Alcohol problems and long-term psychosocial outcome in Chinese patients with bipolar disorder

Alcohol use disorders in patients with bipolar disorder: a systematic review and meta-analysis

Alcohol consumption has a key role in more than 200 diseases and health injuries, being an important factor for social and public health costs. Studies with clinical populations show an association between alcohol use disorders (AUD) and bipolar disorder. In this meta-analysis we included studies, reports, or summaries identified in Google Scholar, Lilacs, Medline, and MedCaribe that reported original data published up to 31 January 2023. We included cross-sectional and longitudinal observational studies that investigated the prevalence of AUD in patients with bipolar disorder. We calculated the prevalence rates and conducted a meta-analysis using a random effects model. The meta-analysis included 20 unique studies conducted in 12 countries, with a total sample of 32,886 individuals with bipolar disorder, comprising 17,923 women and 13,963 men, all aged 18 years or older. The prevalence of AUD in individuals with bipolar disorder was found to be 29.12%, while the prevalence of Alcohol Dependence (AD) was 15.87% and the prevalence of Alcohol Abuse (AA) was 18.74%. The high prevalence of AUD individuals with bipolar disorder is important because it highlights the need for targeted interventions to prevent and address comorbid conditions, which may improve treatment outcomes, reduce harm, and promote public health.

Differences in outcomes between older community-dwelling patients with bipolar disorder and schizophrenia with illness onset at young age

AIM

Older community-dwelling patients with severe mental illness (SMI), particularly those with illness onset at young age, constitute a group of survivors with unique long-term care needs. Using an Asian sample in Taiwan, we attempted to find out the differences in outcomes related to physical health, cognition, and social functioning between older community-dwelling adults with bipolar disorder and schizophrenia with early age onset.

METHODS

Community-dwelling patients aged >50 years with bipolar I disorder or schizophrenia whose illness developed before the age of 40 years were recruited. Clinical data were obtained by reviewing all available medical records and by interviewing the patients and their reliable family members. Medical morbidities, Mini-Mental State Examination (MMSE), Cumulative Illness Rating Scale for Geriatrics (CIRS-G), and Global Assessment of Functioning (GAF) scores were compared between the two groups.

RESULTS

In total, 113 bipolar patients and 104 schizophrenic ones (mean ages = 59.8 and 59.2 years, respectively) became the final subjects. The rates of cognitive impairment (MMSE score <24) were comparable in bipolar disorder (26.5%) and schizophrenia (24.0%) and the mean MMSE scores did not significantly differ from each other. The concurrence (54.9%) of cardiovascular disease (CVD) in the bipolar group was also similar to 51.0% in the schizophrenic one. In a multiple logistic regression analysis, the bipolar group exhibited significantly higher CIRS-G total scores (95% confidence interval (CI) for odds ratio (OR) = 1.01-1.27), body mass index (95% CI for OR = 1.02-1.21), and GAF scores (95% CI for OR = 1.04-1.14).

CONCLUSION

Given better social functioning and the same cognitive function in older community-dwelling patients with bipolar disorder, they may remain at higher risk for obesity and medical morbidity than schizophrenic patients. Treatments targeting cognitive impairment and CVDs across their life span are both necessary to promote the health of community-dwellers with SMI.

Alcohol misuse in bipolar disorder. A systematic review and meta-analysis of comorbidity rates

Aims:

To assess the comorbidity rates of alcohol use disorders (AUDs) in bipolar disorder (BD) and to explore possible sources of heterogeneity.

Methods:

Studies were identified through database searches. Meta-analytic techniques were employed to aggregate data on lifetime comorbidity and to explore possible sources of heterogeneity. Funnel plots were used to detect publication bias.

Results:

In clinical studies, AUDs affected more than one in three subjects with BD. Significant heterogeneity was found, which was largely explained by the geographical location of study populations and gender ratio of participants. AUDs affected more than one in five women and two in five men.

Conclusion:

AUDs are highly prevalent in BD. Our study revealed a substantial heterogeneity across studies. Further research including control groups is needed. Patients with BD should be assessed for current and previous AUDs.

Association between completed suicide and bipolar disorder: A systematic review of the literature

BACKGROUND

Completed suicide is a major cause of death in bipolar disorder (BD) patients.

OBJECTIVE

The aim of this paper is to provide an overall review of the existing literature of completed suicide in BD patients, including clinical and genetic data DATA SOURCES: We performed a systematic review of English and non-English articles published on MEDLINE/PubMed, PsycInfo and Cochrane database (1970-2017). Additional studies were identified by contacting clinical experts, searching bibliographies, major textbooks and website of World Health Organization. Initially we did a broad search for the association of bipolar disorder and suicide and we were narrowing the search in terms included "bipolar disorder" and "completed suicide".

STUDY SELECTION

Inclusion criteria were articles about completed suicide in patients with BD. Articles exclusively focusing on suicide attempts and suicidal behaviour have been excluded. We used PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) consensus for drafting this systematic review.

RESULTS

The initial search generated 2806 articles and a total of 61 meeting our inclusion criteria. We reviewed epidemiological data, genetic factors, risk factors and treatment of completed suicide in BD. Suicide rates in BD vary between studies but our analyses show that they are approximately 20-30-fold greater than in general population. The highest risk of successful suicide was observed in BD-II subjects. The heritability of completed suicide is about 40% and some genes related to major neurotransmitter systems have been associated with suicide. Lithium is the only treatment that has shown anti-suicide potential.

LIMITATIONS

The most important limitation of the present review is the limited existing literature on completed suicide in BD.

CONCLUSIONS

BD patients are at high risk for suicide. It is possible to identify some factors related to completed suicide, such as early onset, family history of suicide among first-degree relatives, previous attempted suicides, comorbidities and treatment. However it is necessary to promote research on this serious health problem.

Factors affecting time to remission for inpatients with bipolar mania - A naturalistic Taiwanese study

BACKGROUND

Bipolar disorder is a complicated and chronic mental disorder. This study investigated factors affecting time to remission for inpatients with bipolar mania after 4 weeks of acute treatment.

METHODS

This naturalistic study recruited inpatients with bipolar mania for acute treatment. Symptom severity was assessed using the Young Mania Rating Scale (YMRS) at weeks 0, 1, 2, 3, and 4. Patients were included if they had had assessments at weeks 0 and 1 Remission was defined as an YMRS score ≤ 12. The Cox regression analysis was used to analyze factors associated with time to remission after 4 weeks of acute treatment.

RESULTS

Four hundred and forty-nine patients entered the analysis. Seventy-one of the 449 subjects (15.8%) reached symptomatic remission within 4 weeks of acute treatment. Using forward multivariate Cox regression analysis, comorbid substance use disorders, earlier age at onset, and greater manic symptom severity at baseline found to be statistically significant predictors of a longer time to reach remission after 4 weeks of treatment.

LIMITATIONS

As a retrospective chart review and naturalistic design, placebo effect and potentially confounding factors such as the possibility of missing records may have limited our results.

CONCLUSIONS

Early identification and intervention with integrated therapy is considered to shorten time to remission for patients at high risk of poor treatment outcome. More studies are needed in other real-world settings to generalize our results.

Bipolar disorder in Asia: Illness course and contributing factors

BACKGROUND

Epidemiological studies analysing the course of Bipolar Disorder (BD) are relatively rare in the Asian context, contributing to the uncertainty regarding the prevalent course patterns and factors influencing such patterns. The current review identifies the regional characteristics of BD course patterns and the associated factors.

