Impact of number of episodes on neurocognitive trajectory in bipolar disorder patients: a 5-year follow-up study

[Long-term courses of bipolar disorders]

BACKGROUND

Bipolar disorder (short: BD) is a severe illness with very heterogeneous trajectories. While some of the patients show no or hardly any long-term impairments, other affected individuals show substantial neurocognitive deficits with a clear decline in psychosocial functioning. Which factors influence the course of the disease is the subject of current research efforts.

OBJECTIVE

This review presents the long-term course of bipolar disease and the factors influencing it. In particular, differential trajectory types are discussed. The cognitive and psychosocial functional level as well as the psychopathological characteristics of the disease are elucidated. In addition, biological factors and treatment approaches influencing the course and prognosis are identified.

MATERIAL AND METHODS

Literature search using PubMed focusing on longitudinal studies over several years (see online supplement).

RESULTS

To date, there are only a few predictors and biomarkers that allow prediction of long-term progression. None have been sufficiently studied to enable clinical use. Appropriate pharmacological and psychotherapeutic treatment of those affected is essential to avoid renewed episodes of the disease.

DISCUSSION

The long-term course of bipolar disorder is highly heterogeneous and multifaceted. Despite intensive research efforts, no predictors have yet been identified that reliably predict the clinical course. This makes further research all the more important in order to offer individualized therapy options, develop new therapies and positively influence the course of the disease at an early stage.

Digital phenotyping in bipolar disorder: Using longitudinal Fitbit data and personalized machine learning to predict mood symptomatology

BACKGROUND

Effective treatment of bipolar disorder (BD) requires prompt response to mood episodes. Preliminary studies suggest that predictions based on passive sensor data from personal digital devices can accurately detect mood episodes (e.g., between routine care appointments), but studies to date do not use methods designed for broad application. This study evaluated whether a novel, personalized machine learning approach, trained entirely on passive Fitbit data, with limited data filtering could accurately detect mood symptomatology in BD patients.

METHODS

We analyzed data from 54 adults with BD, who wore Fitbits and completed bi-weekly self-report measures for 9 months. We applied machine learning (ML) models to Fitbit data aggregated over two-week observation windows to detect occurrences of depressive and (hypo)manic symptomatology, which were defined as two-week windows with scores above established clinical cutoffs for the Patient Health Questionnaire-8 (PHQ-8) and Altman Self-Rating Mania Scale (ASRM) respectively.

RESULTS

As hypothesized, among several ML algorithms, Binary Mixed Model (BiMM) forest achieved the highest area under the receiver operating curve (ROC-AUC) in the validation process. In the testing set, the ROC-AUC was 86.0% for depression and 85.2% for (hypo)mania. Using optimized thresholds calculated with Youden's J statistic, predictive accuracy was 80.1% for depression (sensitivity of 71.2% and specificity of 85.6%) and 89.1% for (hypo)mania (sensitivity of 80.0% and specificity of 90.1%).

CONCLUSION

We achieved sound performance in detecting mood symptomatology in BD patients using methods designed for broad application. Findings expand upon evidence that Fitbit data can produce accurate mood symptomatology predictions. Additionally, to the best of our knowledge, this represents the first application of BiMM forest for mood symptomatology prediction. Overall, results move the field a step toward personalized algorithms suitable for the full population of patients, rather than only those with high compliance, access to specialized devices, or willingness to share invasive data.

The progression trajectory of Bipolar Disorder: results from the application of a staging model over a ten-year observation

BACKGROUND

Trying to better define Bipolar Disorder (BD) progression, different staging models have been conceptualized, each one emphasizing different aspects of illness. In a previous article we retrospectively applied the main staging models to a sample of 100 bipolar patients at four time points over a ten-year observation. In the present study, focusing on Kupka & Hillegers's model, we aimed to assess the transition of the same sample through the different stages of illness and to explore the potential role of clinical variables on the risk of progression.

METHODS

Multistate Model using the mstate package in R and Markov model with stratified hazards were used for statistical analysis.

RESULTS

A high hazard of transition from stage 2 to 3 emerged, with a probability of staying in stage 2 decreasing to 14 % after 3 years. BD II was significantly associated with transition from stage 1 to 2, whereas the number of lifetime episodes >3 and the elevated predominant polarity with transition from stage 3 to 4.

CONCLUSION

Our results corroborated the evidence on BD progression and contributed to outline its trajectory over time. Further effort may help to define a standardized staging approach towards ever increasing tailored interventions.

Long-term course of cognitive functioning in bipolar disorder: A ten-year follow-up study

INTRODUCTION

Cognitive impairments are common in bipolar disorder (BD), but the long-term course remains understudied. Longitudinal data on cognitive functioning from the start of the first treatment could help clarify pathophysiological processes that shape the illness outcome. We here aim to investigate the 10-year cognitive course in BD compared to healthy controls (HC) and the effects of clinical symptoms on cognitive trajectories.

METHODS

Fifty-six BD participants recruited within their first year of treatment and 108 HC completed clinical and cognitive assessments at baseline and 10-year follow-up. We derived eight cognitive domain scores and a cognitive composite score, which were further investigated using linear mixed model analyses. Correlation analyses were used to assess associations between the composite score and depressive, manic and psychotic symptoms.

RESULTS

BD participants performed poorer than HCs in all domains except mental speed and verbal fluency. Verbal learning and memory, verbal fluency and the composite score improved over time in both BD participants and HC, while short-term memory, mental speed, psychomotor speed and working memory were stable. We found no significant correlations between cognition and symptom level at either time point in BD participants.

CONCLUSIONS

We found evidence of long-term cognitive stability or improvement in BD participants from first treatment to 10-year follow-up. Though the BD group was impaired in all domains except mental speed and verbal fluency, the change in cognitive functioning was parallel to that of HCs. These findings are not consistent with the notion of neuroprogression in BD.

