Deconstructing bipolar disorder: a critical review of its diagnostic validity and a proposal for DSM-V and ICD-11

Diagnostic value of structural, functional and effective connectivity in bipolar disorder

INTRODUCTION

The aim of this systematic review is to assess the functional magnetic resonance imaging (fMRI) studies of bipolar disorder (BD) patients that characterize differences in terms of structural, functional, and effective connectivity between the patients with BD, patients with other psychiatric disorders and healthy controls as possible biomarkers for diagnosing the disorder using neuroimaging.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), guidelines a systematic search for recent (since 2015) original studies on connectivity in bipolar disorder was conducted in PUBMED and SCOPUS.

RESULTS

A total of 60 studies were included in this systematic review: 20 of the structural connectivity, 33 of the functional connectivity, and only 7 of the studies focused on effective connectivity complied with the inclusion and exclusion criteria.

DISCUSSION

Despite the great heterogeneity in the findings, there are several trends that emerge. In structural connectivity studies, the main abnormalities in bipolar disorder patients were in the frontal gyrus, anterior, as well as posterior cingulate cortex and differences in emotion and reward-related networks. Cerebellum (vermis) to cerebrum functional connectivity was found to be the most common finding in BD. Moreover, prefrontal cortex and amygdala connectivity as part of the rich-club hubs were often reported to be disrupted. The most common findings based on effective connectivity were alterations in salience network, default mode network and executive control network. Although more studies with larger sample sizes are needed to ascertain altered brain connectivity as diagnostic biomarker, there is a perspective that the method could be used as a single marker of diagnosis in the future, and the process of adoption could be accelerated by using approaches such as semiunsupervised machine learning.

Research progress in role of exosomes exosomes in mental disorders

Exosomes are a class of extracellular vesicles with a structure of lipid bilayer-membrane. In the central nervous system (CNS), exosomes can be secreted from both neurons and glial cells. Exosomes released into the extracellular matrix can freely cross the blood-brain barrier and function as crucial carriers of cellular communication and substance exchange in the CNS. Exosomes play a key role in the pathological process of mental disorders such as schizophrenia, depression, and bipolar disorder, and they have the potential to be used as a targeted carrier of antipsychotic medications. Exosomes are likely to become a new tool in the future to aid in the early prevention, accurate diagnosis, and effective treatment for people with mental disorders.

Choroidal Structural Alterations and Choroidal Vascularity Index in Bipolar Disorder Patients

PURPOSE

The aim of this study was to compare bipolar disorder (BD) patients with age- and sex-matched healthy individuals in order to assess the choroidal structural alterations, retinal nerve fiber layer (RNFL) thickness, and retinal changes in BD patients using encanhed depth imaging optic coherence tomography (EDI-OCT).

METHOD

For this research, 39 eyes of BD patients and 36 eyes of age-matched healthy volunteers were used. Five locations were used to assess the choroidal thickness (CT): subfoveal, 500 µm nasal and 1500 µm nasal to the fovea, 500 µm temporal and 1500 µm temporal to the fovea. Image-J was used to determine the total choroidal area (TCA), luminal area (LA), and choroidal vascularity index (CVI). The Spectralis-OCT device was used to evaluate the central macular thickness (CMT), retinal nerve fiber layer (RNFL), and ganglion cell layer (GCL). The data were statistically compared.

RESULTS

BD patients had significantly decreased subfoveal, nasal, and temporal CTs than controls (for all three, p = 0.0001). The results of CMT and GCL were found to be thinner than controls. (for all p=0.0001) In comparison to the controls, the mean TCA and LA were decreased in the BD group. (p=0.0001, p=0.0001  respectively,).  Between the RNFL and CVI values in the BD and control groups, there was no statistically significant difference (p>0.05).

CONCLUSION

The results of this investigation showed that the retina and choroid of patients with BD had considerable anatomical changes.

Integrating functional neuroimaging and serum proteins improves the diagnosis of major depressive disorder

BACKGROUND

The lack of effective objective diagnostic biomarkers for major depressive disorder (MDD) leads to high misdiagnosis. Compared with healthy controls (HC), abnormal brain functions and protein levels are often observed in MDD. However, it is unclear whether combining these changed multidimensional indicators could help improve the diagnosis of MDD.

METHODS

Sixty-three MDD and eighty-one HC subjects underwent resting-state fMRI scans, among whom 37 MDD and 45 HC provided blood samples. Amplitudes of low-frequency fluctuation (ALFF), regional homogeneity (ReHo), and serum levels of brain-derived neurotrophic factor (BDNF), cortisol, and multiple cytokines were measured and put into the linear discriminant analysis (LDA) to construct corresponding MDD diagnostic models. The area under the receiver operating characteristic curve (AUC) of 5-fold cross-validation was calculated to evaluate each model's performance.

RESULTS

Compared with HC, MDD patients' spontaneous brain activity, serum BDNF, cortisol, interleukin (IL)-4, IL-6, and IL-10 levels changed significantly. The combinations of unidimensional multi-indicator had better diagnostic performance than a single one. The model consisted of multidimensional multi-indicator further exhibited conspicuously superior diagnostic efficiency than those constructed with unidimensional multi-indicator, and its AUC, sensitivity, specificity, and accuracy of 5-fold cross-validation were 0.99, 92.0 %, 100.0 %, and 96.3 %, respectively.

LIMITATIONS

This cross-sectional study consists of relatively small samples and should be replicated in larger samples with follow-up data to optimize the diagnostic model.

CONCLUSIONS

MDD patients' neuroimaging features and serum protein levels significantly changed. The model revealed by LDA could diagnose MDD with high accuracy, which may serve as an ideal diagnostic biomarker for MDD.

Effects of exercise on cognitive functioning in adults with serious mental illness: A meta analytic review

Cognitive performance is usually impaired in those with serious mental illness (SMI). Exercise may improve cognitive functioning, but studies examining the effects of exercise in SMI indicate heterogenous findings. To estimate the effects of exercise on cognitive outcomes in people with SMI. Randomized controlled trials evaluating the acute or chronic effects of exercise on cognitive functioning in SMI were searched from inception to December 26th, 2022 on major electronic databases. Random effect meta-analyses were conducted to assess the effects of exercise on over the cognitive domains and Standardized Mean Differences (SMD) and 95% confidence intervals (CIs) were used as the effect size measure. Funnel plots and Egger's test of effect size and the Trim and Fill procedure applied if evidence of publication bias was noted. Methodological quality was assessed using RoB 2. A total of 15 chronic (1 acute), 936 participants (46.7% women). Exercise showed large effects on reasoning and problem solving; small effects on executive functioning. Per diagnosis, exercise showed moderate positive effects on executive functioning and large effects on processing speed in people with depression; large effects on reasoning and problem solving in people with schizophrenia. The present study indicates a large beneficial effect of chronic physical exercise on reasoning and problem solving and small effects on executive functioning in people with SMI.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

A critical examination of multidimensionality within the Hypomanic Personality Scale

BACKGROUND

The Hypomanic Personality Scale (HPS) assesses bipolar spectrum psychopathology and risk for bipolar disorders. Despite the developers' intent to create a scale that provides a unitary score, several studies have examined whether the HPS has a multidimensional structure. These models have been unable to identify a replicable multidimensional structure, with models varying from fairly similar to entirely dissimilar, and have suffered from theoretical and methodological concerns.

