The genetics of bipolar disorder

Cardiovascular mortality in bipolar disorder: Population-based cohort study

BACKGROUND

Limited evidence base on cause-specific excess cardiovascular disease (CVD) mortality in bipolar disorder (BD) is a barrier to developing preventive interventions aimed at reducing the persistent mortality gap in BD.

OBJECTIVE

To investigate cause-specific CVD mortality in BD.

METHODS

We identified all individuals aged 15+ years during 2004-2018 with a diagnosis of BD using Finnish nationwide routine data. Standardised mortality ratios (SMR) with 95% confidence intervals (CI) were calculated using the mortality rates in the general population as weights.

RESULTS

53,273 individuals with BD (57% women; median age at BD diagnosis, 40 years), were followed up for 428,426 person-years (median, 8.2 years). There were 5988 deaths due to any cause, of which 26% were due to CVD. The leading cause of absolute excess CVD mortality was coronary artery disease (CAD). The leading causes of relative excess mortality were cardiomegaly (SMR, 4.51; 95% CI, 3.58-5.43), venous thromboembolism (3.03; 2.26-3.81), cardiomyopathy (2.46; 1.95-2.97), and hypertensive heart disease (2.12; 1.71-2.54). The leading causes of absolute CVD mortality showed markedly lower relative excess, including CAD (1.47; 1.34-1.61), ischaemic stroke (1.31; 1.06-1.54), and acute myocardial infarction (1.12; 0.98-1.25). Due to the higher relative excess mortality, structural and functional heart disorders contributed as much as atherosclerotic and ischaemic disorders to the absolute excess mortality.

CONCLUSIONS

Cardiomyopathy and hypertensive heart disease as the leading causes of relative excess mortality emphasise the contribution of structural and functional heart disorders to the overall excess mortality alongside coronary artery disease. Interventions targeted at these modifiable causes of death should be priorities in the prevention of premature excess CVD mortality in BD.

Polygenic risk scores for mood and related disorders and environmental factors: Interaction effects on wellbeing in the UK biobank

Mood disorders have a genetic and environmental component and interactions (GxE) on the risk of psychiatric diseases have been investigated. The same GxE interactions may affect wellbeing measures, which go beyond categorical diagnoses and reflect the health-disease continuum. We evaluated GxE effects in the UK Biobank, considering as outcomes subjective wellbeing (feeling good and functioning well) and objective measures (education and income). We estimated the polygenic risk scores (PRSs) of major depressive disorder, bipolar disorder, schizophrenia, and attention deficit hyperactivity disorder. Stressful/traumatic events during adulthood or childhood were considered as E variables, as well as social support. The addition of the PRSxE interaction to PRS and E variables was tested in linear or multinomial regression models, adjusting for confounders. We included 33 k-380 k participants, depending on the variables considered. Most PRSs and E factors showed additive effects on outcomes, with effect sizes generally 3-5 times larger for E variables than PRSs. We found some interaction effects, particularly when considering recent stress, history of a long illness/disability/infirmity, and social support. Higher PRSs increased the negative effects of stress on wellbeing, but they also increased the positive effects of social support, with interaction effects particularly for the outcomes health satisfaction, loneliness, and income (p < Bonferroni corrected threshold of 1.92e-4). PRSxE terms usually added ∼0.01-0.02% variance explained to the corresponding additive model. PRSxE effects on wellbeing involve both positive and negative E factors. Despite small variance explained at the population level, preventive/therapeutic interventions that modify E factors could be beneficial at the individual level.

Network analysis of comorbid aggressive behavior and testosterone among bipolar disorder patients: a cross-sectional study

Testosterone has complex effects on psychological traits and behavior; it is associated with social dominance and competition and is a potential human sex pheromone. This study aimed to investigate the associations between testosterone levels, aggressive behavior, and manic symptoms using a network analysis among bipolar disorder (BD) patients in psychiatric emergency departments (PED). Data from January 2021 and March 2022 BD patients in PED were analyzed. Manic symptoms were assessed using the Young Mania Rating Scale (YMRS). Aggression was assessed with subscale of the PANSS scale (PANSS-AG). The undirected network structures of testosterone levels, aggressive behavior, and manic symptoms were estimated, and centrality and bridge centrality indices were examined. Network stability was examined using the case-dropping procedure. The Network Comparison Test (NCT) was conducted to evaluate whether network characteristics differed by gender. We recruited a total of 898 BD patients, with the mean YMRS score as 13.30 ± 9.58. The prevalence of level II aggression was 35.6% (95%CI = 32.5%-38.7%), level III aggression was 29.5% (95%CI = 26.3%-32.6%), and level VI aggression was 7.0% (95%CI = 5.4%-8.8%). The male participants had a mean testosterone level of 391.71 (Standard Deviation (SD):223.39) compared to 36.90 (SD:30.50) for female participants in the whole sample. Through network analysis, "Increased motor activity-energy" emerged as the central symptom, with the highest centrality expected influence, followed by "Emotional Instability" and "Disruptive/aggression behavior". Notably, "Emotional Instability" appeared to be the bridge symptom linking manic symptoms to aggressive behavior. Within the flow network model, "Speech rate and amount" exhibited the strongest positive correlation with testosterone levels, followed closely by "Disruptive/aggression behavior". The constructed network model demonstrated robust stability, with gender showing no significant impact on the structure. In this study, "Increased motor activity-energy" stood out as the most influential symptom, and "Speech rate and amount" acted as the main bridge symptom linking testosterone levels, aggressive behavior, and manic symptoms. Targeting the central and bridge symptoms may improve the outcomes of aggression interventions implemented among BD patients in psychiatric emergency care.

Multimodal integration of neuroimaging and genetic data for the diagnosis of mood disorders based on computer vision models

Mood disorders, particularly major depressive disorder (MDD) and bipolar disorder (BD), are often underdiagnosed, leading to substantial morbidity. Harnessing the potential of emerging methodologies, we propose a novel multimodal fusion approach that integrates patient-oriented brain structural magnetic resonance imaging (sMRI) scans with DNA whole-exome sequencing (WES) data. Multimodal data fusion aims to improve the detection of mood disorders by employing established deep-learning architectures for computer vision and machine-learning strategies. We analyzed brain imaging genetic data of 321 East Asian individuals, including 147 patients with MDD, 78 patients with BD, and 96 healthy controls. We developed and evaluated six fusion models by leveraging common computer vision models in image classification: Vision Transformer (ViT), Inception-V3, and ResNet50, in conjunction with advanced machine-learning techniques (XGBoost and LightGBM) known for high-dimensional data analysis. Model validation was performed using a 10-fold cross-validation. Our ViT ⊕ XGBoost fusion model with MRI scans, genomic Single Nucleotide polymorphism (SNP) data, and unweighted polygenic risk score (PRS) outperformed baseline models, achieving an incremental area under the curve (AUC) of 0.2162 (32.03% increase) and 0.0675 (+8.19%) and incremental accuracy of 0.1455 (+25.14%) and 0.0849 (+13.28%) compared to SNP-only and image-only baseline models, respectively. Our findings highlight the opportunity to refine mood disorder diagnostics by demonstrating the transformative potential of integrating diverse, yet complementary, data modalities and methodologies.

Transcriptome profiling as a biological marker for bipolar disorder sub-phenotypes

PURPOSE

Bipolar affective disorder (BP) causes major functional impairment and reduced quality of life not only for patients, but also for many close relatives. We aimed to investigate mRNA levels in BP patients to find differentially expressed genes linked to specific clinical course variants; assuming that several gene expression alterations might indicate vulnerability pathways for specific course and severity of the disease.

MATERIALS

We searched for up- and down-regulated genes comparing patients with diagnosis of BP type I (BPI) vs type II (BPII), history of suicide attempts, psychotic symptoms, predominance of manic/hypomanic episodes, and history of numerous episodes and comorbidity of substance use disorders or anxiety disorders. RNA was extracted from peripheral blood mononuclear cells and analyzed with use of microarray slides.

RESULTS

Differentially expressed genes (DEGs) were found in all disease characteristics compared. The lowest number of DEGs were revealed when comparing BPI and BPII patients (18 genes), and the highest number when comparing patients with and without psychotic symptoms (3223 genes). Down-regulated genes identified here with the use of the DAVID database were among others linked to cell migration, defense response, and inflammatory response.

CONCLUSIONS

The most specific transcriptome profile was revealed in BP with psychotic symptoms. Differentially expressed genes in this variant include, among others, genes involved in inflammatory and immune processes. It might suggest the overlap of biological background between BP with a history of psychotic features and schizophrenia.

Identifying prior signals of bipolar disorder using primary care electronic health records: a nested case-control study

BACKGROUND

Bipolar disorders are serious mental illnesses, yet evidence suggests that the diagnosis and treatment of bipolar disorder can be delayed by around 6 years.

AIM

To identify signals of undiagnosed bipolar disorder using routinely collected electronic health records.

