Psychiatric and medical comorbidities of bipolar disorder

Lifetime prevalence of psychiatric comorbidities in patients with bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Bipolar disorder (BD) is a severe psychiatric disease and part of its burden is related to the high rates of lifetime psychiatric comorbidity (PC), with diagnostic, therapeutic, and prognostic implications.

METHODS

Registered in PROSPERO (CRD42021282356). Meta-analyses were performed, searching for relevant papers published from 1993 to 2022 in Medline/PubMed (including E-Pub Ahead of Print), Embase, Cochrane Library (Central), PsycINFO, Scopus, Web of Science and via hand-searching, without language restrictions. 12.698 studies were initially identified, 114 of which were ultimately chosen based on the eligibility criteria. We performed two meta-analyses (prevalence and risk ratio) of mental health conditions among subjects with BD and then conducted a comprehensive examination of moderator effects using multivariable meta-regression models for moderators identified as significant in the univariable analysis.

FINDINGS

Overall PC prevalence of at least one disorder was 38.91 % (95 % CI 35.24-42.70) and the most frequent disorders were: anxiety (40.4 % [34.97-46.06]), SUD (30.7 % [23.73-38.73]), ADHD (18.6 % [10.66-30.33]) and Disruptive, impulse-control and conduct disorder (15 % [6.21-31.84). The moderators with higher association with individual prevalences were UN's Human Development Index (HDI), female gender, age, suicide attempt, and age at onset (AAO).

INTERPRETATION

It becomes evident that the prevalence of PC among individuals with BD is notably high, surpassing rates observed in the general population. This heightened prevalence persists despite significant heterogeneity across studies. Consequently, it is imperative to redirect clinical focus towards comprehensive mental health assessments, emphasizing personalized and routine screening. Additionally, there is a pressing need for the enhancement of public policies to create a supportive environment for individuals with BD, ensuring better therapeutic conditions and sustained assistance. By addressing these aspects, we can collectively strive towards fostering improved mental health outcomes for individuals with BD.

Bipolar disorder staging and the impact it has on its management: an update

INTRODUCTION

The longitudinal course of bipolar disorder (BD) is associated with an active process of neuroprogression, characterized by structural brain alterations and progressive functional impairment. In the last decades, a growing need of a standardized staging model for BD arose, with the aim of a more appropriate definition of stage-specific clinical manifestations and the identification of more customized therapeutic tools.

AREAS COVERED

The authors review the literature on clinical aspects, neurobiological correlates and treatment issues related to BD progression. Thereafter, they address the definition, constructs, and evolution of the staging concept, focusing on the clinical applications of BD staging models available in literature.

EXPERT OPINION

Although several staging models for BD have been proposed to date, their application in clinical practice is still relatively scant. This may have a detrimental impact on the clinical and therapeutic management of BD, in terms of early and proper diagnosis as well as tailored treatment interventions according to the different stages of illness. Future research efforts should tend to the integration of recent insights on neuroimaging and epigenetic markers, toward a standardized and multidimensional staging model.

Evaluation of three-year neurodevelopmental outcomes in infants prenatally exposed to substance use

INTRODUCTION

Prenatal exposure to substance use is associated with long-term deficits in the neurodevelopment of children. The objective was to investigate the association between cognitive, motor, and language neurodevelopment at three years of age in infants prenatally exposed to substance use.

MATERIAL AND METHODS

A prospective matched case-control study was conducted. Biomarkers of fetal exposure were measured in meconium samples. The Bayley Scales of Infant and Toddler Development (BSID-III) were used to calculate neurodevelopment scores.

RESULTS

32 non-exposed and 32 exposed infants were evaluated, of which 16 were exposed to cannabis, 8 to ethanol, 2 to cocaine and 6 to more than one substance. Normal BSID-III scores ≥85 in all domains, were detected in 23 exposed infants to any substance and 29 infants non-exposed. Neurodevelopmental delay was detected in the language domain, specifically in male infants exposed to cannabis. Two infants exposed to cannabis had a severe developmental delay (score<70). Infants exposed to any substance obtained significantly lower total scores than control infants in all domains. Infants exposed to cannabis obtained significantly lower composite scores in the cognitive and motor domains. Infants exposed to more than one substance had lower scores in motor skills. By gender, only males exposed obtained significantly lower composite scores than non-exposed males in the cognitive domain.

CONCLUSIONS

The most common and severe neurodevelopmental delay at 36 months was detected in the domain of language in male infants prenatally exposed to cannabis. Neurodevelopmental disorders detected can enable an early intervention and plan therapeutic strategies.

Adults with both bipolar disorder and ADHD

ADHD and bipolar disorder (BP) commonly coexist, and both share key symptoms, depending on affective state and emotional dysregulation. The overlap poses diagnostic challenges and may lead to underdiagnoses. Comorbid cases exhibit worsened symptom burden, increased psychiatric morbidity, admissions, and suicide attempts. Treating BP before ADHD is recommended. Stimulant use combined with mood stabilisers may be effective and relatively safe; however, this review finds that well-designed randomised controlled studies in the area is warranted.

Computational markers of risky decision-making predict for relapse to alcohol

BACKGROUND

Relapse remains the major challenge in treatment of alcohol use disorder (AUD). Aberrant decision-making has been found as important cognitive mechanism underlying relapse, but factors associated with relapse vulnerability are unclear. Here, we aim to identify potential computational markers of relapse vulnerability by investigating risky decision-making in individuals with AUD.

METHODS

Forty-six healthy controls and fifty-two individuals with AUD were recruited for this study. The risk-taking propensity of these subjects was investigated using the balloon analog risk task (BART). After completion of clinical treatment, all individuals with AUD were followed up and divided into a non-relapse AUD group and a relapse AUD group according to their drinking status.

RESULTS

The risk-taking propensity differed significantly among healthy controls, the non-relapse AUD group, and the relapse AUD group, and was negatively associated with the duration of abstinence in individuals with AUD. Logistic regression models showed that risk-taking propensity, as measured by the computational model, was a valid predictor of alcohol relapse, and higher risk-taking propensity was associated with greater risk of relapse to drink.

CONCLUSION

Our study presents new insights into risk-taking measurement and identifies computational markers that provide prospective information for relapse to drink in individuals with AUD.

Blood epigenome-wide association studies of suicide attempt in adults with bipolar disorder

Suicide attempt (SA) risk is elevated in individuals with bipolar disorder (BD), and DNA methylation patterns may serve as possible biomarkers of SA. We conducted epigenome-wide association studies (EWAS) of blood DNA methylation associated with BD and SA. DNA methylation was measured at >700,000 positions in a discovery cohort of n = 84 adults with BD with a history of SA (BD/SA), n = 79 adults with BD without history of SA (BD/non-SA), and n = 76 non-psychiatric controls (CON). EWAS revealed six differentially methylated positions (DMPs) and seven differentially methylated regions (DMRs) between BD/SA and BD/non-SA, with multiple immune-related genes implicated. There were no epigenome-wide significant differences when BD/SA and BD/non-SA were each compared to CON, and patterns suggested that epigenetics differentiating BD/SA from BD/non-SA do not differentiate BD/non-SA from CON. Weighted gene co-methylation network analysis and trait enrichment analysis of the BD/SA vs. BD/non-SA contrast further corroborated immune system involvement, while gene ontology analysis implicated calcium signalling. In an independent replication cohort of n = 48 BD/SA and n = 47 BD/non-SA, fold changes at the discovery cohort's significant sites showed moderate correlation across cohorts and agreement on direction. In both cohorts, classification accuracy for SA history among individuals with BD was highest when methylation at the significant CpG sites as well as information from clinical interviews were combined, with an AUC of 88.8% (CI = 83.8-93.8%) and 82.1% (CI = 73.6-90.5%) for the combined epigenetic-clinical classifier in the discovery and replication cohorts, respectively. Our results provide novel insight to the role of immune system functioning in SA and BD and also suggest that integrating information from multiple levels of analysis holds promise to improve risk assessment for SA in adults with BD.

Diagnosis and Treatment of Bipolar Disorder: A Review

Importance

Bipolar disorder affects approximately 8 million adults in the US and approximately 40 million individuals worldwide.