PROCEDURES

We therefore examined the multidimensional structure of the HPS in a large undergraduate and adult sample (n = 5002).

MAIN FINDINGS

We failed to reproduce factors with equal congruence to those of previously published models.

PRINCIPLE CONCLUSIONS

We concluded that the HPS lacks factorial validity in previous research as a multidimensional measure of bipolar spectrum psychopathology. We further recommend the creation of a novel multidimensional assessment of bipolar spectrum psychopathology developed from a theoretically driven, comprehensive model, rather than examining a multidimensional model of a pre-existing measure, such as the HPS.

Auditory mismatch negativity in bipolar disorder: a focused review

The auditory mismatch negativity, a component of the event-related potential elicited by an unexpected stimulus in a sequence of acoustic stimuli, provides an objective measure of the accuracy of the echoic information processing of the human brain in vivo. Auditory mismatch negativity is also a useful probe of cortical glutamatergic N-methyl-d-aspartate receptor activity and disturbance. Notably, auditory mismatch negativity is consistently impaired in schizophrenia. Because of the wide spectrum extending from bipolar affective illness and schizoaffective psychosis to typical schizophrenia, we examined the literature on auditory mismatch negativity in bipolar disorder with the aim to find any neurophysiological dysfunction concerning pre-attentive information processing shared by these clinical conditions. This focused review includes 26 original articles published in peer-reviewed journals and indexed in the National Institutes of Health National Library of Medicine (PubMed) search system. Overall, evidence is consistent with the finding that auditory mismatch negativity is impaired in bipolar disorder with psychotic features, even though to a lesser extent than in schizophrenia. It must be acknowledged that, in a few twin and family studies, mismatch negativity abnormalities were not specifically associated with bipolar disorder. In conclusion, auditory mismatch negativity research supports the involvement of the N-methyl-d-aspartate system in the pathophysiology of bipolar disorder, as previously assessed for schizophrenia, thus creating an intriguing trait d'union between these two mental illnesses and stimulating the development of novel therapeutic agents. With additional replication and validation, auditory mismatch negativity may be further considered as a correlate of a common psychopathology of schizophrenia and bipolar spectrum illnesses.

What we learn about bipolar disorder from large-scale neuroimaging: Findings and future directions from the ENIGMA Bipolar Disorder Working Group

MRI-derived brain measures offer a link between genes, the environment and behavior and have been widely studied in bipolar disorder (BD). However, many neuroimaging studies of BD have been underpowered, leading to varied results and uncertainty regarding effects. The Enhancing Neuro Imaging Genetics through Meta-Analysis (ENIGMA) Bipolar Disorder Working Group was formed in 2012 to empower discoveries, generate consensus findings and inform future hypothesis-driven studies of BD. Through this effort, over 150 researchers from 20 countries and 55 institutions pool data and resources to produce the largest neuroimaging studies of BD ever conducted. The ENIGMA Bipolar Disorder Working Group applies standardized processing and analysis techniques to empower large-scale meta- and mega-analyses of multimodal brain MRI and improve the replicability of studies relating brain variation to clinical and genetic data. Initial BD Working Group studies reveal widespread patterns of lower cortical thickness, subcortical volume and disrupted white matter integrity associated with BD. Findings also include mapping brain alterations of common medications like lithium, symptom patterns and clinical risk profiles and have provided further insights into the pathophysiological mechanisms of BD. Here we discuss key findings from the BD working group, its ongoing projects and future directions for large-scale, collaborative studies of mental illness.

Identifying subtypes of bipolar disorder based on clinical and neurobiological characteristics

The ability to classify patients with bipolar disorder (BD) is restricted by their heterogeneity, which limits the understanding of their neuropathology. Therefore, we aimed to investigate clinically discernible and neurobiologically distinguishable BD subtypes. T1-weighted and resting-state functional magnetic resonance images of 112 patients with BD were obtained, and patients were segregated according to diagnostic subtype (i.e., types I and II) and clinical patterns, including the number of episodes and hospitalizations and history of suicide and psychosis. For each clinical pattern, fewer and more occurrences subgroups and types I and II were classified through nested cross-validation for robust performance, with minimum redundancy and maximum relevance, in feature selection. To assess the proportion of variance in cognitive performance explained by the neurobiological markers, multiple linear regression between verbal memory and the selected features was conducted. Satisfactory performance (mean accuracy, 73.60%) in classifying patients with a high or low number of episodes was attained through functional connectivity, mostly from default-mode and motor networks. Moreover, these neurobiological markers explained 62% of the variance in verbal memory. The number of episodes is a potentially critical aspect of the neuropathology of BD. Neurobiological markers can help identify BD neuroprogression.

A system biology approach based on metabolic biomarkers and protein-protein interactions for identifying pathways underlying schizophrenia and bipolar disorder

Mental disorders (MDs), including schizophrenia (SCZ) and bipolar disorder (BD), have attracted special attention from scientists due to their high prevalence and significantly debilitating clinical features. The diagnosis of MDs is still essentially based on clinical interviews, and intensive efforts to introduce biochemical based diagnostic methods have faced several difficulties for implementation in clinics, due to the complexity and still limited knowledge in MDs. In this context, aiming for improving the knowledge in etiology and pathophysiology, many authors have reported several alterations in metabolites in MDs and other brain diseases. After potentially fishing all metabolite biomarkers reported up to now for SCZ and BD, we investigated here the proteins related to these metabolites in order to construct a protein-protein interaction (PPI) network associated with these diseases. We determined the statistically significant clusters in this PPI network and, based on these clusters, we identified 28 significant pathways for SCZ and BDs that essentially compose three groups representing three major systems, namely stress response, energy and neuron systems. By characterizing new pathways with potential to innovate the diagnosis and treatment of psychiatric diseases, the present data may also contribute to the proposal of new intervention for the treatment of still unmet aspects in MDs.

How Does Adding the DSM-5 Criterion Increased Energy/Activity for Mania Change the Bipolar Landscape?

