General Medical Conditions Are Associated With Delay to Treatment in Patients with Bipolar Disorder

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

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

Risk of Pediatric Bipolar Disorder After General Anesthesia in Infants and Toddlers: A Propensity Score-Matched Population-Based Cohort Study

BACKGROUND AND HYPOTHESIS

The potential role of anesthesia as an independent risk factor for childhood bipolar disorder (BD) remains unclear. To address this, we conducted a population-based cohort study employing propensity score matching to compare BD incidence between pediatric patients undergoing surgery with and without general anesthesia.

STUDY DESIGN

Our study included patients aged 0-3 years who received at least 1 episode of general anesthesia and were hospitalized for over 1 day in Taiwan between January 2004 and December 2014. They were matched 1:1 with a population not receiving general anesthesia to assess pediatric BD incidence.

STUDY RESULTS

The study cohort comprised 15 070 patients, equally distributed between the general anesthesia and nongeneral anesthesia groups (7535 each). Multivariate Cox regression analysis revealed adjusted hazard ratios (aHRs; 95% CIs) for pediatric BD in the general anesthesia group as 1.26 (1.04-1.54; P = .021) compared to the nongeneral anesthesia group. Moreover, the incidence rate ratio (95% CI) for the general anesthesia group was 1.26 (1.03-1.53) compared to the nongeneral anesthesia group.

CONCLUSIONS

Early childhood exposure to general anesthesia is significantly associated with an increased risk of pediatric BD. This expands understanding of pediatric BD's complex development, informing preventive strategies, and enhancing mental health outcomes for vulnerable young patients and global pediatric healthcare.

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.

Correlates of long duration of untreated illness (DUI) in patients with bipolar disorder: results of an observational study

BACKGROUND

Despite a high number of studies investigating the correlation between long Duration of Untreated Illness (DUI) and poor course of Bipolar Disorder (BD), the results concerning the impact of DUI on some specific factors, such as suicidality and medical comorbidities, are still inconsistent. This cross-sectional observational study aimed at analyzing potential socio-demographic and clinical correlates of long DUI in a large cohort of real-world, well-characterized BD patients.

METHODS

The socio-demographic and clinical characteristics of 897 patients with BD were collected. The sample was divided for analysis in two groups (short DUI vs long DUI) according to a DUI cutoff of 2 years. Comparisons were performed using χ2 tests for categorical variables and the Kruskal-Wallis test for continuous variables. Logistic regression (LogReg) was used to identify explanatory variables associated with DUI (dependent variable).

RESULTS

Six-hundred and sixty patients (75.5%) presented long DUI (> 2 years) and mean DUI was 15.7 years. The LogReg analysis confirmed the association of long DUI with bipolar II disorder (p: 0.016), lower age at onset (p < 0.001), depressive predominant polarity (p: 0.018), depressive polarity onset (p < 0.001), longer duration of illness (p < 0.001), lifetime suicide attempts (p: 0.045) and current medical comorbidities (p: 0.019).

CONCLUSIONS

The present study confirms the association between long DUI and higher risk of suicide attempts in patients with BD. Moreover, an association between long DUI and higher rates of medical conditions has been found.

The RAS-24: Development and validation of an adherence-to-medication scale for severe mental illness patients

Introduction

Several studies have found that most patients with severe mental illness (SMI) and comorbid (physical) conditions are partially or wholly nonadherent to their medication regimens. Nonadherence to treatment is a serious concern, affecting the successful management of patients with SMIs. Psychiatric disorders tend to worsen and persist in nonadherent patients, worsening their overall health. The study described herein aimed to develop and validate a scale (the Ralat Adherence Scale) to measure nonadherence behaviors in a culturally sensitive way.

Materials and Methods

Guided by a previous study that explored the primary reasons for nonadherence in Puerto Rican patients, we developed a pool of 147 items linked to the concept of adherence. Nine experts reviewed the meaning, content, clarity, and relevance of the individual items, and a content validity ratio was calculated for each one. Forty items remained in the scale's first version. This version was administered to 160 patients (21-60 years old). All the participants had a diagnosis of bipolar disorder, major depressive disorder, or schizoaffective disorder. The STROBE checklist was used as the reporting guideline.

Results

The scale had very good internal consistency (Cronbach's alpha = 0.812). After a factor analysis, the scale was reduced to 24 items; the new scale had a Cronbach's alpha of 0.900.

Conclusions

This adherence scale is a self-administered instrument with very good psychometric properties; it has yielded important information about nonadherence behaviors. The scale can help health professionals and researchers to assess patient adherence or nonadherence to a medication regimen.

A systematic review and meta-analysis of delayed help-seeking, delayed diagnosis and duration of untreated illness in bipolar disorders

OBJECTIVES

To examine the time delay between the age at onset of symptoms or episodes of bipolar disorders (BD) and the age at diagnosis of and/or receipt of clinical practice guideline recommended interventions for BD.

