Childhood maltreatment and unfavourable clinical outcomes in bipolar disorder: a systematic review and meta-analysis

A complex case with generalized epilepsy, probable focal seizures, and functional seizures

In this patient, now 42 years old, genetic generalized epilepsy (juvenile myoclonic epilepsy) manifested itself at the age of 13. At the age of 39, she experienced a status episode with prolonged ICU treatment. She was left with a left-sided hippocampal sclerosis and probably focal seizures. In addition, since the age of 24, the patient also experiences functional seizures on the background of a borderline personality disorder. While generalized epileptic seizures could be controlled with antiseizure medication (ASM), the patient was multiple times admitted to Emergency Departments for her functional seizures with subsequent intensive care treatments, including intubation. As a complication, the patient developed critical illness polyneuropathy and myopathy, resulting in wheelchair dependence. Additionally, she acquired a complex regional pain syndrome after extravasation of ASM. The report demonstrates the uncommon development of hippocampal sclerosis after a generalized tonic-clonic status epilepticus and the poor treatability of functional seizures as compared to generalized and focal seizures.

Clinical and personal predictors of functioning in affective disorders: Exploratory results from baseline and 6-month follow-up of a randomised controlled trial

Comprehensive knowledge of factors causing and sustaining functional impairment in patients with affective disorders is warranted. The aim is to investigate associations between clinical factors (such as affective symptoms) and personal factors (such as personality traits, coping strategies, and childhood trauma experiences) on functioning and improvement of functioning in patients with affective disorders. This exploratory study includes data from 103 patients with bipolar disorder and unipolar depressive disorder. Clinician-rated functioning was assessed at baseline using the Functioning Assessment Short Test (FAST), and performance-based functioning was assessed at baseline and 6-month follow-up using the Assessment of Motor and Process Skills (AMPS). Data on clinical and personal factors were collected at baseline. Personal factors were measured by the Eysenck Personality Inventory (EPQ), Coping Inventory for Stressful Situations (CISS) and Childhood Trauma Questionnaire (CTQ). Pearson correlations and multiple linear regression models were used to analyse the association of clinical and personal factors with baseline functioning (FAST) and to identify predictors of improvement in functioning (AMPS) from baseline to follow-up. At baseline, greater depressive symptom severity, the personality trait neuroticism, emotional coping, and childhood trauma all correlated with poorer functioning (higher FAST scores). In multiple linear regression models, depression severity, emotional coping and childhood trauma were significant predictors of poorer functioning. More childhood trauma was a predictor of less functional improvement measured by AMPS at 6-month follow-up. In conclusion, maladaptive coping styles and depressive symptoms contribute to functional impairment in patients with affective disorders, while childhood trauma has a negative impact on long-term functional outcomes.

Gender differences in the associations between childhood adversity and psychopathology in the general population

PURPOSE

To explore gender differences of the associations between childhood adversity (CA) subtypes and psychiatric symptoms in the general population.

METHODS

Data of 791 participants were retrieved from a general population twin cohort. The Symptom Checklist-90 Revised (SCL-90) and the Childhood Trauma Questionnaire were used to assess overall psychopathology with nine symptom domains scores and total CA with exposure to five CA subtypes, respectively. The associations between CA and psychopathology were analyzed in men and women separately and were subsequently compared.

RESULTS

Total CA was associated with total SCL-90 and all symptom domains without significant gender differences. However, the analyses of CA subtypes showed that the association between emotional abuse and total SCL-90 was stronger in women compared to men [χ2(1) = 4.10, P = 0.043]. Sexual abuse was significantly associated with total SCL-90 in women, but emotional neglect and physical neglect were associated with total SCL-90 in men. Exploratory analyses of CA subtypes and SCL-90 subdomains confirmed the pattern of gender-specific associations. In women, emotional abuse was associated with all symptom domains, and sexual abuse was associated with all except phobic anxiety and interpersonal sensitivity. In men, emotional neglect was associated with depression, and physical neglect was associated with phobic anxiety, anxiety, interpersonal sensitivity, obsessive-compulsive, paranoid ideation, and hostility subdomains.

CONCLUSION

CA is a trans-syndromal risk factor regardless of gender. However, differential associations between CA subtypes and symptom manifestation might exist. Abuse might be particularly associated with psychopathology in women, whereas neglect might be associated with psychopathology in men.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of childhood trauma, social support, cognition, and suicidality in females with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is a severe mental disorder with heavy disease burden. Females with BD are special populations who suffer a lot from childhood trauma, social support, cognitive deficits, and suicidality. In this study, the relationship among childhood trauma, social support, and clinical symptoms of BD was investigated and the risk factors for suicidality were explored in female patients with BD.

METHODS

This study included 57 drug-naive female BD patients, 64 female BD patients with long-term medication, and 50 age-matched female healthy controls. Childhood trauma, social support, clinical symptoms, cognition, and suicidality (suicide ideation, suicide plan, suicide attempt, suicide frequency) were measured with scales.

RESULTS

Compared with healthy controls, females with BD showed higher levels of childhood trauma and suicidality, and lower levels of social support and cognitive deficits. In the drug-naïve BD group, social support mediated the relationship between childhood trauma and insomnia symptoms (indirect effect: ab = 0.025). In the BD with long-term medication group, mania symptom was associated with suicide plan (OR = 1.127, p = 0.030), childhood trauma was associated with suicide attempt (OR = 1.088, p = 0.018), and years of education (OR = 0.773, p = 0.028), childhood trauma (OR = 1.059, p = 0.009), and delayed memory (OR= 1.091, p= 0.016) was associated with suicide frequency (OR = 1.091, p = 0.016).

CONCLUSIONS

This study provides initial evidence that social support partially explains the relationship between childhood trauma and clinical symptoms in females with BD. Additionally, mania symptoms, childhood trauma, and delayed memory were risk factors for suicidality. Interventions providing social support and improving cognitive function may be beneficial for females with BD who are exposed to childhood trauma and with high suicide risk.

Adverse childhood experiences and recent negative events are associated with activated immune and growth factor pathways, the phenome of first episode major depression and suicidal behaviors

This research assessed the effects of adverse childhood experiences (ACEs) and negative life events (NLEs) on forty-eight cytokines/chemokines/growth factors, in 71 FE-MDMD patients and forty heathy controls. ACEs are highly significantly associated with the classical M1 macrophage, T helper (Th)-1, Th-1 polarization, IRS, and neurotoxicity immune profiles, and not with the alternative M2, and Th-2 immune profiles. There are highly significant correlations between ACEs and NLEs and different cytokines/chemokines/growth factors, especially with interleukin (IL)-16, CCL27, stem cell growth factor, and platelet-derived growth factor. Partial Least Squares analysis showed that 62.3 % of the variance in the depression phenome (based on severity of depression, anxiety and suicidal behaviors) was explained by the regression on IL-4 (p = 0.001, inversely), the sum of ACEs + NLEs (p < 0.0001), and a vector extracted from 10 cytokines/chemokines/growth factors (p < 0.0001; both positively associated). The latter partially mediated (p < 0.0001) the effects of ACE + NLEs on the depression phenome. In conclusion, part of the effects of ACEs and NLEs on the depression phenome is mediated via activation of immune and growth factor networks. These pathways have a stronger impact in subjects with lowered activities of the compensatory immune-regulatory system.

How effective are mood stabilizers in treating bipolar patients comorbid with cPTSD? Results from an observational study

BACKGROUND

Multiple traumatic experiences, particularly in childhood, may predict and be a risk factor for the development of complex post-traumatic stress disorder (cPTSD). Unfortunately, individuals with bipolar disorder (BP) are more likely to have suffered traumatic events than the general population. Consequently, cPTSD could be comorbid with BD, and this may negatively affect psychopathological manifestations. To date, no one has explored whether such comorbidity also affects the response to treatment with mood stabilizers in BD patients.

RESULTS

Here, a cross-sectional study was carried out by comparing the response to treatment, measured by the Alda scale, in a cohort of 344 patients diagnosed with BD type I and II, screened for the presence (or absence) of cPTSD using the International Trauma Questionnaire. The main result that emerged from the present study is the poorer response to mood stabilizers in BD patients with comorbid cPTSD compared with BD patients without cPTSD.

CONCLUSIONS

The results collected suggest the need for an add-on therapy focused on trauma in BD patients. This could represent an area of future interest in clinical research, capable of leading to more precise and quicker diagnoses as well as suggesting better tailored and more effective treatments.

Childhood adversity and accelerated reproductive events: a systematic review and meta-analysis

OBJECTIVE

Accelerated female reproductive events represent the early onset of reproductive events involving puberty, menarche, pregnancy loss, first sexual intercourse, first birth, parity, and menopause. This study aimed to explore the association between childhood adversity and accelerated female reproductive events.

DATA SOURCES

PubMed, Web of Science, and Embase were systematically searched from September 22, 2022 to September 23, 2022.

STUDY ELIGIBILITY CRITERIA

Observational cohort, cross-sectional, and case-control studies in human populations were included if they reported the time of reproductive events for female individuals with experience of childhood adversity and were published in English.