According to DSM-IV, the criterion (A) for diagnosing hypomanic/manic episodes is mood change (i.e., elevated, expansive or irritable mood). Criterion (A) was redefined in DSM-5 in 2013, adding increased energy/activity in addition to mood change. This paper examines a potential change of prevalence data for bipolar I or II when adding increased energy/activity to the criterion (A) for the diagnosis of hypomania/mania. Own research suggests that the prevalence of manic/hypomanic episodes drops by at least one third when using DSM-5 criteria. Whether this has positive or negative impact on clinical practice and research still needs further evaluation.

Changes in Non-Coding RNA in Depression and Bipolar Disorder: Can They Be Used as Diagnostic or Theranostic Biomarkers?

The similarities between the depressive symptoms of Major Depressive Disorders (MDD) and Bipolar Disorders (BD) suggest these disorders have some commonality in their molecular pathophysiologies, which is not apparent from the risk genes shared between MDD and BD. This is significant, given the growing literature suggesting that changes in non-coding RNA may be important in both MDD and BD, because they are causing dysfunctions in the control of biochemical pathways that are affected in both disorders. Therefore, understanding the changes in non-coding RNA in MDD and BD will lead to a better understanding of how and why these disorders develop. Furthermore, as a significant number of individuals suffering with MDD and BD do not respond to medication, identifying non-coding RNA that are altered by the drugs used to treat these disorders offer the potential to identify biomarkers that could predict medication response. Such biomarkers offer the potential to quickly identify patients who are unlikely to respond to traditional medications so clinicians can refocus treatment strategies to ensure more effective outcomes for the patient. This review will focus on the evidence supporting the involvement of non-coding RNA in MDD and BD and their potential use as biomarkers for treatment response.

Bright light therapy in the treatment of patients with bipolar disorder: A systematic review and meta-analysis

The treatment of depressive symptoms of bipolar disorder (BD) has received increasing attention. Recently, some studies have shown that bright light therapy (BLT) seems to be useful for BD depression. This meta-analysis is intended to further elucidate the role of BLT in depressive symptoms in patients with BD. Register of Systematic Reviews PROSPERO: CRD 420191 33642.Randomized controlled trials and cohort studies were retrieved in PubMed, Cochrane Library, EMbase, Web of Science, CINHAL, CBM, CNKI, VIP, and Wanfang from their foundation to March 2020, and other sources as supplement was also retrieved. Data were extracted after strict evaluation of literature quality by two researchers, and Meta-analysis was conducted on literatures that met the inclusion criteria. Meta-analysis was performed using Revman 5.3 software. In total, 12 studies including 847 patients with BD depression were included in our meta-analysis. A meta-analysis found significant differences between BLT and placebo for the following outcomes: (1) depression severity before and after BLT [SMD = -0.43, 95% CI (-0.73,-0.13), P<0.05] in RCT and [SMD = -2.12, 95% CI (-2.3,-1.94), P<0.05] in cohort studies.; (2) the efficacy of duration/timing of light therapy for depressive symptoms in BD [I² = 85%, SMD = -1.88, 95% CI (-2.04, -1.71),P<0.05] and [I² = 71%, SMD = -2.1,95% CI(-2.24, -1.96), P<0.05]; (3) the efficacy of different color/color temperatures for depressive symptoms in BD [I² = 0%, SMD = -0.56, 95% CI (-0.92, -0.19), P<0.05] and [I² = 97%, SMD = -1.74, 95% CI (-1.99, -1.49), P<0.05].We performed a subgroup meta-analysis of studies that used different light intensities. The results showed that light intensity≥5000 lux significantly reduced the severity of depression. And patients without psychotropic drugs revealed significantly decreased disease severity [I² = 0%, SMD = -0.6, 95% CI (-1.06,-0.13), P<0.05]. Limitations of the study include studies only assessed short-term effects, and insufficient duration may underestimate adverse reactions and efficacy. Our results highlight the significant efficiency of BLT in the treatment of bipolar depression. Prospective studies with more rigorous design and consistent follow-up.

What is bipolar disorder? A disease model of dysregulated energy expenditure

Advances in the understanding and management of bipolar disorder (BD) have been slow to emerge. Despite notable recent developments in neurosciences, our conceptualization of the nature of this mental disorder has not meaningfully progressed. One of the key reasons for this scenario is the continuing lack of a comprehensive disease model. Within the increasing complexity of modern research methods, there is a clear need for an overarching theoretical framework, in which findings are assimilated and predictions are generated. In this review and hypothesis article, we propose such a framework, one in which dysregulated energy expenditure is a primary, sufficient cause for BD. Our proposed model is centered on the disruption of the molecular and cellular network regulating energy production and expenditure, as well its potential secondary adaptations and compensatory mechanisms. We also focus on the putative longitudinal progression of this pathological process, considering its most likely periods for onset, such as critical periods that challenges energy homeostasis (e.g. neurodevelopment, social isolation), and the resulting short and long-term phenotypical manifestations.

Frequency-Specific Resting Connectome in Bipolar Disorder: An MEG Study

BACKGROUND

Bipolar disorder (BD) is a serious psychiatric disorder that is associated with a high suicide rate, and for which no clinical biomarker has yet been identified. To address this issue, we investigated the use of magnetoencephalography (MEG) as a new prospective tool. MEG has been used to evaluate frequency-specific connectivity between brain regions; however, no previous study has investigated the frequency-specific resting-state connectome in patients with BD. This resting-state MEG study explored the oscillatory representations of clinical symptoms of BD via graph analysis.

METHODS

In this prospective case-control study, 17 patients with BD and 22 healthy controls (HCs) underwent resting-state MEG and evaluations for depressive and manic symptoms. After estimating the source current distribution, orthogonalized envelope correlations between multiple brain regions were evaluated for each frequency band. We separated regions-of-interest into seven left and right network modules, including the frontoparietal network (FPN), limbic network (LM), salience network (SAL), and default mode network (DMN), to compare the intra- and inter-community edges between the two groups.

RESULTS

In the BD group, we found significantly increased inter-community edges of the right LM-right DMN at the gamma band, and decreased inter-community edges of the right SAL-right FPN at the delta band and the left SAL-right SAL at the theta band. Intra-community edges in the left LM at the high beta band were significantly higher in the BD group than in the HC group. The number of connections in the left LM at the high beta band showed positive correlations with the subjective and objective depressive symptoms in the BD group.

CONCLUSION

We introduced graph theory into resting-state MEG studies to investigate the functional connectivity in patients with BD. To the best of our knowledge, this is a novel approach that may be beneficial in the diagnosis of BD. This study describes the spontaneous oscillatory brain networks that compensate for the time-domain issues associated with functional magnetic resonance imaging. These findings suggest that the connectivity of the LM at the beta band may be a good objective biological biomarker of the depressive symptoms associated with BD.