METHODS

A review of the existing literature was done using 'PubMed' and 'Cochrane' databases which yielded 145 studies including those from all 48 Asian countries. Relevant discussions from the Western literature were incorporated.

RESULTS

Regional and cross-national studies reveal a mania-predominant course in BD in Asian countries. Prolonged depressive episodes and comorbid anxiety disorders worsen the course of BD-II. Certain risk factors such as the young age of onset and greater episode frequency are useful predictors of bipolar diatheses. Substance use disorder comorbidity is more prevalent in males whereas depression and suicidal behaviours are more frequent in females with BD. Comorbid anxiety and personality disorders also encumber the illness course. Logistic reasons and ignorance of side-effects were specifically associated with poor adherence. An 'eveningness' chronotype and poor sleep quality were associated with frequent recurrences. Seasonal patterns vary among men and women, especially for depressive episodes.

LIMITATIONS

The effects of treatment and childhood BD course features were not discussed.

CONCLUSIONS

There are region-specific characteristics in bipolar illness course and factors influencing such course patterns compared to the rest of the World. Future research from Asia shall attempt to study the neurobiological underpinnings of such characteristics and plan appropriate strategies to address the same.

Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990-2015: Systematic review and meta-analysis

BACKGROUND

Comorbidity between substance use disorders (SUDs) and bipolar disorder (BD) is highly prevalent to the extent it may almost be regarded the norm. This systematic review and meta-analysis aimed to estimate the prevalence rates of SUDs in treatment seeking patients diagnosed with BD in both inpatient and outpatient settings.

METHODS

A comprehensive literature search of Medline, EMBASE, psychINFO and CINAHL databases was conducted from 1990 to 2015. Prevalence of co-morbid SUDs and BD were extracted and odds ratios (ORs) were calculated using random effects meta-analysis.

RESULTS

There were 151 articles identified by electronic searches that yielded 22 large, multi-site studies and 56 individual studies describing comorbid rates of SUDs amongst community dwelling, BD inpatients or outpatients. The SUDs with the highest prevalence in BD were alcohol use (42%) followed by cannabis use (20%) and other illicit drug use (17%). Meta-analysis showed males had higher lifetime risks of SUDs compared to females. BD and comorbid SUDS were associated with earlier age of onset and slightly more hospitalisations than non-users.

LIMITATIONS

The results do not take into account the possibility that individuals may have more than one comorbid disorder, such as having more than one SUD, anxiety disorder, or other combination. Some of the meta-analyses were based on relatively few studies with high rates of heterogeneity. Most included studies were cross-sectional and therefore causality cannot be inferred.

CONCLUSIONS

This systematic review shows comorbidity between SUDs and bipolar illness is highly prevalent in hospital and community-based samples. The prevalence of SUDs was similar in patients with bipolar I and bipolar II disorders. This study adds to the literature demonstrating that SUDs are common in BD and reinforces the need to provide better interventions and properly conducted treatment trials to reduce the burden conferred by comorbid SUD and BD.

Predicting personality disorder functioning styles by the Chinese Adjective Descriptors of Personality: a preliminary trial in healthy people and personality disorder patients

BACKGROUND

Cultural and personality factors might contribute to the clinical differences of psychiatric patients all over the world including China. One cultural oriented Chinese Adjective Descriptors of Personality (CADP) designed to measure normal personality traits, might be specifically associated with different personality disorder functioning styles.

METHODS

We therefore have invited 201 healthy volunteers and 67 personality disorder patients to undergo CADP, the Parker Personality Measure (PERM), and the Plutchik-van Praag Depression Inventory (PVP) tests.

RESULTS

Patients scored significantly higher on PVP scale and all 11 PERM personality disorder functioning styles, as well as CADP Emotional and Unsocial traits. The PVP was significantly correlated with some CADP traits and PERM styles in both groups. In healthy volunteers, only one CADP trait, Unsocial, prominently predicted 11 PERM styles. By contrast in patients, CADP Intelligent predicted the PERM Narcissistic and Passive-Aggressive styles; CADP Emotional the PERM Paranoid, Borderline, and Histrionic styles; CADP Conscientious the PERM Obsessive-Compulsive style; CADP Unsocial the PERM Schizotypal, Antisocial, Narcissistic, Avoidant, Dependent, and Passive-Aggressive styles; CADP Agreeable the PERM Antisocial style.

CONCLUSION

As a preliminary study, our results demonstrated that, in personality disorder patients, all five CADP traits were specifically associated with almost all 11 personality disorder functioning styles, indicating that CADP might be used as an aid to diagnose personality disorders in China.

Relationship between Chinese adjective descriptors of personality and emotional symptoms in young Chinese patients with bipolar disorders

OBJECTIVE

To investigate whether personality traits are related to emotional symptoms (mania, hypomania, and depression) in Chinese patients with bipolar disorders.

METHODS

Patients with bipolar I and II disorders, and healthy volunteers, were assessed using the Chinese Adjective Descriptors of Personality (CADP) questionnaire, Mood Disorder Questionnaire (MDQ), Hypomanic Checklist (HCL-32), and Plutchik-van Praag Depression Inventory (PVP).

RESULTS

Seventy-three patients with bipolar I disorder, 35 with bipolar II disorder and 216 healthy controls were included. Bipolar I and II groups scored significantly higher on MDQ, HCL-32 and PVP scales than controls; the bipolar II group scored lower on the MDQ, but higher on the HCL-32 and PVP than bipolar I. In the bipolar I group, the CADP Intelligent trait (β, 0.25) predicted MDQ; Intelligent (β, -0.24), Agreeable (β, 0.22) and Emotional (β, 0.34) traits predicted PVP. In the bipolar II group, Intelligent (β, 0.22), Agreeable (β, -0.24) and Unsocial (β, 0.31) traits predicted MDQ; Intelligent (β, -0.20), Agreeable (β, -0.31) and Emotional (β, -0.26) traits predicted HCL-32.

CONCLUSIONS

Four out of five Chinese personality traits were associated with emotional symptoms in patients with bipolar I or II disorder, but displayed different associations depending on disorder type.

Affective temperaments and concomitant alcohol use disorders in bipolar disorder

BACKGROUND

Alcohol misuse (AM) is more common in bipolar disorder (BD) than within the general population but the mechanisms of this association are unclear. We hypothesized that certain affective temperaments (including hyperthymic, cyclothymic, anxious, depressive and/or irritability) might represent 'fundamental states' contributing to risk of both AM and BD and we aimed to assess whether extremes of these five affective temperaments were associated with BD and concomitant AM status.

METHODS

Our sample comprised 1420 individuals with BD who were recruited into a clinical-genetic study conducted by the Bipolar Disorder Research Network. Phenotypic assessments, including evaluation for AM and the 32-item TEMPS-A questionnaire, were conducted. Binary logistic regression was used to determine the effect of TEMPS-A scores on the likelihood of concomitant AM, with adjustment for confounders.

RESULTS

Mean scores for four affective temperaments (hyperthymic, cyclothymic, depressive and irritable) were higher in cases (BD+AMs) than controls (BD only) (p<0.001). Hyperthymic and irritable temperaments in particular significantly increased the odds of concomitant AM within the BD sample after adjustment for potential confounders.

LIMITATIONS

The definition of AM was not directly based on formal diagnostic classification systems. A retrospective, cross-sectional design was used. Our findings may not generalize to other countries and cultures.

CONCLUSIONS

Higher scores on measures of hyperthymic and irritable temperament may contribute to the association between AM and BD. Assessing affective temperaments early in the course of BD may help to predict the development of an AM problem in vulnerable individuals.