METHODS

Two reviewers independently screened studies, obtained data, and assessed study quality, and conflicts were resolved by a third reviewer. Dichotomous outcomes were evaluated using meta-analysis, and pooled odds ratios and 95% confidence intervals were generated using random-effects models. Moderation analysis and meta-regression were used to investigate heterogeneity.

RESULTS

In total, 21 cohort studies, 9 cross-sectional studies, and 3 case-control studies were identified. Overall, female individuals with childhood adversity were nearly 2 times more likely to report accelerated reproductive events than those with no adversity exposure (odds ratio, 1.91; 95% confidence interval, 1.33-2.76; I2=99.6%; P<.001). Moderation analysis indicated that effect sizes for the types of childhood adversity ranged from an odds ratio of 1.61 (95% confidence interval, 1.23-2.09) for low socioeconomic status to 2.13 (95% confidence interval, 1.14-3.99) for dysfunctional family dynamics. Among the 7 groups based on different reproductive events, including early onset of puberty, early menarche, early sexual initiation, teenage childbirth, preterm birth, pregnancy loss, and early menopause, early sexual initiation had a nonsignificant correlation with childhood adversity (odds ratio, 2.70; 95% confidence interval, 0.88-8.30; I2=99.9%; P<.001). Considerable heterogeneity (I2>75%) between estimates was observed for over half of the outcomes. Age, study type, and method of data collection could explain 35.9% of the variance.

CONCLUSION

The literature tentatively corroborates that female individuals who reported adverse events in childhood are more likely to experience accelerated reproductive events. This association is especially strong for exposure to abuse and dysfunctional family dynamics. However, the heterogeneity among studies was high, requiring caution in interpreting the findings and highlighting the need for further evaluation of the types and timing of childhood events that influence accelerated female reproductive events.

Bipolar disorder and cumulative trauma: A systematic review of prevalence and illness outcomes

BACKGROUND

The experience of cumulative trauma may be common in bipolar disorder (BD). However, it is not frequently reported as most studies focus on childhood trauma without examining differences in the amount of trauma experienced. This systematic review aimed to determine the prevalence of lifetime cumulative trauma in BD as well as explore associated illness outcomes.

METHODS

A systematic review was completed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Both the prevalence and outcomes of cumulative trauma in BD were assessed. Five electronic databases were searched (Embase, MEDLINE, PsycINFO, Web of Science, and PTSD Pubs) for records from January 2010 until December 2022.

RESULTS

A total of 20 studies, with 9304 participants were included in the narrative synthesis. At least one-third of BD participants had experienced cumulative trauma, with a prevalence range from 29% to 82%. The main outcomes associated with a history of cumulative trauma were earlier age of onset, longer episode duration, more lifetime mood episodes, greater likelihood of experiencing psychotic features, and higher likelihood of past suicide attempts.

LIMITATIONS

This review has been limited by the lack of studies directly assessing cumulative trauma in BD.

CONCLUSIONS

Cumulative trauma is prevalent in BD. Preliminary evidence indicates an association with a range of adverse outcomes, emphasizing the need for clinicians to obtain a detailed trauma history and to consider these risks in the management of the disorder. Future studies should report on the prevalence of cumulative trauma, particularly in adulthood as this area remains unexplored.

Trauma and comorbid post-traumatic stress disorder in people with bipolar disorder participating in the Heinz C. Prechter Longitudinal Study

BACKGROUND

It is estimated that up to 50 % of people with bipolar disorder (BD) also have comorbid post-traumatic stress disorder (PTSD). However, little is known about the presentation and treatment of people with this comorbidity.

METHODS

Data from 577 individuals diagnosed with bipolar disorder participating in the Heinz C. Prechter Longitudinal Study of BD were explored at baseline, year two and four. Three trauma groups were created: (i) one trauma (n = 75), (ii) multiple traumas (n = 417), and comorbid PTSD (n = 85). Measures of depression, mania, sleep, number of hospitalisations, suicide attempts, and medication use were analysed using regression modelling to determine differences between the three trauma groups.

RESULTS

There was an increase in depression, mania, and sleep scores and a higher number of hospitalisations in participants with comorbid PTSD compared to those experiencing one trauma. Additionally, increased mania and depression scores were reported in participants experiencing multiple traumas compared to those with one trauma. There was no difference in medication use between those who experienced one trauma compared to those with comorbid PTSD.

LIMITATIONS

The trauma groups may include confounding with more participants experiencing PTSD than reported in this study due to screening processes. Additionally, the severity of trauma was not recorded, therefore number of traumas was utilised as a proxy.

CONCLUSION

Comorbid BD and PTSD is associated with worse symptom scores compared to participants reporting one trauma. Clinical implications include the addition of trauma-informed care to clinical settings to identify PTSD to provide appropriate treatments.

Effects of childhood maltreatment and major depressive disorder on functional connectivity in hippocampal subregions

Major Depressive Disorder (MDD) with childhood maltreatment is a prevalent clinical phenotype. Prior studies have observed abnormal hippocampal activity in MDD patients, considering the hippocampus as a single nucleus. However, there is limited research investigating the static and dynamic changes in hippocampal subregion functional connectivity (FC) in MDD patients with childhood maltreatment. Therefore, we employed static and dynamic FC analyses using hippocampal subregions, including the anterior hippocampus and posterior hippocampus, as seed regions to investigate the neurobiological alterations associated with MDD resulting from childhood maltreatment. This study involved four groups: MDD with (n = 48) and without childhood maltreatment (n = 30), as well as healthy controls with (n = 57) and without (n = 46) childhood maltreatment. Compared to MDD patients without childhood maltreatment, those with childhood maltreatment exhibit altered FC between the hippocampal subregion and multiple brain regions, including the anterior cingulate gyrus, superior frontal gyrus, putamen, calcarine gyrus, superior temporal gyrus, angular gyrus, and supplementary motor area. Additionally, dynamic FC between the right medial-2 hippocampal head and the right calcarine gyrus shows a positive correlation with childhood maltreatment across all its subtypes. Moreover, dFC between the right hippocampal tail and the left angular gyrus moderates the relationship between childhood maltreatment and the depression severity. Our findings of distinct FC patterns within hippocampal subregions provide new clues for understanding the neurobiological basis of MDD with childhood maltreatment.

A Glucocorticoid-Sensitive Hippocampal Gene Network Moderates the Impact of Early-Life Adversity on Mental Health Outcomes

BACKGROUND

Early stress increases the risk for psychiatric disorders. Glucocorticoids are stress mediators that regulate transcriptional activity and morphology in the hippocampus, which is implicated in the pathophysiology of multiple psychiatric conditions. We aimed to establish the relevance of hippocampal glucocorticoid-induced transcriptional activity as a mediator of the effects of early life on later psychopathology in humans.

METHODS

RNA sequencing was performed with anterior and posterior hippocampal dentate gyrus from adult female macaques (n = 12/group) that were chronically treated with betamethasone (glucocorticoid receptor agonist) or vehicle. Coexpression network analysis identified a preserved gene network in the posterior hippocampal dentate gyrus that was strongly associated with glucocorticoid exposure. The single nucleotide polymorphisms in the genes in this network were used to create an expression-based polygenic score in humans.

RESULTS

The expression-based polygenic score significantly moderated the association between early adversity and psychotic disorders in adulthood (UK Biobank, women, n = 44,519) and on child peer relations (ALSPAC [Avon Longitudinal Study of Parents and Children], girls, n = 1666 for 9-year-olds and n = 1594 for 11-year-olds), an endophenotype for later psychosis. Analyses revealed that this network was enriched for glucocorticoid-induced epigenetic remodeling in human hippocampal cells. We also found a significant association between single nucleotide polymorphisms from the expression-based polygenic score and adult brain gray matter density.

CONCLUSIONS

We provide an approach for the use of transcriptomic data from animal models together with human data to study the impact of environmental influences on mental health. The results are consistent with the hypothesis that hippocampal glucocorticoid-related transcriptional activity mediates the effects of early adversity on neural mechanisms implicated in psychiatric disorders.

Differences in facial emotion recognition between bipolar disorder and other clinical populations: A systematic review and meta-analysis

Facial emotion (or expression) recognition (FER) is a domain of affective cognition impaired across various psychiatric conditions, including bipolar disorder (BD). We conducted a systematic review and meta-analysis searching for eligible articles published from inception to April 26, 2023, in PubMed/MEDLINE, Scopus, EMBASE, and PsycINFO to examine whether and to what extent FER would differ between people with BD and those with other mental disorders. Thirty-three studies comparing 1506 BD patients with 1973 clinical controls were included in the present systematic review, and twenty-six of them were analyzed in random-effects meta-analyses exploring the discrepancies in discriminating or identifying emotional stimuli at a general and specific level. Individuals with BD were more accurate in identifying each type of emotion during a FER task compared to individuals diagnosed with schizophrenia (SCZ) (SMD = 0.27; p-value = 0.006), with specific differences in the perception of anger (SMD = 0.46; p-value = 1.19e-06), fear (SMD = 0.38; p-value = 8.2e-04), and sadness (SMD = 0.33; p-value = 0.026). In contrast, BD patients were less accurate than individuals with major depressive disorder (MDD) in identifying each type of emotion (SMD = -0.24; p-value = 0.014), but these differences were more specific for sad emotional stimuli (SMD = -0.31; p-value = 0.009). No significant differences were observed when BD was compared with children and adolescents diagnosed with attention-deficit/hyperactivity disorder. FER emerges as a potential integrative instrument for guiding diagnosis by enabling discrimination between BD and SCZ or MDD. Enhancing the standardization of adopted tasks could further enhance the accuracy of this tool, leveraging FER potential as a therapeutic target.

