Neural Function Before and After Mindfulness-Based Cognitive Therapy in Anxious Adolescents at Risk for Developing Bipolar Disorder

Aberrant brain network topology in youth with a familial risk for bipolar disorder: a task-based fMRI connectome study

BACKGROUND

Youth with a family history of bipolar disorder (BD) may be at increased risk for mood disorders and for developing side effects after antidepressant exposure. The neurobiological basis of these risks remains poorly understood. We aimed to identify biomarkers underlying risk by characterizing abnormalities in the brain connectome of symptomatic youth at familial risk for BD.

METHODS

Depressed and/or anxious youth (n = 119, age = 14.9 ± 1.6 years) with a family history of BD but no prior antidepressant exposure and typically developing controls (n = 57, age = 14.8 ± 1.7 years) received functional magnetic resonance imaging (fMRI) during an emotional continuous performance task. A generalized psychophysiological interaction (gPPI) analysis was performed to compare their brain connectome patterns, followed by machine learning of topological metrics.

RESULTS

High-risk youth showed weaker connectivity patterns that were mainly located in the default mode network (DMN) (network weight = 50.1%) relative to controls, and connectivity patterns derived from the visual network (VN) constituted the largest proportion of aberrant stronger pairs (network weight = 54.9%). Global local efficiency (Elocal, p = .022) and clustering coefficient (Cp, p = .029) and nodal metrics of the right superior frontal gyrus (SFG) (Elocal: p < .001; Cp: p = .001) in the high-risk group were significantly higher than those in healthy subjects, and similar patterns were also found in the left insula (degree: p = .004; betweenness: p = .005; age-by-group interaction, p = .038) and right hippocampus (degree: p = .003; betweenness: p = .003). The case-control classifier achieved a cross-validation accuracy of 78.4%.

CONCLUSIONS

Our findings of abnormal connectome organization in the DMN and VN may advance mechanistic understanding of risk for BD. Neuroimaging biomarkers of increased network segregation in the SFG and altered topological centrality in the insula and hippocampus in broader limbic systems may be used to target interventions tailored to mitigate the underlying risk of brain abnormalities in these at-risk youth.

A meta-analysis of mindfulness-based interventions for improving mental health and burden among caregivers of persons living with dementia

BACKGROUND

Mindfulness-based interventions are becoming increasingly popular and are effective in lowering depressive symptoms and caregiver burden. However, the overall efficacy of therapies in stress and anxiety management is unreported, and no study to date has performed a subgroup analysis to investigate the intervention dose response of outcomes.

AIMS

To quantitatively identify the effectiveness of mindfulness-based interventions for caregivers of persons living with dementia.

METHODS

A comprehensive literature search of six databases was undertaken from the date of inception to June 18, 2023. The DerSimonian-Laird model with random effects was used to examine the overall effect and its heterogeneity in the studies. Version 2 of the risk of bias (RoB 2) tool was employed to analyze the publication bias of each randomized study. Funnel and forest plots were created to represent the findings.

RESULTS

Thirteen randomized trials were included in the meta-analysis. Mindfulness-based interventions significantly reduced stress and anxiety of caregivers of persons living with dementia. In addition, interventions provided for ≥8 weeks were beneficial in reducing depression in caregivers. However, mindfulness-based interventions did not offer significant benefits in reducing depression or caregiver burden immediately after the intervention.

CONCLUSION

Mindfulness-based interventions have the potential to help caregivers of people living with dementia. This study could be used as a model for future research into and implementation of mindfulness-based therapies for caregivers.

LINKING EVIDENCE TO ACTION

Mindfulness-based therapies appear to alleviate stress and anxiety but are ineffective in reducing depression and burden in caregivers of persons living with dementia. Well-designed RCTs with more rigorous methodology and a larger sample size should be conducted to firm the conclusion of the effectiveness of mindfulness-based interventions for caregivers of persons living with dementia.

Neural correlates of mindfulness meditation and hypnosis on magnetic resonance imaging: similarities and differences. A scoping review

BACKGROUND

Mindfulness meditation (MM) and hypnosis practices are gaining interest in mental health, but their physiological mechanisms remain poorly understood. This study aimed to synthesize the functional, morphometric and metabolic changes associated with each practice using magnetic resonance imaging (MRI), and to identify their similarities and differences.

METHODS

MRI studies investigating MM and hypnosis in mental health, specifically stress, anxiety, and depression, were systematically screened following PRISMA guidelines from four research databases (PubMed, Web of Science, Embase, PsycINFO) between 2010 and 2022.

RESULTS

In total, 97 references met the inclusion criteria (84 for MM and 13 for hypnosis). This review showed common and divergent points regarding the regions involved and associated brain connectivity during MM practice and hypnosis. The primary commonality between mindfulness and hypnosis was decreased default mode network intrinsic activity and increased central executive network - salience network connectivity. Increased connectivity between the default mode network and the salience network was observed in meditative practice and mindfulness predisposition, but not in hypnosis.

CONCLUSIONS

While MRI studies provide a better understanding of the neural basis of hypnosis and meditation, this review underscores the need for more rigorous studies.

Dispositional mindfulness: Dissociable affective and cognitive processes

Mindfulness has been linked to a range of positive social-emotional and cognitive outcomes, but the underlying mechanisms are unclear. As one of the few traits or dispositions that are associated with both affective and cognitive benefits, we asked whether mindfulness is associated with affective and cognitive outcomes through a shared, unitary process or through two dissociable processes. We examined this in adolescents using behavioral measures and also reanalyzed previously reported neuroimaging findings relating mindfulness training to either affect (negative emotion, stress) or cognition (sustained attention). Using multivariate regression analyses, our findings suggest that the relationships between dispositional mindfulness and affective and cognitive processes are behaviorally dissociable and converge with neuroimaging data indicating that mindfulness modulates affect and cognition through separate neural pathways. These findings support the benefits of trait mindfulness on both affective and cognitive processes, and reveal that those benefits are at least partly dissociable in the mind and brain.

Gray matter abnormalities in patients with major depressive disorder and social anxiety disorder: a voxel-based meta-analysis

BACKGROUND

Major depressive and social anxiety disorders have a high comorbidity rate and similar cognitive patterns. However, their unique and shared neuroanatomical characteristics have not been fully identified.