METHODS

Systematic search of five databases to identify publications from January 2000 to July 2022 that reported one or more of the following reliable and valid estimates of latency: delay in help seeking (DHS), delay in diagnosis (DD) and duration of untreated BD (DUB). Eligible studies were included in random effects meta-analyses and multivariate meta-regression was used to assess factors associated with each latency construct.

RESULTS

Screening of 1074 publications identified 59 eligible studies (reported in 66 publications) of >40,000 individuals that estimated DHS (8 studies), DD (20 studies) and/or DUB (45 studies). The median DHS, DD and DUB were 3.5 (IQR: 2.8, 8.48), 6.7 (IQR: 5.6, 8.9) and 5.9 years (IQR: 1.1, 8.2), respectively. Key factors associated with shorter DD included older age and residing outside North America; shorter DUB was associated with psychotic or manic onset and access to early intervention services.

CONCLUSIONS

Greater consensus on definitions of latency constructs and better-quality targeted research is required regarding DHS, DD and DUB. This review suggests that, while the peak age at onset of BD is 15-25, diagnosis and guideline recommended interventions (e.g., mood stabilizers) are likely to be delayed until age 25-35 years except for a minority of individuals with access to early intervention services.

Risk of Suicide in Patients With Bipolar Disorder Having Comorbid Chronic Pain Disorders: Insights From the Nationwide Inpatient Sample Data From 2016 to 2018

ABSTRACT

Bipolar disorders (BDs) are associated with significant risk of suicide. BD patients (age ≥18 years) admitted to the hospital were identified from the National Inpatient Sample dataset. Based on the secondary diagnosis of chronic pain disorder (CPD), patients were stratified into two groups (1) BD with CPD (BD + CPD) and (2) BD without CPD (BD - CPD). Groups were matched (1:1) for the type of BD and compared for baseline characteristics and suicidal ideation/attempt (SI/SA). Compared with BD - CPD, most patients in the BD + CPD group were older (mean age, 47.6 vs. 40.4 years), female (58.4% vs. 55.2%), and white (77.2% vs. 66.7%). After adjusting for covariates, compared with the BD - CPD group, the BD + CPD group had 21% more risk of SI/SA (odds ratio, 1.21, p < 0.001). CPD is independently associated with the increased risk of suicide among patients with BD. Thus, comorbid CPD among patients admitted for BD can be an essential risk factor for suicide.

Development of a Psychosocial Intervention to Promote Treatment Adherence in Patients with Bipolar Disorder at Risk of Cardiovascular Disease

Nonadherence to treatment is a serious concern that affects the successful management of bipolar disorder (BD) patients. The aim of this study was to pilot test a psychosocial intervention (previously developed by this team) intended to increase adherence to medication and health behaviors targeting cardiovascular disease (CVD) risk factors in BD patients. An open, single-group design was used to assess the feasibility and acceptability of the intervention. The participants had BD, type I/II or unspecified, and CVD risk factors. Baseline demographic measures were taken. We also obtained preliminary effect sizes related to pre-post changes on measures of self-reported adherence to psychiatric medication, depressive and manic symptoms, and pharmacy records. At baseline, 29% of the participants reported recent adherence to psychiatric medications. A total of 71% of the participants completed the intervention. Pre-post improvements by medium and large effect sizes (Cohen’s d = 0.52–0.92) were seen in medication adherence, attitudes toward medication, and mania symptoms. The participants reported high levels of satisfaction with the intervention. A culturally sensitive psychosocial intervention for Puerto Rican BD patients who are at risk of CVD was found to be feasible and acceptable. Improvements in the key outcomes were seen in this small, preliminary study. Further research is needed with a larger sample size.

Manic-Depressive Cycles in Bipolar Disorder: Clinical and Treatment Implications

INTRODUCTION

Cycle patterns of bipolar disorders (BDs) have been previously shown to be associated with clinical characteristics and response to lithium salts. Here, we evaluated the distribution of different types of manic-depressive cycles in a large sample of patients with BD. The associations between a mania-depression-interval (MDI) course and depression-mania-interval (DMI) course with sociodemographic/clinical factors were also assessed in order to define specific clinical profiles.

METHODS

In this cross-sectional study, 806 patients with BD admitted to the Psychiatric Unit of San Luigi Gonzaga Hospital in Orbassano and Molinette Hospital in Turin, Italy, were recruited. Patients were grouped according to the following course patterns: MDI, DMI, continuous cycling (CC, <4 episodes/year without intervals), rapid cycling (RC, ≥4 episodes/year), and irregular (IRR) cycling. We compared several sociodemographic and clinical variables in an MDI versus DMI course by means of ANOVA and Pearson χ2 with Bonferroni correction.

RESULTS

Bipolar cycles were distributed as follows: 50.2% IRR course, 31.5% MDI course, 16% DMI course, 1.2% CC, and 1% RC. Compared to DMI course, patients with an MDI course were more often men, younger, with an earlier onset, a manic polarity onset, and more lifetime compulsory admissions. They were more frequently treated with lithium and antipsychotics. Patients with a DMI course had older age at diagnosis and at first mood-stabilizer treatment and were more often misdiagnosed with a major depressive disorder. These patients were more commonly treated with anticonvulsants, and they had more frequently failed treatment trials with lithium salts in the past.

