Cognitive function, treatment response to lithium, and social functioning in Japanese patients with bipolar disorder

[Effects of lithium, valproic acid, carbamazepine and antipsychotic agents on cognition in bipolar disorders-A systematic review]

BACKGROUND

Until now the long-term consequences of the medical treatment for bipolar disorder have barely been examined, especially the consequences with respect to cognitive impairment and dementia. Some studies show signs that some treatment options have a better effect on the brain than others. This review summarizes the current state of research.

OBJECTIVE

The effects of long-term consequences of lithium, valproic acid, carbamazepine and antipsychotic agents on the development of dementia or cognitive impairments in patients with bipolar disorder were investigated.

METHODS

A systematic literature search was carried out in the PubMed data base from May to July 2022.

RESULTS

The majority of studies showed that lithium has a neuroprotective effect and can lower the risk of developing dementia, whereas an increased risk was found in patients taking valproic acid. There are only very few studies that deal with antipsychotic medication and the long-term consequences concerning dementia.

CONCLUSION

Lithium should be recommended for the long-term treatment of bipolar disorder. Valproic acid should not or carefully be used as it can affect the risk of developing dementia. With respect to antipsychotics there is no recommendation as more studies are needed to evaluate the long-term consequences.

Socio-demographic and clinical predictors of outcome to long-term treatment with lithium in bipolar disorders: a systematic review of the contemporary literature and recommendations from the ISBD/IGSLI Task Force on treatment with lithium

Objective

To identify possible socio-demographic and clinical factors associated with Good Outcome (GO) as compared with Poor Outcome (PO) in adult patients diagnosed with Bipolar Disorder (BD) who received long-term treatment with lithium.

Methods

A comprehensive search of major electronic databases was performed to identify relevant studies that included adults patients (18 years or older) with a diagnosis of BD and reported sociodemographic and/or clinical variables associated with treatment response and/or with illness outcome during long-term treatment to lithium (> = 6 months). The quality of the studies was scored using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the National Institute of Health.

Results

Following review, 34 publications (from 31 independent datasets) were eligible for inclusion in this review. Most of them (n = 25) used a retrospective design. Only 11 studies were graded as good or borderline good quality. Forty-three potential predictors of outcome to lithium were identified. Four factors were associated with PO to lithium: alcohol use disorder; personality disorders; higher lifetime number of hospital admissions and rapid cycling pattern. Two factors were associated with GO in patients treated with lithium: good social support and episodic evolution of BD. However, when the synthesis of findings was limited to the highest (good or borderline good) quality studies (11 studies), only higher lifetime number of hospitalization admissions remained associated with PO to lithium and no associations remained for GO to lithium.

Conclusion

Despite decades of research on lithium and its clinical use, besides lifetime number of hospital admissions, no factor being consistently associated with GO or PO to lithium was identified. Hence, there remains a substantial gap in our understanding of predictors of outcome of lithium treatment indicating there is a need of high quality research on large representative samples.

Social dysfunction in mood disorders and schizophrenia: Clinical modulators in four independent samples

INTRODUCTION

Social dysfunction is a common symptom of several neuropsychiatric disorders. However, only in the last few years research began to systematically investigate clinical aspects of this relevant outcome. Interestingly, its distribution and link with other clinical variables is still unclear. This study investigated social dysfunction in 4 different cohorts of patients affected by mood disorders and schizophrenia to evaluate 1) the degree of social dysfunction in these populations; 2) the associations among social dysfunction and socio-demographic and psychopathological features.

METHODS

Data from 4 independent studies (CATIE, GSRD ES1, ES2 and ES3, STAR*D, STEP-BD) were investigated. Behavioural and affective indicators of social dysfunction were derived and operationalized from scales or questionnaire items related to the interaction with relatives, friends and significant people in patients affected by schizophrenia (N = 765) and mood disorders (N = 2278 + 1954 + 1829). In particular the social dysfunction indicator was derived from Sheehan Disability Scale (SDS) for GSRD sample, from the Work and Social Adjustment Scale (WSAS) for STAR*D sample, from the Life-Range of Impaired Functioning Tool (LRIFT) for STEP-BD sample, and from the Quality of Life Scale (QOLS) for CATIE sample. The distribution of social dysfunction was described and association with socio-demographic and psychopathological characteristics were analysed.