Latrophilins: A Neuro-Centric View of an Evolutionary Conserved Adhesion G Protein-Coupled Receptor Subfamily

The adhesion G protein-coupled receptors latrophilins have been in the limelight for more than 20 years since their discovery as calcium-independent receptors for α-latrotoxin, a spider venom toxin with potent activity directed at neurotransmitter release from a variety of synapse types. Latrophilins are highly expressed in the nervous system. Although a substantial amount of studies has been conducted to describe the role of latrophilins in the toxin-mediated action, the recent identification of endogenous ligands for these receptors helped confirm their function as mediators of adhesion events. Here we hypothesize a role for latrophilins in inter-neuronal contacts and the formation of neuronal networks and we review the most recent information on their role in neurons. We explore molecular, cellular and behavioral aspects related to latrophilin adhesion function in mice, zebrafish, Drosophila melanogaster and Caenorhabditis elegans, in physiological and pathophysiological conditions, including autism spectrum, bipolar, attention deficit and hyperactivity and substance use disorders.

Identifying Needs-Based Groupings Among People Accessing Intellectual Disability Services

There is increasing emphasis on needs-led service provision for people with intellectual disability (ID). This study outlines the statistical cluster analysis of clinical data from 1,692 individuals accessing secondary care ID services in the United Kingdom (U.K.) Using objective needs assessment data from a newly developed ID assessment tool, six clusters were identified. These had clinical face validity and were validated using six concurrently (but independently) rated tools. In keeping with previous studies, the clusters varied in terms of overall level of need as well as specific clinical features (autism spectrum disorder, mental health problems, challenging behaviors and physical health conditions). More work is now needed to further develop these clusters and explore their utility for planning, commissioning and optimizing needs-led services.

Are patients with bipolar disorder and comorbid attention-deficit hyperactivity disorder more neurocognitively impaired?

OBJECTIVE

Research on neurocognitive impairment in adult patients with comorbid bipolar disorder (BD) and attention-deficit hyperactivity disorder (ADHD) is very scarce. This study assessed the neurocognitive profile of a comorbid group (BD+ADHD) compared with that of pure BD (pBD) group, pure ADHD (pADHD) group and healthy controls (HCs).

METHODS

This was a three-site study comprising 229 subjects: 70 patients with pBD, 23 with BD+ADHD, 50 with pADHD, and 86 HCs. All patients with BD had been euthymic for at least 6 months. Neuropsychological performance was assessed using a comprehensive neurocognitive battery.

RESULTS

Our results showed that all the clinical groups had poorer performance than the HCs in all the neurocognitive domains except for executive functions. No significant differences were observed between the pBD and BD+ADHD groups in any of the cognitive domains, with these two groups showing greater impairment than the pADHD group in executive functions and visual memory.

CONCLUSIONS

Our results, although preliminary, suggest that the BD+ADHD group showed the same neurocognitive profile as pBD patients, most likely reflecting the same neurobiological basis. On the other hand, the pADHD group showed a more selective moderate impairment in attention.

Characterizing the experience of auditory verbal hallucinations and accompanying delusions in individuals with a diagnosis of bipolar disorder: A systematic review

OBJECTIVES

The aim of the current study was to inform ongoing attempts to identify clinically meaningful subcategories of auditory verbal hallucination (AVH), and to evaluate evidence that might pertain to the suitability of current psychological interventions for people with bipolar disorder (BD) who experience psychotic symptoms.

METHODS

A comprehensive synthesis of findings on the phenomenology of AVH and delusions in BD is included, alongside a critical review of clinical and cognitive correlates. Studies published in the previous 20 years, until December 2016, were retrieved from the following databases: Embase, CINAHL, MEDLINE, PsycINFO and Web of Science. Thirty-two articles were reviewed after applying a set of predetermined inclusion criteria.

RESULTS

Psychotic symptoms were common in both manic and depressive phases, although higher frequencies were indicated in mania. Few detailed characterizations of AVH phenomenology were identified. Delusions with persecutory, grandiose and referential themes were the most common in BD. AVHs were associated with delusions and there was evidence to suggest that delusion subtype may vary according to mood state and type of AVH. Data on clinical correlates of AVH in BD were sparse. However, the results indicated that cognitive appraisals or interpretations of voices might be different in BD from those established to be predictive of clinical outcomes in schizophrenia spectrum disorders.

CONCLUSIONS

Clear gaps exist in our current understanding of the first-person experience of AVH in BD and the potential relationship to co-occurring symptoms, including delusions. Further research into cognitive interpretations of AVH in BD might inform adapted psychological interventions for psychotic symptoms in this population.

Validating a two-dimensional bipolar spectrum model integrating DSM-5's mixed features specifier for Major Depressive Disorder

INTRODUCTION

The literature on DSM-5's 'Major Depressive Disorder with lifetime mixed features' (MDD-MF) is limited. This study investigated MDD-MF's potential inclusion into a bipolar spectrum.

METHODS

We recruited 287 patients with Bipolar I disorder (BD-I), BD-II, MDD-MF or 'MDD without lifetime mixed features' (MDD-noMF); most (N=280) were stabilized for at least one year on medication. Sixteen validators (clinical features, psychiatric family history, temperament, stabilizing treatment) were compared across groups and subjected to trend analyses. Two discriminant function analyses (DFA; primary and secondary), excluding or including, respectively, treatment-related predictors, explored latent dimensions maximizing between-group discrimination; mahalanobis distances between group 'centroids' were calculated.

RESULTS

Eleven validators differed significantly across groups; nine varied monotonically along a bipolar diathesis gradient with significant linear trends; two peaked at MDD-MF and displayed significant quadratic trends. In the primary DFA, apart from a classic bipolarity dimension, correlating with hospitalizations, early age at onset, lifetime psychosis and lower anxious temperament scores, on which groups ranked along a bipolar propensity gradient, a second dimension was also significant, peaking at BD-II and MDD-MF (challenging the classic bipolar ranking), which correlated with lifetime psychiatric comorbidities, suicidality, lower lifetime psychosis rates, female gender, higher cyclothymic and lower depressive temperament scores; MDD-MF was equipoised amidst BD-II and MDD-noMF. After including treatment-related predictors (secondary DFA), discrimination improved overall but BD-II and MDD-MF were closest than any other pair, suggesting similar treatment patterns for these two groups at this naturalistic setting.

CONCLUSIONS

To our knowledge, this is the first time a two-dimensional bipolar spectrum based on classic external validators is proposed, fitting the data better than a unidimensional model. Additional predictors are warranted to improve BD-II/MDD-MF discrimination.