Observations

Bipolar disorder is characterized by recurrent episodes of depression and mania or hypomania. Bipolar depressive episodes are similar to major depressive episodes. Manic and hypomanic episodes are characterized by a distinct change in mood and behavior during discrete time periods. The age of onset is usually between 15 and 25 years, and depression is the most frequent initial presentation. Approximately 75% of symptomatic time consists of depressive episodes or symptoms. Early diagnosis and treatment are associated with a more favorable prognosis. Diagnosis and optimal treatment are often delayed by a mean of approximately 9 years following an initial depressive episode. Long-term treatment consists of mood stabilizers, such as lithium, valproate, and lamotrigine. Antipsychotic agents, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine, are recommended, but some are associated with weight gain. Antidepressants are not recommended as monotherapy. More than 50% of patients with bipolar disorder are not adherent to treatment. Life expectancy is reduced by approximately 12 to 14 years in people with bipolar disorder, with a 1.6-fold to 2-fold increase in cardiovascular mortality occurring a mean of 17 years earlier compared with the general population. Prevalence rates of metabolic syndrome (37%), obesity (21%), cigarette smoking (45%), and type 2 diabetes (14%) are higher among people with bipolar disorder, contributing to the risk of early mortality. The annual suicide rate is approximately 0.9% among individuals with bipolar disorder, compared with 0.014% in the general population. Approximately 15% to 20% of people with bipolar disorder die by suicide.

Conclusions and Relevance

Bipolar disorder affects approximately 8 million adults in the US. First-line therapy includes mood stabilizers, such as lithium, anticonvulsants, such as valproate and lamotrigine, and atypical antipsychotic drugs, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine.

Lifestyle in bipolar disorder: A cross-sectional study

BACKGROUND

Modifiable lifestyle behaviors are important factors for improving mental health, yet there has been a lack of research studying lifestyle as a multidimensional construct in bipolar disorder (BD). The aim of this cross-sectional study was to compare the lifestyle patterns of individuals with BD in a current mood episode with healthy controls (HCs) using the Short Multidimensional Inventory Lifestyle Evaluation (SMILE).

MATERIALS AND METHODS

The sample consisted of 46 individuals with BD currently experiencing a depressive or manic episode and 50 HC, assessed using the MINI International Neuropsychiatric Interview, Montgomery-Åsberg Depression Rating Scale (MADRS), and the Young Mania Rating Scale (YMRS). The SMILE scale assesses lifestyle across seven domains: diet and nutrition, substance abuse, physical activity, stress management, restorative sleep, social support, and environmental exposures. Between-groups comparisons were performed based on the presence of a psychiatric diagnosis and the type of BD episode.

RESULTS

We found significant differences in the total SMILE score (r=0.75, p<0.001) and in scores from each domain of the scale between BD and HC (p<0.05), where individuals with BD in a depressive or manic episode with or without mixed features reported worse lifestyle across all domains. Differences between individuals with BD in different mood episodes across domains on the SMILE scale were non-significant.

CONCLUSION

Findings from this study highlight the presence of unhealthy lifestyle patterns in people with BD regardless of the polarity of their mood episode. Implementation of multidimensional lifestyle assessments is an essential step toward detecting the clustering of unhealthy lifestyle patterns in BD.

Morphological abnormalities in youth with bipolar disorder and their relationship to clinical characteristics

OBJECTIVES

To characterize the neuroanatomy of BD in youth and its correlation to clinical characteristics.

METHODS

The current study includes a sample of 105 unmedicated youth with first-episode BD, aged between 10.1 and 17.9 years, and 61 healthy comparison adolescents, aged between 10.1 and 17.7 years, who were matched for age, race, sex, socioeconomic status, intelligence quotient (IQ), and education level. T1-weighted magnetic resonance imaging (MRI) images were obtained using a 4 T MRI scanner. Freesurfer (V6.0) was used to preprocess and parcellate the structural data, and 68 cortical and 12 subcortical regions were considered for statistical comparisons. The relationship between morphological deficits and clinical and demographic characteristics were evaluated using linear models.

RESULTS

Compared with healthy youth, youth with BD had decreased cortical thickness in frontal, parietal, and anterior cingulate regions. These youth also showed decreased gray matter volumes in 6 of the 12 subcortical regions examined including thalamus, putamen, amygdala and caudate. In further subgroup analyses, we found that youth with BD with comorbid attention-deficit hyperactivity disorder (ADHD) or with psychotic symptoms had more significant deficits in subcortical gray matter volume.

LIMITATIONS

We cannot provide information about the course of structural changes and impact of treatment and illness progression.

CONCLUSIONS

Our findings indicate that youth with BD have significant neurostructural deficits in both cortical and subcortical regions mainly located in the regions related to emotion processing and regulation. Variability in clinical characteristics and comorbidities may contribute to the severity of anatomic alterations in this disorder.

Alcohol use disorders in patients with bipolar disorder: a systematic review and meta-analysis

Alcohol consumption has a key role in more than 200 diseases and health injuries, being an important factor for social and public health costs. Studies with clinical populations show an association between alcohol use disorders (AUD) and bipolar disorder. In this meta-analysis we included studies, reports, or summaries identified in Google Scholar, Lilacs, Medline, and MedCaribe that reported original data published up to 31 January 2023. We included cross-sectional and longitudinal observational studies that investigated the prevalence of AUD in patients with bipolar disorder. We calculated the prevalence rates and conducted a meta-analysis using a random effects model. The meta-analysis included 20 unique studies conducted in 12 countries, with a total sample of 32,886 individuals with bipolar disorder, comprising 17,923 women and 13,963 men, all aged 18 years or older. The prevalence of AUD in individuals with bipolar disorder was found to be 29.12%, while the prevalence of Alcohol Dependence (AD) was 15.87% and the prevalence of Alcohol Abuse (AA) was 18.74%. The high prevalence of AUD individuals with bipolar disorder is important because it highlights the need for targeted interventions to prevent and address comorbid conditions, which may improve treatment outcomes, reduce harm, and promote public health.

Blood epigenome-wide association studies of suicide attempt in adults with bipolar disorder

Suicide attempt (SA) risk is elevated in individuals with bipolar disorder (BD), and DNA methylation patterns may serve as possible biomarkers of SA. We conducted epigenome-wide association studies (EWAS) of blood DNA methylation associated with BD and SA. DNA methylation was measured at > 700,000 positions in a discovery cohort of n = 84 adults with BD with a history of SA (BD/SA), n = 79 adults with BD without history of SA (BD/non-SA), and n = 76 non-psychiatric controls (CON). EWAS revealed six differentially methylated positions (DMPs) and seven differentially methylated regions (DMRs) between BD/SA and BD/non-SA, with multiple immune-related genes implicated. There were no epigenome-wide significant differences when BD/SA and BD/non-SA were each compared to CON, and patterns suggested that epigenetics differentiating BD/SA from BD/non-SA do not differentiate BD/non-SA from CON. Weighted gene co-methylation network analysis and trait enrichment analysis of the BD/SA vs. BD/non-SA contrast further corroborated immune system involvement, while gene ontology analysis implicated calcium signalling. In an independent replication cohort of n = 48 BD/SA and n = 47 BD/non-SA, fold-changes at the discovery cohort's significant sites showed moderate correlation across cohorts and agreement on direction. In both cohorts, classification accuracy for SA history among individuals with BD was highest when methylation at the significant CpG sites as well as information from clinical interviews were combined, with an AUC of 88.8% (CI = 83.8-93.8%) and 82.1% (CI = 73.6-90.5%) for the combined epigenetic-clinical predictor in the discovery and replication cohorts, respectively. Our results provide novel insight to the role of immune system functioning in SA and BD and also suggest that integrating information from multiple levels of analysis holds promise to improve risk assessment for SA in adults with BD.