Comparative analysis of anticholinergic burden scales to explain iatrogenic cognitive impairment and self-reported side effects in the euthymic phase of bipolar disorders: Results from the FACE-BD cohort

Bipolar disorders (BD) are characterized by cognitive impairment during the euthymic phase, to which treatments can contribute. The anticholinergic properties of medications, i.e., the ability of a treatment to inhibit cholinergic receptors, are associated with cognitive impairment in elderly patients and people with schizophrenia but this association has not been well characterized in individuals with remitted BD. Moreover, the validity of only one anticholinergic burden scale designed to assess the anticholinergic load of medications has been tested in BD. In a literature review, we identified 31 existing scales. We first measured the associations between 27 out of the 31 scales and objective cognitive impairment in bivariable regressions. We then adjusted the bivariable models with covariates: the scales significantly associated with cognitive impairment in bivariable and multiple logistic regressions were defined as having good concurrent validity to assess cognitive impairment. In a sample of 2,031 individuals with euthymic BD evaluated with a neuropsychological battery, two scales had good concurrent validity to assess cognitive impairment, whereas chlorpromazine equivalents, lorazepam equivalents, the number of antipsychotics, or the number of treatments had not. Finally, similar analyses with subjective anticholinergic side-effects as outcome variables reported 14 scales with good concurrent validity to assess self-reported peripheral anticholinergic side-effects and 13 to assess self-reported central anticholinergic side-effects. Thus, we identified valid scales to monitor the anticholinergic burden in BD, which may be useful in estimating iatrogenic cognitive impairment in studies investigating cognition in BD.

Are There Any Differences in Clinical and Biochemical Variables between Bipolar Patients with or without Lifetime Psychotic Symptoms?

INTRODUCTION

Psychotic symptoms occur in more than half of patients affected by Bipolar Disorder (BD) and are associated with an unfavorable course of the disorder. The objective of this study is to identify the differences in the clinical and biochemical parameters between bipolar patients with or without psychotic symptoms.

METHODS

A total of 665 inpatients were recruited. Demographic, clinical, and biochemical data related to the first day of hospitalization were obtained via a screening of the clinical charts and intranet hospital applications. The two groups identified via the lifetime presence of psychotic symptoms were compared using t tests for quantitative variables and χ2 tests for qualitative ones; binary logistic regression models were subsequently performed.

RESULTS

Patients with psychotic BD (compared to non-psychotic ones) showed a longer duration of hospitalization (p < 0.001), higher Young Mania Rating Scale scores (p < 0.001), lower Global Assessment of Functioning scores (p = 0.002), a less frequent history of lifetime suicide attempts (p = 0.019), less achievement of remission during the current hospitalization (p = 0.028), and a higher Neutrophile to Lymphocyte Ratio (NLR) (p = 0.006), but lower total cholesterol (p = 0.018) and triglycerides (p = 0.013).

CONCLUSIONS

Patients with psychotic BD have a different clinical and biochemical profile compared to their counterparts, characterized by more clinical severity, fewer metabolic alterations, and a higher grade of inflammation. Further multi-center studies have to confirm the results of this present study.

Impact of lithium on mortality among older adults with major psychiatric disorders: A 5-year prospective multicenter study

OBJECTIVE

Prior studies report conflicting results about the association between lithium use and all-cause mortality. In addition, data are scarce on this association among older adults with psychiatric disorders. In this report, we sought to examine the associations of lithium use with all-cause mortality and specific causes of death (i.e., due to cardiovascular disorder, non-cardiovascular disease, accident, or suicide) among older adults with psychiatric disorders during a 5-year follow-up period.

METHODS

In this observational epidemiological study, we used data from 561 patients belonging to a Cohort of individuals with Schizophrenia or Affective disorders aged 55-years or more (CSA). Patients taking lithium at baseline were first compared to patients not taking lithium, and then to patients taking (i) antiepileptics and (ii) atypical antipsychotics in sensitivity analyses. Analyses were adjusted for socio-demographic (e.g., age, gender), clinical characteristics (e.g., psychiatric diagnosis, cognitive functioning), and other psychotropic medications (e.g. benzodiazepines).

RESULTS

There was no significant association between lithium use and all-cause mortality [AOR=1.12; 95%CI=0.45-2.79; p=0.810] or disease-related mortality [AOR=1.37; 95%CI=0.51-3.65; p=0.530]. None of the 44 patients taking lithium died from suicide, whereas 4.0% (N=16) of patients not receiving lithium did.

CONCLUSION

These findings suggest that lithium may not be associated with all-cause or disease-related mortality and might be associated with reduced risk of suicide in this population. They argue against the underuse of lithium as compared with antiepileptics and atypical antipsychotics among older adults with mood disorders.

Brain age and cognitive functioning in first-episode bipolar disorder

BACKGROUND

There is significant heterogeneity in cognitive function in patients with bipolar I disorder (BDI); however, there is a dearth of research into biological mechanisms that might underlie cognitive heterogeneity, especially at disease onset. To this end, this study investigated the association between accelerated or delayed age-related brain structural changes and cognition in early-stage BDI.

METHODS

First episode patients with BDI (n = 80) underwent cognitive assessment to yield demographically normed composite global and domain-specific scores in verbal memory, non-verbal memory, working memory, processing speed, attention, and executive functioning. Structural magnetic resonance imaging data were also collected from all participants and subjected to machine learning to compute the brain-predicted age difference (brainPAD), calculated by subtracting chronological age from age predicted by neuroimaging data (positive brainPAD values indicating age-related acceleration in brain structural changes and negative values indicating delay). Patients were divided into tertiles based on brainPAD values, and cognitive performance compared amongst tertiles with ANCOVA.

RESULTS

Patients in the lowest (delayed) tertile of brainPAD values (brainPAD range -17.9 to -6.5 years) had significantly lower global cognitive scores (p = 0.025) compared to patients in the age-congruent tertile (brainPAD range -5.3 to 2.4 yrs), and significantly lower verbal memory scores (p = 0.001) compared to the age-congruent and accelerated (brainPAD range 2.8 to 16.1 yrs) tertiles.

CONCLUSION

These results provide evidence linking cognitive dysfunction in the early stage of BDI to apparent delay in typical age-related brain changes. Further studies are required to assess how age-related brain changes and cognitive functioning evolve over time.

Neurocognitive subgroups among newly diagnosed patients with schizophrenia spectrum or bipolar disorders: A hierarchical cluster analysis

Studies across schizophrenia (SZ) and bipolar disorder (BD) indicate common transdiagnostic neurocognitive subgroups. However, existing studies of patients with long-term illness precludes insight into whether impairments result from effects of chronic illness, medication or other factors. This study aimed to investigate whether neurocognitive subgroups across SZ and BD can be demonstrated during early illness stages. Data from overlapping neuropsychological tests were pooled from cohort studies of antipsychotic-naïve patients with first-episode SZ spectrum disorders (n = 150), recently diagnosed BD (n = 189) or healthy controls (HC) (n = 280). Hierarchical cluster analysis was conducted to examine if transdiagnostic subgroups could be identified based on the neurocognitive profile. Patterns of cognitive impairments and patient characteristics across subgroups were examined. Patients could be clustered into two, three and four subgroups, of which the three-cluster solution (with 83% accuracy) was selected for posthoc analyses. This solution revealed a subgroup covering 39% of patients (predominantly BD) who were cognitively relatively intact, a subgroup of 33% of patients (more equal distributions of SZ and BD) displaying selective deficits, particularly in working memory and processing speed, and a subgroup of 28% (mainly SZ) with global impairments. The globally impaired group exhibited lower estimated premorbid intelligence than the other subgroups. Globally impaired BD patients also showed more functional disability than cognitively relatively intact patients. No differences were observed across subgroups in symptoms or medications. Neurocognitive results can be understood by clustering analysis with similar clustering solutions occurring across diagnoses. The subgroups were not explained by clinical symptoms or medication, suggesting neurodevelopmental origins.