METHODS

Voxel-based morphometric studies comparing gray matter volume between patients with major depressive disorder/social anxiety disorder and healthy controls were searched using 4 electronic databases from the inception to March 2022. Stereotactic data were extracted and subsequently tested for convergence and differences using activation likelihood estimation. In addition, based on the result of the meta-analysis, behavioral analysis was performed to assess the functional roles of the regions affected by major depressive disorder and/or social anxiety disorder.

RESULTS

In total, 34 studies on major depressive disorder with 2873 participants, and 10 studies on social anxiety disorder with 1004 subjects were included. Gray matter volume conjunction analysis showed that the right parahippocampal gyrus region, especially the amygdala, was smaller in patients compared to healthy controls. The contrast analysis of major depressive disorder and social anxiety disorder revealed lower gray matter volume in the right lentiform nucleus and medial frontal gyrus in social anxiety disorder and lower gray matter volume in the left parahippocampal gyrus in major depressive disorder. Behavioral analysis showed that regions with lower gray matter volume in social anxiety disorder are strongly associated with negative emotional processes.

CONCLUSIONS

The shared and unique patterns of gray matter volume abnormalities in patients with major depressive and social anxiety disorder may be linked to the underlying neuropathogenesis of these mental illnesses and provide potential biomarkers. PROSPERO registration number: CRD42021277546.

Preventive interventions for individuals at risk of developing bipolar disorder: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to explore whether early interventions can reduce affective symptoms and have long-term benefits among individuals at risk of bipolar disorder (BD).

METHODS

The PubMed, Embase, and Web of Science databases were searched. The primary outcome was continuous symptom scores before and after treatment. Random effects meta-analyses were conducted for each outcome arm studied and pooled mean difference estimates were calculated.

RESULTS

The search identified 10 controlled studies involving 425 participants and 6 single-arm studies involving 90 participants. For controlled trials, meta-analysis showed that the interventions led to greater reduction in clinical global score than placebo (standardized mean differences (SMD) = -0.96, 95 % CI:-1.32, -0.60), and supported a long-term longitudinal effect for pharmacotherapy (SMD = -0.42, 95 % CI: -0.79, -0.05). For single-arm trials, both pharmacotherapy and psychotherapy showed efficacy for depressive symptoms, while pharmacotherapy only showed efficacy for hypomania symptoms (effect size (ES) = -9.16, 95 % CI:-11.29, -7.04). Discontinuation of pharmacotherapy due to adverse effects did not show a difference.

LIMITATIONS

The primary limitations are the small number of RCTs and the influence of medication dosage.

CONCLUSIONS

Based on the limited available data, early interventions show efficacy for individuals at risk of BD. Psychological therapy might be more beneficial for depressive symptoms and have long-term benefits for hypomania. Pharmacotherapy may be appropriate in situations of severe hypomanic symptoms and the poor functioning. Large, well-designed, double-blind -controlled trials are needed to make solid conclusions about the efficacy of early interventions.

Daring to Feel: Emotion-Focused Psychotherapy Increases Amygdala Activation and Connectivity in Euthymic Bipolar Disorder-A Randomized Controlled Trial

BACKGROUND

In bipolar disorder (BD), the alternation of extreme mood states indicates deficits in emotion processing, accompanied by aberrant neural function of the emotion network. The present study investigated the effects of an emotion-centered psychotherapeutic intervention on amygdala responsivity and connectivity during emotional face processing in BD.

METHODS

In a randomized controlled trial within the multicentric BipoLife project, euthymic patients with BD received one of two interventions over 6 months: an unstructured, emotion-focused intervention (FEST), where patients were guided to adequately perceive and label their emotions (n = 28), or a specific, structured, cognitive behavioral intervention (SEKT) (n = 31). Before and after interventions, functional magnetic resonance imaging was conducted while patients completed an emotional face-matching paradigm (final functional magnetic resonance imaging sample of patients completing both measurements: SEKT, n = 17; FEST, n = 17). Healthy control subjects (n = 32) were scanned twice after the same interval without receiving any intervention. Given the focus of FEST on emotion processing, we expected FEST to strengthen amygdala activation and connectivity.

RESULTS

Clinically, both interventions stabilized patients' euthymic states in terms of affective symptoms. At the neural level, FEST versus SEKT increased amygdala activation and amygdala-insula connectivity at postintervention relative to preintervention time point. In FEST, the increase in amygdala activation was associated with fewer depressive symptoms (r = 0.72) 6 months after intervention.

CONCLUSIONS

Enhanced activation and functional connectivity of the amygdala after FEST versus SEKT may represent a neural marker of improved emotion processing, supporting the FEST intervention as an effective tool in relapse prevention in patients with BD.

Neurobiology of Treatment in Pediatric Anxiety Disorders

Both pharmacologic and psychotherapeutic treatment-related changes increase activity in brain regions implicated in prefrontal regulatory circuits, and the functional connectivity of these regions with the amygdala is enhanced following pharmacological treatment. This may suggest overlapping mechanisms of action across therapeutic modalities. The existing literature is best viewed as a partially constructed scaffold on which to construct a vigorous understanding of biomarkers in pediatric anxiety syndromes. As the field approaches leveraging "fingerprints" in neuroimaging with "outputs" in neuropsychiatric tasks and scale, we can move beyond one-size-fits-all selection of psychiatric interventions toward more nuanced therapeutic strategies that recognize individual differences.

Brain functional activation and first mood episode in youth at risk for bipolar disorder

BACKGROUND

In order to identify biomarkers of prodromal mood disorders, we examined functional brain activation in children and adolescent at familial risk for bipolar disorder.

METHODS

Offspring of parents with bipolar I disorder (at-risk youth; N = 115, mean ± SD age: 13.6 ± 2.7; 54 % girls) and group-matched offspring of healthy parents (healthy controls; N = 58, mean ± SD age: 14.2 ± 3.0; 53 % girls) underwent functional magnetic resonance imaging while performing a continuous performance task with emotional and neutral distracters. At baseline, at-risk youth had no history of mood episodes or psychotic disorders. Subjects were followed longitudinally until developing their first mood episode or being lost to follow-up. Standard event-related region-of-interest (ROI) analyses were performed to compare brain activation at baseline between groups and in survival analyses.