Independent Predictors of 30-Day Readmission to Acute Psychiatric Wards in Patients With Mental Disorders: A Systematic Review and Meta-Analysis

Psychiatric readmissions have long been considered significant indicators for healthcare planning. The aim of this study was to identify factors influencing early (30-day) readmissions to acute psychiatric wards. A meta-analysis and systematic review were conducted according to Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Comprehensive database searching was conducted using online databases, including PubMed and Google Scholar, to search for articles identifying factors associated with early (30-day) readmissions to acute psychiatric wards. Keywords used to search for relevant articles included "Mental illness," "readmission," and factors along with their synonyms and Medical Subject Headings (MeSH) terms. The search included studies published between 2011 and June 2023. A total of 13 studies were included in this meta-analysis. The pooled rate of the 30-day readmission was 16% (95% confidence interval: 13%-20%). A pooled analysis showed that factors significantly associated with an unplanned hospital readmission included gender, length of stay, and insurance status as predictors of the unplanned hospital readmission among individuals with psychiatric illness. Additionally, we also found that the rate of 30-day unplanned admissions was greater in patients with schizophrenia, followed by personality disorder, bipolar disorder, depression, and substance use. This study highlights the importance of providing targeted interventions and support for individuals with these conditions to reduce the risk of readmissions.

The Manic Idea Creator? A Review and Meta-Analysis of the Relationship between Bipolar Disorder and Creative Cognitive Potential

Even though a relationship between psychopathology and creativity has been postulated since the time of ancient Greece, systematic meta-analyses on this topic are still scarce. Thus, the meta-analysis described here can be considered the first to date that specifically focuses on the relationship between creative potential, as measured by divergent thinking, and bipolar disorder, as opposed to psychopathology in general. An extensive literature search of 4670 screened hits identified 13 suitable studies, including a total of 42 effect sizes and 1857 participants. The random-effects model showed an overall significant, positive, yet diminutively small effect (d = 0.11, 95% CI: [0.002, 0.209], p = 0.045) between divergent thinking and bipolar disorder. A handful of moderators were examined, which revealed a significant moderating effect for bipolar status, as either euthymic (d = 0.14, p = 0.043), subclinical (d = 0.17, p = 0.001), manic (d = 0.25, p = 0.097), or depressed (d = -0.51, p < 0.001). However, moderator analyses should be treated with caution because of the observed confounding of moderators. Finally, none of the employed methods for publication-bias detection revealed any evidence for publication bias. We discuss further results, especially regarding the differences between subclinical and clinical samples.

Crossed clinical features between eating disorders and types of bipolar disorder: Results from the FondaMental Advanced Centers of Expertise - Bipolar Disorder cohort

BACKGROUND

Eating disorders (EDs) are liable to alter the disease course of bipolar disorder (BD). We explored the crossed clinical features between EDs and BD, particularly as a function of BD type (BD1 vs. BD2).

METHODS

2929 outpatients attending FondaMental Advanced Centers of Expertise were assessed for BD and lifetime EDs with a semi-structured interview, and their sociodemographic, dimensional and clinical data were collected according to a standardized procedure. For each ED type, bivariate analyses were used to investigate associations between these variables and the type of BD type followed by multinomial regressions with the variables associated with EDs and BDs after Bonferroni correction.

RESULTS

Comorbid EDs were diagnosed in 478 (16.4 %) cases, and were more prevalent in patients with BD2 than in those with BD1 (20.6 % vs. 12.4 %, p < 0.001). Regression models showed no difference according to the subtype of bipolar disorder on the characteristics of patients with anorexia nervosa (AN), bulimia nervosa (BN) or binge eating disorder (BED). After multiple adjustments, the factors differentiating BD patients with versus without ED were primarily age, gender, body mass index, more affective lability and comorbidity with anxiety disorders. BD patients with BED also scored higher regarding childhood trauma. BD patients with AN also showed higher risk of past suicide attempts than those with BED.

CONCLUSIONS

In a large sample of patients with BD, we found a high prevalence of lifetime EDs, especially for the BD2 type. EDs were associated with several severity indicators, but not with BD type-specific characteristics. This should prompt clinicians to carefully screen patients with BD for EDs, regardless of BD and ED types.

Insulin resistance in bipolar disorder: A systematic review of illness course and clinical correlates

BACKGROUND

Although insulin resistance (IR) and cardiometabolic syndrome are prevalent in patients with bipolar disorder (BD), only a few studies have attempted to precisely assess the degree and clinical impact of IR in BD.

METHODS

A comprehensive search was conducted from multiple research databases through May 2022, following a pre-defined protocol (PROSPERO: CRD42022359259). We extracted neuroimaging, cognition, illness course, and treatment response findings from individuals with BD with evidence of IR compared with euglycemic BD individuals.

RESULTS

Of 1436 identified articles, 10 reports fulfilling inclusion criteria were included (n = 1183). BD patients with IR displayed worse composite verbal memory scores and worse executive function and exhibited smaller hippocampal volumes along with prefrontal neurochemical alterations compared to euglycemic BD patients. Fixed-effect meta-analysis revealed that BD patients with impaired glucose metabolism (IGM) were more likely to develop a chronic and rapid cycling course when compared with euglycemic BD patients (k = 2, OR = 2.96, 95 % CI 1.69-5.17, OR = 2.88, 95 % CI 1.59-5.21, p < 0.001, respectively), with a trend for significantly lower Global Assessment of Functioning scores (k = 5, MD = -4, 95 % CI -8.23-0.23, p = 0.06). BD patients with IGM displayed a higher rate of poor response to mood stabilizers when compared with euglycemic BD patients (k = 2, OR = 6.74, 95 % CI 1.04-43.54, p = 0.04).

LIMITATIONS

Cross-sectional design and small sample sizes of studies included limit the generalizability of results.

CONCLUSION

IR is associated with worse clinical outcomes of BD and inadequate treatment response. Implementing strategies to prevent and treat IR in BD is crucial to improve the prognosis of such a difficult-to-treat population.

An update on potential pharmacotherapies for cognitive impairment in bipolar disorder

INTRODUCTION

Cognitive impairment is a core feature of bipolar disorder (BD) that impedes recovery by preventing the return to optimal socio-occupational functioning and reducing quality of life. Presently, there are no efficacious treatments for cognitive impairment in BD, but many pharmacological interventions are being considered as they have the potential to target the underlying pathophysiology of the disorder.

AREAS COVERED

This review summarizes the available evidence for pharmacological interventions for cognitive impairment in bipolar disorder. We searched PubMed, MedLine, and PsycInfo from inception to December 1^st, 2022. Traditional treatments, such as lithium, anticonvulsants (lamotrigine), antipsychotics (aripiprazole, asenapine, cariprazine, lurasidone, and olanzapine), antidepressants (vortioxetine, fluoxetine, and tianeptine) and psychostimulants (modafinil), and emerging interventions, such as acetylcholinesterase inhibitors (galantamine and donepezil), dopamine agonists (pramipexole), erythropoietin, glucocorticoid receptor antagonists (mifepristone), immune modulators (infliximab, minocycline and doxycycline), ketamine, metabolic agents (insulin, metformin, and liraglutide), probiotic supplements, and Withania somnifera are discussed.

EXPERT OPINION

The investigation of interventions for cognitive impairment in BD is a relatively under-researched area. In the past, methodological pitfalls in BD cognition trials have also been a critical limiting factor. Expanding on the existing literature and identifying novel pharmacological and non-pharmacological treatments for cognitive impairment in BD should be a priority.

Role of DSM5 anxious distress specifier interview in acute manic episode: sociodemographic characteristics, clinical presentation and quality of life

Background

DSM 5 anxious distress specifier is one of the newly added specifiers for bipolar and related disorders. It may have impacts on the symptoms severity, insight, impulsivity, and different domains of quality of life of acute manic episodes of bipolar disorders. The current study aimed to study the effects of DSM 5 anxious distress specifier in acute manic episodes and its relation to sociodemographic data, clinical characteristics, and quality of life. 380 patients with the diagnosis of acute manic episode were recruited in the study, sociodemographic data, clinical features, DSM 5 anxious distress specifier interview, attitude and insight of the disorder, impulsivity and different aspects of quality of life were also evaluated in those patients.

Results

The studied patients were divided into 2 subgroups according to the presence of high DSM5 anxious distress specifier interview score. The duration of a manic episode (P < 0.001), the severity of the manic episode (P < 0.001), and the presence of psychotic features (P = 0.002) were more common in the subgroup with high DSM 5 anxious distress. DSM 5 anxious distress specifier was severe (P < 0.001) and more frequent (P < 0.001) in the 1st subgroup than the 2nd one. There was a statistically significant difference regarding the attentional facet of the Barratt impulsiveness scale between the studied groups (P = 0.002). In addition, there was a statistically significant difference regarding the mean score (P < 0.001) and severe impairment (P < 0.001) domains of work and social adjustment scale between the 2 subgroups.

