incidence, prevalence and YLDs in both males and females. The largest increase in incidence between 1990 and 2019 was observed in those aged 20-24 years old (from 51.76 per 100 000 population (95% UI: 26.81 to 87.20) in 1990 to 58.37 per 100 000 population (95% UI: 30.39 to 98.55) in 2019; AAPC 0.42 (95% CI: 0.38 to 0.47)). By the SDI quintile, the largest increase in incidence was observed in the middle SDI; however, the high SDI countries had the highest incidence. Regionally, the largest increase in incidence was observed in southern Latin America. At the national level, the most pronounced increase in the incidence was in Greenland.

Conclusions

The global increase in incidence among adolescents and young adults between 1990 and 2019 indicates that strategies to improve their mental health still need to be emphasised.

Oxidation of DNA and RNA in young patients with newly diagnosed bipolar disorder and relatives

Excessive oxidative stress-generated nucleoside damage seems to play a key role in bipolar disorder (BD) and may present a trait phenomenon associated with familial risk and is one of the putative mechanisms explaining accelerated atherosclerosis and premature cardiovascular diseases (CVD) in younger patients with BD. However, oxidative stress-generated nucleoside damage has not been studied in young BD patients and their unaffected relatives (UR). Therefore, we compared oxidative stress-generated damage to DNA and RNA in young patients newly diagnosed with BD, UR, and healthy control individuals (HC). Systemic oxidative stress-generated DNA and RNA damage levels were compared by analyzing urinary levels of 8-oxo-7,8-dihydro-2'-deoxyguanosine and 8-oxo-7,8-dihydroguanosine in participants aged 15-25 years, including 133 patients newly diagnosed with BD, 57 UR, and 83 HC. Compared with HC, damage to DNA was 21.8% higher in BD patients (B = 1.218, 95% CI = 1.111-1.335, p = <0.001) and 22.5% higher in UR (B = 1.225, 95% CI = 1.090-1.377, p = <0.002), while damage to RNA was 14.8% higher in BD patients (B = 1.148, 95% CI = 1.082-1.219, p = <0.001) and 14.0% higher in UR (B = 1.140, 95% CI = 1.055-1.230, p = < 0.001) in models adjusted for sex and age after correction for multiple comparison. Levels did not differ between patients with BD and UR. Our findings support higher oxidative stress-generated nucleoside damage being a trait phenomenon in BD associated with familial risk and highlight the importance of early diagnosis and treatment to prevent illness progression and development of premature CVD.

Mapping the global, regional and national burden of bipolar disorder from 1990 to 2019: trend analysis on the Global Burden of Disease Study 2019

BACKGROUND

Data on trends in the epidemiological burden of bipolar disorder are scarce.

AIMS

To provide an overview of trends in bipolar disorder burden from 1990 to 2019.

METHOD

Revisiting the Global Burden of Disease Study 2019, we analysed the number of cases, calculated the age-standardised rate (per 100 000 population) and estimated annual percentage change (EAPC) of incidence, prevalence and years lived with disability (YLDs) for bipolar disorder from 1990 to 2019. The independent effects of age, period and cohort were estimated by the age-period-cohort modelling.

RESULTS

Globally, the bipolar disorder-related prevalent cases, incident cases and number of YLDs all increased from 1990 to 2019. Regionally, the World Health Organization Region of the Americas accounted for the highest estimated YLD number and rate, with the highest age-standardised prevalence rate in 1990 and 2019 and highest EAPC of prevalence. By sociodemographic index (SDI) quintiles, all five SDI regions saw an increase in estimated incident cases. Nationally, New Zealand reported the highest age-standardised rate of incidence, prevalence and YLDs in 1990 and 2019. The most prominent age effect on incidence rate was in those aged 15-19 years. Decreased effects of period on incidence, prevalence and YLD rates was observed overall and in females, not in males. The incidence, prevalence and YLD rates showed an unfavourable trend in the younger cohorts born after 1990, with males reporting a higher cohort risk than females.

CONCLUSIONS

From 1990 to 2019, the overall trend of bipolar disorder burden presents regional and national variations and differs by age, sex, period and cohort.

Beyond traditional metrics: A novel method for measuring mood instability in bipolar disorder

Background

Clinical care for bipolar disorder (BD) has a narrow focus on prevention and remission of episodes with pre/post treatment reductions in symptom severity as the 'gold standard' for outcomes in clinical trials and measurement-based care strategies. The study aim was to provide a novel method for measuring outcomes in BD that has clinical utility and can stratify individuals with BD based on mood instability.

Methods

Participants were 603 with a BD (n=385), other or non-affective disorder (n=71), or no psychiatric history (n=147) enrolled in an intensive longitudinal cohort for at least 10 years that collects patient reported outcomes measures (PROMs) assessing depression, (hypo)mania, anxiety, and functioning every two months. Mood instability was calculated as the within-person variance of PROMs and stratified into low, moderate, and high thresholds, respectively.

Outcomes

Individuals with BD had significantly higher mood instability index's for depression, (hypo)mania, and anxiety compared to psychiatric comparisons (moderate effects, p's<.001) and healthy controls (large effects, p's<.001). A significantly greater proportion of individuals with BD fell into the moderate (depression: 52·8%; anxiety: 51·4%; (hypo)mania: 48·3%) and high instability thresholds (depression: 11·5%; anxiety: 9·1%; (hypo)mania: 10·8%) compared to psychiatric comparisons (moderate: 25·5 - 26·6%; high: 0% - 4·7%) and healthy controls (moderate: 2·9% - 17·1%; high: 0% - 1·4%). Being in the high or moderate instability threshold predicted worse health functioning (p's < .00, small to large effects).

Interpretation

Mood instability, as measured in commonly used PROMs, characterized the course of illness over time, correlated with functional outcomes, and significantly differentiated those with BD from healthy controls and psychiatric comparisons. Results suggest a paradigm shift in monitoring outcomes in BD, by measuring mood instability as a primary outcome index.

Global, regional, and national burden and quality of care index (QCI) of bipolar disorder: A systematic analysis of the Global Burden of Disease Study 1990 to 2019

BACKGROUND

Bipolar disorders (BD) are significant debilitating mental problems. Here, we introduced a novel index as a representative of the quality of care delivered to BD patients worldwide.

METHODS

The Global Burden of Disease (GBD) 2019 study was the primary data source on BD, including prevalence, incidence, and years lived with disability (YLDs). Secondary indices were created and transformed into a single component that accounted for most of the variation, using the Principal Component Analysis (PCA) method. This component, reported on a scale of 0 to 100, was presented as the quality of care index (QCI). The QCI was estimated in different age groups and areas within a 30-year time frame. Gender disparity ratio (GDR), as the female-to-male ratio of the QCI, was reported.

RESULTS

The Global QCI slightly increased from 50.4 in 1990 to 53.1 in 2019. The GDR value was 0.95 in 2019. The high-middle SDI quintile had the highest QCI estimate of 63.0, and the lowest QCI value of 36.9 was regarding the low SDI quintile. Western-Pacific Region and South-East Asia had the highest and lowest QCI among WHO regions, with estimates of 70.7 and 31.2, respectively. The age group of 20 to 24 years old patients reported the lowest QCI estimate of 30.2, and the highest QCI of 59.8 was regarding 40 to 44 years old patients.

