Decision making in euthymic bipolar I and bipolar II disorders

Association between cognitive functioning, suicidal ideation and suicide attempts in major depressive disorder, bipolar disorder, schizophrenia and related disorders: A systematic review and meta-analysis

INTRODUCTION

Treatable mental disorders, such as psychotic, major depressive disorder (MDD), and bipolar disorder (BD), contribute to a substantial portion of suicide risk, often accompanied by neurocognitive deficits. We report the association between cognitive function and suicidal ideation/suicide attempts (SI/SA) in individuals with schizoaffective disorder, BD, and MDD.

METHODS

A systematic search was conducted on PubMed, Ovid and Scopus databases for primary studies published from inception to April 2024. Eligible articles that reported on the effect size of association between cognition and SI/SA were pooled using a random effects model.

RESULTS

A total of 41 studies were included for analysis. There was a negative association between executive functioning and SI/SA in schizoaffective disorder (SA: Corr = -0·78, 95 % CI [-1·00, 0·98]; SI: Corr = -0·06, 95 % CI [-0·85, 0·82]) and MDD (SA: Corr = -0·227, 95 % CI [-0·419, -0·017]; SI: Corr = -0·14, 95 % CI [-0·33, 0·06]). Results were mixed for BD, with a significant positive association between SA and global executive functioning (Corr = 0·08, 95 % CI [0·01, 0·15]) and negative association with emotion inhibition. Mixed results were observed for processing speed, attention, and learning and memory, transdiagnostically.

LIMITATIONS

There is heterogeneity across sample compositions and cognitive measures. We did not have detailed information on individuals with respect to demographics and comorbidities.

CONCLUSIONS

We observed a transdiagnostic association between measures of cognitive functions and aspects of suicidality. The interplay of cognitive disturbances, particularly in reward-based functioning, may underlie suicidality in individuals with mental disorders. Disturbances in impulse control, planning, and working memory may contribute to self-injurious behavior and suicide.

The comparison of hot and cold executive functions in patients with bipolar II disorder, borderline personality disorder, and healthy individuals

Background

Differential diagnosis of bipolar II disorder (BD-II) and borderline personality disorder (BPD) has always been challenging for clinicians due to symptoms' overlap. This study aimed to compare hot and cold executive functions (EFs) in BD-II patients, as well as BPD and healthy controls (HCs), in order to differentiate these two disorders.

Methods

In the present study, 30 BD-II and 30 BPD patients undergoing the drug therapy with mood stabilizers, and 30 HC were examined using EFs evaluated tests. The data were then analyzed using ANOVA and Tukey post hoc test.

Results

The BD-II Patients performed significantly less in all cold EFs than the HC. Also, BPD patients had meaningfully lesser performance compared to HC in all cold EFs except sustained attention. No significant difference was perceived between the two patient groups in the cold EFs. In BD-II patients, the risky decision-making as a hot EFs' component was not significantly different from HC; nevertheless, its amount was significantly higher in BPD than in the HC and BD-II patients.

Conclusion

These findings underline the differences between the two mentioned disorders based on the hot EFs, which may indicate further disorder in the emotional information processing system among the BPD patients.

The Types of Psychosocial Factors Associated with Suicidality Outcomes for People Living with Bipolar Disorder: A Scoping Review

Bipolar Disorder is associated with high rates of suicidal thoughts, behaviors, and outcomes, yet the lived experience of suicidality and Bipolar Disorder is not particularly well understood. Understanding the role of psychosocial aetiologies in suicidality outcomes for those living with Bipolar Disorder is key for developing appropriately targeted interventions focusing on factors that are amenable to change. In line with PRISMA guidance, we conducted a scoping review to identify the types of psychosocial factors studied in relation to the experience of suicidality for people living with Bipolar Disorder diagnoses. Systematic literature searches identified a sample of 166 articles from which key study data were extracted and charted. A narrative synthesis of the reviewed literature is presented ordered by the factors investigated across studies, a frequency count of the types of psychological/social aetiologies studied, and a brief overview of the key findings for each aetiology. Most of the identified literature took the form of quantitative cross-sectional studies, with only one qualitative study and 18 quantitative prospective studies. The most studied aetiologies were trauma (specifically early adverse experiences and childhood traumas) and stressful life events, impulsivity (primarily subjective self-reported trait impulsivity), social support and functioning, and personality/temperament factors. Only six studies in the final sample reported basing their research questions and/or hypotheses on an explicit theoretical model of suicide. The literature was primarily focused on using self-report measurements of key aetiologies and on factors which lead to worsened suicidality rather than focusing on potentially protective or buffering factors. Future research needs to better justify the aetiologies investigated in relation to suicidality outcomes for people living with Bipolar Disorder, including a firmer basis in theory and hypothesis testing, more prospective designs, and the use of alternative assessments of psychosocial aetiologies in addition to self-report questionnaires.

Status of Type II vs. Type I Bipolar Disorder: Systematic Review with Meta-Analyses

LEARNING OBJECTIVES AFTER PARTICIPATING IN THIS CME ACTIVITY, THE PSYCHIATRIST SHOULD BE BETTER ABLE TO

• Analyze and compare the different bipolar disorder (BD) types.• Identify markers that distinguish BD types and explain how the DSM-IV defines the disorder.

ABSTRACT

Since the status of type II bipolar disorder (BD2) as a separate and distinct form of bipolar disorder (BD) remains controversial, we reviewed studies that directly compare BD2 to type I bipolar disorder (BD1). Systematic literature searching yielded 36 reports with head-to-head comparisons involving 52,631 BD1 and 37,363 BD2 patients (total N = 89,994) observed for 14.6 years, regarding 21 factors (with 12 reports/factor). BD2 subjects had significantly more additional psychiatric diagnoses, depressions/year, rapid cycling, family psychiatric history, female sex, and antidepressant treatment, but less treatment with lithium or antipsychotics, fewer hospitalizations or psychotic features, and lower unemployment rates than BD1 subjects. However, the diagnostic groups did not differ significantly in education, onset age, marital status, [hypo]manias/year, risk of suicide attempts, substance use disorders, medical comorbidities, or access to psychotherapy. Heterogeneity in reported comparisons of BD2 and BD1 limits the firmness of some observations, but study findings indicate that the BD types differ substantially by several descriptive and clinical measures and that BD2 remains diagnostically stable over many years. We conclude that BD2 requires better clinical recognition and significantly more research aimed at optimizing its treatment.

Emotion regulation in bipolar disorder type-I: multivariate analysis of fMRI data

BACKGROUND

Bipolar disorder type-I (BD-I) patients are known to show emotion regulation abnormalities. In a previous fMRI study using an explicit emotion regulation paradigm, we compared responses from 19 BD-I patients and 17 matched healthy controls (HC). A standard general linear model-based univariate analysis revealed that BD patients showed increased activations in inferior frontal gyrus when instructed to decrease their emotional response as elicited by neutral images. We implemented multivariate pattern recognition analyses on the same data to examine if we could classify conditions within-group as well as HC versus BD.

METHODS

We reanalyzed explicit emotion regulation data using a multivariate pattern recognition approach, as implemented in PRONTO software. The original experimental paradigm consisted of a full 2 × 2 factorial design, with valence (Negative/Neutral) and instruction (Look/Decrease) as within subject factors.

RESULTS

The multivariate models were able to accurately classify different task conditions when HC and BD were analyzed separately (63.24%-75.00%, p = 0.001-0.012). In addition, the models were able to correctly classify HC versus BD with significant accuracy in conditions where subjects were instructed to downregulate their felt emotion (59.60%-60.84%, p = 0.014-0.018). The results for HC versus BD classification demonstrated contributions from the salience network, several occipital and frontal regions, inferior parietal lobes, as well as other cortical regions, to achieve above-chance classifications.