Conclusions

DSM 5 anxious distress specifier interview is a very crucial parameter of evaluation the patients with acute manic episodes which may have implications on the clinical presentations, symptoms severity, impulsivity, and variable aspects of quality of life in those patients. All these implications might change the course, prognosis, and outcomes of an acute manic episode of bipolar disorder.

Biomarkers of neuroprogression and late staging in bipolar disorder: A systematic review

BACKGROUND

Bipolar disorder may undertake a progressive course in a subset of patients, and research efforts have been made to understand the biological basis underlying this process. This systematic review examined the literature available on biological markers associated with illness progression in bipolar disorder.

METHODS

Peer-reviewed articles were assessed using Embase, PsycINFO and PubMed, as well as from external sources. After initial screening, a total of 871 citations from databases and other sources were identified. Participants with a diagnosis of bipolar disorder were included in our systematic review; however, studies with participants younger than 15 or older than 65 were excluded. All studies were assessed using the Newcastle-Ottawa Scale assessment tool, and data pertaining to the results were extracted into tabular form using Google Sheets and Google Documents. The systematic review was registered on PROSPERO international prospective register of systematic reviews (ID Number: CRD42020154305).

RESULTS

A total of 35 studies were included in the systematic review. Increased ventricular size and reduction of grey matter volume were the most common brain changes associated with illness progression in bipolar disorder. Among the several biomarkers evaluated in this systematic review, findings also indicate a role of peripheral inflammatory markers in this process.

DISCUSSION

The studies evaluating the biological basis of the illness progression in bipolar disorder are still scarce and heterogeneous. However, current evidence supports the notion of neuroprogression, the pathophysiological process related to progressive brain changes associated with clinical progression in patients with bipolar disorder. The increase in peripheral inflammatory biomarkers and the neuroanatomical changes in bipolar disorder suggest progressive systemic and structural brain alterations, respectively.

Cardiometabolic and endocrine comorbidities in women with bipolar disorder: A systematic review

INTRODUCTION

Bipolar Disorder (BD) is known to be equally distributed among males and females. The well-documented increased risk of medical comorbidities in patients with BD, in comparison to BD patients without medical comorbidities, shows a negative impact on the course of illness. There is some evidence suggesting that women with BD have higher psychiatric and medical comorbidities in comparison to men with BD, however there is no evidence in comparison to women without BD or other major psychiatric illness. These comorbidities, along with various psychosocial factors, are known to affect the course of BD.

METHODS

We aimed to systematically review the literature on cardiovascular, metabolic and endocrine comorbidities in women with BD in comparison to men with BD and control women. A comprehensive search of electronic databases including PubMed, PsycINFO, Embase, and SCOPUS was conducted, and a total of 61 identified studies were included in this review.

RESULTS

Women with BD had higher rates of cardiovascular risk factors/mortality, diabetes mellitus II and thyroid disorders compared to women in the general population. In comparison to men with BD, women with BD had comparable cardiovascular risk but higher prevalence of metabolic and thyroid disorders.

LIMITATIONS

Gender specific data was limited in multiple studies.

CONCLUSIONS

Results present a need for gender-specific screening and interventions for various medical comorbidities in patients with BD.

Impact of Preexisting Alcohol Use Disorder, Bipolar Disorder, and Schizophrenia on Ischemic Stroke Risk and Severity: A Lebanese Case-Control Study

BACKGROUND

Stroke remains a major leading cause of morbidity and death globally. For ischemic stroke, the most frequent type of stroke, there are numerous risk models and risk assessments offered. Further research into potential risk factors or triggers is being sought to improve stroke risk models. Schizophrenia, bipolar disorder, and alcohol use disorder are all common causes of serious mental illnesses in the general population. Due to the tangled relationship between stroke and many chronic illnesses, lifestyle factors, and diet that may be present in a patient with a mental disease, the relationship between mental diseases and stroke requires further validation. Consequently, the purpose of this study is to assess the potential influence of bipolar disorder, schizophrenia, and alcohol use disorder on stroke patients as compared to non-stroke participants, after controlling for demographic, physical, and medical conditions. We aimed, as a secondary objective, to evaluate the impact of these pre-existing disorders on stroke severity levels.

METHODS

This research is a case-control survey study involving 113 Lebanese patients with a clinical diagnosis of ischemic stroke and 451 gender-matched volunteers without clinical signs of stroke as controls recruited from several hospitals in Lebanon (April 2020-April 2021). Based on the participant's consent, data was collected by filling out an anonymous paper-based questionnaire.

RESULTS

All of the odds ratios (ORs) generated by our regression model were greater than 1, indicating that the factors studied were associated with an increased risk of ischemic stroke. As such having schizophrenia (adjusted OR [aOR]: 6.162, 95% confidence interval [CI]: 1.136-33.423), bipolar disorder (aOR: 4.653, 95% CI: 1.214-17.834), alcohol use disorder (aOR: 3.918, 95% CI: 1.584-9.689), atrial fibrillation (aOR: 2.415, 95% CI: 1.235-4.721), diabetes (aOR: 1.865, 95% CI: 1.117-3.115), heart diseases (aOR: 9.890, 95% CI: 5.099-19.184), and asthma-COPD (aOR: 1.971, 95% CI: 1.190-3.263) were all involved with a high risk of developing an ischemic stroke. Moreover, obesity (aOR: 1.732, 95% CI: 1.049-2.861) and vigorous physical activity (aOR: 4.614, 95% CI: 2.669-7.978) were also linked to an increased risk of stroke. Moreover, our multinomial regression model revealed that the odds of moderate to severe/severe stroke were significantly higher in people with pre-stroke alcohol use disorder (aOR: 1.719, 95% CI: 1.385-2.133), bipolar disorder (aOR: 1.656, 95% CI: 1.281-2.141), and schizophrenia (aOR: 6.884, 95% CI: 3.294-11.492) compared to people who had never had a stroke.

CONCLUSION

The findings in our study suggest that individuals with schizophrenia, bipolar disorder, and alcohol use disorder may be at a higher risk for ischemic stroke and exhibit more severe symptoms. We believe that the first step toward creating beneficial preventative and treatment interventions is determining individuals with schizophrenia, bipolar disorder, or alcohol use disorder, assessing their risk of ischemic stroke, developing more integrated treatments, and closely monitoring the long-term outcome in the event of an ischemic stroke.

Psychiatric comorbidity in individuals with bipolar disorder: relation with clinical outcomes and functioning

The aim was to assess the lifetime prevalence of psychiatric comorbidity (PC) in Brazilian euthymic individuals with bipolar disorder type I, and investigate its effects on clinical outcomes and functioning. A group of 179 outpatients with BD-I in the recuperation phase were assessed, of whom 75 (41.9%) had PC and 104 (58.1%) had not. Both groups were compared using sociodemographic/clinical questionnaire, Structured Clinical Interview for DSM-IV axis I and II, Sheehan Disability and Barratt Impulsiveness Scales. Patients with PC presented less religious affiliation, more history of lifetime psychotic symptoms, rapid cycling, suicide attempts, worse scores of functioning, and higher prevalence of personality disorders. Ordinal logistic regression indicated that PC was associated with increased odds of worse levels of disability. Therefore, it could be observed that patients with BD evaluated only in euthymia presented a high mental disorders comorbidity. Considering their burdensome impact, appropriate management is a challenging reality and a crucial factor in reducing morbidity and mortality associated with BD. Further longitudinal studies on their relationship may broaden interventions to reduce patient's suffering.

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.

Sex-specific associations between lifetime diagnosis of bipolar disorder and cardiovascular disease: A cross-sectional analysis of 257,673 participants from the UK Biobank

BACKGROUND

Sex is seldom considered as a potential moderator of the impact of bipolar disorder (BD) on cardiovascular disease (CVD) risk. We aimed to characterize the sex-specific association of CVD and BD using data from the UK Biobank.

