The neuropathology of bipolar disorder: systematic review and meta-analysis

A Magnetic Resonance Spectroscopy Study on Polarity Subphenotypes in Bipolar Disorder

Although magnetic resonance spectroscopy (MRS) has provided in vivo measurements of brain chemical profiles in bipolar disorder (BD), there are no data on clinically and therapeutically important onset polarity (OP) and predominant polarity (PP). We conducted a proton MRS study in BD polarity subphenotypes, focusing on emotion regulation brain regions. Forty-one euthymic BD patients stratified according to OP and PP and sixteen healthy controls (HC) were compared. 1H-MRS spectra of the anterior and posterior cingulate cortex (ACC, PCC), left and right hippocampus (LHIPPO, RHIPPO) were acquired at 3.0T to determine metabolite concentrations. We found significant main effects of OP in ACC mI, mI/tNAA, mI/tCr, mI/tCho, PCC tCho, and RHIPPO tNAA/tCho and tCho/tCr. Although PP had no significant main effects, several medium and large effect sizes emerged. Compared to HC, manic subphenotypes (i.e., manic-OP, manic-PP) showed greater differences in RHIPPO and PCC, whereas depressive suphenotypes (i.e., depressive-OP, depressive-PP) in ACC. Effect sizes were consistent between OP and PP as high intraclass correlation coefficients (ICC) were confirmed. Our findings support the utility of MRS in the study of the neurobiological underpinnings of OP and PP, highlighting that the regional specificity of metabolite changes within the emotion regulation network consistently marks both polarity subphenotypes.

Bipolar disorders and schizophrenia: discrete disorders?

Background

With similarities in heritability, neurobiology and symptomatology, the question has been raised whether schizophrenia and bipolar disorder are truly distinctive disorders or belong to a continuum. This narrative review summarizes common and distinctive findings from genetics, neuroimaging, cognition and clinical course that may help to solve this ethiopathogenetic puzzle.

Methods

The authors conducted a literature search for papers listed in PubMed and Google Scholar, using the search terms "schizophrenia" and "bipolar disorder" combined with different terms such as "genes", "neuroimaging studies", "phenomenology differences", "cognition", "epidemiology". Articles were considered for inclusion if they were written in English or Spanish, published as full articles, if they compared subjects with schizophrenia and bipolar disorder, or subjects with either disorder with healthy controls, addressing differences between groups.

Results

Several findings support the hypothesis that schizophrenia and bipolar disorder are discrete disorders, yet some overlapping of findings exists. The evidence for heritability of both SZ and BD is obvious, as well as the environmental impact on individual manifestations of both disorders. Neuroimaging studies support subtle differences between disorders, it appears to be rather a pattern of irregularities than an unequivocally unique finding distinguishing schizophrenia from bipolar disorder. The cognitive profile displays differences between disorders in certain domains, such as premorbid intellectual functioning and executive functions. Finally, the timing and trajectory of cognitive impairment in both disorders also differs.

Conclusion

The question whether SZ and BD belong to a continuum or are separate disorders remains a challenge for further research. Currently, our research tools may be not precise enough to carve out distinctive, unique and undisputable differences between SZ and BD, but current evidence favors separate disorders. Given that differences are subtle, a way to overcome diagnostic uncertainties in the future could be the application of artificial intelligence based on BigData.

Limitations

Despite the detailed search, this article is not a full and complete review of all available studies on the topic. The search and selection of papers was also limited to articles in English and Spanish. Selection of papers and conclusions may be biased by the personal view and clinical experience of the authors.

Comparing stem cells, transdifferentiation and brain organoids as tools for psychiatric research

The inaccessibility of neurons coming directly from patients has hindered our understanding of mental illnesses at the cellular level. To overcome this obstacle, six different cellular approaches that carry the genetic vulnerability to psychiatric disorders are currently available: Olfactory Neuroepithelial Cells, Mesenchymal Stem Cells, Pluripotent Monocytes, Induced Pluripotent Stem Cells, Induced Neuronal cells and more recently Brain Organoids. Here we contrast advantages and disadvantages of each of these six cell-based methodologies. Neuronal-like cells derived from pluripotent monocytes are presented in more detail as this technique was recently used in psychiatry for the first time. Among the parameters used for comparison are; accessibility, need for reprograming, time to deliver differentiated cells, differentiation efficiency, reproducibility of results and cost. We provide a timeline on the discovery of these cell-based methodologies, but, our main goal is to assist researchers selecting which cellular approach is best suited for any given project. This manuscript also aims to help readers better interpret results from the published literature. With this goal in mind, we end our work with a discussion about the differences and similarities between cell-based techniques and postmortem research, the only currently available tools that allow the study of mental illness in neurons or neuronal-like cells coming directly from patients.

Astrocytes in human central nervous system diseases: a frontier for new therapies

Astroglia are a broad class of neural parenchymal cells primarily dedicated to homoeostasis and defence of the central nervous system (CNS). Astroglia contribute to the pathophysiology of all neurological and neuropsychiatric disorders in ways that can be either beneficial or detrimental to disorder outcome. Pathophysiological changes in astroglia can be primary or secondary and can result in gain or loss of functions. Astroglia respond to external, non-cell autonomous signals associated with any form of CNS pathology by undergoing complex and variable changes in their structure, molecular expression, and function. In addition, internally driven, cell autonomous changes of astroglial innate properties can lead to CNS pathologies. Astroglial pathophysiology is complex, with different pathophysiological cell states and cell phenotypes that are context-specific and vary with disorder, disorder-stage, comorbidities, age, and sex. Here, we classify astroglial pathophysiology into (i) reactive astrogliosis, (ii) astroglial atrophy with loss of function, (iii) astroglial degeneration and death, and (iv) astrocytopathies characterised by aberrant forms that drive disease. We review astroglial pathophysiology across the spectrum of human CNS diseases and disorders, including neurotrauma, stroke, neuroinfection, autoimmune attack and epilepsy, as well as neurodevelopmental, neurodegenerative, metabolic and neuropsychiatric disorders. Characterising cellular and molecular mechanisms of astroglial pathophysiology represents a new frontier to identify novel therapeutic strategies.