CONCLUSIONS

Our multivariate analysis successfully reproduced some of the main results obtained in the previous univariate analysis, confirming that these findings are not dependent on the analysis approach. In particular, both types of analyses suggest that there is a significant difference of neural patterns between conditions within each subject group. The multivariate approach also revealed that reappraisal conditions provide the most informative activity for differentiating HC versus BD, irrespective of emotional valence (negative or neutral). The current results illustrate the importance of investigating the cognitive control of emotion in BD. We also propose a set of candidate regions for further study of emotional control in BD.

Dissociated deficits of anticipated and experienced regret in at-risk suicidal individuals

Backgrounds

Decision-making deficits have been reported as trans-diagnostic characteristics of vulnerability to suicidal behaviors, independent of co-existing psychiatric disorders. Individuals with suicidal behaviors often regret their decision to attempt suicide and may have impairments in future-oriented processing. However, it is not clear how people with suicidal dispositions use future-oriented cognition and past experience of regret to guide decision-making. Here, we examined the processes of regret anticipation and experience in subclinical youth with and without suicidal ideation during value-based decision-making.

Methods

In total, 80 young adults with suicidal ideation and 79 healthy controls completed a computational counterfactual thinking task and self-reported measures of suicidal behaviors, depression, anxiety, impulsivity, rumination, hopelessness, and childhood maltreatment.

Results

Individuals with suicidal ideation showed a reduced ability to anticipate regret compared to healthy controls. Specifically, suicidal ideators’ experience of regret/relief was significantly different from that of healthy controls upon obtained outcomes, while their disappointment/pleasure experience was not significantly different from healthy controls.

Conclusion

These findings suggest that young adults with suicidal ideation have difficulty predicting the consequences or the future value of their behavior. Individuals with suicidal ideation showed impairments in value comparison and flat affect to retrospective rewards, whereas individuals with high suicidality showed blunted affect to immediate rewards. Identifying the counterfactual decision-making characteristics of at-risk suicidal individuals may help to elucidate measurable markers of suicidal vulnerability and identify future intervention targets.

Self-injurious thoughts and behaviors and alterations in positive valence systems: A systematic review of the literature

Self-injurious thoughts and behaviors (SITBs), which include suicidal ideation (SI), suicide attempts (SA), and nonsuicidal self-injury (NSSI), are prevalent and associated with impairments in functioning and elevated risk of suicide deaths. Preventing suicide is a complex problem, with numerous systems likely contributing to the onset and maintenance of SITBs, and there is a critical need to identify more precise predictors of risk. Positive valence systems (PVS) are an understudied domain with promise for improving understanding of risk processes underlying SITBs. In this systematic review, we evaluate the evidence for the potential role of altered PVS function in SI, SA, and/or NSSI, including alterations in reward responsiveness, learning, and valuation assessed through behavioral, physiological and circuit measures. Results provide preliminary support for associations between distinct aspects of PVS function and alterations in SITBs. Specifically, SI appears to be characterized by low reward responsiveness, whereas little research has examined reward responsiveness in SA, and NSSI has been characterized by hyper-responsiveness to rewards. Alterations in reward learning and valuation are commonly examined in SA, with some evidence that they may be more strongly associated with attempts than SI or NSSI. At the same time, the literature is limited in that some constructs are commonly examined in one form of SITBs but not others. Further, research is predominantly cross-sectional and focused on adults, raising questions about the role of PVS function in developmental pathways to SITBs. We conclude by integrating the research to date and highlighting promising directions for future research.

Deficits of social cognition in bipolar disorder: Systematic review and meta-analysis

BACKGROUND

The association between impaired social cognition and bipolar disorder (BD) is well established. However, to our knowledge, there has not been a recent systematic review that characterizes disparate dimensions of social cognition in BD. Herein, this systematic review and meta-analysis aimed to synthesize the literature on core aspects of social cognition (i.e., Theory of Mind, emotion recognition, and social judgment) to identify potential areas of impairment.

METHODS

Online databases (i.e., PubMed, Cochrane Libraries, PsycINFO) and Google Scholar were searched from inception to May 2021. Studies with populations ages ≥16 with DSM-IV or DSM-5 defined BD (I or II) either in a euthymic or symptomatic state were included. The risk of bias was measured using the ROBINS-1 tool, and the quality of the sources was evaluated using GRADE criteria. The results of the studies were quantitatively measured by synthesizing Hedge's g effect sizes through a random effects meta-analytic approach.

RESULTS

A total of 29 studies were included in the final review (i.e., 12 studies on the Theory of Mind, 11 on emotion recognition, and 6 on social judgment). Overall, results demonstrated social cognition to be moderately impaired in individuals with BD (d = 0.59). The individual domains ranged in effect size (0.38 < d < 0.70), providing evidence for variation in impairment within social cognition.

DISCUSSION

Individuals with BD exhibit clinically significant deficits in social cognition during euthymic and symptomatic states. Social cognition impairments in individuals with BD are an important therapeutic target for treatment discovery and development.

No group differences in Traditional Economics Measures of loss aversion and framing effects in bipolar I disorder

Bipolar disorder (BD) is associated with impaired decision making, yet few studies have adopted paradigms from behavioral economics to decompose which, if any, aspects of decision making may be impacted. This may be particularly relevant for decision-making processes relevant to known difficulties with emotive dysfunction and corresponding reward dysregulation in BD. Participants with bipolar I disorder (BD; n = 44) and non-psychiatric healthy controls (CTL; n = 28) completed three well-validated behavioral economics decision making tasks via a remote-based survey, including loss aversion and framing effects, that examined sensitivity to probabilities and potential gains and losses in monetary and non-monetary domains. Consistent with past work, we found evidence of moderate loss aversion and framing effects across all participants. No group differences were found in any of the measures of loss aversion or framing effects. We report no group differences between bipolar and non-psychiatric groups with respect to loss aversion and framing effects using a remote-based survey approach. These results provide a framework future studies to explore similar tasks in clinical populations and suggest the context and degree to which decision making is altered in BD may be rooted in a more complex cognitive mechanism that warrants future research.

Decision-making in suicidal behavior: A systematic review and meta-analysis

Impaired decision-making (DM) is well-known in suicidal behavior (SB). We aimed to review the evidence on DM and its mediating factors in SB and perform a meta-analysis on DM assessed using the Iowa Gambling Task (IGT). We conducted a search on databases of papers published on DM and SB up to 2020: 46 studies were included in the systematic review, and 18 in the meta-analysis. For meta-analysis, we compared DM performance between suicide attempters (SAs) and patients (PCs) or healthy controls (HCs). The systematic review showed that SAs have greater difficulties in all DM domains. The meta-analysis found worse IGT performance among SAs in comparison with PCs and HCs. A meta-regression did not find differences for age, gender, psychiatric disorder, and clinical status. Our findings indicate that SAs exhibited deficits in DM under conditions of risk though not ambiguity. Worse DM was independent of age, gender, psychiatric disorder, and suggested that DM impairment could be considered a cognitive trait of suicidal vulnerability, a risk factor and an attribute of SAs.