Attempted suicide in people with co-occurring bipolar and substance use disorders: systematic review and meta-analysis

BACKGROUND

Both individuals with bipolar (BD) and those with alcohol (AUD) and other substance (SUD) use disorders are likely to attempt suicide. Comorbidity of BD and AUD/SUD may increase the likelihood of suicide attempts. We conducted a meta-analysis to estimate the association of comorbid AUD/SUD and suicide attempts in subjects with BD in the literature to date.

METHODS

Electronic databases through January 2013 were searched. Studies reporting rates of suicide attempts in people with co-occurring BD and AUD/SUD were retrieved. Comorbid AUD and SUD and suicide attempts rates as well as demographic, clinical, and methodological variables were extracted from each publication or obtained directly from its authors.

RESULTS

Twenty-nine of 222 studies assessed for eligibility met the inclusion criteria, comprising a total of 31,294 individuals with BD, of whom 6308 (20.1%) had documented suicide attempts. There were consistent findings across the studies included. As compared to controls, subjects with BD and comorbid AUD/SUD were more likely to attempt suicide. The cross-sectional association estimates showed random-effects pooled crude ORs of 1.96 (95% CI=1.56-2.47; p<0.01), 1.72 (95% CI=1.52-1.95; p<0.01), and 1.77 (95% CI=1.49-2.10; p<0.01), for combined AUD/SUD, AUD, and SUD. There was no publication bias and sensitivity analyses based on the highest quality studies confirmed core results.

LIMITATIONS

The effects of the number and the type of suicide attempts could not be investigated due to insufficient information.

CONCLUSIONS

Comorbid AUD and SUD in individuals with BD are significantly associated with suicide attempts. Individuals with this comorbidity should be targeted for intensive suicide prevention efforts.

Clozapine for treatment-resistant bipolar disorder: a systematic review

OBJECTIVE

To evaluate the efficacy and safety of clozapine for treatment-resistant bipolar disorder (TRBD).

METHODS

A systematic review of randomized controlled studies, open-label prospective studies, and retrospective studies of patients with TRBD was carried out. Interventions included clozapine monotherapy or clozapine combined with other medications. Outcome measures were efficacy and adverse drug reactions (ADRs).

RESULTS

Fifteen clinical trials with a total sample of 1,044 patients met the inclusion criteria. Clozapine monotherapy or clozapine combined with other treatments for TRBD was associated with improvement in: (i) symptoms of mania, depression, rapid cycling, and psychotic symptoms, with many patients with TRBD achieving a remission or response; (ii) the number and duration of hospitalizations, the number of psychotropic co-medications, and the number of hospital visits for somatic reasons for intentional self-harm/overdose; (iii) suicidal ideation and aggressive behavior; and (iv) social functioning. In addition, patients with TRBD showed greater clinical improvement in long-term follow-up when compared with published schizophrenia data. Sedation (12%), constipation (5.0%), sialorrhea (5.2%), weight gain (4%), and body ache/pain (2%) were the commonly reported ADRs; however, these symptoms but did not usually require drug discontinuation. The percentage of severe ADRs reported, such as leukopenia (2%), agranulocytosis (0.3%), and seizure (0.5%), appeared to be lower than those reported in the published schizophrenia literature.

CONCLUSION

The limited current evidence supports the concept that clozapine may be both an effective and a relatively safe medication for TRBD.

Psychological Outcomes and Medical Morbidity of Patients With Bipolar Disorder and Co-Occurring Alcohol Use Disorder

OBJECTIVE

Patients with bipolar disorder are at a high risk for comorbid alcohol use disorder, and both disorders are associated with poor outcomes and multiple morbidities. This study aimed to explore not only the psychosocial functioning and psychopathological outcomes but also the medical morbidity of patients with bipolar disorder with and without alcohol use disorder.

METHODS

Outpatients with bipolar I disorder (DSM-IV) were recruited from a psychiatric teaching hospital in Taiwan (N = 393). Data on psychiatric symptoms, psychosocial functioning, and physical health were obtained through interviews with patients and collaterals, patient self-report, and medical record reviews.

RESULTS

Participants had a mean age of 41.1 years (SD = 11.9) and were mostly female (n = 255, 64.9%). Fewer than 10% (n = 34, 8.7%) met criteria for alcohol use disorder, and these participants were more likely to be male, to smoke, and to have a history of rapid cycling, higher mean body mass index, and higher incidences of gastrointestinal and hepatobiliary morbidities. A multiple logistic regression analysis revealed that patients with, versus those without, alcohol use disorder were more prone to gastrointestinal diseases (adjusted OR = 4.25, 95% CI [1.44-12.53], p <.01), hepatobiliary diseases (adjusted OR = 3.14, 95% CI [1.20-8.25], p <.025), and history of rapid cycling (adjusted OR = 2.53, 95% CI [0.91-7.01], p <.075).

CONCLUSIONS

Comorbid alcohol use disorders may have a stronger impact on physical health than on psychosocial or psychopathological outcomes of patients with bipolar disorder.

The effects of ethnic, social and cultural factors on axis I comorbidity of bipolar disorder: results from the clinical setting in Korea

OBJECTIVE

Ethnic, social and cultural factors contribute to axis I comorbid conditions in bipolar disorder (BPD). Korea has strict laws against illicit drugs and a relatively permissive prevailing attitude toward alcohol. The present study aimed to explore the lifetime axis I comorbidity rate in patients with BPD in Korea.

METHODS

Clinically stable patients with bipolar I (n=222) and bipolar II (n=194) disorders were recruited from four tertiary medical centers in Korea. The subjects׳ diagnoses and axis I comorbid conditions were evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) and the Korean version of the Diagnostic Interview for Genetic Studies (K-DIGS). The lifetime prevalence of anxiety disorders, substance use disorders and eating disorders was explored. The prevalence of these axis I comorbid conditions was compared with data from prior studies in other countries and to data concerning the general Korean population.

RESULTS

A total of 45.1% of all subjects had at least one axis I comorbid condition. Anxiety disorders (30.2%) were the most common comorbidity, followed by alcohol use disorders (16.8%). Males with BPD showed a higher rate of alcohol dependence compared to the general male population and females with BPD showed a greater risk of having alcohol use disorder compared to the general female population. The rate of drug use disorder was extremely low (1.7%), and only one subject had an illicit-drug-related problem.

LIMITATION

Cross-sectional studies.

CONCLUSION

Comorbid conditions of Korean patients with BPD showed a distinct pattern, which is associated with the ethnic, social and cultural characteristics in Korea.

The prevalence and correlates of alcohol use disorder amongst bipolar patients in a hospital setting, Malaysia

OBJECTIVE

To determine the prevalence of alcohol-use disorder and associated correlates amongst bipolar patients in a university hospital in Malaysia.

METHODS

In this cross-sectional study, a total of 121 bipolar disorder patients were included. Their alcohol use disorders were assessed with the Mini International Neuropsychiatric Interview (plus version) and the Addiction Severity Index-Lite-Clinical Factors version. The number of lifetime hospitalizations and the survival days (the number of days between the last discharge and the most current readmission) were calculated.

RESULTS

The prevalence of alcohol-use disorder amongst bipolar patients was 18.2%. Indian ethnicity was the only demographic factor that was statistically associated with alcohol-use disorder (p < 0.03). Those with alcohol-use disorder had a significantly higher rate of suicidal attempt (p < 0.01) and more psychiatric hospitalizations than those without after adjusting for gender, race, employment status, education level and duration of illness (p < 0.01).

