Residual symptoms and specific functional impairments in euthymic patients with bipolar disorder

Factors associated with sexual dysfunction in patients with bipolar disorder

OBJECTIVES

The aims of our study were to assess the sexual function in men with bipolar disorder type 1 in remission and to determine the various sociodemographic, clinical and therapeutic factors associated with sexual dysfunction.

METHODS

We conducted a cross-sectional study over an 18-month period (January 2020-June 2021) in which we included men followed up for bipolar disorder type 1 in the euthymic phase strictly defined by a score <8 on the Young Mania Rating Scale and a score ≤7 on the Hamilton Depression Rating Scale. Sexual function was assessed using the Arizona Sexual Experiences Scale (Asex) in its Arabic-validated version.

RESULTS

Sixty patients were included in the study. The mean age was 42.5 (SD=11.1) years. Among the patients, 68% had sexual dysfunction according to the total score of the Asex scale. According to univariate analysis, several factors were significantly associated with sexual dysfunction in patients with bipolar disorder type 1: age (P=0.001), total number of hospitalizations for thymic relapse (P=0.015), total number of depressive episodes (P=0.006) and depressive dominant polarity (P=0.046). The factors identified as modifying sexuality according to the total score of the Asex scale by multivariate analysis were age at first antipsychotic prescription: P=0.01; ORa=1.109; 95% CI [1.021-1.206] and number of hospitalizations for thymic relapse: P=0.015; ORa=1.259; 95% CI [1.046-1.546].

CONCLUSION

Studies assessing factors associated with sexual dysfunction in patients with bipolar disorder type 1 in euthymia were mostly concerned with the effects of psychotropic drugs on sexual function, with factors inherent in bipolar illness itself not widely addressed in the literature. According to the results of our study, sexual dysfunction in patients with bipolar disorder in the euthymic phase is frequent and significantly associated with clinical factors inherent in the bipolar illness itself and its course.

Study protocol: group-based psychoeducation for relatives of patients with bipolar disorder-a large scale real-world randomized controlled parallel group trial, the R-bipolar RCT

BACKGROUND

Relatives of patients with bipolar disorder (BD) often experience emotional burden with stress and depressive symptoms that again increase the likelihood of destabilization and relapses in the patient. The effects of group-based psychoeducation have not been investigated in large-scale real-world settings. We are currently conducting a large-scale real-world randomized controlled parallel group trial (RCT) to test whether group-based psychoeducation for 200 relatives to patients with BD improves mood instability and other critical outcomes in relatives and the corresponding patients with BD.

METHODS

The trial is designed as a two-arm, parallel-group randomized trial with a balanced randomization 1:1 to either group-based psychoeducation or a waiting list for approximately 4 months and subsequent group-based psychoeducation. The primary outcome measure is mood instability calculated based on daily smartphone-based mood self-assessments. Other relevant outcomes are measured, including patients' reported outcomes, assessing self-assessed burden, self-efficacy, and knowledge about BD.

DISCUSSION

This protocol describes our currently ongoing randomized controlled trial (RCT) that aims at investigating group-based psychoeducation as an intervention for relatives of individuals diagnosed with bipolar disorder (BD). The study is the first large-scale real-world RCT to focus on a relatively short intervention of psychoeducation (6 sessions of 2 h each) in a large group of relatives (approximately 30 participants per group). With this focus, we wish to test an intervention that is feasible to implement in real-life psychiatric settings with limited budgets and time. It is also the first study to use mood instability in relatives as the primary outcome measure and to investigate whether mood instability and other affective symptoms in patients and relatives covary. It could be considered as limitations, that the trial is not blinded and does not include long-term follow-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06176001. Registered on 2023-12-19. The study is approved by the data agency (P-2021-809). The project was allowed to be initiated without permission from the Scientific Ethical Committees for the Capital Region, because it according to section 1, paragraph 4 of the Committee Act was not defined as a health scientific intervention study (case number 21063013).

Early warning signals observed in motor activity preceding mood state change in bipolar disorder

INTRODUCTION

Alterations in motor activity are well-established symptoms of bipolar disorder, and time series of motor activity can be considered complex dynamical systems. In such systems, early warning signals (EWS) occur in a critical transition period preceding a sudden shift (tipping point) in the system. EWS are statistical observations occurring due to a system's declining ability to maintain homeostasis when approaching a tipping point. The aim was to identify critical transition periods preceding bipolar mood state changes.

METHODS

Participants with a validated bipolar diagnosis were included to a one-year follow-up study, with repeated assessments of the participants' mood. Motor activity was recorded continuously by a wrist-worn actigraph. Participants assessed to have relapsed during follow-up were analyzed. Recognized EWS features were extracted from the motor activity data and analyzed by an unsupervised change point detection algorithm, capable of processing multi-dimensional data and developed to identify when the statistical property of a time series changes.

RESULTS

Of 49 participants, four depressive and four hypomanic/manic relapses among six individuals occurred, recording actigraphy for 23.8 ± 0.2 h/day, for 39.8 ± 4.6 days. The algorithm detected change points in the time series and identified critical transition periods spanning 13.5 ± 7.2 days. For depressions 11.4 ± 1.8, and hypomania/mania 15.6 ± 10.2 days.

CONCLUSION

The change point detection algorithm seems capable of recognizing impending mood episodes in continuous flowing data streams. Hence, we present an innovative method for forecasting approaching relapses to improve the clinical management of bipolar disorder.

Functioning in older adults with bipolar disorder: A report on recommendations by the International Society of bipolar disorder (ISBD) older adults with bipolar disorder (OABD) task force

OBJECTIVES

Despite the importance of psychosocial functioning impairment in Bipolar Disorder (BD), its role among Older Adults with BD (OABD) is not well known. The development of guidelines for the assessment of psychosocial functioning helps to facilitate a better understanding of OABD and can lead to better tailored interventions to improve the clinical outcomes of this population.

METHODS

Through a series of virtual meetings, experts from eight countries in the International Society of Bipolar Disorder (ISBD) on OABD task force developed recommendations for the assessment of psychosocial functioning.

RESULTS

We present (1) a conceptualization of functioning in OABD and differences compared with younger patients; (2) factors related to functioning in OABD; (3) current measures of functioning in OABD and their strengths and limitations; and, (4) other potential sources of information to assess functioning.

CONCLUSIONS

The task force created recommendations for assessing functioning in OABD. Current instruments are limited, so measures specifically designed for OABD, such as the validated FAST-O scale, should be more widely adopted. Following the proposed recommendations for assessment can improve research and clinical care in OABD and potentially lead to better treatment outcomes.

Circadian, Reward, and Emotion Systems in Teens prospective longitudinal study: protocol overview of an integrative reward-circadian rhythm model of first onset of bipolar spectrum disorder in adolescence

BACKGROUND

Bipolar spectrum disorders (BSDs) are associated with a heightened sensitivity to rewards and elevated reward-related brain function in cortico-striatal circuitry. A separate literature documents social and circadian rhythm disruption in BSDs. Recently, integrated reward-circadian models of BSDs have been proposed. These models draw on work indicating that the two systems influence each other and interact to affect mood functioning. When dysregulated, reward and circadian system signaling may combine to form a positive feedback loop, whereby dysregulation in one system exacerbates dysregulation in the other. Project CREST (Circadian, Reward, and Emotion Systems in Teens) provides a first systematic test of reward-circadian dysregulation as a synergistic and dynamic vulnerability for first onset of BSD and increases in bipolar symptoms during adolescence.

METHODS

This NIMH-funded R01 study is a 3-year prospective, longitudinal investigation of approximately 320 community adolescents from the broader Philadelphia area, United States of America. Eligible participants must be 13-16 years old, fluent in English, and without a prior BSD or hypomanic episode. They are being selected along the entire dimension of self-reported reward responsiveness, with oversampling at the high tail of the dimension in order to increase the likelihood of BSD onsets. At Times 1-6, every 6 months, participants will complete assessments of reward-relevant and social rhythm disruption life events and self-report and diagnostic assessments of bipolar symptoms and episodes. Yearly, at Times 1, 3, and 5, participants also will complete self-report measures of circadian chronotype (morningness-eveningness) and social rhythm regularity, a salivary dim light melatonin onset (DLMO) procedure to assess circadian phase, self-report, behavioral, and neural (fMRI) assessments of monetary and social reward responsiveness, and a 7-day ecological momentary assessment (EMA) period. During each EMA period, participants will complete continuous measures of sleep/wake and activity (actigraphy), a daily sleep diary, and three within-day (morning, afternoon, evening) measures of life events coded for reward-relevance and social rhythm disruption, monetary and social reward responsiveness, positive and negative affect, and hypo/manic and depressive symptoms. The fMRI scan will occur on the day before and the DLMO procedure will occur on the first evening of the 7-day EMA period.