Influence Factors for Decision-Making Performance of Suicide Attempters and Suicide Ideators: The Roles of Somatic Markers and Explicit Knowledge

Impaired decision-making has been observed in suicide attempters during the Iowa Gambling Task (IGT). Decision-making performance is influenced by somatic markers and explicit knowledge, but it is still unclear of the influencing role on decision-making performance in suicidal individuals. We aimed to investigate whether there is a decision-making deficit in suicide attempters, suicide ideators, as well as the distinct roles of somatic markers and explicit knowledge wherein. Thirteen suicide attempters, 23 suicide ideators, and 19 healthy controls performed the IGT. Both somatic markers (by the skin conductance responses, SCRs) and explicit knowledge (by the subjective experience rating and a list of questions) were recorded. No significant differences were found among the three groups on IGT performance, explicit knowledge, and anticipatory SCRs. IGT Performance of suicide attempters was positively correlated with explicit knowledge index while behavior performance was positively associated with the SCRs in healthy controls. These results indicate that the suicide attempters seem to apply a compensatory strategy by mostly utilizing explicit knowledge to perform normally as healthy controls in the IGT.

Decision making and its associations to neurocognitive functions, psychopathology, and the home environment in seven-year-old children at familial high risk of schizophrenia or bipolar disorder: The Danish High Risk and Resilience Study VIA 7

BACKGROUND

Slower and suboptimal decision making has been identified in adults with schizophrenia and bipolar disorder. Owing to the limited evidence on decision making in first-degree relatives, we aimed to investigate, whether alterations in decision making are present in young children at familial high risk of bipolar disorder or schizophrenia.

METHODS

In this population-based cohort study we assessed decision making in 197 children at familial high risk of schizophrenia (FHR-SZ), 115 children at familial high risk of bipolar disorder (FHR-BP), and 190 controls aged seven using the Cambridge Gambling Task. Potential associations to neurocognition, psychopathology, and the home environment were investigated.

RESULTS

Children at FHR-SZ or FHR-BP displayed intact decision making. Quality of decision making showed significant but weak cross-sectional associations to neurocognition and adequacy of the home environment. Associations to aspects of executive functions and the home environment differed across groups.

LIMITATIONS

Due to the cross-sectional nature of this study, the predictive value of efficient and inefficient decision making remains to be investigated in planned follow-up studies of this cohort.

CONCLUSIONS

Young children at FHR-SZ or FHR-BP do not differ from controls in decision making efficacy, which does not appear to be an early risk marker of bipolar disorder or schizophrenia. Decision making is weakly associated to neurocognition and the home environment, but not to general intelligence or psychopathology.

Risky decision-making in suicide attempters, and the choice of a violent suicidal means: an updated meta-analysis

BACKGROUND

Studies showed disadvantageous decision-making in suicide attempters. The present meta-analysis aims to examine the stability of these findings and related questions.

METHODS

EMBASE and Pubmed databases were searched for studies published between 01/01/2000 and 01/01/2020 with an additional search through bibliographical references. English or French articles published in peer-reviewed journals, reporting quantitative task-based measures of decision-making in suicide attempters were included: 3,582 records were identified, 33 full-text articles screened, and 21 articles finally included.

RESULTS

All studies were conducted in mood disorders; 18 used the Iowa Gambling Task (IGT) and 3 the Cambridge Gamble Task (CGT). With the IGT, suicide attempters showed riskier choices than patient controls (Hedges' g=-0.28 95%CI (-0.44 - -0.12)) and healthy controls (g=-0.54 (-0.83 - -0.25)) with no significant difference between control groups. The difference between suicide attempters and patient controls was not related to age group, mood disorder type, author, or research center while an effect of time of publication was found (p=0.006). Poorer performance was also found in suicide attempters compared to patient controls when using the CGT (g=-0.57 95%CI (-0.82 - -0.31)). Suicide attempters who used a violent means showed poorer IGT performance than those who used a non-violent means (3 studies).

LIMITATION

Limited number of studies outside mood disorders. No data to calculate a gender effect.

CONCLUSION

The present meta-analysis confirmed riskier decision-making in suicide attempters. Although group differences appear to be of modest effect size in general, they were particularly marked in the subgroup of those who used a violent suicidal means.

Recollecting Cross-Cultural Evidences: Are Decision Makers Really Foresighted in Iowa Gambling Task?

The Iowa Gambling Task (IGT) has become a remarkable experimental paradigm of dynamic emotion decision making. In recent years, research has emphasized the "prominent deck B (PDB) phenomenon" among normal (control group) participants, in which they favor "bad" deck B with its high-frequency gain structure-a finding that is incongruent with the original IGT hypothesis concerning foresightedness. Some studies have attributed such performance inconsistencies to cultural differences. In the present review, 86 studies featuring data on individual deck selections were drawn from an initial sample of 958 IGT-related studies published from 1994 to 2017 for further investigation. The PDB phenomenon was found in 67.44% of the studies (58 of 86), and most participants were recorded as having adopted the "gain-stay loss-randomize" strategy to cope with uncertainty. Notably, participants in our sample of studies originated from 16 areas across North America, South America, Europe, Oceania, and Asia, and the findings suggest that the PDB phenomenon may be cross-cultural.

Social cognition in siblings of patients with bipolar disorders

BACKGROUND

Identifying people at risk of developing bipolar disorder (BD) using endophenotypes is of recent interest. Few studies on social cognition in first-degree relatives of patients with BD have shown inconsistent findings. This study aimed to evaluate the social cognitive deficits (SCD) and its correlates among siblings of patients with BD.

METHODOLOGY

In this cross-sectional study, patients of BD (n = 32), their siblings (n = 32), and healthy control (HC) subjects (n = 38) matched for age, gender, and education were evaluated on social cognition rating tools in Indian setting and neurocognitive tests (color trail test, Wisconsin card sorting test [WCST], and Hopkin's verbal learning test [HVLT]).

RESULTS

When the siblings of patients with BD were compared with patients with BD and the HCs, siblings (mean 0.6 [standard deviation [SD]: 0.2]) performed worse than the HCs (mean 0.9 [SD: 0.1]) (P ≤ 0.001) on the Faux pas composite index. Compared to HCs, siblings performed worse on all the subtests of HVLT (Trial delayed) (P < 0.001) and WCST (total correct, total errors, and conceptual responses) (P < 0.001).

CONCLUSION

Presence of elevated level of SCD among siblings, especially the Faux pas composite index in comparison to HCs, imply that these are stable traits, which are more often present in the patients and at risk individuals. This implies that SCD can be considered as another important endophenotype for BD.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Impulsivity, decision-making and risk-taking behaviour in bipolar disorder: a systematic review and meta-analysis

Despite the robust body of work on cognitive aspects of bipolar disorder (BD), a clear profile of associated impairments in impulsivity, decision-making and risk-taking from studies that use behavioural measures has yet to be established. A systematic review, across four electronic databases (PsycINFO, MEDLINE/PubMed, ScienceDirect and Scopus), of literature published between January 1999 and December 2018 was carried out in accordance with the PRISMA statement. The protocol was registered on PROSPERO (CRD42018114684). A fixed-effect and random-effects meta-analysis using the Hedges' g (ES) estimate was performed. The analysis revealed significant impairment in BD individuals with medium effect sizes in various aspects of impulsivity - response inhibition (ES = 0.49; p < 0.0001), delay of gratification (ES = 0.54; p < 0.0001) and inattention (ES = 0.49; p < 0.0001) - and in decision-making (ES = 0.61, p = 0.0002), but no significant impairment in risk-taking behaviour (ES = 0.41; p = 0.0598). Furthermore, we found significant heterogeneity between studies for decision-making and risk-taking behaviour but not for impulsivity. Impaired risk-taking behaviour was significant in a subgroup of BD-I and euthymic individuals (ES = 0.92; p < 0.0001) with no significant heterogeneity. A stratification analysis revealed comparable results in euthymic and non-euthymic individuals for impulsivity. Our findings suggest that behaviour impulsivity is elevated in all phases of BD, representing a core and clinically relevant feature that persists beyond mood symptoms. More studies about decision-making and risk-taking are necessary to establish if they are impaired in BD and to analyze the role of mood state.