DESIGN AND SETTING

A nested case-control study conducted using the UK Clinical Practice Research Datalink (CPRD) GOLD dataset, an anonymised electronic primary care patient database linked with hospital records. 'Cases' were adult patients with incident bipolar disorder diagnoses between 1 January 2010 and 31 July 2017.

METHOD

The patients with bipolar disorder (the bipolar disorder group) were matched by age, sex, and registered general practice to 20 'controls' without recorded bipolar disorder (the control group). Annual episode incidence rates were estimated and odds ratios from conditional logistic regression models were reported for recorded health events before the index (diagnosis) date.

RESULTS

There were 2366 patients with incident bipolar disorder diagnoses and 47 138 matched control patients (median age 40 years and 60.4% female: n = 1430/2366 with bipolar disorder and n = 28 471/47 138 without). Compared with the control group, the bipolar disorder group had a higher incidence of diagnosed depressive, psychotic, anxiety, and personality disorders and escalating self-harm up to 10 years before a bipolar disorder diagnosis. Sleep disturbance, substance misuse, and mood swings were more frequent among the bipolar disorder group than the control group. The bipolar disorder group had more frequent face-to-face consultations, and were more likely to miss multiple scheduled appointments and to be prescribed ≥3 different psychotropic medication classes in a given year.

CONCLUSION

Psychiatric diagnoses, psychotropic prescriptions, and health service use patterns might be signals of unreported bipolar disorder. Recognising these signals could prompt further investigation for undiagnosed significant psychopathology, leading to timely referral, assessment, and initiation of appropriate treatments.

Cortical alterations in relatives of patients with bipolar disorder: A review of magnetic resonance imaging studies

INTRODUCTION

Bipolar disorder (BD) is a severe mental disorder characterized by high heritability rates. Widespread brain cortical alterations have been reported in BD patients, mostly involving the frontal, temporal and parietal regions. Importantly, also unaffected relatives of BD patients (BD-RELs) present abnormalities in cortical measures, which are not influenced by disease-related factors, such as medication use and illness duration. Here, we collected all available evidence on cortical measures in BD-RELs to further our knowledge on the potential cortical alterations associated with the vulnerability and the resilience to BD.

METHODS

A search on PubMed, Web of Science and Scopus was performed to identify neuroimaging studies exploring cortical alterations in BD-RELs, including cortical thickness (CT), surface area (SA), gyrification (GI) and cortical complexity. Eleven studies were included. Of these, five assessed CT, five examined CT and SA and one explored CT, SA and GI.

RESULTS

Overall, a heterogeneous pattern of cortical alterations emerged. The areas more consistently linked with genetic liability for BD were the prefrontal and sensorimotor regions. Mixed evidence was reported in the temporal and cingulate areas.

LIMITATIONS

The small sample size and the heterogeneity in terms of methodologies and the characteristics of the participants limit the generalizability of our results.

CONCLUSIONS

Our findings suggest that the genetic liability for BD is related to reduced CT in the prefrontal cortex, which might be a marker of risk for BD, and increased CT within the sensorimotor cortex, which could represent a marker of resilience.

Bipolar disorder-iPSC derived neural progenitor cells exhibit dysregulation of store-operated Ca2+ entry and accelerated differentiation

While most of the efforts to uncover mechanisms contributing to bipolar disorder (BD) focused on phenotypes at the mature neuron stage, little research has considered events that may occur during earlier timepoints of neurodevelopment. Further, although aberrant calcium (Ca2+) signaling has been implicated in the etiology of this condition, the possible contribution of store-operated Ca2+ entry (SOCE) is not well understood. Here, we report Ca2+ and developmental dysregulations related to SOCE in BD patient induced pluripotent stem cell (iPSC)-derived neural progenitor cells (BD-NPCs) and cortical-like glutamatergic neurons. First, using a Ca2+ re-addition assay we found that BD-NPCs and neurons had attenuated SOCE. Intrigued by this finding, we then performed RNA-sequencing and uncovered a unique transcriptome profile in BD-NPCs suggesting accelerated neurodifferentiation. Consistent with these results, we measured a slower rate of proliferation, increased neurite outgrowth, and decreased size in neurosphere formations with BD-NPCs. Also, we observed decreased subventricular areas in developing BD cerebral organoids. Finally, BD NPCs demonstrated high expression of the let-7 family while BD neurons had increased miR-34a, both being microRNAs previously implicated in neurodevelopmental deviations and BD etiology. In summary, we present evidence supporting an accelerated transition towards the neuronal stage in BD-NPCs that may be indicative of early pathophysiological features of the disorder.

Genome-wide significant risk loci for mood disorders in the Old Order Amish founder population

Genome-wide association studies (GWAS) of mood disorders in large case-control cohorts have identified numerous risk loci, yet pathophysiological mechanisms remain elusive, primarily due to the very small effects of common variants. We sought to discover risk variants with larger effects by conducting a genome-wide association study of mood disorders in a founder population, the Old Order Amish (OOA, n = 1,672). Our analysis revealed four genome-wide significant risk loci, all of which were associated with >2-fold relative risk. Quantitative behavioral and neurocognitive assessments (n = 314) revealed effects of risk variants on sub-clinical depressive symptoms and information processing speed. Network analysis suggested that OOA-specific risk loci harbor novel risk-associated genes that interact with known neuropsychiatry-associated genes via gene interaction networks. Annotation of the variants at these risk loci revealed population-enriched, non-synonymous variants in two genes encoding neurodevelopmental transcription factors, CUX1 and CNOT1. Our findings provide insight into the genetic architecture of mood disorders and a substrate for mechanistic and clinical studies.

Psychosis Endophenotypes: A Gene-Set-Specific Polygenic Risk Score Analysis

BACKGROUND AND HYPOTHESIS

Endophenotypes can help to bridge the gap between psychosis and its genetic predispositions, but their underlying mechanisms remain largely unknown. This study aims to identify biological mechanisms that are relevant to the endophenotypes for psychosis, by partitioning polygenic risk scores into specific gene sets and testing their associations with endophenotypes.

STUDY DESIGN

We computed polygenic risk scores for schizophrenia and bipolar disorder restricted to brain-related gene sets retrieved from public databases and previous publications. Three hundred and seventy-eight gene-set-specific polygenic risk scores were generated for 4506 participants. Seven endophenotypes were also measured in the sample. Linear mixed-effects models were fitted to test associations between each endophenotype and each gene-set-specific polygenic risk score.

STUDY RESULTS

After correction for multiple testing, we found that a reduced P300 amplitude was associated with a higher schizophrenia polygenic risk score of the forebrain regionalization gene set (mean difference per SD increase in the polygenic risk score: -1.15 µV; 95% CI: -1.70 to -0.59 µV; P = 6 × 10-5). The schizophrenia polygenic risk score of forebrain regionalization also explained more variance of the P300 amplitude (R2 = 0.032) than other polygenic risk scores, including the genome-wide polygenic risk scores.

CONCLUSIONS

Our finding on reduced P300 amplitudes suggests that certain genetic variants alter early brain development thereby increasing schizophrenia risk years later. Gene-set-specific polygenic risk scores are a useful tool to elucidate biological mechanisms of psychosis and endophenotypes, offering leads for experimental validation in cellular and animal models.

Association between polymorphisms of TLR2-1-6 and bipolar disorder in a tunisian population

BACKGROUND

Bipolar disorder (BD) is a complex neuropsychiatric disease that has been strongly linked to immune dysregulation. In particular, an abnormal inflammatory response mediated by toll-like receptor 2 - 1/6 (TLR2-1/6) was described in BD. Nevertheless, genetic factors' contribution is still unknown. Thus, we suggested that functional polymorphisms of TLR2, 1 and 6 could be involved in BD predisposition.

METHODS AND RESULTS

TLR2, 1 and 6 polymorphisms were genotyped by PCR-RFLP in 292 controls and 131 patients from a Tunisian population. Polymorphisms and haplotype associations were explored in BD and binary logistic regression analysis was performed for more powerful associations. In dominant model, we found a significantly higher genotype and minor allele frequencies in healthy females compared to patients for TLR2-196-174Ins/Del (p = 0.04; OR = 0.3, p = 0.04; OR = 0.3, respectively) and for TLR6-S249P only with minor allele (p = 0.03; OR = 0.2). In contrast, TLR2-R677W CT + TT and T allele frequencies were significantly higher in BD (padjusted<10- 4; ORadjusted =46.6, p < 10- 4; OR = 6.3, respectively), specifically in females (CT + TT: 100%). Similarly, TLR1-R80T showed significantly increased GC + CC and C allele frequencies in patients compared to controls (padjusted=0.04; ORadjusted=4, p = 0.009; OR = 4.3, respectively). Moreover, haplotype investigation demonstrated that InsGTCGT (p < 10- 4, OR = 275) and delGCCGT (p = 0.03, OR = 18.5) were significantly overrepresented in BD patients compared to controls.