EMDR therapy vs. supportive therapy as adjunctive treatment in trauma-exposed bipolar patients: A randomised controlled trial

INTRODUCTION

Patients with bipolar disorder (BD) are frequently exposed to traumatic events which worsen disease course, but this study is the first multicentre randomised controlled trial to test the efficacy of a trauma-focused adjunctive psychotherapy in reducing BD affective relapse rates.

MATERIALS AND METHODS

This multicentre randomised controlled trial included 77 patients with BD and current trauma-related symptoms. Participants were randomised to either 20 sessions of trauma-focused Eye Movement Desensitization and Reprocessing (EMDR) therapy for BD, or 20 sessions of supportive therapy (ST). The primary outcome was relapse rates over 24-months, and secondary outcomes were improvements in affective and trauma symptoms, general functioning, and cognitive impairment, assessed at baseline, post-treatment, and at 12- and 24-month follow-up. The trial was registered prior to starting enrolment in clinical trials (NCT02634372) and carried out in accordance with CONSORT guidelines.

RESULTS

There was no significant difference between treatment conditions in terms of relapse rates either with or without hospitalisation. EMDR was significantly superior to ST at the 12-month follow up in terms of reducing depressive symptoms (p=0.0006, d=0.969), manic symptoms (p=0.027, d=0.513), and improving functioning (p=0.038, d=0.486). There was no significant difference in dropout between treatment arms.

CONCLUSIONS

Although the primary efficacy criterion was not met in the current study, trauma-focused EMDR was superior to ST in reducing of affective symptoms and improvement of functioning, with benefits maintained at six months following the end of treatment. Both EMDR and ST reduced trauma symptoms as compared to baseline, possibly due to a shared benefit of psychotherapy. Importantly, focusing on traumatic events did not increase relapses or dropouts, suggesting psychological trauma can safely be addressed in a BD population using this protocol.

Inflammation and emotion regulation: a narrative review of evidence and mechanisms in emotion dysregulation disorders

Emotion dysregulation (ED) describes a difficulty with the modulation of which emotions are felt, as well as when and how these emotions are experienced or expressed. It is a focal overarching symptom in many severe and prevalent neuropsychiatric diseases, including bipolar disorders (BD), attention deficit/hyperactivity disorder (ADHD), and borderline personality disorder (BPD). In all these disorders, ED can manifest through symptoms of depression, anxiety, or affective lability. Considering the many symptomatic similarities between BD, ADHD, and BPD, a transdiagnostic approach is a promising lens of investigation. Mounting evidence supports the role of peripheral inflammatory markers and stress in the multifactorial aetiology and physiopathology of BD, ADHD, and BPD. Of note, neural circuits that regulate emotions appear particularly vulnerable to inflammatory insults and peripheral inflammation, which can impact the neuroimmune milieu of the central nervous system. Thus far, few studies have examined the link between ED and inflammation in BD, ADHD, and BPD. To our knowledge, no specific work has provided a critical comparison of the results from these disorders. To fill this gap in the literature, we review the known associations and mechanisms linking ED and inflammation in general, and clinically, in BD, ADHD, and BD. Our narrative review begins with an examination of the routes linking ED and inflammation, followed by a discussion of disorder-specific results accounting for methodological limitations and relevant confounding factors. Finally, we critically discuss both correspondences and discrepancies in the results and comment on potential vulnerability markers and promising therapeutic interventions.

A systematic review of childhood maltreatment and resting state functional connectivity

Resting-state functional connectivity (rsFC) has the potential to shed light on how childhood abuse and neglect relates to negative psychiatric outcomes. However, a comprehensive review of the impact of childhood maltreatment on the brain's resting state functional organization has not yet been undertaken. We systematically searched rsFC studies in children and youth exposed to maltreatment. Nineteen studies (total n = 3079) met our inclusion criteria. Two consistent findings were observed. Childhood maltreatment was linked to reduced connectivity between the anterior insula and dorsal anterior cingulate cortex, and with widespread heightened amygdala connectivity with key structures in the salience, default mode, and prefrontal regulatory networks. Other brain regions showing altered connectivity included the ventral anterior cingulate cortex, dorsolateral prefrontal cortex, and hippocampus. These patterns of altered functional connectivity associated with maltreatment exposure were independent of symptoms, yet comparable to those seen in individuals with overt clinical disorder. Summative findings indicate that rsFC alterations associated with maltreatment experience are related to poor cognitive and social functioning and are prognostic of future symptoms. In conclusion, maltreatment is associated with altered rsFC in emotional reactivity, regulation, learning, and salience detection brain circuits. This indicates patterns of recalibration of putative mechanisms implicated in maladaptive developmental outcomes.

Child maltreatment and resilience in adulthood: a protocol for a systematic review and meta-analysis

Background: Although child maltreatment (CM) has been linked to health problems and poor psychosocial functioning, not all individuals exposed to CM develop or experience negative consequences later in life. This suggests that some individuals show resilience after being exposed to CM. However, conclusions have been limited by inconsistent findings across different CM subtypes and resilience domains.Objective: To develop a protocol for conducting a systematic review and meta-analysis to quantify associations between CM (overall and its subtypes) and resilience (global and its multiple domains) in adulthood, and to examine moderators and mediators of these associations.Method: PubMed, PsycINFO, Embase, Scopus, and Web of Science will be searched to identify relevant studies on the association between CM (exposure) and resilience (outcome) in adults (≥ 18 years). Data will be screened and extracted by at least two independent reviewers. The methodological quality of the included studies will be independently assessed with a modified version of the Newcastle-Ottawa Scale (NOS). If deemed viable, a meta-analysis will be conducted using a random effects model. Heterogeneity of evidence will be estimated with the I2 statistic, and publication bias will be assessed. The effects of potential moderators (e.g. timing and severity of CM, age, sex, family cohesion, socio-economic status, country/region) will be analysed using meta-regression and subgroup analyses, and meta-analytical structural equation modelling will be employed to synthesise indirect mediation effects. Candidate moderators and mediators (e.g. genetic factors, brain functioning, attachment style, personality traits, physical activity, and social support) will be also examined qualitatively.Conclusions: This protocol will facilitate a systematic review and meta-analysis that has the potential to enhance our knowledge about the association between CM exposure in early life and resilience in adulthood. Understanding associations and underlying mechanisms between CM and resilience is potentially important in informing prevention and interventions to sustain health and improve outcomes among adults with a history of CM.PROSPERO registration: CRD42023394120.

Multiple psychiatric polygenic risk scores predict associations between childhood adversity and bipolar disorder

BACKGROUND

It remains unclear how adverse childhood experiences (ACE) and increased genetic risk for bipolar disorder (BD) interact to influence BD symptom outcomes. Here we calculated multiple psychiatric polygenic risk scores (PRS) and used the measures of ACE to understand these gene-environment interactions.

METHOD

885 BD subjects were included for analyses. BD, ADHD, MDD and SCZ PRSs were calculated using the PRS-CS-auto method. ACEs were evaluated using the Children Life Event Questionnaire (CLEQ). Participants were divided into groups based on the presence of ACE and the total number of ACEs. The associations between total ACE number, PRSs and their interactions were evaluated using multiple linear and logistic regressions. Secondary analyses were performed to evaluate the influence of ACE and PRS on sub-phenotypes of BD.

RESULTS

The number of ACEs increased with the ADHD PRS. BD participants who had ACEs showed an earlier age of BD onset and higher odds of having rapid cycling. Increased BD PRS was associated with increased odds of developing psychotic symptoms. Higher ADHD PRS was associated with increased odds of having rapid cycling. No prediction effect was observed from MDD and SCZ PRS. And, we found no significant interaction between ACE numbers and any of the PRSs in predicting any selected BD sub-phenotypes.

LIMITATIONS

The study was limited by sample size, ACE definition, and cross-sectional data collection method.

CONCLUSIONS

The findings consolidate the importance of considering multiple psychiatric PRSs in predicting symptom outcomes among BD patients.

Cerebellar morphological differences and associations with extrinsic factors in bipolar disorder type I

BACKGROUND

The neural underpinnings of bipolar disorder (BD) remain poorly understood. The cerebellum is ideally positioned to modulate emotional regulation circuitry yet has been understudied in BD. Literature suggests differences in cerebellar activity and metabolism in BD, however findings on structural differences remain contradictory. Potential reasons include combining BD subtypes, small sample sizes, and potential moderators such as genetics, adverse childhood experiences (ACEs), and pharmacotherapy.

METHODS

We collected 3 T MRI scans from participants with (N = 131) and without (N = 81) BD type I, as well as blood and questionnaires. We assessed differences in cerebellar volumes and explored potentially influential factors.