The many "Neurofaces" of Prohibitins 1 and 2: Crucial for the healthy brain, dysregulated in numerous brain disorders

Prohibitin 1 (PHB1) and prohibitin 2 (PHB2) are proteins that are nearly ubiquitously expressed. They are localized in mitochondria, cytosol and cell nuclei. In the healthy CNS, they occur in neurons and non-neuronal cells (oligodendrocytes, astrocytes, microglia, and endothelial cells) and fulfill pivotal functions in brain development and aging, the regulation of brain metabolism, maintenance of structural integrity, synapse formation, aminoacidergic neurotransmission and, probably, regulation of brain action of certain hypothalamic-pituitary hormones.With regard to the diseased brain there is increasing evidence that prohibitins are prominently involved in numerous major diseases of the CNS, which are summarized and discussed in the present review (brain tumors, neurotropic viruses, Alzheimer disease, Down syndrome, Fronto-temporal and vascular dementia, dementia with Lewy bodies, Parkinson disease, Huntington disease, Multiple sclerosis, Amyotrophic lateral sclerosis, stroke, alcohol use disorder, schizophrenia and autism). Unfortunately, there is no PHB-targeted therapy available for any of these diseases.

Brain atrophy and cognitive decline in bipolar disorder: Influence of medication use, symptomatology and illness duration

Bipolar disorder (BPD) is a chronic condition characterized by recurrent episodes of mania and depression. To date, the association of biological and psychopathological processes in BPD has not been extensively studied on a cognitive and cortical basis at the same time. We investigated whether brain atrophy (in prefrontal, temporal and occipital cortices) was associated with cognitive, biological and clinical processes in patients with BPD and healthy controls (HCs). A total of 104 participants (56 with BPD) completed tasks that measured attention, memory, information processing speed, inhibitory control, visuospatial working memory and cognitive flexibility. In addition, structural brain scans were obtained using high-resolution MRI. Outcomes of the measurements were examined using robust multiple mediation analyses. BPD patients showed greater cortical atrophy across all regions of interest when compared to HCs, linked to cognitive decline. BPD patients had slower reaction times and markedly increased errors of commission on the tasks. The outcomes were significantly influenced by medication use, symptomatology and illness duration. The findings showcase the complexity of brain structures and networks as well as the physiological mechanisms underlying diverse BPD symptomatology and endophenotypes. These differences were pronounced in patients with BPD, motivating further investigations of pathophysiological mechanisms involved in brain atrophy and cognitive decline.

Prefrontal microglia deficiency during adolescence disrupts adult cognitive functions and synaptic structures: A follow-up study in female mice

The prefrontal cortex (PFC) provides executive top-down control of a variety of cognitive processes. A distinctive feature of the PFC is its protracted structural and functional maturation throughout adolescence to early adulthood, which is necessary for acquiring mature cognitive abilities. Using a mouse model of cell-specific, transient and local depletion of microglia, which is based on intracerebral injection of clodronate disodium salt (CDS) into the PFC of adolescent male mice, we recently demonstrated that microglia contribute to the functional and structural maturation of the PFC in males. Because microglia biology and cortical maturation are partly sexually dimorphic, the main objective of the present study was to examine whether microglia similarly regulate this maturational process in female mice as well. Here, we show that a single, bilateral intra-PFC injection of CDS in adolescent (6-week-old) female mice induces a local and transient depletion (70 to 80% decrease from controls) of prefrontal microglia during a restricted window of adolescence without affecting neuronal or astrocytic cell populations. This transient microglia deficiency was sufficient to disrupt PFC-associated cognitive functions and synaptic structures at adult age. Inducing transient prefrontal microglia depletion in adult female mice did not cause these deficits, demonstrating that the adult PFC, unlike the adolescent PFC, is resilient to transient microglia deficiency in terms of lasting cognitive and synaptic maladaptations. Together with our previous findings in males, the present findings suggest that microglia contribute to the maturation of the female PFC in a similar way as to the prefrontal maturation occurring in males.

Functional connectivity gradients of the cingulate cortex

Heterogeneity of the cingulate cortex is evident in multiple dimensions including anatomy, function, connectivity, and involvement in networks and diseases. Using the recently developed functional connectivity gradient approach and resting-state functional MRI data, we found three functional connectivity gradients that captured distinct dimensions of cingulate hierarchical organization. The principal gradient exhibited a radiating organization with transitions from the middle toward both anterior and posterior parts of the cingulate cortex and was related to canonical functional networks and corresponding behavioral domains. The second gradient showed an anterior-posterior axis across the cingulate cortex and had prominent geometric distance dependence. The third gradient displayed a marked differentiation of subgenual and caudal middle with other parts of the cingulate cortex and was associated with cortical morphology. Aside from providing an updated framework for understanding the multifaceted nature of cingulate heterogeneity, the observed hierarchical organization of the cingulate cortex may constitute a novel research agenda with potential applications in basic and clinical neuroscience.