Mania-related effects on structural brain changes in bipolar disorder - a narrative review of the evidence

Cross-sectional neuroimaging studies show that bipolar disorder is associated with structural brain abnormalities, predominantly observed in prefrontal and temporal cortex, cingulate gyrus, and subcortical regions. However, longitudinal studies are needed to elucidate whether these abnormalities presage disease onset or are consequences of disease processes, and to identify potential contributing factors. Here, we narratively review and summarize longitudinal structural magnetic resonance imaging studies that relate imaging outcomes to manic episodes. First, we conclude that longitudinal brain imaging studies suggest an association of bipolar disorder with aberrant brain changes, including both deviant decreases and increases in morphometric measures. Second, we conclude that manic episodes have been related to accelerated cortical volume and thickness decreases, with the most consistent findings occurring in prefrontal brain areas. Importantly, evidence also suggests that in contrast to healthy controls, who in general show age-related cortical decline, brain metrics remain stable or increase during euthymic periods in bipolar disorder patients, potentially reflecting structural recovering mechanisms. The findings stress the importance of preventing manic episodes. We further propose a model of prefrontal cortical trajectories in relation to the occurrence of manic episodes. Finally, we discuss potential mechanisms at play, remaining limitations, and future directions.

Aripiprazole Plasma Concentrations Delivered from Two 2-Month Long-Acting Injectable Formulations: An Indirect Comparison

Aripiprazole 2-month ready-to-use 960 mg (Ari 2MRTU 960) is a novel long-acting injectable (LAI) formulation of aripiprazole monohydrate for administration once every 2 months, developed for the treatment of schizophrenia or maintenance monotherapy treatment of bipolar I disorder in adults (indication will vary by country). Aripiprazole lauroxil 1064 mg (AL 1064) is an LAI formulation of aripiprazole lauroxil, an aripiprazole prodrug, for administration once every 2 months, indicated for the treatment of schizophrenia in adults. This analysis provides an indirect comparison of aripiprazole plasma concentrations following multiple doses of either formulation. Clinical trial data were used to determine average steady-state aripiprazole plasma concentration (Cavg,ss), maximum aripiprazole plasma concentration (Cmax), and other pharmacokinetic parameters of either formulation following four administrations (96 patients received Ari 2MRTU 960; 28 patients received AL 1064). All pharmacokinetic parameters were considered in the context of a minimum aripiprazole therapeutic concentration (Cmin) of ≥95 ng/mL. An exposure-response analysis using data from two Phase III trials of aripiprazole once-monthly (an aripiprazole monohydrate LAI, administered monthly), showed that patients with a Cmin ≥95 ng/mL are 4.41 times less likely to relapse than patients with a Cmin <95 ng/mL. A similar analysis has not been performed for AL 1064. However, consensus guidelines for therapeutic drug monitoring recommend a range of 100-350 ng/mL for aripiprazole. Following four administrations, mean (standard deviation [SD]) Cavg,ss over the 2-month dosing interval was 263 (133) ng/mL for Ari 2MRTU 960 and 140.7 (57.3) ng/mL for AL 1064. Mean (SD) Cmax during the fourth dosing interval was 342 (157) ng/mL for Ari 2MRTU 960 and 188.8 (79.8) ng/mL for AL 1064. This indirect comparison showed that, following four administrations, Ari 2MRTU 960 and AL 1064 delivered mean aripiprazole plasma concentrations that remained above the minimum therapeutic concentration of aripiprazole over the 2-month dosing interval.

Associations between emotional and non-emotional cognition and subsequent mood episodes in recently diagnosed patients with bipolar disorder: A 16-month follow-up study

BACKGROUND

Bipolar disorder (BD) is associated with impairments in both emotional and non-emotional cognition. Recently, cognitive impairments have attracted increasing research interest as markers of prognosis and possible treatment targets in patients with BD. However, there is a paucity of studies investigating cognitive predictors of prognosis in BD.

METHODS

We assessed 148 recently diagnosed, symptomatically stable patients with BD with a battery of emotional and non-emotional cognitive tests and followed them up over 16 months as part of an ongoing cohort study. Multiple linear regression analyses were conducted to examine the associations between cognitive performance at baseline and the recurrence and duration of (hypo)manic and depressive episodes, respectively, with adjustment for age, sex, subsyndromal symptoms and time between assessments.

RESULTS

Poorer recognition of negative facial expressions and more negative emotions in neutral daily life scenarios were associated with greater frequency (ps ≤ .04) and longer duration (ps ≤ .03) of subsequent (hypo)manic episodes over the 16-month follow-up period. In addition, poorer global cognition, attention and psychomotor speed, and verbal fluency were associated with more (hypo)manic episodes (ps ≤ .04). Finally, more difficulty down-regulating emotion in negative social scenarios was associated with depressive relapse (p = .007). It was a limitation that patients had a delayed diagnosis of seven years from their first mood episode despite being recently diagnosed.

CONCLUSION

Trait-related cognitive impairments influence the early course in recently diagnosed patients with BD, particularly (hypo)manic relapse. Early prophylactic strategies targeting cognitive impairments may increase resilience and the course of illness in recently diagnosed patients with BD.