DISCUSSION

This study is an innovative integration of research on multi-organ systems involved in reward and circadian signaling in understanding first onset of BSD in adolescence. It has the potential to facilitate novel pharmacological, neural, and behavioral interventions to treat, and ideally prevent, bipolar conditions.

Disability and its correlates among persons with bipolar disorder: Exploratory findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

Aim

This study aimed to evaluate the disability and its correlates in persons with Bipolar Disorder during the remission phase.

Materials and Methods

As part of the multicentric study, 773 patients with bipolar disorder, currently in clinical remission, were evaluated for disability on the Indian Disability Assessment Evaluation Scale.

Results

About one-fifth of the participants had some level of disability in the domain of self-care, one-third had some level of disability in the interpersonal domain, one-fourth had some level of disability in communication and understanding, and a maximum proportion (43.7%) had some disability in the domain of work. Overall, about one-fifth (18.4%) were considered to have a benchmark disability (i.e., disability >40%). In terms of correlates, those with a disability had a short duration of current remission, a higher number of manic and mixed episodes, a higher mean number of total episodes, spent more time in the episodes, had lower severity of the depressive episodes, higher residual depressive and manic symptoms, had overall higher manic affective morbidity, had a higher level of cognitive deficits, and had poorer insight.

Conclusion

A significant proportion of patients with bipolar disorder have disability in work domain, and the presence of residual symptoms of either polarity are associated with higher level of disability.

The relationship between sleep disturbance and cognitive impairment in mood disorders: A systematic review

BACKGROUND

Cognitive impairment experienced by people with bipolar disorders (BD) or major depressive disorder (MDD) is associated with impaired psychosocial function and poorer quality of life. Sleep disturbance is another core symptom of mood disorders which may be associated with, and perhaps worsen, cognitive impairments. The aim of this systematic review was to critically assess the relationship between sleep disturbance and cognitive impairment in mood disorders.

METHODS

In this systematic review, relevant studies were identified using electronic database searches of PsychINFO, MEDLINE, Embase and Web of Science.

FINDINGS

Fourteen studies were included; eight investigated people with BD, five investigated people with MDD, and one included both people with MDD and people with BD. One study was an intervention for sleep disturbance and the remaining thirteen studies used either a longitudinal or cross-sectional observational design. Ten studies reported a significant association between subjectively measured sleep disturbance and cognitive impairment in people with MDD or BD after adjusting for demographic and clinical covariates, whereas no such association was found in healthy participants. Two studies reported a significant association between objectively measured (actigraphy or polysomnography) sleep abnormalities and cognitive impairment in mood disorders. One study of cognitive behavioural therapy for insomnia modified for BD (CBTI-BD) found an association between improvements in sleep and cognitive performance in BD.

INTERPRETATION

There is preliminary evidence to suggest a significant association between sleep disturbance and cognitive impairment in mood disorders. These findings highlight the need for further research of sleep disturbances and cognitive impairment in people with mood disorders.

Risk of Mania After Methylphenidate in Patients With Bipolar Disorder

BACKGROUND

Bipolar disorder and attention-deficit/hyperactivity disorder are common comorbidities. Attention-deficit/hyperactivity disorder is commonly treated with stimulants (eg, methylphenidate), which, however, have been suggested to cause treatment-emergent mania in patients with bipolar disorder. Here, we assessed the risk of mania, depressive episodes, and psychiatric admissions after initiation of methylphenidate treatment in patients with bipolar disorder.

METHODS

Using Danish health registries, we identified all individuals registered with a diagnosis of bipolar disorder from January 1, 2000, to January 1, 2018, who were treated with methylphenidate. We applied a 1-year mirror-image model to compare the occurrence of mania, depression, and psychiatric admissions in the period leading up to and after methylphenidate treatment initiation. We furthermore assessed the trend in these outcomes from 4 years before to 1 year after initiation of methylphenidate treatment.

RESULTS

A total of 1043 patients with bipolar disorder initiated treatment with methylphenidate. The number of manic episodes decreased by 48% after methylphenidate treatment initiation (P = 0.01), both among patients using mood stabilizers (-50%) and among patients not using mood stabilizers (-45%). The number of manic episodes, however, peaked approximately 6 months before methylphenidate. The results were similar for the secondary outcomes.

CONCLUSIONS

Initiation of methylphenidate treatment was not associated with an increased risk of mania in patients with bipolar disorder. A decrease in mania, depressive episodes, and psychiatric admissions was observed after methylphenidate. However, these decreases seemed to be driven by regression to the mean after clinical deterioration preceding methylphenidate treatment, rather than by the methylphenidate treatment itself.

Bipolar affektif bozukluk tanılı hastalarda COVID- 19 korkusunun kalıntı belirtiler ve işlevsellik ile ilişkisi

Amaç: Bu çalışmada bipolar affektif bozukluk tanılı hastalarda COVID-19 korkusu ile kalıntı belirtiler ve işlevsellik düzeyleri arasındaki ilişkinin saptanması amaçlanmıştır. Gereç ve Yöntem: Çalışmaya DSM-5’e göre bipolar affektif bozukluk tanısı bulunan, 18-65 yaş arasında ve okur yazar olan, polikliniğe kendisi başvuran ardışık 85 bipolar affektif bozukluk tanılı hasta alınmıştır. Hastalar depresif /manik belirtiler gösteren, remisyonda olup da kalıntı belirtileri olanlar olarak gruplandırılmıştır. Bulgular: YMDÖ’ye göre ‘manik kalıntı belirtileri olan’ olarak sınıflandırılan katılımcıların bu ölçekte medyan puanı 1 ± 1,14'tü. Katılımcılar arasında manik kalıntı belirti olup olmamasına göre COVID-19 Korkusu Ölçek puanları açısından anlamlı bir fark bulunmadı. Depresif kalıntı semptomu olmayan katılımcılar, depresif kalıntı semptomu olanlara göre COVID-19 Korkusu Ölçeğinde anlamlı şekilde daha düşük puanlar göstermiştir. HAM-D Ölçeği, . İşlevsellik Kısa Değerlendirme Testi ile COVID-19 Korkusu Ölçeği puanları arasında anlamlı düzeyde pozitif korelasyon saptanmıştır Sonuç: Depresif kalıntı semptomu olan hastalar COVID -19 korku ölçeğinde anlamlı şekilde daha yüksek puan almışlardır. Stres döneminde hastalarda dayanıklılık hastalık korkusu ve kalıntı belirtilerin çalışılması da takip ve tedavi stratejilerinin belirlenmesi açısından kıymetli olacaktır.

The relationship between morningness-eveningness and mood symptoms and quality of life in euthymic state of mood disorders: Results from a prospective observational cohort study

BACKGROUND

The clinical importance of morningness-eveningness, especially in mood disorders, is prevailing. The differential relation of chronotype with diagnoses of early-onset mood disorders, mood symptoms, anxiety, and quality of life was evaluated.

METHODS

Early-onset mood disorder patients [n = 419; 146 major depressive disorder (MDD); 123 bipolar I disorder (BDI); 150 bipolar II disorder (BDII)] from the Mood Disorder Cohort Research Consortium were assessed for chronotype using the composite scale for morningness (CSM) and its association with clinical variables obtained during the clinician-verified euthymic state.

RESULTS

The mean total CSM of BDI was significantly higher than MDD and BDII (p < 0.001). In all types of mood disorders, higher total CSM was associated with lower Quick inventory of depressive symptomatology (p < 0.005) and higher WHO quality of life (p < 0.005). Such negative correlations between the total CSM and Montgomery-Asberg depression rating were significant in MDD and BDI (p < 0.05) and marginally significant in BDII (p = 0.077). CSM was a significant contributor to quality of life in BDI (p < 0.001) and BDII (p = 0.011), but it was not for MDD.

LIMITATIONS

The defined 'euthymic state' that may not fully reflect the remission of episode; limited generalizability due to clinical characteristic of early-onset mood disorder; the disparity between diurnal preference measured by the CSM and chronotype; possible effects of the last mood episode polarity and medication; and, lack of control group.

CONCLUSION

Less eveningness was associated with less severe depressive symptoms and better quality of life. This suggests that morningness may reduce residual depressive symptoms and recover function of patients.