CONCLUSION

The QCI in BD had only a subtle increase from 1990 to 2019 and is in need of further improvement. Inequalities between different regions and age groups are considerable and require proper attention.

Bipolar Disorder

This review focuses on recent advances made towards understanding the neurobiology of bipolar disorder (BD), a chronic neuropsychiatric illness characterized by altered mood and energy states. The past few years have seen the completion of the largest genetic studies by far, which have emphasized the polygenic nature of BD as well as it's connection to other psychiatric illnesses. Furthermore, the use of inducible pluripotent stem cells has rapidly expanded. These studies support previous work that implicates dysregulation of neurodevelopment, mitochondria, and calcium homeostasis, while also allowing for investigation into the underlying mechanisms of individual responsivity to lithium. Sleep and circadian rhythms have also been heavily implicated in BD, from disruptions in activity patterns to molecular abnormalities.

Trends in deaths and disability-adjusted life-years of stroke attributable to low physical activity worldwide, 1990-2019

BACKGROUND

Low physical activity (LPA) is linked to the risk of stroke, but the disease burden of stroke attributable to LPA needs to be understood to develop effective preventive strategies. We aim to assess spatiotemporal trends in the global burden of stroke attributable to LPA from 1990 to 2019.

METHODS

Based on the Global Burden of Disease, Injuries, and Risk Factors Study, our research examined deaths, the Disability-Adjusted Life Years (DALYs), the Age-Standardized Mortality Rate (ASMR), the Age-Standardized DALY Rate (ASDR), and the Estimated Annual Percentage Change (EAPC) for stroke attributable to LPA.

RESULTS

Deaths and DALYs were on the rise worldwide from 1990 to 2019, with increases of 72.72% for the former and 67.41% for the latter; ASMR and ASDR decreased, with the ASMR-related EAPC of -1.61 (95% CI:-1.71--1.5) and ASDR-related EAPC of -1.35 (95% CI:-1.43--1.27); females had more numbers of deaths and DALYs, and the majorities of deaths and DALYs were shared by those aged ≥ 70. The highest burden rates were shared by North Africa, the Middle East, and Tropical Latin America; the ASMR-related EAPC was associated with the ASMR in 1990 (R = -0.26, P < 0.001) and the Socio-Demographic Index (SDI) across different countries in 2019 (R = -0.61, P < 0.001), respectively, and such patterns were similar to what ASDR and the ASDR-related EAPC had; the Human Development Index (HDI) in 2019 was associated with the ASMR-related EAPC (R = 0.63, P < 0.001) and the ASDR-related EAPC across different countries (R = -0.62, P < 0.001), respectively.

CONCLUSIONS

Globally, deaths and DALYs of stroke attributable to LPA were on the rise, although their age-standardized rates presented downward over the past three decades; the burden of stroke attributable to LPA showed upward trends especially in those aged ≥ 70 and females in the regions of East Asia, North Africa, and the Middle East, which need more attention to the effects of physical activity on health interventions.

Examining Factors Associated With Medication Adherence in Youth With Bipolar Disorder

Objective

To assess medication adherence and factors associated with poor adherence in youth with bipolar disorder (BD) followed from adolescence through young adulthood.

Method

Participants with BD recruited through the Course and Outcome of Bipolar Youth (COBY) study were included in this study if they were prescribed psychotropic medications and had at least 3 follow-up assessments of medication adherence (N= 179, ages 12-36). Medication adherence had been evaluated for a median of 8 years using a questionnaire derived from the Coronary Artery Risk Development in Young Adults (CARDIA) study. For the longitudinal evaluation, adherence was measured as the percentage of follow-up assessments in which the participants did not endorse any of the nonadherence items included in the questionnaire. Concurrent and future predictors of poor adherence were assessed using both univariate and multivariate longitudinal analyses.

Results

Among the participants, 51% reported poor adherence in more than 50% of their follow-up assessments. Younger age, family conflicts, polypharmacy, lower functioning, greater severity of mood symptoms, and comorbid disorders were associated with poor adherence in the univariate analyses. In the multivariate analyses, comorbid ADHD was the single most influential factor associated with concurrent and future poor adherence in all age groups. Participants' most reported reasons for poor adherence were forgetfulness (56%), negative attitudes toward medication treatment (10.5%), and disturbed daily routine (7%).

Conclusions

Poor medication adherence is a significant problem in youth with BD with the most influential factor being the presence of comorbid ADHD. Thus, it is important to identify and appropriately treat comorbid ADHD to improve medication adherence and patients' prognosis. Providers should also recommend tools to enhance consistent medication intake and address patients' concerns and negative beliefs about their illness and treatment.

Barriers to and facilitators of success for early and Mid-Career professionals focused on bipolar disorder: A global needs survey by the International Society for Bipolar Disorders

INTRODUCTION

The International Society for Bipolar Disorders created the Early Mid-Career Committee (EMCC) to support career development of the next generation of researchers and clinicians specializing in bipolar disorder (BD). To develop new infrastructure and initiatives, the EMCC completed a Needs Survey of the current limitations and gaps that restrict recruitment and retention of researchers and clinicians focused on BD.

METHODS

The EMCC Needs Survey was developed through an iterative process, relying on literature and content expertise of workgroup members. The survey included 8 domains: navigating transitional career stages, creating and fostering mentorship, research activities, raising academic profile, clinical-research balance, networking and collaboration, community engagement, work-life balance. The final survey was deployed from May to August 2022 and was available in English, Spanish, Portuguese, Italian, and Chinese.

RESULTS

Three hundred participants across six continents completed the Needs Survey. Half of the participants self-identified as belonging to an underrepresented group in health-related sciences (i.e., from certain gender, racial, ethnic, cultural, or disadvantaged backgrounds including individuals with disabilities). Quantitative results and qualitative content analysis revealed key barriers to pursuing a research career focused on BD with unique challenges specific to scientific writing and grant funding. Participants highlighted mentorship as a key facilitator of success in research and clinical work.

CONCLUSION

The results of the Needs Survey are a call to action to support early- and midcareer professionals pursuing a career in BD. Interventions required to address the identified barriers will take coordination, creativity, and resources to develop, implement, and encourage uptake but will have long-lasting benefits for research, clinical practice, and ultimately those affected by BD.

Metabolic regulation to treat bipolar depression: mechanisms and targeting by trimetazidine

Bipolar disorder's core feature is the pathological disturbances in mood, often accompanied by disrupted thinking and behavior. Its complex and heterogeneous etiology implies that a range of inherited and environmental factors are involved. This heterogeneity and poorly understood neurobiology pose significant challenges to existing drug development paradigms, resulting in scarce treatment options, especially for bipolar depression. Therefore, novel approaches are needed to discover new treatment options. In this review, we first highlight the main molecular mechanisms known to be associated with bipolar depression-mitochondrial dysfunction, inflammation and oxidative stress. We then examine the available literature for the effects of trimetazidine in said alterations. Trimetazidine was identified without a priori hypothesis using a gene-expression signature for the effects of a combination of drugs used to treat bipolar disorder and screening a library of off-patent drugs in cultured human neuronal-like cells. Trimetazidine is used to treat angina pectoris for its cytoprotective and metabolic effects (improved glucose utilization for energy production). The preclinical and clinical literature strongly support trimetazidine's potential to treat bipolar depression, having anti-inflammatory and antioxidant properties while normalizing mitochondrial function only when it is compromised. Further, trimetazidine's demonstrated safety and tolerability provide a strong rationale for clinical trials to test its efficacy to treat bipolar depression that could fast-track its repurposing to address such an unmet need as bipolar depression.