The trajectory of emotional and non-emotional cognitive function in newly diagnosed patients with bipolar disorder and their unaffected relatives: A 16-month follow-up study

Cognitive impairments are evident in remitted patients with bipolar disorder (BD) and their unaffected relatives (UR) compared to healthy controls (HC). However, the temporal course of cognition, and whether cognition is marked by neuroprogressive changes, remain unclear. In a large prospective study of newly diagnosed patients with BD, we assessed patients with BD (n = 266), UR (n = 105) and HC (n = 190) using an extensive cognitive battery of non-emotional and emotional cognition at baseline and 16-months follow-up. Cognitive change across groups was examined with linear mixed-model analyses. Results showed no evidence of trajectory differences between patients with BD, UR, and HC in neurocognition and emotional cognition (ps≥.10). Patients with BD showed stable impairments in global neurocognitive functioning over time, as well as within the domains of 'working memory and executive function' and 'attention and psychomotor speed', compared to HC. Patients who relapsed during the follow-up time were less successful at down-regulating emotions in positive social scenarios compared to HC. Unaffected relatives also displayed stable deficits in 'working memory and executive function' over time, with performance at intermediate levels between BD probands and HC. Finally, poorer neurocognition and positive emotion regulation were associated with more subsyndromal symptoms and functional impairments. In conclusion, we found no evidence of a neuroprogressive origin of cognitive impairments in the newly diagnosed BD or in their UR. Patients' and UR's impairments in working memory and executive function may reflect a stable cognitive trait-marker of familial risk. Difficulties with positive emotion regulation may be associated with illness progression in BD.

A five-year follow-up of the verbal memory performance of individuals with bipolar disorder and schizophrenia: evidence of unchanging deficits under treatment

OBJECTIVE

Bipolar disorder (BD) and schizophrenia (SZ) are chronic and heterogeneous mental disorders that present cognitive and functional impairments. Verbal memory is considered an important predictor of functioning and a domain vulnerable to the aging process. However, only few studies investigate the progression of memory longitudinally in BD and SZ, especially in lower- and middle-income countries. Therefore, we aim to evaluate the course of verbal memory in individuals with BD and SZ.

METHODS

We assessed 31 individuals with BD and 27 individuals with SZ under treatment at outpatient clinics at baseline and after five years. They were assessed through a sociodemographic questionnaire, memory and estimated IQ (eIQ) instruments, and clinical scales.

RESULTS

Individuals with SZ showed worse verbal memory performance in comparison to BD, however, we did not observe changes over time within patient groups. Individuals with BD with higher eIQ showed a better verbal memory performance, while no effect of eIQ was found for subjects with SZ.

CONCLUSION

Patients with SZ and BD showed different levels of verbal memory impairment, although they had similar unchanging trajectories after 5 years under psychiatric treatment. This finding indicates a relative stable cognitive course for both disorders.

Cognitive functioning in late life affective disorders: Comparing older adults with bipolar disorder, late life depression and healthy controls

INTRODUCTION

Both older age bipolar disorder (OABD) and late life depression (LLD) have been associated with cognitive dysfunction. It is unclear how cognitive functioning differs between these disorders and what the influence of current depressive symptoms is.

METHODS

We compared OABD (n = 148), LLD (n = 378) and healthy controls (HC) (n = 132) on cognitive functioning. Cognitive functioning was measured by an extensive neuropsychological assessment, and divided into four domains: episodic memory, processing speed, interference inhibition and working memory. Separate linear regression analyses were conducted with OABD as reference category, controlling for age, gender, level of education and severity of depressive symptoms.

RESULTS

Our findings show that OABD and LLD patients exhibit more cognitive dysfunction than HC, with OABD showing worst cognitive functioning on all cognitive domains, except for interference inhibition. These differences remained significant, even after controlling for the effect of depressive symptoms at the time of testing.

DISCUSSION

Our findings suggest that cognitive dysfunction in OABD is more severe in magnitude albeit in the same domains as in LLD. This difference cannot be fully explained by the severity of depressive symptoms. Future research should focus on other disease characteristics and how these characteristics are associated with the complex concept of cognitive functioning in both OABD and LLD.

Neurocognitive correlates of the varied domains of outcomes at 20 year follow-up of first-episode psychosis

Little is known about long-term outcomes of the first episode of psychosis (FEP) other than in the symptomatic domain. We hypothesised that cognitive impairment is associated with poorer multi-domain outcomes at a long-term follow-up of FEP patients. We followed-up 172 FEP patients for a mean of 20.3 years. Ten outcome dimensions were assessed (symptomatic, functional and personal recovery, social disadvantage, physical health, suicide attempts, number of episodes, current drug use, chlorpromazine equivalent doses (CPZ), and schizophrenia/schizoaffective disorder final diagnosis). Cognition was assessed at follow-up. Processing speed and verbal memory deficits showed significant associations with poor outcomes on symptomatic, social functioning, social disadvantage, higher number of episodes, and higher CPZ. Significant associations were found between visual memory impairments were significantly associated with low symptomatic and functional recovery, between attentional deficits and a final diagnosis of schizophrenia/schizoaffective disorder, and between social cognition deficits and poor personal recovery.Lower cognitive global scores were significantly associated with all outcome dimensions except for drug abuse and physical status. Using multiple outcome dimensions allowed for the inclusion of the patients' perspective and other commonly neglected outcome measures. Taken together, cognitive impairment in FEP patients is strongly related to poor performance on several outcome dimensions beyond symptomatic remission.

Peripheral insulin sensitivity predicting cognitive function in euthymic bipolar disorder patients

OBJECTIVE

High prevalence of insulin resistance (IR) has been reported in bipolar disorder (BD) patients. Importantly, impaired insulin sensitivity could modulate the course and treatment outcome in BD. Here, we hypothesized that insulin sensitivity could be potentially associated with the neurocognitive trajectory in euthymic BD. We aimed to examine differences in insulin sensitivity and executive function between BD patients and controls.

METHODS

Sixty-two patients with BD receiving mood stabilizer treatment and 62 controls, matching age, sex, and body mass index, were recruited in this study. Insulin sensitivity was estimated using the homeostasis model assessment of insulin resistance (HOMA-IR). The Wisconsin card-sorting test (WCST) was applied to test participants' ability to shift cognitive set. Group differences were measured and multivariate regression analysis was performed to examine relationships among factors.

RESULTS

The results indicated that the HOMA-IR (P = .048) value in the patients with BD were significantly higher than those in controls. With regards to executive function, the BD patients performed significantly poorer than the control subjects (P < .05). Moreover, the interaction effect between BD diagnosis and HOMA-IR value on the WCST-preservation errors was significant (P = .01), and post-hoc analyses showed that the cognitive abilities were worse in the BD patients with a higher IR than in the others groups.

CONCLUSION

Insulin sensitivity is associated with the neurocognitive performance in euthymic BD patients. Although the underlying mechanisms remain unclear, interventions to improve insulin sensitivity could potentially improve the functional outcome of BD.