Combined serum levels of multiple proteins in tPA-BDNF pathway may aid the diagnosis of five mental disorders

Mental disorders are severe, disabling conditions with unknown etiology and are commonly misdiagnosed when clinical symptomology criteria are solely used. Our previous work indicated that combination of serum levels of multiple proteins in tissue plasminogen activator (tPA)-brain-derived neurotrophic factor (BDNF) pathway improved accuracy of diagnosis of major depressive disorder (MDD). Here, we measured serum levels of tPA, plasminogen activator inhibitor-1 (PAI-1), BDNF, precursor-BDNF (proBDNF), tropomyosin-related kinase B (TrkB) and neurotrophin receptor p75 (p75NTR) in patients with paranoid schizophrenia (SZ, n = 34), MDD (n = 30), bipolar mania (BM, n = 30), bipolar depression (BD, n = 22), panic disorder (PD, n = 30), and healthy controls (HCs, n = 30) by Enzyme-linked immunosorbent assay kits. We used receiver operating characteristic (ROC) curve to analyze diagnostic potential of these proteins. We found, compared with HCs, that serum tPA and proBDNF were lower in SZ, BM and BD; TrkB was lower in SZ and BD; and p75NTR was declined in SZ and BM. ROC analysis showed that combined serum level of tPA, PAI-1, BDNF, proBDNF, TrkB and p75NTR was better than any single protein in accuracy of diagnosis and differentiation, suggesting that the combination of multiple serum proteins levels in tPA-BDNF pathway may have a potential for a diagnostic panel in mental disorders.

The extension of a set of needs-led mental health clusters to accommodate people accessing UK intellectual disability health services

BACKGROUND

A development of a needs-led mental health classification system based on the Health of the National Outcome Scales (HoNOS) has previously been developed.

AIMS

To extend the needs-based mental health (MH) clusters to accommodate the additional needs of people accessing UK intellectual disabilities health services.

METHOD

Hierarchical cluster analysis was performed on assessment data from 18 National Health Service (NHS) provider organisations. The statistical results were clinically shaped through multi-disciplinary workshops. The resulting clusters were combined with six independently rated measures for a second data collection exercise. Based on these data, refinements were made before performing internal and external validity checks.

RESULTS

Eight additional clusters for people with health needs associated with their intellectual disabilities were produced. Three described primarily physical health (PH) needs, four described needs arising from behaviours which challenged (with/without autism) whilst one described people with generally low needs. Together, these covered 83.4% of cases with only a 10% overlap. The clusters were replicable and had clinical utility and validity.

CONCLUSIONS

It was possible to extend the needs-led mental health classification system to capture the additional needs of people accessing UK intellectual disability services.

Pharmacology and psychiatry at the origins of Greek medicine: The myth of Melampus and the madness of the Proetides

Melampus is a seer-healer of Greek myth attributed with having healed the young princesses of Argos of madness. Analysis of this legend and its sources sheds light on the early stages of the "medicalizing" shift in the history of ancient Greek medicine. Retrospective psychological diagnosis suggests that the descriptions of the youths' madness rose from actual observation of behavioral and mental disorders. Melampus is credited with having healed them by administering hellebore. Pharmacological analysis of botanical specimens proves that Helleborus niger features actual neurological properties effective in the treatment of mental disorders. The discussion aims at examining the rational aspects of the treatment of mental conditions in Greco-Roman antiquity.

Investigation of the clinical utility of the hypomania checklist 32 (HCL-32) for the screening of bipolar disorders in the non-clinical adult population

BACKGROUND

The hypomania checklist-32 (HCL-32) is a widely used questionnaire developed for identifying hypomanic components in patients with a depressive episode. Measuring and screening previous hypomanic symptoms in individuals without any definite history of depressive episode would also be needed for early detection of bipolar disorders (BDs). This study aimed at testing the clinical utility of the HCL-32 for screening of BDs in the non-clinical population.

METHODS

Lifetime history of hypomanic symptoms was evaluated by using the HCL-32 in 220 patients with BDs and 313 non-clinical individuals. Sensitivity, specificity, and the area under the curve (AUC) of the Receiver Operating Characteristic (ROC) were evaluated for assessing the discriminatory power of the scale and its two sub-domains in screening BDs.

RESULTS

The mean HCL-32 total score was significantly higher in the Bipolar II disorder group compared to the non-clinical group (P < 0.001). Most of the items (10/12) of the irritable/risk-taking factor showed higher positive responses in patient groups. Items of active/elated factor showed mixed results. The HCL-32 total score and the active/elated factor score were not adequate for both BDs and its subgroups with AUC values of less than 0.7. The irritable/risk-taking factor score showed higher discrimination power, i.e. AUC for BDs, Bipolar I disorder, and Bipolar II disorder was 0.71, 0.67, and 0.75, respectively.

CONCLUSIONS

The HCL-32 could not adequately distinguish BD patients from the non-clinical adult population. However, the current study identified items of irritable/risk-taking factor of the scale that could be useful in screening BDs in the general population.

Bipolar disorder

Bipolar disorder is a recurrent chronic disorder characterised by fluctuations in mood state and energy. It affects more than 1% of the world's population irrespective of nationality, ethnic origin, or socioeconomic status. Bipolar disorder is one of the main causes of disability among young people, leading to cognitive and functional impairment and raised mortality, particularly death by suicide. A high prevalence of psychiatric and medical comorbidities is typical in affected individuals. Accurate diagnosis of bipolar disorder is difficult in clinical practice because onset is most commonly a depressive episode and looks similar to unipolar depression. Moreover, there are currently no valid biomarkers for the disorder. Therefore, the role of clinical assessment remains key. Detection of hypomanic periods and longitudinal assessment are crucial to differentiate bipolar disorder from other conditions. Current knowledge of the evolving pharmacological and psychological strategies in bipolar disorder is of utmost importance.

Working memory networks and activation patterns in schizophrenia and bipolar disorder: comparison with healthy controls

BACKGROUND

Schizophrenia and bipolar disorder are severe mental disorders with overlapping genetic and clinical characteristics, including cognitive impairments. An important question is whether these disorders also have overlapping neuronal deficits.

AIMS

To determine whether large-scale brain networks associated with working memory, as measured with functional magnetic resonance imaging (fMRI), are the same in both schizophrenia and bipolar disorder, and how they differ from those in healthy individuals.

METHOD

Patients with schizophrenia (n = 100) and bipolar disorder (n = 100) and a healthy control group (n = 100) performed a 2-back working memory task while fMRI data were acquired. The imaging data were analysed using independent component analysis to extract large-scale networks of task-related activations.

RESULTS

Similar working memory networks were activated in all groups. However, in three out of nine networks related to the experimental task there was a graded response difference in fMRI signal amplitudes, where patients with schizophrenia showed greater activation than those with bipolar disorder, who in turn showed more activation than healthy controls. Secondary analysis of the patient groups showed that these activation patterns were associated with history of psychosis and current elevated mood in bipolar disorder.