RESULTS

At baseline, at-risk youth exhibited reduced activation to emotional distracters in the right ventrolateral prefrontal cortex (VLPFC) (p = 0.04). Activation was not significantly altered in additional ROIs, including left VLPFC, bilateral amygdala, caudate, or putamen. In those at-risk youth who developed their first mood episode during follow-up (n = 17), baseline increased activation in right VLPFC, right caudate, and right putamen activation predicted the development of a mood episode.

LIMITATIONS

Sample size of converters, loss to follow-up, and number of statistical comparisons.

CONCLUSIONS

We found preliminary evidence that a reduced activation in right VLPFC might be a marker of risk for or resilience to mood disorders in at-risk youth. Conversely, an increased activation in the right VLPFC, caudate, and putamen might indicate an increased risk for the later development of their first mood episode.

Child and adolescent anxiety as a risk factor for bipolar disorder: A systematic review of longitudinal studies

OBJECTIVES

Several studies have suggested that anxiety disorders in childhood and adolescence often precede the onset of bipolar disorder. We therefore systematically reviewed the relationship between child and adolescent anxiety and later bipolar disorder.

METHODS

Online databases (Medline [for Ovid], EMBASE and PsychINFO) were searched for original, peer-reviewed studies examining the relationship between child and adolescent anxiety and later bipolar disorder. Studies in both community samples and bipolar offspring samples were included.

RESULTS

A total of 16 studies were included in the review. The results were broadly consistent and revealed that child and adolescent anxiety disorders are associated with later bipolar disorder in community samples. In bipolar offspring, child and adolescent anxiety disorders are a marker of increased risk and predict the onset of bipolar disorder and other major mood disorders.

CONCLUSIONS

There is evidence that anxiety disorders in childhood and adolescence increase the risk of later bipolar disorder. Anxiety disorders may be a useful target for early intervention in those at high-risk of bipolar disorder.

The Neurophysiology Behind Trauma-Focused Therapy Modalities Used to Treat Post-Traumatic Stress Disorder Across the Life Course: A Systematic Review

This review presents the current state of understanding of trauma-informed modalities in light of current research in neuroscience, analyzing which brain structures and processes are impacted by these modalities. Studies included in the present review met the inclusion criteria of 1) addressing post-traumatic stress disorder (PTSD) in a specific population, 2) treatment of PTSD using any of the evidence-based trauma-informed modalities considered in this review, and 3) presenting functional magnetic resonance imagery (fMRI) data, derived from BOLD signals and voxel-compression maps, of brain structures impacted by these trauma-informed modalities. Articles for this review were collated through PubMed and MEDLINE, using key terms in descending order, such as 'childhood trauma', 'adolescent trauma', and 'adulthood trauma', to 'PTSD', 'fMRI', and so on, depending on the modality in question. Based on these criteria and research methods, 37 studies remained for inclusion in the present review. Among a number of critical findings, this review demonstrates that eye movement desensitization and reprocessing (EMDR) and mindfulness therapy effectively deactivate hindbrain regions implicated in the downregulation of autonomic nervous system (ANS) hyperarousal. This review also shows that trauma-focused cognitive behavioral therapy (TF-CBT) and EMDR activate the hippocampus, anterior cingulate cortex (ACC), medial prefrontal cortex (mPFC), and orbitofrontal cortex (OFC)-areas that are implicated in crucial cognitive, affective, and behavioral processes that aid trauma survivors in navigating their challenges.

Anxiety in bipolar disorder: A review of publication trends

BACKGROUND

Although anxiety is highly prevalent in people with bipolar disorders and has deleterious impact on the course of the illness, past reviews have shown that many aspects of the topic remain under-researched. This scoping review aims to provide a comprehensive overview of the literature addressing anxiety in bipolar disorder (A-BD) between 2011 and 2020, assess if the interest in the topic has increased over the period and map the publication trends.

METHODS

Three databases were systematically searched, and all articles were screened at the title/abstract and full text level based on inclusion and exclusion criteria. Of these, 1099 articles were included in the study. The annual number of articles on A-BD published between 2011 and 2020 was calculated and articles addressing it as a primary topic (n = 310) were classified into 4 categories and 11 subcategories to identify gaps in the knowledge.

RESULTS

The results show no clear increase in the number of annual publications during the period and much of the available literature is of a descriptive nature. Less is known about the processes underlying the comorbidity and about treatment approaches.

LIMITATIONS

Given the large scope of the research question, no quality assessment of the evidence was made. Only articles in English or French were considered.

CONCLUSIONS

These results highlight the need to change the focus of research efforts to better understand and address this unique set of conditions in clinical settings.

A preliminary study of the effects of mindfulness-based cognitive therapy on structural brain networks in mood-dysregulated youth with a familial risk for bipolar disorder

BACKGROUND

Mindfulness-based cognitive therapy for children (MBCT-C), as a psychotherapeutic intervention, has been shown to be effective for treating mood dysregulation (MD). While previous neuroimaging studies of MD have reported both pre-treatment structural and functional alterations, the effects of MBCT-C on brain morphological network organisation has not been investigated.

METHODS

We investigated brain morphological network organisation in 10 mood-dysregulated youth with familial risk for bipolar disorder and 15 matched healthy comparison youth (HC). Effects of 12 weeks of MBCT-C were examined in the mood-dysregulated youth. Topological properties of brain networks used for analyses were constructed based on morphological similarities in regional grey matter using a graph-theory approach using MRI data.

RESULTS

At baseline, compared with the HC group, the mood-dysregulated group exhibited increased global efficiency (E_glob ), decreased path length (L_p ), and abnormal nodal properties, mainly in the limbic system. Right temporal pole alterations at baseline predicted change in Child and Adolescent Mindfulness Measure scores after treatment. The mood-dysregulated group showed significant decreases in both the E_glob and L_p metrics after MBCT-C, suggesting an improved capacity for optimal information processing. Changes in L_p were correlated with changes in Emotion Regulation Checklist scores. Our results show significant topological alterations in the mood-dysregulated group as compared to controls at baseline. After MBCT-C, disrupted topological properties in the mood-dysregulated group were significantly reduced.