Trends in deaths and disability-adjusted life-years of stroke attributable to high body-mass index worldwide, 1990-2019

Background

High body mass index (HBMI) is an independent risk factor for stroke. Previous studies on the incremental burden of the rapid growth of stroke attributable to HBMI are incomplete and lag behind. We aim to assess the global burden of stroke attributable to HBMI based on a public database online.

Materials and methods

Study data were taken from the Global Burden of Disease, Injuries, and Risk Factors Study; deaths, the Disability-Adjusted Life-Years (DALYs), and their age-standardized rates were screened. The join point regression was used, wherein age-standardized rates were referred to as temporal trends in disease burden.

Results

Deaths from stroke attributable to HBMI worldwide were on the rise during 1990-2019, with an increase of 88.75%. Age-standardized DALYs were on the rise during 1990-2003 but declined during 2003-2013, with a turning point in 2013 and an increasing trend since then [the Annual Percentage Change (APC) = 0.30%, p < 0.05]. China, India, Indonesia, the Russian Federation, and the United States of America shared in sequence the rate of leading deaths and DALYs in 2019. The Socio-Demographic Index (SDI) was associated with an increasing trend in age-standardized deaths (R = -0.24, p < 0.001) and age-standardized DALYs (R = -0.22, p = 0.0018).

Conclusion

A range of indicators for the global burden of stroke attributable to HBMI have been on the rise for the past three decades. Tremendous efforts worldwide should be in place to control and treat stroke attributable to HBMI, especially in regions with high-middle and middle SDIs and among middle-aged and aged populations.

The quality of mental health care for people with bipolar disorders in the Italian mental health system: the QUADIM project

BACKGROUND

The assessment of the quality of care pathways delivered to people with severe mental disorders in a community-based system remains uncommon, especially using healthcare utilization databases. The aim of the study was to evaluate the quality of care provided to people with bipolar disorders taken-in-care by mental health services of four Italian areas (Lombardy, Emilia-Romagna, Lazio, province of Palermo).

METHODS

Thirty-six quality indicators were implemented to assess quality of mental health care for patients with bipolar disorders, according to three dimensions (accessibility and appropriateness, continuity, and safety). Data were retrieved from healthcare utilization (HCU) databases, which contain data on mental health treatments, hospital admissions, outpatient interventions, laboratory tests and drug prescriptions.

RESULTS

29,242 prevalent and 752 incident cases taken-in-care by regional mental health services with a diagnosis of bipolar disorder in 2015 were identified. Age-standardized treated prevalence rate was 16.2 (per 10,000 adult residents) and treated incidence rate 1.3. In the year of evaluation, 97% of prevalent cases had ≥ 1 outpatient/day-care contacts and 88% had ≥ 1 psychiatric visits. The median of outpatient/day-care contacts was 9.3 interventions per-year. Psychoeducation was provided to 3.5% of patients and psychotherapy to 11.5%, with low intensity. 63% prevalent cases were treated with antipsychotics, 71.5% with mood stabilizers, 46.6% with antidepressants. Appropriate laboratory tests were conducted in less than one-third of prevalent patients with a prescription of antipsychotics; three quarters of those with a prescription of lithium. Lower proportions were observed for incident patients. In prevalent patients, the Standardized Mortality Ratio was 1.35 (95% CI: 1.26-1.44): 1.18 (1.07-1.29) in females, 1.60 (1.45-1.77) in males. Heterogeneity across areas was considerable in both cohorts.

CONCLUSIONS

We found a meaningful treatment gap in bipolar disorders in Italian mental health services, suggesting that the fact they are entirely community-based does not assure sufficient coverage by itself. Continuity of contacts was sufficient, but intensity of care was low, suggesting the risk of suboptimal treatment and low effectiveness. Care pathways were monitored and evaluated using administrative healthcare databases, adding evidence that such data may contribute to assess the quality of clinical pathways in mental health.

Machine Learning Prediction of Estimated Risk for Bipolar Disorders Using Hippocampal Subfield and Amygdala Nuclei Volumes

The pathophysiology of bipolar disorder (BD) remains mostly unclear. Yet, a valid biomarker is necessary to improve upon the early detection of this serious disorder. Patients with manifest BD display reduced volumes of the hippocampal subfields and amygdala nuclei. In this pre-registered analysis, we used structural MRI (n = 271, 7 sites) to compare volumes of hippocampus, amygdala and their subfields/nuclei between help-seeking subjects divided into risk groups for BD as estimated by BPSS-P, BARS and EPIbipolar. We performed between-group comparisons using linear mixed effects models for all three risk assessment tools. Additionally, we aimed to differentiate the risk groups using a linear support vector machine. We found no significant volume differences between the risk groups for all limbic structures during the main analysis. However, the SVM could still classify subjects at risk according to BPSS-P criteria with a balanced accuracy of 66.90% (95% CI 59.2-74.6) for 10-fold cross-validation and 61.9% (95% CI 52.0-71.9) for leave-one-site-out. Structural alterations of the hippocampus and amygdala may not be as pronounced in young people at risk; nonetheless, machine learning can predict the estimated risk for BD above chance. This suggests that neural changes may not merely be a consequence of BD and may have prognostic clinical value.

The maladaptive domains according to the alternative model of personality disorders (AMPD) criterion B in patients with affective disorders and temperamental triads related to these domains: two unique profiles

OBJECTIVES

The study aimed to (i) compare the maladaptive domains and facets according to the Alternative Model of Personality Disorders (AMPD) Criterion B in patients with a type II bipolar disorder (BD-II) or major depressive disorder (MDD) with healthy controls (HCs), and (ii) investigating the relationship between affective temperaments and these domains and facets in the total sample.

METHODS

Outpatients diagnosed with current BD-II (n = 37; female 62.2%) or MDD (n = 17; female 82.4%) based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria and community HCs (n = 177; female 62.1%) in Kermanshah from July to October 2020 included this case-control study. All participants completed the Personality Inventory for DSM-5 (PID-5), the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A), and the second version of the Beck Depression Inventory (BDI-II). Data were analyzed using analysis of variance (ANOVA), Pearson correlation, and multiple regression.

RESULTS

The score of patients with BD-II in all five domains and those with MDD in three domains including negative affectivity, detachment, and disinhibition are significantly higher than the HCs (p < 0.05). Depressive temperament (related to negative affectivity, detachment, and disinhibition) and cyclothymic temperament (related to antagonism and psychoticism) were the most important correlates of the maladaptive domains.