RESULTS

Social dysfunction indicators showed a broad distribution in all samples investigated. Consistently across studies, social dysfunction was associated with higher psychopathological severity (all samples except CATIE) and suicide risk (GSRD ES1 and ES2, STAR*D, and STEP-BD) that explain up to 47% of the variance, but also to lower education level (GSRD ES2, STAR*D, CATIE, and STEP-BD), poorer professional/work status (GSRD ES2 and ES3, STAR*D, CATIE, and STEP-BD), marital status (STAR*D and CATIE), age (younger age in GSRD ES1 and STAR*D, older age in CATIE), higher BMI (GSRD ES2 and ES3, and STEP-BD), and smoking (GSRD ES2 and ES3).

CONCLUSION

Our results demonstrated that a significant percentage of patients affected by both mood disorders and schizophrenia shows relevant social dysfunction. Social dysfunction is related, but not completely explained by psychopathological severity. In several patients, it tends to persist also during remission state. Socio-demographic and lifestyle factors were also found to play a role and should therefore be taken into consideration in further studies investigating social dysfunction.

Association of genetic variants at 22q11.2 chromosomal region with cognitive performance in Japanese patients with schizophrenia

22q11.2 heterozygous multigene deletions confer an increased risk of schizophrenia with marked impairment of cognition. We explored whether genes on 22q11.2 are associated with cognitive performance in patients with idiopathic schizophrenia. A total of 240 schizophrenia patients and 240 healthy controls underwent the Japanese-language version of the Brief Assessment of Cognition in Schizophrenia (BACS) and were genotyped for 115 tag single-nucleotide polymorphisms (tag SNPs) at the 22q11.2 region using the golden gate assay (Illumina®). Associations between z-scores of the BACS cognitive domains and SNPs and haplotypes were analyzed using linear regression in PLINK 1.07. An additional set of 149 patients with bipolar disorder were included for cognitive assessment and selected SNPs were genotyped using real-time PCR. Patients with schizophrenia and bipolar disorder showed qualitatively comparable profiles of cognitive impairment across BACS subdomains, as revealed by significant correlation between the two groups in the resulting cognitive effect sizes relative to controls. rs4819522 (TBX1) and rs2238769 (UFD1L) were significantly and nominally associated, respectively, with symbol coding in patients with schizophrenia. Haplotype analyses revealed that haplotypes containing the A allele at rs4819522 and G allele at rs2238769 showed significant negative associations with symbol coding in patients with schizophrenia. There was no effect of any haplotypes on cognition in patients with bipolar disorder. Our results have implications for the understanding of the role of haplotypes of UFD1L and TBX1 genes associated with symbol coding in patients with schizophrenia. Further replication studies in a cohort of newly diagnosed patients and other ethnicities are warranted.

A systematic review and meta-analysis of clinical predictors of lithium response in bipolar disorder

OBJECTIVE

To determine clinical predictors of lithium response in bipolar disorder.

METHODS

Systematic review of studies examining clinical predictors of lithium response was conducted. Meta-analyses were performed when ≥2 studies examined the same potential predictor.

RESULTS

A total of 71 studies, including over 12 000 patients, identified six predictors of good response: mania-depression-interval sequence [odds ratio (OR): 4.27; 95% CI: 2.61, 6.97; P < 0.001], absence of rapid cycling (OR for rapid cycling: 0.30; 95% CI: 0.17, 0.53; P < 0.001), absence of psychotic symptoms (OR for psychotic symptoms: 0.52; 95% CI: 0.34, 0.79; P = 0.002), family history of bipolar disorder (OR: 1.61; 95% CI: 1.03, 2.52; P = 0.036), shorter prelithium illness duration [standardised mean difference (SMD): -0.26; 95% CI: -0.41, -0.12; P < 0.001] and later age of onset (SMD: 0.17; 95% CI: 0.02, 0.36; P = 0.029). Additionally, higher body mass index was associated with poor response in two studies (SMD: -0.61; 95% CI: -0.90, -0.32; P < 0.001). There was weak evidence for number of episodes prior to lithium treatment (SMD: -0.42; 95% CI: -0.84, -0.01; P = 0.046), number of hospitalisations before lithium (SMD: -0.40; 95% CI: -0.81, 0.01; P = 0.055) and family history of lithium response (OR: 10.28; 95% CI: 0.66, 161.26; P = 0.097).

CONCLUSIONS

The relative importance of these clinical characteristics should be interpreted with caution because of potential biases and confounding.