CONCLUSION

MBCT-C may facilitate clinically meaningful changes in the brain structural network in mood-dysregulated individuals.

Coping drinking motives, neural functional coupling during emotion processing, and alcohol use in young adults with bipolar disorder

BACKGROUND

Rates of alcohol use disorders in individuals with bipolar disorder are 3 to 5 times greater than in the general population and exceed rates of alcohol use disorders reported in other affective and anxiety disorders. Despite this high rate of comorbidity, our understanding of the psychosocial and neural mechanisms that underlie the initiation of alcohol misuse in young adults with bipolar disorder remains limited. Prior work suggests that individuals with bipolar disorder may misuse alcohol as a coping mechanism, yet the neural correlates of coping drinking motives and associated alcohol use have not been previously investigated in this population.

METHODS

Forty-eight young adults (22 bipolar disorder type I, 26 typically developing; 71% women; average age ± standard deviation = 22 ± 2 years) completed the Drinking Motives and Daily Drinking Questionnaires, and a Continuous Performance Functional magnetic resonance imaging (fMRI) Task with Emotional and Neutral Distracters. We calculated the relative difference in anterior cingulate cortex (ACC) functional coupling with the anterior insula and amygdala in response to emotional distracters compared with neutral stimuli and investigated the relations with coping drinking motives and alcohol use.

RESULTS

Across all participants, coping drinking motives were associated with greater quantity of recent alcohol use. In individuals with bipolar disorder, greater ACC-anterior insula functional coupling was associated with greater coping drinking motives, and greater quantity and frequency of recent alcohol use. The relative difference in ACC-anterior insula functional coupling was not associated with coping drinking motives or alcohol use in the typically developing group. Greater ACC-anterior insula functional coupling in individuals with bipolar disorder was also associated with greater anxiety symptoms and recent perceived psychological stress. Exploratory analyses suggest that the relations between ACC-anterior insula functional coupling and coping drinking motives may be confounded by anticonvulsant use.

CONCLUSION

Results suggest that a difference in ACC-anterior insula functional coupling during emotion processing may underlie alcohol use as a maladaptive coping mechanism in young adults with bipolar disorder.

Executive Functioning in Pediatric Anxiety and Its Relationship to Selective Serotonin Reuptake Inhibitor Treatment Response: A Double-Blind, Placebo-Controlled Trial

Objective: To characterize executive function in adolescents with generalized anxiety disorder (GAD) and its relationship to treatment. Methods: Using data from a double-blind, placebo-controlled trial of escitalopram in adolescents (N = 51) 12-17 years of age with GAD, we used the self-report version of the Behavior Rating Inventory of Executive Function (BRIEF-SR) to assess executive function, at baseline, and examined its relationship to treatment response as measured by the Pediatric Anxiety Rating Scale (PARS). Results: For all baseline subscores of the BRIEF-SR, T-scores were significantly elevated in adolescents with GAD compared to an age- and sex-matched normative healthy sample. In escitalopram-treated patients, baseline BRIEF-SR scores for Emotional Control (β = 0.256, 95% credibility interval [CrI]: 0.367 to 0.146, p < 0.001), Working Memory (β = 0.204, CrI: 0.2952 to 0.1134, p < 0.001), Planning/Organizing (β = -0.223, CrI: -0.1021 to -0.3436, p = 0.004), and Task Completion (β = -0.152, CrI: 0.075 to 0.228, p = 0.002) predicted the trajectory of improvement in PARS score over the 8-week trial. For youth who received placebo, only the Inhibit score was significantly, but weakly, associated with response trajectory (β = -0.081, CrI: -0.0167 to -0.1461, p = 0.015). For adolescents who had clinically significant impairment in Emotional Control, Working Memory, Planning/Organizing, and Task Completion (i.e., T-score >65), the trajectory of improvement significantly differed from patients without scores in the clinically significant range. Conclusions: Taken together, these findings point to the potential value of assessing executive function in youth with anxiety disorders as one strategy for guiding treatment selection. These data suggest that executive function may predict treatment response to psychopharmacologic treatment and point to numerous avenues for further personalizing treatment.

Neurocircuitry of Treatment in Anxiety Disorders

Background:

Methods:

Results:

Conclusions:

Psychosocial Treatments for Bipolar Disorder in Children and Adolescents

Evidence suggests that adjunctive psychosocial intervention for the treatment of pediatric bipolar spectrum disorders (BPSDs) is effective, feasible, and highly accepted as both an acute and maintenance treatment for youth with BPSD diagnoses as well as a preventive treatment for high-risk youth who are either asymptomatic or exhibit subsyndromal mood symptoms. Here, we provide a comprehensive review of all known evidence-based interventions, including detailed descriptions of treatment targets and core components, results of clinical trials, and updated research on mediators and moderators of treatment efficacy. Treatments are presented systematically according to level of empirical support (i.e., well established, probably efficacious, possibly efficacious, experimental, or questionable); upcoming and ongoing trials are included when possible. In line with a staging approach, preventive interventions are presented separately. Recommendations for best practices based on age, stage, and additional evidence-based child and family factors shown to affect treatment outcomes are provided. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Neural changes in youth at high risk for bipolar disorder undergoing family-focused therapy or psychoeducation

BACKGROUND

Patients with mood disorders may benefit from psychosocial interventions through changes in brain networks underlying emotion processing. In this study, we used functional magnetic resonance imaging (fMRI) to investigate treatment-related changes in emotion processing networks in youth at familial high risk for bipolar disorder (BD).

METHODS

Youth, ages 9-17, were randomly assigned to family-focused therapy for high-risk youth (FFT-HR) or an active comparison treatment, Enhanced Care (EC). Before and after these 4-month treatments, participants underwent fMRI while viewing happy, fearful, and calm facial expressions. Twenty youth in FFT-HR and 20 in EC were included in analyses of pre- to post-treatment changes in activation across the whole brain. Significant clusters were assessed for correlation with mood symptom improvement.

RESULTS

In the dorsolateral prefrontal cortex (DLPFC), activation increased from pre- to post-treatment in the FFT-HR group and decreased in the EC group. Insula activation decreased in the FFT-HR group and did not change in the EC group. Across both treatments, decreasing activation in the hippocampus and amygdala was correlated with pre- to post-treatment improvement in hypomania, while increasing activation in the DLPFC was correlated with pre- to post-treatment improvement in depression.