CONCLUSIONS

Two unique profiles are proposed, including three domains of negative affectivity, detachment, and disinhibition associated with the depressive temperament for MDD, and two domains of antagonism and psychoticism related to cyclothymic temperament for BD-II.

Persistent increase over time in oxidatively stress generated RNA and DNA damage in patients with newly diagnosed bipolar disorder and their unaffected first-degree relatives - An up to 5-year prospective study

OBJECTIVES

Increased oxidative stress generated nucleoside damage seems to play a crucial role in bipolar disorder (BD) pathophysiology. It may contribute to accelerated ageing and reduced life expectancy in patients with BD.

METHODS

In the five-year prospective "Bipolar Illness Onset study", we investigated repeated measurements of oxidative stress generated RNA and DNA damage in 357 patients with newly diagnosed/first-episode BD (880 visits), 132 of their unaffected first-degree relatives (236 visits) and 198 healthy age- and sex-matched control persons with no personal or first-degree family history of affective disorder (432 visits). Amongst patients with BD, we further investigated associations of oxidative stress generated RNA- and DNA damage with affective phases and measures of illness load.

RESULTS

Patients newly diagnosed with BD and their unaffected relatives had higher levels of oxidative stress generated RNA damage than healthy control individuals and these differences persisted over time, whereas DNA damage was less consistently elevated. Neither illness load nor affective phase impacted the levels in patients with BD.

CONCLUSIONS

Our findings support elevated oxidative stress generated RNA damage being a trait phenomenon in BD as indicated by persistent increase in RNA damage over time in patients newly diagnosed with BD and in their unaffected first-degree relatives compared with healthy control individuals. We did not detect state alterations in levels of oxidative stress.

Prenatal and perinatal risk factors for bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Perinatal and prenatal risk factors may be implicated in the development of bipolar disorder, but literature lacks a comprehensive account of possible associations.

METHODS

We performed a systematic review and meta-analyses of observational studies detailing the association between prenatal and perinatal risk factors and bipolar disorder in adulthood by searching PubMed, Embase, Web of Science and Psycinfo for articles published in any language between January 1st, 1960 and September 20th, 2021. Meta-analyses were performed when risk factors were available in at least two studies.

FINDINGS

Twenty seven studies were included with 18 prenatal or perinatal factors reported across the literature. Peripartum asphyxia (k = 5, OR = 1.46 [1.02; 2.11]), maternal stress during pregnancy (k = 2, OR = 12.00 [3.30; 43.59]), obstetric complications (k = 6, OR = 1.41 [1.18; 1.69]), and birth weight less than 2500 g (k = 5, OR = 1.28 [1.04; 1.56]) were associated with an increased risk for bipolar disorder.

INTERPRETATION

Perinatal and prenatal risk factors are implicated in the pathogenesis of bipolar disorder, supporting a role of prenatal care in preventing the condition.

The impact of pharmacological and non-pharmacological interventions on physical health outcomes in people with mood disorders across the lifespan: An umbrella review of the evidence from randomised controlled trials

OBJECTIVE

People with mood disorders have increased risk of comorbid medical diseases versus the general population. It is paramount to identify interventions to improve physical health in this population.

METHODS

Umbrella review of meta-analyses of randomised controlled trials (RCTs) on pharmacological/non-pharmacological interventions for physical health outcomes/intolerability-related discontinuation in mood disorders (any age).

RESULTS

Ninety-seven meta-analyses were included. Among youths, against placebo, in depression, antidepressants/antipsychotics had higher discontinuation rates; in bipolar depression, olanzapine+fluoxetine worsened total cholesterol (TC)/triglycerides/weight gain (WG) (large ES). In adults with bipolar disorder, olanzapine worsened HbA1c/TC/WG (moderate/large ES); asenapine increased fasting glucose (small ES); quetiapine/cariprazine/risperidone induced WG (small/moderate ES). In bipolar depression, lurasidone was metabolically neutral. In depression, psychological interventions improved physical health-related quality of life (PHQoL) (small ES), fasting glucose/HbA1c (medium/large ES); SSRIs improved fasting glucose/HbA1c, readmission for coronary disease, pain (small ES); quetiapine/aripiprazole/olanzapine induced WG (small to large ES). Exercise improved cardiorespiratory fitness (moderate ES). In the elderly, fluoxetine yielded more detrimental cardiovascular effects than sertraline/escitalopram (large ES); antidepressants were neutral on exercise tolerance and PHQoL. In mixed age groups, in bipolar disorder aripiprazole was metabolically neutral; in depression, SSRIs lowered blood pressure versus placebo and serotonin-noradrenaline reuptake inhibitors (small ES); brexpiprazole augmentation caused WG and was less tolerated (small ES); exercise improved PHQoL (moderate ES).

CONCLUSIONS

Some interventions (psychological therapies, exercise and SSRIs) improve certain physical health outcomes in mood disorders, few are neutral, but various pharmacological interventions are associated with negative effects. Evidence from this umbrella review has limitations, should consider evidence from other disorders and should be integrated with recent evidence from individual RCTs, and observational evidence. Effective treatments with either beneficial or physically neutral profiles should be prioritized.

Familial load of psychiatric disorders and overall functioning in patients newly diagnosed with bipolar disorder and their unaffected first-degree relatives

BACKGROUND

Overall functioning is already impaired in patients newly diagnosed with bipolar disorder (BD) and, to a lesser degree, also in their unaffected first-degree relatives (UR). Further, aggregation of psychiatric disorders among the patients' first-degree relatives seems to be associated with higher illness burden and poorer prognosis. However, whether this aggregation of psychiatric disorders among first-degree relatives, the familial load (FL), impacts overall functioning in patients newly diagnosed with BD and their UR remains unresolved.

METHODS

In total, 388 patients newly diagnosed with BD, 144 of their UR and 201 healthy control individuals were included. Overall functioning was assessed using three different assessment methods: The interviewer based "Functioning Assessment Short Test" (FAST), the questionnaire "Work and Social Adjustment Scale" (WSAS) and six outcome measures covering the participants' socio-economic status (SES); educational achievement, employment, work ability, relationship, cohabitation and marital status. Familial load of psychiatric disorder was assessed using the "Family History Research Diagnostic Criteria" interview. Associations between FL and overall functioning in patients and UR were investigated categorically using logistic and continuously in linear regression models.

RESULTS

Contrasting with the hypotheses, the FL of psychiatric disorders was not associated with impaired overall functioning, neither in patients newly diagnosed with BD nor in their UR.

CONCLUSION

The findings indicate that impaired functioning in the early phase of BD is not associated with aggregation of psychiatric disorders among first-degree relatives. The observed functional impairment in patients newly diagnosed with BD seems driven by the personal impact of the disorder rather than the impact of having first-degree relatives with psychiatric disorders.