CONCLUSIONS

We suggest that TLR2-196-174Ins/Del and TLR6-S249P could be protective factors of females against BD. However, TLR2-R677W and TLR1-R80T could be strongly associated with higher risk of BD. Interestingly, TLR2-R677W could be a genetic marker for BD in females. However, further studies with larger groups are needed to confirm these findings.

Regional cerebral blood flow at rest in schizophrenia and major depressive disorder: A functional neuroimaging meta-analysis

Severe mental disorders (SMDs) such as schizophrenia (SCZ), major depressive disorder (MDD) and bipolar disorder (BD) are associated with altered brain function. Neuroimaging studies have illustrated spontaneous activity alterations across SMDs, but no meta-analysis has directly compared resting-state regional cerebral blood flow (rCBF) with one another. We conducted a meta-analysis of PET, SPECT and ASL neuroimaging studies to identify specific alterations of rCBF at rest in SMDs. Included are 20 studies in MDD, and 18 studies in SCZ. Due to the insufficient number of studies in BD, this disorder was left out of the analyses. Compared to controls, the SCZ group displayed reduced rCBF in the triangular part of the left inferior frontal gyrus and in the medial orbital part of the bilateral superior frontal gyrus. After correction, only a small cluster in the right inferior frontal gyrus exhibited reduced rCBF in MDD, compared to controls. Differences were found in these brain regions between SCZ and MDD. SCZ displayed reduced rCBF at rest in regions associated with default-mode, reward processing and language processing. MDD was associated with reduced rCBF in a cluster involved in response inhibition. Our meta-analysis highlights differences in the resting-state rCBF alterations between SCZ and MDD.

Bipolar disorder: Diagnosis, treatment and future directions

Bipolar disorder is a relatively common mental illness, characterised by recurrent episodes of mania (or hypomania) and major depression, and associated with a significant burden of morbidity and premature mortality. Physicians across all specialities are likely to encounter individuals with the condition within their clinical practice. This short review provides an up-to-date overview of the clinical features, epidemiology, pathophysiology, evidence-based management, prognosis and future directions for treatment and research in bipolar disorder. Aspects of cross-specialty relevance are highlighted, including the physical health burden associated with the condition, and the side effects and safety considerations of medication regimes used in bipolar disorder.

Towards the First Biomarker Test for Bipolar Spectrum Disorder: An Evaluation of 199 Patients in an Outpatient Setting

Bipolar spectrum disorder seems to be challenging to diagnose, particularly unspecified or subthreshold types. The delay in diagnosis in the UK for bipolar I and II types is a staggering 10-13 years, with only 15% correctly diagnosed without delay. In the USA, the delay is 6-8 years, and there is a 60% incorrect diagnosis rate. The HCL-32 questionnaire is adequate, but not sufficient by itself, and patients may find it difficult to complete, particularly if they are unwell. We have investigated a biomarker test which can be used in day-to-day clinical practice to assist diagnosis. We evaluated 199 patients diagnosed with ICD-10 bipolar I, II, and unspecified disorders, using the HCL-32 questionnaire with a cut-off point of 14 and above, supplemented by history taking and examination using the principles of the CIDI 3, interviews of relatives, and longitudinal mood charts where available. The results were compared to the general population and a sample of patients diagnosed with recurrent depression for assessment of sensitivity and specificity. We evaluated four mutations of SLCO1C1, DiO1, and two DiO2alleles as potential biomarkers for bipolar spectrum disorder, and identified three mutations that exhibited high sensitivity, with rates of up to 87% and specificity of up to 46% in distinguishing bipolar spectrum disorders from recurrent depressive disorder. Additionally, mutations in SLCO1C1 and DiO1 exhibited a sensitivity of up to 86% and a specificity of up to 60% in detecting bipolar spectrum disorder compared to the general population within a clinical setting. These biomarkers have the potential to be used as a diagnostic test that is not open to subjective interpretation and can be administered even if patients are very unwell, requiring, though, the patient's consent. Further studies confirming these results are needed to compare the validity of using individual or a best combination of single nucleotide polymorphisms to identify bipolar spectrum disorders, particularly subthreshold presentations, and to differentiate them from other mood disorders such as major depression and recurrent depressive disorder.

Mental health and labor supply: Evidence from Canada

This study investigates the relationship between mental health and employment using an instrumental variable approach with the 2012 Canadian Community Health Survey-Mental Health. Using a family member's mental health problem(s) as an instrument for poor mental health, the estimates reveal that poor mental health significantly reduces employment outcomes. These findings are robust to various specifications, such as an alternative instrument and a relaxation of the exclusion restriction assumption. In addition, the relationship is driven mainly by men and younger workers. Moreover, the findings suggest that the relationship is mediated by a decline in cognitive abilities, such as difficulties in concentration and motivation, and social relations with acquaintances and friends. Finally, the estimates show that this phenomenon is contagious: poor mental health has a significant spillover effect on coworkers' mental health in workplaces. This study demonstrates the importance of mental health illness in Canada and other developed countries.

Genetics of bipolar disorder: insights into its complex architecture and biology from common and rare variants

Bipolar disorder (BD) is a common mental disorder characterized by recurrent mood episodes, which causes major socioeconomic burdens globally. Though its disease pathogenesis is largely unknown, the high heritability of BD indicates strong contributions from genetic factors. In this review, we summarize the recent achievements in the genetics of BD, particularly those from genome-wide association study (GWAS) of common variants and next-generation sequencing analysis of rare variants. These include the identification of dozens of robust disease-associated loci, deepening of our understanding of the biology of BD, objective description of correlations with other psychiatric disorders and behavioral traits, formulation of methods for predicting disease risk and drug response, and the discovery of a single gene associated with bipolar disorder and schizophrenia spectrum with a large effect size. On the other hand, the findings to date have not yet made a clear contribution to the improvement of clinical psychiatry of BD. We overview the remaining challenges as well as possible paths to resolve them, referring to studies of other major neuropsychiatric disorders.

The Genetic Side of the Mood: A Scientometric Review of the Genetic Basis of Mood Disorders

Mood disorders are highly heritable psychiatric disorders. Over the years, many genetic polymorphisms have been identified to pose a higher risk for the development of mood disorders. To overview the literature on the genetics of mood disorders, a scientometric analysis was performed on a sample of 5342 documents downloaded from Scopus. The most active countries and the most impactful documents in the field were identified. Furthermore, a total of 13 main thematic clusters emerged in the literature. From the qualitative inspection of clusters, it emerged that the research interest moved from a monogenic to a polygenic risk framework. Researchers have moved from the study of single genes in the early 1990s to conducting genome-wide association studies around 2015. In this way, genetic overlaps between mood disorders and other psychiatric conditions emerged too. Furthermore, around the 2010s, the interaction between genes and environmental factors emerged as pivotal in understanding the risk for mood disorders. The inspection of thematic clusters provides a valuable insight into the past and recent trends of research in the genetics of mood disorders and sheds light onto future lines of research.

Triple Diagnosis of Attention-Deficit/Hyperactivity Disorder with Coexisting Bipolar and Alcohol Use Disorders: Clinical Aspects and Pharmacological Treatments

Attention-Deficit/Hyperactivity Disorder (ADHD), Bipolar Disorder (BD) and Alcohol Use Disorder (AUD) are common medical conditions often coexisting and exerting mutual influence on disease course and pharmacological treatment response. Each disorder, when considered separately, relies on different therapeutic approaches, making it crucial to detect the plausible association between them. Treating solely the emerging condition (e.g., alcoholism) and disregarding the patient's whole psychopathological ground often leads to treatment failure and relapse. Clinical experience and scientific evidence rather show that tailoring treatments for these three conditions considering their co-occurrence as a sole complex disorder yields more fulfilling and durable clinical outcomes. In light of the above considerations, the purpose of the present review is to critically discuss the pharmacological strategies in the personalized treatment of complex conditions defined by ADHD-bipolarityalcoholism coexistence.

Role of TNF-α -308G/A Polymorphism in Bipolar Disorder and its Relationship with Clinical and Demographic Variables

Objective

Gene-environment interactions might play a significant role in the development of bipolar disorder (BD). The objective of the current study was to investigate the association between tumor necrosis factor (TNF)-α -308 G/A polymorphism and BD and conduct a bioinformatics analysis of the protein-protein network of TNF-α. Gene-environment interactions and the relationship between stressful life events (SLEs) and substance abuse with TNF genotypes and other characteristics were analyzed.

Methods

The genomic deoxyribonucleic acid (DNA) of 400 patients with BD and 200 control subjects were extracted and genotyped for TNF-α -308 G/A polymorphism. SLEs and substance abuse were evaluated using the Life Event and Difficulty Schedule (LEDS) and a self-designed substance abuse questionnaire for the events six months prior to the onset of the disease, respectively. Gene-environment interactions were assessed by multiple statistical tools. Bioinformatics analysis of the TNF-α network and its interacting proteins was carried out using STRING and Cytoscape softwares.