CONCLUSIONS

The same brain networks were related to working memory in schizophrenia, bipolar disorder and controls. However, some key networks showed a graded hyperactivation in the two patient groups, in line with a continuum of neuronal abnormalities across psychotic disorders.

Pharmaco-utilisation and related costs of drugs used to treat schizophrenia and bipolar disorder in Italy: the IBIS study

BACKGROUND

Schizophrenia and bipolar disorder (BD) are psychiatric diseases that are commonly managed with antipsychotics. Treatment pathways are highly variable and no universal treatment guidelines are available. The primary objective of the Italian Burden of Illness in Schizophrenia and BD (IBIS) study was to describe pharmaco-utilisation of antipsychotic treatments and characteristics of patients affected by schizophrenia or BD. A secondary objective was to describe costs of illness for patients with schizophrenia or BD.

METHODS

IBIS was a multicentre, real-world, retrospective, observational cohort study based on data obtained from administrative databases of 16 Local Health Units in Italy (~7.5 million individuals). Patients with schizophrenia or BD ≥18 years of age treated with antipsychotics between 1 January 2008 and 31 December 2009 were included in the primary analysis. Pharmaco-utilisation data were gathered over a follow-up period of 12 months.

RESULTS

Patients with schizophrenia and BD received a wide variety of antipsychotic medications. The proportion of patients on antipsychotic monotherapy was 68% in patients with schizophrenia and 70% in patients with BD. In patients with schizophrenia, ~1/3 of patients receiving antipsychotic monotherapy also received mood stabilisers and/or antidepressants (34.7%) compared with over half of those on antipsychotic polytherapy (52.2%). In patients with BD, use of mood stabilisers and/or antidepressants was even higher; 76.9% of patients receiving antipsychotic monotherapy also received mood stabilisers and/or antidepressants compared with 85.5% of patients on antipsychotic polytherapy. Switch therapy was more frequent in patients with BD than in patients with schizophrenia, whereas add-on therapy was more frequent in patients with schizophrenia than in patients with BD. The mean total disease-related cost per patient per annum was higher in patients with schizophrenia (€4,157) than in patients with BD (€3,301). The number and cost of hospitalisations was higher in patients with BD, whereas the number and cost of nursing home stays was higher in patients with schizophrenia.

CONCLUSION

Use of administrative databases has permitted retrieval of comprehensive information about therapeutic pathways, diagnostic history and costs in patients affected by schizophrenia or BD. A need for personalised treatment pathways has been described.

TRIAL REGISTRATION

clinicaltrials.gov: NCT01392482 ; first received June 29, 2011.

Lifetime mood spectrum symptoms among bipolar patients and healthy controls: a cross sectional study with the Mood Spectrum Self-Report questionnaire

BACKGROUND

The "spectrum" model has advantages for the conceptualization of mental disorders, representing a complementary approach to the currently available categorical systems. We carried out a study in order to assess lifetime mood symptoms among patients with bipolar disorder (BD) and healthy controls from a dimensional perspective.

METHODS

The Mood Spectrum Self-Report instrument (MOODS-SR) was administered to 101 bipolar patients (52 BD I, 32 BD II, and 17 BD NOS, 36 males/65 females, mean age+SD=36.10±13.34 years) and 38 healthy controls (16 males/22females, mean age+SD=35.18±13.70 years). The scores of the different MOOD-SR scales and subscales among patients and controls were compared using non-parametric tests (Mann-Whitney and Kruskal-Wallis).

RESULTS

Bipolar patients scored significantly higher than healthy controls on the total MOOD-SR scores (BD: mean±SD=98.65±22.17; HC: mean±SD=12.92±10.72; p<0.01) and all subdomains. Multiple comparisons revealed lower scores among controls when compared to each one of the subtypes of BD, also regarding the total scores and all subdomains (p<0.01). Comparisons across the different subtypes of BD revealed statistically significant higher scores among BD I patients when compared to BD II and BD NOS patients, only in regard to the total MOOD-SR scores (BD I: mean±SD=102.94±22.79; BD II: mean±SD=93.53±21.97; BD NOS: mean±SD= 94.88±18.68; p=0.03) and two subdomains: mood mania and energy mania.

CONCLUSIONS

These results, although preliminary, suggest that even though the MOODS-SR seems effective in distinguishing BD patients from HC, it is not as good in discriminating different subtypes of BD, especially in respect to lifetime depressive symptoms.

LIMITATIONS

Our sample size was small, and comprised by outpatients. The MOOD-SR measures only lifetime symptoms and does not take into account the progression of mood symptoms or the current mood state of patients.

Efficacy of olanzapine monotherapy in the treatment of bipolar depression with mixed features

BACKGROUND

This analysis investigated the correlations between the efficacy of olanzapine monotherapy and the number of concurrent manic symptoms in patients treated for bipolar depression.

METHODS

Pooled data from 2 placebo-controlled olanzapine studies in patients with bipolar I depression were analyzed (total 1214 patients; 690 olanzapine monotherapy patients and 524 placebo patients). Patients were categorized for mixed features by the number of concurrent manic symptoms at baseline (0, 1 or 2, and ≥3, respectively, as measured by a Young Mania Rating Scale item score ≥1). Efficacy was evaluated by change in Montgomery-Åsberg Depression Rating Scale (MADRS) total score from baseline to 6 weeks.

RESULTS

Least-squares mean differences between olanzapine and placebo in the change of MADRS total scores were -3.76 (p=0.002), -3.20 (p<0.001), and -3.44 (p=0.002) for mixed features 0, 1 or 2, and ≥3, respectively. The response rates for olanzapine versus (vs.) placebo were 52.6% vs. 39.8%, 50.3% vs. 40.0%, and 42.2% vs. 33.7% for mixed features 0, 1 or 2, and ≥3, respectively. The remission rates for olanzapine vs. placebo group were 46.1% vs. 34.3%, 39.5% vs. 32.0%, and 34.8% vs. 24.1% for mixed features 0, 1 or 2, and ≥3, respectively. No significant interaction between mixed features and treatment was seen in the MADRS changes or response and remission rates.

LIMITATIONS

Post hoc analyses of the data from 2 previous randomized clinical studies.

CONCLUSIONS

Olanzapine monotherapy was shown to be effective in the treatment of bipolar depression irrespective of the presence of concurrent manic symptoms.