RESULTS

The cerebellar cortex was smaller bilaterally in participants with BD. Polygenic propensity score did not predict any cerebellar volumes, suggesting that non-genetic factors may have greater influence on the cerebellar volume difference we observed in BD. Proportionate cerebellar white matter volumes appeared larger with more ACEs, but this may result from reduced ICV. Time from onset and symptom burden were not associated with cerebellar volumes. Finally, taking sedatives was associated with larger cerebellar white matter and non-significantly larger cortical volume.

LIMITATIONS

This study was cross-sectional, limiting interpretation of possible mechanisms. Most of our participants were White, which could limit the generalizability. Additionally, we did not account for potential polypharmacy interactions.

CONCLUSIONS

These findings suggest that external factors, such as sedatives and childhood experiences, may influence cerebellum structure in BD and may mask underlying differences. Accounting for such variables may be critical for consistent findings in future studies.

Treating Trauma in Criminal Justice-Involved with SMI: "Trauma Is a Huge Part of It"

Individuals with serious mental illness are both disproportionately represented in the criminal justice system and more likely to experience correlates with offending (e.g., trauma, substance abuse, and homelessness). Moreover, research using the Adverse Childhood Experiences has found strong correlation between childhood trauma and later negative outcomes, including criminal justice involvement. Despite this, research has yet to examine how trauma can influence treatment decisions for criminal justice-involved individuals with SMI. Using a qualitative approach and in-depth semi-structured interviews with 61 community mental health service providers, the current study addresses this gap in the literature. Findings confirm the high prevalence of trauma in this population as well as suggests a number of key findings for this population including (1) how trauma affects treatment decisions, (2) the existing barriers related to the treatment of trauma, and (3) what service providers need to effectively treat trauma. Implications for policy and practice are extensive.

Childhood maltreatment contributes to the medical morbidity of individuals with bipolar disorders

BACKGROUND

Individuals with bipolar disorders (BD) are at risk of premature death, mainly due to medical comorbidities. Childhood maltreatment might contribute to this medical morbidity, which remains underexplored in the literature.

METHODS

We assessed 2891 outpatients with BD (according to DSM-IV criteria). Childhood maltreatment was assessed using the Childhood Trauma Questionnaire. Lifetime diagnoses for medical disorders were retrospectively assessed using a systematic interview and checked against medical notes. Medical morbidity was defined by the sum of medical disorders. We investigated associations between childhood maltreatment (neglect and abuse) and medical morbidity while adjusting for potential confounders.

RESULTS

One quarter of individuals had no medical comorbidities, while almost half of them had at least two. Multivariable regression showed that childhood maltreatment (mainly abuse, but also sexual abuse) was associated with a higher medical morbidity. Medical morbidity was also associated with sex, age, body mass index, sleep disturbances, lifetime anxiety disorders and lifetime density of mood episodes. Childhood maltreatment was associated with an increased prevalence of four (i.e. migraine/headache, drug eruption, duodenal ulcer, and thyroid diseases) of the fifteen most frequent medical disorders, however with no difference in terms of age at onset.

CONCLUSIONS

This large cross-sectional study confirmed a high medical morbidity in BD and its association with childhood maltreatment. The assessment of childhood maltreatment in individuals with BD should be systematically included in routine care and the potential impact on physical health of psycho-social interventions targeting childhood maltreatment and its consequences should be evaluated.

Early sexual or physical abuse in female and male mood disorder patients

Early abuse has been associated with psychiatric morbidity but comparisons of bipolar (BD) and major depressive (MDD) disorder subjects with versus without early sexual or physical abuse are rare. Patients (n = 684) diagnosed with a DSM-5-TR major mood disorder were evaluated and followed for several years at mood disorder centers to compare details of history and clinical status in participants with versus without early sexual or physical abuse. Early history of sexual (16.2%) or physical abuse (11.9%) was prevalent; 5.15% reported both. Both types of abuse were much more prevalent with BD than MDD. Sexual abuse was associated with younger illness-onset and somewhat younger menarche in females; both abuse-types were associated with familial mood disorders, especially BD. Prospective, long-term illness episode-frequency, depressions or [hypo]manias/year and %-time [hypo]manic all were greater following sexual abuse but morbidity measures did not differ following physical abuse. Prevalence of suicidal behavior ranked: double (48.5%) > physical (32.1%) > sexual (30.3%) abuse, and with BD > MDD (OR = 2.31). Recall bias and not using psychometric instruments to define abuse severity or type may limit interpretation of findings. Early sexual (more than physical) abuse, led to greater morbidity and both abuses were strongly associated with familial mood disorders and greater suicidal risk, especially with double-abuse and BD diagnosis. We support a bilateral relationship between abuse and diagnosis of BD: abuse may facilitate early appearance of BD but also may result from the actions of abusive BD family members.

Hard-to-treat or hard-to-catch? Clinical features and therapeutic outcomes of help-seeking foster care youths with mood disorders

Introduction

The high level of emotional problems in youths placed in foster care contrasts with the limited use of evidence-based treatments. This study aims to better characterize the clinical features and therapeutic outcomes of foster care youths with mood disorders.

Methods

A secondary analysis of data collected in the context of a French-Canadian clinical research network on pediatric mood disorders in four sites was conducted to compare three groups of patients with depressive or bipolar disorder: those without exposure to child welfare intervention (WCWI, n = 181), those who received non-placement psychosocial intervention (NPI, n = 62), and those in placement interventions (PI, n = 41).

Results

We observed a very high rate of academic problems in patients in the groups NPI/PI compared to those in the WCWI group. Patients in the PI group had more disruptive behavioral disorders (OR = 6.87, 95% CI [3.25-14.52]), trauma-related disorders (OR = 3.78, 95% CI [1.6-8.94]), and any neurodevelopmental disorders (OR = 2.73, 95% CI [1.36-5.49]) compared to the other groups (NPI/WCWI). Among inpatients, the Clinical Global Impression-Improvement scale and the change in the Children Global Assessment Scale during the hospital stay did not differ across the three groups. We observed a higher prescription rate of antipsychotics in the PI group compared to the NPI/WCWI groups, but no significant difference for antidepressants and mood stabilizers.

Discussion

These findings support the view that, when provided with dedicated support, fostered inpatient youths can improve in a range comparable to other inpatients. Undetected neurodevelopmental disorders and academic problems are likely important contributors of the burden of mood disorders in these youths.

Predicting functional impairment in euthymic patients with mood disorder: A 5-year follow-up

Major Depressive Disorder and Bipolar Disorder are psychiatric disorders associated with psychosocial impairment. Despite clinical improvement, functional complaints usually remain, mainly impairing occupational and cognitive performance. The aim of this study was to use machine learning techniques to predict functional impairment in patients with mood disorders. For that, analyzes were performed using a population-based cohort study. Participants diagnosed with a mood disorder at baseline and reassessed were considered (n = 282). Random forest (RF) with previous recursive feature selection and LASSO algorithms were applied to a training set with imputed data by bagged trees resulting in two main models. Following recursive feature selection, 25 variables were retained. The RF model had the best performance compared to LASSO. The most important variables in predicting functional impairment were sexual abuse, severity of depressive, anxiety, and somatic symptoms, physical neglect, emotional abuse, and physical abuse. The model demonstrated acceptable performance to predict functional impairment. However, our sample is composed of young participants and the model may not generalize to older individuals with mood disorders. More studies are needed in this direction. The presented calculator has clinical, sociodemographic, and environmental data, demonstrating that it is possible to use such information to predict functional performance.

Associations Between Objective and Subjective Experiences of Childhood Maltreatment and the Course of Emotional Disorders in Adulthood

Importance

A history of childhood maltreatment is associated with an unfavorable course of illness for emotional disorders. However, the origins and mechanisms underlying these associations are unknown.

Objective

To examine the relative associations of objective and subjective measures of childhood maltreatment and continuity in psychopathology with the course of emotional disorders in adulthood.

Design, Setting, and Participants

This prospective cohort study followed up until age 40 years participants residing in a metropolitan county of the US Midwest with substantiated records of childhood physical and sexual abuse and/or neglect between 1967 and 1971 and a demographically matched group of participants experiencing no abuse or neglect in childhood. The collected data were analyzed between October 2021 and April 2022.

Exposures

The objective experience of childhood maltreatment before age 12 years was prospectively measured through official court records, whereas the subjective experience was measured through retrospective self-report at a mean (SD) age of 29 (3.8) years. Current and previous lifetime psychopathology was also assessed at a mean age of 29 (3.8) years.

Main Outcomes and Measures

Symptoms of depression and anxiety were measured at mean (SD) ages of 39.5 (3.5) and 41.2 (3.5) years using Poisson regression models.

Results

In a cohort of 1196 participants (582 [48.7%] female and 614 [51.3%] male) followed up to age 40 years, those with objective plus subjective measures of childhood maltreatment had a greater number of subsequent follow-up phases with depression or anxiety than controls (depression: incidence rate ratio [IRR], 2.28 [95% CI, 1.65-3.15]; anxiety: IRR, 2.30 [95% CI, 1.54-3.42]), as did those with subjective-only measures (depression: IRR, 1.49 [95% CI, 1.02-2.18]; anxiety: IRR, 1.58 [95% CI, 0.99-2.52]). In contrast, participants with objective-only measures did not have a greater number of follow-up phases with depression or anxiety (depression: IRR, 1.37 [95% CI, 0.89-2.11]; anxiety: IRR, 1.40 [95% CI, 0.84-2.31]). Current and lifetime psychopathology measured at the time the subjective experience was assessed explained its association with a later course of emotional disorders in participants with subjective-only measures but not in those with objective plus subjective measures.