Gene expression alterations in the postmortem hippocampus from older patients with bipolar disorder - A hypothesis generating study

Bipolar disorder (BD) presents with a progressive course in a subset of patients. However, our knowledge of molecular changes in older BD is limited. In this study, we examined gene expression changes in the hippocampus of BD from the Biobank of Aging Studies to identify genes of interest that warrant further exploration. RNA was extracted from the hippocampus from 11 subjects with BD and 11 age and sex-matched controls. Gene expression data was generated using the SurePrint G3 Human Gene Expression v3 microarray. Rank feature selection was performed to identify a subset of features that can optimally differentiate BD and controls. Genes ranked in the top 0.1% with log₂ fold change >1.2 were identified as genes of interest. Average age of the subjects was 64 years old; duration of disease was 21 years and 82% were female. Twenty-five genes were identified, of which all but one was downregulated in BD. Of these, CNTNAP4, MAP4, SLC4A1, COBL, and NEURL4 had been associated with BD and other psychiatric conditions in previous studies. We believe our findings have identified promising targets to inform future studies aiming to understand the pathophysiology of BD in later life.

Thalamic nuclei volumes in schizophrenia and bipolar spectrum disorders - Associations with diagnosis and clinical characteristics

BACKGROUND

The thalamus is central to brain functions ranging from primary sensory processing to higher-order cognition. Structural deficits in thalamic association nuclei such as the pulvinar and mediodorsal nuclei have previously been reported in schizophrenia. However, the specificity with regards to clinical presentation, and whether or not bipolar disorder (BD) is associated with similar alterations is unclear.

METHODS

We investigated thalamic nuclei volumes in 334 patients with schizophrenia spectrum disorders (SSD) (median age 29 years, 59 % male), 322 patients with BD (30 years, 40 % male), and 826 healthy controls (HC) (34 years, 54 % male). Volumes of 25 thalamic nuclei were extracted from T1-weighted magnetic resonance imaging using an automated Bayesian segmentation method and compared between groups. Furthermore, we explored associations with clinical characteristics across diagnostic groups, including psychotic and mood symptoms and medication use, as well as diagnostic subtype in BD.

RESULTS

Significantly smaller volumes were found in the mediodorsal, pulvinar, and lateral and medial geniculate thalamic nuclei in SSD. Similarly, smaller volumes were found in BD in the same four regions, but mediodorsal nucleus volume alterations were limited to its lateral part and pulvinar alterations to its anterior region. Smaller volumes in BD compared to HC were seen only in BD type I, not BD type II. Across diagnoses, having more negative symptoms was associated with smaller pulvinar volumes.

CONCLUSIONS

Structural alterations were found in both SSD and BD, mainly in the thalamic association nuclei. Structural deficits in the pulvinar may be of relevance for negative symptoms.

Brain Inflammatory Marker Abnormalities in Major Psychiatric Diseases: a Systematic Review of Postmortem Brain Studies

Schizophrenia (SCZ), bipolar disorder (BD), and major depressive disorder (MDD) are common neuropsychiatric disorders that lead to neuroinflammation in the pathogenesis. It is possible to further explore the connection between inflammation in the brain and SCZ, BD, and MDD. Therefore, we systematically reviewed PubMed and Web of Science on brain inflammatory markers measured in SCZ, BD, and MDD postmortem brains. Out of 2166 studies yielded by the search, 46 studies met the inclusion criteria in SCZ, BD, and MDD postmortem brains. The results were variable across inflammatory markers. For example, 26 studies were included to measure the differential expression between SCZ and control subjects. Similarly, seven of the included studies measured the differential expression of inflammatory markers in patients with BD. The heterogeneity from the included studies is not clear at present, which may be caused by several factors, including the measured brain region, disease stage, brain source, medication, and other factors.

Changes in neurofilament light chain protein (NEFL) in children and adolescents with Schizophrenia and Bipolar Disorder: Early period neurodegeneration

AIM

Neurofilament light chain protein (NEFL), is defined as a structural protein which exists particularly in axones of neurons and is released to the cerum in consequence of neuroaxonal damage. The aim of this study is to investigate the peripheral cerumNEFLlevels of children and adolescents with early onset schizophrenia and bipolar disorder.

METHOD

In this study, we evaluated serum levels of NEFL in children and adolescents (13-17 years) with schizophrenia, bipolar disorder and healthy control group. The study is conducted with 35 schizophrenia, 38 bipolar disorder manic episode patients and 40 healthy controls.

RESULTS

The median age of the patient and control groups was 16 (IQR- Interquartile Range: 2). There was no statistical difference in median age (p = 0.52) and gender distribution(p = 0.53) between groups. NEFL levels of the patients with schizophrenia were significantly higher than the controls. NEFL levels of the patients with bipolar disorder were significantly higher than the controls. Serum levels of NEFL of the schizophrenia were higher than the bipolar disorder; however, the difference was not statistically significant.

CONCLUSION

In conclusion, serum NEFL level, as a confidential marker of neural damage, is increased in the children and adolescents with bipolar disorder and schizophrenia. This result may indicatea degenerative period in neurons of children and adolescents with schizophrenia or bipolar disorder and may play a role in the pathophisiology of these disorders. This result shows that there is neuronal damage in both diseases, but neuronal damage may be more in schizophrenia.