CONCLUSION

This study supports the utility of classifying BD according to their course patterns. This classification holds prognostic as well as therapeutic implications.

Early identification of bipolar disorder among young adults - a 22-year community birth cohort

OBJECTIVE

We set forth to build a prediction model of individuals who would develop bipolar disorder (BD) using machine learning techniques in a large birth cohort.

METHODS

A total of 3748 subjects were studied at birth, 11, 15, 18, and 22 years of age in a community birth cohort. We used the elastic net algorithm with 10-fold cross-validation to predict which individuals would develop BD at endpoint (22 years) at each follow-up visit before diagnosis (from birth up to 18 years). Afterward, we used the best model to calculate the subgroups of subjects at higher and lower risk of developing BD and analyzed the clinical differences among them.

RESULTS

A total of 107 (2.8%) individuals within the cohort presented with BD type I, 26 (0.6%) with BD type II, and 87 (2.3%) with BD not otherwise specified. Frequency of female individuals was 58.82% (n = 150) in the BD sample and 53.02% (n = 1868) among the unaffected population. The model with variables assessed at the 18-year follow-up visit achieved the best performance: AUC 0.82 (CI 0.75-0.88), balanced accuracy 0.75, sensitivity 0.72, and specificity 0.77. The most important variables to detect BD at the 18-year follow-up visit were suicide risk, generalized anxiety disorder, parental physical abuse, and financial problems. Additionally, the high-risk subgroup of BD showed a high frequency of drug use and depressive symptoms.

CONCLUSIONS

We developed a risk calculator for BD incorporating both demographic and clinical variables from a 22-year birth cohort. Our findings support previous studies in high-risk samples showing the significance of suicide risk and generalized anxiety disorder prior to the onset of BD, and highlight the role of social factors and adverse life events.

Association between periodontitis and bipolar disorder: A nationwide cohort study

Whether periodontitis is a risk factor for developing bipolar disorders (BD) has not been investigated. We aimed to determine whether periodontitis is associated with the subsequent development of BD and examine the risk factors for BD among patients with periodontitis.Using ambulatory and inpatient claims data from the National Health Insurance Research Database (NHIRD), we identified 12,337 patients who were aged at least 20 years and newly diagnosed with periodontitis between 2000 and 2004. The date of the first claim with a periodontitis diagnosis was set as the index date. For each patient with periodontitis, 4 subjects without a history of periodontitis were randomly selected from the NHIRD and frequency-matched with the patients with periodontitis according to sex, age (in 5-year bands), and index year.The periodontitis group had a mean age of 44.0 ± 13.7 years and slight predominance of men (51.3%). Compared with the subjects without periodontitis, the patients with periodontitis had higher prevalence of diabetes mellitus, hyperlipidemia, hypertension, ischemic heart disease, stroke, head injury, major depressive disorder, chronic obstructive pulmonary disease (COPD), and asthma (P < .001). The incidence rate of BD was higher in the periodontitis group than in the non-periodontitis group (2.74 vs 1.46 per 1000 person-year), with an adjusted hazard ratio of 1.82 (95% confidence interval = 1.59-2.08) after adjustment for sex, age, and comorbidities.The patients with periodontitis exhibited a significantly higher risk of developing BD. Keep the better oral hygiene to reduce periodontitis might be a preventive strategy for BD.

THE MANAGEMENT OF CARDIOVASCULAR DISEASE RISK FACTORS IN BIPOLAR DISORDER PATIENTS IN PRIMARY HEALTHCARE SETTINGS

Accumulating evidence supports the association between cardiovascular disease (CVD) risk factors and bipolar disorder (BD). CVD is the leading cause of morbidity and mortality in patients with bipolar disorder. However, there is a need to study the management of the risk factors in the primary healthcare context. This narrative review aims to appraise the different approaches of care that have been used in the management of these patients to address CVD risk factors in primary care. We reviewed articles from PubMed, Science Direct and other studies cited in the articles found. The keywords used for this review included "bipolar," "bipolar disorder," "cardiovascular" or "metabolic syndrome," "screening," "primary care," and "integrative" or "integrated care model" or "collaborative care model." This review includes studies published over a period of 48 months (January 2016 through December 2019). We identified 128 articles, removing two duplicates. From them, 115 articles are excluded based on the inclusion/exclusion criteria leaving eleven relevant articles. Upon full-text review, six studies were excluded. The final studies included are five. We used the study-quality assessment tools from the National Heart, Lung, and Blood Institute to assess the quality of the articles found. CVD risk factors in patients with BD and forms of other severe mental illness (SMI) are often underdetected. Primary healthcare providers need to identify these risk factors in the management of these patients to determine and recommend appropriate strategies.