Cognitive modelling to assess decision-making impairments in patients with current depression and with/without suicide history

It has been reported that decision making is impaired in suicide attempters. Decision making is a complex process and little is known about its different components. Yet, this information would help to understand the functioning of suicidal minds. In this study, the Prospect Valence-Learning (PVL) computational model was applied to the Iowa Gambling Task (IGT) to investigate and compare decision-making components in patients with affective disorder and with/without history of suicide attempts and in healthy controls. To this aim, 116 inpatients with current major depressive episode (among whom 62 suicide attempters) and 38 healthy controls were recruited. Decision-making performance was measured using the IGT. The Bayesian computational PVL model was applied to compare the feedback sensitivity, loss aversion, learning/memory, and choice consistency components of decision making in the different groups. Depressive symptomatology was assessed using the Beck Depression Inventory short form (BDI-SF). The total IGT net score and the loss aversion and learning/memory scores were lower in suicide attempters than in healthy controls. The choice consistency score was low in all patients (with/without suicide history) compared with healthy controls. Moreover, patients with high BDI score showed a positive relationship between the choice consistency score and suicide attempt. These findings suggest that decision-making impairment in depressed patients with and without suicidal history might be the result of underlying problems in feedback processing and task learning, which influence the building of long-term strategies. All these impairments should be targeted in therapeutic strategies for suicidal patients.

A transdiagnostic comparison of affective decision-making in patients with schizophrenia, major depressive disorder, or bipolar disorder

Deficit in decision-making has been found in patients with schizophrenia (SCZ), major depressive disorder (MDD), and bipolar disorder (BD), respectively, while the common and distinct characteristics of this deficit among these patients are still unclear. The present study aimed to make a transdiagnostic comparison of the affective decision-making ability in patients with SCZ, MDD, and BD. In this study, 33 patients with SCZ, 23 patients with MDD, 29 patients with BD, and 34 healthy controls (HCs) were recruited and the Iowa Gambling Task (IGT) was used to assess the affective decision-making ability. The results showed that all three diagnostic groups tended to select the disadvantageous decks but not advantageous decks compared to HCs. For patients with SCZ, an excessive preference for the disadvantageous decks with larger-magnitude less frequent punishments (deck B) may be the main reason of the deficit in affective decision-making, while that in patients with MDD was a significantly decreased ability to choose advantageous decks on the whole but with larger-magnitude less frequent punishments (deck D). As regards patients with BD, the concurrence of more choices of deck B and fewer choices of deck D was the characteristic of the deficit in affective decision-making. Our findings suggest a common affective decision-making impairment in the context of multiple choices in patients with SCZ, MDD, and BD, while the underlying mechanisms of the impairment among these patients may be slightly different.

Lower estimated intelligence quotient is associated with suicide attempts in pediatric bipolar disorder

BACKGROUND

Approximately 20% of individual with pediatric bipolar disorder (PBD) have a lifetime history of suicide attempt. Some cognitive measures were associated with a suicide attempt, but no study has assessed the association of this event with the estimated intelligence quotient (IQ) in PBI. In adult Bipolar Disorder no association between IQ and suicidality was found, with different correlations between cognitive measures. There are studies in general population showing a negative correlation and others did not find any association. In Schizophrenia, IQ had a positive correlation with suicide attempt. So, the correlation between IQ and suicidality still controversial.

METHODS

We recruited 63 children and adolescents younger than 18 years of age with PBD based on DSM-IV criteria from an outpatient clinic in Brazil. Manic and depressive symptoms were assessed with the YMRS and CDRS, respectively. Estimated IQ was assessed with the WISC-III. The presence or absense of suicidal attempt, clinical and demographic variables were assessed with the K-SADS-PL-W.

RESULTS

Patients who attempted suicide had lower estimated IQ compared to patients who did not attempt suicide (82.72 ± 18.70 vs. 101.0 ± 14.36; p = 0.009). This finding remained after correction for depressive symptoms and family income (OR = 0.94; 95% CI = 0.89 - 0.99; p = 0.029).

LIMITATIONS

Small sample, reverse causality could not be discarded, we only used two subscales of the WISC-III to estimate intelligence.

CONCLUSION

Estimated IQ and suicide attempts were negative correlated in PBD. Future longitudinal and larger studies may confirm our findings.

Affective cognition in bipolar disorder: A systematic review by the ISBD targeting cognition task force

BACKGROUND

Impairments in affective cognition are part of the neurocognitive profile and possible treatment targets in bipolar disorder (BD), but the findings are heterogeneous. The International Society of Bipolar Disorder (ISBD) Targeting Cognition Task Force conducted a systematic review to (i) identify the most consistent findings in affective cognition in BD, and (ii) provide suggestions for affective cognitive domains for future study and meta-analyses.

METHODS

The review included original studies reporting behavioral measures of affective cognition in BD patients vs controls following the procedures of the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement. Searches were conducted on PubMed/MEDLINE, EMBASE, and PsychInfo from inception until November 2018.

RESULTS

A total of 106 articles were included (of which nine included data for several affective domains); 41 studies assessed emotional face processing; 23 studies investigated reactivity to emotional words and images; 3 investigated explicit emotion regulation; 17 assessed implicit emotion regulation; 31 assessed reward processing and affective decision making. In general, findings were inconsistent. The most consistent findings were trait-related difficulties in facial emotion recognition and implicit emotion regulation, and impairments in reward processing and affective decision making during mood episodes. Studies using eye-tracking and facial emotion analysis revealed subtle trait-related abnormalities in emotional reactivity.

CONCLUSION

The ISBD Task Force recommends facial expression recognition, implicit emotion regulation, and reward processing as domains for future research and meta-analyses. An important step to aid comparability between studies in the field would be to reach consensus on an affective cognition test battery for BD.

Adaptation and validation of the Melbourne Decision Making Questionnaire to Brazilian Portuguese

Abstract Introduction: Decision making (DM) is among the most important abilities for everyday functioning. However, the most widely used measures of DM come from behavioral paradigms, whose ecological validity and standalone use has been criticized in the literature. Though these issues could be addressed by the use of DM questionnaires as a complementary assessment method, no such instruments have been validated for use in Brazilian Portuguese. Therefore, the aim of this study was to conduct the translation and validation of the Melbourne Decision Making Questionnaire (MDMQ) for use in a Brazilian population. Methods: The adaptation of the MDMQ involved the following steps: translation, back-translation, expert review and pilot study. These steps were followed by factor analysis and internal consistency measurements, which led to the exclusion of 4 items from the scale. The 18-item version of the MDMQ was then administered to a validation sample consisting of healthy adults, as well as patients with bipolar disorder (BD) and major depressive disorder (MDD). Results: The instrument displayed good internal consistency, with the hypervigilance subscale showing the lowest, though still acceptable, Cronbach's alpha value. Its factor structure was comparable to that of the original MDMQ according to confirmatory factor analysis. Nevertheless, the MDMQ was sensitive to both depression severity and the presence of MDD and BD, both of which are known to have an impact on DM ability. Conclusion: The version of the MDMQ produced in the present study may be an important addition to neuropsychological assessment batteries with a focus on DM and related abilities

Executive functioning deficits among adults with Bipolar Disorder (types I and II): A systematic review and meta-analysis

BACKGROUND

Executive functioning (EF) deficits contribute to a significant proportion of the burden of disease associated with bipolar disorder (BD). Yet, there is still debate in the literature regarding the exact profile of executive functioning in BD. The purpose of the present project was to assess whether EF deficits exist among adults suffering BD, and whether these deficits (if apparent) differ by BD subtype.