DISCUSSION

Psychosocial treatment addresses abnormalities in emotion regulation networks in youth at high risk for BD. Increased prefrontal cortex activation suggests enhanced emotion regulation from pre- to post-treatment with FFT-HR. Improvements in family interactions may facilitate the development of prefrontal resources that provide protection against future mood episodes.

Early detection of bipolar disorders and treatment recommendations for help-seeking adolescents and young adults: Findings of the Early Detection and Intervention Center Dresden

Background

Early identification and intervention of individuals with risk factors for or subtle prodromal symptoms of bipolar disorders (BD) may improve the illness course and prevent adverse long-term consequences.

Methods

We examined sociodemographic, clinical and psychopathological characteristics of help-seeking adolescents and young adults who consulted the Early Detection and Intervention Center Dresden at the University of Dresden (Germany) and presented with or without pre-defined at-risk criteria for BD. The standardized diagnostic procedure for all help-seeking youth included a comprehensive psychiatric history and a structured clinical interview. When BD at-risk state was suspected, early detection instruments (EPIbipolar, BPSS-FP) were applied. Treatment recommendations were formulated in multi-professional case conferences.

Results

Out of 890 help-seeking persons between 05/2009 and 04/2018, 582 (65%) completed the diagnostic process. Of these, 24 (4%) had manifest BD and 125 (21%) fulfilled at-risk BD criteria (age = 23.9 ± 0.6 years, female = 62%). Of the pre-defined main risk factors, family history for BD was reported in 22% of the at-risk persons, (hypo-)mania risk state in 44%, and increasing cyclothymic mood swings with increased activity in 48%. The most common secondary risk factors were decreased psychosocial functioning (78%), lifetime diagnosis of depressive disorder (67%) and specific sleep/circadian rhythm disturbances (59%). Substance use was very common in subjects at-risk for BD (cannabis = 50%, alcohol = 33%) and highest in patients with BD (cannabis = 75%, alcohol = 40%). Psychiatric treatment history, including psychopharmacological therapy, was similar between the groups, while treatment recommendations differed, with more advice for psychotherapy and antidepressants in the at-risk group with a lifetime diagnosis of depression and more advice for specialized BD treatment including mood stabilizers in patients with BD.

Conclusion

This analysis on the phenomenology of different BD at-risk stages suggests that early detection of individuals presenting with suggested risk factors for the development of BD is feasible in help-seeking young people. Future research should further develop/test stage-specific prevention and early targeted intervention approaches that were described in a naturalistic setting.

Network-level functional topological changes after mindfulness-based cognitive therapy in mood dysregulated adolescents at familial risk for bipolar disorder: a pilot study

BACKGROUND

Given that psychopharmacological approaches routinely used to treat mood-related problems may result in adverse outcomes in mood dysregulated adolescents at familial risk for bipolar disorder (BD), Mindfulness-Based Cognitive Therapy for Children (MBCT-C) provides an alternative effective and safe option. However, little is known about the brain mechanisms of beneficial outcomes from this intervention. Herein, we aimed to investigate the network-level neurofunctional effects of MBCT-C in mood dysregulated adolescents.

METHODS

Ten mood dysregulated adolescents at familial risk for BD underwent a 12-week MBCT-C intervention. Resting-state functional magnetic resonance imaging (fMRI) was performed prior to and following MBCT-C. Topological metrics of three intrinsic functional networks (default mode network (DMN), fronto-parietal network (FPN) and cingulo-opercular network (CON)) were investigated respectively using graph theory analysis.

RESULTS

Following MBCT-C, mood dysregulated adolescents showed increased global efficiency and decreased characteristic path length within both CON and FPN. Enhanced functional connectivity strength of frontal and limbic areas were identified within the DMN and CON. Moreover, change in characteristic path length within the CON was suggested to be significantly related to change in the Emotion Regulation Checklist score.

CONCLUSIONS

12-week MBCT-C treatment in mood dysregulated adolescents at familial risk for BD yield network-level neurofunctional effects within the FPN and CON, suggesting enhanced functional integration of the dual-network. Decreased characteristic path length of the CON may be associated with the improvement of emotion regulation following mindfulness training. However, current findings derived from small sample size should be interpreted with caution. Future randomized controlled trials including larger samples are critical to validate our findings.

Research Review: Pediatric anxiety disorders - what have we learnt in the last 10 years?

BACKGROUND

Anxiety disorders first emerge during the critical developmental periods of childhood and adolescence. This review synthesizes recent findings on the prevalence, risk factors, and course of the anxiety disorders; and their neurobiology and treatment.

METHODS

For this review, searches were conducted using PubMed, PsycINFO, and clinicaltrials.gov. Findings related to the epidemiology, neurobiology, risk factors, and treatment of pediatric anxiety disorders were then summarized.

FINDINGS

Anxiety disorders are high prevalence, and early-onset conditions associated with multiple risk factors including early inhibited temperament, environment stress, and structural and functional abnormalities in the prefrontal-amygdala circuitry as well as the default mode and salience networks. The anxiety disorders are effectively treated with cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs).

CONCLUSIONS

Anxiety disorders are high prevalence, early-onset conditions associated with a distinct neurobiological fingerprint, and are consistently responsive to treatment. Questions remain regarding who is at risk of developing anxiety disorders as well as the way in which neurobiology predicts treatment response.

Training-Induced Neural Plasticity in Youth: A Systematic Review of Structural and Functional MRI Studies

Experience-dependent neural plasticity is high in the developing brain, presenting a unique window of opportunity for training. To optimize existing training programs and develop new interventions, it is important to understand what processes take place in the developing brain during training. Here, we systematically review MRI-based evidence of training-induced neural plasticity in children and adolescents. A total of 71 articles were included in the review. Significant changes in brain activation, structure, microstructure, and structural and functional connectivity were reported with different types of trainings in the majority (87%) of the studies. Significant correlation of performance improvement with neural changes was reported in 51% of the studies. Yet, only 48% of the studies had a control condition. Overall, the review supports the hypothesized neural changes with training while at the same time charting empirical and methodological desiderata for future research.