Results

Genotyping analysis revealed a significant association between TNF-α -308 G/A polymorphism and BD (p<0.009). Furthermore, analysis of gene-environment interaction revealed a significant association between TNF-α -308 G/A and SLEs (p=0.001) and TNF-α -308 G/A and substance abuse (p=0.001). Three distinct proteins, RELA, RIPK1, and BIRC3, were identified through hub analysis of the protein network.

Conclusion

TNF-α -308 G/A polymorphism is positively associated with BD. SLEs and substance abuse might trigger the early onset of BD. Proteins identified through bioinformatics analysis might contribute to the TNF-α mediated pathophysiology of BD and can be the potential therapeutic targets.

Gattaca as a lens on contemporary genetics: marking 25 years into the film's "not-too-distant" future

The 1997 film Gattaca has emerged as a canonical pop culture reference used to discuss modern controversies in genetics and bioethics. It appeared in theaters a few years prior to the announcement of the "completion" of the human genome (2000), as the science of human genetics was developing a renewed sense of its social implications. The story is set in a near-future world in which parents can, with technological assistance, influence the genetic composition of their offspring on the basis of predicted life outcomes. The current moment-25 years after the film's release-offers an opportunity to reflect on where society currently stands with respect to the ideas explored in Gattaca. Here, we review and discuss several active areas of genetic research-genetic prediction, embryo selection, forensic genetics, and others-that interface directly with scenes and concepts in the film. On its silver anniversary, we argue that Gattaca remains an important reflection of society's expectations and fears with respect to the ways that genetic science has manifested in the real world. In accompanying supplemental material, we offer some thought questions to guide group discussions inside and outside of the classroom.

Brain-wide versus genome-wide vulnerability biomarkers for severe mental illnesses

Severe mental illnesses (SMI), including major depressive (MDD), bipolar (BD), and schizophrenia spectrum (SSD) disorders have multifactorial risk factors and capturing their complex etiopathophysiology in an individual remains challenging. Regional vulnerability index (RVI) was used to measure individual's brain-wide similarity to the expected SMI patterns derived from meta-analytical studies. It is analogous to polygenic risk scores (PRS) that measure individual's similarity to genome-wide patterns in SMI. We hypothesized that RVI is an intermediary phenotype between genome and symptoms and is sensitive to both genetic and environmental risks for SMI. UK Biobank sample of N = 17,053/19,265 M/F (age = 64.8 ± 7.4 years) and an independent sample of SSD patients and controls (N = 115/111 M/F, age = 35.2 ± 13.4) were used to test this hypothesis. UKBB participants with MDD had significantly higher RVI-MDD (Cohen's d = 0.20, p = 1 × 10-23 ) and PRS-MDD (d = 0.17, p = 1 × 10-15 ) than nonpsychiatric controls. UKBB participants with BD and SSD showed significant elevation in the respective RVIs (d = 0.65 and 0.60; p = 3 × 10-5 and .009, respectively) and PRS (d = 0.57 and 1.34; p = .002 and .002, respectively). Elevated RVI-SSD were replicated in an independent sample (d = 0.53, p = 5 × 10-5 ). RVI-MDD and RVI-SSD but not RVI-BD were associated with childhood adversity (p < .01). In nonpsychiatric controls, elevation in RVI and PRS were associated with lower cognitive performance (p < 10-5 ) in six out of seven domains and showed specificity with disorder-associated deficits. In summary, the RVI is a novel brain index for SMI and shows similar or better specificity for SMI than PRS, and together they may complement each other in the efforts to characterize the genomic to brain level risks for SMI.

Cardiovascular disease and subsequent risk of psychiatric disorders: a nationwide sibling-controlled study

Background

The association between cardiovascular disease (CVD) and selected psychiatric disorders has frequently been suggested while the potential role of familial factors and comorbidities in such association has rarely been investigated.

Methods

We identified 869,056 patients newly diagnosed with CVD from 1987 to 2016 in Sweden with no history of psychiatric disorders, and 910,178 full siblings of these patients as well as 10 individually age- and sex-matched unrelated population controls (N = 8,690,560). Adjusting for multiple comorbid conditions, we used flexible parametric models and Cox models to estimate the association of CVD with risk of all subsequent psychiatric disorders, comparing rates of first incident psychiatric disorder among CVD patients with rates among unaffected full siblings and population controls.

Results

The median age at diagnosis was 60 years for patients with CVD and 59.2% were male. During up to 30 years of follow-up, the crude incidence rates of psychiatric disorder were 7.1, 4.6, and 4.0 per 1000 person-years for patients with CVD, their siblings and population controls. In the sibling comparison, we observed an increased risk of psychiatric disorder during the first year after CVD diagnosis (hazard ratio [HR], 2.74; 95% confidence interval [CI], 2.62-2.87) and thereafter (1.45; 95% CI, 1.42-1.48). Increased risks were observed for all types of psychiatric disorders and among all diagnoses of CVD. We observed similar associations in the population comparison. CVD patients who developed a comorbid psychiatric disorder during the first year after diagnosis were at elevated risk of subsequent CVD death compared to patients without such comorbidity (HR, 1.55; 95% CI, 1.44-1.67).

Conclusions

Patients diagnosed with CVD are at an elevated risk for subsequent psychiatric disorders independent of shared familial factors and comorbid conditions. Comorbid psychiatric disorders in patients with CVD are associated with higher risk of cardiovascular mortality suggesting that surveillance and treatment of psychiatric comorbidities should be considered as an integral part of clinical management of newly diagnosed CVD patients.

Funding

This work was supported by the EU Horizon 2020 Research and Innovation Action Grant (CoMorMent, grant no. 847776 to UV, PFS, and FF), Grant of Excellence, Icelandic Research Fund (grant no. 163362-051 to UV), ERC Consolidator Grant (StressGene, grant no. 726413 to UV), Swedish Research Council (grant no. D0886501 to PFS), and US NIMH R01 MH123724 (to PFS).

An ecological study of objective rest-activity markers of lithium response in bipolar-I-disorder

BACKGROUND

Despite its pivotal role in prophylaxis for bipolar-I-disorders (BD-I), variability in lithium (Li) response is poorly understood and only a third of patients show a good outcome. Converging research strands indicate that rest-activity rhythms can help characterize BD-I and might differentiate good responders (GR) and non-responders (NR).

METHODS

Seventy outpatients with BD-I receiving Li prophylaxis were categorized as GR or NR according to the ratings on the retrospective assessment of response to lithium scale (Alda scale). Participants undertook 21 consecutive days of actigraphy monitoring of sleep quantity (SQ), sleep variability (SV) and circadian rhythmicity (CR).

RESULTS

Twenty-five individuals were categorized as GR (36%). After correcting statistical analysis to minimize false discoveries, four variables (intra-daily variability; median activity level; amplitude; and relative amplitude of activity) significantly differentiated GR from NR. The odds of being classified as a GR case were greatest for individuals showing more regular/stable CR (1.41; 95% confidence interval (CI) 1.08, 2.05; p < 0.04). Also, there was a trend for lower SV to be associated with GR (odds ratio: 0.56; 95% CI 0.31, 1.01; p < 0.06).

CONCLUSIONS

To our knowledge, this is the largest actigraphy study of rest-activity rhythms and Li response. Circadian markers associated with fragmentation, variability, amount and/or amplitude of day and night-time activity best-identified GR. However, associations were modest and future research must determine whether these objectively measured parameters, singly or together, represent robust treatment response biomarkers. Actigraphy may offer an adjunct to multi-platform approaches aimed at developing personalized treatments or stratification of individuals with BD-I into treatment-relevant subgroups.

Retinal changes in bipolar disorder as an endophenotype candidate: Comparison of OCT-detected retinal changes in patients, siblings, and healthy controls

Optical coherence tomography (OCT) is a non-invasive imaging technique that detects retinal changes reflecting neurodegeneration. In recent studies in patients with bipolar disorder (BD) abnormal OCT findings have shown. In this study, we aimed to investigate the retinal changes in BD patients and their healthy siblings (HS) by comparing them with the healthy control (HC) group and to explore these findings as potential endophenotype candidates. 31 patients with BD, 31 age-matched HSs and 46 HCs were included and peripapillary retinal nerve fiber layer (RNFL), ganglion cell layer (GCL)+inner plexiform layer (IPL) and macular volume (MV) thicknesses were measured by OCT. The relationship between disease severity parameters, functionality and OCT measurements in the patient group was also investigated. In results, the mean RNFL thicknesses did not differ between groups. All GCL+IPL thicknesses were found to be significantly lower in the patient and sibling groups compared to the HCs. GCL+IPL thicknesses were significantly correlated with functionality of patients and severity of the disorder. Our findings suggest that analysis of retinal layers with OCT may be a beneficial indicator to show neuronal changes in BD and GCL+IPL may be a suitable endophenotype candidate.