METHODS

A systematic search identified relevant literature. Randomised controlled trials that used neuropsychological assessment to investigate EF among adults 16-65 years) with a remitted DSM diagnosis of BD (type I or II) were included. Studies were published between 1994 and 2015. A systematic review and meta-analysis were undertaken. For individual studies, standardised mean differences (Cohen's d) and 95% confidence intervals were calculated and represented in forest plots to illustrate differences in executive performance between groups. Summary effects were produced and tests of heterogeneity employed to assess the dispersion and generalisability of results.

RESULTS

Thirty-six studies met criteria for inclusion. Six domains of EF were identified: Set-shifting (SS), inhibition (INH), planning (PLA), verbal fluency (VF), working memory (WM), and attention (ATT). BD1s performed worse than HCs in all domains. BD2s demonstrated impairment in VF, WM, SS, and ATT. The results were mixed for comparisons between BD1s and BD2s, but revealed that BD2s can experience similar (or sometimes greater) EF impairment.

LIMITATIONS

Only a limited number of studies that included BD2 samples were available for inclusion in the current study. Subgroup analysis to elucidate potential moderators of within-study variance was not undertaken.

CONCLUSION

This is the first systematic review and meta-analysis to have compared the EF of remitted BD1s, BD2s, and HCs. The results provided useful insight into the EF profile of patients with BD, and offered commentary as to some of the contradictory results reported in the literature. A standardised methodological protocol for assessment of EF in BD was proposed. The information in this review could enhance our understanding of EF impairment inherent in BD, and the methods and efficacy with which clinicians assess and treat this population.

Behavioral and Electrophysiological Alterations for Reinforcement Learning in Manic and Euthymic Patients with Bipolar Disorder

AIMS

Bipolar disorder is characterized by behavioral changes such as risk-taking and increasing goal-directed activities, which may result from altered reward processing. Patients with bipolar disorder show impaired reward learning in situations that require the integration of reinforced feedback over time. In this study, we examined the behavioral and electrophysiological characteristics of reward learning in manic and euthymic patients with bipolar disorder using a probabilistic reward task.

METHODS

Twenty-four manic and 20 euthymic patients with bipolar I disorder and 24 healthy control subjects performed the probabilistic reward task. We assessed response bias (RB) as a preference for the stimulus paired with the more frequent reward and feedback-related negativity (FRN) to correct identification of the rich stimulus.

RESULTS

Both manic and euthymic patients showed significantly lower RB scores in the early learning stage (block 1) in comparison with the late learning stage (block 2 or block 3) of the task, as well as significantly lower RB scores in the early stage compared to healthy subjects. Relatively more negative FRN amplitude is elicited by no presentation of an expected reward, compared to that elicited by presentation of expected feedback. The FRN became significantly more negative from the early (block 1) to the later stages (blocks 2 and 3) in both manic and euthymic patients, but not in healthy subjects. Changes in RB scores and FRN amplitudes between blocks 2 and 3 and block 1 correlated positively in healthy controls, but correlated negatively in manic and euthymic patients. The severity of manic symptoms correlated positively with reward learning scores and negatively with the FRN.

CONCLUSIONS

These findings suggest that patients with bipolar disorder during euthymic or manic states have behavioral and electrophysiological alterations in reward learning compared to healthy subjects. This dysfunctional reward processing may be related to the abnormal decision-making or altered goal-directed activities frequently seen in patients with bipolar disorder.

Systematic Review of Cognitive Function in Euthymic Bipolar Disorder and Pre-Surgical Temporal Lobe Epilepsy

BACKGROUND

Bipolar disorder (BD) and temporal lobe epilepsy (TLE) overlap in domains including epidemiology, treatment response, shared neurotransmitter involvement and temporal lobe pathology. Comparison of cognitive function in both disorders may indicate temporal lobe mediated processes relevant to BD. This systematic review examines neuropsychological test profiles in euthymic bipolar disorder type I (BD-I) and pre-surgical TLE and compares experimental designs used.

METHODS

A search of PubMed, PsychINFO, and Scopus using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. Inclusion criteria were comparison group or pre- to post-surgical patients; reported neuropsychological tests; participants aged 18-60 years. Fifty six studies met criteria: 27 BD-I; 29 TLE.

RESULTS

Deficits in BD-I compared to healthy controls (HC) were in executive function, attention span and verbal memory. Deficits in TLE compared to HC were in executive function and memory. In the pre- to post-surgical comparisons, verbal memory in left temporal lobe (LTL) and, less consistently, visuospatial memory in right temporal lobe (RTL) epilepsy declined following surgery. BD-I studies used comprehensive test batteries in well-defined euthymic patients compared to matched HC groups. TLE studies used convenience samples pre- to post-surgery, comparing LTL and RTL subgroups, few included comparisons to HC (5 studies). TLE studies typically examined a narrow range of known temporal lobe-mediated neuropsychological functions, particularly verbal and visuospatial memory.

CONCLUSION

Both disorders exhibit deficits in executive function and verbal memory suggestive of both frontal and temporal lobe involvement. However, deficits in TLE are measured pre- to post-surgery and not controlled at baseline pre-surgery. Further research involving a head-to-head comparison of the two disorders on a broad range of neuropsychological tests is needed to clarify the nature and extent of cognitive deficits and potential overlaps.

Prevalence and correlates of cognitive impairment in euthymic adults with bipolar disorder: A systematic review

BACKGROUND

Previous reviews have identified medium-large group differences in cognitive performance in adults with bipolar disorder (BD) compared to healthy peers, but the proportion with clinically relevant cognitive impairment has not yet been established. This review aimed to quantify the prevalence of cognitive impairment in euthymic adults with BD, and to describe sociodemographic, clinical and other factors that are significantly associated with cognitive impairment.

METHODS

Systematic literature review. The population was euthymic community-dwelling adults with BD, aged 18-70 years, and recruited consecutively or randomly. The outcome was cognitive impairment, relative to healthy population norms. Electronic databases and reference lists of relevant articles were searched, and authors were contacted. Original cross-sectional studies published in peer-reviewed English-language journals from January 1994 to February 2015 were included. Methodological bias and reporting bias were assessed using standard tools. A narrative synthesis is presented together with tables and forest plots.

RESULTS

Thirty articles were included, of which 15 contributed prevalence data. At the 5th percentile impairment threshold, prevalence ranges were: executive function 5.3-57.7%; attention/working memory 9.6-51.9%; speed/reaction time 23.3-44.2%; verbal memory 8.2-42.1%; visual memory 11.5-32.9%. More severe or longstanding illness and antipsychotic medication were associated with greater cognitive impairment.

LIMITATIONS

The synthesis was limited by heterogeneity in cognitive measures and impairment thresholds, precluding meta-analysis.

CONCLUSIONS

Cognitive impairment affects a substantial proportion of euthymic adults with BD. Future research with more consistent measurement and reporting will facilitate an improved understanding of cognitive impairment burden in BD.

Clinical features, impulsivity, temperament and functioning and their role in suicidality in patients with bipolar disorder

OBJECTIVE

Our aim was to analyse sociodemographic and clinical differences between non-suicidal (NS) bipolar patients (BP), BP reporting only suicidal ideation (SI) and BP suicide attempters according to Columbia-Suicide Severity Rating Scale (C-SRSS) criteria. Secondarily, we also investigated whether the C-SRSS Intensity Scale was associated with emergence of suicidal behaviour (SB).