Early intervention for people at high risk of developing bipolar disorder: a systematic review of clinical trials

Early intervention approaches are built on the premise of preventing disability, burden, and cognitive sequelae caused by bipolar disorder. The objective of this systematic review was to characterise the effectiveness of all the available psychological and pharmacological treatments for early intervention in people at high risk of developing bipolar disorder. The study was registered with PROSPERO (CRD42019133420). We did a systematic search to identify studies published in ten databases up to March 27, 2020. Randomised controlled trials and cohort studies that assessed the effect of pharmacological or psychological interventions in people at high risk of developing bipolar disorder were included. Studies of first episodes of mania were excluded. Eligible papers were assessed for quality and data were extracted. The primary outcomes were change in manic and depressive symptoms from baseline to endpoint. Of the 2856 citations retrieved by our search, 16 studies were included; five evaluated pharmacotherapeutic strategies (three randomised controlled trials and two open-label studies), ten assessed psychotherapeutic strategies (four randomised controlled trials and six open-label studies), and one randomised controlled trial assessed combination therapy; these 16 trials included a total of 755 participants at high risk of developing bipolar disorder. Quality assessment indicated fair to good quality for open-label studies, and a high risk of bias in four randomised controlled trials. Among the pharmacotherapeutic interventions, there is preliminary support for the efficacy of aripiprazole in reducing mood symptoms in people at high risk of developing bipolar disorder. Psychological interventions were effective for various outcomes. There was substantial methodological heterogeneity across studies. This systematic review underscores the need for multicentre, prospective, methodologically homogeneous studies evaluating conversion to bipolar disorder as an outcome measure.

Efficacy of cognitive-behavioral group therapy in patients at risk for serious mental illness presenting with subthreshold bipolar symptoms: Results from a prespecified interim analysis of a multicenter, randomized, controlled study

OBJECTIVE

Most patients with bipolar disorders (BD) exhibit prodromal symptoms before a first (hypo)manic episode. Patients with clinically significant symptoms fulfilling at-risk criteria for serious mental illness (SMI) require effective and safe treatment. Cognitive-behavioral psychotherapy (CBT) has shown promising results in early stages of BD and in patients at high risk for psychosis. We aimed to investigate whether group CBT can improve symptoms and functional deficits in young patients at risk for SMI presenting with subthreshold bipolar symptoms.

METHOD

In a multicenter, randomized, controlled trial, patients at clinical risk for SMI presenting with subthreshold bipolar symptoms aged 15-30 years were randomized to 14 weeks of at-risk for BD-specific group CBT or unstructured group meetings. Primary efficacy endpoints were differences in affective symptomatology and psychosocial functioning at 14 weeks. At-risk status was defined as a combination of subthreshold bipolar symptomatology, reduction of psychosocial functioning and a family history for (schizo)affective disorders. A prespecified interim analysis was conducted at 75% of the targeted sample.

RESULTS

Of 128 screened participants, 75 were randomized to group CBT (n = 38, completers = 65.8%) vs unstructured group meetings (n = 37, completers = 78.4%). Affective symptomatology and psychosocial functioning improved significantly at week 14 (P < .001) and during 6 months (P < .001) in both groups, without significant between-group differences. Findings are limited by the interim character of the analysis, the use of not fully validated early detection interviews, a newly adapted intervention manual, and the substantial drop-outs.

CONCLUSIONS

Results suggest that young patients at-risk for SMI presenting with subthreshold bipolar symptoms benefit from early group sessions. The degree of specificity and psychotherapeutic interaction needed requires clarification.

Toward prevention of bipolar disorder in at-risk children: Potential strategies ahead of the data

BACKGROUND

Despite the well-documented negative impact of untreated bipolar illness, approaches to early intervention in childhood-onset bipolar and related disorders are not well delineated.

METHODS

We reviewed the extant treatment literature on children at high risk for bipolar disorder, with definitions based on family history, childhood adversity, and prodromal symptoms.

RESULTS

A panoply of approaches have been described, but most interventions are based on an inadequate database to support their routine implementation. We classify early stage interventions as a function of their safety and tolerability with the hope that these might generate more rigorous study and a stronger database.

LIMITATIONS

Critics may rightly argue that identifying viable treatment methods is premature given our lack of ability to reliably predict illness trajectory in very young children. However, many of the psychosocial and pharmacological interventions we present could have nonspecific positive effects across a variety of symptoms, syndromes, and diagnoses, further enhancing the rationale for more rigorous study.

CONCLUSIONS

Early stage interventions have the potential to improve functioning in prodromal illness and exert long-term positive effects on the course of illness. Many of the safest interventions deserve consideration for implementation and dissemination studies.

Mindfulness in Family Caregivers of Persons with Dementia: Systematic Review and Meta-Analysis

Social and healthcare problems associated with dementia not only affect those who suffer from this disease, but their caregivers as well. The purpose of this study was to analyze the efficacy of mindfulness intervention on psychological variables of caregivers of persons with dementia. A search for scientific articles published from 2000 to 2019 in the PubMed, Web of Science and PsycINFO databases found a total of 282 articles. After screening with preestablished inclusion criteria, ten studies with participation of 161 caregivers remained for the meta-analysis. The results were significant in favor of mindfulness intervention for the variables studied with a standardized difference of mean of 0.71 at a 95% CI, 0.71 (0.52, 0.89); p ≤ 0.00001. Heterogeneity of the studies included was moderate (I² = 40%). The main conclusion suggested by empirical evidence was that mindfulness intervention seems to be effective for the variables analyzed. However, continued in-depth study of this subject is recommended.

Mindfulness-based cognitive therapy for children and adolescents with anxiety disorders at-risk for bipolar disorder: A psychoeducation waitlist controlled pilot trial

AIM

Previous studies suggest that Mindfulness-Based Cognitive Therapy for Children (MBCT-C) is feasible and may improve anxiety and emotion regulation in youth with anxiety disorders at-risk for bipolar disorder. However, controlled studies are warranted to replicate and extend these findings.

METHODS

In the current study, 24 youth with anxiety disorders who have at least one parent with bipolar disorder participated in a MBCT-C treatment period (n = 24; M_age = 13.6, 75% girls, 79% White) with a subset also participating in a prior psychoeducation waitlist control period (n = 19 M_age = 13.8, 68% girls, 84% White). Participants in both the waitlist and MBCT-C periods completed independently-rated symptom scales at each time point. Participants in the waitlist period received educational materials 12 weeks prior to the beginning of MBCT-C.