Mindfulness based cognitive therapy (MBCT) reduces depression-related self-referential processing in patients with bipolar disorder: an exploratory task-based study

Negative self-referential processing has fruitfully been studied in unipolar depressed patients, but remarkably less in patients with bipolar disorder (BD). This exploratory study examines the relation between task-based self-referential processing and depressive symptoms in BD and their possible importance to the working mechanism of mindfulness-based cognitive therapy (MBCT) for BD. The study population consisted of a subsample of patients with BD (n = 49) participating in an RCT of MBCT for BD, who were assigned to MBCT + TAU (n = 23) or treatment as usual (TAU) (n = 26). Patients performed the self-referential encoding task (SRET), which measures (1) positive and (2) negative attributions to oneself as well as (3) negative self-referential memory bias, before and after MBCT + TAU or TAU. At baseline, all three SRET measures were significantly related to depressive symptoms in patients with BD. Moreover, repeated measures analyses of variance revealed that negative self-referential memory bias diminished over time in the MBCT + TAU group, compared with the TAU group. Given the preliminary nature of our findings, future research should explore the possibly mediating role of reducing negative self-referential memory bias in preventing and treating depressive symptoms in BD through MBCT.

Peripheral insulin sensitivity predicting cognitive function in euthymic bipolar disorder patients

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sexual dysfunction among males and females with bipolar disorder and healthy subjects: The burden of illness severity

OBJECTIVES

Sexual dysfunction has wide-ranging impacts on the person's functioning and quality of life, being associated with higher severity of psychiatric illnesses and poor therapeutic response. Given the paucity of data on this topic in bipolar disorder (BD), we investigated sexual functioning among males and females with BD and healthy controls (HCs) as well as whether illness severity markers and subthreshold mood symptoms were associated with sexual dysfunctions in BD patients.

METHODS

The study included 80 BD outpatients and 70 HCs. Sexual functioning was evaluated using the validated, gender-specific Changes in Sexual Functioning Questionnaire (CSFQ-14).

RESULTS

BD patients had a significantly poorer sexual functioning than HCs (p < 0.00001). The odds of sexual dysfunction doubled given a one-unit increase in the number of suicide attempts (adjusted OR = 2.01, 95% CI:1.23-3.55; p < 0.01) and increased by 60% for every additional hospitalization (p < 0.05). Greater illness duration was associated with arousal/orgasmic (p < 0.05) and overall sexual dysfunctions (p < 0.01). BD patients with more mixed or (hypo)manic episodes had a lower likelihood of libido loss and arousal/orgasmic disturbances (p < 0.01), respectively. Higher levels of subthreshold depressive symptoms increased by 20% the odds of sexual interest/frequency dysfunctions (p < 0.05), and up to 60% regarding orgasmic disturbances (p < 0.01).

CONCLUSIONS

Sexual functioning may be a useful proxy of illness severity as well as a relevant dimension to more deeply characterize BD patients. Further studies are warranted to replicate our findings, to evaluate temporal associations between sexual dysfunctions and illness severity across the BD mood and treatment spectrums and to explore neurobiological underpinnings of these associations.

The effect of mindfulness-based cognitive therapy on rumination and a task-based measure of intrusive thoughts in patients with bipolar disorder

Background

Preliminary evidence suggests that Mindfulness-Based Cognitive Therapy (MBCT) is a promising treatment for bipolar disorder (BD). A proposed working mechanism of MBCT in attenuating depressive symptoms is reducing depressive rumination. The primary aim of this study was to investigate the effect of MBCT on self-reported trait depressive rumination and an experimental state measure of negative intrusive thoughts in BD patients. Exploratively, we investigated the effect of MBCT on positive rumination and positive intrusive thoughts.

Methods

The study population consisted of a subsample of bipolar type I or II patients participating in a multicenter randomized controlled trial comparing MBCT + treatment as usual (TAU) (N = 25) to TAU alone (N = 24). Trait depressive rumination (RRS brooding subscale) and intrusive thoughts (breathing focus task (BFT)) were assessed at baseline (full subsample) and post-treatment (MBCT + TAU; n = 15, TAU; n = 15). During the BFT, participants were asked to report negative, positive and neutral intrusive thoughts while focusing on their breathing.

Results

Compared to TAU alone, MBCT + TAU resulted in a significant pre- to post-treatment reduction of trait depressive rumination (R² = .16, F(1, 27) = 5.15, p = 0.031; medium effect size (f² = 0.19)) and negative intrusive thoughts on the BFT (R² = .15, F(1, 28) = 4.88, p = 0.036; medium effect size (f² = 0.17)). MBCT did not significantly change positive rumination or positive intrusive thoughts.

Conclusions

MBCT might be a helpful additional intervention to reduce depressive rumination in BD which might reduce risk of depressive relapse or recurrence. Considering the preliminary nature of our findings, future research should replicate our findings and explore whether this reduction in rumination following MBCT indeed mediates a reduction in depressive symptoms and relapse or recurrence in BD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00269-1.

The relations between executive functions and occupational functioning in individuals with bipolar disorder: a scoping review

Background

Patients with bipolar disorder experience impairments in their occupational functioning, despite remission of symptoms. Previous research has shown that neurocognitive deficits, especially deficits in executive functions, may persist during euthymia and are associated with diminished occupational functioning.

Objectives

The aim of this scoping review was to identify published studies that report on the relationships between executive functions and occupational functioning in BD to review current knowledge and identify knowledge gaps. In addition to traditional neuropsychological approaches, we aimed to describe executive functioning from a self-regulation perspective, including emotion regulation.

Methods

We applied the methodological framework as described by Arksey and O’Malley (Int J Soc Res Methodol Theory Pract 8:19–32, 2005) and Levac et al. (Implement Sci 5:1–9, 2010). We searched PubMed and psycINFO for literature up to November 2021, after which we screened papers based on inclusion criteria. Two reviewers independently performed the screening process, data charting process, and synthesis of results.

Results

The search yielded 1202 references after deduplication, of which 222 remained after initial screening. The screening and inclusion process yielded 82 eligible papers in which relationships between executive functions and occupational functioning are examined.

Conclusion

Neurocognitive deficits, including in executive functions and self-regulation, are associated with and predictive of diminished occupational functioning. Definitions and measurements for neurocognitive functions and occupational functioning differ greatly between studies, which complicates comparisons. Studies on functional remediation show promising results for improving occupational functioning in patients with BD. In research and clinical practice more attention is needed towards the quality of work functioning and the various contexts in which patients with BD experience deficits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00255-7.

The significance of sleep quality in euthymic bipolar patients from Nigeria

Background

Bipolar disorder is highly under-researched in Africa. Existing studies show that racial/ethnic disparities exist for sleep quality. Poor sleep quality in bipolar disorder causes significant morbidity and mortality even during periods of euthymia.

Aim

This study aimed to assess sleep quality and its correlates amongst euthymic patients with bipolar I disorder from Nigeria.

Setting

The study was carried out in a teaching hospital, and state hospital, in Ibadan, Nigeria.

Method

This cross-sectional study was conducted amongst 76 euthymic bipolar patients aged between 18 and 60 years, meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for bipolar disorder. Euthymia was defined as having a score of ≤ 5 on the Young Mania Rating Scale and < 8 on the Hamilton Depression Rating Scale. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI).

Results

A total of 37 (48.7%) participants had poor quality sleep. Sleep quality was associated with marital status (p = 0.013) and suicide plan (p = 0.047). Participants with good sleep quality had higher total sleep duration, lower time to fall asleep (sleep latency), better subjective quality of sleep, were less likely to use sleep medications and had less daytime dysfunction than participants with poor sleep quality. All p-values were < 0.05. Subjective quality of sleep, ongoing use of sleep medication, daytime dysfunction were independently associated with poor sleep quality.

Conclusion

Poor sleep quality frequently persists during euthymic periods in patients with bipolar disorder. The correlates identified can be targeted for intervention during treatment.

Affective temperaments and sexual functioning in euthymic patients with bipolar disorder

Sexual functioning in bipolar disorder (BD) is dependent on multiple clinical and demographic determinants that can eventually lead to sexual dysfunction. However, the contribution of affective temperaments remains unstudied in this population. In this cross-sectional multicentric work, we studied the impact of temperament traits on sexual functioning in 100 euthymic BD outpatients treated only with mood stabilizers with or without benzodiazepines. Temperament was evaluated using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego - Autoquestionnaire (TEMPS-A) and sexual functioning with the Changes on Sexual Functioning Questionnaire (CSFQ-14). The effect of temperament on sexual functioning was analyzed using Bayesian ordinal regression models, which included age, gender, BD type, dominant polarity, metabolic syndrome, marital status, and affective symptomatology. Our results showed that hyperthymic traits predicted a significantly higher CSFQ-14 score for global sexual functioning (OR = 1.222; 95% CI [1.073, 1.431]), desire (OR = 1.164; 95% CI [1.025, 1.357]), arousal (OR = 1.278; 95% CI: [1.083, 1.551]), and orgasm (OR = 1.182; 95% CI [1.037, 1.365]). We did not find a significant contribution for other types of temperaments. Better sexual functioning was also associated with a better quality of life. Our findings highlight the importance of temperament traits in sexual functioning in euthymic BD, which may have implications in sexual dysfunction prevention.