Immune–Inflammatory Biomarkers Predict Cognition and Social Functioning in Patients With Type 2 Diabetes Mellitus, Major Depressive Disorder, Bipolar Disorder, and Schizophrenia: A 1-Year Follow-Up Study

Background

Systemic, low-grade immune–inflammatory activity, together with social and neurocognitive performance deficits are a transdiagnostic trait of people suffering from type 2 diabetes mellitus (T2DM) and severe mental illnesses (SMIs), such as schizophrenia (SZ), major depressive disorder (MDD), and bipolar disorder (BD). We aimed to determine if immune–inflammatory mediators were significantly altered in people with SMIs or T2DM compared with healthy controls (HC) and whether these biomarkers could help predict their cognition and social functioning 1 year after assessment.

Methods

We performed a prospective, 1-year follow-up cohort study with 165 participants at baseline (TB), including 30 with SZ, 42 with BD, 35 with MDD, 30 with T2DM, and 28 HC; and 125 at 1-year follow-up (TY), and determined executive domain (ED), global social functioning score (GSFS), and peripheral blood immune–inflammatory and oxidative stress biomarkers.

Results

Participants with SMIs and T2DM showed increased peripheral levels of inflammatory markers, such as interleukin-10 (p < 0.01; η²p = 0.07) and tumor necrosis factor-α (p < 0.05; η²p = 0.08); and oxidative stress biomarkers, such as reactive oxygen species (ROS) (p < 0.05; η²p = 0.07) and mitochondrial ROS (p < 0.01; η²p = 0.08). The different combinations of the exposed biomarkers anticipated 46–57.3% of the total ED and 23.8–35.7% of GSFS for the participants with SMIs.

Limitations

Participants' treatment, as usual, was continued without no specific interventions; thus, it was difficult to anticipate substantial changes related to the psychopharmacological pattern.

Conclusion

People with SMIs show significantly increased levels of peripheral immune–inflammatory biomarkers, which may contribute to the neurocognitive and social deficits observed in SMIs, T2DM, and other diseases with systemic immune–inflammatory activation of chronic development. These parameters could help identify the subset of patients who could benefit from immune–inflammatory modulator strategies to ameliorate their functional outcomes.

Genetics in psychiatry: Methods, clinical applications and future perspectives

Psychiatric disorders and related traits have a demonstrated genetic component, with heritability estimated by twin studies generally between 80% and 40%. Their pathogenesis is complex and multi-determined: environmental factors interact with a polygenic architecture, making difficult the development of models able to stratify patients or predict mental health outcomes. Despite this difficult challenge, relevant progress has been made in the field of psychiatric genetics in recent years. This review aims to present the main current methods in psychiatric genetics, their output, limitations, clinical applications, and possible future developments. Genome-wide association studies (GWASs) performed in increasingly large samples have led to the identification of replicated genetic loci associated with the risk of major psychiatric disorders, including schizophrenia and mood disorders. Statistical and biological approaches have been developed to improve our understanding of the etiopathogenetic mechanisms behind genome-wide significant associations, as well as for estimating the cumulative effect of risk variants at the individual level and the genetic overlap between different disorders, as pleiotropy is the rule rather than the exception. Clinical applications are available in the pharmacogenetics field. The main issues that remain to be addressed include improving ethnic diversity in genetic studies and the optimization of statistical power through methodological improvements, such as the definition of dimensional phenotypes with specific biological correlates and the integration of different types of omics data.

The association between childhood trauma and the age of onset in drug-free bipolar depression

OBJECTIVE

This study aimed to investigate the relationship between childhood trauma and clinical correlates in bipolar depression.

METHODS

A total of 61 bipolar depression patients were enrolled and assessed based on the Childhood Trauma Questionnaire-Short Form (CTQ-SF), Patient Health Questionaire-15 (PHQ-15), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) systems.

RESULTS

The age of onset in bipolar depression patients with either trauma or abuse or neglect was significantly lower than in patients without these factors. There were statistically significant negative correlations between the age of onset and the number of different trauma types in bipolar depression patients. Multiple variable regression showed a significant association between the number of trauma types and the age of onset. Furthermore, there was a significant negative correlation between the age of onset with CTQ-SF total score (CTS), emotional abuse score and emotional neglect score, and physical neglect score. However, multiple variable regression analysis revealed that there was a significant association between emotional abuse score and the age of onset of bipolar depression patients.

CONCLUSION

Our results suggest that childhood trauma may be associated with physical symptoms and the age of onset in bipolar depression patients.

Neurocognitive heterogeneity in 7-year-old children at familial high risk of schizophrenia or bipolar disorder: The Danish high risk and resilience study - VIA 7

BACKGROUND

Studies of neurocognitive heterogeneity in young children at familial high-risk of bipolar disorder (FHR-BP) or schizophrenia (FHR-SZ) are important to investigate inter-individual neurocognitive differences. We aimed to identify neurocognitive subgroups, describe prevalence of FHR-BP or FHR-SZ children herein, and examine risk ratios (RR) compared with controls.

METHODS

In a population-based cohort of 514 7-year-old children (197 FHR-SZ, 118 FHR-BP, and 199 matched controls) we used hierarchical cluster analyses to identify subgroups across 14 neurocognitive indices.

RESULTS

Three neurocognitive subgroups were derived: A Mildly Impaired (30%), Typical (51%), and Above Average subgroup (19%). The Mildly Impaired subgroup significantly underperformed controls (Cohen d = 0.11-1.45; Ps < 0.001) except in set-shifting (P = .84). FHR-SZ children were significantly more prevalent in the Mildly Impaired subgroup; FHR-BP children were more so in the Above Average subgroup (X² (2, N = 315) = 9.64, P < .01). 79.7% FHR-BP and 64.6% FHR-SZ children demonstrated typical or above average neurocognitive functions. Neurocognitive heterogeneity related significantly to concurrent functioning, psychopathology severity, home environment adequacy, and polygenic scores for schizophrenia (Ps <. 01). Compared with controls, FHR-SZ and FHR-BP children had a 93% (RR, 1.93; 95% CI, 1.40-2.64) and 8% (RR, 1.08; 95% CI, 0.71-1.66) increased risk of Mildly Impaired subgroup membership.

LIMITATIONS

Limitations include the cross-sectional design and smaller FHR-BP sample size.

CONCLUSIONS

Identification of neurocognitive heterogeneity in preadolescent children at FHR-BP or FHR-SZ may ease stigma and enable pre-emptive interventions to enhance neurocognitive functioning and resilience to mental illness in the impaired sub-population.

Bipolar spectrum disorders are associated with increased gray matter volume in the medial orbitofrontal cortex and nucleus accumbens

Objective

Elevated sensitivity to rewards prospectively predicts Bipolar Spectrum Disorder (BSD) onset; however, it is unclear whether volumetric abnormalities also reflect BSD risk. BSDs emerge when critical neurodevelopment in frontal and striatal regions occurs in sex-specific ways. The current paper examined the volume of frontal and striatal brain regions in both individuals with and at risk for a BSD with exploratory analyses examining sex-specificity.

Methods

One hundred fourteen medication-free individuals ages 18-27 at low-risk for BSD (moderate-reward sensitivity; N = 37), at high-risk without a BSD (high-reward sensitivity; N = 47), or with a BSD (N = 30) completed a structural MRI scan of the brain. We examined group differences in gray matter volume in a priori medial orbitofrontal cortex (mOFC) and nucleus accumbens (NAcc) regions-of-interest.

Results

The BSD group had enlarged frontostriatal volumes (mOFC, NAcc) compared to low individuals (d = 1.01). The mOFC volume in BSD was larger than low-risk (d = 1.01) and the high-risk groups (d = 0.74). This effect was driven by males with a BSD, who showed an enlarged mOFC compared to low (d = 1.01) and high-risk males (d = 0.74). Males with a BSD also showed a greater NAcc volume compared to males at low-risk (d = 0.49), but not high-risk males.

Conclusions

An enlarged frontostriatal volume (averaged mOFC, NAcc) is associated with the presence of a BSD, while subvolumes (mOFC vs. NAcc) showed unique patterning in relation to risk. We report preliminary evidence that sex moderates frontostriatal volume in BSD, highlighting the need for larger longitudinal risk studies examining the role of sex-specific neurodevelopmental trajectories in emerging BSDs.