CONCLUSIONS

The prevalence of alcohol-use disorder was low in bipolar patients but highin the general population of Malaysia. Since alcohol-use disorder, as well as the potential interactions with the course of the disorder, is highly prevalent amongst bipolar patients, alcohol use should be addressed in these patients.

Employment outcomes in people with bipolar disorder: a systematic review

OBJECTIVE

Employment outcome in bipolar disorder is an under investigated, but important area. The aim of this study was to identify the long-term employment outcomes of people with bipolar disorder.

METHOD

A systematic review using the Medline, PsychInfo and Web of Science databases.

RESULTS

Of 1962 abstracts retrieved, 151 full text papers were read. Data were extracted from 25 papers representing a sample of 4892 people with bipolar disorder and a mean length of follow-up of 4.9 years. Seventeen studies had follow-up periods of up to 4 years and eight follow-up of 5-15 years. Most studies with samples of people with established bipolar disorder suggest approximately 40-60% of people are in employment. Studies using work functioning measures mirrored this result. Bipolar disorder appears to lead to workplace underperformance and 40-50% of people may suffer a slide in their occupational status over time. Employment levels in early bipolar disorder were higher than in more established illness.

CONCLUSION

Bipolar disorder damages employment outcome in the longer term, but up to 60% of people may be in employment. Whilst further studies are necessary, the current evidence provides support for extending the early intervention paradigm to bipolar disorder.

Neuropsychological functions in bipolar disorders I and II with and without comorbid alcohol dependence

OBJECTIVE

Bipolar disorder (BP) is a mental disorder most likely to co-occur with substance dependence and abuse, especially alcohol dependence (ALD). Whether the effect of comorbid alcoholism is different between the BP-I and BP-II subtypes remains unclear. We aimed to identify the neuropsychological performance of BP patients with and without comorbid ALD in partial remission from depression or mania, and compare it with that of healthy controls (HCs).

METHODS

We recruited 29 HCs and 94 BP patients, whom we categorized into four groups: (1) BP-I without a history of alcohol abuse or dependence (BP-I(-ALD); n=22), (2) BP-II without a history of alcohol abuse and dependence (BP-II(-ALD); n=38), (3) BP-I with comorbid ALD (BP-I(+ALD); n=16), and (4) BP-II with comorbid ALD (BP-II(+ALD); n=18). Only males were recruited in this study.

RESULTS

When patients comorbid with ALD were not excluded, there were no significant differences on neuropsychological tests between the BP-I and BP-II groups. However, when patients with comorbid ALD were excluded, there were significant differences between the two BP(-ALD) groups. The BP-I(-ALD) group had lower scores on memory subtests (p≤0.01) than the HC and BP-II(-ALD) groups, but the BP-II(-ALD) and HC groups had similar scores.

CONCLUSION

We found it important to exclude ALD comorbidity when evaluating neuropsychological functions due to our finding that ALD affected the cognitive performance in BP-I more severely than in the BP-II group. ALD not only impairs neuropsychological function, but also worsen the clinical course and leads to a more pernicious status and negative cycle.

Epidemiology of comorbid substance use and psychiatric disorders in Asia

PURPOSE OF REVIEW

Studying comorbidities between substance use disorders (SUDs) and psychiatric disorders in different regions is important from public health and heuristic perspectives. In this study we review recent studies conducted in Asian countries on these comorbidities.

RECENT FINDINGS

Comprehensive and methodologically sound studies conducted with focus on comorbidity between SUDs and psychiatric disorders are few and far between in Asian countries. Studies differ widely in their focus and methodological rigor. Some studies from China, Japan and Taiwan report fairly low rates of comorbidity of SUDs, particularly with illicit substances, among individuals with psychiatric disorders. Similar findings exist for rates of psychiatric disorders among those with SUDs. Recent research is lacking in several Asian countries on the issue of comorbidity.

SUMMARY

Interesting regional differences exist in the rates of comorbidity both across the Asian countries and between these countries and the west. Genetic and socio-cultural differences may be responsible for these differences. Methodologically sound, multicenter studies, involving several Asian countries, specifically examining the epidemiology of comorbidity between SUDs and psychiatric disorders, will have the potential to provide useful insights in this regard.

Cross-cultural comparisons on Wisconsin Card Sorting Test performance in euthymic patients with bipolar disorder

We compared executive dysfunction with the Wisconsin Card Sorting Test (WCST) among distinct national and ethnic patients with bipolar disorder in euthymia. Bipolar patients, aged 16-45years, from the United States (n=25) and Taiwan (n=30) did not differ significantly on any measure. The WCST score for number Failure to Maintain Set was significantly positively correlated with residual affective symptoms in Taiwanese and US patients. Selective executive dysfunction in euthymia is inherent to bipolar disorder. Euthymic bipolar patients of various ethnic groups may exhibit similar executive dysfunction.

Benzodiazepine prescription among patients with severe mental illness and co-occurring alcohol abuse/dependence in Taiwan

OBJECTIVE

Because benzodiazepines (BZDs) may be abused, prescribing them is debatable. The purpose of this study was to investigate the prescription of BZDs to explore the current status of BZD use at discharge and at 4 months after discharge.

METHODS

From 1 January 2006 to 31 December 2006, prescribed doses for BZDs at discharge and at 4 months after discharge were recorded for all discharged inpatients with schizophrenia, bipolar I disorder, and major depressive disorder. Two‐way analysis of variance was used to analyze the effects of severe mental illness and co‐occurring alcohol abuse/dependence on BZD doses at discharge and at 4 months after discharge.

RESULTS

Patients with severe mental illness prescribed with significantly higher rates and higher doses of BZDs at discharge and at 4 months after discharge are more likely to have major depressive disorder and to have co‐occurring alcohol abuse/dependence problems. No significant interactions were found between severe mental illness and co‐occurring alcohol abuse/dependence.

CONCLUSIONS

These findings suggest that caution should be applied in prescribing BZDs to patients with severe mental illness, particularly those with major depressive disorder and co‐occurring alcohol abuse/dependence. Future studies require being conducted in many different mental health‐care systems in Taiwan to generalize the findings.

Is sex important? Gender differences in bipolar disorder

Sex is clearly important in unipolar mood disorder with compelling evidence that depression is approximately twice as common in women than in men. In the case of bipolar disorder, however, it is widely perceived that the reported equal rate of illness in men and women reflects no important gender distinctions. In this paper we review the literature on gender differences in bipolar illness and attempt to summarize what is known and what requires further study. Despite the uncertainties that remain some conclusions can be drawn. Most studies, but not all, report an almost equal gender ratio in the prevalence of bipolar disorder but the majority of studies do report an increased risk in women of bipolar II/hypomania, rapid cycling and mixed episodes. Important gender distinctions are also found in patterns of co-morbidity. No consistent gender differences have been found in a number of variables including rates of depressive episodes, age and polarity of onset, symptoms, severity of the illness, response to treatment and suicidal behaviour. Unsurprisingly, however, perhaps the major distinction between men and women with bipolar disorder is the impact that reproductive life events, particularly childbirth, have on women with this diagnosis.