A Meta-Analysis of Group Cognitive Behavioral Therapy and Group Psychoeducation for Treating Symptoms and Preventing Relapse in People Living with Bipolar Disorder

Objectives: This meta-analysis aims to evaluate the treatment outcomes of patients treated with Group cognitive behavioural therapy (GCBT) or group psychoeducation (GPE) as an adjunct to pharmacotherapy. Methods: Systematic search of PubMed, EMBASE, PsycINFO, and CENTRAL from inception till 1 March 2022 was conducted. Randomized-controlled-trials (RCTs) comparing GCBT/GPE with controls (treatment-as-usual/individualized therapy) in adults with bipolar disorder were eligible. The outcomes were relapse rates of any depressive or manic episodes and control of depressive and manic symptoms post-intervention. Overall odds-ratio was used to evaluate the relapse rates. Standard Mean Differences were pooled using a random-effects model for the control of depressive and manic symptoms. Results: 25 articles were assessed full-text independently by two members, and 11 studies were included in this meta-analysis. 601 and 590 participants were randomized into group-therapy (GCBT/GPE) and control, respectively. GPE significantly reduces relapse rates at post-intervention with Odds ratio of 0.43 (95% CI = 0.28-to-0.62, p < 0.0001) (I² = 41%) compared to control, however, no significant results were found for GPE on control of depressive or manic symptoms. No significant results were found for GCBT in all outcomes. Conclusion: This meta-analysis provides some evidence that GPE could be an efficacious treatment as an adjunct to treatment-as-usual in reducing the relapse rates of patients with bipolar disorder.

Genetic Polymorphisms in miR-137 and Its Target Genes, TCF4 and CACNA1C, Contribute to the Risk of Bipolar Disorder: A Preliminary Case-Control Study and Bioinformatics Analysis

Accumulating evidence has suggested that miR-137 and its target genes, CACNA1C, and TCF4, are amongst the most robustly implicated genes in psychiatric disorders. This preliminary study is aimed at investigating the effects of genetic variations in miR-137 (rs1625579A/C), TCF4 (rs1261084C/T), and CACNA1C (rs10774053A/G and rs10466907G/T) on BD susceptibility. We recruited 252 BD patients and 213 healthy subjects as the control group. Genotyping was performed using PCR-RFLP and ARMS-PCR methods. Enhanced risk of BD was found under the codominant homozygous, dominant, and allelic models of TCF4 rs1261084C/T, codominant homozygous and allelic models of CACNA1C rs10466907G/T polymorphisms, as well as codominant homozygous, dominant, recessive, and allelic models of the CACNA1C rs10774053A/G. Moreover, both TT/AG/GT/AA and TT/GG/GT/AC genotype combinations strongly increased the risk of BD in the participants. The bioinformatics analyses revealed that rs1261084C/T and rs10466907G/T created and disrupted binding sites of some miRNAs in the 3'-untranslated region of TCF4 and CACNA1C genes. In contrast, the rs10774053A/G created a new binding site for a major splicing factor and might have an effective role in the function of the CACNA1C protein. We have found that all the studied SNPs are positively associated with BD susceptibility. Replicated studies on different ethnicities are required to confirm these findings.

Neuropsychiatric outcomes in offspring after fetal exposure to maternal influenza infection during pregnancy: A systematic review

Increasing evidence suggests that influenza infection in pregnancy may disrupt fetal neurodevelopment. The impact of maternal influenza infection on offspring neuropsychiatric health has not been comprehensively reviewed. We systematically reviewed comparative studies evaluating associations between maternal influenza infection and neuropsychiatric health outcomes in offspring. We searched MEDLINE, EMBASE, CINAHL, and Web of Science for articles published until January 7, 2022. Included were English studies evaluating neuropsychiatric outcomes in offspring aged > 6 months born to women with and without influenza during pregnancy, defined as clinical or laboratory-confirmed influenza illness, or being pregnant during pandemics/epidemics. Of 12,010 records screened, 42 studies were included. Heterogeneity in study design, exposures, and outcome definitions precluded meta-analyses. Four of 14 studies assessing schizophrenia reported adjusted ratio estimates from 0.5 to 8.2; most 95% CIs contained the null value; study quality was high in three of four. Two studies reported an increased risk of schizophrenia with influenza exposure any time during pregnancy (adjusted incidence rate ratio 8.2, 95% CI: 1.4-48.8; adjusted odds ratio 1.3, 95% CI: 1.2-1.5); another reported a reduced risk with first-trimester exposure (adjusted risk ratio 0.5, 95% CI: 0.3-0.9). Seven studies of autism spectrum disorder reported adjusted ratio estimates from 0.9 to 4.0; all 95% CIs included the null value; study quality was high in four. No conclusions could be drawn about the association between exposure to maternal influenza and neuropsychiatric outcomes due to the limited quantity and quality of available research. Large observational studies with long-term follow-up are required to investigate these associations.

Associations between oxidative stress markers and patient-reported smartphone-based symptoms in patients newly diagnosed with bipolar disorder: An exploratory study

Oxidative stress generated nucleoside damage seems to represent key pathophysiological mechanisms of bipolar disorder (BD). Likewise, mood and activity are core features of BD and can be reliably monitored using smartphone-based applications. The aim was to investigate whether oxidative stress generated nucleoside damage could reflect psychopathology in BD using easily available and non-invasive patient-reported smartphone-based symptoms. We included 223 patients newly diagnosed with BD and employed linear mixed-effect regression models to associate baseline measurements of 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG) and 8-oxo-7,8-dihydroguanosine (8-oxoGuo) levels with patient-reported smartphone measures of mood, activity, anxiety, stress and sleep duration monitored three days prior to and 30 days after the baseline visit in the longitudinal Bipolar Illness Onset Study. In patients newly diagnosed with BD higher 8-oxoGuo levels were inversely associated with the patient-reported activity level (B = 0.953, 95%CI = 0.909;0.99, p = 0.043) and positively associated with patient-reported anxiety (B = 1.104, 95%CI = 1.022;1.161, p=0.012), perceived stress (B = 1.092, 95%CI = 1.009;1.183, p = 0.014) and sleep duration (B = 1.000, 95%CI = 1.000;1.001, p = 0.001), respectively, in analyses, adjusted for sex and age. The associations between 8-oxoGuo levels and anxiety, perceived stress and sleep duration, respectively, withstood adjustment for sex, age, smoking, BMI and alcohol intake. No associations between 8-oxodG levels and patient-reported smartphone-based data were found and mood was not associated with 8-oxoGuo. Oxidative stress was associated with patient-reported smartphone-based data on activity, anxiety, stress and sleep duration pointing towards that oxidative stress generated nucleoside damage may reflect ongoing psychopathology in BD.

Socio-economic status and functioning in patients newly diagnosed with bipolar disorder and their unaffected siblings - Results from a cross-sectional clinical study

BACKGROUND

Few studies have reported socio-economic status and functioning in patients newly diagnosed with bipolar disorder (BD) and their unaffected siblings (US).

METHODS

Socio-economic status and functioning were compared in a cross-sectional clinical study including 382 patients newly diagnosed with BD, 129 of their US, and 200 healthy control individuals (HC).