The many facets of CD26/dipeptidyl peptidase 4 and its inhibitors in disorders of the CNS - a critical overview

Dipeptidyl peptidase 4 is a serine protease that cleaves X-proline or X-alanine in the penultimate position. Natural substrates of the enzyme are glucagon-like peptide-1, glucagon inhibiting peptide, glucagon, neuropeptide Y, secretin, substance P, pituitary adenylate cyclase-activating polypeptide, endorphins, endomorphins, brain natriuretic peptide, beta-melanocyte stimulating hormone and amyloid peptides as well as some cytokines and chemokines. The enzyme is involved in the maintenance of blood glucose homeostasis and regulation of the immune system. It is expressed in many organs including the brain. DPP4 activity may be effectively depressed by DPP4 inhibitors. Apart from enzyme activity, DPP4 acts as a cell surface (co)receptor, associates with adeosine deaminase, interacts with extracellular matrix, and controls cell migration and differentiation. This review aims at revealing the impact of DPP4 and DPP4 inhibitors for several brain diseases (virus infections affecting the brain, tumours of the CNS, neurological and psychiatric disorders). Special emphasis is given to a possible involvement of DPP4 expressed in the brain.While prominent contributions of extracerebral DPP4 are evident for a majority of diseases discussed herein; a possible role of "brain" DPP4 is restricted to brain cancers and Alzheimer disease. For a number of diseases (Covid-19 infection, type 2 diabetes, Alzheimer disease, vascular dementia, Parkinson disease, Huntington disease, multiple sclerosis, stroke, and epilepsy), use of DPP4 inhibitors has been shown to have a disease-mitigating effect. However, these beneficial effects should mostly be attributed to the depression of "peripheral" DPP4, since currently used DPP4 inhibitors are not able to pass through the intact blood-brain barrier.

Investigating the contribution of cytoarchitecture to diffusion MRI measures in gray matter using histology

Postmortem studies are currently considered a gold standard for investigating brain structure at the cellular level. To investigate cellular changes in the context of human development, aging, or disease treatment, non-invasive in-vivo imaging methods such as diffusion MRI (dMRI) are needed. However, dMRI measures are only indirect measures and require validation in gray matter (GM) in the context of their sensitivity to the underlying cytoarchitecture, which has been lacking. Therefore, in this study we conducted direct comparisons between in-vivo dMRI measures and histology acquired from the same four rhesus monkeys. Average and heterogeneity of fractional anisotropy and trace from diffusion tensor imaging and mean squared displacement (MSD) and return-to-origin-probability from biexponential model were calculated in nine cytoarchitectonically different GM regions using dMRI data. DMRI measures were compared with corresponding histology measures of regional average and heterogeneity in cell area density. Results show that both average and heterogeneity in trace and MSD measures are sensitive to the underlying cytoarchitecture (cell area density) and capture different aspects of cell composition and organization. Trace and MSD thus would prove valuable as non-invasive imaging biomarkers in future studies investigating GM cytoarchitectural changes related to development and aging as well as abnormal cellular pathologies in clinical studies.

Phenotypes, mechanisms and therapeutics: insights from bipolar disorder GWAS findings

Genome-wide association studies (GWAS) have reported substantial genomic loci significantly associated with clinical risk of bipolar disorder (BD), and studies combining techniques of genetics, neuroscience, neuroimaging, and pharmacology are believed to help tackle clinical problems (e.g., identifying novel therapeutic targets). However, translating findings of psychiatric genetics into biological mechanisms underlying BD pathogenesis remains less successful. Biological impacts of majority of BD GWAS risk loci are obscure, and the involvement of many GWAS risk genes in this illness is yet to be investigated. It is thus necessary to review the progress of applying BD GWAS risk genes in the research and intervention of the disorder. A comprehensive literature search found that a number of such risk genes had been investigated in cellular or animal models, even before they were highlighted in BD GWAS. Intriguingly, manipulation of many BD risk genes (e.g., ANK3, CACNA1C, CACNA1B, HOMER1, KCNB1, MCHR1, NCAN, SHANK2 etc.) resulted in altered murine behaviors largely restoring BD clinical manifestations, including mania-like symptoms such as hyperactivity, anxiolytic-like behavior, as well as antidepressant-like behavior, and these abnormalities could be attenuated by mood stabilizers. In addition to recapitulating phenotypic characteristics of BD, some GWAS risk genes further provided clues for the neurobiology of this illness, such as aberrant activation and functional connectivity of brain areas in the limbic system, and modulated dendritic spine morphogenesis as well as synaptic plasticity and transmission. Therefore, BD GWAS risk genes are undoubtedly pivotal resources for modeling this illness, and might be translational therapeutic targets in the future clinical management of BD. We discuss both promising prospects and cautions in utilizing the bulk of useful resources generated by GWAS studies. Systematic integrations of findings from genetic and neuroscience studies are called for to promote our understanding and intervention of BD.

Deficits in auditory and visual steady-state responses in adolescents with bipolar disorder

BACKGROUND

Many aspects of steady-state responses of the brain remain unclear in bipolar disorder (BD) due to the small number of auditory steady-state response (ASSR) studies and the lack of steady-state visual evoked potential (SSVEP) studies on this complex disorder. Therefore, we assessed the patterns of SSVEP and ASSR in adolescents with BD during an active task to detect possible deficits in these important brain responses compared to normal subjects.

METHODS

27 adolescents with BD and 30 healthy adolescents were assessed in this study. The blinking background of the monitor presented at 15 Hz and the tone signal stimulation at 40 Hz evoked SSVEPs and ASSRs, respectively. The phase and amplitude of the steady-state responses were calculated in the auditory and visual conditions.

RESULTS

Patients exhibited a substantially worse performance in the motor control inhibition task during both auditory and visual modalities. Patients showed increased SSVEP amplitude and phase in the frontal region compared to control adolescents. Also, patients exhibited decreased ASSR amplitude in the prefrontal and increased ASSR amplitude in the right-frontal and centro-parietal areas compared to healthy adolescents.

CONCLUSIONS

impairments in the production and preservation of SSVEP and ASSR are evident in BD, implicating abnormalities in visual and auditory pathways. Neurophysiological deficits and worse performance in BD adolescents may imply that visual and auditory pathways cannot well transfer the pertinent information from arriving sensory data to the visual and auditory cortices, and the frontal cortex cannot well integrate incoming signals into a unified and coherent perceptual action.