METHODS

In a cross-sectional analysis, we compared the odds ratio between women and men with BD for seven CVD diagnoses (coronary artery disease, myocardial infarction, angina, atrial fibrillation, heart failure, stroke, and essential hypertension) and four cardiovascular biomarkers (arterial stiffness index, low-density lipoprotein, C-reactive protein, and HbA1c) in 293 participants with BD and 257,380 psychiatrically healthy controls in the UK Biobank.

RESULTS

After adjusting for age, we found a two- to three-fold stronger association among women than among men between BD and rates of coronary artery disease, heart failure, and essential hypertension, with a significant sex-by-diagnosis interactions. The association remained significant after controlling for self-reported race, education, income, and smoking status. After controlling for potential confounders, there was no significant association between sex and any cardiovascular biomarkers.

LIMITATIONS

These analyses could not disentangle effects of BD from its treatment.

CONCLUSIONS

Our results underscore the importance of incorporating sex and mental illness in risk estimation tools for CVD, and improving screening for, and timely treatment of, CVD in those with BD. Future research is needed to better understand the contributors and mechanisms of sex differences related to CVD risk in BD.

Predictors of behavioral health unit readmission within 30 days of discharge: A retrospective study

Several studies have aimed to describe associated demographic and psychiatric risk factors that would lead to readmission to a behavioral health unit within 30 days of discharge. Here we considered 1,095 patients that were discharged from Millcreek Community Hospital (MCH) in Erie, Pennsylvania between June 2018 and June 2019. We extracted electronic medical data and analyzed various risk factors using a SPSS software and performed Chi square analysis to determine significance. We determined that patients between the age 30–39 that were diagnosed with major depressive disorder or bipolar disorder, and patients that had 12 or more previous behavioral health admissions were significantly more likely to be readmitted within 30 days of discharge. By analyzing risk factors that lead to a higher percentage of readmission rates, physicians can be more readily equipped and prepared while treating inpatient psychiatric patients. These physicians can take more precautionary measures when discharging patients with specific characteristic profiles to prevent the risk of being readmitted within 30 days of discharge.

Falls in community-dwelling women with bipolar disorder: a case-control study

BACKGROUND

Falls are a common occurrence in psychiatric hospital settings, however population-based research among individuals with psychiatric disorders, in particular bipolar disorder (BD) is scant. Thus, we aimed to investigate falls risk in community-dwelling women diagnosed with BD.

METHODS

Women with BD (cases, n = 119) were recruited from health care settings located in southeast Victoria, Australia. Age-matched controls (n = 357, ratio 3:1) without BD were participants in the Geelong Osteoporosis Study drawn from the same geographical region. Lifetime history of BD was identified by semi-structured clinical interview (SCID-IV/NP). Previous 12-month falls data were obtained via questionnaire. Information on mobility, alcohol use, general health, medication use, blood pressure, body mass index, socioeconomic status and use of a walking aid was collected. Generalised Estimating Equations, binary and ordinal logistic regression were used to determine the odds ratio (OR) and 95% confidence interval (CI) for falls following adjustment for confounders.

RESULTS

During the 12-month period, 34 (28.6%, median age 48.4 yr) cases and 70 (19.6%, median age 49.1 yr) controls reported one fall; 22 (18.5%) cases and 18 (5.0%) controls reported ≥ two falls (p < 0.001). Cases had 2.5-fold increased odds of at least one fall and 2.9-fold increased likelihood of increasing falls categories (0 vs. 1 vs. 2 +), compared to controls [adjOR 2.5, 95%CI (1.8, 3.4), adjOR OR 2.9, 95%CI (2.0, 4.1)].

CONCLUSION

Risk of falls was greater among women with BD. Balance training could be a research and clinical focus for falls prevention programs among women with bipolar disorder to prevent the detrimental outcomes associated with falling.

Index of multiple deprivation contributed to common psychiatric disorders: A systematic review and comprehensive analysis

BACKGROUND

Limited studies have been conducted to explore the interaction effects of social environmental and genetic factors on the risks of common psychiatric disorders.

METHODS

56,613-106,695 individuals were collected from the UK Biobank cohort. Logistic or liner regression models were first used to evaluate the associations of index of multiple deprivation (IMD) with bipolar disorder (BD), depression and anxiety in UK Biobank cohort. Then, for the significant IMD associated with BD, depression and anxiety, genome-wide gene-environment interaction study (GWEIS) was performed by PLINK 2.0.

RESULT

Totally, the higher levels of IMD were significantly associated with higher risks of BD, depression and anxiety. For BD, GWEIS identified multiple significant SNPs interacting with IMD, such as rs75182167 for income and rs111841503 for education. For depression and anxiety, GWEIS found significant SNPs interacting with income and education, such as rs147013419 for income and rs142366753 for education.

CONCLUSION

Social environmental deprivations contributed to the risks of psychiatric disorders. Besides, we reported multiple candidate genetic loci interacting with IMD, providing novel insights into the biological mechanism.

Strategies and foundations for scientific discovery in longitudinal studies of bipolar disorder

Bipolar disorder (BD) is a complex and dynamic condition with a typical onset in late adolescence or early adulthood followed by an episodic course with intervening periods of subthreshold symptoms or euthymia. It is complicated by the accumulation of comorbid medical and psychiatric disorders. The etiology of BD remains unknown and no reliable biological markers have yet been identified. This is likely due to lack of comprehensive ontological framework and, most importantly, the fact that most studies have been based on small nonrepresentative clinical samples with cross-sectional designs. We propose to establish large, global longitudinal cohorts of BD studied consistently in a multidimensional and multidisciplinary manner to determine etiology and help improve treatment. Herein we propose collection of a broad range of data that reflect the heterogenic phenotypic manifestations of BD that include dimensional and categorical measures of mood, neurocognitive, personality, behavior, sleep and circadian, life-story, and outcomes domains. In combination with genetic and biological information such an approach promotes the integrating and harmonizing of data within and across current ontology systems while supporting a paradigm shift that will facilitate discovery and become the basis for novel hypotheses.

Long-term work disability due to type I and II bipolar disorder: findings of a six-year prospective study

Background

Bipolar disorder (BD) is one of the leading causes of disability worldwide. However, the prevalence and predictors of long-term work disability among patients with type I and II BD have scarcely been studied. We investigated the clinical predictors of long-term work disability among patients with BD.

Methods

The Jorvi Bipolar Study (JoBS) is a naturalistic prospective cohort study (n = 191) of adult psychiatric in- and out-patients with DSM-IV type I and II BD in three Finnish cities. Within JoBS we examined the prevalence and predictors of disability pension being granted during a six-year follow-up of the 152 patients in the labor force at baseline and collected information on granted pensions from national registers. We determined the predictors of disability pension using logistic regression models.

Results

Over the 6 years, 44% of the patients belonging to the labor force at baseline were granted a disability pension. Older age; type I BD; comorbidity with generalized anxiety disorder, post-traumatic stress disorder or avoidant personality disorder; and duration of time with depressive or mixed symptoms predicted disability pensions. Including disability pensions granted before baseline increased their total prevalence to 55.5%. The observed predictors were similar.

Conclusion

This regionally representative long-term prospective study found that about half of patients with type I or II bipolar disorder suffer from persistent work disability that leads to disability pension. In addition to the severity of the clinical course and type I bipolar disorder, the longitudinal accumulation of time depressed, psychiatric comorbidity, and older age predicted pensioning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00264-6.

Psychiatric comorbidity and quality of life in patients with bipolar disorder

BACKGROUND

Psychiatric comorbidity in patients with bipolar disorder (BD) has been associated with an earlier onset, rapid cycling, worsening severity and outcome, and increased suicidality. Patients with BD have been reported to have poor quality of life (QOL) even during remission.

AIMS AND OBJECTIVES

Estimate the prevalence of psychiatric comorbidity and assess the QOL in patients with BD, and find the associated sociodemographic and clinical variables.

MATERIALS AND METHODS

This cross-sectional study was done in a general hospital psychiatric unit on 100 patients (both inpatients and outpatients) with DSM-IV-TR BD in partial or complete remission. Patients were assessed using a semi-structured pro forma, Mini International Neuropsychiatric Interview 6.0 - Hindi version, Hamilton Rating Scale for Depression or Young Mania Rating Scale and World Health Organization QOL instrument, short-form (WHOQOL-BREF), Hindi Version.