METHOD

A total of 215 euthymic bipolar out-patients were recruited. Semistructured interviews including the C-SRSS were used to assess sociodemographic and clinical data. Patients were grouped according to C-SRSS criteria: patients who scored ≤1 on the Severity Scale were classified as NS. The remaining patients were grouped into two groups: 'patients with history of SI' and 'patients with history of SI and SB' according to whether they did or did not have a past actual suicide attempt respectively.

RESULTS

Patients from the three groups differed in illness onset, diagnosis, number of episodes and admissions, family history, comorbidities, rapid cycling and medication, as well as level of education, functioning, impulsivity and temperamental profile.

CONCLUSION

Our results suggest that increased impulsivity, higher rates of psychiatric admissions and a reported poor controllability of SI significantly increased the risk for suicidal acts among patients presenting SI.

Executive function impairments in depression and bipolar disorder: association with functional impairment and quality of life

BACKGROUND

The neuropsychological correlates of major depressive (MDD) and bipolar disorder (BD), and their association with quality of life (QOL) and functioning, have not been sufficiently studied in the literature. The present study aimed to compare executive functions, attention, processing speed, QOL and disability between patients with BD type I, BD type II, MDD and healthy controls.

METHOD

205 participants (n=37 BDI, 81% female; n=35 BDII, 80% female; n=45 MDD, 69% female; n=89C, 46% female) aged between 18 and 67 years were administered an extensive neurocognitive battery consisting of widely used standardized measures such as the Trail Making Test, the Stroop Color-Word Test and a modified version of the Wisconsin Card Sorting Task. Z-scores were compared between groups by ANCOVA. The prevalence of impairments on each measure (Z-score<1.5) was compared between groups using chi-square tests. The associations between cognition, quality of life and functioning were evaluated through correlational analysis.

RESULTS

Patients with MDD showed poor selective and sustained attention, and exhibited impairments in timed tasks, suggesting low efficiency of executive processing. Patients with BDI displayed more widespread cognitive impairment than the remaining groups, and performed worse than subjects with MDD on measures of sustained attention and inhibitory control. Decision-making ability and attentional control were able to distinguish between patients with BDI and BDII. QOL and disability were most impaired in patients with BDI, and more closely associated with cognitive impairment than in the remaining groups.

LIMITATIONS

No control of pharmacological variables, clinical or demographic characteristics.

CONCLUSIONS

Our results provide important information regarding the nature and severity of the cognitive alterations associated with different mood disorders, and may contribute to the diagnosis, rehabilitation and treatment of these conditions.

Lithium might be associated with better decision-making performance in euthymic bipolar patients

Bipolar disorder is associated with impaired decision-making. Little is known about how treatment, especially lithium, influences decision-making abilities in bipolar patients when euthymic. We aimed at testing for an association between lithium medication and decision-making performance in remitted bipolar patients. Decision-making was measured using the Iowa Gambling Task in 3 groups of subjects: 34 and 56 euthymic outpatients with bipolar disorder, treated with lithium (monotherapy and lithium combined with anticonvulsant or antipsychotic) and without lithium (anticonvulsant, antipsychotic and combination treatment), respectively, and 152 matched healthy controls. Performance was compared between the 3 groups. In the 90 euthymic patients, the relationship between different sociodemographic and clinical variables and decision-making was assessed by stepwise multivariate regression analysis. Euthymic patients with lithium (p=0.007) and healthy controls (p=0.001) selected significantly more cards from the safe decks than euthymic patients without lithium, with no significant difference between euthymic patients with lithium and healthy controls (p=0.9). In the 90 euthymic patients, the stepwise linear multivariate regression revealed that decision-making was significantly predicted (p<0.001) by lithium dose, level of education and no family history of bipolar disorder (all p≤0.01). Because medication was not randomized, it was not possible to discriminate the effect of different medications. Lithium medication might be associated with better decision-making in remitted bipolar patients. A randomized trial is required to test for the hypothesis that lithium, but not other mood stabilizers, may specifically improve decision-making abilities in bipolar disorder.

The Mediating Role of Perceived Burdensomeness in Relations Between Domains of Cognitive Functioning and Indicators of Suicide Risk

OBJECTIVES

Psychiatric inpatients are at elevated risk for suicide, but there are mixed findings regarding cognitive functioning (i.e., executive functioning and problem-solving abilities) and suicide risk in this population. We hypothesized that a mediating variable (i.e., perceived burdensomeness) may explain these mixed findings.

METHOD

This hypothesis was tested in a sample of psychiatric inpatients admitted for suicide-related concerns (N = 110; 58.18% female, M(age) = 36.45) using a nonparametric bootstrapping procedure.

RESULTS

Perceived burdensomeness did not act as a mediator between any domain of cognitive functioning and current suicide ideation nor presence of recent suicide attempts. However, perceived burdensomeness was the strongest predictor of suicide ideation and mediated the relation between objective problem-solving skill and suicide risk (a weighted variable comprising current ideation and previous attempts).

CONCLUSIONS

Perceived burdensomeness may be associated with elevated suicide ideation, suggesting that perceived burdensomeness should be assessed to inform suicide risk decisions.

A meta-analysis of neuropsychological markers of vulnerability to suicidal behavior in mood disorders

BACKGROUND

Suicidal behavior results from a complex interplay between stressful events and vulnerability factors, including cognitive deficits. However, it is not clear which cognitive tests may best reveal this vulnerability. The objective was to identify neuropsychological tests of vulnerability to suicidal acts in patients with mood disorders.

METHOD

A search was made of Medline, EMBASE and PsycINFO databases, and article references. A total of 25 studies (2323 participants) met the selection criteria. A total of seven neuropsychological tests [Iowa gambling task (IGT), Stroop test, trail making test part B, Wisconsin card sorting test, category and semantic verbal fluencies, and continuous performance test] were used in at least three studies to be analysed.

RESULTS

IGT and category verbal fluency performances were lower in suicide attempters than in patient controls [respectively, g = -0.47, 95% confidence interval (CI) -0.65 to -0.29 and g = -0.32, 95% CI -0.60 to -0.04] and healthy controls, with no difference between the last two groups. Stroop performance was lower in suicide attempters than in patient controls (g = 0.37, 95% CI 0.10-0.63) and healthy controls, with patient controls scoring lower than healthy controls. The four other tests were altered in both patient groups versus healthy controls but did not differ between patient groups.

CONCLUSIONS

Deficits in decision-making, category verbal fluency and the Stroop interference test were associated with histories of suicidal behavior in patients with mood disorders. Altered value-based and cognitive control processes may be important factors of suicidal vulnerability. These tests may also have the potential of guiding therapeutic interventions and becoming part of future systematic assessment of suicide risk.

The impact of frontal and cerebellar lesions on decision making: evidence from the Iowa Gambling Task

Although the frontal lobes have traditionally been considered the neural substrates of executive functioning (EF), recent studies have suggested that other structures, such as the cerebellum, may be associated with these abilities. The role of the cerebellum has only been sparsely investigated in connection with decision making (DM), an important component of EF, and the few results obtained on this front have been inconclusive. The current study sought to investigate the role of the cerebellum in DM by comparing the performance of patients with cerebellar strokes, frontal-damaged patients, and a healthy control group on the Iowa Gambling Task (IGT). A total of nine cerebellar-damaged adults participated in the study, as well as nine individuals with frontal strokes and 18 control individuals. Patients were administered a version of the IGT adapted to the population of Southern Brazil. There was a marginal difference in mean IGT net scores between the two clinical groups, although both displayed impaired performance as compared to the control group. Overall, the DM ability of patients with cerebellar damage proved to be more preserved than that of individuals with frontal lobe strokes, but less preserved than that of the control group. These data suggested that, while the frontal lobes may be the most important brain structures for DM, the cerebellum might also play an active role in this cognitive function. Future studies assessing participants with lesions in different cerebellar regions and hemispheres will prove invaluable for the understanding of the neural structures involved in DM, and make significant contributions to the globalist-localizationist debate in DM neuroscience.