The DSM: mindful science or mindless power? A critical review

In this paper we review the Diagnostic and Statistical Manual of mental health (DSM), its scientific bases and utility. The concepts of "normality," "pathology," and boundaries between them are critically reviewed. We further use the concepts of mindfulness and mindlessness, and evidence from cognitive and social sciences to investigate the DSM clinical and social impact and we argue against its assigned overpower. We recommend including alternative perspectives to the DSM, such as mindfulness and positive psychology. We also argue for including mindfulness training in psychiatric residency and clinical psychology programs.

Evaluation of the psychometric characteristics of the Spanish version of the Anorectic Behaviour Observation Scale

AIMS

The Anorectic Behaviour Observation Scale (ABOS) was designed to obtain information from relatives about behaviours and attitudes of patients with eating disorders (ED). The aim of this study was to validate the ABOS into Spanish.

METHODS

We evaluated the psychometric characteristics of the Spanish version of the ABOS in a clinical ED sample (239 caregivers of 143 ED patients). Instrument reliability (internal consistency), validity (construct, convergent and discriminant, known groups), responsiveness and goodness-of-fit were measured.

RESULTS

Data from the Spanish population revealed a three-factor structure similar to that of the original ABOS, although the composition of subscales differed somewhat from the original. An ABOS cut-point of 21 was identified. The Cronbach's alpha coefficient for the total ABOS score was 0.81. Correlations with other instruments demonstrated convergent and divergent validity. Among caregivers, the total ABOS score and Factor scores significantly discriminated between anxiety, depression and health-related quality of life, while among ED patients they discriminated between diagnosis, severity and level of ED symptoms - evidence of known-groups validity.

CONCLUSION

These findings suggest that the ABOS can be reliably and validly used in Spain in a number of different clinical contexts, by researchers and clinicians alike.

Overdiagnosis of bipolar disorder: a critical analysis of the literature

Bipolar disorder (BD) is considered one of the most disabling mental conditions, with high rates of morbidity, disability, and premature death from suicide. Although BD is often misdiagnosed as major depressive disorder, some attention has recently been drawn to the possibility that BD could be overdiagnosed in some settings. The present paper focuses on a critical analysis of the overdiagnosis issue among bipolar patients. It includes a review of the available literature findings, followed by some recommendations aiming at optimizing the diagnosis of BD and increasing its reliability.

The symptom structure of bipolar acute episodes: in search for the mixing link

OBJECTIVE

The nature of mixed mood episodes is still a matter of controversy amongst experts. Currently, the approach to this syndrome is mainly categorical and very restrictive. The factor-structure of bipolar mood episodes has not been studied yet. We performed a dimensional analysis of the structure of bipolar episodes aimed at identifying a factor deconstructing mixed episodes; furthermore, we analyzed correlations of factors emerging from the factorial analysis of the Brief Psychiatric Rating Scale (BPRS) with Temperament Evaluation of Memphis-Pisa-Paris-San Diego (TEMPS-A) and predominant polarity.

METHOD

187 consecutive bipolar I inpatients hospitalized for DSM-IV-TR acute mood episodes (depressive, manic or mixed) underwent a standardized assessment, including the 24-item Brief Psychiatric Rating Scale (BPRS 4.0), the 21-item Hamilton Depression Rating Scale (HDRS-21), the Young Mania Rating Scale (YMRS) and the TEMPS-A. Principal factor analysis was performed on BPRS-24 items.

RESULTS

This analysis revealed five factors corresponding to "psychosis", "euphoric mania", "mixity", "dysphoria" and "inhibited depression", capturing 71.89% of the rotated variance. The mixity factor was characterized by higher rates of suicidal ideation, more mixed episodes, higher frequencies of antidepressant (AD) use, depressive predominant polarity and anxious temperament.

DISCUSSION

The factor-structure of the BPRS in inpatients with bipolar I disorder with an acute episode of any type is pentafactorial; one factor identified is the mixity factor, which is independent from other factors and characterized by anxiety and motor hyperactivity and by the absence of motor retardation. Our results should prompt reconsideration of proposals for DSM-5 diagnostic criteria for the mixed features specifier. Limitations of the study include the relative small sample, the absence of drug-naïve patients and the use of rating scales no specific for mixed states.

Mixed states in DSM-5: implications for clinical care, education, and research

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) nomenclature for the co-occurrence of manic and depressive symptoms (mixed states) has been revised in the new DSM-5 version to accommodate a mixed categorical-dimensional concept. The new classification will capture subthreshold non-overlapping symptoms of the opposite pole using a "with mixed features" specifier to be applied to manic episodes in bipolar disorder I (BD I), hypomanic, and major depressive episodes experienced in BD I, BD II, bipolar disorder not otherwise specified, and major depressive disorder. The revision will have a substantial impact in several fields: epidemiology, diagnosis, treatment, research, education, and regulations. The new concept is data-driven and overcomes the problems derived from the extremely narrow definition in the DSM-IV-TR. However, it is unclear how clinicians will deal with the possibility of diagnosing major depression with mixed features and how this may impact the bipolar-unipolar dichotomy and diagnostic reliability. Clinical trials may also need to address treatment effects according to the presence or absence of mixed features. The medications that are effective in treating mixed episodes per the DSM-IV-TR definition may also be effective in treating mixed features per the DSM-5, but new studies are needed to demonstrate it.

Bipolar disorder diagnosis: challenges and future directions

Bipolar disorder refers to a group of affective disorders, which together are characterised by depressive and manic or hypomanic episodes. These disorders include: bipolar disorder type I (depressive and manic episodes: this disorder can be diagnosed on the basis of one manic episode); bipolar disorder type II (depressive and hypomanic episodes); cyclothymic disorder (hypomanic and depressive symptoms that do not meet criteria for depressive episodes); and bipolar disorder not otherwise specified (depressive and hypomanic-like symptoms that do not meet the diagnostic criteria for any of the aforementioned disorders). Bipolar disorder type II is especially difficult to diagnose accurately because of the difficulty in differentiation of this disorder from recurrent unipolar depression (recurrent depressive episodes) in depressed patients. The identification of objective biomarkers that represent pathophysiologic processes that differ between bipolar disorder and unipolar depression can both inform bipolar disorder diagnosis and provide biological targets for the development of new and personalised treatments. Neuroimaging studies could help the identification of biomarkers that differentiate bipolar disorder from unipolar depression, but the problem in detection of a clear boundary between these disorders suggests that they might be better represented as a continuum of affective disorders. Innovative combinations of neuroimaging and pattern recognition approaches can identify individual patterns of neural structure and function that accurately ascertain where a patient might lie on a behavioural scale. Ultimately, an integrative approach, with several biological measurements using different scales, could yield patterns of biomarkers (biosignatures) to help identify biological targets for personalised and new treatments for all affective disorders.