Mindfulness, mood symptom tendencies and quality of life in bipolar disorder: An examination of the mediating influence of emotion regulation difficulties

BACKGROUND

The aim of this cross-sectional study was to investigate dispositional mindfulness and its association with depression and manic tendencies, and subjective life quality in bipolar disorder (BD). Furthermore, this study sought to examine the potential mediating effects of emotion regulation difficulties on these relationships.

METHOD

Twenty-eight healthy controls (HC) and 66 clinically stable outpatients with a DSM-IV-TR diagnosis of BD completed the Mindfulness Attention Awareness Scale (MAAS), Difficulties in Emotion Regulation Scale (DERS), Seven Up (7 Up) Seven Down (7 Down) and the Quality of Life in Bipolar Disorder Questionnaire (QoL.BD). These variables were compared between groups and entered into a series of mediation analyzes using PROCESS in the BD group only.

RESULTS

Lower MAAS scores were detected amongst the BD patients compared to HCs. Lower MAAS scores in BD patients predicted higher 7 Up, 7 Down and lower QoL.BD scores. For the 7 Down and QoL.BD, the associations were completely mediated by DERS scores, with difficulties in strategy use and emotional clarity mediating the association between mindfulness and depressive tendencies and quality of life, respectively. No significant direct or indirect effects were detected for the 7 Up model.

LIMITATIONS

The cross-sectional design precludes causal inference. The MAAS conceptualises mindfulness as unidimensional. Self-report scales of depressive and manic tendencies utilised.

CONCLUSIONS

This study detected a significant association between dispositional mindfulness and depressive tendencies and life quality in BD, and found that these associations were influenced by emotion regulation difficulties. These findings encourage further investigation of mindfulness-based interventions in BD.

Complexity and variability analyses of motor activity distinguish mood states in bipolar disorder

Changes in motor activity are core symptoms of mood episodes in bipolar disorder. The manic state is characterized by increased variance, augmented complexity and irregular circadian rhythmicity when compared to healthy controls. No previous studies have compared mania to euthymia intra-individually in motor activity. The aim of this study was to characterize differences in motor activity when comparing manic patients to their euthymic selves. Motor activity was collected from 16 bipolar inpatients in mania and remission. 24-h recordings and 2-h time series in the morning and evening were analyzed for mean activity, variability and complexity. Lastly, the recordings were analyzed with the similarity graph algorithm and graph theory concepts such as edges, bridges, connected components and cliques. The similarity graph measures fluctuations in activity reasonably comparable to both variability and complexity measures. However, direct comparisons are difficult as most graph measures reveal variability in constricted time windows. Compared to sample entropy, the similarity graph is less sensitive to outliers. The little-understood estimate Bridges is possibly revealing underlying dynamics in the time series. When compared to euthymia, over the duration of approximately one circadian cycle, the manic state presented reduced variability, displayed by decreased standard deviation (p = 0.013) and augmented complexity shown by increased sample entropy (p = 0.025). During mania there were also fewer edges (p = 0.039) and more bridges (p = 0.026). Similar significant changes in variability and complexity were observed in the 2-h morning and evening sequences, mainly in the estimates of the similarity graph algorithm. Finally, augmented complexity was present in morning samples during mania, displayed by increased sample entropy (p = 0.015). In conclusion, the motor activity of mania is characterized by altered complexity and variability when compared within-subject to euthymia.

Domain-Based Functional Improvements in Bipolar Disorder After Interpersonal and Social Rhythm Therapy

BACKGROUND

Studies typically report overall change in function when assessing bipolar disorder (BD) interventions, but individual domains are not analyzed. Which aspects of functioning are impacted is clearly important and may differ between treatments.

METHODS

Data were analyzed from two previous clinical trials of Interpersonal and Social Rhythm Therapy (IPSRT) for BD patients. Change in total and subscale scores on the Social Adjustment Scale Self-Report (SAS-SR) from 0 to 78 weeks, were analyzed.

RESULTS

152 BD patients took part in randomized controlled trials of IPSRT (n = 38) vs. Specialist Supportive Care (SSC) (n = 43), and of IPSRT (n = 41) vs. treatment as usual (TAU) which was discharge to primary care (n = 30). IPSRT was superior to TAU on change in the social and leisure activities and extended family subscales, and SAS-SR total score over 18 months.

LIMITATIONS

Studies were not designed to be pooled. Patients in study 1 were younger and symptomatic at baseline. Patients assigned to TAU were more likely to drop-out. Patients did not respond to subscales that were not personally applicable (work, marital, children).

CONCLUSION

IPSRT had a positive impact on two SAS-SR subscales compared to TAU over 18 months. Other subscales were limited by the lack of respondents due to individual applicability. Different psychotherapy may have differential effects on different domains of function. Measures of function and research into functioning in BD should include domain-based measures, and report the numbers of participants who respond to questions in each domain.

The impact of bipolar spectrum disorders on professional functioning: A systematic review

AIMS

The impact of bipolar spectrum (BS) disorders on professional functioning has not been systematically reviewed yet. Since even subsyndromal symptoms may disturb functioning, the determination of the prognostic value of the spectrum of bipolarity for employment seems extremely relevant. The aim of this study was to assess the impact of BS disorders on professional functioning.

MATERIALS AND METHODS

A systematic review of the literature (namely, cohort and cross-sectional studies) investigating a link between BS disorders and employment was performed in accordance with PRISMA guidelines. BS was defined based on the concept of two-dimensional BS by Angst. Occupational outcomes and factors affecting employment were evaluated as well.

RESULTS

Seventy-four studies were included. All disorders comprising BS had a negative impact on occupational status, work performance, work costs, and salary, with the greatest unfavorable effect reported by bipolar disorder (BD), followed by borderline personality disorder (BPD), major depressive disorder (MDD), and dysthymia. Employment rates ranged from 40 to 75% (BD), 33 to 67% (BPD), 61 to 88% (MDD), and 86% (dysthymia). The factors affecting employment most included: cognitive impairments, number/severity of symptoms, namely, subsyndromal symptoms (mainly depressive), older age, education, and comorbidity (substance abuse, personality disorders, anxiety, depression, ADHD, PTSD).

CONCLUSION

Bipolar spectrum symptoms exert a negative impact on professional functioning. Further evaluation of affecting factors is crucial for preventing occupational disability.

Bipolar Disorder and Polysubstance Use Disorder: Sociodemographic and Clinical Correlates

INTRODUCTION

Patients with bipolar disorder (BD) often show comorbidity with substance use disorder (SUD) with a negative impact on clinical course, prognosis, and functioning. The role of polysubstance use disorder (polySUD) is understudied. The aim of the present paper is to evaluate the sociodemographic and clinical characteristics associated with BD and comorbid SUD, focusing on polySUD, in order to phenotype this specific group of patients and implement adequate treatment and prevention strategies.

METHODS

A cross-sectional study was conducted involving 556 patients with a primary diagnosis of BD (376 without SUD, 101 with SUD, and 79 with polySUD). A semi-structured interview was administered to collect sociodemographic variables, clinical characteristics, and pharmacological treatment. ANOVA and chi-square tests were used to compare the three groups. Significantly different variables were then inserted in multivariate logistic regression.

RESULTS

Patients affected by BD and polySUD were younger, and more frequently males and single, than patients with SUD or without SUD. Indeed, the prevalence of patients affected by BD and polySUD living in residential facilities was higher than in the other groups. Moreover, earlier age at onset, higher prevalence of psychotic and residual symptoms, involuntary hospitalization, and a family history of psychiatric disorders were associated with polySUD in patients suffering from BD. Lastly, patients with BD and polySUD were more likely to take four or more medications, particularly benzodiazepines and other drugs. At the multinomial regression, younger age, male gender, early age at onset, psychotic and residual symptoms, positive family history of psychiatric disorders, and use of benzodiazepines remained significantly associated with polySUD in patients with BD.

CONCLUSION

Our findings show a specific profile of patients with BD and polySUD. It is important to conduct research on this topic in order to adopt specific therapeutic strategies, minimize the use of polypharmacy, and aim at full remission and mood stabilization.