An Ensemble Hybrid Feature Selection Method for Neuropsychiatric Disorder Classification

Magnetic resonance imagings (MRIs) are providing increased access to neuropsychiatric disorders that can be made available for advanced data analysis. However, the single type of data limits the ability of psychiatrists to distinguish the subclasses of this disease. In this paper, we propose an ensemble hybrid features selection method for the neuropsychiatric disorder classification. The method consists of a 3D DenseNet and a XGBoost, which are used to select the image features from structural MRI images and the phenotypic feature from phenotypic records, respectively. The hybrid feature is composed of image features and phenotypic features. The proposed method is validated in the Consortium for Neuropsychiatric Phenomics (CNP) dataset, where samples are classified into one of the four classes (healthy controls (HC), attention deficit hyperactivity disorder (ADHD), bipolar disorder (BD), and schizophrenia (SD)). Experimental results show that the hybrid feature can improve the performance of classification methods. The best accuracy of binary and multi-class classification can reach 91.22 and 78.62 percent, respectively. We analyze the importance of phenotypic features and image features in different classification tasks. The importance of the structure MRI images is highlighted by incorporating phenotypic features with image features to generate hybrid features. We also visualize the features of three neuropsychiatric disorders and analyze their locations in the brain region.

Serum levels of olanzapine are associated with acute cognitive effects in bipolar disorder

Bipolar (BPD) patients have deficits in cognition, but there are still controversies about the effects of some medications on their cognitive performance. Here, we investigated the relationship between cognition in terms of executive functions, memory, and attention in both first-episode medication-naive BPD patients and BPD patients taking olanzapine. Forty-one healthy controls, 40 unmedicated drug-naive BPD patients, and 34 BPD patients who took only olanzapine were recruited for the study. Cognitive performance was assessed using the Flanker test, Stroop test, and Corsi-block test. Bayesian multivariate regression analysis was run considering maximum robustness to avoid bias and to predict the outcomes. Our results revealed that unmedicated medication-naive BPD patients performed worse than healthy controls and the olanzapine group in some tasks. Additionally, BPD patients who took olanzapine had better cognitive performance than healthy controls and unmedicated BPD patients. The acute cognitive effects were predicted by olanzapine dosage and serum levels (i.e., large effects). The potential pro-cognitive effects of olanzapine in BPD patients should be carefully interpreted by considering various other clinical variables. We expect that our findings will contribute to further research in this area, with the goal of helping other researchers, patients, and the population.

Adolescence is a sensitive period for prefrontal microglia to act on cognitive development

The prefrontal cortex (PFC) is a cortical brain region that regulates various cognitive functions. One distinctive feature of the PFC is its protracted adolescent maturation, which is necessary for acquiring mature cognitive abilities in adulthood. Here, we show that microglia, the brain's resident immune cells, contribute to this maturational process. We find that transient and cell-specific deficiency of prefrontal microglia in adolescence is sufficient to induce an adult emergence of PFC-associated impairments in cognitive functions, dendritic complexity, and synaptic structures. While prefrontal microglia deficiency in adolescence also altered the excitatory-inhibitory balance in adult prefrontal circuits, there were no cognitive sequelae when prefrontal microglia were depleted in adulthood. Thus, our findings identify adolescence as a sensitive period for prefrontal microglia to act on cognitive development.

Pathway-specific contribution of parvalbumin interneuron NMDARs to synaptic currents and thalamocortical feedforward inhibition

Prefrontal cortex (PFC) is a site of information convergence important for behaviors relevant to psychiatric disorders. Despite the importance of inhibitory GABAergic parvalbumin-expressing (PV+) interneurons to PFC circuit function and decades of interest in N-methyl-D-aspartate receptors (NMDARs) in these neurons, examples of defined circuit functions that depend on PV+ interneuron NMDARs have been elusive. Indeed, it remains controversial whether all PV+ interneurons contain functional NMDARs in adult PFC, which has major consequences for hypotheses of the pathogenesis of psychiatric disorders. Using a combination of fluorescent in situ hybridization, pathway-specific optogenetics, cell-type-specific gene ablation, and electrophysiological recordings from PV+ interneurons, here we resolve this controversy. We found that nearly 100% of PV+ interneurons in adult medial PFC (mPFC) express transcripts encoding GluN1 and GluN2B, and they have functional NMDARs. By optogenetically stimulating corticocortical and thalamocortical inputs to mPFC, we show that synaptic NMDAR contribution to PV+ interneuron EPSCs is pathway-specific, which likely explains earlier reports of PV+ interneurons without synaptic NMDAR currents. Lastly, we report a major contribution of NMDARs in PV+ interneurons to thalamus-mediated feedforward inhibition in adult mPFC circuits, suggesting molecular and circuit-based mechanisms for cognitive impairment under conditions of reduced NMDAR function. These findings represent an important conceptual advance that has major implications for hypotheses of the pathogenesis of psychiatric disorders.

Astrocytes in Bipolar Disorder

Bipolar disorder (BD) is a complex group of neuropsychiatric disorders, typically comprising both manic and depressive episodes. The underlying neuropathology of BD is not established, but a consistent feature is progressive thinning of cortical grey matter (GM) and white matter (WM) in specific pathways, due to loss of subpopulations of neurons and astrocytes, with accompanying disturbance of connectivity. Dysregulation of astrocyte homeostatic functions are implicated in BD, notably regulation of glutamate, calcium signalling, circadian rhythms and metabolism. Furthermore, the beneficial therapeutic effects of the frontline treatments for BD are due at least in part to their positive actions on astrocytes, notably lithium, valproic acid (VPA) and carbamazepine (CBZ), as well as antidepressants and antipsychotics that are used in the management of this disorder. Treatments for BD are ineffective in a large proportion of cases, and astrocytes represent new therapeutic targets that can also serve as biomarkers of illness progression and treatment responsiveness in BD.