Auditory mismatch negativity in bipolar disorder: a focused review

The auditory mismatch negativity, a component of the event-related potential elicited by an unexpected stimulus in a sequence of acoustic stimuli, provides an objective measure of the accuracy of the echoic information processing of the human brain in vivo. Auditory mismatch negativity is also a useful probe of cortical glutamatergic N-methyl-d-aspartate receptor activity and disturbance. Notably, auditory mismatch negativity is consistently impaired in schizophrenia. Because of the wide spectrum extending from bipolar affective illness and schizoaffective psychosis to typical schizophrenia, we examined the literature on auditory mismatch negativity in bipolar disorder with the aim to find any neurophysiological dysfunction concerning pre-attentive information processing shared by these clinical conditions. This focused review includes 26 original articles published in peer-reviewed journals and indexed in the National Institutes of Health National Library of Medicine (PubMed) search system. Overall, evidence is consistent with the finding that auditory mismatch negativity is impaired in bipolar disorder with psychotic features, even though to a lesser extent than in schizophrenia. It must be acknowledged that, in a few twin and family studies, mismatch negativity abnormalities were not specifically associated with bipolar disorder. In conclusion, auditory mismatch negativity research supports the involvement of the N-methyl-d-aspartate system in the pathophysiology of bipolar disorder, as previously assessed for schizophrenia, thus creating an intriguing trait d'union between these two mental illnesses and stimulating the development of novel therapeutic agents. With additional replication and validation, auditory mismatch negativity may be further considered as a correlate of a common psychopathology of schizophrenia and bipolar spectrum illnesses.

Associations between cognition and subsequent mood episodes in patients with bipolar disorder and their unaffected relatives: A systematic review

BACKGROUND

Bipolar disorder (BD) is highly recurrent and prevention of relapse and illness onset is an urgent treatment priority. This systematic review examined whether cognitive assessments can aid prediction of recurrence in patients with BD and/or illness onset in individuals at familial risk.

METHODS

The review included longitudinal studies of patients with BD or individuals at familial risk of mood disorder that examined the association between cognitive functions and subsequent relapse or illness onset, respectively. We followed the procedures of the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) 2020 statement. Searches were conducted on PubMed/MEDLINE, EMBASE and PsychInfo databases from inception up until May 10th 2021.

RESULTS

We identified 19 eligible studies; 12 studies investigated cognitive predictors of recurrence in BD (N = 36-76) and seven investigated cognitive predictors of illness onset in at-risk individuals (N = 84-234). In BD, general cognitive impairment, poorer verbal memory and executive function and positive bias were associated with subsequent (hypo)manic relapse -but with not depressive relapse or mood episodes in general. In first-degree relatives, impairments in attention, verbal memory and executive functions and positive bias were associated with subsequent illness onset.

LIMITATIONS

The findings should be considered preliminary given the small-to-moderate sample sizes and scarcity of studies.

CONCLUSIONS

Subject to replication, the associations between cognitive impairment and (hypo)mania relapse and illness onset may provide a platform for personalised treatment and prophylactic strategies.

Adolescent Verbal Memory as a Psychosis Endophenotype: A Genome-Wide Association Study in an Ancestrally Diverse Sample

Verbal memory impairment is one of the most prominent cognitive deficits in psychosis. However, few studies have investigated the genetic basis of verbal memory in a neurodevelopmental context, and most genome-wide association studies (GWASs) have been conducted in European-ancestry populations. We conducted a GWAS on verbal memory in a maximum of 11,017 participants aged 8.9 to 11.1 years in the Adolescent Brain Cognitive Development Study®, recruited from a diverse population in the United States. Verbal memory was assessed by the Rey Auditory Verbal Learning Test, which included three measures of verbal memory: immediate recall, short-delay recall, and long-delay recall. We adopted a mixed-model approach to perform a joint GWAS of all participants, adjusting for ancestral background and familial relatedness. The inclusion of participants from all ancestries increased the power of the GWAS. Two novel genome-wide significant associations were found for short-delay and long-delay recall verbal memory. In particular, one locus (rs9896243) associated with long-delay recall was mapped to the NSF (N-Ethylmaleimide Sensitive Factor, Vesicle Fusing ATPase) gene, indicating the role of membrane fusion in adolescent verbal memory. Based on the GWAS in the European subset, we estimated the SNP-heritability to be 15% to 29% for the three verbal memory traits. We found that verbal memory was genetically correlated with schizophrenia, providing further evidence supporting verbal memory as an endophenotype for psychosis.

Risk and protective factors for mental disorders beyond genetics: an evidence-based atlas

Decades of research have revealed numerous risk factors for mental disorders beyond genetics, but their consistency and magnitude remain uncer-tain. We conducted a "meta-umbrella" systematic synthesis of umbrella reviews, which are systematic reviews of meta-analyses of individual studies, by searching international databases from inception to January 1, 2021. We included umbrella reviews on non-purely genetic risk or protective factors for any ICD/DSM mental disorders, applying an established classification of the credibility of the evidence: class I (convincing), class II (highly suggestive), class III (suggestive), class IV (weak). Sensitivity analyses were conducted on prospective studies to test for temporality (reverse causation), TRANSD criteria were applied to test transdiagnosticity of factors, and A Measurement Tool to Assess Systematic Reviews (AMSTAR) was employed to address the quality of meta-analyses. Fourteen eligible umbrella reviews were retrieved, summarizing 390 meta-analyses and 1,180 associations between putative risk or protective factors and mental disorders. We included 176 class I to III evidence associations, relating to 142 risk/protective factors. The most robust risk factors (class I or II, from prospective designs) were 21. For dementia, they included type 2 diabetes mellitus (risk ratio, RR from 1.54 to 2.28), depression (RR from 1.65 to 1.99) and low frequency of social contacts (RR=1.57). For opioid use disorders, the most robust risk factor was tobacco smoking (odds ratio, OR=3.07). For non-organic psychotic disorders, the most robust risk factors were clinical high risk state for psychosis (OR=9.32), cannabis use (OR=3.90), and childhood adversities (OR=2.80). For depressive disorders, they were widowhood (RR=5.59), sexual dysfunction (OR=2.71), three (OR=1.99) or four-five (OR=2.06) metabolic factors, childhood physical (OR=1.98) and sexual (OR=2.42) abuse, job strain (OR=1.77), obesity (OR=1.35), and sleep disturbances (RR=1.92). For autism spectrum disorder, the most robust risk factor was maternal overweight pre/during pregnancy (RR=1.28). For attention-deficit/hyperactivity disorder (ADHD), they were maternal pre-pregnancy obesity (OR=1.63), maternal smoking during pregnancy (OR=1.60), and maternal overweight pre/during pregnancy (OR=1.28). Only one robust protective factor was detected: high physical activity (hazard ratio, HR=0.62) for Alzheimer's disease. In all, 32.9% of the associations were of high quality, 48.9% of medium quality, and 18.2% of low quality. Transdiagnostic class I-III risk/protective factors were mostly involved in the early neurodevelopmental period. The evidence-based atlas of key risk and protective factors identified in this study represents a benchmark for advancing clinical characterization and research, and for expanding early intervention and preventive strategies for mental disorders.

Precision and personalized assessment, diagnosis and treatment in psychiatry

"Precision medicine" and "personalized medicine" constitute goals of research since antiquity and this was intensified with the arrival of the "evidence-based medicine." precision and personalized psychiatry (3P) when achieved will constitute a radical shift in our paradigm and it will be even more transformative than in other fields of medicine. The biggest problems so far are the problematic definition of mental disorder, available treatments seem to concern broad categories rather than specific disorders and finally clinical predictors of treatment response or side effects and biological markers do not exist. Precision and personalized psychiatry like all precision medicine will be a laborious and costly task; thus the partnership of scientists with industry and the commercialization of new methods and technologies will be an important element for success. The development of an appropriate legal framework which will both support development and progress but also will protect the rights and the privacy of patients and their families is essential.

Extensive bidirectional genetic overlap between bipolar disorder and cardiovascular disease phenotypes

Patients with bipolar disorder (BIP) have a high risk of cardiovascular disease (CVD), despite considerable individual variation. The mechanisms underlying comorbid CVD in BIP remain largely unknown. We investigated polygenic overlap between BIP and CVD phenotypes, including CVD risk factors and coronary artery disease (CAD). We analyzed large genome-wide association studies of BIP (n = 51,710) and CVD phenotypes (n = 159,208-795,640), using bivariate causal mixture model (MiXeR), which estimates the total amount of shared genetic variants, and conjunctional false discovery rate (FDR), which identifies specific overlapping loci. MiXeR revealed polygenic overlap between BIP and body mass index (BMI) (82%), diastolic and systolic blood pressure (20-22%) and CAD (11%) despite insignificant genetic correlations. Using conjunctional FDR < 0.05, we identified 129 shared loci between BIP and CVD phenotypes, mainly BMI (n = 69), systolic (n = 53), and diastolic (n = 53) blood pressure, of which 22 are novel BIP loci. There was a pattern of mixed effect directions of the shared loci between BIP and CVD phenotypes. Functional analyses indicated that the shared loci are linked to brain-expressed genes and involved in neurodevelopment, lipid metabolism, chromatin assembly/disassembly and intracellular processes. Altogether, the study revealed extensive polygenic overlap between BIP and comorbid CVD, implicating shared molecular genetic mechanisms. The mixed effect directions of the shared loci suggest variation in genetic susceptibility to CVD across BIP subgroups, which may underlie the heterogeneity of CVD comorbidity in BIP patients. The findings suggest more focus on targeted lifestyle interventions and personalized pharmacological treatment to reduce CVD comorbidity in BIP.