Conclusions and Relevance

In this cohort study, the associations seen between childhood maltreatment and poor course of emotional disorders over the subsequent decade were largely attributable to the subjective experience of maltreatment, which was partly explained by continuity in psychopathology. Modification of the subjective experience of childhood maltreatment could improve the longitudinal course of emotional disorders.

A comprehensive evaluation of adverse childhood experiences, social-emotional impairments, and neurodevelopmental disorders in cannabis-use disorder: Implications for clinical practice

BACKGROUND

Adverse childhood experiences (ACEs), social-emotional impairments (SEIs), and neurodevelopmental disorders (NDs) are frequent in psychiatric disorders, including substance-use disorders. We aimed to determine the prevalence of ACE, SEI, or ND in individuals with cannabis-use disorder (CUD). We compared individuals with preCUD-onset ACE, SEI, or ND to those without.

METHODS

We crosssectionally studied 323 inpatients or outpatients with a history of past or current CUD, aged 12-35 years (mean age 22.94 ± 4.79), 64.5% of whom were male. The sample was divided into two groups: the non-premorbid (N = 52) and the premorbid ACE/SEI/ND group (N = 271). Within the premorbid group, further subgroups were based on ACEs, SEI, and NDs. We also analyzed other substance use and psychiatric symptoms/diagnoses based on the non-premorbid-premorbid dichotomy in the CUD sample.

RESULTS

Pre-CUD ACE-SEI-ND had higher prevalence of bipolar, schizoaffective, borderline personality, and attention-deficit/hyperactivity disorders, and a history of agitation, hallucinations, and self-injury. The ACE group had higher rates of agitation, depression, delusions, hallucinations, eating disorders, and use of cocaine, amphetamines, and hallucinogens than the SEI or ND. Patients in the premorbid group initiated cannabis use at an earlier age, experienced the first comorbid psychiatric episode earlier, and were hospitalized earlier than those in the non- premorbid ACE-SEI-ND group.

CONCLUSIONS

PreCUD-onset ACE, SEI, or ND conditions in individuals with CUDare linked to earlier onset of comorbid mental illness. Furthermore, ACEs contribute to significant and potentially severe clinical symptoms, as well as the use of substances other than cannabis.

Older age bipolar disorder

PURPOSE OF REVIEW

Older age bipolar disorder (OABD) refers to patients with bipolar disorder aged 50 years and over. There is a paucity of evidence-based guidelines specific to OABD, but in recent years, several studies have been published on OABD. The current review synthesizes previous literature (up to January 1, 2021) as well as most recent literature on OABD (since January 1, 2021).

RECENT FINDINGS

This review covers the following themes: diagnosis and specifiers, clinical course, psychosocial functioning, cognition, physical comorbidities, and pharmacotherapy. On the basis of the latest data, specific clinical recommendations are proposed for each theme.

SUMMARY

OABD forms a more complex subgroup of bipolar disorder, with an increased risk of cognitive deficits, physical comorbidities, impaired psychosocial functioning, and premature death. The distinctions between BD-I and BD-II and between EOBD and LOBD do not clinically represent relevant subtypes for OABD patients. Mental healthcare professionals should treat all OABD patients with an integrative care model that takes into account cognitive and physical comorbidities and that contains elements aimed at improvement of psychosocial functioning and quality of life. Older age itself should not be a reason to withhold lithium treatment. Future research should collect data on essential data domains using validated measurement scales.

Bipolar disorder: Diagnosis, treatment and future directions

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

Self-reported low self-esteem due to poor maternal care improves with the existential approach in bipolar disorder: a case report

Parental nurturing attitudes influence children and are linked to the establishment of self-esteem. Females who have experienced poor maternal care during their childhood may have low self-esteem, and this factor may significantly augment the likelihood of depression. Particularly, childhood maltreatment among individuals with bipolar disorder is associated with unfavorable clinical features, such as a heightened risk of severe manic, depressive, or psychotic symptoms, as well as suicide attempts. Here, we report a case of a woman with bipolar disorder who had self-reported low self-esteem due to poor maternal care, which subsequently improved via an existential approach. This existential approach confers meaning to the lives of every individual, even in the face of adversity. Our findings suggest that the existential approach may enable the discovery of more positive life values during times of hardship and could improve self-reported low self-esteem due to poor maternal and change the way of life in patients with bipolar disorder.

Immune cell subsets in patients with bipolar disorder or schizophrenia with history of childhood maltreatment

A history of Childhood Maltreatment (CM) has been repeatedly associated with an increased risk of developing bipolar disorders (BD) or schizophrenia (SZ). The impact of severe stress induced by CM has been proposed to be mediated by elevated inflammation reflected by dysregulated inflammatory processes. Little is known about the potential impact of CM on lymphocyte subpopulations or the role of pre-existing infections on CM physiological consequences. This study therefore explored the role of CM and past infection exposure impact on lymphocyte subpopulations to give an indication of their relevance as stressors in the pathoetiology of major mood and psychotic disorders. 118 adult patients with SZ, and 152 with BD were included in the analysis. CM history was assessed by the Childhood Trauma Questionnaire (CTQ), with current and past psychiatric symptomatology also evaluated. Circulating immune cell subsets were analyzed using flow cytometry-based analysis. Past exposure to common infectious stigma including toxoplasma, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) were measured by solid phase-enzyme microplate and ELISA immunoassays. The relationship between CM, biological phenotypes (including immune cell subsets distribution and past infectious status) and clinical phenotypes were analyzed using univariate and multivariate analyses. BD patients with, versus without, CM had higher levels of CD3+CD8+ cytotoxic T cells and CMV antibodies along with decreased levels of CD45RA+CCR7+CD8+ naïve CD8+ T cells, and a more severe clinical profile. CMV antibody levels were inversely associated with the CD3 + CD8 + lymphocyte subset level. SZ patients with, versus without, CM, showed lower levels of CD14 + monocytes and no specific clinical characteristics. The accumulation of different types of maltreatment associated with increased body mass index and CMV autoantibodies as well as decreased levels of CD14 + monocytes. In both BD and SZ, further analysis according to the type and the number of CM subtypes showed association with specific changes in lymphocyte cell subsets, clinical profile, and infectious stigma. Adults with BD or SZ exposed to CM exhibit specific immune cell subset profiles, clinical features, and stigma of past infections. In BD, our data indicate an interplay between CM and CMV infections, which may possibly contribute to premature aging and cellular senescence, both of which have previously been shown to associate with mood disorders. Longitudinal studies of CM-exposed patients are required to clarify the interactions of CM and viral infections, including as to the pathophysiological processes driving patient symptomatology.

Factors associated with psychiatric and physical comorbidities in bipolar disorder: a nationwide multicenter cross-sectional observational study

BACKGROUND

Bipolar disorder (BD) is a chronic and disabling affective disorder with significant morbidity and mortality. Despite the high rate of psychiatric and physical health comorbidity, little is known about the complex interrelationships between clinical features of bipolar illness and comorbid conditions. The present study sought to examine, quantify and characterize the cross-sectional associations of psychiatric and physical comorbidities with selected demographic and clinical characteristics of adults with BD.

METHODS

A nationwide multicenter cross-sectional observational epidemiological study conducted from October 2015 to March 2017 in Slovakia.

RESULTS

Out of 179 study participants [median age 49 years (interquartile range IQR 38-58); 57.5% females], 22.4% were free of comorbidity, 42.5% had both psychiatric and physical comorbidities, 53.6% at least one psychiatric comorbidity, and 66.5% at least one physical comorbidity. The most prevalent were the essential hypertension (33.5%), various psychoactive substance-related disorders (21.2%), specific personality disorders (14.6%), obesity (14.5%), and disorders of lipoprotein metabolism (14%). The presence of an at least one physical comorbidity, atypical symptoms of BD, and unemployed status were each associated with an at least one psychiatric comorbidity independent of sex, early onset of BD (age of onset <35 years), BD duration and pattern of BD illness progression (p < 0.001). The presence of various psychoactive substance-related disorders, BD duration, atypical symptoms of BD, unemployed status, pension, female sex, and not using antipsychotics were each associated with an at least one physical comorbidity independent of the pattern of BD illness progression (p < 0.001). In several other multiple regression models, the use of antipsychotics (in particular, olanzapine) was associated with a decreased probability of the essential hypertension and predicted the clinical phenotype of comorbidity-free BD (p < 0.05).

CONCLUSION

This cross-national study has reported novel estimates and clinical correlates related to both the comorbidity-free phenotype and the factors associated with psychiatric and physical comorbidities in adults with BD in Slovakia. The findings provide new insights into understanding of the clinical presentation of BD that can inform clinical practice and further research to continue to investigate potential mechanisms of BD adverse outcomes and disease complications onset.