Understanding the Barriers and Facilitators to Employment for People with Bipolar Disorder

People with Bipolar Disorder (BD) consistently report a desire for employment; however, this is not reflected in employment figures. Individuals' perceptions of barriers to employment, along with endorsement of facilitators to employment remain under-investigated. We aimed to address this limitation by: (i) first examining differences in employed versus unemployed individuals (demographic, clinical, functioning); then (ii) identifying barriers and/or facilitators to employment, perception of same, and subsequent impact on employment. We assessed demographics, functioning, and illness-related characteristics in 35 participants with BD (19 employed, 16 unemployed). Participants were asked to indicate perception of common barriers and facilitators to employment. Groups did not differ regarding demographic or clinical variables. High levels of absenteeism, termination of last role and commonly perceived barriers were attributed to mental ill-health. 93.3% of unemployed participants reportedly desired employment, and more perceived barriers were observed in the unemployed group. Identified facilitators included increased support and flexible work strategies. A comprehensive understanding of perceptions of limiting and helpful factors related to employment for people with BD was obtained. These findings have implications for service provision, encouraging targeted discussion, and tailored treatment approaches to individual's unique perceptions of factors related to employment.

Predictors of psychosocial functioning in euthymic patients with bipolar disorder: A model selection approach

BACKGROUND

Functional impairment is a major target in the treatment of bipolar disorder (BD), but the magnitude and type of functional difficulties differ across patients. Findings on predictors of overall functioning and specific functional areas are inconsistent. We aimed to characterize functional difficulties and identify factors associated with global functioning and individual domains in euthymic patients.

METHODS

The Functional Assessment Short Test (FAST) was used to assess overall psychosocial functioning and specific functional domains in 80 euthymic participants with BD. Participants also completed a clinical interview and a cognitive assessment. Model selection with elastic net regression was performed to identify predictors of global functioning. We then examined the association of these predictors with individual functional domains using correlation.

RESULTS

FAST scores indicated moderate or severe impairment for 54% of the sample, with occupational functioning showing the highest impairment rate. Elastic net regression selected a model with three variables (higher residual depressive symptoms, lower executive functioning, more perceived cognitive deficits) as predictors of overall functioning. No significant associations were found between these predictors. Depressive symptoms were associated with interpersonal relationships and leisure time, executive skills with occupational functioning, and perceived deficits with cognitive functioning.

CONCLUSIONS

Residual depressive symptoms were the strongest predictor of overall functioning which highlights the importance of assessing and targeting subthreshold symptoms for recovery. Executive difficulties were associated with functioning, particularly occupational skills, independently of depressive symptoms. Interventions targeting these difficulties, such as cognitive and functional remediation, may be key treatment options towards facilitating functional recovery.

Early neurophysiological stimulus processing during a performance-monitoring task differentiates women with bipolar disorder from women with ADHD

Adults with attention-deficit/hyperactivity disorder (ADHD) or bipolar disorder (BD) may display similar cognitive impairments and clinical symptoms, which might reflect shared mechanisms. Initial evidence indicates disorder-specific and overlapping neurophysiological alterations using event-related potentials (ERPs) in individuals with BD or ADHD during attentional tasks, but it is unknown whether impairments generalize across other processes and tasks. We conduct the first comparison between women with ADHD (n = 20), women with BD (n = 20) and control women (n = 20) on ERPs from a performance-monitoring flanker task. The BD group showed a significantly attenuated frontal ERP of conflict monitoring (N2) compared to the ADHD group across both low-conflict (congruent) and high-conflict (incongruent) task conditions, and compared to controls in the high-conflict condition. However, when controlling for an earlier attentional ERP (frontal N1), which was significantly reduced in participants with BD compared to participants with ADHD and controls, N2 group differences were no longer significant. These results indicate that ERP differences in conflict monitoring may be attributable to differences in earlier attentional processes. These findings identify neural differences in early attention between BD and ADHD which precede conflict monitoring processes, potentially pointing to distinct neural mechanisms implicated in the two disorders.

Is the 4-factor model of symptomology equivalent across bipolar disorder subtypes?

Background

Research with the BDS_x (Bipolar Disorder Symptom Scale) suggests a 4-factor structure of responses: two depression (cognitive, somatic) and two hypo/mania factors (elation/loss of insight, affrontive symptoms). The two depression and two hypo/mania factors are correlated; and affrontive symptoms of hypo/mania (e.g., furious, disgusted, argumentative) are positively correlated with both depression factors suggesting pathways for mixed symptom presentation. This grouping of affrontive symptoms of hypo/mania organically emerged in exploratory research and has subsequently been supported in confirmatory analyses between samples and over time. The BDS_x has been clinically validated with BD outpatients.

Results

Over 19 days, we recruited an international sample of 784 adults with BD using micro-targeted, social media advertising (M  =  44.48 years, range 18–82). All participants indicated that they had BD (subtype, if known) and had been diagnosed with BD (month, year). This sample size was sufficient to confirm the 4-factor model across subtypes and compare the three (BD I, BD II, BD NOS). Responses to 19 of 20 BDS_x items were psychometrically consistent across BD subtypes. Only responses to the ‘hopeless’ item were significantly higher for those with BD II.

Conclusions

When comparing models, it appears that affrontive symptoms are significantly and uniformly associated with hypo/mania and both depression factors across subtypes. In contrast to BD diagnostic criteria, this suggests that affrontive symptoms are central to the clinical presentation of hypo/mania and mixed symptomology across BD subtypes.

Associations of Attachment and Coping Styles With Social Functioning in Patients With Bipolar Disorder I

ABSTRACT

The aim of this study was to investigate the relationship of attachment and coping mechanisms with social functioning in patients with bipolar disorder (BD). Sixty-three patients with BD type I and 63 healthy controls were evaluated. Structured Clinical Interview for DSM-IV Axis I Disorders, Hamilton Depression Rating Scale, Young Mania Rating Scale, Experiences in Close Relationships Questionnaire II, Coping Orientation to Problems Experienced (COPE) inventory, and Social Functioning Scale were used. In the BD group, adaptive coping style scores and attachment avoidance scores were significantly lower than the control group, but mean scores of maladaptive coping styles were higher than the control group. Regression analysis showed that positive reinterpretation and growth, active coping, use of emotional social support, planning, religious activities, and mental disengagement subscales of COPE were significantly associated with social functioning. Psychosocial interventions to strengthen adaptive coping mechanisms may help improve the social functioning in patients with BD.

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

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

Experiences of health care costs among people with employer-sponsored insurance and bipolar disorder

BACKGROUND

Cost-sharing disproportionately affects people with chronic illnesses needing more care. Our qualitative study examined lived experiences navigating insurance benefits and treatment for bipolar disorder, which requires ongoing access to behavioral specialists and psychotropic medications.

METHODS

Forty semi-structured telephone interviews with individuals with bipolar disorder and employer-sponsored health insurance, or their family caregivers, explored health care needs, coverage details, out-of-pocket (OOP) costs, and perspectives on value. An iterative analytic approach identified salient themes.

RESULTS

Most individuals in our sample faced an annual insurance deductible, from $350-$10,000. OOP costs for specialist visits ranged from $0-$450 and for monthly psychotropic medications from $0-$1650. Acute episodes and care for comorbidities, including medication side effects, added to cost burdens. Medication nonadherence due to OOP costs was rare; respondents frequently pointed to the necessity of medications: "whatever it takes to get those"; "it's a life or death situation." Respondents also prioritized visits to psychiatrist prescribers, though visits were maximally spaced because of cost. Psychotherapy was often deemed unaffordable and forgone, despite perceived need. Interviewees cited limited networks and high out-of-network costs as barriers to specialists. Cost-sharing sometimes led to debt, skimping on nonbehavioral care or other necessities, exacerbated or prolonged mood symptoms, and stress at home.

LIMITATIONS

Volunteer respondents may not fully represent the target population.

CONCLUSIONS

Many people with bipolar disorder in US employer-sponsored plans experience undertreatment, hardship, and adverse health consequences due to high cost-sharing. More nuanced insurance benefit designs should accommodate the needs of individuals with complex conditions.

Determinants of the remission heterogeneity in bipolar disorders: The importance of early maladaptive schemas (EMS)

BACKGROUND

A crucial health issue is to understand the remission heterogeneity of Bipolar Disorders by considering symptomatology as well as functioning. A new perspective could be elements of the construction of individual identity. This exploratory study aimed to explore the remission heterogeneity of patients with BD in terms of Early Maladaptive Schemas (EMS) by preferring a person-oriented approach.

METHODS

This study included euthymic patients recruited into the FACE-BD cohort. The remission was assessed by the Montgomery-Asberg Depression Rating Scale and the Young Mania Rating Scale for its symptomatic dimension and by the Functioning Assessment Short Test for its functional dimension. The activation of the eighteen EMS was assessed by the Young Schema Questionnaire 3 Short Form. Clustering was performed to identify profiles according to the patients' remission. Clusters identified were compared on the EMS activation by using analysis of variance and post-hoc tests.

RESULTS

Among the 100 euthymic patients included, four profiles of remission were identified: cluster 1 "Global Remission" (34%), cluster 2 "Hypomanic residual" (20%), cluster 3 "Depressive residual and functional impairment" (36%) and cluster 4 "Global handicap" (10%). Two out of three EMS discriminated against these profiles. The activation of specific EMS clarifies the singularity of each remission profile.