Time to rehospitalization in patients with major depression vs. those with schizophrenia or bipolar I disorder in a public psychiatric hospital

Compared rehospitalization rates in patients with schizophrenia or bipolar I disorder to patients with major depressive disorder remains unclear. This study aimed to compare the time to rehospitalization of the three groups. Other clinical variables were also examined. Rehospitalization status was monitored for all admitted inpatients with schizophrenia (n=637), bipolar I disorder (n=197), or major depressive disorder (n=191), from January 1, 2006 to December 31, 2006. Time to rehospitalization within 1 year after discharge was measured using the Kaplan-Meier method. Risk factors associated with rehospitalization were examined using the Cox proportional hazards regression model. The three groups were comparable for comorbid alcohol abuse/dependence, family history of severe psychiatric illness, years of education, and number of previous hospitalizations. No significant differences were noted among the three groups for the time to rehospitalization or the time to discontinuation. Age onset and number of previous admission were associated with risks of rehospitalization. This study suggests that the major depressive disorder, schizophrenia, and bipolar I disorder have comparable influences on time to rehospitalization and discontinuation from treatment and that earlier onset of illness and more previous hospitalizations are associated with higher risks of rehospitalization. Further prospective research is warranted.

Excessive substance use in bipolar disorder is associated with impaired functioning rather than clinical characteristics, a descriptive study

BACKGROUND

There is a strong association between bipolar disorder (BD) and substance use disorder (SUD). The clinical and functional correlates of SUD in BD are still unclear and little is known about the role of excessive substance use that does not meet SUD criteria. Thus, the aims of the current study were to investigate lifetime rates of illicit substance use in BD relative to the normal population and if there are differences in clinical and functional features between BD patients with and without excessive substance use.

METHODS

125 consecutively recruited BD in- and outpatients from the Oslo University Hospitals and 327 persons randomly drawn from the population in Oslo, Norway participated. Clinical and functional variables were assessed. Excessive substance use was defined as DSM-IV SUD and/or excessive use according to predefined criteria.

RESULTS

The rate of lifetime illicit substance use was significantly higher among patients compared to the reference population (OR = 3.03, CI = 1.9-4.8, p < .001). Patients with excessive substance use (45% of total) had poorer educational level, occupational status, GAF-scores and medication compliance, with a trend towards higher suicidality rates, compared to patients without. There were no significant group differences in current symptom levels or disease course between groups.

CONCLUSION

The percentage of patients with BD that had tried illicit substances was significantly higher than in the normal population. BD patients with excessive substance use clearly had impaired functioning, but not a worse course of illness compared to patients without excessive substance use. An assessment of substance use beyond SUD criteria in BD is clinically relevant.

Cognitive dysfunction and medical morbidity in elderly outpatients with bipolar disorder

OBJECTIVE

The authors investigated the differences in cognitive function, medical burden, and sociodemographic characteristics between elderly community-dwelling bipolar patients and age-matched and education-matched normal individuals.

DESIGN

Case-control study.

SETTING

Taipei Medical University Hospital, with 75 psychiatric beds, and Taipei City Psychiatric Center-a 612-bed psychiatric teaching hospital providing comprehensive psychiatric services.

PARTICIPANTS

Eighty-two euthymic outpatients with bipolar I disorder aged older than 60 years received assessment for research purpose, 59 of whom were matched with one normal control for age and years of education.

MEASUREMENTS

All subjects had measurements of cognitive function (Clock-drawing test and Mini-Mental State Examination [MMSE]). Medical morbidity and health condition were according to the medical records, results of free annual elderly health examination, and physical examination on research interviewing.

RESULTS

Elderly bipolar patients were found to be more likely than the comparison group to have diabetes mellitus (27.1%), atopic diseases (20.3%), abnormal education-adjusted MMSE scores (32.2%), smoking habit (23.7%), and unfavorable social functioning (22%). Despite having noticeably higher heart rates, the bipolar patients' mean systolic blood pressure and prevalence of hypertension (44.1%) were significantly lower than those of the comparison group.

CONCLUSIONS

Although community-dwelling elderly patients with bipolar disorder seem to be characterized by a greater likelihood of developing cognitive dysfunction and concurrent diabetes mellitus, there is no apparent increase in the morbidity of circulatory diseases, particularly less hypertension among those without previous dementia.

Prevalence and identification of alcohol use disorders among severe mental illness inpatients in Taiwan

AIMS

A higher prevalence of alcohol use disorders (AUD) among psychiatric patients has been reported previously and the identification rate is relatively low. This study was designed to investigate the prevalence and identification of AUD among acute psychiatric inpatients with severe mental illness in a psychiatric hospital in Taiwan.

METHODS

In a two-phase case identification strategy, the Alcohol Use Disorders Identification Test (AUDIT) was used as the first phase screening tool and the Structured Clinical Interview for DSM-IV-TR as the second phase diagnostic interview. The definition of identification was diagnosis of AUD on medical record at discharge.

RESULTS

Of 400 respondents, 42 screened positive and 358 screened negative. All screen-positive respondents and 35 screen-negative respondents entered the second phase interview. The weighted lifetime prevalence of alcohol dependence was 8.3% (95% confidence interval [CI]: 4.6-11.9%); alcohol abuse, 1.5% (95%CI: 0.2-2.8%); and AUD, 9.8% (95%CI: 5.7-13.8%). The overall identification rate of AUD by medical staff was 28.2% (0% for alcohol abuse and 33.3% for alcohol dependence). Patients with mood disorders were prone to being undetected as having AUD.

CONCLUSION

AUD comorbidity was common among inpatients with severe mental illness in Taiwan and was easily neglected by medical staff. It is necessary to use a validated screening questionnaire, such as AUDIT, to detect high-risk patients and then give appropriate interventions to enhance treatment outcome.

Outcome following a first manic episode: cross-national US and Taiwan comparison

OBJECTIVES

Bipolar disorder (BD) is recognized as a significant psychiatric condition worldwide, yet little is known about cross-national differences in the course of illness. This information might clarify features of the disorder that are illness versus culturally specific. Therefore, the aim of this study was to identify differential and shared outcome predictors in first-episode manic bipolar patients in Cincinnati, OH, USA and Taipei, Taiwan.

METHODS

DSM-IV bipolar patients were identified at the time of their first manic or mixed episode and were prospectively followed in a naturalistic, longitudinal study for one year. Patients were recruited from a first psychiatric hospitalization at university-affiliated, urban hospitals in Taipei and Cincinnati. The primary outcome measures were remission, recovery, recurrence and percent of follow-up spent with affective symptoms and syndromes. Treatment adherence was also assessed, as were a number of possible mediator variables.

RESULTS

The two patient groups showed a number of significant differences in index clinical presentation on characteristics previously associated with outcome in other studies (e.g., substance abuse). The patients in Taipei showed significantly better outcome on virtually all measures. Some of these findings reflected differences in index (mediator) variables, whereas others persisted after controlling for potential baseline confounds.

CONCLUSIONS

The early course of BD varies between Chinese and American patients. Some of this variance results from demographic and clinical cross-national differences in premorbid variables. Other sources of variance remain to be identified.

Mood symptoms and serum lipids in acute phase of bipolar disorder in Taiwan

Serum lipids have been found to play important roles in the pathophysiology of mood disorders. The aim of the present study was therefore to investigate the relationship between symptom dimensions and serum cholesterol and triglyceride levels, and to explore correlates of lipid levels during acute mood episodes of bipolar I disorder in Taiwan. Measurements were taken of the serum cholesterol and triglyceride levels in patients with bipolar I disorder hospitalized for acute mood episodes (68 manic, eight depressive, and six mixed). The relationships between serum lipids levels and various clinical variables were examined. The mean serum levels of cholesterol (4.54 mmol/L) and triglycerides (1.16 mmol/L) of sampled patients were comparable to those of the general population in the same age segment. Severe depressive symptoms and comorbid atopic diseases were associated with higher serum cholesterol levels. A negative association was noted between serum triglyceride levels and overall psychiatric symptoms. Compared with previous studies on Western populations, racial differences may exist in lipids profiles of bipolar disorder patients during acute mood episodes. Increased serum cholesterol levels may have greater relevance to immunomodulatory system and depressive symptoms, in comparison with manic symptoms.