Childhood maltreatment and adult medical morbidity in mood disorders: comparison of unipolar depression with bipolar disorder

BACKGROUND

The medical burden in mood disorders is high; various factors are thought to drive this pattern. Little research has examined the role of childhood maltreatment and its effects on medical morbidity in adulthood among people with unipolar depression and bipolar disorder.AimsThis is the first study to explore the association between childhood maltreatment and medical morbidity in bipolar disorder and in unipolar depression, and examine whether the impact of abuse and neglect are distinct or combined.

METHOD

The participants consisted of 354 psychiatrically healthy controls, 248 participants with recurrent unipolar depression and 72 with bipolar disorder. Participants completed the Childhood Trauma Questionnaire and received a validated medical history interview.

RESULTS

Any type of childhood maltreatment, child abuse and child neglect were significantly associated with the medical burden in bipolar disorder, but not unipolar depression or for controls. These associations worked in a dose-response fashion where participants with bipolar disorder with a history of two or more types of childhood maltreatment had the highest odds of having a medical illness relative to those without such history or those who reported one form. No such significant dose-response patterns were detected for participants with unipolar depression or controls.

CONCLUSIONS

These findings suggest that childhood maltreatment may play a stronger role in the development of medical illnesses in individuals with bipolar disorder relative to those with unipolar depression. Individuals who had been maltreated with a mood disorder, especially bipolar disorder may benefit most from prevention and intervention efforts surrounding physical health.Declaration of interestNone.

Reasons for Nonadherence to Psychiatric Medication and Cardiovascular Risk Factors Treatment Among Latino Bipolar Disorder Patients Living in Puerto Rico: A Qualitative Study

Latinos with bipolar disorder (BD) have a high rate of nonadherence to psychiatric medication and treatment for other medical conditions such as cardiovascular disease (CVD) risk factors than non-Latinos with BD. The aim of this study is to identify patients' perspectives on the reasons for nonadherence to psychiatric medication and for CVD risk factors conditions in outpatients with BD. Three focus group sessions were held for a total of 22 adults ranging from 23 to 60 years old. Participants had BD, Type I/II and CVD risk factors. Audio-recordings of focus groups were transcribed and a content analysis was performed. Reasons identified as barriers to adherence were somewhat different for BD medications in comparison to CVD risk factors suggesting the need for integrated interventions targeting these barriers to adherence for both BD and CVD risk factors.

Epigenetics of Metabolic Syndrome as a Mood Disorder

Mood disorders comprise major depressive disorder (MDD), bipolar disorder (BD) and the milder forms of these two disorders. Reccurring MDD is also known as unipolar disorder. The distinction between unipolar and bipolar disorders was first suggested in 1957 by Leonard and was made official after support by several studies in 1980. Indeed, in 150 AD, Aretaeus of Cappadocia wrote “It seems to me that melancholia is the beginning and a part of mania”. Additionally, Kraepelin, who proposed the first medical disease model in psychiatry a century ago, considered recurrent unipolar depression cases under the category of bipolar disorder and conceptualized spectrum disorders. Because today’s classification systems conduct cross-sectional diagnosis, they do not consider family history, long-term characteristics and multidimensional approaches on symptoms. This method prioritizes reliability over validity and it rules out psychiatric disorders in etiology. Actually, a spectrum model which covers physical diseases is conceivable. The concept of epigenetics considers mood disorders, Alzheimer’s disease, attention deficit and hyperactivity disorder, Carney syndrome, multiple endocrine neoplasia type I and II, breast and prostate cancers, carsinoid tumors, cerebrovascular and cardiovascular diseases and metabolic syndrome together. This review addressed the relationship between metabolic syndrome and mood disorders in this context along with genetic, clinical and environmental factors such as climate, geographic factors, migration and changeable lifestyles. Genetic and clinical variables are affective temperament, childhood trauma and use of antidepressants and antipsychotics.

The Impact of General Medical Conditions in Obsessive-Compulsive Disorder

OBJECTIVE

The co-occurrence of general medical conditions (GMCs) and major psychiatric disorders is well documented. The aim of this study was to assess the prevalence of GMCs in patients with a primary diagnosis of obsessive-compulsive disorder (OCD) and, secondly, to investigate which clinical variables are associated with the presence of a GMC.

METHODS

Subjects with a primary diagnosis of OCD were included. Socio-demographic and clinical characteristics were collected. GMCs were classified using the ICD-10 and grouped according to the Cumulative Illness Rating Scale (CIRS) in: cardiac, vascular, hematopoietic, respiratory, ear/nose/throat, upper and lower gastrointestinal, hepatic, renal, genitourinary, musculoskeletal, neurologic, endocrine/metabolic. The association between the presence of GMCs and demographic/clinical variables of OCD was investigated.

RESULTS

A total of 162 patients with OCD were included. 78 (48.1%) patients had at least one comorbid GMC. Most frequent GMCs were endocrine/metabolic diseases (25.9%), followed by upper/lower gastrointestinal (20.5%) and cardio-vascular diseases (13.6%). The presence of a GMC was significantly associated with female gender, older age, duration of untreated illness (DUI), and absence of physical activity.