Lifetime and point prevalence of psychotic symptoms in adults with bipolar disorders: a systematic review and meta-analysis

Psychotic symptoms, that we defined as delusions or hallucinations, are common in bipolar disorders (BD). This systematic review and meta-analysis aims to synthesise the literature on both lifetime and point prevalence rates of psychotic symptoms across different BD subtypes, including both BD type I (BDI) and BD type II (BDII). We performed a systematic search of Medline, PsycINFO, Embase and Cochrane Library until 5 August 2021. Fifty-four studies (N = 23 461) of adults with BD met the predefined inclusion criteria for evaluating lifetime prevalence, and 24 studies (N = 6480) for evaluating point prevalence. Quality assessment and assessment of publication bias were performed. Prevalence rates were calculated using random effects meta-analysis, here expressed as percentages with a 95% confidence interval (CI). In studies of at least moderate quality, the pooled lifetime prevalence of psychotic symptoms in BDI was 63% (95% CI 57.5-68) and 22% (95% CI 14-33) in BDII. For BDI inpatients, the pooled lifetime prevalence was 71% (95% CI 61-79). There were no studies of community samples or inpatient BDII. The pooled point prevalence of psychotic symptoms in BDI was 54% (95 CI 41-67). The point prevalence was 57% (95% CI 47-66) in manic episodes and 13% (95% CI 7-23.5) in depressive episodes. There were not enough studies in BDII, BDI depression, mixed episodes and outpatient BDI. The pooled prevalence of psychotic symptoms in BDI may be higher than previously reported. More studies are needed for depressive and mixed episodes and community samples.Prospero registration number: CRD 42017052706.

Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review

BACKGROUND

Lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment. However, despite a considerable amount of research, the impact of psychotic symptoms on BD remains unclear, and there are very few systematic reviews on the subject.

AIM

To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. An electronic literature search of six English-language databases and a manual search was undertaken to identify published articles on psychotic symptoms in BD from January 1940 to December 2021. Combinations of the relevant Medical Subject Headings terms were used to search for these studies. Articles were selected after a screening phase, followed by a review of the full texts of the articles. Assessment of the methodological quality of the studies and the risk of bias was conducted using standard tools.

RESULTS

This systematic review included 339 studies of patients with BD. Lifetime psychosis was found in more than a half to two-thirds of the patients, while current psychosis was found in a little less than half of them. Delusions were more common than hallucinations in all phases of BD. About a third of the patients reported first-rank symptoms or mood-incongruent psychotic symptoms, particularly during manic episodes. Psychotic symptoms were more frequent in bipolar type I compared to bipolar type II disorder and in mania or mixed episodes compared to bipolar depression. Although psychotic symptoms were not more severe in BD, the severity of the illness in psychotic BD was consistently greater. Psychosis was usually associated with poor insight and a higher frequency of agitation, anxiety, and hostility but not with psychiatric comorbidity. Psychosis was consistently linked with increased rates and the duration of hospitalizations, switching among patients with depression, and poorer outcomes with mood-incongruent symptoms. In contrast, psychosis was less likely to be accompanied by a rapid-cycling course, longer illness duration, and heightened suicidal risk. There was no significant impact of psychosis on the other parameters of course and outcome.

CONCLUSION

Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.

Cognitive subgroups and their longitudinal trajectories in bipolar disorder

INTRODUCTION

Cognitive functioning in bipolar disorder is heterogeneous with evidence for multiple subgroups. However, cognitive subgroup change patterns over time remains unknown. While prior work suggests minimal differences in cognitive functioning patterns over time between those with bipolar disorder and controls, group-based analyses may obscure unique subgroup-based changes.

MATERIAL AND METHODS

Participants diagnosed with bipolar disorder (I, II, NOS; n = 568) and unaffected controls (n = 234) completed baseline, one- and five-year neuropsychological assessments. Data reduction techniques were used to limit the number of neuropsychological variables. Bipolar disorder participant baseline neuropsychological data were entered into hierarchical cluster analyses and resultant clusters were entered in multilevel models, which tested for differences in baseline and longitudinal cognitive changes in cognition among the cluster groups and with controls.

RESULTS

Results were consistent with bipolar disorder participants forming three subgroups with high (n = 209), mid (n = 259), and low (n = 100) cognition. These groups were associated with unique clinical characteristics. Multilevel models demonstrated that over a five-year period, the low group improved, relative to the high and mid groups, and with controls, in auditory memory. Over the five-year period, the mid group, in comparison with the high group, improved in visual memory; additionally, the high group remained stable, in comparison with a slight decline in the control group, in inhibitory control.

CONCLUSION

These results demonstrate that cognition-based subgroups of bipolar disorder participants have minimal differences in their longitudinal course in relation to each other and with unaffected controls.

Aging in bipolar disorder: Cognitive performance and clinical factors based on an adulthood-lifespan perspective

BACKGROUND

The evolution of cognitive performance throughout the lifespan in bipolar disorder (BD) is understudied. This cross-sectional study aims to describe the cognitive performance across age groups.

METHODS

A sample of 654 participants was recruited for this study (BD = 432 and healthy controls -HC- =222). Three subgroups, divided according to age range (18 to 35, 36 to 49, and ≥50 years old) were analyzed after administering a comprehensive neuropsychological battery including six cognitive domains. Demographic, clinical, and psychosocial functioning data were also analyzed. Generalized linear models (GLM) with age, diagnostic group, and age × group as main effects were carried out to examine their potential association on cognitive domains. Subsequently, a GLM in the BD sample was conducted to analyze interactions of several clinical variables by age on each cognitive domain.

RESULTS

Main effects of diagnostic group and age were found in all cognitive domains. Significant group × age effect interaction was found for attention domain (p = 0.02) demonstrating a worse cognitive evolution across age in BD, driven by older age, but not in HC. Significant interaction effects of higher number of manic episodes and older age were also found in attention and verbal memory. Older age was also associated with a longer duration of illness, higher number of episodes, more somatic comorbidities, and poorer psychosocial functioning.

CONCLUSIONS

These results suggest that older age was associated with a selective cognitive decline in BD in the attentional domain. These findings highlight the importance of developing interventions targeting cognitive dysfunction throughout the BD adulthood lifespan.

Randomised controlled cognition trials in remitted patients with mood disorders published between 2015 and 2021: A systematic review by the International Society for Bipolar Disorders Targeting Cognition Task Force

BACKGROUND

Cognitive impairments are an emerging treatment target in mood disorders, but currently there are no evidence-based pro-cognitive treatments indicated for patients in remission. With this systematic review of randomised controlled trials (RCTs), the International Society for Bipolar Disorders (ISBD) Targeting Cognition Task force provides an update of the most promising treatments and methodological recommendations.