The impact of bipolar disorder upon work functioning: a qualitative analysis

OBJECTIVES

One important but sometimes poorly-captured area of functioning concerns an individual's ability to work. Several quantitative studies have now indicated that bipolar disorder (BD) can have a severe, and often enduring, negative impact upon occupational functioning. While this data indicates that employment rates are relatively low in this patient population, it throws little light on the specific ways in which this complex psychiatric condition can affect work, or upon how these effects are subjectively interpreted by individuals with BD. In order to further elucidate the relationship between BD and work, we report here on a series of exploratory qualitative interviews undertaken to develop a disease-specific measure of quality of life in BD.

METHODS

We conducted 52 interviews with people with BD (n = 35), their caregivers (n = 5) and healthcare professionals (n = 12) identified by both convenience and purposive sampling. The affected sample came from a variety of employment situations, ranging between people with no employment history through to those in highly skilled, stable professional positions. Interviews were tape recorded, transcribed verbatim and analysed thematically.

RESULTS

Respondents described the different ways in which the symptoms of depression and hypo/mania presented in the workplace. Five main themes emerged from the data: lack of continuity in work history, loss, illness management strategies in the workplace, stigma and disclosure in the workplace, and interpersonal problems at work.

CONCLUSIONS

Patient outcome in BD has traditionally been determined by the assessment of clinical characteristics such as rates of relapse, hospitalization, or degree of symptom reduction. More recently, however, there has been increasing interest in expanding the assessment of outcome to include the measurement of indices such as functioning, a key facet of which relates to an individual's ability to work. The qualitative data obtained here highlights the often complex, varied and intermittent effects of an episodic condition such as BD upon work functioning, and points to the importance of developing more sophisticated and precise measures of occupational functioning for this population.

Epidemiology of bipolar disorders

Bipolar, or manic-depressive, disorders are frequent and severe mental illnesses associated with considerable morbidity and mortality. Epilepsy and bipolar disorder could probably share some aspects of pathophysiology because manic as well as depressive symptoms are seen in patients with seizures, and a number of antiepileptic drugs are effectively used in the acute and prophylactic treatment of bipolar disorder. Epidemiologic research suggests a dimensional composition of bipolar illness at the population level. Apart from the DSM-IV diagnostic features of bipolar I (mania and depression) and bipolar II (hypomania and depression), the concept of bipolar spectrum disorders comprises a range of bipolar conditions with less obvious manifestations with estimated lifetime prevalence rates ranging from 2.8 to 6.5%. Expanding the definition of bipolar II disorders shows that half of the patients currently diagnosed with a unipolar depressive episode could suffer from unrecognized bipolar II disorder, and about the same number of mild depressive patients could be minor bipolars. Research efforts to refine the diagnostic criteria of bipolar disorder aim at an earlier and complete recognition of the disease to provide appropriate pharmacological and nonpharmacological treatment early in the course of the illness to anticipate individual suffering, suicidal behavior, and increased socioeconomic costs for society. This article also discusses risk factors, comorbid conditions, course of illness, as well as the individual and socioeconomic impact of bipolar disorders.

CONCLUSIONS

The findings suggest reconceptualizing bipolar illnesses as highly recurrent, malignant disorders that occur far more frequently than previously thought. Interdisciplinary knowledge transfer could help to increase our understanding of the pathophysiology of these disorders as well as provide grounds for better recognition and treatment of patients with manic and/or depressive symptoms.

Prevalence and distinct correlates of anxiety, substance, and combined comorbidity in a multi-site public sector sample with bipolar disorder

BACKGROUND

Recent data indicate high prevalence of both anxiety and substance comorbidity in bipolar disorder. However, few studies have utilized public sector samples, and only one has attempted to separate contributions of each type of comorbidity.

METHODS

328 inpatient veterans with bipolar disorder across 11 sites were assessed using selected Structured Clinical Interview for DSM-IV modules and self-reports.

RESULTS

Comorbidity was common (current: 57.3%; lifetime: 78.4%), with multiple current comorbidities in 29.8%. Substance comorbidity rate was comparable to rates typically reported in non-veteran inpatient samples (33.8% current, 72.3% lifetime). Selected anxiety comorbidity rates exceeded those in other inpatient samples and appeared more chronic than episodic/recurrent (38.3% current, 43.3% lifetime). 49% of PTSD was due to non-combat stressors. Major correlates of current substance comorbidity alone were younger age, worse marital status, and higher current employability. Correlates of current anxiety comorbidity alone were early age of onset, greater number of prior-year depressive episodes, higher rates of disability pension receipt, and lower self-reported mental and physical function. Combined comorbidity resembled anxiety comorbidity.

LIMITATIONS

This is a cross-sectional analysis of acutely hospitalized veterans.

CONCLUSIONS

Distinct patterns of substance and anxiety comorbidity are striking, and may be subserved by distinct neurobiologic mechanisms. The prevalence, chronicity and functional impact of anxiety disorders indicate the need for improved recognition and treatment of this other dual diagnosis group is warranted. Clinical and research interventions should recognize these divergent comorbidity patterns and provide individualized treatment built "from the patient out."

A systematic review evaluating health-related quality of life, work impairment, and healthcare costs and utilization in bipolar disorder

BACKGROUND

Bipolar disorder greatly impacts health-related quality of life (HRQoL), physical and social functioning, employment, and work productivity, and greatly increases health-care utilization and costs. Our objective was to characterize how bipolar disorder impacts HRQoL, work impairment, and health-care utilization and costs.

DATA SOURCES AND STUDY SELECTION

A systematic literature review was conducted to identify bipolar disorder studies of HRQoL, functioning, work impairment, and health-care utilization and costs. We searched Medline, ClinPSYC, and HealthSTAR for English-language articles published between January 1985 and November 2002 using MeSH headings and keywords. Additional articles were identified from references of relevant articles.

RESULTS

We identified 65 HRQoL articles, 14 work-impairment articles, and 28 utilization-and-care-cost articles. For all HRQoL instruments used, bipolar disorder patients' HRQoL was rated similarly to that of unipolar depression patients, and equal to or lower compared with patients with other chronic nonmental illnesses. Current treatments have been shown to improve HRQoL and physical and social functioning; some data indicate that management may improve selfreported work impairment and absenteeism. Bipolar disorder patients have been found to utilize health-care services more than do patients with depression or chronic medical conditions. Inpatient costs are the largest cost contributor; treatment to prevent recurrence has been shown to be the most effective way to reduce costs.

CONCLUSIONS

Bipolar disorder imposes a tremendous burden on patients and the health-care system, resulting in decreased HRQoL and increased medical and work impairment costs. Limited data suggest that appropriate management can improve HRQoL and functioning while reducing utilization and cost.