RESULTS

There were significantly greater improvements in overall clinical severity in the MBCT-C period compared to the waitlist period, but not in clinician- and child-rated anxiety, emotion regulation or mindfulness. However, increases in mindfulness were associated with improvements in anxiety and emotion regulation in the MBCT-C period, but not the waitlist period.

CONCLUSIONS

Findings suggest that MBCT-C may be effective for improving overall clinical severity in youth with anxiety disorders who are at-risk for bipolar disorder. However, waitlist controlled designs may inflate effect sizes so interpret with caution. Larger studies utilizing prospective randomized controlled designs are warranted.

Theoretical Model of Mindful Coping Power: Optimizing a Cognitive Behavioral Program for High-Risk Children and Their Parents by Integrating Mindfulness

This paper describes a theoretical model of Mindful Coping Power, a preventive intervention targeting high-risk children and their parents. Mindful Coping Power integrated mindfulness into Coping Power, an evidence-based cognitive behavioral intervention. Reactive aggression is emotionally driven, impulsive, and often referred to as being "hot-blooded." It has been resistant to change, given the high level of emotional arousal and impulsive angry outbursts. Our premise is that mindfulness impacts the mechanisms of reactive aggression-attentional, cognitive, behavioral, and emotional dysregulation. Also in the model are parents who exhibit emotionally charged interactions with their child. Mindful parenting focuses on parents' own emotional self-regulation and being fully present with their child. Our model sets the stage for incorporating mindfulness into existing interventions, thereby optimizing programs and maximizing effects.

Mindfulness-based interventions in the early phase of affective and non-affective psychoses: Special Section on "Translational and Neuroscience Studies in Affective Disorders" Section Editor, Maria Nobile MD, PhD

BACKGROUND

In the last 10 years, psychological approaches based on mindfulness techniques have been proposed for the management of psychotic experiences.

METHOD

In this brief review we summarized, to our knowledge for the first time, published studies on mindfulness-based interventions (MBIs) applied to the early phase of major psychoses (affective and non-affective).

RESULTS

Despite the great variability in terms of MBIs protocols, available studies on young people at risk to develop or with a first episode of psychosis suggest MBIs as a feasible, well-tolerated and effective approach in ameliorating symptoms, functioning, emotion regulation, and finally reducing the psychological distress associated with the onset of mania and/or psychotic experience.

LIMITATIONS

The small sample size and inconsistencies between studies in terms of design, MBIs protocols and outcome measures suggest being cautious in interpreting and generalizing results. Moreover, specific guidelines are missing for the adaptation of MBIs to youth at risk of developing affective psychoses.

CONCLUSIONS

Preliminary findings show that MBIs may be considered a promising adjunctive therapy for the treatment of major psychoses in the early phases of the illness. However, the conduct of further studies in larger samples and with a more rigorous methodology is warranted to confirm the beneficial effect of MBIs in the early stages of major psychoses.

Task MRI-Based Functional Brain Network of Anxiety

Magnetic resonance imaging (MRI) is a good tool for researchers to understand the biological mechanisms and pathophysiology of the brain due to the translational characteristics of MRI methods. For the psychiatric illness, this kind of mental disorders usually have minor alterations when compared to traditional neurological disorders. Therefore the functional study, such as functional connectivity, would play a significant role for understanding the pathophysiology of mental disorders. This chapter would focus on the discussion of task MRI-based functional network studies in anxiety. For social anxiety disorder, the limbic system, such as the temporal lobe, amygdala, and hippocampus, would show alterations in the functional connectivity with frontal regions, such as anterior cingulate, prefrontal, and orbitofrontal cortices. PD has anterior cingulate cortex-amygdala alterations in fear conditioning, frontoparietal alterations in attention network task, and limbic-prefrontal alterations in emotional task. A similar amygdala-based aberrant functional connectivity in specific phobia is observed. The mesocorticolimbic and limbic-prefrontal functional alterations are found in generalized anxiety disorder. The major components of task MRI-based functional connectivity in anxiety include limbic and frontal regions which might play a vital role for the origination of anxiety under different scenarios and tasks.

Major Depressive Disorder Is Associated with Impaired Interoceptive Accuracy: A Systematic Review

Interoception is the sense of the physiological condition of the entire body. Impaired interoception has been associated with aberrant activity of the insula in major depressive disorder (MDD) during heartbeat perception tasks. Despite clinical relevance, studies investigating interoceptive impairments in MDD have never been reviewed systematically according to the guidelines of the PRISMA protocol, and therefore we collated studies that assessed accuracy in detecting heartbeat sensations (interoceptive accuracy, IAc) in MDD (databases: PubMed/Medline, PsycINFO, and PsycARTICLES). Out of 389 records, six studies met the inclusion criteria. The main findings suggest that (i) moderately depressed samples exhibit the largest interoceptive deficits as compared with healthy adults. (ii) difficulties in decision making and low affect intensity are correlated with low IAc, and (iii) IAc seems to normalize in severely depressed subjects. These associations may be confounded by sex, anxiety or panic disorder, and intake of selective serotonin reuptake inhibitors. Our findings have implications for the development of interoceptive treatments that might relieve MDD-related symptoms or prevent relapse in recurrent depression by targeting the interoceptive nervous system.

Psychological interventions for young people at risk for bipolar disorder: A systematic review

OBJECTIVES

Several studies have recently been conducted that have explored the benefits of psychological interventions in reducing symptomatology or improving outcomes in young people at-risk of developing bipolar disorder. The aim of this review was to explore if such interventions reduce current psychiatric symptoms and prevent the development of new symptoms.

METHODS

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Databases searched were MEDLINE, EMBASE, PsychInfo, CINAHL and SCOPUS from January 1990 until August 2018. The inclusion criteria were young people aged under 30 years with a family history of bipolar disorder and any empirical studies that contained a psychological or psychoeducation intervention.