RESULTS

Socio-economic status was lower in patients newly diagnosed with BD compared with HC within educational achievement, employment status, workability and relationship status (p < 0.001, OR between 0.02 and 0.53). Regarding US and HC, US had lower educational achievement (p < 0.001, OR = 0.27 [0.16; 0.46]), as the only affected socio-economic outcome. Functioning was substantially impaired according to the Functional Assessment Short Test (FAST) (p < 0.001, Cohen's d = 2.12) and Work and Social Adjustment Scale (WSAS) (p < 0.001, Cohen's d = 2.76) in patients newly diagnosed with BD compared with HC. US expressed the same pattern with impaired overall functioning. Within patients, the impaired functioning was associated with a longer illness duration.

LIMITATIONS

Patients had an illness duration of 10.5 [IQR: 6.1; 16.2] years, even though they were included shortly after a diagnosis of BD (0.3 [IQR: 0.1; 0.7] years), highlighting the obstacles of research in illness onset of BD.

CONCLUSIONS

Patients newly diagnosed with BD, and to a lesser degree their US, exhibit lower socio-economic status and impaired overall functioning. These findings emphasise the importance of early diagnosis, treatment and focus on functional recovery and stress that intervention strategies and further research in high-risk individuals are needed.

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.

Quality of life of family primary caregivers of individuals with bipolar disorder and schizophrenia in south of Brazil

BACKGROUND

The process of deinstitutionalization of individuals with mental disorders (MD) brought greater family responsibility in terms of patient care.

AIMS

Evaluate the Quality of Life (QoL) and its associated factors of primary caregivers of bipolar and schizophrenic subjects.

METHODS

A cross-sectional survey was conducted from 2012 to 2015 with 125 caregivers at an outpatient service of a teaching hospital in the South of Brazil. QoL instruments (WHOQOL-Bref, SF-36), questionnaires regarding socio-demographic, clinical data and depressive symptoms (BDI) were applied.

RESULTS

Caregivers of schizophrenic individuals presented lower QoL scores than caregivers of bipolar individuals, with moderate effect in physical, and social domains of WHOQOL-Bref, and in physical functioning, role-physical, and role-emotional domains of SF-36. QoL scores of caregivers were lower when compared with the normative data of the Brazilian population. The factors associated with lower QoL scores were: patient diagnosis of schizophrenia, female gender, presence of clinical disease and presence of depressive symptoms in the caregiver.

CONCLUSIONS

Caregivers of patients with schizophrenia or bipolar disorder present a significant impairment in their QoL when compared with the general population, highlighting the relevance of developing support programs in the mental health services that include these caregivers.

Existing and emerging pharmacological approaches to the treatment of mania: A critical overview

Manic episodes are a defining, frequent and dramatically disabling occurrence in the course of Bipolar Disorder type I. Current pharmacotherapy of mania lists a good number of agents, but differences in efficacy and safety profiles among these agents must be considered in order to tailor personalized therapies, especially when the long-term course of the illness is considered. There is wide room and need to ameliorate current pharmacological approaches to mania, but ongoing pharmacological research on the topic is scant. In this work we try to critically assess clinical factors and patients' characteristics that may influence the treatment choice for manic episodes. In addition, we conduct a narrative review on experimental pharmacology of bipolar mania and psychotic disorders, presenting a critical overview on agents which could represent treatment alternatives for a manic episode in the next future. Results show limited novel or ongoing research on agents acting as mood stabilizers (Ebselen, Valnoctamide and Eslicarbazepine did not reach statistical significance in demonstrating antimanic efficacy). As for the emerging experimental antipsychotic, some of them (including KarXT, SEP-363856, RO6889450, ALKS3831) have demonstrated good antipsychotic efficacy and a favorable safety profile, but little is known about their use in patients with bipolar disorder and specifically designed trials are needed. Lastly, some benefits for the treatment of mania could be expected to come in the next future from non-mood stabilizers/non-antipsychotic agents (especially PKC inhibitors like Endoxifen): long-term trials are needed to confirm positive results in terms of long-term efficacy and safety.

Trends in Prevalence Cases and Disability-Adjusted Life-Years of Parkinson's disease: Findings from the Global Burden of Disease Study 2019

BACKGROUND

Parkinson's disease is a common, age-related progressive neurodegenerative disorder with considerable socioeconomic burdens, although the studies in incremental burdens to the disease' rapid growth are incomplete and lag behind. We aim to assess global burdens of Parkinson's disease based on a public database online.

METHODS

Based on the Global Burden of Disease, Injuries, and Risk Factors Study, we screened a range of indicators including prevalence cases, disability-adjusted life-years (DALY), age-standardized prevalence rates (ASPR) and age-standardized DALY (ASDR). The Join point regression was used to assess the indicators, wherein the ASPR and the ASDR were referred to temporal trends for burdens of Parkinson's disease.

RESULTS

Prevalence cases of global Parkinson's disease were on the rise for 30 years, with an increase of 155.51% during 1990-2019. Temporal trend of ASDRs was on the rise during 1990-2002 but in decline during 2002-2019. The ASPRs had a turning point in 2017 and a decline during 2017-2019 (APC (annual percentage changes) =-0.51%, P > 0.05). China, India, the United States, Japan and Germany shared the five highest prevalence cases and DALYs in 2019. Socio-demographic Index (SDI) was in relation to a significantly positive ASPR (R=0.61, P < 0.001) but not a significantly negative ASDR (R=-0.044, P=0.53), respectively.

CONCLUSIONS

In this study, a range of indicators for global burdens of Parkinson's disease were on the rise during 1990-2019. Tremendous efforts should be in place to prevent Parkinson's disease, especially among the populations of males, with advanced ages, in East Asia, and in regions with high SDI.

Machine learning approaches for prediction of bipolar disorder based on biological, clinical and neuropsychological markers: a systematic review and meta-analysis

Applying machine learning (ML) to objective markers may overcome prognosis uncertainty due to the subjective nature of the diagnosis of bipolar disorder (BD). This PRISMA-compliant meta-analysis provides new systematic evidence of the BD classification accuracy reached by different markers and ML algorithms. We focused on neuroimaging, electrophysiological techniques, peripheral biomarkers, genetic data, neuropsychological or clinical measures, and multimodal approaches. PubMed, Embase and Scopus were searched through 3^rd December 2020. Meta-analyses were performed using random-effect models. Overall, 81 studies were included in this systematic review and 65 in the meta-analysis (11,336 participants, 3,903 BD). The overall pooled classification accuracy was 0.77 (95%CI[0.75;0.80]). Despite subgroup analyses for diagnostic comparison group, psychiatric disorders, marker, ML algorithm, and validation procedure were not significant, linear discriminant analysis significantly outperformed support vector machine for peripheral biomarkers (p=0.03). Sample size was inversely related to accuracy. Evidence of publication bias was detected. Ultimately, although ML reached a high accuracy in differentiating BD from other psychiatric disorders, best practices in methodology are needed for the advancement of future studies.

Trends in the incidence and DALYs of anxiety disorders at the global, regional, and national levels: Estimates from the Global Burden of Disease Study 2019

BACKGROUND

Anxiety disorders are the second leading mental health-related cause of disability-adjusted life-years (DALYs) and years lived with disability (YLDs) worldwide. This study aimed to quantitatively assess the burden of anxiety disorders at the global, regional, and national levels in 1990 and 2019 and the trends over this period.