The collective impact of childhood abuse, psychache, and interpersonal needs on suicidal ideation among individuals with bipolar disorder: A discriminant analysis

BACKGROUND

Suicide is one of the ten leading causes of death in the United States. Childhood abuse, psychache (intense emotional pain), and interpersonal needs are widely known to be associated with suicidal thoughts and behaviors. However, only a limited number of studies investigate whether these variables, when analyzed collectively, are able to distinguish between a group of individuals who report suicidal ideation and those who deny such thoughts.

PARTICIPANTS AND SETTING

Data were collected from individuals (N =177) with a diagnosis of bipolar disorder participating in an intensive outpatient program that provides mental health care to indigent, mostly minority patients in Southeast United States.

METHODS

The dependent variable was item number 9 on the Beck Depression Inventory that asks about any suicidal thoughts in the past two weeks. We utilized discriminant analysis to test whether childhood abuse, interpersonal needs, and psychache were collectively able to accurately identify group membership of the study participants.

RESULTS

The discriminant model included six independent variables: three different types of childhood abuse (emotional, physical, and sexual), interpersonal needs (perceived burdensomeness and thwarted belongingness), and psychache. Results revealed that the model was able to correctly classify group membership in 75% of the individuals in the study.

CONCLUSION

In context of bipolar disorder, history of childhood abuse (particularly sexual and emotional abuse), intense psychache, and greater perceived thwarted belongingness and burdensomeness put an individual at a higher risk of suicidal ideation. Gaining insight into the interactions among these variables may lead to formulating early interventions to prevent suicide in patients reporting this constellation of symptoms.

Rates and associations of relapse over 5 years of 2649 people with bipolar disorder: a retrospective UK cohort study

BACKGROUND

Evidence regarding the rate of relapse in people with bipolar disorder (BD), particularly from the UK, is lacking. This study aimed to evaluate the rate and associations of clinician-defined relapse over 5 years in a large sample of BD patients receiving routine care from a UK mental health service.

METHOD

We utilised de-identified electronic health records to sample people with BD at baseline. Relapse was defined as either hospitalisation, or a referral to acute mental health crisis services, between June 2014 and June 2019. We calculated the 5-year rate of relapse and examined the sociodemographic and clinical factors that were independently associated with relapse status and the number of relapses, over the 5-year period.

RESULTS

Of 2649 patients diagnosed with BD and receiving care from secondary mental health services, 25.5% (n = 676) experienced at least one relapse over 5 years. Of the 676 people who relapsed, 60.9% experienced one relapse, with the remainder experiencing multiple relapses. 7.2% of the baseline sample had died during the 5-year follow-up. Significant factors associated with experiencing any relapse, after adjustment for relevant covariates, were history of self-harm/suicidality (OR 2.17, CI 1.15-4.10, p = 0.02), comorbidity (OR 2.59, CI 1.35-4.97, p = 0.004) and psychotic symptoms (OR 3.66, CI  1.89-7.08, p < 0.001). Factors associated with the number of relapses over 5 years, after adjustment for covariates, were self-harm/suicidality (β = 0.69, CI 0.21-1.17, p = 0.005), history of trauma (β = 0.51, CI = 0.07-0.95, p = 0.03), psychotic symptoms (β = 1.05, CI 0.55-1.56, p < 0.001), comorbidity (β = 0.52, CI 0.07-1.03, p = 0.047) and ethnicity (β = - 0.44, CI - 0.87 to - 0.003, p = 0.048).

CONCLUSIONS

Around 1 in 4 people with BD in a large sample of people with BD receiving secondary mental health services in the UK relapsed over a 5-year period. Interventions targeting the impacts of trauma, suicidality, presence of psychotic symptoms and comorbidity could help to prevent relapse in people with BD and should be considered in relapse prevention plans.

Prevalence and outcomes of rapid cycling bipolar disorder: Mixed method systematic meta-review

Rapid-cycling in bipolar disorder (RC-BD) is associated with greater illness morbidity and inferior treatment response but many aspects remain unclear, prompting this systematic review of its definitions, prevalence, and clinical characteristics. We searched multiple literature databases through April 2022 for systematic reviews or meta-analyses on RC-BD and extracted associated definitions, prevalence, risk-factors, and clinical outcomes. We assessed study quality (NIH Quality Assessment Tool) and levels of evidence (Oxford criteria). Of 146 identified reviews, 22 fulfilling selection criteria were included, yielding 30 studies involving 13,698 BD patients, of whom 3777 (27.6% [CI: 26.8-28.3]) were considered RC-BD, as defined in 14 reports by ≥4 recurrences/year within the past 12 months or in any year, without considering responsiveness to treatment. Random-effects meta-analytically pooled one-year prevalence was 22.3% [CI: 14.4-32.9] in 12 reports and lifetime prevalence was 35.5% [27.6-44.3] in 18 heterogenous reports. Meta-regression indicated greater lifetime prevalence of RC-BD among women than men (p=0.003). Association of RC-BD with suicide attempts, and unsatisfactory response to mood-stabilizers was supported by strong evidence (Level 1); associations with childhood maltreatment, mixed-features, female sex, and type-II BD had moderate evidence (Level 2). Other factors: genetic predisposition, metabolic disturbances or hypothyroidism, antidepressant exposure, predominant depressive polarity (Level 3), along with greater illness duration and immune-inflammatory dysfunction (Level 4) require further study. RC-BD was consistently recognized as having high prevalence (22.3%-35.5% of BD cases) and inferior treatment response. Identified associated factors can inform clinical practice. Long-term illness-course, metabolic factors, and optimal treatment require further investigation.

The Consequences of Child Abuse

This review provides an overview of the consequences of early adverse experiences across various domains of life. Drawing on the Adverse Childhood Experiences (ACEs) conceptual framework, we discuss the ACE pyramid and the varying degrees of consequences that ACE exposure may elicit. Using online search engines such as Google Scholar, the authors sifted through empirical research to locate relevant articles and research to help prepare this review. This article sheds light on the implications of ACEs for health, socio-emotional and psychosocial well-being, relationships, personality, and cognitive functioning.

Characteristics of rapid cycling in 1261 bipolar disorder patients

BACKGROUND

Rapid-cycling (RC; ≥ 4 episodes/year) in bipolar disorder (BD) has been recognized since the 1970s and associated with inferior treatment response. However, associations of single years of RC with overall cycling rate, long-term morbidity, and diagnostic subtypes are not clear.

RESULTS

We compared descriptive and clinical characteristics in 1261 BD patients with/without RC, based on history and prospective follow-up for several years. RC in any previous year was identified in 9.36% of BD subjects (3.74% in BD1, 15.2% BD2), and somewhat more among women than men. RC-BD subjects had 3.21-fold greater average prospective annual rates of recurrence but not hospitalizations, had less difference in %-time-ill, received more mood-stabilizing treatments, and had greater suicidal risk, lacked familial psychiatric illnesses, had more cyclothymic temperament, were more likely to be married, had more siblings and children, experienced early sexual abuse, but were less likely to abuse drugs (not alcohol) or smoke. In multivariable regression modeling, older age, mood-switching with antidepressants, and BD2 > BD1 diagnosis, as well as more episodes/year were independently associated with RC. Notably, prospective mean recurrence rates were below 4/year in 79.5% of previously RC patients, and below 2/year in 48.1%.

CONCLUSIONS

Lifetime risk of RC in BD was 9.36%, more likely in women, with older age, and in BD2 > BD1. With RC, recurrence rates were much higher, especially for depression with less effect on %-time ill, suggesting shorter episodes. Variable associations with unfavorable outcomes and prospective recurrence rates well below 4/year in most previously RC patients indicate that RC was not a sustained characteristic and probably was associated with use of antidepressants.

Childhood trauma and cognitive functioning in mood disorders: A systematic review

BACKGROUND

Cognitive impairment is a core feature of mood disorders and has been identified as an important treatment target. A better understanding of the factors contributing to cognitive impairment in mood disorders would be beneficial in developing interventions to address cognitive impairment. One key factor is childhood trauma. The aim of this review was to systematically synthesise and review research examining associations between reported childhood trauma and cognitive functioning in mood disorders.

METHODS

Studies in adult samples examining the relationship between objective cognitive function and reported childhood trauma in major depressive disorder and/or bipolar disorder (in-episode or euthymia) were identified. Searches were conducted on PubMed, Embase and PsycINFO until January 2022. A narrative review technique was used due to the heterogeneity of group comparisons, cognitive tests and data analysis across studies.

RESULTS

Seventeen studies met the criteria for inclusion (mood disorders N = 1723, healthy controls N = 797). Evidence for childhood trauma being related to poorer cognitive functioning was consistent across global cognitive functioning and executive function domains for euthymic patients and psychomotor speed for in-episode patients. There was mixed evidence for verbal learning and memory and executive function for in-episode patients. Identification of patterns within other domains was difficult due to limited number of studies.

CONCLUSION

Findings from this review suggest childhood trauma is associated with poorer cognitive functioning in people with mood disorders. Targeted interventions to improve cognition may be warranted for this group.