RESULTS

A total of 7 articles (N = 138, 55 males) were included (mean age ranged from 12 to 15 years). Interventions conducted included Family Focussed Therapy, Interpersonal and Social Rhythm Therapy, and Mindfulness-based Cognitive Therapy for Children. Significant results were found in some studies, depending on the sample's initial symptoms, with reduced time to relapse and reduced symptoms of anxiety, depression and hypo/mania being found.

LIMITATIONS

No studies have explored if interventions may delay the time to onset of first hypo/manic episodes and only two randomised controlled trials were identified.

CONCLUSIONS

Some significant results were noted with lower symptoms of anxiety, depression and hypo/mania being found in some studies. It is currently unclear if psychological interventions may prevent the development of bipolar disorder or other psychiatric symptoms over time; further longitudinal studies are required.

Mindfulness-based cognitive therapy for bipolar disorder: A systematic review

BACKGROUND

Persisting high levels of relapse, morbidity and mortality in bipolar disorder (BD) in spite of first-line, evidence-based psychopharmacology has spurred development and research on adjunctive psychotherapies. Mindfulness-based cognitive therapy (MBCT) is an emerging psychotherapy that has shown benefit in related and comorbid conditions such as major depressive, anxiety, and substance disorders. Furthermore, neurocognitive studies of MBCT suggest that it may have effects on some of the theorized pathophysiological processes in BD.

METHODS

We conducted a systematic literature review using PsychINFO and PubMed databases to identify studies reporting clinical and/or neurocognitive findings for MBCT for BD.

RESULTS

This search revealed 13 articles. There was a wide range in methodological quality and most studies were underpowered or did not present power calculations. However, MBCT did not appear to precipitate mania, and there is preliminary evidence to support a positive effect on anxiety, residual depression, mood regulation, and broad attentional and frontal-executive control.

LIMITATIONS

As meta-analysis is not yet possible due to study heterogeneity and quality, the current review is a narrative synthesis, and therefore net effects cannot be estimated.

CONCLUSIONS

MBCT for BD holds promise, but more high-quality studies are needed in order to ascertain its clinical efficacy. Recommendations to address the limitations of the current research are made.

An explorative study on coping flexibility with behavioral approach system-activating stimuli: A comparison of people with and without bipolar disorder

Life events play a significant role in affecting mood symptoms of people with bipolar disorder (BD). However, we lack empirical data about the associations among disorder, mood state, behavioral activation system (BAS) sensitivity, and psychosocial functioning level. Thus, the present study aimed to identify the role of coping flexibility with BAS activating stimuli in relation to mood states among a sample of individuals with BD (n = 90) and a healthy control group (n = 90). Through multiple regressions, the moderating role of coping flexibility was determined. Findings showed that coping flexibility had an additional value in predicting mood states beyond BAS sensitivity and psychosocial functioning level. Specifically, perceived controllability was considerably important for the BD group, whereas fit index was crucial in the controls. In addition, a moderation analysis showed that perceived controllability alleviated the effects of BD diagnosis, BAS sensitivity, and psychosocial functioning level on mood states. Theoretically, this study helps integrate the concept of coping flexibility into the BAS dysregulation theory as it applies to BD. The practical implication for enhancing mindfulness practice is also discussed.

Mind the Hype: A Critical Evaluation and Prescriptive Agenda for Research on Mindfulness and Meditation

During the past two decades, mindfulness meditation has gone from being a fringe topic of scientific investigation to being an occasional replacement for psychotherapy, tool of corporate well-being, widely implemented educational practice, and "key to building more resilient soldiers." Yet the mindfulness movement and empirical evidence supporting it have not gone without criticism. Misinformation and poor methodology associated with past studies of mindfulness may lead public consumers to be harmed, misled, and disappointed. Addressing such concerns, the present article discusses the difficulties of defining mindfulness, delineates the proper scope of research into mindfulness practices, and explicates crucial methodological issues for interpreting results from investigations of mindfulness. For doing so, the authors draw on their diverse areas of expertise to review the present state of mindfulness research, comprehensively summarizing what we do and do not know, while providing a prescriptive agenda for contemplative science, with a particular focus on assessment, mindfulness training, possible adverse effects, and intersection with brain imaging. Our goals are to inform interested scientists, the news media, and the public, to minimize harm, curb poor research practices, and staunch the flow of misinformation about the benefits, costs, and future prospects of mindfulness meditation.

Treatment of psychiatric symptoms among offspring of parents with bipolar disorder

Purpose of Review

Bipolar disorder is highly familial and has a protracted and diagnostically confusing prodrome. This review critically evaluates recently published literature relevant to the treatment of psychiatric symptoms in high-risk offspring of parents with Bipolar Disorder.

Recent Findings

Non-pharmacological treatment options including psychotherapy, resilience promotion through good sleep, diet, and exercise hygiene, and omega-3 fatty acid supplementation are important first line interventions for high-risk offspring. There has been some success in treating this population with open-label trials with mood stabilizers and atypical antipsychotics; however, these results have not been replicated in randomized controlled trails.

Summary

Despite some progress in early identification of symptoms in offspring of parents with Bipolar Disorder, there is scarce evidence supporting the treatment of these high-risk youth to prevent psychiatric symptoms from progressing to threshold bipolar or other psychiatric disorders. There is a need for prospective and randomized trials and research that identifies reliable biomarkers to individualize treatments for these youth.

Neurobiology of Pediatric Anxiety Disorders

While the fear-based anxiety disorders (i.e., generalized anxiety disorder, social phobia and separation anxiety disorder) are among the most common psychiatric conditions in children and adolescents, only recently has an integrated understanding of the neurobiology of these disorders developed. In this regard, both structural and functional neuroimaging studies have demonstrated neuroanatomic and functional abnormalities within the amygdala and prefrontal cortex in youth with fear-based anxiety disorders, and have also suggested altered functional connectivity among components of the anterior limbic network (ALN), as well as alterations in neurochemistry within the anterior cingulate cortex. Additionally, several prefrontal structures and regions (e.g., medial prefrontal cortex) appear to be dysregulated in youth who are at risk of developing anxiety disorders (e.g., youth with inhibited temperament, behavioral inhibition, etc.). Finally, emerging data raise the possibility that functional activity within these amygdala-prefrontal networks may be affected by successful psychopharmacologic and psychotherapeutic treatment and may predict outcome.