METHODS

The review included RCTs of candidate pro-cognitive interventions in fully or partially remitted patients with major depressive disorder or bipolar disorder. We followed the procedures of the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) 2020 statement. Searches were conducted on PubMed/MEDLINE, PsycInfo, EMBASE and Cochrane Library from January 2015, when two prior systematic reviews were conducted, until February 2021. Two independent authors reviewed the studies with the Revised Cochrane Collaboration's Risk of Bias tool for Randomised trials.

RESULTS

We identified 16 RCTs (N = 859) investigating cognitive remediation (CR; k = 6; N = 311), direct current or repetitive magnetic stimulation (k = 3; N = 127), or pharmacological interventions (k = 7; N = 421). CR showed most consistent cognitive benefits, with two trials showing improvements on primary outcomes. Neuromodulatory interventions revealed no clear efficacy. Among pharmacological interventions, modafinil and lurasidone showed early positive results. Sources of bias included small samples, lack of pre-screening for objective cognitive impairment, no primary outcome and no information on allocation sequence masking.

CONCLUSIONS

Evidence for pro-cognitive treatments in mood disorders is emerging. Recommendations are to increase sample sizes, pre-screen for impairment in targeted domain(s), select one primary outcome, aid transfer to real-world functioning, investigate multimodal interventions and include neuroimaging.

Combined influence of medication and symptom severity on visual processing in bipolar disorder

Previous studies have reported visual impairments in patients with bipolar disorder (BPD), but unclear were whether clinical variables would be associated with those disturbances. Here, we investigate the relationship between visual functioning, in terms of color discrimination, and the impact of BPD duration, mood state, and the patients' medication. Forty-five participants (25-45 years old) were recruited for this study. Color discrimination was performed using the Cambridge Colour Test. Serial multiple mediations were run to investigate the assumption of association between color discrimination and the clinical variables. Our findings showed that, compared with healthy controls, BPD patients' performance was worse for the Protan, Deutan, and Tritan vectors, revealing deterioration of color discrimination. In addition, the mediation analyses revealed a strong direct (p < .001) and moderate-to-high indirect effects (p < .01) of medication and symptom severity on color discrimination. Overall, both longer the duration of the disease and greater the symptom severity of BPD patients resulted in worse performance. It highlights the importance of examining the wider clinical context of an affective disorder to understand how it affects visual processing in this population.

Associations between cognition and subsequent mood episodes in patients with bipolar disorder and their unaffected relatives: A systematic review

BACKGROUND

Bipolar disorder (BD) is highly recurrent and prevention of relapse and illness onset is an urgent treatment priority. This systematic review examined whether cognitive assessments can aid prediction of recurrence in patients with BD and/or illness onset in individuals at familial risk.

METHODS

The review included longitudinal studies of patients with BD or individuals at familial risk of mood disorder that examined the association between cognitive functions and subsequent relapse or illness onset, respectively. We followed the procedures of the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) 2020 statement. Searches were conducted on PubMed/MEDLINE, EMBASE and PsychInfo databases from inception up until May 10th 2021.

RESULTS

We identified 19 eligible studies; 12 studies investigated cognitive predictors of recurrence in BD (N = 36-76) and seven investigated cognitive predictors of illness onset in at-risk individuals (N = 84-234). In BD, general cognitive impairment, poorer verbal memory and executive function and positive bias were associated with subsequent (hypo)manic relapse -but with not depressive relapse or mood episodes in general. In first-degree relatives, impairments in attention, verbal memory and executive functions and positive bias were associated with subsequent illness onset.

LIMITATIONS

The findings should be considered preliminary given the small-to-moderate sample sizes and scarcity of studies.

CONCLUSIONS

Subject to replication, the associations between cognitive impairment and (hypo)mania relapse and illness onset may provide a platform for personalised treatment and prophylactic strategies.

The long-term course of cognition in bipolar disorder: a systematic review and meta-analysis of patient-control differences in test-score changes

Neuropsychological impairment represents a key aspect of bipolar disorder (BD) that is evident even in early-course patients and is a strong predictor of functional outcomes among those affected. Previous meta-analyses of longitudinal studies suggest that BD-related cognitive deficits may not progress along the course of the disorder. However, short test-retest periods were used in most primary studies and comparisons with healthy controls were limited. The aim of this review was to synthesize the findings of research reports comparing long-term neurocognitive trajectories between BD patients and healthy individuals. PubMed, PsycINFO, and Scopus databases were searched from inception through July 2021. Publications were considered for inclusion if they reported cognitive test scores of BD patients and healthy controls at two different time points, with a minimum test-retest interval of 5 years. Fifteen studies compared the long-term course of cognition in BD patients with that of healthy controls. Ten of these were included in the quantitative analysis and involved 540 BD patients and 644 healthy individuals (mean follow-up period: 8.9 years). Patient-control effect sizes (standardized mean differences) were calculated for test-score changes in 24 neuropsychological variables and combined by means of meta-analytic procedures. No significant differences were found between patients and controls regarding long-term cognitive outcomes. These findings are consistent with previous shorter-term longitudinal meta-analyses and do not provide evidence for progressive cognitive deterioration in most bipolar individuals. Future studies should address the longitudinal course of cognition in different subgroups of BD patients and its prognostic and therapeutic value.

Cognitive performance in older-age bipolar disorder: Investigating psychiatric characteristics, cardiovascular burden and psychotropic medication

OBJECTIVE

This study aimed to explore a large range of candidate determinants of cognitive performance in older-age bipolar disorder (OABD).

METHODS

A cross-sectional study was performed in 172 BD patients aged ≥50 years. Demographics, psychiatric characteristics and psychotropic medication use were collected using self-report questionnaires and structured interviews. The presence of cardiovascular risk factors was determined by combining information from structured interviews, physical examination and laboratory assessments. Cognitive performance was investigated by an extensive neuropsychological assessment of 13 tests, covering the domains of attention, learning/ memory, verbal fluency and executive functioning. The average of 13 neuropsychological test Z-scores resulted in a composite cognitive score. A linear multiple regression model was created using forward selection with the composite cognitive score as outcome variable. Domain cognitive scores were used as secondary outcome variables.