CONCLUSION

Patients with OCD have high rates of comorbid GMCs. A longer DUI is associated with having at least one GMCs; this might be due to the long-lasting adoption of unhealthy lifestyles, not counterbalanced by appropriate treatment and psychoeducation.

Increased risk of chronic obstructive pulmonary disease in patients with bipolar disorder: A population-based study

BACKGROUND

We conducted this nationwide study to examine the prevalence and incidence of chronic obstructive pulmonary disease (COPD) among patients with bipolar disorder in Taiwan.

METHODS

We used a random sample of 766,427 subjects who were aged ≥18 years in 2005. Patients with at least one primary diagnosis of bipolar disorder were identified. Study participants with one primary or secondary diagnosis of COPD for either ambulatory or inpatient care were also identified. We compared the prevalence of COPD in patients with bipolar disorder and the general population in 2005. In addition, we further investigated this cohort from 2006 to 2010 to detect incident cases of COPD in patients with bipolar disorder compared with the general population. The factors associated with COPD among patients with bipolar disorder were also analyzed.

RESULTS

The prevalence of COPD in patients with bipolar disorder was higher than in the general population in 2005 (5.68% vs. 2.88%, odds ratio 2.03; 95% confidence interval, 1.53-2.67). The average annual incidence of COPD in patients with bipolar disorder was also higher than in the general population (2.03% vs. 1.03%, risk ratio 1.94; 95% confidence interval, 1.65-2.29) from 2006 to 2010.

LIMITATIONS

Some risk factors for COPD such as substance use, obesity, or lifestyle pattern were not available in this study.

CONCLUSIONS

Patients with bipolar disorder had a higher prevalence and incidence of COPD compared with the general population. Higher prevalence of COPD among bipolar patients was associated with increased age, males, hypertension, and second-generation antidepressant use.

Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls

People with severe mental illness (SMI) - schizophrenia, bipolar disorder and major depressive disorder - appear at risk for cardiovascular disease (CVD), but a comprehensive meta-analysis is lacking. We conducted a large-scale meta-analysis assessing the prevalence and incidence of CVD; coronary heart disease; stroke, transient ischemic attack or cerebrovascular disease; congestive heart failure; peripheral vascular disease; and CVD-related death in SMI patients (N=3,211,768) versus controls (N=113,383,368) (92 studies). The pooled CVD prevalence in SMI patients (mean age 50 years) was 9.9% (95% CI: 7.4-13.3). Adjusting for a median of seven confounders, patients had significantly higher odds of CVD versus controls in cross-sectional studies (odds ratio, OR=1.53, 95% CI: 1.27-1.83; 11 studies), and higher odds of coronary heart disease (OR=1.51, 95% CI: 1.47-1.55) and cerebrovascular disease (OR=1.42, 95% CI: 1.21-1.66). People with major depressive disorder were at increased risk for coronary heart disease, while those with schizophrenia were at increased risk for coronary heart disease, cerebrovascular disease and congestive heart failure. Cumulative CVD incidence in SMI patients was 3.6% (95% CI: 2.7-5.3) during a median follow-up of 8.4 years (range 1.8-30.0). Adjusting for a median of six confounders, SMI patients had significantly higher CVD incidence than controls in longitudinal studies (hazard ratio, HR=1.78, 95% CI: 1.60-1.98; 31 studies). The incidence was also higher for coronary heart disease (HR=1.54, 95% CI: 1.30-1.82), cerebrovascular disease (HR=1.64, 95% CI: 1.26-2.14), congestive heart failure (HR=2.10, 95% CI: 1.64-2.70), and CVD-related death (HR=1.85, 95% CI: 1.53-2.24). People with major depressive disorder, bipolar disorder and schizophrenia were all at increased risk of CVD-related death versus controls. CVD incidence increased with antipsychotic use (p=0.008), higher body mass index (p=0.008) and higher baseline CVD prevalence (p=0.03) in patients vs.

CONTROLS

Moreover, CVD prevalence (p=0.007), but not CVD incidence (p=0.21), increased in more recently conducted studies. This large-scale meta-analysis confirms that SMI patients have significantly increased risk of CVD and CVD-related mortality, and that elevated body mass index, antipsychotic use, and CVD screening and management require urgent clinical attention.

Predictors of metabolic syndrome in first manic episode

OBJECTIVE

In the present study we aimed to investigate, whether an association between metabolic syndrome (MetS) and clinical features and affective temperaments exists or not in first manic episode of bipolar disorder (BD) and to clarify the prevalence and predictors of MetS.

METHOD

A total of 150 patients who were received a diagnosis of bipolar disorder type I according to DSM-IV criteria and who were experiencing their first manic episode (FME) were screened consecutively for inclusion. NCEP ATP III formulated an operational definition of MetS based on the presence of three or more of the following characteristics: abdominal obesity (waist circumference), hypertriglyceridemia, low HDL or being on an antilipidemic agent, high blood pressure or being on an antihypertensive agent, and fasting hyperglycemia or being on antiglycemic agent. The patients who had been in remission period for at least 8 weeks were evaluated with SKIP-TURK and TEMPS-A. Remission was defined as YMRS score <5.