Impulsivity: present during euthymia in bipolar disorder? - a systematic review

Because impulsivity is part of the presentation of bipolar disorder (BD) and is associated with its course, this systematic review presents the evidence whether increased impulsivity is present in a stable, euthymic mood and therefore potentially a vulnerability marker for BD. A multi-faceted model of impulsivity was adopted to explore how different facets may relate differently to BD. The evidence was explored in relation to studies employing measures of trait impulsivity (in self-report format) and studies exploring impulsivity with behavioural paradigms. Behavioural paradigms were separated into studies measuring response inhibition and those measuring the ability to delay gratification. Twenty-three papers met the inclusion criteria. Most studies using self-report measures found significant differences between euthymic BD patients and healthy controls. There was little evidence of increased impulsivity as measured by behavioural paradigms. Most studies found no significant difference in response inhibition between groups, though it is possible that much of the literature in this area was underpowered to detect an effect. Only five studies explored delay of gratification, of which the two methodologically strongest studies found no group differences. In conclusion, there is evidence that euthymic patients with BD report increased impulsivity when using self-ratings. However, there is currently limited evidence of impulsivity on behavioural measures assessing response inhibition, and this might be restricted to more severe cases. More research is needed on the ability to delay gratification before drawing any conclusions. However, to establish facets of impulsivity as vulnerability markers, future studies should include at-risk individuals to evaluate whether self-rated or behavioural impulsivity precedes the onset of BD.

Dopaminergic influences on emotional decision making in euthymic bipolar patients

We recently reported that the D2/D3 agonist pramipexole may have pro-cognitive effects in euthymic patients with bipolar disorder (BPD); however, the emergence of impulse-control disorders has been documented in Parkinson's disease (PD) after pramipexole treatment. Performance on reward-based tasks is altered in healthy subjects after a single dose of pramipexole, but its potential to induce abnormalities in BPD patients is unknown. We assessed reward-dependent decision making in euthymic BPD patients pre- and post 8 weeks of treatment with pramipexole or placebo by using the Iowa Gambling Task (IGT). The IGT requires subjects to choose among four card decks (two risky and two conservative) and is designed to promote learning to make advantageous (conservative) choices over time. Thirty-four BPD patients completed both assessments (18 placebo and 16 pramipexole). Baseline performance did not differ by treatment group (F=0.63; p=0.64); however, at week 8, BPD patients on pramipexole demonstrated a significantly greater tendency to make increasingly high-risk, high-reward choices across the five blocks, whereas the placebo group's pattern was similar to that reported in healthy individuals (treatment × time × block interaction, p<0.05). Analyses of choice strategy using the expectancy valence model revealed that after 8 weeks on pramipexole, BPD patients attended more readily to feedback related to gains than to losses, which could explain the impaired learning. There were no significant changes in mood symptoms over the 8 weeks, and no increased propensity toward manic-like behaviors were reported. Our results suggest that the enhancement of dopaminergic activity influences risk-associated decision-making performance in euthymic BPD. The clinical implications remain unknown.

Reward signals, attempted suicide, and impulsivity in late-life depression

IMPORTANCE—Suicide can be viewed as an escape from unendurable punishment at the cost of any future rewards. Could faulty estimation of these outcomes predispose to suicidal behavior? In behavioral studies, many of those who have attempted suicide misestimate expected rewards on gambling and probabilistic learning tasks.OBJECTIVES—To describe the neural circuit abnormalities that underlie disadvantageous choices in people at risk for suicide and to relate these abnormalities to impulsivity, which is one of the components of vulnerability to suicide.DESIGN—Case-control functional magnetic resonance imaging study of reward learning using are inforcement learning model.SETTING—University hospital and outpatient clinic.PATIENTS—Fifty-three participants 60 years or older, including 15 depressed patients who had attempted suicide, 18 depressed patients who had never attempted suicide (depressed control subjects), and 20 psychiatrically healthy controls.MAIN OUTCOMES AND MEASURES—Components of the cortical blood oxygenation level–dependent response tracking expected and unpredicted rewards.RESULTS—Depressed elderly participants displayed 2 distinct disruptions of control over reward-guided behavior. First, impulsivity and a history of suicide attempts (particularly poorly planned ones) were associated with a weakened expected reward signal in the paralimbic cortex,which in turn predicted the behavioral insensitivity to contingency change. Second, depression was associated with disrupted corticostriatothalamic encoding of unpredicted rewards, which in turn predicted the behavioral over sensitivity to punishment. These results were robust to the effects of possible brain damage from suicide attempts, depressive severity, co-occurring substance use and anxiety disorders, antidepressant and anticholinergic exposure, lifetime exposure to electroconvulsive therapy, vascular illness, and incipient dementia.CONCLUSIONS AND RELEVANCE—Altered paralimbic reward signals and impulsivity and/or carelessness may facilitate unplanned suicidal acts. This pattern, also seen in gambling and cocaine use, may reflect a primary deficit in the paralimbic cortex or in its mesolimbic input. The over reactivity to punishment in depression may be caused in part by a disruption of appetitive learning in the corticostriatothalamic circuits.

Iowa Gambling Task performance in euthymic bipolar I disorder: a meta-analysis and empirical study

BACKGROUND

The Iowa Gambling Task (IGT) has been recommended as an index of reward sensitivity, which is elevated in bipolar disorder. We conducted a meta-analysis of IGT performance in euthymic bipolar I disorder compared with control participants. Findings indicated that people with bipolar disorder make more risky choices than control participants, though the effect is small (g=0.35). It is not clear which of the many processes involved in IGT performance are involved in producing the observed group difference.

METHODS

Fifty-five euthymic people with bipolar disorder and 39 control participants completed the IGT. The Expectancy Valence Model was used to examine differences in IGT. We also examined whether variation in IGT performance within the bipolar group was related to current mood, illness course, impulsivity, or demographics.

RESULTS

Bipolar and control groups did not differ on the total number of risky choices, rate of learning, or any of the parameters of the Expectancy Valence Model. IGT performance in bipolar disorder was not related to any of the examined individual differences.

LIMITATIONS

It is possible that there are group differences that are too small to detect at our sample size or that are not amenable to study via the Expectancy Valence Model.

CONCLUSIONS

We were unable to identify group differences on the IGT or correlates of IGT performance within bipolar disorder. Though the IGT may serve as a useful model for decision-making, its structure may make it unsuitable for behavioral assessment of reward sensitivity independent of punishment sensitivity.

Increased salience of gains versus decreased associative learning differentiate bipolar disorder from schizophrenia during incentive decision making

BACKGROUND

Abnormalities in incentive decision making, typically assessed using the Iowa Gambling Task (IGT), have been reported in both schizophrenia (SZ) and bipolar disorder (BD). We applied the Expectancy-Valence (E-V) model to determine whether motivational, cognitive and response selection component processes of IGT performance are differentially affected in SZ and BD.

METHOD

Performance on the IGT was assessed in 280 individuals comprising 70 remitted patients with SZ, 70 remitted patients with BD and 140 age-, sex- and IQ-matched healthy individuals. Based on the E-V model, we extracted three parameters, 'attention to gains or loses', 'expectancy learning' and 'response consistency', that respectively reflect motivational, cognitive and response selection influences on IGT performance.