Induced Pluripotent Stem Cells in Psychiatry: An Overview and Critical Perspective

A key challenge in psychiatry research is the development of high-fidelity model systems that can be experimentally manipulated to explore and test pathophysiological mechanisms of illness. In this respect, the emerging capacity to derive neural cells and circuits from human induced pluripotent stem cells (iPSCs) has generated significant excitement. This review aims to provide a critical appraisal of the potential for iPSCs in illuminating pathophysiological mechanisms in the context of other available technical approaches. We discuss the selection of iPSC phenotypes relevant to psychiatry, the information that researchers can draw on to help guide these decisions, and how researchers choose between the use of 2-dimensional cultures and the use of more complex 3-dimensional model systems. We discuss the strengths and limitations of current models and the challenges and opportunities that they present. Finally, we discuss the potential of iPSC-based model systems for clarifying the mechanisms underlying genetic risk for psychiatry and the steps that will be needed to ensure that robust and reliable conclusions can be drawn. We argue that while iPSC-based models are ideally placed to study fundamental processes occurring within and between neural cells, they are often less well suited for case-control studies, given issues relating to statistical power and the challenges in identifying which cellular phenotypes are meaningful at the level of the whole individual. Our aim is to highlight the importance of considering the hypotheses of a given study to guide decisions about which, if any, iPSC-based system is most appropriate to address it.

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.

Lithium as a Neuroprotective Agent for Bipolar Disorder: An Overview

Lithium (Li⁺) is a first option treatment for adult acute episodes of Bipolar Disorder (BD) and for the prophylaxis of new depressed or manic episodes. It is also the preferred choice as maintenance treatment. Numerous studies have shown morphological abnormalities in the brains of BD patients, suggesting that this highly heritable disorder may exhibit progressive and deleterious changes in brain structure. Since treatment with Li⁺ ameliorates these abnormalities, it has been postulated that Li⁺ is a neuroprotective agent in the same way atypical antipsychotics are neuroprotective in patients diagnosed with schizophrenia spectrum disorders. Li⁺'s neuroprotective properties are related to its modulation of nerve growth factors, inflammation, mitochondrial function, oxidative stress, and programmed cell death mechanisms such as autophagy and apoptosis. Notwithstanding, it is not known whether Li⁺-induced neuroprotection is related to the inhibition of its putative molecular targets in a BD episode: the enzymes inositol-monophosphatase, (IMPase), glycogen-synthase-kinase 3β (GSK3), and Protein kinase C (PKC). Furthermore, it is uncertain whether these neuroprotective mechanisms are correlated with Li⁺'s clinical efficacy in maintaining mood stability. It is expected that in a nearby future, precision medicine approaches will improve diagnosis and expand treatment options. This will certainly contribute to ameliorating the medical and economic burden created by this devastating mood disorder.

Incidence of Parkinson's disease, dementia, cerebrovascular disease and stroke in bipolar disorder compared to other psychiatric disorders: An electronic health records network study of 66 million people

OBJECTIVES

Bipolar disorder has been associated with an increased risk for neurodegenerative diseases, but uncertainties remain. The risk relative to other psychiatric disorders is not established.

METHODS

We used a federated electronic health records network of 66 million people including over 700,000 with bipolar disorder. We assessed incidence of a first diagnosis of Parkinson's disease, dementia, cerebrovascular disease and stroke, in patients at least 1 year after diagnosis of bipolar disorder. Rates were compared to propensity score matched cohorts of subjects with mixed disorders, recurrent major depressive disorder (MDD) or schizophrenia.

RESULTS

Parkinson's disease was commoner in bipolar disorder compared to all three cohorts (odds ratios [OR] ranging from 1.26 to 2.65). Dementia incidence was greater in bipolar disorder than in mixed disorders (OR = 1.61) or MDD (OR = 1.40), but not different from schizophrenia (OR = 0.96). Cerebrovascular disease and stroke were commoner in bipolar disorder than in schizophrenia (OR = 1.35) or mixed disorders (OR = 1.20) and equivocally raised compared to MDD. Results were robust to a wide range of confounding demographic, diagnostic and medication risk factors for neurodegenerative disorders.

CONCLUSIONS

Bipolar disorder confers an elevated risk for developing neurodegenerative disorders and cerebrovascular disease compared to other major adult psychiatric disorders. The results cannot be attributed to recognised confounders. The results are consistent with neuroprogressive views of bipolar disorder. The underlying mechanisms remain to be discovered.

The magnitude and variability of brain structural alterations in bipolar disorder: A double meta-analysis of 5534 patients and 6651 healthy controls

BACKGROUND

Bipolar disorder is thought to be associated with structural brain alterations, but findings have been inconsistent. Our double meta-analysis investigated the variability and magnitude of differences in regional brain volumes in patients with bipolar disorder relative to healthy volunteers.

METHODS

Databases were systematically searched for MRI studies reporting regional brain volumetric measures in patients with bipolar disorder and controls. The primary outcome measures were variability ratio (VR), coefficient of variability ratio (CVR) and Hedge's g.

RESULTS

118 studies comprising 5534 patients and 6651 controls were included. The variability meta-analysis showed higher variability in amygdala (VR, 1.14; P = .02; CVR, 1.25; P = .005) and hippocampal (VR, 1.16; P = .001; CVR, 1.22; P = <.001) volumes in patients relative to controls. The meta-analysis of volume differences showed higher lateral (g, -0.43; P = <.0001) and third ventricle (g, -0.22; P = .01) volumes in patients; and lower hippocampus (g, 0.41; P = .001), grey matter (g, 0.25; P = .001), white matter (g, 0.23; P = .0002) and total brain volumes (g, 0.20; P = .003) in patients relative to controls. A higher proportion of male subjects was associated with decreased mean volumes of the amygdala, hippocampus and thalamus and increased lateral ventricle volumes.