RESULTS

Sixty-one percent of the sample had at least one psychiatric comorbidity, and the commonest comorbid disorders were substance use disorders (SUD) (30%) and anxiety disorders (AD) (28%). Male gender was identified as a predictor for comorbidity in BD. The mean QOL-BREF score was 85.96 ± 14.35. Poor QOL was associated with older age at onset of comorbidity, multiple comorbidities, mixed episodes, rapid cycling, partial remission, and increased severity of depression while patients with current hypomanic symptoms were found to have better QOL. BD with comorbidity had worse QOL than those without comorbidity.

CONCLUSION

The majority of patients with BD had at least one comorbidity. SUD were the most common comorbid disorders. QOL, already poor in BD patients, was poorer in cases with comorbidity.

Clinical profiles of subsequent stages in bipolar disorder: Results from the Dutch Bipolar Cohort

INTRODUCTION

The manifestation of bipolar disorder (BD) is hypothesized to be determined by clinical characteristics such as familial loading, childhood abuse, age at onset, illness duration, comorbid psychiatric disorders, addiction, treatment resistance, and premorbid cognitive functioning. Which of these are associated with a more severe course and worse outcome is currently unknown. Our objective is to find a combination of clinical characteristics associated with advancement to subsequent stages in two clinical staging models for BD.

METHODS

Using cross-sectional data from the Dutch Bipolar Cohort, staging was applied to determine the progression of bipolar-I-disorder (BD-I; N = 1396). Model A is primarily defined by recurrence of mood episodes, ranging from prodromal to chronicity. Model B is defined by level of inter-episodic functioning, ranging from prodromal to inability to function autonomously. For both models, ordinal logistic regression was conducted to test which clinical characteristics are associated with subsequent stages.

RESULTS

For model A, familial loading, childhood abuse, earlier onset, longer illness duration, psychiatric comorbidity, and treatment resistance were all predictors for a higher stage in contrast to addiction and cognitive functioning. For model B, childhood abuse, psychiatric comorbidity, cognitive functioning, and treatment resistance were predictors for a more severe stage, whereas age at onset, illness duration, and addiction were not.

DISCUSSION/CONCLUSIONS

Differences in clinical characteristics across stages support the construct validity of both staging models. Characteristics associated with a higher stage largely overlapped across both models. This study is a first step toward determining different clinical profiles, with a corresponding course and outcome.

Do psychological interventions reduce symptoms of depression for patients with bipolar I or II disorder? A meta-analysis

BACKGROUND

Psychological therapies may play an important role in the treatment of bipolar disorders. Several meta-analyses that examine the effectiveness of psychotherapies for patients with bipolar disorder include conclusions about the impact upon bipolar depression. However, these tend not to consider differences in depression outcome depending upon whether the therapy primarily targets acute depression, nor severity of baseline depression. This may affect the conclusions drawn about the effectiveness of these therapies for acute bipolar depression treatment.

OBJECTIVES

This meta-analysis explored the effectiveness of psychological therapies in reducing bipolar depression, in particular examining whether: (1) the effect of therapy is greater when baseline depressive symptoms are more severe, and (2) the effect of therapy is greater when the primary focus of the therapy is the treatment of acute bipolar depression?

DATA SOURCES

A systematic search was conducted using the following electronic databases; Cochrane Controlled Register of Trials (1996), MEDLINE (1966 onwards), EMBASE (1980 onwards), PsycINFO (1974 onwards), Scopus, Web of Science and Clinical Trials Registries (listed at:https://www.hhs.gov/ohrp/international/clinical-trial-registries/index.html).

ELIGIBILITY CRITERIA

Eligible studies were randomized controlled trials evaluating a psychological intervention for adults diagnosed with Bipolar I or II disorder. The comparators were usual care, wait-list, placebo, active treatment control. Post-treatment depression status was required to be measured continuously using a validated self- or observer- report measure, or categorically by a validated diagnostic instrument or clinical diagnosis by a suitably qualified person.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts were screened, followed by full texts. Two reviewers conducted each stage until agreement was reached, and both independently extracted study information. Means, standard deviations (SDs) and number of participants were retrieved from articles and used to perform a meta-analysis. The primary outcome was depressive symptom score.

RESULTS

The database search identified 6388 studies. After removing the duplicates, 3298 studies remained, of which, 28 studies were included in the qualitative review and 22 in the meta-analysis. Effect sizes range from -1.99 [-2.50, -1.49] to 0.89 [-0.12, 1.90]. There was low quality evidence of a significant effect on symptoms of depression for cognitive behavioral therapy and dialectical behavior therapy. Trials of psychoeducation, mindfulness-based therapy, family therapy and interpersonal and social rhythm therapy showed no evidence of any effect on depression. We found no significant relationship between baseline depression score and depression outcome post-treatment when we controlled for therapy type and comparator. The result also showed that the effect sizes for studies targeting acute depression to be tightly clustered around a small overall effect size.

CONCLUSIONS

Some psychological therapies may reduce acute bipolar depression although this conclusion should be viewed with caution given the low quality of evidence. More research using similar therapy types and comparators is needed to better understand the relationship between depression status at baseline and outcome.

Obesity and overweight among children and adolescents with bipolar disorder from the general population: A review of the scientific literature and a meta-analysis

There is substantial evidence of the high prevalence of obesity (OB) and overweight (OW) and their association with increased medical and psychiatric burden among adults with bipolar disorder (BD). However, little is known regarding its prevalence among young people with BD, other than the risk from psychotropic medication, which has been the focus of research in this population. We present a systematic review and meta-analysis of the literature on prevalence and correlates of OB and OW children and adolescents with BD using a different perspective than impact of medication. Four studies met inclusion criteria. The prevalence of OB in children and adolescents with BD was 15% (95% CI 11-20%). We observed a higher prevalence of OB in comparison to the general population. Different studies found significant associations between OB, OW, and BD in young populations including non-Caucasian race, physical abuse, suicide attempts, self-injurious behaviours, psychotropic medication, and psychiatric hospitalizations.

Gender disparity in bipolar disorder diagnosis in the United States: A retrospective analysis of the 2005-2017 MarketScan Commercial Claims database

OBJECTIVE

To examine gender disparities in the diagnosis of bipolar disorder (BD) within a privately insured population in the United States and investigate potential contributing factors for these gender differences.

METHODS

This retrospective cohort study utilized 2005-2017 claims data from the MarketScan^® Commercial Claims and Encounters database. The study cohort included subjects, aged 10-64 years, who had a minimum of 1-year continuous insurance coverage and no record of a BD diagnosis before cohort entry. We examined the gender difference in BD diagnosis rate, overall and by subgroups. We then used Cox regression models to evaluate the gender effect on time to first BD diagnosis, and the potential moderators of gender effect.

RESULTS

The study cohort consisted of 97,193,443 subjects; 0.45% of subjects were diagnosed with BDs after cohort entry with males having a lower diagnosis rate than females (0.36% vs. 0.54%). The Cox regression analysis indicated that males were less likely to be diagnosed with BDs (unadjusted Hazard Ratio, HR [95% CI]: 0.69 [0.68-0.69]) and gender difference remained significant after adjusting for demographics, comorbidity and healthcare utilizations (adjusted HR [95% CI]: 0.77 [0.76-0.77]). Gender disparity was consistently strong among most age groups, but varied in other demographic subgroups.

CONCLUSIONS

Even though the prevalence of BDs is approximately equal between genders in the general population, our study found a much lower diagnosis rate in men compared to women for a privately insured U.S.

POPULATION

Future studies aimed at identifying and understanding the barriers to diagnosis of BDs in men are warranted.

Frequency of psychiatric comorbid symptoms in bipolar disorder patients in remission

INTRODUCTION

Psychiatric comorbidity has been detected in one-third of bipolar patients. The illness itself may be a precipitating factor for developing substance use and anxiety disorders. Comorbid anxiety disorders with bipolar disorder (BD) are associated with decreased chances of recovery, poorer role functioning, and quality of life, and greater likelihood of suicide attempts. Hence, identifying comorbid symptoms in remitting patients has important preventive and therapeutic implications.

