The longitudinal course of cognitive insight and mood in bipolar disorder

Factors influencing the level of insight and treatment attitude: a cross-sectional study of 141 elderly patients of major depression in Guangzhou, China

Objective

To explore the insight, treatment attitude, and related influencing factors of hospitalized elderly patients suffering from major depression.

Methods

A total of 141 hospitalized elderly patients with depression were selected as the research objects. Insight was evaluated by the total score of the Insight and Treatment Attitude questionnaire (ITAQ). The data collected included sociodemographic characteristics, psychiatric symptoms, delirium status, social functioning, social support, suicide risk, and cognitive function.

Results

The sample included 74.5% of female patients, and the mean age was 67.53 (sd=7.19) years. The influencing factors of inpatients with depression included alcohol consumption, length of hospitalization, admission types, and the main caregivers (P<0.05). The various factors were further analyzed by linear regression, revealing that the insight and treatment attitude of elderly depressed hospitalized patients were mainly related to the Mini-Mental State Examination (MMSE) (β= 0.225, 95% CI 0.055-0.395, P=0.01), dependent on a caregiver (β=-5.810, 95% CI -8.086~-3.535, P<0.001), the type of admission (involuntary admission) (β=-3.365, 95% CI -5.448~-1.283, P=0.002), Functional Activities Questionnaire (FAQ) (β=-0.156, 95% CI -0.303~-0.010, P=0.037), and length of stay (≤28 days) (β=2.272, 95% CI 0.055~-4.489, P=0.045).

Conclusion

The level of insight was affected by cognitive function, involuntary admission, dependent on a caregiver, social function and length of stay. Future studies should focus on cognitive function recovery, observation of admission mode, and self-care ability in elderly patients with depression.

The additive impact of cardio-metabolic disorders and psychiatric illnesses on accelerated brain aging

Severe mental illnesses (SMI) including major depressive disorder (MDD), bipolar disorder (BD), and schizophrenia spectrum disorder (SSD) elevate accelerated brain aging risks. Cardio‐metabolic disorders (CMD) are common comorbidities in SMI and negatively impact brain health. We validated a linear quantile regression index (QRI) approach against the machine learning “BrainAge” index in an independent SSD cohort (N = 206). We tested the direct and additive effects of SMI and CMD effects on accelerated brain aging in the N = 1,618 (604 M/1,014 F, average age = 63.53 ± 7.38) subjects with SMI and N = 11,849 (5,719 M/6,130 F; 64.42 ± 7.38) controls from the UK Biobank. Subjects were subdivided based on diagnostic status: SMI+/CMD+ (N = 665), SMI+/CMD− (N = 964), SMI−/CMD+ (N = 3,765), SMI−/CMD− (N = 8,083). SMI (F = 40.47, p = 2.06 × 10⁻¹⁰) and CMD (F = 24.69, p = 6.82 × 10⁻⁷) significantly, independently impacted whole‐brain QRI in SMI+. SSD had the largest effect (Cohen’s d = 1.42) then BD (d = 0.55), and MDD (d = 0.15). Hypertension had a significant effect on SMI+ (d = 0.19) and SMI− (d = 0.14). SMI effects were direct, independent of MD, and remained significant after correcting for effects of antipsychotic medications. Whole‐brain QRI was significantly (p < 10⁻¹⁶) associated with the volume of white matter hyperintensities (WMH). However, WMH did not show significant association with SMI and was driven by CMD, chiefly hypertension (p < 10⁻¹⁶). We used a simple and robust index, QRI, the demonstrate additive effect of SMI and CMD on accelerated brain aging. We showed a greater effect of psychiatric illnesses on QRI compared to cardio‐metabolic illness. Our findings suggest that subjects with SMI should be among the targets for interventions to protect against age‐related cognitive decline.

Exploring Clinical Correlates of Metacognition in Bipolar Disorders Using Moderation Analyses: The Role of Antipsychotics

The determinants of metacognition are still poorly understood in bipolar disorders (BD). We aimed to examine the clinical determinants of metacognition, defined as the agreement between objective and subjective cognition in individuals with BD. The participants consisted of 281 patients with BD who underwent an extensive neuropsychological battery and clinical evaluation. To assess subjective cognition, participants provided a general rating of their estimated cognitive difficulties. Clinical characteristics of BD were also recorded, along with medication. We studied the potential moderation of the association between cognitive complaints and global objective cognitive performance by several clinical variables with ordinal logistic regressions. Depression and impulsivity were associated with greater cognitive complaints. The only variable that moderated the relationship between objective and subjective cognition in the global model was the prescription of antipsychotics. Patients taking antipsychotics had a poorer association between cognitive complaints and objective neuropsychological performance. This result suggests a role for dopamine in the modulation of metacognitive performance, and calls for the systematic control of antipsychotic medication in future studies documenting metacognitive deficits in severe and persistent mental disorders. Depression and impulsivity should be investigated as potential therapeutic targets for individuals with BD and cognitive complaints, before proposing an extensive neuropsychological evaluation.