METHODS

We used data for incidence cases, DALYs, age-standardized incidence rate (ASIR) and age-standardized DALYs rate (ASDR) from Global Burden of Disease Study 2019 (GBD 2019) and calculated the estimated annual percentage changes (EAPCs) to assess the incidence rate and DALYs rate trends for anxiety disorders.

RESULTS

The incidence cases of anxiety disorders increased by 47.19%, from 31.13 million in 1990 to 45.82 million in 2019, and DALYs increased by 53.70%, from 18.66 million in 1990 to 28.68 million in 2019. Over the past 29 years, the changes of ASIR and ASDR worldwide were stable (EAPC = 0.011 and -0.001, respectively). Women were more likely to experience anxiety disorders. Participants aged 10-14 had the highest incidence rate, followed by those aged 35-44. Those aged 15-19 and 40-44 had the highest estimated DALYs rate. The ASIR and ASDR were estimated to be the highest in Iran and Portugal, and Portugal and Brazil, respectively. Both of ASIR and ASDR were high in high- sociodemographic index regions in 2019.

LIMITATIONS

Further exploration of related risk factors needs to be analyzed in the future studies.

CONCLUSIONS

Compared with 1990, the absolute increase in incidence cases and DALYs of anxiety disorders in 2019 still remained high. Our findings contribute to the formulation of health policies for controlling and preventing anxiety disorders in different countries and regions.

Association between abnormal glycolipid level and cognitive dysfunction in drug-naïve patients with bipolar disorder

OBJECTIVES

Cognitive impairment and abnormal glycolipid metabolism are common clinical features of bipolar disorder (BD). The purpose of this study was to investigate the relationship between conventional glycolipid metabolism indicators and cognitive impairment in patients with BD.

METHODS

A total of 132 drug-naïve patients with BD and 129 healthy controls (HC) were recruited in the study. Five serum glycolipid metabolism indicators were measured and cognitive function was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and the Stroop Color-Word Test (Stroop test) for each participant.

RESULTS

The scores of immediate memory, attention, language and delayed memory in BD group were significantly lower than those in HC group (P < 0.05). The triglyceride (TG) level in BD group was higher than that in HC group (P = 0.011), and the total cholesterol and high-density lipoprotein cholesterol (HDL) levels were lower than those in HC group (P = 0.026; P = 0.001). Regression analysis showed that TG level was significantly correlated with RBANS total score (β = 0.245, P = 0.008), attention (β = 0.289, P = 0.03) and delayed memory (β = 0.221, P = 0.023). Fasting blood glucose (FBG) level was significantly correlated with language subscale score (β = -0.187, P = 0.046) in BD.

LIMITATIONS

Cross-sectional design and limited control variables.

CONCLUSIONS

Elevated FBG and TG levels may be associated with cognitive dysfunction in BD patients. Improving glycolipid metabolism in patients with BD may help to improve certain domain-specific cognitive functions.

Prevalence and associated factors of obesity and overweight in Chinese patients with bipolar disorder

OBJECT

Despite abundant literature demonstrating a high prevalence of obesity and overweight in people with bipolar disorder (BD), little is known about this topic in China. Therefore, we assessed the prevalence and associated factors of obesity and overweight among inpatients with BD in our hospital, one of the largest public psychiatric hospitals in China.

METHODS

In this retrospective, cross-sectional study, 1,169 inpatients ≥18 years with BD during 2019 were included. Obesity was defined as having a BMI ≥25 kg/m², and overweight was defined as having a BMI from 23 kg/m² to <25 kg/m². Binary logistic regression analysis was performed to identify factors associated with obesity and overweight.

RESULTS

The prevalence of obesity and overweight was 21.0% and 32.2% in patients with BD, respectively. Compared to patients with overweight and normal weight, patients with obesity were older, had a longer duration of BD and a longer length of hospital stay, had a higher prevalence of diabetes and hypertension, and had a higher level of all metabolic indices, except for HDL cholesterol. Binary logistic regression analysis showed that duration of BD, uric acid, alanine aminotransferase (ALT), triglyceride, and LDL cholesterol were significantly associated with obesity, and male sex and uric acid level were significantly associated with overweight (p < 0.05).

CONCLUSIONS

Obesity and overweight were fairly prevalent in Chinese BD patients, and several factors were related to obesity and overweight. The results of the present study call for the need to implement early screening, prevention and interventions for obesity and overweight in patients with BD in China.

Associations between childhood maltreatment and oxidative nucleoside damage in affective disorders

Background

Childhood maltreatment is an established risk factor for incident unipolar disorder and bipolar disorder. It is separately observed that affective disorders (AD) are also associated with higher nucleoside damage by oxidation. Childhood maltreatment may induce higher levels of nucleoside damage by oxidation and thus contribute to the development of AD; however, this relation is only sparsely investigated.

Methods

In total, 860 participants (468 patients with AD, 151 unaffected first-degree relatives, and 241 healthy control persons) completed the Childhood Trauma Questionnaire (CTQ). The association between CTQ scores and markers of systemic DNA and RNA damage by oxidation as measured by urinary excretion of 8-oxo-7,8-dihydro-2′-deoxyguanosine (8-oxodG) and 8-oxo-7,8-dihydroguanosine (8-oxoGuo) levels, respectively, was investigated.

Results

In multiple regression models adjusted for sex- and age, 8-oxodG and 8-oxoGuo levels were found to be higher in individuals who had experienced more childhood maltreatment. These associations persisted in models additionally adjusted for body mass index, alcohol, and current smoking status. Emotional abuse, sexual abuse, and emotional neglect were principally responsible for the foregoing associations.

Conclusions

Our findings of an association between childhood maltreatment and oxidative stress markers suggest that childhood maltreatment overall, notably emotional abuse and emotional neglect, is associated with enhanced systemic damage to DNA and RNA in adulthood. Further, individuals with AD reported a higher prevalence of childhood maltreatment, which may induce higher levels of nucleoside damage by oxidation in adulthood, possibly leading to increased risk of developing AD. Longitudinal studies are needed to clarify this relationship further.

Cancer Risk in Patients With Bipolar Disorder and Unaffected Siblings of Such Patients: A Nationwide Population-Based Study

Increasing evidence suggests that patients with bipolar disorder are more likely to develop malignant cancer than is the general population. However, the overall cancer risk in the unaffected siblings of such patients remains unknown. From the National Health Insurance Research Database of Taiwan, 25,356 patients with bipolar disorder, 25,356 age-matched unaffected siblings of patients with bipolar disorder, and 101,422 age-matched controls without severe mental disorders between 1996 and 2010 were enrolled in this study. Patients who developed cancer between the time of enrollment and the end of 2011 were identified. Cancers were divided into 3 subgroups based on the related layer of embryonic development: ectodermal, mesodermal, and endodermal cancers. Patients with bipolar disorder (odds ratio [OR] = 1.22, 95% confidence interval [CI]: [1.06, 1.40]) and unaffected siblings of such patients (OR = 1.17, 95% CI [1.02, 1.34]) had greater risk of developing malignant cancer than did controls. Furthermore, only those aged <50 years, for both patients with bipolar disorder (OR = 1.90, 95% CI [1.38, 2.61]) and unaffected siblings (OR = 1.65, 95% CI [1.19, 2.28]), were more likely to develop the ectodermal cancer, especially breast cancer, than the control group. The associations of bipolar disorder and susceptibility to bipolar disorder with increased cancer risk in the younger population may imply a genetic overlap in neurodevelopment and malignancy pathogenesis. Our findings may encourage clinicians to monitor cancer risk factors and warning sings closely in patients with bipolar disorder and in unaffected siblings of such patients. This article is protected by copyright. All rights reserved.