RESULTS

37 (32.5%) patients had a MetS. Previous depressive episode, seasonality, negative family history and childhood trauma are determined as the predictors of MetS. Anxious and irritable temperament scores were higher in MetS (+) patients.

CONCLUSION

According to our results, links between MetS and BD may also have been predicted by genetic and environmental factors.

Duration of untreated illness in first-treatment bipolar I disorder in relation to clinical outcome and cannabis use

There is little knowledge about the role of the duration of untreated bipolar (DUB) illness in first-treatment bipolar disorder I (BD I), its association with symptoms at start of first treatment, and development over the first year, and limited knowledge about factors that influence the length of DUB. Substance use has shown to delay identification of primary psychiatric disorders, and while cannabis use is common in BD the role of cannabis in relationship to DUB is unclear. The aim of the present study is to examine the associations between DUB and key clinical outcomes at baseline in BD I, and at one year follow-up, and to evaluate the influence of cannabis use. Patients with first-treatment BD I (N=62) completed comprehensive clinical evaluations, which included both DUB and the number of previous episodes. There were no significant associations between DUB and key clinical outcomes. Longer duration from first manic episode to treatment was associated with risk of starting excessive cannabis use after onset of the bipolar disorder. The main finding is the lack of significant associations between features of previous illness episodes and clinical outcomes. Long duration of untreated mania seems to increase the risk for later cannabis use.

Bipolar disorder and diabetes mellitus: evidence for disease-modifying effects and treatment implications

BACKGROUND

Bipolar disorder refers to a group of chronic psychiatric disorders of mood and energy levels. While dramatic psychiatric symptoms dominate the acute phase of the diseases, the chronic course is often determined by an increasing burden of co-occurring medical conditions. High rates of diabetes mellitus in patients with bipolar disorder are particularly striking, yet unexplained. Treatment and lifestyle factors could play a significant role, and some studies also suggest shared pathophysiology and risk factors.

OBJECTIVE

In this systematic literature review, we explored data around the relationship between bipolar disorder and diabetes mellitus in recently published population-based cohort studies with special focus on the elderly.

METHODS

A systematic search in the PubMed database for the combined terms "bipolar disorder" AND "elderly" AND "diabetes" in papers published between January 2009 and December 2015 revealed 117 publications; 7 studies were large cohort studies, and therefore, were included in our review.

RESULTS

We found that age- and gender- adjusted risk for diabetes mellitus was increased in patients with bipolar disorder and vice versa (odds ratio range between 1.7 and 3.2).

DISCUSSION

Our results in large population-based cohort studies are consistent with the results of smaller studies and chart reviews. Even though it is likely that heterogeneous risk factors may play a role in diabetes mellitus and in bipolar disorder, growing evidence from cell culture experiments and animal studies suggests shared disease mechanisms. Furthermore, disease-modifying effects of bipolar disorder and diabetes mellitus on each other appear to be substantial, impacting both treatment response and outcomes.

CONCLUSIONS

The risk of diabetes mellitus in patients with bipolar disorder is increased. Our findings add to the growing literature on this topic. Increasing evidence for shared disease mechanisms suggests new disease models that could explain the results of our study. A better understanding of the complex relationship between bipolar disorder and diabetes mellitus could lead to novel therapeutic approaches and improved outcomes.

Increased risk of fracture in patients with bipolar disorder: a nationwide cohort study

OBJECTIVES

Bipolar disorder (BD) is a systemic inflammatory disease, and disrupted bone metabolism due to the inflammatory process can cause fracture. Despite evidence of an association between lower bone mineral density and an increased risk of fracture among patients with depression, schizophrenia, and anorexia nervosa, whether BD is a risk factor for subsequent fracture is unknown. To determine the association between BD and fracture and to examine the risk factors for fracture among patients with BD.

METHODS

In this study, we enrolled patients diagnosed with BD from the Taiwan National Health Insurance Research Database. Patients newly diagnosed with BD (ICD-9-CM 296) from 2001 to 2008 were included in the BD cohort, and the date of the initial diagnosis of BD was used as the index date. The comparison cohort, comprising participants without BD, was frequency matched to the BD cohort by age, sex, and index year, and the occurrence of fracture was evaluated in both cohorts.

RESULTS

The BD and comparison cohorts were comprised of 47,271 patients with BD and 1,89,084 frequency-matched participants without BD, respectively. The incidence of fracture was higher among patients with BD than among the controls. Cox models showed that BD was an independent risk factor for fracture irrespective of comorbidities [hazard ratio (HR) = 1.79, 95 % confidence interval (CI) = 1.73-1.84, p < .001].

CONCLUSION

Our study showed that patients with BD have a higher risk of subsequent fracture. Additional prospective clinical studies investigating the relationship between BD and fracture are warranted.