RESULTS

Both patient groups underperformed in the IGT compared to healthy individuals. However, the source of these deficits was diagnosis specific. Associative learning underlying the representation of expectancies was disrupted in SZ whereas BD was associated with increased incentive salience of gains. These findings were not attributable to non-specific effects of sex, IQ, psychopathology or medication.

CONCLUSIONS

Our results point to dissociable processes underlying abnormal incentive decision making in BD and SZ that could potentially be mapped to different neural circuits.

Use of next generation sequencing technologies in research and beyond: are participants with mental health disorders fully protected?

Background

Next Generation Sequencing (NGS) is expected to help find the elusive, causative genetic defects associated with Bipolar Disorder (BD). This article identifies the importance of NGS and further analyses the social and ethical implications of this approach when used in research projects studying BD, as well as other psychiatric ailments, with a view to ensuring the protection of research participants.

Methods

We performed a systematic review of studies through PubMed, followed by a manual search through the titles and abstracts of original articles, including the reviews, commentaries and letters published in the last five years and dealing with the ethical and social issues raised by NGS technologies and genomics studies of mental disorders, especially BD. A total of 217 studies contributed to identify the themes discussed herein.

Results

The amount of information generated by NGS renders individuals suffering from BD particularly vulnerable, and increases the need for educational support throughout the consent process, and, subsequently, of genetic counselling, when communicating individual research results and incidental findings to them. Our results highlight the importance and difficulty of respecting participants’ autonomy while avoiding any therapeutic misconception. We also analysed the need for specific regulations on the use and communication of incidental findings, as well as the increasing influence of NGS in health care.

Conclusions

Shared efforts on the part of researchers and their institutions, Research Ethics Boards as well as participants’ representatives are needed to delineate a tailored consent process so as to better protect research participants. However, health care professionals involved in BD care and treatment need to first determine the scientific validity and clinical utility of NGS-generated findings, and thereafter their prevention and treatment significance.

The neural basis of decision-making and reward processing in adults with euthymic bipolar disorder or attention-deficit/hyperactivity disorder (ADHD)

Background

Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) share DSM-IV criteria in adults and cause problems in decision-making. Nevertheless, no previous report has assessed a decision-making task that includes the examination of the neural correlates of reward and gambling in adults with ADHD and those with BD.

Methodology/Principal Findings

We used the Iowa gambling task (IGT), a task of rational decision-making under risk (RDMUR) and a rapid-decision gambling task (RDGT) which elicits behavioral measures as well as event-related potentials (ERPs: fERN and P3) in connection to the motivational impact of events. We did not observe between-group differences for decision-making under risk or ambiguity (RDMUR and IGT); however, there were significant differences for the ERP-assessed RDGT. Compared to controls, the ADHD group showed a pattern of impaired learning by feedback (fERN) and insensitivity to reward magnitude (P3). This ERP pattern (fERN and P3) was associated with impulsivity, hyperactivity, executive function and working memory. Compared to controls, the BD group showed fERN- and P3-enhanced responses to reward magnitude regardless of valence. This ERP pattern (fERN and P3) was associated with mood and inhibitory control. Consistent with the ERP findings, an analysis of source location revealed reduced responses of the cingulate cortex to the valence and magnitude of rewards in patients with ADHD and BD.

Conclusions/Significance

Our data suggest that neurophysiological (ERPs) paradigms such as the RDGT are well suited to assess subclinical decision-making processes in patients with ADHD and BD as well as for linking the cingulate cortex with action monitoring systems.

Impaired decision making in adolescent suicide attempters

OBJECTIVE

Decision-making deficits have been linked to suicidal behavior in adults. However, it remains unclear whether impaired decision making plays a role in the etiopathogenesis of youth suicidal behavior. The purpose of this study was to examine decision-making processes in adolescent suicide attempters and never-suicidal comparison subjects.

METHOD

Using the Iowa Gambling Task, the authors examined decision making in 40 adolescent suicide attempters, 13 to 18 years old, and 40 never-suicidal, demographically matched psychiatric comparison subjects.

RESULTS

Overall, suicide attempters performed significantly worse on the Iowa Gambling Task than comparison subjects. This difference in overall task performance between the groups persisted in an exact conditional logistic regression analysis that controlled for affective disorder, current psychotropic medication use, impulsivity, and hostility (adjusted odds ratio = 0.96, 95% confidence interval = 0.90-0.99, p < 0.05). A two-way repeated-measures analysis of variance revealed a significant group-by-block interaction, demonstrating that attempters failed to learn during the task, picking approximately the same proportion of disadvantageous cards in the first and final blocks of the task. In contrast, comparison subjects picked proportionately fewer cards from the disadvantageous decks as the task progressed. Within the attempter group, overall task performance did not correlate with any characteristic of the index attempt or with the personality dimensions of impulsivity, hostility, and emotional lability.

CONCLUSIONS

Similar to findings in adults, impaired decision making is associated with suicidal behavior in adolescents. Longitudinal studies are needed to elucidate the temporal relationship between decision-making processes and suicidal behavior and to help frame potential targets for early identification and preventive interventions to reduce youth suicide and suicidal behavior.

The behavioral activation system and mania

For over two decades, theorists have suggested that mania relates to heightened sensitivity of the behavioral activation system (BAS). In this article, we review a burgeoning empirical literature on this model, drawing on both cross-sectional and prospective studies. As evidence has emerged for this model, we argue that it is time to consider more specific aspects of BAS sensitivity in this disorder. We review evidence that bipolar disorder relates to an increased willingness to expend effort toward reward and to increases in energy and goal pursuit after an initial reward. We conclude by considering the strengths and weaknesses of this literature, with an eye toward future directions and implications for treatment.

The behavioral activation system and mania

For over two decades, theorists have suggested that mania relates to heightened sensitivity of the behavioral activation system (BAS). In this article, we review a burgeoning empirical literature on this model, drawing on both cross-sectional and prospective studies. As evidence has emerged for this model, we argue that it is time to consider more specific aspects of BAS sensitivity in this disorder. We review evidence that bipolar disorder relates to an increased willingness to expend effort toward reward and to increases in energy and goal pursuit after an initial reward. We conclude by considering the strengths and weaknesses of this literature, with an eye toward future directions and implications for treatment.

The neuroscience of suicidal behaviors: what can we expect from endophenotype strategies?

Vulnerability to suicidal behavior (SB) is likely mediated by an underlying genetic predisposition interacting with environmental and probable epigenetic factors throughout the lifespan to modify the function of neuronal circuits, thus rendering an individual more likely to engage in a suicidal act. Improving our understanding of the neuroscience underlying SBs, both attempts and completions, at all developmental stages is crucial for more effective preventive treatments and for better identification of vulnerable individuals. Recent studies have characterized SB using an endophenotype strategy, which aims to identify quantitative measures that reflect genetically influenced stable changes in brain function. In addition to aiding in the functional characterization of susceptibility genes, endophenotypic research strategies may have a wider impact in determining vulnerability to SB, as well as the translation of human findings to animal models, and vice versa. Endophenotypes associated with vulnerability to SB include impulsive/aggressive personality traits and disadvantageous decision making. Deficits in realistic risk evaluation represent key processes in vulnerability to SB. Serotonin dysfunction, indicated by neuroendocrine responses and neuroimaging, is also strongly implicated as a potential endophenotype and is linked with impulsive aggression and disadvantageous decision making. Specific endophenotypes may represent heritable markers for the identification of vulnerable patients and may be relevant targets for successful suicide prevention and treatments.