Preventive psychiatry: a blueprint for improving the mental health of young people

Preventive approaches have latterly gained traction for improving mental health in young people. In this paper, we first appraise the conceptual foundations of preventive psychiatry, encompassing the public health, Gordon's, US Institute of Medicine, World Health Organization, and good mental health frameworks, and neurodevelopmentally-sensitive clinical staging models. We then review the evidence supporting primary prevention of psychotic, bipolar and common mental disorders and promotion of good mental health as potential transformative strategies to reduce the incidence of these disorders in young people. Within indicated approaches, the clinical high-risk for psychosis paradigm has received the most empirical validation, while clinical high-risk states for bipolar and common mental disorders are increasingly becoming a focus of attention. Selective approaches have mostly targeted familial vulnerability and non-genetic risk exposures. Selective screening and psychological/psychoeducational interventions in vulnerable subgroups may improve anxiety/depressive symptoms, but their efficacy in reducing the incidence of psychotic/bipolar/common mental disorders is unproven. Selective physical exercise may reduce the incidence of anxiety disorders. Universal psychological/psychoeducational interventions may improve anxiety symptoms but not prevent depressive/anxiety disorders, while universal physical exercise may reduce the incidence of anxiety disorders. Universal public health approaches targeting school climate or social determinants (demographic, economic, neighbourhood, environmental, social/cultural) of mental disorders hold the greatest potential for reducing the risk profile of the population as a whole. The approach to promotion of good mental health is currently fragmented. We leverage the knowledge gained from the review to develop a blueprint for future research and practice of preventive psychiatry in young people: integrating universal and targeted frameworks; advancing multivariable, transdiagnostic, multi-endpoint epidemiological knowledge; synergically preventing common and infrequent mental disorders; preventing physical and mental health burden together; implementing stratified/personalized prognosis; establishing evidence-based preventive interventions; developing an ethical framework, improving prevention through education/training; consolidating the cost-effectiveness of preventive psychiatry; and decreasing inequalities. These goals can only be achieved through an urgent individual, societal, and global level response, which promotes a vigorous collaboration across scientific, health care, societal and governmental sectors for implementing preventive psychiatry, as much is at stake for young people with or at risk for emerging mental disorders.

Cortical mediation of relationships between dopamine receptor D2 and cognition is absent in youth at risk of bipolar disorder

Bipolar disorder is associated with cognitive deficits and cortical changes for which the developmental dynamics are not well understood. The dopamine D2 receptor (DRD2) gene has been associated with both psychiatric disorders and cognitive variability. Here we examined the mediating role of brain structure in the relationship between DRD2 genomic variation and cognitive performance, with target cortical regions selected based on evidence of association with DRD2, bipolar disorder and/or cognition from prior literature. Participants (n = 143) were aged 12-30 years and comprised 62 first-degree relatives of bipolar patients (deemed 'at-risk'), 55 controls, and 26 patients with established bipolar disorder; all were unrelated Caucasian individuals with complete data across the three required modalities (structural magnetic resonance imaging, neuropsychological and genetic data). A DRD2 haplotype was derived from three functional polymorphisms (rs1800497, rs1076560, rs2283265) associated with alternative splicing (i.e., D2-short/-long isoforms). Moderated mediation analyses explored group differences in relationships between this DRD2 haplotype, three structural brain networks which subsume the identified cortical regions of interest (frontoparietal, dorsal-attention, and ventral-attention), and three cognitive indices (intelligence, attention, and immediate memory). Controls who were homozygous for the DRD2 major haplotype demonstrated greater cognitive performance as a result of dorsal-attention network mediation. However, this association was absent in the 'at-risk' group. This study provides the first evidence of a functional DRD2-brain-cognition pathway. The absence of typical brain-cognition relationships in young 'at-risk' individuals may reflect biological differences that precede illness onset. Further insight into early pathogenic processes may facilitate targeted early interventions.

Concepts of Neuroinflammation and Their Relationship With Impaired Mitochondrial Functions in Bipolar Disorder

Bipolar disorder (BD) is a chronic psychiatric disease, characterized by frequent behavioral episodes of depression and mania, and neurologically by dysregulated neurotransmission, neuroplasticity, growth factor signaling, and metabolism, as well as oxidative stress, and neuronal apoptosis, contributing to chronic neuroinflammation. These abnormalities result from complex interactions between multiple susceptibility genes and environmental factors such as stress. The neurocellular abnormalities of BD can result in gross morphological changes, such as reduced prefrontal and hippocampal volume, and circuit reorganization resulting in cognitive and emotional deficits. The term "neuroprogression" is used to denote the progressive changes from early to late stages, as BD severity and loss of treatment response correlate with the number of past episodes. In addition to circuit and cellular abnormalities, BD is associated with dysfunctional mitochondria, leading to severe metabolic disruption in high energy-demanding neurons and glia. Indeed, mitochondrial dysfunction involving electron transport chain (ETC) disruption is considered the primary cause of chronic oxidative stress in BD. The ensuing damage to membrane lipids, proteins, and DNA further perpetuates oxidative stress and neuroinflammation, creating a perpetuating pathogenic cycle. A deeper understanding of BD pathophysiology and identification of associated biomarkers of neuroinflammation are needed to facilitate early diagnosis and treatment of this debilitating disorder.

The Role of Genetics in Bipolar Disorder

Bipolar disorder (BP) is a highly heritable disease, with heritability estimated between 60 and 85% by twin studies. The underlying genetic architecture was poorly understood for years since the available technology was limited to the candidate gene approach that did not allow to explore the contribution of multiple loci throughout the genome. BP is a complex disorder, which pathogenesis is influenced by a number of genetic variants, each with small effect size, and environmental exposures. Genome-wide association studies (GWAS) provided meaningful insights into the genetics of BP, including replicated genetic variants, and allowed the development of novel multi-marker methods for gene/pathway analysis and for estimating the genetic overlap between BP and other traits. However, the existing GWAS had also relevant limitations. Notably insufficient statistical power and lack of consideration of rare variants, which may be responsible for the relatively low heritability explained (~20% in the largest GWAS) compared to twin studies. The availability of data from large biobanks and automated phenotyping from electronic health records or digital phenotyping represent key steps for providing samples with adequate power for genetic analysis. Next-generation sequencing is becoming more and more feasible in terms of costs, leading to the rapid growth in the number of samples with whole-genome or whole-exome sequence data. These recent and unprecedented resources are of key importance for a more comprehensive understanding of the specific genetic factors involved in BP and their mechanistic action in determining disease onset and prognosis.

Mood, activity, and sleep measured via daily smartphone-based self-monitoring in young patients with newly diagnosed bipolar disorder, their unaffected relatives and healthy control individuals

Diagnostic evaluations and early interventions of patients with bipolar disorder (BD) rely on clinical evaluations. Smartphones have been proposed to facilitate continuous and fine-grained self-monitoring of symptoms. The present study aimed to (1) validate daily smartphone-based self-monitored mood, activity, and sleep, against validated questionnaires and clinical ratings in young patients with newly diagnosed BD, unaffected relatives (UR), and healthy controls persons (HC); (2) investigate differences in daily smartphone-based self-monitored mood, activity, and sleep in young patients with newly diagnosed BD, UR, and HC; (3) investigate associations between self-monitored mood and self-monitored activity and sleep, respectively, in young patients with newly diagnosed BD. 105 young patients with newly diagnosed BD, 24 UR and 77 HC self-monitored 2 to 1077 days (median [IQR] = 65 [17.5-112.5]). There was a statistically significantly negative association between the mood item on Hamilton Depression Rating Scale (HAMD) and smartphone-based self-monitored mood (B = - 0.76, 95% CI - 0.91; - 0.63, p < 0.001) and between psychomotor item on HAMD and self-monitored activity (B = - 0.44, 95% CI - 0.63; - 0.25, p < 0.001). Smartphone-based self-monitored mood differed between young patients with newly diagnosed BD and HC (p < 0.001), and between UR and HC (p = 0.008) and was positively associated with smartphone-based self-reported activity (p < 0.001) and sleep duration (p < 0.001). The findings support the potential of smartphone-based self-monitoring of mood and activity as part of a biomarker for young patients with BD and UR. Smartphone-based self-monitored mood is better to discriminate between young patients with newly diagnosed BD and HC, and between UR and HC, compared with smartphone-based activity and sleep.Trial registration clinicaltrials.gov NCT0288826.