LIMITATIONS

For the symptomatic dimension, cut-offs chosen could be discussed as well as the scale assessing residual depressive symptoms.

CONCLUSIONS

This study participates in a comprehensive model of remission by integrating the symptomatology, the functioning, and the EMS. Identifying and treating EMS may improve patients remission to reach recovery.

Evolution and characteristics of the use of valproate in women of childbearing age with bipolar disorder: Results from the FACE-BD cohort

BACKGROUND

Valproate is associated with teratogenic and neurodevelopmental effects. Several agencies have restricted the conditions of its prescription in bipolar disorders (BD). We aimed to assess the evolution of valproate prescription and the clinical profile of BD women of childbearing age receiving valproate.

METHODS

Based on a large national cohort, we included all BD women 16-50 years old. Sociodemographic, clinical and pharmacological data were recorded. Logistic regression analyses were used to describe variables associated with valproate prescription.

RESULTS

Of the 1018 included women 16-50 years old, 26.9% were treated with valproate with a mean daily dosage of 968 mg. The prevalence of BD women using valproate was 32.6% before May 2015 and 17.3% after May 2015 (p<0.001), the date of French regulatory publication of restriction of valproate prescription. The multivariate analysis revealed that the inclusion period after May 2015 (OR=0.54, CI 95% 0.37-0.78, p=0.001), the age lower than 40 years (OR=0.65, CI 95% 0.43-0.98, p=0.040) and the number of lifetime mood episodes (OR=0.98, CI 95% 0.95-0.99, p=0.040) were the variables negatively associated with the use of valproate.

LIMITATIONS

Study could be underpowered to determine a clinical profile associated with valproate prescription.

CONCLUSIONS

The regulatory change in BD women of childbearing age had a significant impact on valproate prescription, even if the prescription rate remains high. Important efforts are needed to help clinicians and patients to improve quality of care in BD women of childbearing age.

Reliability and validity of the functioning assessment short test for older adults with bipolar disorder (FAST-O)

Background

Many frequently used instruments fail to assess psychosocial functioning in patients with bipolar disorder. The Functioning Assessment Short Test (FAST) was developed in order to tackle this problem and to assess the main functioning problems experienced by patients with bipolar disorder. However, the original FAST is not fully applicable in older adults due to the domain of occupational functioning. The aim of our study was to validate an adapted version for Older adults (FAST-O) in a group of older adults with bipolar disorder (OABD).

Methods

88 patients aged 50 years and over diagnosed with bipolar disorder were included. We adapted the items in the area of “work-related functioning” of the FAST into items assessing “societal functioning”. Several measurements were conducted in order to analyse the psychometric qualities of the FAST-O (confirmatory factor analysis for internal structure, Cronbach’s alpha for internal consistency, Spearman’s rho for concurrent validity, Mann–Whitney U test for discriminant validity).

Results

Mean age in the study sample was 65.3 (SD = 7.5) and 57.3% was female. The internal structure was most similar to the internal structure of the original FAST. The internal consistency was excellent (Cronbach’s alpha = .93). The concurrent validity when correlated with the Social and Occupational Functioning Assessment Scale was low, but significant. The FAST-O was also able to distinguish between euthymic and symptomatic OABD patients.

Conclusions

The FAST-O has strong psychometric qualities. Based on our results, we can conclude that the FAST-O is a short, efficient solution in order to replace global rating scales or extensive test batteries in order to assess daily functioning of older psychiatric patients in a valid and reliable manner.

Trajectories of functioning in bipolar disorders: A longitudinal study in the FondaMental Advanced Centers of Expertise in Bipolar Disorders cohort

OBJECTIVE

We aimed at identifying distinct trajectories of functioning and at describing their respective clinical characteristics in a cohort of individuals with bipolar disorders.

METHODS

We included a sample of 2351 individuals with bipolar disorders who have been followed-up to 3 years as part as the FondaMental Advanced Centers of Expertise in Bipolar Disorders cohort. Global functioning was measured using the Functioning Assessment Short Test. We used latent class mixed models to identify distinct longitudinal trajectories of functioning over 3 years. Multivariable logistic regression models were used to identify the baseline factors that were associated with the membership to each trajectory of functioning.

RESULTS

Three distinct trajectories of functioning were identified: (1) a majority of individuals (72%) had a stable trajectory of mild functional impairment, (2) 20% of individuals had a stable trajectory of severe functional impairment and (3) 8% of individuals had a trajectory of moderate functional impairment that improved over time. The membership to a trajectory of stable severe versus stable mild functional impairment was associated with unemployment, a higher number of previous hospitalizations, childhood maltreatment, a higher level of residual depressive symptoms, higher sleep disturbances, a higher body mass index and a higher number of psychotropic medications being prescribed at baseline. The model that included these seven factors led to an area under the curve of 0.85.

CONCLUSION

This study enabled to stratify individuals with bipolar disorders according to three distinct trajectories of functioning. The results regarding the potential determinants of the trajectory of severe functional impairment needs to be replicated in independent samples. Nevertheless, these potential determinants may represent possible therapeutic targets to improve the prognosis of those patients at risk of persistent poor functioning.

Functioning in euthymic patients with bipolar disorder: A systematic review and meta-analysis using the Functioning Assessment Short Test

OBJECTIVES

Systematically review the prevalence of functional impairment (FI) in euthymic patients with bipolar disorder (BD), as assessed only with the Functioning Assessment Short Test (FAST), explore the prevalence of this impairment among all the domains, identify the most compromised of them and the clinical variables associated with low functioning in this population.

METHODS

Meta-analyses were performed, searching for relevant papers published from 2007 to 2019 in Medline, Embase, Cochrane, PsycINFO databases and via hand-searching, without language restrictions. 1128 studies were initially identified, 13 of which were ultimately chosen based on the eligibility criteria. A two-step meta-analysis was performed using the mean difference with a 95% confidence interval for continuous variables and proportion estimation with a fixed-effects model for categorical variables.

RESULTS

In the first step, all FAST domains showed worse FI in patients than in healthy controls, with significant differences between groups. In the second step, the prevalence of FI domains were as follows: global, 58.6%; occupational, 65.6%; cognitive, 49.2%; autonomy, 42.6%; interpersonal relationships, 42.1%; leisure, 29.2%; and financial issues, 28.8%. Residual depressive symptoms were the most frequently cited variable associated with FI.

CONCLUSIONS

This study reinforces the relevant functional impact of BD in this population and suggests that the occupational domain may be the most impaired. Greater efforts should be directed toward targeting functioning in patient care, as it constitutes the most meaningful endpoint of response to treatment, especially with occupational and cognitive rehabilitation, thus allowing patients to overcome the course of illness and carry fulfilling lives.

A Randomized Controlled Trial of Transcultural Validation of Group-Based Psychosocial Intervention for Patients with Bipolar Disorder

Adjunctive psychosocial interventions are part of the preferred method to treat bipolar disorder (BD). This study aimed to conduct a randomized control and protocol-guided trial, in order to evaluate the feasibility and effectiveness of adjunctive group-based treatments for Chinese outpatients with BD. A single-blind trial in which 68 outpatients with BD were randomly assigned to either treatment as usual (TAU) or to an experimental group with 12 additional weekly sessions and 3 monthly booster sessions. Participants were assessed at baseline for mood condition, suicidal ideation, medication adherence, and quality of life (QoL), with follow-up assessments every 3 months over a 1-year period. The overall retention rate of this study was 89.7%. The results showed significant differences between groups for the variables evaluated, which included achieving euthymia, decrease of depression symptoms, and improvement of QoL. No improvements in medication adherence, reduction in manic symptoms, or suicidal ideation was observed. The results of this study support the transcultural validity and efficacy of group-based psychosocial intervention as anadjunct to TAU among Chinese outpatients with BD to promote improvements during the course of the illness including achieving euthymia, reducing depressive symptoms, and improving QoL.

Prevalence and clinical correlates of residual symptoms in remitted patients with bipolar disorder: An exploratory study

OBJECTIVE

This cross-sectional study aimed to evaluate the prevalence and factors associated with residual symptoms (both depressive and manic) in subjects with bipolar disorder (BD).

MATERIALS AND METHODS

A total of 844 subjects diagnosed BD with an illness of 2 years' duration and minimum of two lifetime episodes and in clinical remission were evaluated for residual symptoms using Hamilton Depression Rating Scale (HAM-D) and Young Mania Rating Scale (YMRS). Based on the severity of residual symptoms, the study groups were divided into four groups.