Affective temperaments mediate the effect of childhood maltreatment on bipolar depression severity

Aim

Bipolar disorder is a leading disorder contributing to global disease burden, and bipolar depression often becomes severe and refractory. Therefore, clarifying the pathophysiology of bipolar disorder is an urgent issue. Previous reports suggested that factors, such as affective temperaments and childhood maltreatment, aggravate bipolar depression severity. However, to our knowledge, no reports to date have clarified the interrelationship between the above factors and bipolar depression severity. We here hypothesized that childhood maltreatment worsens bipolar depression severity via increasing affective temperaments. To test this hypothesis, a covariance structural analysis was conducted.

Methods

The following information was evaluated for a total of 75 people with bipolar disorder using self-administered questionnaires: demographic characteristics, depressive symptoms (Patient Health Questionnaire-9), history of childhood maltreatment (Child Abuse and Trauma Scale), and affective temperaments (Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire). The results were analyzed using covariance structure analysis.

Results

A significant indirect effect of childhood maltreatment on bipolar depression severity via increasing affective temperaments was identified, whereas the direct effect of childhood maltreatment was not significant.

Conclusion

Our results reveal that affective temperaments can mediate the adverse effects of childhood maltreatment on the severity of bipolar depression.

Childhood trauma and its influence on the clinical features of bipolar disorder

BACKGROUND

Childhood trauma is an environmental risk factor for bipolar disorder (BD), But its influence on the clinical features of BD has not been examined sufficiently.

OBJECTIVE

We compared the childhood trauma between patients with BD and healthy controls (HCs) and determined how childhood trauma impacts clinical features, such as severity, mood episodes, and disease duration.

PARTICIPANTS AND SETTING

The study population comprised patients with BD (in a state of euthymia or depression, n = 90) and HCs (n = 94).

METHODS

The Structured Clinical Interview for DSM-IV Axis I Disorders was used to diagnose BD and ascertain its clinical features. The Childhood Trauma Questionnaire (CTQ) was used to assess childhood trauma.

RESULTS

The total CTQ score and scores for the CTQ subscales emotional abuse, sexual abuse, emotional neglect, and physical neglect, significantly differed between the BD and HC groups. Emotional abuse was correlated with higher Hamilton Anxiety Rating Scale (HARS) score and more frequent mood episodes; emotional neglect was correlated with higher HARS score, longer disease duration, and more mood episodes; and total CTQ score was positively correlated with HARS score, disease duration, and mood episodes. Regression analysis showed that emotional neglect significantly predicted HARS score, Hamilton Depression Rating Scale score, and disease duration in the BD group (P < 0.05).

CONCLUSIONS

Patients with BD have more serious childhood trauma. General childhood trauma, emotional abuse, and emotional neglect negatively affect the clinical features of BD.

Childhood trauma relates to worse memory functioning in bipolar disorder

BACKGROUND

Childhood trauma is commonly experienced by individuals diagnosed with bipolar disorder (BP). In BP, childhood trauma is related to a more severe clinical course, but its association with cognition remains unclear.

METHODS

This study evaluated 405 adult participants diagnosed with BP and 136 controls. Participants completed the Childhood Trauma Questionnaire and a comprehensive neuropsychological battery. High versus low childhood trauma was defined with one standard deviation above the control participant's mean Childhood Trauma Questionnaire score. Neuropsychological data was transformed into eight cognitive factors, including four executive functioning, auditory and visual memory, fine motor, and emotion processing. Multivariate analysis of covariance evaluated group differences in cognition, while adjusting for covariates.

RESULTS

There were significant differences among the three groups, F(16, 968) = 4.05, p < .001, Wilks' Λ = 0.88, partial η² = 0.06. Comparing the high and low trauma BP groups, high trauma was related to lower auditory and visual memory factor scores (p < .05). As compared to controls, the BP high trauma group had lower scores on six of eight factors (all p < .01), while the BP low trauma group had lower scores on four of eight factors (all p < .01).

LIMITATIONS

Analyses of factor score do not address which aspect of the memory process is affected and biomarkers may help guide interventions addressing underlying biological process.

CONCLUSIONS

Adults diagnosed with BP with higher childhood trauma have worse memory functioning, beyond the lower childhood trauma BP group, highlighting the importance of understanding the long-term cognitive outcomes of childhood trauma.

Cumulative trauma in bipolar disorder: An examination of prevalence and outcomes across the lifespan

BACKGROUND

Trauma is highly prevalent in bipolar disorder, and while considerable research has been undertaken in relation to childhood trauma, little is known about the experience and the impact of exposure to multiple trauma types across the lifespan, otherwise known as cumulative trauma. This study aimed to examine the prevalence of cumulative trauma in bipolar disorder and explore its association with illness and other outcomes.

METHODS

Participants were recruited online globally and comprised 114 adults aged 23 to 73 years with BD-I (41.2 %) or BD-II (58.8 %). Participants completed an online questionnaire containing items regarding symptoms and trauma history followed by a diagnostic interview to confirm their BD diagnosis and assess BD symptoms.

RESULTS

Cumulative trauma accounted for most of the trauma exposure across both childhood (n = 89; 78.1 %) and adulthood (n = 72; 63.2 %). Those with lifetime cumulative trauma (n = 64; 56 %) were more likely to experience at least one other co-morbid mental health condition in addition to their BD diagnosis (88 %) and report significantly lower ratings of perceived social support compared to those who did not experience any cumulative trauma (N = 15; 13 %).

LIMITATIONS

This study has been limited by the cross-sectional retrospective design as well as the use of self-selection to participate.

CONCLUSIONS

Cumulative trauma is highly prevalent in bipolar disorder and is associated with greater likelihood of experiencing a psychiatric comorbidity and decreased levels of social support. More research is needed to explore the nature of this relationship and determine whether increasing social support may be of benefit.

Diagnosis and management of bipolar disorders

Bipolar disorders (BDs) are recurrent and sometimes chronic disorders of mood that affect around 2% of the world's population and encompass a spectrum between severe elevated and excitable mood states (mania) to the dysphoria, low energy, and despondency of depressive episodes. The illness commonly starts in young adults and is a leading cause of disability and premature mortality. The clinical manifestations of bipolar disorder can be markedly varied between and within individuals across their lifespan. Early diagnosis is challenging and misdiagnoses are frequent, potentially resulting in missed early intervention and increasing the risk of iatrogenic harm. Over 15 approved treatments exist for the various phases of bipolar disorder, but outcomes are often suboptimal owing to insufficient efficacy, side effects, or lack of availability. Lithium, the first approved treatment for bipolar disorder, continues to be the most effective drug overall, although full remission is only seen in a subset of patients. Newer atypical antipsychotics are increasingly being found to be effective in the treatment of bipolar depression; however, their long term tolerability and safety are uncertain. For many with bipolar disorder, combination therapy and adjunctive psychotherapy might be necessary to treat symptoms across different phases of illness. Several classes of medications exist for treating bipolar disorder but predicting which medication is likely to be most effective or tolerable is not yet possible. As pathophysiological insights into the causes of bipolar disorders are revealed, a new era of targeted treatments aimed at causal mechanisms, be they pharmacological or psychosocial, will hopefully be developed. For the time being, however, clinical judgment, shared decision making, and empirical follow-up remain essential elements of clinical care. This review provides an overview of the clinical features, diagnostic subtypes, and major treatment modalities available to treat people with bipolar disorder, highlighting recent advances and ongoing therapeutic challenges.

Research and Diagnostic Algorithmic Rules (RADAR) for mood disorders, recurrence of illness, suicidal behaviours, and the patient's lifetime trajectory

The top-down Diagnostic and Statistical Manual/International Statistical Classification of Diseases categories of mood disorders are inaccurate, and their dogmatic nature precludes both deductive (as indisputable) and inductive (as top-down) remodelling of case definitions. In trials, psychiatric rating scale scores employed as outcome variables are invalid and rely on folk psychology-like narratives. Using machine learning techniques, we developed a new precision nomothetic model of mood disorders with a recurrence of illness (ROI) index, a new endophenotype class, namely Major Dysmood Disorder (MDMD), characterised by increased ROI, a more severe phenome, and more disabilities. Nonetheless, our previous studies did not compute Research and Diagnostic Algorithmic Rules (RADAR) to diagnose MDMD and score ROI, lifetime (LT), and current suicidal behaviours, as well as the phenome of mood disorders. Here, we provide rules to compute bottom-up RADAR scores for MDMD, ROI, LT and current suicidal ideation and attempts, the phenome of mood disorders, and the lifetime trajectory of mood disorder patients from a family history of mood disorders and substance abuse to adverse childhood experiences, ROI, and the phenome. We also demonstrate how to plot the 12 major scores in a single RADAR graph, which displays all features in a two-dimensional plot. These graphs allow the characteristics of a patient to be displayed as an idiomatic fingerprint, allowing one to estimate the key traits and severity of the illness at a glance. Consequently, biomarker research into mood disorders should use our RADAR scores to examine pan-omics data, which should be used to enlarge our precision models and RADAR graph.