The Neurobiology of Bipolar Disorder

Bipolar disorders are severe and have a high prevalence; despite this, the neurobiological mechanisms are far from being elucidated, and this limits the development of new treatments. Although the aetiology of bipolar disorders is not yet fully understood, it is accepted that the disorder(s) may result from the interaction between genetic factors that cause susceptibility and predisposing, precipitating and perpetuating environmental factors, such as stress and traumatic events. A pathophysiological formulation of the disease suggests that dysfunctions in intracellular biochemical cascades, oxidative stress and mitochondrial dysfunction impair the processes linked to neuronal plasticity, leading to cell damage and the consequent loss of brain tissue that has been identified in post-mortem and neuroimaging studies. The data we have reviewed suggests that peripheral biomarkers related to hormones, inflammation, oxidative stress and neurotrophins are altered in bipolar disorders, especially during acute mood episodes. Together, these changes have been associated with a systemic toxicity of the disease and the damage resulting from multiple episodes. Systemic toxicity related to recurrent episodes in bipolar disorder may influence brain anatomical changes associated with the progression of stress and neuroplasticity in bipolar disorder and the response to treatment.

Association Analysis Between Catechol-O-Methyltransferase Expression and Cognitive Function in Patients with Schizophrenia, Bipolar Disorder, or Major Depression

INTRODUCTION

Schizophrenia, bipolar disorder (BD), and major depressive disorder are three common mental disorders. Although their diagnosis and treatment differ, they partially overlap.

METHODS

To explore the similarities and characteristics of these three psychiatric diseases, an intelligence quotient (IQ) assessment was performed to evaluate cognitive deficits. Relative catechol-O-methyltransferase (COMT) expression in peripheral blood mononuclear cells was examined in all three groups compared with healthy controls (HCs).

RESULTS

The results indicated that patients with any of the three psychiatric diseases presented IQ deficits, and that the first-episode schizophrenia (FES) group had even lower cognitive function than the other two groups. The relative COMT expression decreased in the FES group and increased in the BD group compared with the HC group. The correlation analysis of COMT expression level and IQ scores showed a positive correlation between relative COMT expression and full-scale IQ in the HC group. However, this correlation disappeared in all three psychiatric diseases studied.

CONCLUSION

In conclusion, this cross-disease strategy provided important clues to explain lower IQ scores and dysregulated COMT expression among three common mental illnesses.

Bipolar disorders

Bipolar disorders are a complex group of severe and chronic disorders that includes bipolar I disorder, defined by the presence of a syndromal, manic episode, and bipolar II disorder, defined by the presence of a syndromal, hypomanic episode and a major depressive episode. Bipolar disorders substantially reduce psychosocial functioning and are associated with a loss of approximately 10-20 potential years of life. The mortality gap between populations with bipolar disorders and the general population is principally a result of excess deaths from cardiovascular disease and suicide. Bipolar disorder has a high heritability (approximately 70%). Bipolar disorders share genetic risk alleles with other mental and medical disorders. Bipolar I has a closer genetic association with schizophrenia relative to bipolar II, which has a closer genetic association with major depressive disorder. Although the pathogenesis of bipolar disorders is unknown, implicated processes include disturbances in neuronal-glial plasticity, monoaminergic signalling, inflammatory homoeostasis, cellular metabolic pathways, and mitochondrial function. The high prevalence of childhood maltreatment in people with bipolar disorders and the association between childhood maltreatment and a more complex presentation of bipolar disorder (eg, one including suicidality) highlight the role of adverse environmental exposures on the presentation of bipolar disorders. Although mania defines bipolar I disorder, depressive episodes and symptoms dominate the longitudinal course of, and disproportionately account for morbidity and mortality in, bipolar disorders. Lithium is the gold standard mood-stabilising agent for the treatment of people with bipolar disorders, and has antimanic, antidepressant, and anti-suicide effects. Although antipsychotics are effective in treating mania, few antipsychotics have proven to be effective in bipolar depression. Divalproex and carbamazepine are effective in the treatment of acute mania and lamotrigine is effective at treating and preventing bipolar depression. Antidepressants are widely prescribed for bipolar disorders despite a paucity of compelling evidence for their short-term or long-term efficacy. Moreover, antidepressant prescription in bipolar disorder is associated, in many cases, with mood destabilisation, especially during maintenance treatment. Unfortunately, effective pharmacological treatments for bipolar disorders are not universally available, particularly in low-income and middle-income countries. Targeting medical and psychiatric comorbidity, integrating adjunctive psychosocial treatments, and involving caregivers have been shown to improve health outcomes for people with bipolar disorders. The aim of this Seminar, which is intended mainly for primary care physicians, is to provide an overview of diagnostic, pathogenetic, and treatment considerations in bipolar disorders. Towards the foregoing aim, we review and synthesise evidence on the epidemiology, mechanisms, screening, and treatment of bipolar disorders.

Comorbidity and patterns of familial aggregation in attention-deficit/hyperactivity disorder and bipolar disorder in a family study of affective and anxiety spectrum disorders

The aim of this study is to examine the familial aggregation of Attention-deficit/hyperactivity disorder (ADHD) and its cross-transmission with bipolar disorder (BD) in a community-based family study of mood spectrum disorders. A clinically-enriched community sample of 562 probands recruited from the greater Washington, DC metropolitan area and their 698 directly interviewed relatives were included in analyses. Inclusion criteria were English speaking and consent to contact at least two first-degree relatives. Standard family study methodology was used and DSM-IV classified mental disorders were ascertained through a best-estimate procedure based on direct semi-structured interviews and multiple family history reports. There was specificity of familial aggregation of both bipolar I disorder (BD I) and bipolar II disorder (BD II) (i.e., BD I OR = 6.08 [1.66, 22.3]; BD II OR = 2.98 [1.11, 7.96]) and ADHD (ADHD OR = 2.13 [1.16, 3.95]). However, there was no evidence for cross-transmission of BD and ADHD in first degree relatives (i.e., did not observe increased rates of BD in relatives of those with ADHD and vice versa; all ps > 0.05). The specificity of familial aggregation of ADHD and BD alongside the absence of shared familial risk are consistent with the notion that the comorbidity between ADHD and BD may be attributable to diagnostic artifact, could represent a distinct BD suptype characterized by childhood-onset symptoms, or the possibility that attention problems serve as a precursor or consequence of BD.

Integrative analyses prioritize GNL3 as a risk gene for bipolar disorder

Genome-wide association studies (GWASs) have identified numerous single nucleotide polymorphisms (SNPs) associated with bipolar disorder (BD), but what the causal variants are and how they contribute to BD is largely unknown. In this study, we used FUMA, a GWAS annotation tool, to pinpoint potential causal variants and genes from the latest BD GWAS findings, and performed integrative analyses, including brain expression quantitative trait loci (eQTL), gene coexpression network, differential gene expression, protein-protein interaction, and brain intermediate phenotype association analysis to identify the functions of a prioritized gene and its connection to BD. Convergent lines of evidence prioritized protein-coding gene G Protein Nucleolar 3 (GNL3) as a BD risk gene, with integrative analyses revealing GNL3's roles in cell proliferation, neuronal functions, and brain phenotypes. We experimentally revealed that BD-related eQTL SNPs rs10865973, rs12635140, and rs4687644 regulate GNL3 expression using dual luciferase reporter assay and CRISPR interference experiment in human neural progenitor cells. We further identified that GNL3 knockdown and overexpression led to aberrant neuronal proliferation and differentiation, using two-dimensional human neural cell cultures and three-dimensional forebrain organoid model. This study gathers evidence that BD-related genetic variants regulate GNL3 expression which subsequently affects neuronal proliferation and differentiation.

Positional cloning and comprehensive mutation analysis of a Japanese family with lithium-responsive bipolar disorder identifies a novel DOCK5 mutation

Bipolar disorder (BD) is a severe psychiatric disorder characterized by the recurrence of depressive and manic episodes. Its heritability is high, and many linkage and association studies have been performed. Although various linkage regions and candidate genes have been reported, few have shown sufficient reproducibility, and none have identified the pathogenic genes based on the results of the linkage analysis. To find functional variants that are expected to be rare and have strong genetic effects, we recruited ten healthy individuals, two individuals with unknown status, and six patients with BD or recurrent major depressive disorder (MDD) from a Japanese family consisting of 21 members. We performed a genome-wide linkage analysis using a 100K single-nucleotide polymorphism (SNP) array and microsatellite markers to narrow linkage regions within this family. Subsequently, we performed whole-exome sequencing for two patients with BD to identify genetic mutations in the narrowed linkage regions. Then, we performed co-segregation analysis for DNA variants obtained from the results of the exome sequencing. Finally, we identified a rare heterozygous mutation in exon 31 of DOCK5 (c.3170A>G, p.E1057G). Convergent functional genomics analysis revealed that DOCK5 was listed as one of the biomarkers for mood state and suicidality. Although DOCK5 is still a functionally unknown gene, our findings highlight the possibility of a pathological relationship between BD and DOCK5.