Gender differences in bipolar disorder

The presentation and course of bipolar disorder differs between women and men. The onset of bipolar disorder tends to occur later in women than men, and women more often have a seasonal pattern of the mood disturbance. Women experience depressive episodes, mixed mania, and rapid cycling more often than men. Bipolar II disorder, which is predominated by depressive episodes, also appears to be more common in women than men. Comorbidity of medical and psychiatric disorders is more common in women than men and adversely affects recovery from bipolar disorder more often in women. Comorbidity, particularly thyroid disease, migraine, obesity, and anxiety disorders occur more frequently in women than men, whereas substance use disorders are more common in men. Although the course and clinical features of bipolar disorder differ between women and men, there is no evidence that gender affects treatment response to mood stabilizers. However, women may be more susceptible to delayed diagnosis and treatment. Treatment of women during pregnancy and lactation is challenging because available mood stabilizers pose potential risks to the developing fetus and infant. Pregnancy neither protects nor exacerbates bipolar disorder, and many women require continuation of medication during the pregnancy. The postpartum period is a time of high risk for onset and recurrence of bipolar disorder in women, and prophylaxis with mood stabilizers might be needed. Individualized risk/benefit assessments of pregnant and postpartum women with bipolar disorder are required to promote the health of the woman and avoid or limit exposure of the fetus or infant to potential adverse effects of medication.

Plasma levels of soluble transferrin receptors and Clara cell protein (CC16) during bipolar mania and subsequent remission

Clara cell protein (CC16) and transferrin receptor (TfR) have been reported as possible biological markers for major depression and schizophrenia. However, the alternations of plasma TfR and CC16 levels and the influences of numerous clinical variables on them during bipolar mania are not sufficiently described. We investigated the immune function of 36 bipolar I, manic (DSM-IV) patients with Young Mania Rating Scale (YMRS) scores > or =26 as well as during the subsequent remission (YMRS < or =12) and age- and sex- matched healthy controls. The plasma TfR levels were increased during acute mania along with subsequent remission and were independent of medication status, individual variations, clinical and erythrocyte variables. Among inflammatory parameters and haematological variables, the plasma TfR levels merely had significant and negative relationship with the percentage of monocyte in circulating leukocyte counts despite of elevated plasma soluble interleukin-2 receptors levels during bipolar mania. The plasma levels of CC16 of bipolar patients did not significantly alter during acute mania, whereas smoking, body mass index, and co-existing psychotic features collectively contributed 42% of the plasma levels of CC16. We provide additional evidence to indicate the pathophysiological role of the immune systems in affective disorders. It is suggested that the elevation of plasma TfR levels might be a trait phenomenon in bipolar disorder.

Comorbidity of bipolar disorder and substance abuse in Costa Rica: pedigree- and population-based studies

BACKGROUND

The purpose of this study was to determine the prevalence of substance use disorders (substance abuse or substance dependence: SA/SD) in a large sample of Bipolar Type I (BPI) patients drawn from the Costa Rican population and to describe the effects of SA/SD on the course of their bipolar disorder.

METHOD

110 subjects from two high-risk (for BPI) Costa Rican pedigrees and 205 unrelated Costa Rican BPI subjects were assessed using structured interviews and a best estimate process. Chi(2) and survival analyses were performed to assess the effect of gender on comorbidity risk, and the effect of comorbidity on the clinical course of BPI.

RESULTS

SA/SD (primarily alcohol dependence) occurred in 17% of the BPI patients from the population sample and 35% of the BPI patients from the pedigree sample. Comorbid SA/SD was strongly associated with gender chi(2) = 16.84, P = 0.00004). In comorbid subjects, alcohol dependence tended to predate the first manic episode (chi(2) = 6.54, P < 0.025). History of SA/SD did not significantly alter the prevalence of psychosis or age of onset of mania in BPI subjects.

CONCLUSIONS

These results suggest that SA/SD comorbidity rates are lower in this type of population than in BPI patient populations in the US. Gender is a strong predictor of comorbidity prevalence in BPI patients from this population. Although SA/SD may be a risk factor for precipitating BPI in those at risk, in this population comorbid BPI subjects do not have a different onset or course of BPI in comparison to BPI patients without comorbidity.

Reduced production of interferon-gamma but not interleukin-10 in bipolar mania and subsequent remission

BACKGROUND

Activation of inflammatory response system (IRS) is suggested by increased levels of plasma soluble interleukin-2 receptor (sIL-2R) in patients with bipolar mania. The reasons for changes in stimulated interferon-gamma (IFN-gamma) and interleukin-10 (IL-10) production in bipolar mania along with subsequent remission remain unclear.

METHODS

We measured phytohemagglutinin (PHA)-stimulated IFN-gamma and IL-10 production in 20 physically healthy inpatients aged between 18 and 45 years with bipolar mania (DSM-IV) using Young Mania Rating Scale (YMRS) scores > or = 26 and in subsequent remission (YMRS < or = 12), as well as in 15 age- and sex-matched healthy normal controls.

RESULTS

The mean values of IFN-gamma production in patients in acute mania and in subsequent remission were significantly lower than those of healthy controls (P=0.0004, P=0.0005, respectively). There was no significant difference in IL-10 production between bipolar patients in acute mania as well as in subsequent remission and healthy controls. In acute mania, the mean values of IFN-gamma and IL-10 production in medicated patients (n = 13) did not differ from those of drug-free patients (n = 7). Other clinical variables had no effect on IFN-gamma and IL-10 production.

LIMITATION

The uncontrolled medication, small sample size of the bipolar individuals, and some immune re-measurements prior to full remission periods, limit generalization from the data in this study.

CONCLUSION

Reduced production of IFN-gamma without alternation of IL-10 in bipolar mania and subsequent remission suggest that the immune modulation may vary in patients with different major psychiatric disorders.

How does work work for people with bipolar affective disorder?

Despite modern treatments, bipolar disorder remains a chronic, relapsing disorder that leads to long-term psychosocial disability. A review of the literature suggests that while employment rates amongst individuals with bipolar disorder may improve over time, and are relatively better compared to some other chronic mental disorders, employment prospects do not match the high scholastic achievements seen amongst this group of people before the onset of their illness. For those with bipolar disorder, clinical recovery does not necessarily mean functional recovery, and the usual early age of onset may further reduce an individual's preparedness for employment. Two brief vignettes are used to discuss how occupational therapists can help their clients maintain their sense of hope in vocational recovery, gain better self-awareness and work with clients at various stages of recovery rather than waiting for full functional recovery. Further research is required to help identify specific factors that contribute to the success of employment integration amongst people with bipolar disorder.

Population isolates: their special value for locating genes for bipolar disorder

OBJECTIVES

Population isolates offer several advantages for those hoping to identify predisposition genes for bipolar disorder (BP). In this review article, the rationale for performing gene mapping studies in this type of population and the results of genetic mapping studies performed to date in population isolates are presented.

METHODS

This article begins with a brief review of the concepts involved in mapping genes for BP. The concept of populations that show some degree of historical isolation and their special utility for certain types of gene mapping is presented. Methods of statistical analysis particularly relevant for gene mapping of complex diseases like BP are presented. Finally, several BP gene studies conducted to date in several population isolates are reviewed.

RESULTS

Genetic mapping studies of BP have occurred thus far in several isolates or sub-isolates, including the Amish population, Costa Ricans, Finnish, and Canadians (in Quebec), and significant linkage scores have been identified in the latter three isolates.

CONCLUSIONS

Possible greater homogeneity and greater consistency of diagnosis are factors that have been cited in several studies of BP done in isolates to date. Another special advantage of working in certain types of population isolate is their appropriateness for using certain types of association or linkage disequilibrium-based approaches at both the genome screening and fine mapping stages. These tests include mapping by linkage disequilibrium analyses, an approach that allows mapping to occur at the population, rather than the pedigree, level.

Effects of symptomatic severity on elevation of plasma soluble interleukin-2 receptor in bipolar mania

BACKGROUND

Circulating soluble interleukin-2 receptors (sIL-2Rs) and soluble interleukin-6 receptors (sIL-6Rs) are stable immune measures. Elevated plasma sIL-2R levels are present in patients with schizophrenia, major depression, and bipolar mania, but not with minor psychiatric disorders. The increased plasma sIL-2R levels are state-dependent in bipolar mania. However, altered production of plasma sIL-6R and the effects of clinical characteristics on plasma sIL-6R and sIL-2R levels in bipolar disorder remains uncertain.