RESULTS

Sixty-nine percent of the subjects had residual depressive symptoms (i.e., HAM-D score in the range of 1-7) and 59% had residual manic symptoms (i.e., YMRS score in the range of 1-7). The most common residual depressive symptom was psychic anxiety (34%) followed by impaired insight (29%). The most common manic symptom was poor insight (31%) followed by sleep disturbances (25%). Subjects with both sets of residual symptoms had onset of BD at a relatively young age, when compared to those with only residual depressive symptoms. Presence of any comorbid physical illness and substance abuse disorder was significantly higher in those with both sets of residual symptoms.

CONCLUSIONS

The present study suggests that a substantial proportion of patients with BD have residual symptoms of both types. Comorbid physical illness and substance use were associated with residual symptoms. Identification and management of residual symptoms are highly essential to improve the overall outcome of patients with BD.

Psychometric properties of the MATRICS Consensus Cognitive Battery (MCCB) in Chinese patients with major depressive disorder

BACKGROUND

Major depression disorder (MDD) is often associated with cognitive impairment. The development of an accurate and effective battery to measure cognitive deficit is necessary for both research and clinical practice in MDD. Our study was designed to test the psychometric properties of the MATRICS Consensus Cognitive Battery (MCCB) in patients with MDD.

METHOD

Forty-eight patients with MDD, forty-three euthymic patients with bipolar disorder (BD) and thirty-two remitted patients with schizophrenia (SCH) were recruited from Tianjin Anding Hospital in Tianjin, China. The MCCB, the Montreal Cognitive Assessment (MoCA) and the Hamilton Depression Rating Scale-17 (HDRS-17) were administered to assess cognitive impairment and depressive symptoms at both baseline and one month later.

RESULT

Our findings showed that the MCCB had good internal consistency and acceptable reliability in Chinese MDD patients. Our findings revealed a high correlation between the MCCB and the MoCA, indicating good concurrent validity of the MCCB. Furthermore, the MCCB showed high discriminant ability between MDD patients and healthy controls, and a principal component analysis of the MCCB in MDD patients revealed four domains with acceptable internal structure.

LIMITATIONS

We did not consider confounding factors, such as the course, severity of symptoms and medication treatments, which might bias the cognitive assessment. In addition, the use of the MoCA as a reference scale for mild cognitive impairment could weaken the concurrent validity of the MCCB in MDD patients.

CONCLUSION

Our findings demonstrated that the MCCB may be clinically useful as a cognitive impairment rating battery in Chinese patients with MDD.

Sexual Dysfunction and Mood Stabilizers in Long-Term Stable Patients With Bipolar Disorder

BACKGROUND

In addition to factors intrinsic to bipolar disorder (BD), sexual functioning (SF) can be affected by extrinsic causes, such as psychotropic drugs. However, the effect of mood stabilizers on SF and quality of life (QoL) is an underexplored research area.

AIM

To analyze SF in BD outpatients in euthymia for at least 6 months treated only with mood stabilizers and the association between SF and QoL.

METHODS

A multicenter cross-sectional study was conducted in 114 BD outpatients treated with (i) lithium alone (L group); (ii) anticonvulsants alone (valproate or lamotrigine; A group); (iii) lithium plus anticonvulsants (L+A group); or (iv) lithium plus benzodiazepines (L+B group). The Changes in Sexual Functioning Questionnaire Short Form (CSFQ-14) was used. Statistical analyses were performed to compare CSFQ-14 scores among the pharmacological groups. An adaptive lasso was used to identify potential confounding variables, and linear regression models were used to study the association of the CSFQ-14 with QoL.

MAIN OUTCOME MEASURES

Self-reports on phases of the sexual response cycle (ie, desire, arousal, and orgasm) and QoL were assessed.

RESULTS

The A group had better total SF scores than the L group and the L+B group. Relative to the A group, the L and L+B groups had worse sexual desire; the L group had worse sexual arousal; and the L+A group and the L+B group had worse sexual orgasm. Regarding sociodemographic factors, being female and older age were associated with worse total SF and all subscale scores. Among all subscales scores, higher sexual arousal scores were associated with better QoL.

CLINICAL IMPLICATIONS

Potential modified extrinsic factors such as psychotropic medication that can affect SF can be addressed and adjusted to lessen side effects on SF.

STRENGTHS & LIMITATIONS

Sample of patients with euthymic BD in treatment with mood stabilizers and no antipsychotics or antidepressants, substance use as an exclusion criterion, and use of a validated, gender-specific scale to evaluate SF. Major limitations were cross-sectional design, sample size, and lack of information about stability of relationship with partner.

CONCLUSIONS

Lithium in monotherapy or in combination with benzodiazepines is related to worse total SF and worse sexual desire than anticonvulsants in monotherapy. While the addition of benzodiazepines or anticonvulsants to lithium negatively affects sexual orgasm, sexual arousal (which plays a significant role in QoL) improves when benzodiazepines are added to lithium. Anticonvulsants in monotherapy have the least negative effects on SF in patients with BD. García-Blanco A, García-Portilla MP, Fuente-Tomás L de la, et al. Sexual Dysfunction and Mood Stabilizers in Long-Term Stable Patients With Bipolar Disorder. J Sex Med 2020;17:930-940.

Inflammation as a Mechanism of Bipolar Disorder Neuroprogression

Bipolar disorder (BD) is a severe, debilitating psychiatric condition with onset in adolescence or young adulthood and often follows a relapsing and remitting course throughout life. The concept of neuroprogression in BD refers to the progressive path with an identifiable trajectory that takes place with recurrent mood episodes, which eventually leads to cognitive, functional, and clinical deterioration in the course of BD. Understanding the biological basis of neuroprogression helps to explain the subset of BD patients who experience worsening of their disorder over time. Additionally, the study of the neurobiological mechanisms underpinning neuroprogression will help BD staging based on systems biology. Replicated epidemiological studies have suggested inflammatory mechanisms as primary contributors to the neuroprogression of mood disorders. It is known that dysregulated inflammatory/immune pathways are often associated with BD pathophysiology. Hence, in this chapter, we focus on the evidence for the involvement of inflammation and immune regulated pathways in the neurobiological consequences of BD neuroprogression. Herein we put forth the evidence of immune markers from autoimmune disorders, chronic infections, and gut-brain axis that lead to BD neuroprogression. Further, we highlighted the peripheral and central inflammatory components measured along with BD progression.

[Exploring Early Maladaptative Schema (EMS) in adults with bipolar disorder: A systematic review of the scientific literature]

OBJECTIVES

Clinical heterogeneity during euthymic states is a crucial issue in bipolar disorders. Indeed, actual data are not sufficient to understand why some patients are unharmed by subthreshold symptoms and have functional impairments whereas others have a functional remission but have subthreshold symptoms. Based on the Ball model, cognitive and schematic vulnerability interact with genetic vulnerability and trigger affective symptoms with the intervention of stressful life events. Furthermore, according to this model, adjustment and adaptation to illness assessed by functional outcome and illness experience are associated with this cognitive and schematic vulnerability. So, theoretical arguments support that childhood adversity and temperamental deregulation characterize patients with bipolar disorders. Thus, the aim of this study is to systematically review studies of Early Maladaptive Schemas in bipolar disorder, to determine whether Early Maladaptive Schemas have specificity in bipolar disorder in comparison with other populations, and to identify which Early Maladaptive Schemas could be activated. The challenge of this review is to identify if the taking of early maladaptive schemas into account could allow us to better identify, understand and manage bipolar disorders.

METHODS

This systematic review was led according to the Preferred Reporting Items for Systematic review and Meta-Analysis statement on the electronic databases Cochrane, PsycArticles, Psychology and Behavioral Sciences Collection, PsycInfo, PubMed, ScienceDirect and Scopus with « early maladaptive schemas » AND « bipolar disorder » as keywords. Only studies meeting eligibility criteria concerning publication status, language, population and outcomes were included after several screenings on basis of title, abstract and full-text. Then, we carried out data extraction in accordance with criteria defined in principle (about characteristics of participants, objectives, materiel and methods, principle results and bias).

RESULTS

Among 39 records identified, a total of 10 studies met eligibility criteria for inclusion in this review. Synthesizing findings across the studies revealed three important topics. First, early maladaptive schemas appear as potential cognitive characteristics that clinicians have to investigate in clinical practice. Indeed, patients with bipolar disorders present greater activation of the early maladaptive schemas in comparison with people who have no disorder. This point supports the first part of Ball's theoretical model that considers schemas as a vulnerability to bipolarity. Secondly, early maladaptive schemas are relevant to distinguish bipolar disorders from unipolar depression and borderline personality disorder. A greater and a lower activation are respectively identified among bipolar disorders. Thirdly, supporting the second part of Ball's model, early maladaptive schemas play a key role in recovery regarding their impact on the course of bipolarity, in particular on suicidality and functional impairment. Finally, these dysfunctional schemas allow us to understand the clinical heterogeneity of bipolar disorder, and among others, about the type of bipolarity. These results have several implications, but there are some limits in this systematic review. First, no French study has been done. Then, reduced sample sizes in these studies increased the risk to conclude wrongly to an activation difference between groups. Furthermore, probably due to the variety of methods and populations, we could not identify an homogeneous pattern of early activated maladaptive schemas. Overall, scientific approaches used in these studies are based on statistical models using mean and standard deviation. These types of statistical analyses are the main limit because they cannot represent the heterogeneity of early maladaptive schemas profiles.