AIMS

The aim of the study was to estimate the frequency of psychiatric comorbid symptoms in patients of bipolar affective disorder in remission and to identify its relationship with sociodemographic variables.

METHODOLOGY

This is a cross-sectional study conducted in Father Muller Medical College and Hospital, Mangalore (April 2019-July 2019), which included 90 patients aged 18-50 years with BD, manic, or depressive episodes in remission for 8 weeks who were evaluated using mini international neuropsychiatric interview plus, Hamilton rating scale for depression, and young mania rating scale. Sociodemographic details were assessed by a semi-structured pro forma. The data were analyzed using frequency, Chi-square test, and t-test.

RESULTS

Most common psychiatry comorbid symptoms seen in BD were found to be drug dependence/abuse (n = 31), second most common being alcohol dependence/abuse (n = 21), followed by suicidality (n = 8), antisocial personality, social phobia, panic disorder, and agoraphobia. Significance was found for suicidality, agoraphobia, and social phobia if the last episode was depressive and for suicidality if index episode was depressive and if age of onset was >40 years.

CONCLUSION

Psychiatric comorbidities in BD may worsen the course and prognosis of the disorder and hence, clinicians must maintain a high index of suspicion for them. Furthermore, comorbidities may need to be identified and appropriate interventions employed to prevent iatrogenic complications.

Real-world clinical predictors of manic/hypomanic episodes among outpatients with bipolar disorder

Background

Bipolar disorder is a mental illness in which manic and depressive states are repeated, causing psychosocial dysfunction. Manic/hypomanic episodes cause problems with interpersonal, social and financial activities, but there is limited evidence regarding the predictors of manic/hypomanic episodes in real-world clinical practice.

Methods

The multicenter treatment survey on bipolar disorder (MUSUBI) in Japanese psychiatric clinics was administered in an observational study that was conducted to accumulate evidence regarding bipolar disorder in real-world clinical practice. Psychiatrists were asked to complete a questionnaire about patients with bipolar disorder who visited 176 member clinics of the Japanese Association of Neuro-Psychiatric Clinics by conducting a retrospective medical record survey. Our study extracted baseline patient characteristics from September to October 2016, including comorbidities, mental status, duration of treatment, Global Assessment of Functioning (GAF) score, and pharmacological treatment details. We investigated the presence or absence of manic/hypomanic episodes over the course of one year from baseline to September-October 2017.

Results

In total, 2231 participants were included in our study, 29.1% of whom had manic/hypomanic episodes over the course of one year from baseline. Binomial logistic regression analysis revealed that the presence of manic/hypomanic episodes was correlated with lower baseline GAF scores, rapid cycling, personality disorder, bipolar I disorder, and a mood state with manic or mixed features. Substance abuse was also a risk factor for manic episodes. There was no significant association between a baseline antidepressant prescription and manic/hypomanic episodes.

Conclusions

In Japan, 29.1% of outpatients with bipolar disorder had manic/hypomanic episodes over the course of one year. Our study suggested that a low GAF score, rapid cycling, personality disorder, bipolar I disorder, substance abuse, and baseline mood state could be predictors of manic/hypomanic episodes. Based on our findings, an antidepressant prescription is not a predictor of manic/hypomanic episodes.

Symptom profiles of women at risk of mood disorders: A latent class analysis

BACKGROUND

Depression is the leading cause of disease burden among women worldwide. However, an understanding of symptom profiles among women at risk of mood disorders is limited. We determined distinct profiles of affective symptoms among high risk women, along with their distinguishing characteristics.

METHODS

Women were recruited from 17 clinical sites affiliated with the National Network of Depression Centers. They completed measures of depression (Patient Health Questionnaire - 9) and anxiety (Generalized Anxiety Disorder - 7) as well as questions regarding demographics, reproductive status, behavioral/mental health history, and life stress/adversity. Latent class analysis and multinomial logistic regression were used to identify and characterize symptom profiles.

RESULTS

5792 women participated, ages 18 to 90 (M = 38). Three latent classes were identified: generally asymptomatic (48%), elevated symptoms of comorbid anxiety and depression (16%), and somatic symptoms (36%). Financial security and greater social support were protective factors that distinguished asymptomatic women. The profile of the class with elevated anxiety/depressive symptoms constituted a complex mix of adverse social determinants and potentially heritable clinical features, including a diagnosis of Bipolar Disorder. Women in the 3rd latent class were characterized by menstrual irregularity and a stronger expression of neurovegetative symptoms, especially sleep disturbance and fatigue.

LIMITATIONS

Limitations included less than optimal racial diversity of our sample and reliance on self-report.

CONCLUSIONS

Different symptom profiles may reflect distinct subtypes of women at risk of mood disorders. Understanding the etiology and mechanisms underlying clinical and psychosocial features of these profiles can inform more precisely targeted interventions to address women's diverse needs.

Comorbidity Patterns of Mood Disorders in Adult Inpatients: Applying Association Rule Mining

This study explored physical and psychiatric comorbidities of mood disorders using association rule mining. There were 7709 subjects who were patients (≥19 years old) diagnosed with mood disorders and included in the data collected by the Korean National Hospital Discharge In-depth Injury Survey (KNHDS) between 2006 and 2018. Physical comorbidities (46.17%) were higher than that of psychiatric comorbidities (27.28%). The frequent comorbidities of mood disorders (F30-F39) were hypertensive diseases (I10-I15), neurotic, stress-related and somatoform disorders (F40-F48), diabetes mellitus (E10-E14), and diseases of esophagus, stomach, and duodenum (K20-K31). The bidirectional association path of mood disorders (F30-F39) with hypertensive diseases (I10-I15) and diabetes mellitus (E10-E14) were the strongest. Depressive episodes (F32) and recurrent depressive disorders (F33) revealed strong bidirectional association paths with other degenerative diseases of the nervous system (G30-G32) and organic, including symptomatic and mental disorders (F00-F09). Bipolar affective disorders (F31) revealed strong bidirectional association paths with diabetes mellitus (E10-E14) and hypertensive diseases (I10-I15). It was found that different physical and psychiatric disorders are comorbid according to the sub-classification of mood disorders. Understanding the comorbidity patterns of major comorbidities for each mood disorder can assist mental health providers in treating and managing patients with mood disorders.

Efficacy and safety of lurasidone in children and adolescents: Recommendations for clinical management and future research

Lurasidone is a novel azapirone derivative, and atypical antipsychotic agent with a high binding affinity for dopaminergic (D2), serotoninergic (5-HT2A), and 5-HT7 receptors (antagonist), a moderate affinity for 5-HT1A receptors (partial agonist), and no appreciable affinity for histaminergic (H1) and muscarinic (M1) receptors. It was recently included by the European Medication Agency among the in-label pharmacological treatments for children and adolescents affected by early onset schizophrenia. As a dopamine and serotonin antagonist, lurasidone acts on a variety of receptors and showed its efficacy both as an antipsychotic and an activating compound. Administered with food or within 30 minutes from a meal, it presents sufficient bioavailability and does not interact ith most of the other drugs during metabolism. With little effects on hormones and weight gain, potential procognitive profile due to its 5-HT7 antagonism, and reduced extrapyramidal side effects, lurasidone could be a good choice in terms of both effectiveness and tolerability, particularly for patients headed towards a long-term treatment. This article aims to summarize the available scientific evidence from the literature on the use of lurasidone in children and adolescents and to provide recommendations for clinical management and future research.

Lithium therapy and weight change in people with bipolar disorder: A systematic review and meta-analysis

Lithium remains the gold standard maintenance treatment for Bipolar Disorder (BD). However, weight gain is a side effect of increasing relevance due to its metabolic implications. We conducted a systematic review and meta-analysis aimed at summarizing evidence on the use of lithium and weight change in BD. We followed the PRISMA methodology, searching Pubmed, Scopus and Web of Science. From 1003 screened references, 20 studies were included in the systematic review and 9 included in the meta-analysis. In line with the studies included in the systematic review, the meta-analysis revealed that weight gain with lithium was not significant, noting a weight increase of 0.462 Kg (p = 0158). A shorter duration of treatment was significantly associated with more weight gain. Compared to placebo, there were no significant differences in weight gain. Weight gain was significantly lower with lithium than with active comparators. This work reveals a low impact of lithium on weight change, especially compared to some of the most widely used active comparators. Our results could impact clinical decisions.