METHODS

Plasma sIL-2R and sIL-6R levels were measured in 31 Taiwanese bipolar manic (DSM-IV) patients with Young Mania Rating Scale (YMRS) scores of > or =26 as well as during the subsequent remission (YMRS< or =12), and equal numbers of age- and gender-matched healthy controls. The relationships of clinical variables such as age, age of onset, smoking, medication status, coexisting psychotic features, number of prior episodes, duration of illness, presence of depression before or following the manic episode, and manic severity to plasma sIL-2R and sIL-6R levels in acute mania along with remission were examined.

RESULTS

Plasma sIL-2R but not sIL-6R levels were significantly higher in acute mania than in subsequent remission (P<0.05) and controls (P<0.0005). In acute mania, the plasma sIL-2R levels were significantly correlated to YMRS scores (r=0.34, P<0.05). The remaining clinical variables had no effect on plasma sIL-2R and sIL-6R levels in acute mania or remission. There was a significantly positive relationship between the reduction of plasma sIL-2R levels from the acute to follow-up measurements (DeltasIL-2R) and symptomatic improvement of acute mania (DeltaYMRS) (r=0.61, P<0.001).

LIMITATIONS

Our sample included medicated and unmedicated patients in acute mania. The psychotropic medication may have divergent effects on the plasma sIL-2R levels in acute mania and subsequent remission.

CONCLUSIONS

Elevation of plasma sIL-2R but not sIL-6R levels in bipolar mania supports the idea that the immunomodulatory mechanism may vary in different psychotic disorders. In contrast to being a trait marker in schizophrenia and depressive disorder, plasma sIL-2R levels may be considered a biological indicator of manic severity in a group of bipolar affective patients.

15-year outcome of treated bipolar disorder

BACKGROUND

Prior reports suggested that bipolar patients in Taiwan had comparable long-term outcome to Western patients despite markedly lower rates of co-occurring substance use disorders. Thus, predictors of long-term outcome identified from Taiwanese bipolar samples may be less influenced by substance abuse.

METHODS

One hundred and one patients with bipolar disorder (DSM-III-R) having been naturalistically treated for at least 15 years were recruited. These patients were annually followed for 2 years to assess overall outcome, psychiatric symptoms, rehospitalization, work, and social adjustment. A combination of medical record reviews and direct personal interviews with patients and family members provided the clinical data.

RESULTS

Of these patients, 16.8% expressed a poor overall long-term outcome, even though only two (2.0%) patients exhibited alcohol dependence during the follow-up period. Multivariate regression showed that full compliance with medication was the strongest predictor of favorable overall long-term outcome, followed by younger age at onset and male sex. Younger age at onset as well as male sex, but not full compliance, also predicted a favorable psychosocial outcome.

LIMITATIONS

Recruiting our sample from a clinical population with uncontrollable long-term treatment limits the generalizability of the findings.

CONCLUSIONS

Compliance with pharmacotherapy is important to achieve a favorable overall long-term outcome of bipolar disorder. A portion of bipolar patients may have an unfavorable psychosocial outcome regardless of the psychopharmacological intervention or presence of substance abuse.

The correlates of community functioning in patients with bipolar disorder

BACKGROUND

Although bipolar disorder is associated with substantial levels of disability, efforts to investigate the correlates of impairment have been meagre.

METHODS

Sixty-one euthymic patients with a diagnosis of bipolar disorder were administered a variety of quality of life measures, including a measure of community functioning entitled the Occupational Performance Questionnaire (OPQ). This measure included a Community Functioning Scale (CFS) that provides a rating of adaptive level of functioning that was compared with other clinical and functional indices.

RESULTS

The OPQ was found responsive to the assessment of community functioning among euthymic patients, as about one third of the patients did not meet the criteria for adequate level of community functioning. Moreover, a positive history for alcoholism or alcohol abuse and reported current levels of high anxiety were associated with the impairment in community functioning.

LIMITATIONS

This study relied on self-report data derived from a measure of community functioning developed specifically for this study.

CONCLUSION

Despite the preliminary nature of these findings, further investigation of the functional impairments associated with bipolar disorder is needed.

Activation of indices of cell-mediated immunity in bipolar mania

BACKGROUND

Evidence supports that macrophages as well as lymphocytes and their products may be involved in the pathophysiology of psychiatric disorders. Whether patients with bipolar disorder have activation or reduction of immunity during a manic episode remains unclear.

METHODS

The purpose of this case-control study was to investigate the lymphocyte proliferation to phytohemagglutinin (PHA), concanavalin A, and pokeweed mitogen, and plasma levels of soluble interleukin-2 receptor (sIL-2R) and sIL-6R in patients with bipolar mania (DSM-III-R). The subjects were 23 physically healthy patients with Young Mania Rating Scale (YMRS) scores > or = 26 as well as aged < or = 45 years and 23 age- and gender-matched normal control subjects. The above immune variables were measured in acute mania and consequent remission (YMRS scores < or = 12) among bipolar patients.

RESULTS

The lymphocyte proliferation to PHA and the plasma sIL-2R levels, but not sIL-6R, of bipolar patients were significantly higher in acute mania than in consequent remission. These elevations were not due to differences in medication status. Only in acute mania were the plasma sIL-2R levels of patients significantly higher than control subjects. A positive correlation between the changes of manic severity and plasma sIL-2R levels was observed. Remitted bipolar patients and normal control subjects did not differ in any of these measures.

CONCLUSIONS

Cell-mediated immunity activation in bipolar mania was demonstrated and may be through a specifically state-dependent immune response.

Characteristics and psychosocial problems of patients with bipolar disorder at high risk for suicide attempt

BACKGROUND

Bipolar disorder with a history of substance abuse or suicide attempt is a strong predictor of suicide. A high comorbidity of substance use disorders may obscure the specificity of findings about suicide behaviors in Western patients with bipolar disorder.

METHODS

The clinical data of Chinese bipolar patients (DSM-III-R) in Taiwan who had been naturalistically followed up for at least 15 years were obtained by a combination of chart reviews and interviews with patients and family members. The national identity numbers were used to search for deceased subjects.

RESULTS

There were 158 patients originally included for chart review; 4 of them died from suicide. A 9.9% lifetime prevalence of alcohol use disorders was found in 101 final subjects who accepting interview. Multiple logistic regression showed that subjects with a history of suicide attempt (n = 53, 52.5%) were more likely to have interpersonal problems with spouse or romantic partner (adjusted odds ratio = 2.85, 95% C.I. = 0.69-11.51), occupational problems mainly maladjustment and frequently changing job (adjusted odds ratio = 3.08, 95% C.I. = 1.12-10.49), and an earlier age (< or = 22 years) of onset (adjusted odds ratio = 0.96, 95% C.I. = 0.90-1.02).

LIMITATION

To use an interview schedule for assessing the psychosocial problems of clinical population limits the interpretation and generalisability of the data.

CONCLUSION

Despite low comorbidity of alcohol/drug use disorders in Chinese bipolar patients, a consistently high rate of suicide attempts reinforces that bipolar disorder is a high-risk group of suicide. An earlier age of onset, interpersonal problems with spouse or romantic partner, and occupational maladjustment rather than demographic characteristics may collectively identify those at high risk of suicide attempt in bipolar disorder.