European Network of Bipolar Research Expert Centre (ENBREC): a network to foster research and promote innovative care

Bipolar disorders rank as one of the most disabling illnesses in working age adults worldwide. Despite this, the quality of care offered to patients with this disorder is suboptimal, largely due to limitations in our understanding of the pathology. Improving this scenario requires the development of a critical mass of expertise and multicentre collaborative projects. Within the framework of the European FP7 programme, we developed a European Network of Bipolar Research Expert Centres (ENBREC) designed specifically to facilitate EU-wide studies. ENBREC provides an integrated support structure facilitating research on disease mechanisms and clinical outcomes across six European countries (France, Germany, Italy, Norway, Spain and the UK). The centres are adopting a standardised clinical assessment that explores multiple aspects of bipolar disorder through a structured evaluation designed to inform clinical decision-making as well as being applicable to research. Reliable, established measures have been prioritised, and instruments have been translated and validated when necessary. An electronic healthcare record and monitoring system (e-ENBREC©) has been developed to collate the data. Protocols to conduct multicentre clinical observational studies and joint studies on cognitive function, biomarkers, genetics, and neuroimaging are in progress; a pilot study has been completed on strategies for routine implementation of psycho-education. The network demonstrates 'proof of principle' that expert centres across Europe can collaborate on a wide range of basic science and clinical programmes using shared protocols. This paper is to describe the network and how it aims to improve the quality and effectiveness of research in a neglected priority area.

Improved detection of common variants associated with schizophrenia and bipolar disorder using pleiotropy-informed conditional false discovery rate

Several lines of evidence suggest that genome-wide association studies (GWAS) have the potential to explain more of the "missing heritability" of common complex phenotypes. However, reliable methods to identify a larger proportion of single nucleotide polymorphisms (SNPs) that impact disease risk are currently lacking. Here, we use a genetic pleiotropy-informed conditional false discovery rate (FDR) method on GWAS summary statistics data to identify new loci associated with schizophrenia (SCZ) and bipolar disorders (BD), two highly heritable disorders with significant missing heritability. Epidemiological and clinical evidence suggest similar disease characteristics and overlapping genes between SCZ and BD. Here, we computed conditional Q-Q curves of data from the Psychiatric Genome Consortium (SCZ; n = 9,379 cases and n = 7,736 controls; BD: n = 6,990 cases and n = 4,820 controls) to show enrichment of SNPs associated with SCZ as a function of association with BD and vice versa with a corresponding reduction in FDR. Applying the conditional FDR method, we identified 58 loci associated with SCZ and 35 loci associated with BD below the conditional FDR level of 0.05. Of these, 14 loci were associated with both SCZ and BD (conjunction FDR). Together, these findings show the feasibility of genetic pleiotropy-informed methods to improve gene discovery in SCZ and BD and indicate overlapping genetic mechanisms between these two disorders.

Global prefrontal and fronto-amygdala dysconnectivity in bipolar I disorder with psychosis history

BACKGROUND

Pathophysiological models of bipolar disorder postulate that mood dysregulation arises from fronto-limbic dysfunction, marked by reduced prefrontal cortex (PFC) inhibitory control. This might occur due to both disruptions within PFC networks and abnormal inhibition over subcortical structures involved in emotional processing. However, no study has examined global PFC dysconnectivity in bipolar disorder and tested whether regions with within-PFC dysconnectivity also exhibit fronto-limbic connectivity deficits. Furthermore, no study has investigated whether such connectivity disruptions differ for bipolar patients with psychosis history, who might exhibit a more severe clinical course.

METHODS

We collected resting-state functional magnetic resonance imaging at 3T in 68 remitted bipolar I patients (34 with psychosis history) and 51 demographically matched healthy participants. We employed a recently developed global brain connectivity method, restricted to PFC (rGBC). We also independently tested connectivity between anatomically defined amygdala and PFC.

RESULTS

Bipolar patients exhibited reduced medial prefrontal cortex (mPFC) rGBC, increased amygdala-mPFC connectivity, and reduced connectivity between amygdala and dorsolateral PFC. All effects were driven by psychosis history. Moreover, the magnitude of observed effects was significantly associated with lifetime psychotic symptom severity.

CONCLUSIONS

This convergence between rGBC, seed-based amygdala findings, and symptom severity analyses highlights that mPFC, a core emotion regulation region, exhibits both within-PFC dysconnectivity and connectivity abnormalities with limbic structures in bipolar illness. Furthermore, lateral PFC dysconnectivity in patients with psychosis history converges with published work in schizophrenia, indicating possible shared risk factors. Observed dysconnectivity in remitted patients suggests a bipolar trait characteristic and might constitute a risk factor for phasic features of the disorder.

Are bipolar disorders underdiagnosed in patients with depressive episodes? Results of the multicenter BRIDGE screening study in Germany

BACKGROUND

Recent reports indicate that the prevalence of bipolar disorder (BD) in patients with an acute major depressive episode might be higher than previously thought. We aimed to study systematically all patients who sought therapy for major depressive episode (MDE) within the BRIDGE study in Germany, reporting on an increased number (increased from 2 in the international BRIDGE report to 5) of different diagnostic algorithms.

METHODS

A total of 252 patients with acute MDE (DSM-IV confirmed) were examined for the existence of BD (a) according to DSM-IV criteria, (b) according to modified DSM-IV criteria (without the exclusion criterion of 'mania not induced by substances/antidepressants'), (c) according to a Bipolarity Specifier Algorithm which expands the DSM-IV criteria, (d) according to HCL-32R (Hypomania-Checklist-32R), and (e) according to a criteria-free physician's diagnosis.

RESULTS

The five different diagnostic approaches yielded immensely variable prevalences for BD: (a) 11.6; (b) 24.8%; (c) 40.6%; (d) 58.7; e) 18.4% with only partial overlap between diagnoses according to the physician's diagnosis or HCL-32R with diagnoses according to the three DSM-based algorithms.

CONCLUSIONS

The diagnosis of BD in patients with MDE depends strongly on the method and criteria employed. The considerable difference between criteria-free physician's diagnosis and the remaining algorithms indicate the usefulness of criteria lists within the everyday clinical setting.

LIMITATIONS

Diagnoses based on DSM were only made with checklists. The diagnoses of (hypo-) manic episodes in the patient history were not systematically verifiable by indirect anamnesis.

The quality of life construct in bipolar disorder research and practice: past, present, and possible futures

The quality of life (QoL) construct is becoming more prominent in bipolar disorder (BD) research and practice. Uptake of the construct parallels an earlier trend in schizophrenia research, and coincides with growing interest in psychosocial components of BD's aetiology, phenomenology, and treatment. We argue that, although QoL and symptom measures derive from competing paradigms in mental health (the biopsychosocial and medical model, respectively), they are best seen as complementary. This pluralistic stance is clinically appropriate, and generates important questions for future research.