RESULTS

The final multivariable model (N = 125), which controlled for age and education level, included number of depressive episodes, number of (hypo)manic episodes, late onset, five or more psychiatric admissions, lifetime smoking, metabolic syndrome and current use of benzodiazepines. Together, these determinants explained 43.0% of the variance in composite cognitive score. Late onset and number of depressive episodes were significantly related to better cognitive performance whereas five or more psychiatric admissions and benzodiazepine use were significantly related to worse cognitive performance.

CONCLUSION

Psychiatric characteristics, cardiovascular risk and benzodiazepine use are related to cognitive performance in OABD. Cognitive variability in OABD thus seems multifactorial. Strategies aimed at improving cognition in BD should include cardiovascular risk management and minimizing benzodiazepine use.

The effect of systemic antidepressant treatments in early stage on neurocognitive function of euthymic bipolar patients initiated with a depressive onset: An observational, cross-sectional, single-blind study protocol

OBJECTIVES

Patients with bipolar disorder (BD) have a wide range of neurocognitive dysfunction even in euthymic state, leading to impaired psychosocial function and reduced quality of life. However, the understanding on risk factors related to neurocognitive impairment in such group of people is limited. In view of significantly delayed diagnosis of BD and common use of antidepressants prior to the BD diagnosis, the study aims to clarify whether systemic antidepressant use in early stage, defined as from the initial depressive episode to the diagnosis of BD, could impact neurocognitive function of euthymic bipolar patients.

METHODS

It is an observational, cross-sectional, single-blind trial, making a comparison in neurocognitive function between euthymic bipolar patients who had a depressive episode as initial onset and being with and without systemic antidepressant treatments in early stage (n = 62 and 62, respectively); secondary outcomes include the impact of systemic antidepressant use on global function, quality of life, sleep quality, positive and negative affect, and peripheral level of neuron-specific enolase.

DISCUSSION

The study will provide a comprehensive and in-depth understanding on the effect of systemic antidepressant treatments in early stage in such group of patients. It is expected to better guide the related prevention and treatment work of BD management.

TRIAL REGISTRATION

The study was registered on Clinicaltrials.gov with protocol ID (TJAH2020-18) and clinicaltrials.gov ID (NCT04564573).

Automatic Diagnosis of Bipolar Disorder Using Optical Coherence Tomography Data and Artificial Intelligence

Background: The aim of this study is to explore an objective approach that aids the diagnosis of bipolar disorder (BD), based on optical coherence tomography (OCT) data which are analyzed using artificial intelligence. Methods: Structural analyses of nine layers of the retina were analyzed in 17 type I BD patients and 42 controls, according to the areas defined by the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. The most discriminating variables made up the feature vector of several automatic classifiers: Gaussian Naive Bayes, K-nearest neighbors and support vector machines. Results: BD patients presented retinal thinning affecting most layers, compared to controls. The retinal thickness of the parafoveolar area showed a high capacity to discriminate BD subjects from healthy individuals, specifically for the ganglion cell (area under the curve (AUC) = 0.82) and internal plexiform (AUC = 0.83) layers. The best classifier showed an accuracy of 0.95 for classifying BD versus controls, using as variables of the feature vector the IPL (inner nasal region) and the INL (outer nasal and inner inferior regions) thickness. Conclusions: Our patients with BD present structural alterations in the retina, and artificial intelligence seem to be a useful tool in BD diagnosis, but larger studies are needed to confirm our findings.

The Heterogeneity of Longitudinal Cognitive Decline in Euthymic Bipolar I Disorder With Clinical Characteristics and Functional Outcomes

We characterized the heterogeneity and risk factors of cognitive decline in euthymic bipolar disorder (BD), and their magnitude of associations with subjective daily functions. In this retrospective cohort, BD type I patients (N = 128) were followed for an average of 6.5 years. Intelligence quotient (IQ) at index date was recorded, and premorbid IQ was estimated. We used Brief Assessment of Cognition in Affective Disorders (BAC-A) to assess cognition at follow-up. We evaluated current functions with World Health Organization Disability Assessment Schedule 2.0. Clinical and sociodemographic factors were examined for their independent effects on longitudinal cognitive decline. In addition, we employed multivariate adaptive regression spline to detect inflection points for the nature of slope changes in cognitive decline among BD patients. During follow-up years, 21 BD patients (16.4%) showed longitudinal cognitive decline. In cognitive decline group, all cognitive domains of BAC-A were significantly worsened. We found that density of episodes with psychotic features was an independent risk factor for cognitive decline after adjusted for age, gender and dose of mood stabilizer. After the age of 42 years, a steeper cognitive change was observed in the cognitive decline group. The correlation pattern between cognitive domains and functional outcomes differed between patients with and without cognitive decline. The present study characterized cognitive heterogeneity longitudinally in BD patients. As density of episodes play roles for cognitive decline, our results emphasize the importance of relapse prevention. Our findings provide hints for future personalized interventions and facilitating genetic and biological studies for dissecting the heterogeneity of bipolar illness.

Long-term trajectory of cognitive performance in people with bipolar disorder and controls: 6-year longitudinal study

BACKGROUND

Cross-sectional studies have found impaired cognitive functioning in patients with bipolar disorder, but long-term longitudinal studies are scarce.

AIMS

The aims of this study were to examine the 6-year longitudinal course of cognitive functioning in patients with bipolar disorder and healthy controls. Subsets of patients were examined to investigate possible differences in cognitive trajectories.

METHOD

Patients with bipolar I disorder (n = 44) or bipolar II disorder (n = 28) and healthy controls (n = 59) were tested with a comprehensive cognitive test battery at baseline and retested after 6 years. We conducted repeated measures ANCOVAs with group as a between-subject factor and tested the significance of group and time interaction.

RESULTS

By and large, the change in cognitive functioning between baseline and follow-up did not differ significantly between participants with bipolar disorder and healthy controls. Comparing subsets of patients, for example those with bipolar I and II disorder and those with and without manic episodes during follow-up, did not reveal subgroups more vulnerable to cognitive decline.

CONCLUSIONS

Cognitive performance remained stable in patients with bipolar disorder over a 6-year period and evolved similarly to healthy controls. These findings argue against the notion of a general progressive decline in cognitive functioning in bipolar disorder.