Associations between cognitive impairment and illness awareness in fully remitted bipolar outpatients

The euthymic state of bipolar disorder is often characterized by impaired cognitive function. In this investigation, we hypothesized that subjective cognitive function is impaired and illness awareness is inadequate and we further explored the associations among cognitive complaints, objective cognitive functions, and current illness awareness in Japanese patients. Twenty-seven patients in remission and 27 healthy subjects were recruited in this study. The Japanese version of the Cognitive Complaints in Bipolar Disorder Rating Assessment (COBRA) and Scale to Assess Unawareness in Mental Disorders (Japanese, SUMD-J) were used to assess each patient. All patients underwent neuropsychological tests for the assessment of objective cognitive functions. Only SUMD2.C (current awareness of the effects of medication) was significantly correlated with COBRA, and the objective cognitive assessments, Word Fluency Test and Stroop Test Reaction Time, represented significant correlations with SUMD1.C (current awareness of mental illness). In remitted bipolar outpatients, both the objective and subjective cognitive functions were found to be associated with illness awareness. However, subjective and objective cognitive functions differed in the related illness awareness subscales in fully remitted bipolar outpatients.

The Patient Health Questionnaire-9 vs. the Hamilton Rating Scale for Depression in Assessing Major Depressive Disorder

Background: The Hamilton Rating Scale for Depression (HAMD-17) has been used for several decades to assess the severity of depression. Multiple studies have documented defects in this scale and deemed it unsuitable for clinical evaluation. The HAMD-6, which is the abbreviated version of HAMD-17, has been shown to be effective in assessing the core symptoms of depression with greater sensitivity than HAMD-17. And the Patient Health Questionnaire-9 (PHQ-9) is suggested as an effective alternative to the HAMD-17 because of its simplicity and ease-of-use. Methods: Research was completed involving 1,741 participants having major depressive disorder. Cronbach's alpha, intraclass correlation coefficient (ICC) and weighted Kappa analysis was used to determine the reliability of the scales. Pearson correlation analysis and factor analysis were used to analyze validity. Item response theory (IRT) was used to analyze psychological characteristics of items in both the HAMD-17 and PHQ-9. Results: Reliability analysis showed that the Cronbach's alpha of the HAMD-17, HAMD-6 and PHQ-9 were 0.829, 0.764, and 0.893 respectively, and the ICC of the three scales ranged from 0.606 to 0.744. The Kappa score of the consistency of depression severity assessment was 0.248. Validity analysis showed that the PHQ-9 was a single factor structure, and the total score of the scale was strongly correlated with the HAMD-17 (r = 0.724, P < 0.001). The IRT analysis showed that the discrimination parameters of the PHQ-9 were higher than that of the HAMD-17 in all dimensions. The HAMD-6 had the lowest measurement accuracy in distinguishing the severity of depression, while the PHQ-9 had the highest measurement accuracy. Conclusion: Results showed that the PHQ-9 was satisfactory in terms of reliability, validity and distinguishing the severity of depression. It is a simple, rapid, effective and reliable tool which can be used as an alternative to the HAMD-17 to assess the severity of depression.

A qualitative exploration of how people with bipolar disorder consider risk-taking in everyday decisions

BACKGROUND

Difficulties with decision making and risk taking in individuals with bipolar disorder (BD) have been associated with mood episodes. However, there is limited information about these experiences during euthymia, the mood state where people with BD spent the majority of their time.

AIMS

To examine how individuals with BD consider risk in everyday decisions during their euthymic phase.

METHOD

We conducted a qualitative study that used semi-structured audio recorded interviews. Eight euthymic participants with confirmed BD were interviewed, and we used interpretative phenomenological analysis to analyse the data.

RESULTS

We identified four themes. The first theme, 'Who I really am', involves the relationship between individual identity and risks taken. The second theme, 'Taking back control of my life', explored the relationship between risks taken as participants strove to keep control of their lives. The third theme, 'Fear of the "what ifs"', represents how the fear of negative consequences from taking risks impacts risk decisions. Finally, the fourth theme, 'The role of family and friends', highlights the important role that a supporting network can play in their lives in the context of taking risks.

CONCLUSIONS

The study highlights aspects that can impact on an individual with BD's consideration of risk during euthymia. Identity, control, fear and support all play a role when a person considers risk in their decision-making process, and they should be taken into consideration when exploring risk with individuals with BD in clinical settings, and inform the design of future interventions.

Metacognitive functioning in bipolar disorder versus controls and its correlations with neurocognitive functioning in a cross-sectional design

INTRODUCTION

Metacognition is an important factor in the development and persistence of bipolar disorder. One of the most striking examples of impairment in metacognitive functioning in bipolar disorder is the lack of insight these patients have in their disorder. Despite its importance, research regarding metacognition in bipolar disorder is scarce. Furthermore, the neurocognitive basis of metacognitive functioning is unknown.

METHODS

The current study included 29 patients with bipolar disorder and 29 age, educational level and gender matched healthy controls. All the participants filled in a metacognition questionnaire that examined their metacognitive beliefs. In addition, it was tested how well they estimated their performance on a neurocognitive test-battery beforehand (metacognitive knowledge) and afterwards (metacognitive experience).

RESULTS

Bipolar disorder patients showed maladaptive metacognitive beliefs in comparison with the healthy controls. They also showed impaired metacognitive knowledge and experience. That is, they overestimated their own cognitive performance. However, the latter result was also true for the healthy controls. In addition, metacognition had neurocognitive correlates. However, for the bipolar patients, depressive symptomatology had an important effect on this relationship and on metacognition in general.

CONCLUSION

Maladaptive metacognitive skills are related to depression in bipolar disorder. A more healthy metacognitive thinking should be promoted. An effective training for this could be a therapy that includes various elements, from basic cognitive- to higher order metacognitive training.