Revisiting the bipolar disorder with migraine phenotype: Clinical features and comorbidity

INTRODUCTION

To evaluate the prevalence and clinical correlates of lifetime migraine among patients with bipolar disorder (BD).

METHODS

In a cross-sectional study, we evaluated 721 adults with BD from the Mayo Clinic Bipolar Disorder Biobank and compared clinical correlates of those with and without a lifetime history of migraine. A structured clinical interview (DSM-IV) and a clinician-assessed questionnaire were utilized to establish a BD diagnosis, lifetime history of migraine, and clinical correlates.

RESULTS

Two hundred and seven (29%) BD patients had a lifetime history of migraine. BD patients with migraine were younger and more likely to be female as compared to those without migraine (p values <0.01). In a multivariate logistic regression model, younger age (OR=0.98, p<0.01), female sex (OR=2.02, p<0.01), higher shape/weight concern (OR=1.04, p=0.02), greater anxiety disorder comorbidities (OR=1.24, p<0.01), and evening chronotype (OR=1.65, p=0.03) were associated with migraine. In separate regression models for each general medical comorbidity (controlled for age, sex, and site), migraines were significantly associated with fibromyalgia (OR=3.17, p<0.01), psoriasis (OR=2.65, p=0.03), and asthma (OR=2.0, p<0.01). Participants with migraine were receiving ADHD medication (OR=1.53, p=0.05) or compounds associated with weight loss (OR=1.53, p=0.02) at higher rates compared to those without migraine.

LIMITATIONS

Study design precludes determination of causality. Migraine subtypes and features were not assessed.

CONCLUSIONS

Migraine prevalence is high in BD and is associated with a more severe clinical burden that includes increased comorbidity with pain and inflammatory conditions. Further study of the BD-migraine phenotype may provide insight into common underlying neurobiological mechanisms.

Peripheral levels of C-reactive protein, tumor necrosis factor-α, interleukin-6, and interleukin-1β across the mood spectrum in bipolar disorder: A meta-analysis of mean differences and variability

IMPORTANCE

It is unclear whether differences exist in the magnitude and variability of pro-inflammatory mediators in the different phases of bipolar disorder (BD) and among subjects with BD, as compared to healthy controls.

OBJECTIVE

To run a comparative meta-analysis of C-Reactive Protein (CRP), IL-1, IL-6, TNF-α in BD vs healthy controls, measuring mean and variability effects on all subjects. Sensitivity analyses include disease activity.

DATA SOURCES

Systematic review of observational studies in PubMed and PsycInfo up to February 2nd, 2020.

STUDY SELECTION

Case-control studies reporting inflammatory mediators' levels in BD and controls.

DATA EXTRACTION AND SYNTHESIS

Summary distribution measures of circulating CRP, IL-1β, IL-6, TNF-α in participants with BD and control groups were extracted. Random-effects multivariate meta-analyses were conducted based on individual study/mediator effect sizes (Hedge's g).

MAIN OUTCOMES AND MEASURES

Co-primary outcomes were inflammatory mediators' levels (Hedge's g) and variability (coefficient of variance ratio (CVR)) differences between participants with BD across the mood spectrum and controls.

RESULTS

Out of the initial 729 papers, 72 were assessed and then excluded after full-text review, and ultimately 53 studies were included in the systematic review, while 49 were included in the meta-analysis. The mean age was 36.96 (SD: 9.29) years, and the mean female percentage was 56.31 (SD: 16.61). CRP (g = 0.70, 95% CI 0.31-1.09, k = 37, BD = 2,215 vs HC = 3,750), IL-6 (g = 0.81, 95% CI 0.46-1.16, k = 45, BD = 1,956 vs HC = 4,106), TNF-α (g = 0.49, 95% CI 0.19-0.78, k = 49, BD = 2,231 vs HC = 3,017) were elevated in subjects with BD vs HC, but not IL-1β (g = -0.28, 95% CI -0.68-0.12, k = 4, BD = 87 vs HC = 66). When considering euthymic, depressive, and manic episodes separately, CRP and TNF-α were elevated in both depressive and manic episodes, but not in euthymia, while IL-6 remained elevated regardless of the disease state. No difference in CVR emerged for CRP, IL-1β, and TNF-α, while a lower CVR was observed for IL-6. When considering disease phases, CVR was higher in BD than in HCs for CRP during depressive episodes, lower for IL-6 during euthymia, and higher during manic episodes for CRP, IL-6, and TNF-α. Sensitivity analyses after excluding outliers identified with funnel plot visual inspection, low-quality studies, and considering only studies matched per body mass index confirmed the main results. Meta-regression showed that age (IL-6, TNF-α), gender (CRP), duration of illness (CRP) moderated elevated individual inflammatory levels.

CONCLUSIONS AND RELEVANCE

Peripheral pro-inflammatory marker elevations were confirmed in BD. CRP and TNF-α could represent state markers, as they were only elevated during mood episodes, while IL-6 appeared to be a trait marker for BD. Increased variability of specific inflammatory mediators in specific disease active states suggests that a subset of subjects with BD may exhibit elevated inflammation as part of a manic or depressive episode.

Development of a psychological intervention for people with bipolar disorder in rural Ethiopia

Background

Evidence from high- and middle-income countries indicates that psychological interventions (PSIs) can improve the well-being of people with bipolar disorder. However, there is no evidence from low-income countries. Cultural and contextual adaptation is recommended to ensure that PSIs are feasible and acceptable when transferred to new settings, and to maximise effectiveness.

Aims

To develop a manualised PSI for people with bipolar disorder in rural Ethiopia.

Method

We used the Medical Research Council framework for the development and evaluation of complex interventions and integrated a participatory theory-of-change (ToC) approach. We conducted a mental health expert workshop (n = 12), four independent ToC workshops and a final workshop with all participants. The four independent ToC workshops comprised people with bipolar disorder and caregivers (n = 19), male community leaders (n = 8), female community leaders (n = 11) and primary care workers (n = 21).

Results

During the workshops, participants collaborated on the development of a ToC roadmap to achieve the shared goal of improved quality of life and reduced family burden for people with bipolar disorder. The developed PSI had five sessions: needs assessment and goal-setting; psychoeducation about bipolar disorder and its causes; treatment; promotion of well-being, including sleep hygiene and problem-solving techniques; and behavioural techniques to reduce anxiety and prevent relapse. Participants suggested that the intervention sessions be linked with patients’ monthly scheduled healthcare follow-ups, to reduce economic barriers to access.

Conclusions

We developed a contextually appropriate PSI for people with bipolar disorder in rural Ethiopia. This intervention will now be piloted for feasibility and acceptability before its wider implementation.