Progression of the functional deficit in a group of patients with bipolar disorder: a cluster analysis based on longitudinal data

We aimed to examine the trajectory of psychosocial functioning in a sample of euthymic patients with bipolar disorder (BD) throughout a 5-year follow-up. Ninety-nine euthymic bipolar patients and 40 healthy controls (HC) were included. A neurocognitive assessment (17 neurocognitive measures grouped in 6 domains) was carried out at baseline. The split version of the Global Assessment of Functioning scale (GAF-F) and the Functioning Assessment Short Test (FAST) were used to examine psychosocial functioning at baseline (T1), and after a 5-year follow-up (T2). The statistical analysis was performed through repeated measures ANOVA and hierarchical cluster analysis based on the GAF-F and the FAST scores at T1 and T2. Eighty-seven patients (87.9%) were evaluated at T2. The cluster analysis identified two groups of patients. The first group included 44 patients (50.6%) who did not show a progression of the functional impairment (BD-NPI). The second cluster, which included 43 patients (49.4%), was characterized by a progression of the functional impairment (BD-PI). The BD-PI had a higher number of relapses and a higher number of hospitalizations during the follow-up period, as well as worse neurocognitive functioning than the BD-NPI. The repeated measures ANOVA confirmed that the psychosocial performance of BD-NPI is stable while there was a progression of the functional deterioration in BD-PI. The trajectory of the psychosocial functioning of patients with BD is not homogeneous. Our results suggest that in at least one subset of patients with BD, which might account for half of the patients, the disease has a progressive course.

Increased Risk of Dementia Among Veterans With Bipolar Disorder or Schizophrenia Receiving Care in the VA Health System

OBJECTIVE

The Veterans Health Administration (VHA) provides a continuum of care over the life course. Among U.S. adults, bipolar disorder and schizophrenia are associated with increased risk of dementia. To inform service planning, this study assessed the incidence of dementia among veteran VHA patients with bipolar disorder or schizophrenia, with adjustment for comorbid medical conditions.

METHODS

Using data from the VHA Corporate Data Warehouse, the authors identified all veterans who received VHA care in 2004 and 2005 without a dementia diagnosis and who were alive and between ages 18 and 100 as of January 1, 2006. Individuals were categorized as having bipolar disorder, schizophrenia, or neither condition on the basis of diagnoses in 2004-2005. Among ongoing VHA users, incidence of dementia was assessed for up to 10 years (2006-2015).

RESULTS

The cohort included 3,648,852 individuals. After analyses controlled for baseline comorbid general medical conditions and substance use disorders, the incidence rate ratios (IRRs) for dementia were 2.92 for those with schizophrenia and 2.26 for those with bipolar disorder, compared with VHA patients with neither condition.

CONCLUSIONS

Among veterans receiving VHA care, diagnoses of bipolar disorder and schizophrenia were each associated with increased risk of receiving a new diagnosis of dementia, even when analyses controlled for baseline medical comorbidities. IRRs were elevated for patients with either condition, compared with those with neither condition, and highest for those with schizophrenia. VHA clinicians should evaluate patients for dementia when signs or symptoms of cognitive impairment are present.

Three-year longitudinal cognitive functioning in patients recently diagnosed with bipolar disorder

OBJECTIVE

The longitudinal course of neuropsychological functioning after the first manic episode in bipolar disorder is unknown. The present study evaluated cognitive change in bipolar disorder in the first 3 years after the initial manic episode.

METHODS

Ninety-one newly diagnosed patients with bipolar disorder and 61 demographically similar healthy participants received a neuropsychological evaluation assessing multiple cognitive domains at baseline, 1-year, and 3-year time points. Patients also received clinical assessments including mood ratings at all time points.

RESULTS

Patients showed deficits in all domains at baseline, but similar longitudinal trajectories across time relative to healthy participants in most cognitive domains. For processing speed, patients showed more gains than controls from baseline to 1 year, but these gains stabilized thereafter. Patients with alcohol/substance abuse showed an initial delay but subsequent recovery in executive functioning. Patients who discontinued antipsychotic treatment showed better cognitive outcomes in verbal memory.

CONCLUSION

Appropriately treated patients with bipolar disorder showed favorable cognitive outcome in the first 3 years after experiencing an initial manic episode, arguing against cognitive neuroprogression at this stage of the illness. Discontinuation of antipsychotic treatment may be associated with better cognitive outcomes, but clarification of the role of antipsychotics on cognitive functioning requires further investigation.

Cognitive Impairment in Patients with Bipolar Disorder: Impact of Pharmacological Treatment

Bipolar disorder is an illness characterised by periods of elated and depressed mood. These mood episodes are associated with changes in cognitive function and there is evidence to suggest that cognitive dysfunction persists during euthymia. The extent to which this is a function of the illness or a result of treatment is less clear. In this narrative review, we explore the impact of commonly used medications for bipolar disorder on cognitive function. Specific impairments in executive function and verbal memory have been noted in bipolar disorder. The impact of pharmacological treatments upon cognitive function is mixed with a number of studies reporting conflicting results. Interpretation of the data is further complicated by the variety of cognitive tests employed, study design, the relatively small numbers of patients included and confounding by indication. Overall, there is some evidence that while lithium improves some cognitive domains, it impedes others. Antipsychotics may be deleterious to cognition, although this may relate to the patient population in which they are prescribed. Sodium valproate is also associated with worse cognitive outcomes, while the impact of other antiepileptics is unclear. Overall the quality of evidence is poor and is derived from a relatively small number of studies that often do not account for the significant heterogeneity of the disorder or common comorbidities. The use of consistent methodologies and measures of cognition across studies, as well as in naturalistic settings, would enable more certain conclusions to be drawn.

Lifetime Psychotic Symptoms, Subthreshold Depression and Cognitive Impairment as Barriers to Functional Recovery in Patients with Bipolar Disorder

(1) Background: bipolar disorder (BD) is a chronic disease that often leads to functional impairment. The objective of this study is to elucidate which variables are associated with better functional outcomes in a sample of euthymic patients with BD. (2) Methods: patients were recruited at the Hospital Clinic of Barcelona and they underwent a clinical interview, a functional assessment, and a comprehensive neuropsychological evaluation. After that, patients were divided into two groups according to the Functioning Assessment Short Test total score: functionally remitted vs. functionally impaired. Following this, a multivariate logistic regression was run in order to identify clinical, demographic and cognitive factors associated with functional remission. (3) Results: a total of 420 euthymic patients with BD were assessed for this study, distributed as follows: functionally remitted (n = 221) and functionally impaired (n = 199). Finally, the multivariate logistic regression revealed that only five variables significantly contributed to the model, including: lifetime history of psychotic symptoms (the variable that contributed the most to the model), followed by the Hamilton Depression total score, and cognitive performance (executive functions and verbal memory). (4) Conclusions: treatments to ensure a good functional outcome in BD should specially prevent psychosis, target subthreshold depressive symptoms and enhance cognition, more specifically executive functions and verbal memory.