Disparities in Treatment and Service Utilization Among Hispanics and Non-Hispanic Whites with Bipolar Disorder

OBJECTIVES

Due to the serious and recurrent nature of bipolar disorder, continuous long-term medication treatment is typically recommended. Little is known about whether these treatment recommendations are effectively implemented for Hispanics. This study examined differences in mood stabilizer use and mental health service utilization between adult English-speaking Hispanic and non-Hispanic white respondents with bipolar disorder.

METHODS

The sample included 163 participants with lifetime bipolar I and II disorders in the National Comorbidity Survey Replication. Demographics, symptom presentation, and acculturation were examined as covariates.

RESULTS

None of the 26 Hispanic respondents were taking mood-stabilizing medication, compared to 21 % of non-Hispanic whites, and Hispanics were less likely to receive medications for emotional problems, see a professional for manic episodes, or attend psychotherapy. Even after accounting for differences in symptom profiles and sociodemographics, ethnicity continued to be a significant predictor of mood stabilizer use and psychotherapy attendance. There was a non-significant trend toward lower acculturation among Hispanics being associated with even poorer service utilization.

CONCLUSIONS

No Hispanics were receiving minimally adequate treatment for their bipolar disorder. Future research should focus on identifying the barriers that lead to these stark ethnic disparities in treatment.

Patient perceptions of physical health and bipolar symptoms: The intersection of mental and physical health

BACKGROUND

Affective symptoms and medical comorbidities have a negative impact on the course of bipolar disorder. The aim of this analysis was to examine how the perceptions of physical health and functioning in individuals with bipolar disorder relate to their mood symptoms.

METHODS

We analyzed longitudinal data from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) on the physical subscales of the Short Form Health Survey (SF-36) (physical functioning, role limitations due to physical problems, bodily pain, and general health).

RESULTS

Participants' perception of their overall physical health predicted severity of mania/hypomania, depression, and life satisfaction at concurrent and future visits. Perceptions of role limitations due to physical health problems predicted depressive symptoms and poor life satisfaction. Worse bodily pain predicted symptoms of mania/hypomania. Reports of specific or concrete physical limitations in daily life showed no associations with psychiatric symptoms at concurrent assessments, but did predict worse course of illness one year later. SF-36 scores showed significant, but small associations with the presence of medical comorbidities.

LIMITATIONS

Perceptions of physical health and quality of life were self-report, potentially lending themselves to transient negative biases, particularly among depressed participants. Additionally, the SF-36 was selected as a generic, widely used measure; as a result, it was not specific to the illness burden of bipolar disorder.

CONCLUSION

Overall, broad perceptions of poor physical health were associated with worse course of illness over the 24 months of the study. Though further research is warranted, changes in subjective physical health related quality of life, even independent of objective health changes, may offer important insight into global wellbeing and be targets of psychotherapy treatment.

A bipolar II cohort (ABC): The association of functional disability with gender and rapid cycling

BACKGROUND

Bipolar II disorder (BP II) is a chronic, frequently co-morbid, and complex disorder with similar rates of attempted suicide to BP I. However, case identification for BP II studies that is based on clinician diagnosis alone is prone to error. This paper reports on differences between clinical and research diagnoses and then describes the clinical characteristics of a carefully defined BP II cohort.

METHODS

A cohort of rigorously defined BP II cases were recruited from a range of primary and secondary health services in the North of England to participate in a programme of cross-sectional and prospective studies. Case identification, and rapid cycling, comorbidities and functioning were examined.

RESULTS

Of 355 probable clinical cases of BP II disorder, 176 (∼50%) met rigorous diagnostic criteria. The sample mean age was ∼44 years, with a mean duration of mood disorder of ∼18 years. Two thirds of the cohort were female (n=116), but only 40% were in paid employment. Current and past year functioning was more impaired in females and those with rapid cycling.

LIMITATIONS

This paper describes only the preliminary assessments of the cohort, so it was not possible to examine additional factors that may contribute to the explained variance in functioning.

CONCLUSIONS

This carefully ascertained cohort of BP II cases show few gender differences, except for levels of functional impairment. Interestingly, the most common problem identified with using case note diagnoses of BP II arose because of failure to record prior episodes of mania, not failure to identify hypomania.

Increased Subsequent Risk of Peptic Ulcer Diseases in Patients With Bipolar Disorders

Previous studies have reported that patients with bipolar disorders (BDs) exhibit increased physical comorbidity and psychological distress. Studies have shown that schizophrenia and anxiety increase the risk of peptic ulcer diseases (PUDs). Therefore, we conducted this study to determine the association between these 2 diseases and examine the possible risk factors. We used patients diagnosed with BDs from the Taiwan National Health Insurance Research Database. A comparison cohort comprising patients without BDs was frequency matched by age, sex, and comorbidities, and the occurrence of PUDs was evaluated in both the cohorts. The BD and non-BD cohort consisted of 21,060 patients with BDs and 84,240 frequency-matched patients without BDs, respectively. The incidence of PUDs (hazard ratio, 1.51; 95% confidence interval, 1.43-1.59; P < 0.001) was higher among the patients with BDs than the control patients. Cox models showed that irrespective of comorbidities, BDs were an independent risk factor for PUDs. Patients with BDs exhibit a substantially higher risk for developing PUDs. According to our data, we suggest that, following a diagnosis of BD, practitioners could notice the occurrence of PUD and associated prevention. Further prospective clinical studies investigating the relationship between BDs and PUDs are warranted.