CONCLUSIONS

Schema theory proves to be a relevant approach in bipolar disorders, and early maladaptive schemas appear to be important to take into account in clinical practice. Nevertheless, in order to propose schemas therapy appropriately, it is necessary to specify if early maladaptive schemas are activated and to specify therapeutic indications because of clinical heterogeneity. Moreover, data do not yet allow us to understand the disparity of profiles during the inter-episode period. Indeed, a French research perspective is being considered that will prefer a person-oriented approach.

Association of subthreshold manic symptoms and cognitive impairments in euthymic patients with bipolar disorder I

Cognitive impairments exist during the euthymic period of bipolar disorder (BD). However, the impact of clinical factors (e.g., subthreshold symptoms and body mass index) on cognitive function in euthymic patients with bipolar disorder I is inconsistent. This cross-sectional study included 83 patients with euthymic BD I and 115 healthy controls. The Repeatable Battery for the Assessment of Neuropsychological Status indices were used to assess cognitive function. We assessed the relationship between cognitive function and clinical impact factors. Performance in language abilities, attention, and immediate memory was worse in euthymic BD I. Spearman's correlation revealed that indices for immediate memory and attention were negatively correlated with subthreshold manic symptoms, and indices for delayed memory were positively correlated with years of education. Linear regressions indicated that subthreshold manic symptoms were the best predictors of immediate memory and attention. Years of education predicted performance in most cognitive domains, except immediate memory. Individuals with euthymic BD I exhibited cognitive deficits in language learning, attention, and immediate memory. Our study highlights the importance of the effect of subthreshold manic symptoms on cognitive function in remitted BD; these symptoms should receive more attention and be targeted in personalized clinical therapeutic interventions.

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

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

Improving Functioning, Quality of Life, and Well-being in Patients With Bipolar Disorder

People with bipolar disorder frequently experience persistent residual symptoms, problems in psychosocial functioning, cognitive impairment, and poor quality of life. In the last decade, the treatment target in clinical and research settings has focused not only on clinical remission, but also on functional recovery and, more lately, in personal recovery, taking into account patients' well-being and quality of life. Hence, the trend in psychiatry and psychology is to treat bipolar disorder in an integrative and holistic manner. This literature review offers an overview regarding psychosocial functioning in bipolar disorder. First, a brief summary is provided regarding the definition of psychosocial functioning and the tools to measure it. Then, the most reported variables influencing the functional outcome in patients with bipolar disorder are listed. Thereafter, we include a section discussing therapies with proven efficacy at enhancing functional outcomes. Other possible therapies that could be useful to prevent functional decline and improve functioning are presented in another section. Finally, in the last part of this review, different interventions directed to improve patients' well-being, quality of life, and personal recovery are briefly described.

Social cognition and interaction training (SCIT) for partially remitted patients with bipolar disorder in China

Bipolar disorder (BD) is associated with functional impairment. Social Cognition and Interaction Training (SCIT) has been shown to be feasible and effective at improving social functioning in patients with schizophrenia. We aimed to explore the association between SCIT and improvements in the clinical symptoms and functioning of partially remitted patients with BD in China. Seventy-four BD patients were randomly assigned to the SCIT and psychoeducation (Control) groups. All subjects participated in group interventions weekly for 8 weeks. Furthermore, the participants were administered the Young Mania Rating Scale (YMRS), the 17-item Hamilton Depression Rating Scale (HDRS-17), the Function Assessment Short Test (FAST) and neurocognitive measures at baseline and after eight weeks. There were no differences in demographics, the HDRS-17, YRMS, and FAST scores or neurocognitive measures between the groups at baseline (p>0.05). The repeated-measures analysis revealed that SCIT resulted in greater improvement in the HDRS, YMRS, and FAST scores (including six domains) (p<0.01) and two neurocognitive measures (p<0.05) compared to psychoeducation. Our findings suggest that SCIT is a feasible and promising intervention for the clinical symptoms and functioning of partially remitted patients with BD. Further longitudinal studies are needed to observe the long-term impact of SCIT on emotional and functional improvement in these patients.

Perceived childhood adversities: Impact of childhood trauma to estimated intellectual functioning of individuals with bipolar disorder

Maltreatments in childhood may have implications for neurodevelopment that could remain throughout life. Childhood trauma seems to be associated with the onset of bipolar disorder (BD), and its occurrence might accentuate the overall disease impairments related to cognitive deficits in BD. We aimed to evaluate the effects of a history of childhood trauma to estimated intellectual functioning (IQ) of individuals with BD. We included 72 subjects with BD during euthymia. Participants underwent a clinical interview and were assessed through the Childhood Trauma Questionnaire (CTQ) and Wechsler Abbreviated Scale of Intelligence (WASI). Most prevalent trauma subtypes were emotional abuse and neglect (54.1%). A linear regression model that included perceived childhood trauma, family history of severe mental disorders, age at diagnosis and psychotic symptoms during the first episode as main factors showed that only childhood trauma had a significant effect in predicting estimated IQ. Therefore, the history of childhood trauma in individuals with BD may play a role in intellectual development, suggesting that adversities during development result in decreased general cognitive abilities. These results reinforce the need to promote early interventions to protect childhood and to promote the well-being of children, contributing to the growth of healthy adults.

Identifying cognitive subgroups in bipolar disorder: A cluster analysis

BACKGROUND

Evidence has shown heterogeneity of cognitive function among patients with bipolar disorder (BD). Our study aims to replicate recent findings of cognitive subgroups, as well as we assessed subjective cognitive difficulties and functioning in each cluster.

METHODS

Hierarchical cluster analysis was conducted to examine whether there were distinct neurocognitive subgroups based on neurocognitive battery. Cognitive Complaints in Bipolar Disorder Rating Assessment (COBRA) and Functioning Assessment Short Test (FAST) were used to assess subjective cognitive difficulties and functional impairment.

RESULTS

We found three distinct subgroups: a first cluster with intact cognition (n = 30, 43.5%), a second cluster with selective cognitive impairment (n = 23, 33.3%), and a third cluster with globally cognitive impairment (n = 16, 23.3%). The intact group had more years of education (p < .001) and higher estimated IQ (p < .001) than globally and selectively impaired subgroups. Additionally, they were younger (p = .011), had an earlier age at bipolar diagnosis (p < .037) and earlier age of first hospitalization (p < .035) compared to individuals with globally cognitive impairment.

LIMITATIONS

This is a cross-sectional design with a small sample including only patients from a tertiary hospital.

CONCLUSION

Our results give support to the existence of a continuum of severity from patients without impairment to those with poor cognitive functioning. Patients in the intact group seem to have higher cognitive reserve than other two groups. However, they also experienced cognitive complaints and some degree of functional impairment. These findings suggest the importance of using a combo of instruments (e.g., objective and subjective cognitive measures plus functioning instruments) for a complete assessment of patients with BD.

Emotion regulation strategies in bipolar disorder: A systematic and critical review

Theoretical frameworks emphasise associations between interpretations and responses to affect and bipolar disorder (BD). This review (PROSPERO CRD42016043801) investigated which emotion regulation (ER) strategies have been applied to BD, are elevated in BD compared to clinical and non-clinical controls, and are associated with clinical and functional outcomes in BD METHODS: Search terms relating to emotion regulation, coping and bipolar disorder were entered into Embase, MedLine and PsycInfo. Quantitative studies investigating relationships between ER strategies and BD were eligible for this narrative synthesis RESULTS: A large volume of research (n = 47) investigated specific ER strategies in BD. Maladaptive strategies such as rumination and dampening were elevated in BD compared to controls and these particular strategies had a detrimental impact on outcomes such as mood symptoms. BD had a similar profile of ER strategies to unipolar depression, but there was limited comparison to other clinical groups. People with BD did not generally have deficits in using adaptive strategies, as evidenced by comparisons with controls and experimental studies LIMITATIONS: Methodological heterogeneity and a lack of ecologically valid ER assessments CONCLUSIONS: Empirical literature is critiqued in line with contemporary theories of BD and of emotion regulation more generally, in order to inform future research recommendations. This includes investigation of the importance of context in the impact of ER strategies, and discrepancies between trait and state use of ER strategies, particularly through experience sampling.