LIMITATIONS

There was significant publication bias and between-study inconsistency for several brain regions.

CONCLUSIONS

Bipolar disorder is associated with generalised alterations in white and grey matter brain volumes, particularly marked in the hippocampus volumes, which were smaller but showed greater variability in volumes relative to controls. This suggests that heterogeneity in neurobiological processes involving the hippocampus contribute to clinical heterogeneity in the disorder, and this may be more marked in males than females.

Evaluating endophenotypes for bipolar disorder

BACKGROUND

Phenotypic heterogeneity is a major impediment to the elucidation of the neurobiology and genetics of bipolar disorder. Endophenotype could help in reducing heterogeneity by defining biological traits that are more direct expressions of gene effects. The aim of this review is to examine the recent literature on clinical, epidemiological, neurobiological, and genetic findings and to select and evaluate candidate endophenotypes for bipolar disorder. Evaluating putative endophenotype could be helpful in better understanding the neurobiology of bipolar disorder by improving the definition of bipolar-related phenotypes in genetic studies. In this manner, research on endophenotypes could be useful to improve psychopathological diagnostics in the long-run by dissecting psychiatric macro phenotypes into biologically valid components.

MAIN BODY

The associations among the psychopathological and biological endophenotypes are discussed with respect to specificity, temporal stability, heritability, familiarity, and clinical and biological plausibility. Numerous findings regarding brain function, brain structure, neuropsychology and altered neurochemical pathways in patients with bipolar disorder and their relatives deserve further investigation. Overall, major findings suggest a developmental origin of this disorder as all the candidate endophenotypes that we have been able to select are present both in the early stages of the disorder as well as in subjects at risk.

CONCLUSIONS

Among the stronger candidate endophenotypes, we suggest circadian rhythm instability, dysmodulation of emotion and reward, altered neuroimmune state, attention and executive dysfunctions, anterior cingulate cortex thickness and early white matter abnormalities. In particular, early white matter abnormalities could be the result of a vulnerable brain on which new stressors are added in young adulthood which favours the onset of the disorder. Possible pathways that lead to a vulnerable brain are discussed starting from the data about molecular and imaging endophenotypes of bipolar disorder.

The clinical relevance of gray matter atrophy and microstructural brain changes across the psychosis continuum

Patients with psychotic spectrum disorders (PSD) exhibit similar patterns of atrophy and microstructural changes that may be associated with common symptomatology (e.g., symptom burden and/or cognitive impairment). Gray matter concentration values (proxy for atrophy), fractional anisotropy (FA), mean diffusivity (MD), intracellular neurite density (Vic) and isotropic diffusion volume (Viso) measures were therefore compared in 150 PSD (schizophrenia, schizoaffective disorder, and bipolar disorder Type I) and 63 healthy controls (HC). Additional analyses evaluated whether regions showing atrophy and/or microstructure abnormalities were better explained by DSM diagnoses, symptom burden or cognitive dysfunction. PSD exhibited increased atrophy within bilateral medial temporal lobes and subcortical structures. Gray matter along the left lateral sulcus showed evidence of increased atrophy and MD. Increased MD was also observed in homotopic fronto-temporal regions, suggesting it may serve as a precursor to atrophic changes. Global cognitive dysfunction, rather than DSM diagnoses or psychotic symptom burden, was the best predictor of increased gray matter MD. Regions of decreased FA (i.e., left frontal gray and white matter) and Vic (i.e., frontal and temporal regions and along central sulcus) were also observed for PSD, but were neither spatially concurrent with atrophic regions nor associated with clinical symptoms. Evidence of expanding microstructural spaces in gray matter demonstrated the greatest spatial overlap with current and potentially future regions of atrophy, and was associated with cognitive deficits. These results suggest that this particular structural abnormality could potentially underlie global cognitive impairment that spans traditional diagnostic categories.

Cellular calcium in bipolar disorder: systematic review and meta-analysis

Calcium signalling has long been implicated in bipolar disorder, especially by reports of altered intracellular calcium ion concentrations ([Ca²⁺]). However, the evidence has not been appraised critically. We carried out a systematic review and meta-analysis of studies of cellular calcium indices in bipolar disorder. 2281 records were identified and 117 screened, of which 32 were eligible and 21 were suitable for meta-analyses. The latter each involved up to 642 patients and 404 control subjects. We found that basal free intracellular [Ca²⁺] is increased in bipolar disorder, both in platelets and in lymphocytes. The effect size is 0.55, with an estimated elevation of 29%. It is observed in medication-free patients. It is present in mania and bipolar depression, but data are equivocal for euthymia. Cells from bipolar disorder individuals also show an enhanced [Ca²⁺] response to stimulation with 5-HT or thrombin, by an estimated 25%, with an effect size of 0.63. In studies which included other diagnoses, intracellular basal [Ca²⁺] was higher in bipolar disorder than in unipolar depression, but not significantly different from schizophrenia. Functional parameters of cellular Ca²⁺ (e.g. calcium transients), and neuronal [Ca²⁺], have been much less investigated, and no firm conclusions can be drawn. In summary, there is a robust, medium effect size elevation of basal and stimulated free intracellular [Ca²⁺] in bipolar disorder. The results suggest altered calcium functioning in the disorder, and encourage further investigations into the underlying mechanisms, and the implications for pathophysiology and therapeutics.