Medical burden in bipolar disorder: findings from the Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder study (Bipolar CHOICE)

OBJECTIVES

Individuals with bipolar disorder have high rates of other medical comorbidity, which is associated with higher mortality rates and worse course of illness. The present study examined common predictors of medical comorbidity.

METHODS

The Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder study (Bipolar CHOICE) enrolled 482 participants with bipolar I or bipolar II disorder in a six-month, randomized comparative effectiveness trial. Baseline assessments included current and lifetime DSM-IV-TR diagnoses, demographic information, psychiatric and medical history, severity of psychiatric symptoms, level of functioning, and a fasting blood draw. Medical comorbidities were categorized into two groups: cardiometabolic (e.g., diabetes, hyperlipidemia, and metabolic syndrome) and non-cardiovascular (e.g., seizures, asthma, and cancer). Additionally, we looked at comorbid substance use (e.g., smoking and drug dependence).

RESULTS

We found that 96.3% of participants had at least one other medical comorbidity. Older age predicted a greater likelihood of having a cardiometabolic condition. Early age of onset of bipolar symptoms was associated with a lower chance of having a cardiometabolic condition, but a greater chance of having other types of medical comorbidity. Additional predictors of other medical comorbidities in bipolar disorder included more time spent depressed, less time spent manic/hypomanic, and longer duration of illness. Medications associated with weight gain were associated with low high-density lipoprotein and abnormal triglycerides.

CONCLUSIONS

There appears to be a substantial medical burden associated with bipolar disorder, highlighting the need for collaborative care among psychiatric and general medical providers to address both psychiatric and other medical needs concomitantly in this group of patients.

Lovastatin as an adjuvant to lithium for treating manic phase of bipolar disorder: a 4-week, randomized, double-blind, placebo-controlled clinical trial

Objectives. Many patients with bipolar disorder suffer from metabolic disorder. Lovastatin is effective for treating major depression. This double-blind randomized placebo controlled clinical trial investigates whether lovastatin is a useful adjuvant to lithium for treating mania. Methods. Fifty-four patients with bipolar disorder-manic phase were randomly allocated into lovastatin or placebo group. The clinical symptoms were assessed at baseline, week 2, and week 4 using Young Mania Rating Scale. Adverse effects were checked. Results. Forty-six out of 54 patients completed this trial. The mania score in the lovastatin group decreased from 40.6 (11.1) at baseline to 12.9 (8.7) and 4.1 (5.4) at weeks 2 and 4, respectively. The score in the placebo group decreased from 41.0 (11.2) at baseline to 12.8 (8.07) and 5.8 (4.6) at weeks 2 and 4, respectively. However, there was no significant difference between groups at week 2 and week 4. The adverse effects rates were comparable between the two groups. No serious adverse effect was found. Tremor and nausea were the most common adverse effects. Conclusions. Lovastatin neither exacerbated nor decreased the symptoms of mania in patients with bipolar disorder. Current results support that the combination of lovastatin with lithium is tolerated well in bipolar disorder. The trial was registered with the Iranian Clinical Trials Registry (IRCT201302203930N18).

Factors associated with chronic pain in patients with bipolar depression: a cross-sectional study

BACKGROUND

While pain is frequently associated with unipolar depression, few studies have investigated the link between pain and bipolar depression. In the present study we estimated the prevalence and characteristics of pain among patients with bipolar depression treated by psychiatrists in their regular clinical practice. The study was designed to identify factors associated with the manifestation of pain in these patients.

METHODS

Patients diagnosed with bipolar disorder (n=121) were selected to participate in a cross-sectional study in which DSM-IV-TR criteria were employed to identify depressive episodes. The patients were asked to describe any pain experienced during the study, and in the 6 weeks beforehand, by means of a Visual Analogical Scale (VAS).

RESULTS

Over half of the bipolar depressed patients (51.2%, 95% CI: 41.9%-60.6%), and 2/3 of the female experienced concomitant pain. The pain was of moderate to severe intensity and prolonged duration, and it occurred at multiple sites, significantly limiting the patient's everyday activities. The most important factors associated with the presence of pain were older age, sleep disorders and delayed diagnosis of bipolar disorder.

CONCLUSIONS

Chronic pain is common in bipolar depressed patients, and it is related to sleep disorders and delayed diagnosis of their disorder. More attention should be paid to study the presence of pain in bipolar depressed patients, in order to achieve more accurate diagnoses and to provide better treatment options.