Early-life stress biases responding to negative feedback and increases amygdala volume and vulnerability to later-life stress

Early-life stress (ELS) or adversity, particularly in the form of childhood neglect and abuse, is associated with poor mental and physical health outcomes in adulthood. However, whether these relationships are mediated by the consequences of ELS itself or by other exposures that frequently co-occur with ELS is unclear. To address this question, we carried out a longitudinal study in rats to isolate the effects of ELS on regional brain volumes and behavioral phenotypes relevant to anxiety and depression. We used the repeated maternal separation (RMS) model of chronic ELS, and conducted behavioral measurements throughout adulthood, including of probabilistic reversal learning (PRL), responding on a progressive ratio task, sucrose preference, novelty preference, novelty reactivity, and putative anxiety-like behavior on the elevated plus maze. Our behavioral assessment was combined with magnetic resonance imaging (MRI) for quantitation of regional brain volumes at three time points: immediately following RMS, young adulthood without further stress, and late adulthood with further stress. We found that RMS caused long-lasting, sexually dimorphic biased responding to negative feedback on the PRL task. RMS also slowed response time on the PRL task, but without this directly impacting task performance. RMS animals were also uniquely sensitive to a second stressor, which disproportionately impaired their performance and slowed their responding on the PRL task. MRI at the time of the adult stress revealed a larger amygdala volume in RMS animals compared with controls. These behavioral and neurobiological effects persisted well into adulthood despite a lack of effects on conventional tests of 'depression-like' and 'anxiety-like' behavior, and a lack of any evidence of anhedonia. Our findings indicate that ELS has long-lasting cognitive and neurobehavioral effects that interact with stress in adulthood and may have relevance for understanding the etiology of anxiety and depression in humans.

Course of subthreshold manic symptoms and related risk factors in the general population: A three-year follow-up study

OBJECTIVES

Subthreshold manic symptoms (subM) are a risk factor for the onset and recurrence of bipolar disorder (BD). Individuals with subM may benefit from preventive interventions, however, their development is hampered by a lack of knowledge on subM prevalence and subsequent course. This study examines subM characteristics, course, and risk factors for an unfavourable course.

METHODS

In a Dutch representative, population-based sample aged 18-64 (N = 4618), we assessed subM, defined as the occurrence of manic core symptoms (elation/irritability), without meeting full DSM-IV criteria for BD I or II in the past 3 years. Comparison groups had either no manic symptoms (noM) or hypomania/mania in the context of BD (mBD) in the past 3 years. Furthermore, we differentiated a mild and moderate type of subM, based on the number of manic symptoms. A subsequent three-year course was assessed prospectively.

RESULTS

SubM had a three-year prevalence of 4.9%. Its prevalence, characteristics, and course were in between noM and mBD, and there were few differences between mild and moderate subM. Over the 3-year follow-up, 25.0% of individuals with subM had persistent subM and another 6.1% transitioned to mBD. Eleven significant risk factors for this unfavourable course were found. The most important were a history of depression/dysthymia (OR 3.75, p ≤ 0.001), living alone (OR 2.61, p ≤ 0.01) and elevated neuroticism score (OR 1.21, p ≤ 0.001).

CONCLUSIONS

This study supports the validity and clinical relevance of subM as a BD prodrome. It demonstrates that subM symptoms often persist or increase during follow-up and identifies 11 risk factors that are associated with an unfavourable course.

Reliability and convergent validity of retrospective reports of childhood maltreatment by individuals with bipolar disorder

Childhood maltreatment is associated with the etiology and clinical course of bipolar disorder. Most studies employ retrospective maltreatment self-reports which are vulnerable to bias, raising questions about their validity and reliability. This study examined the test-retest reliability over 10 years, the convergent validity and the impact of current mood on retrospective reports of childhood maltreatment in a bipolar sample. 85 participants with bipolar I disorder completed the Childhood Trauma Questionnaire [CTQ] and the Parental Bonding Instrument [PBI] at baseline. Beck Depression Inventory and Self Report Mania Inventory assessed depressive and manic symptoms, respectively. 53 participants completed the CTQ at baseline and 10-year follow-up. Good levels of convergent validity were observed between the CTQ and PBI. Correlations ranged from r_s= -0.35 (CTQ emotional abuse and PBI paternal care) to r_s= -0.65 (CTQ emotional neglect and PBI maternal care). Good agreement between CTQ reports at baseline and 10-year follow-up were found (range: κ=0.41 for physical neglect to κ=0.83 for sexual abuse). Higher depression and mania scores were recorded among participants who reported abuse (but not neglect) compared to those without such reports. These findings support using this method in research and clinical practice, though current mood should be taken into account.

Risk of childhood trauma exposure and severity of bipolar disorder in Colombia

BACKGROUND

Bipolar disorder (BD) is higher in developing countries. Childhood trauma exposure is a common environmental risk factor in Colombia and might be associated with a more severe course of bipolar disorder in Low-Middle Income-Countries. We carried out the first case-control study in Colombia using a structural clinical interview and the Childhood Trauma Questionnaire-Short Form (CTQ-SF) to describe the prevalence and association between trauma exposure during childhood with a severe course of illness (early age onset, rapid cycling, ideation or suicide attempt, or ≥ 3 hospitalization) in a sample of BD patients.

RESULTS

A total of 114 cases and 191 controls evaluated showed the following results. Cases included 61.4% BD type I and 38.6% BD type II. The median age was 31.5 years (IQR, 75-24) for BD patients and 31 years old (IQR, 38-24) for healthy controls. A higher prevalence of childhood trauma was evidenced in cases compared to controls. Emotional abuse, physical abuse, sexual abuse, physical neglect and emotional neglect evidenced a strong association with severe bipolar disorder (OR = 3.42, p < .001; OR = 4.68, p < .001; OR = 4.30, p = .003; OR = 5.10, p < .001; OR = 5.64, p < .001, respectively).

CONCLUSIONS

This is the first association study between childhood trauma exposure as a higher risk for a severe course of illness in BD patients in Colombian. Our findings highlight the higher prevalence of childhood trauma in bipolar patients and the strong association of childhood trauma with severe bipolar disorder. These findings are relevant for screening and evaluating childhood trauma exposure during the course of BD patients.

Socio-economic functioning in patients with bipolar disorder and their unaffected siblings - results from a nation-wide population-based longitudinal study

BACKGROUND

Few studies have reported real-life data on socio-economic functioning in patients with bipolar disorder and their unaffected first-degree relatives.

METHODS

We used Danish nation-wide population-based longitudinal register linkage to investigate socio-economic functioning in 19 955 patients with bipolar disorder, their 13 923 siblings and 20 sex, age and calendar-matched control individuals from the general population. Follow-up was from 1995 to 2017.

RESULTS

Patients with a diagnosis of bipolar disorder had lower odds of having achieved the highest educational level [OR 0.75 (95% confidence interval (CI) 0.73-0.77)], being employed [OR 0.16 (95% CI 0.159-0.168)], having achieved the 80% highest quartile of income [OR 0.33 (95% CI 0.32-0.35)], cohabitating [OR 0.44 (95% CI 0.43-0.46)] and being married [OR 0.54 (95% CI 0.52-0.55)] at first contact to hospital psychiatry as inpatient or outpatient compared with control individuals from the general population. Similarly, siblings to patients with bipolar disorder had a lower functioning within all five socio-economic areas than control individuals. Furthermore, patients and partly siblings showed substantially decreased ability to enhance their socio-economic functioning during the 23 years follow-up compared to controls.

CONCLUSIONS

Socio-economic functioning is substantially decreased in patients with bipolar disorder and their siblings and does not improve during long-term follow-up after the initial hospital contact, highlighting a severe and overlooked treatment gap.

Maximal Sensitivity to Child Maltreatment at the Ages of 6 and 11 Years is Associated with the Risk of Bipolar Disorder

Adverse childhood experiences, including child maltreatment (CM), are relevant environmental risk factors for bipolar disorder (BD). However, little is known about the interaction of the type, duration and frequency of abuse with the timing of abuse in BD. The aim of this study was to investigate the different patterns of childhood trauma (frequency, type and chronology) between BD patients and healthy controls (HCs) and to identify BD-sensitive periods of exposure to CM that could influence functioning outcomes. The Maltreatment and Abuse Chronology Exposure (MACE) scale was used to evaluate the importance of the type and timing of maltreatment in a sample of 60 patients diagnosed with euthymic BD. Additionally, 76 HCs were recruited for comparison. All participants were of European-Caucasian origin and were assessed in the 2016-2019 period. To identify the variables that maximally differentiated the type and timing of exposure to CM between the BD and HC groups, a linear mixed effects model and random forest (RF) analyses were applied. We showed that multiplicity and severity, nonverbal emotional abuse, witnessing interparental violence and emotional neglect were the main factors associated with BD. In addition, regarding the occurrence of maltreatment in BD patients, we identified two sensitive periods with a principal peak at the age of 6 and a secondary peak at the age of 11. Functionality at the assessment time was associated with CM in adolescence for both HC and BD participants. Although the sample size and retrospective nature of the MACE instrument were the main limitations of our study, we were unable to explore the role of variables such as sex or socioeconomic status. We concluded that the multiplicity and sensitivity of CM exposure, mainly of the emotional type, during middle childhood are important risk factors for BD, at least in the European-Caucasian cultural setting.