In vivo hippocampal subfield volumes in bipolar disorder—A mega‐analysis from The Enhancing Neuro Imaging Genetics through Meta‐Analysis Bipolar Disorder Working Group

The hippocampus consists of anatomically and functionally distinct subfields that may be differentially involved in the pathophysiology of bipolar disorder (BD). Here we, the Enhancing NeuroImaging Genetics through Meta‐Analysis Bipolar Disorder workinggroup, study hippocampal subfield volumetry in BD. T1‐weighted magnetic resonance imaging scans from 4,698 individuals (BD = 1,472, healthy controls [HC] = 3,226) from 23 sites worldwide were processed with FreeSurfer. We used linear mixed‐effects models and mega‐analysis to investigate differences in hippocampal subfield volumes between BD and HC, followed by analyses of clinical characteristics and medication use. BD showed significantly smaller volumes of the whole hippocampus (Cohen's d = −0.20), cornu ammonis (CA)1 (d = −0.18), CA2/3 (d = −0.11), CA4 (d = −0.19), molecular layer (d = −0.21), granule cell layer of dentate gyrus (d = −0.21), hippocampal tail (d = −0.10), subiculum (d = −0.15), presubiculum (d = −0.18), and hippocampal amygdala transition area (d = −0.17) compared to HC. Lithium users did not show volume differences compared to HC, while non‐users did. Antipsychotics or antiepileptic use was associated with smaller volumes. In this largest study of hippocampal subfields in BD to date, we show widespread reductions in nine of 12 subfields studied. The associations were modulated by medication use and specifically the lack of differences between lithium users and HC supports a possible protective role of lithium in BD.

Longitudinal Cortical Thickness Changes in Bipolar Disorder and the Relationship to Genetic Risk, Mania, and Lithium Use

BACKGROUND

Bipolar disorder (BD) is a highly heritable psychiatric disorder characterized by episodes of manic and depressed mood states and associated with cortical brain abnormalities. Although the course of BD is often progressive, longitudinal brain imaging studies are scarce. It remains unknown whether brain abnormalities are static traits of BD or result from pathological changes over time. Moreover, the genetic effect on implicated brain regions remains unknown.

METHODS

Patients with BD and healthy control (HC) subjects underwent structural magnetic resonance imaging at baseline (123 patients, 83 HC subjects) and after 6 years (90 patients, 61 HC subjects). Cortical thickness maps were generated using FreeSurfer. Using linear mixed effects models, we compared longitudinal changes in cortical thickness between patients with BD and HC subjects across the whole brain. We related our findings to genetic risk for BD and tested for effects of demographic and clinical variables.

RESULTS

Patients showed abnormal cortical thinning of temporal cortices and thickness increases in visual/somatosensory brain areas. Thickness increases were related to genetic risk and lithium use. Patients who experienced hypomanic or manic episodes between time points showed abnormal thinning in inferior frontal cortices. Cortical changes did not differ between diagnostic BD subtypes I and II.

CONCLUSIONS

In the largest longitudinal BD study to date, we detected abnormal cortical changes with high anatomical resolution. We delineated regional effects of clinical symptoms, genetic factors, and medication that may explain progressive brain changes in BD. Our study yields important insights into disease mechanisms and suggests that neuroprogression plays a role in BD.

Astrocyte Changes in the Prefrontal Cortex From Aged Non-suicidal Depressed Patients

Glia alterations in the anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex (DLPFC) have been postulated to play an important role in the pathophysiology of psychiatric disorders. Astroglia is the most abundant type of glial cells in the central nervous system. The expression levels of astrocyte markers (glial fibrillary acidic protein (GFAP), synemin-α, synemin-β, vimentin, nestin) in isolated gray matter from postmortem ACC and DLPFC were determined to investigate the possible involvement of astrocytes in depression. Donors were aged non-suicidal subjects with bipolar disorder (BPD) or major depressive disorder (MDD), and matched controls. GFAP mRNA levels were significantly increased in the ACC of BPD patients. However, GFAP immunohistochemistry showed that the area fraction of GFAP immunoreactive astrocytes was decreased in the ACC of BPD patients, while there were no changes in the cell density and integrated optical density (IOD), indicating that there might be a reduction of GFAP-positive astrocyte processes and remodeling of the astrocyte network in BPD. Furthermore, in controls, DLPFC GFAP mRNA levels were significantly lower with a time of death at daytime (08:01–20:00 h) compared to nighttime (20:01–08:00 h). In depression, such a diurnal pattern was not present. These findings in BPD and MDD subjects warrant further studies given the crucial roles of astrocytes in the central nervous system.

A review on shared clinical and molecular mechanisms between bipolar disorder and frontotemporal dementia

Mental disorders are highly prevalent and important causes of medical burden worldwide. Co-occurrence of neurological and psychiatric symptoms are observed among mental disorders, representing a challenge for their differential diagnosis. Psychiatrists and neurologists have faced challenges in diagnosing old adults presenting behavioral changes. This is the case for early frontotemporal dementia (FTD) and bipolar disorder. In its initial stages, FTD is characterized by behavioral or language disturbances in the absence of cognitive symptoms. Consequently, patients with the behavioral subtype of FTD (bv-FTD) can be initially misdiagnosed as having a psychiatric disorder, typically major depression disorder (MDD) or bipolar disorder (BD). Bipolar disorder is associated with a higher risk of dementia in older adults and with cognitive impairment, with a subset of patients presents a neuroprogressive pattern during the disease course. No mendelian mutations were identified in BD, whereas three major genetic causes of FTD have been identified. Clinical similarities between BD and bv-FTD raise the question whether common molecular pathways might explain shared clinical symptoms. Here, we reviewed existing data on clinical and molecular similarities between BD and FTD to propose biological pathways that can be further investigated as common or specific markers of BD and FTD.