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.

Older Age Bipolar Disorder

Further understanding of older age bipolar disorder (OABD) may lead to more specific recommendations for treatment adjusted to the specific characteristics and needs caused by age-related somatic and cognitive changes. Late-onset mania has a broad differential diagnosis and requires full psychiatric and somatic work-up, including brain imaging. Research on pharmacotherapy in OABD is limited. First-line treatment of OABD is similar to that for adult bipolar disorder (BD), with specific attention to vulnerability to side effects and somatic comorbidity. Because findings in younger adults with BD cannot be extrapolated to OABD, more research in OABD is warranted.

Bipolar disorder and the risk for stroke incidence and mortality: a meta-analysis

OBJECTIVE

Bipolar disorder (BD) may be associated with an increased risk of stroke, but to date, the results of the studies are still controversial. This study aimed to assess the association of BD with stroke incidence and mortality by a meta-analysis.

METHOD

PubMed, EMBASE, the Cochrane library databases, and Web of Science databases were searched from inception to July 2020. We regarded stroke as a composite endpoint. The pooled hazard ratio (HRs) of 95% confidence interval (Cls) was calculated. Subgroup and sensitivity analyses were performed to assess the potential sources of heterogeneity of the pooled estimation.

RESULTS

A total of 7 studies involving a total of 13,305,007 participants were included in this meta-analysis. Pooled analysis showed participants with BD experienced a significantly increased risk of both stroke incidence (combined HR, 1.43; 95% CI, 1.24-1.66; p = 0.000) and stroke mortality (combined HR, 1.54; 95% CI, 1.09-2.18; p = 0.013) compared to participants without BD. In addition, the pooled estimate of multivariate HRs of stroke incidence and mortality were 1.35 (95% CI: 1.26-1.45); 2.30 ( 95% CI: 1.37-3.85) among men and 1.43 (95% CI:1.27-1.60); 2.08 (95% CI:1.60-2.71) among women respectively.

CONCLUSIONS

This meta-analysis suggests that BD may modestly increase the risk of both stroke incidence and mortality. Extensive clinical observational studies should be conducted in the future to explore whether BD is a potentially modifiable risk factor for stroke.

Neurostructural phenotypes of CACNA1C rs1006737 in adolescents with bipolar disorder and healthy controls

OBJECTIVE

Investigate the effects of CACNA1C rs1006737 on cortical and subcortical neurostructural phenotypes in Caucasian bipolar disorder (BD) and healthy control (HC) adolescents.

METHODS

Seventy-one adolescents (14-20 years; 38BD, 33HC) underwent 3-Tesla Magnetic Resonance Imaging (MRI). Region of interest (ROI) and vertex-wise analyses examined cortical volume, surface area (SA), and thickness, as well as subcortical volume. ROIs included the ventromedial prefrontal cortex (vmPFC), ventrolateral prefrontal cortex (vlPFC), anterior cingulate cortex (ACC), putamen, and amygdala. General linear models included main effects of diagnosis and rs1006737, and an interaction term, controlling for age, sex, and total intracranial volume.

RESULTS

Vertex-wise analysis found significant BD-by-rs1006737 interactions for prefrontal and occipital regions such that BD A-carriers were found to have greater SA relative to BD non-carriers, while HC A-carriers had reduced SA relative to HC non-carriers. ROI analysis found an interaction in the ACC such that BD A-carriers were found to have greater SA relative to BD non-carriers, while no significant difference was found in HCs. Main effects of rs1006737 were also found on ACC SA from ROI analysis, and occipital SA from vertex-wise analysis, such that A-carriers had larger SA relative to non-carriers in both of these regions.

CONCLUSIONS

The current study identified neurostructural intermediate phenotypes relevant to the impact of CACNA1C rs1006737 on adolescent BD. Further investigation is warranted into the neurofunctional and neurocognitive relevance of rs1006737 associations with BD-specific elevations in regional SA.

Physical Health Profile and Associated Behavior During the COVID-19 Pandemic in Patients With Bipolar Disorder

Background: The COVID-19 pandemic has led to an increased psychological strain on public mental health and may impact behavioral, mental, and physical health, presumably with effects on patients with severe mental disorders. This study examines pandemic-related physical and mental health and (compensatory) behavioral changes, in patients with BD as compared to healthy control individuals. Method: Physical and mental health and self-reported changes in daily structure and behavior due to the pandemic were assessed using a self-constructed questionnaire and the brief symptom inventory (BSI) in Germany, Austria, and Denmark in individuals with BD and a healthy control group. Results: The present study included 118 individuals with BD and 215 healthy controls. Individuals with BD reported statistically significant higher physical risk burden, increased weight gain, more physical comorbidities, and a decrease in physical activity and they further reported higher rates of COVID-19 testing, had more worries concerning health, and experienced more anxiety but less social distancing. Conclusion: The COVID-19 pandemic seems to have a greater impact on physical health in individuals with BD than in healthy controls. Individuals with BD appear to be having more difficulties compensating their behavior due to the pandemic which could amplify the effect of risk factors associated with poorer physical health. This highlights the necessity for optimizing and targeting the overall treatment of both mental and physical health in patients with BD during periods with far-reaching changes such as the COVID-19 pandemic. Limitations: Sampling issues and self-report forms, selectivity (missing elderly, and those lacking access or knowledge of technology).

Patients with psychiatric diagnoses have increased odds of morbidity and mortality in elective orthopedic surgery

Psychiatric diagnoses (PD) present a significant burden on elective surgery patients and may have potentially dramatic impacts on outcomes. As ailments of the spine can be particularly debilitating, the effect of PD on outcomes was compared between elective spine surgery patients and other common elective orthopedic surgery procedures. This study included 412,777 elective orthopedic patients who were concurrently diagnosed with PD within the years 2005 to 2016. 30.2% of PD patients experienced a post-operative complication, compared to 25.1% for non-PD patients (p < 0.001). Mood Disorders (bipolar or depressive disorders) were the most commonly diagnosed PD for all elective Orthopedic procedures, followed by anxiety, then dementia (p < 0.001). Logistic regression analysis found PD to be a significant predictor of higher cost to charge ratio (CCR), length of stay (LOS), and death (all p < 0.001). Between, hand, elbow, and shoulder specialties, spine patients had the highest odds of increased CCR and unfavorable discharge, and the second highest odds of death (all p < 0.001).

Cannabis Use, Cannabis Use Disorder, and Comorbid Psychiatric Illness: A Narrative Review

BACKGROUND

The landscape of attitudes, legal status and patterns of use of cannabis is rapidly changing in the United States and elsewhere. Therefore, the primary aim of this narrative review is to provide a concise overview of the literature on the comorbidity of cannabis use and cannabis use disorder (CUD) with other substance use and psychiatric disorders, and to use this information to accurately guide future directions for the field.

METHODS

A literature review of PubMed was conducted for studies relating to cannabis use, CUD, and a co-occurring psychiatric disorder. To provide an overview of representative data, the literature review focused on national-level, population-based work from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and National Survey on Drug Use and Health (NSDUH) surveys. Considering rapidly changing cannabis laws, recent (past five-year) studies were addressed.

RESULTS

A strong body of literature shows associations between cannabis use and CUD with other drug use, psychosis, mood disorders, anxiety disorders, and personality disorders. The strongest evidence of a potential causal relationship exists between cannabis use and psychotic disorders. While some evidence shows potential directionality between cannabis use and mood and anxiety disorders, results are inconsistent. Studies have established higher rates of CUD among those with personality disorders, but little about the specifics of this relationship is understood.

CONCLUSIONS

Although the general population in the United States increasingly perceives cannabis to be a harmless substance, empirical evidence shows that cannabis use is associated both with CUD and comorbid psychiatric illness. However, there is mixed evidence regarding the role of cannabis in the etiology, course, and prognosis of a co-occurring disorder across all categories of psychiatric disorders. Future research should expand on the existing body of literature with representative, longitudinal data, in order to better understand the acute and long-term effects of cannabis on comorbid psychiatric illness.