High risk of silent stroke in older bipolar patients with typical-onset age

AIM

Older patients with bipolar disorder (BD) are at a high risk of stroke. Silent stroke could be neglected in BD patients after middle age, particularly in those with illness onset at the young age. Therefore, we investigated the morbidity and related factors for stroke in older BD patients with typical-onset age.

METHODS

Older patients with bipolar I disorder (age > 50 years) and their illness onset prior to the age of 40 years were recruited. After whole-brain magnetic resonance imaging was conducted, the patients were divided into stroke and non-stroke groups. Clinical data were obtained by reviewing all available medical records and directly interviewing the patients along with their reliable family members.

RESULTS

We recruited 62 patients with a mean age of 60.4 years and illness onset at the mean age of 28.4 years. Cerebral infarction or old stroke was observed in 24 (38.7%) patients, including 22 without any reported clinical history of stroke. That is, silent stroke (n = 22) was detected in 36.7% of 60 patients without clinical history of stroke. The stroke group had significantly higher mean numbers of lifetime mood episodes (P = 0.006) than the non-stroke one. Logistic regression analysis showed that 10 or more prior mood episodes (odds ratio = 3.43, 95% confidence interval = 1.12-10.47, P < 0·04) was significantly associated with the occurrence of stroke. The two study groups did not exhibit any other differences in demographic and clinical variables, such as age, laboratory or physical measurements during the last acute psychiatric hospitalisation, body mass index, and substance use problems and concurrent medical diseases.

CONCLUSIONS

High morbidity of stroke, particularly silent stroke, could be found in older bipolar patients with typical-onset age. In addition to traditional risk factors, the number of recurrent mood episodes in a lifetime may increase the risk of stroke in older BD patients.

Genes involved in stress response influence lithium efficacy in bipolar patients

OBJECTIVES

In mood disorders, chronic stimulation with stress results in aberrant regulation of the hypothalamic-pituitary-adrenal (HPA) axis. Lithium was shown to influence HPA axis function. The underlying genetic background as well as environmental context may influence the stress response, and therefore lithium efficacy. The aim of the present study was to analyze if genetic variants located in genes involved in HPA axis regulation affect the response to long-term lithium treatment in bipolar patients.

METHODS

We included 93 patients with bipolar disorder (32 males and 61 females), aged 31-80 years. The patients had been treated with lithium carbonate for at least 5 years. The magnitude of the lithium response was assessed using the Alda scale. Genotyping was performed for 28 polymorphisms in the genes encoding the following proteins involved in HPA axis regulation: corticotropin-releasing hormone receptor 1 (CRHR1), arginine vasopressin receptor 1B (AVPR1b), FK506 binding protein (FKBP) 5, FKBP4, BCL2-associated athanogene 1 (BAG1), stress induced phosphoprotein 1 (STIP1), glucocorticoid-induced transcript 1 (GLCC1), dual specificity phosphatase 1 (DUSP1) serine and arginine rich splicing factor (SRSF) 3, SRSF9, SRSF5, and acid phosphatase 1 (ACP1). Linkage disequilibrium and haplotype analysis were then performed, followed by statistical analysis (Statistica v.12; Stasoft, Krakow, Poland).

RESULTS

We found a correlation between stressful life events at first episode and worse response to lithium (P=.019). In single marker analysis, we observed a significant association between three FKBP5 polymorphisms (rs1360780, rs7748266 and rs9296158), one ACP1 variant (rs300774) and one glucocorticoid-induced transcript 1 gene (GLCC1) variant (rs37972) and the degree of lithium response. Five out of seven FKBP5 polymorphisms showed strong linkage with one haplotype demonstrating an association with lithium efficacy (P=.008). No relationship was found between the other analyzed polymorphisms and lithium response.

CONCLUSION

The response to lithium may depend on the variants of genes regulating the HPA axis and stressful life events in bipolar patients.

Psychosocial functioning in patients with psychotic and non-psychotic bipolar I disorder. A comparative study with individuals with schizophrenia

BACKGROUND

More than 50% of individuals with bipolar disorder (BD) do not reach full psychosocial functioning, even during periods of euthymia. It has been suggested that history of psychotic symptoms is one of the factors which are associated with a worse functional outcome. The objective was to compare psychosocial functioning between patients with BD, with (BD-P), and without (BD-NP) a history of psychotic symptoms, and to examine whether the history of psychotic symptoms, or other clinical or neurocognitive variables predict psychosocial functioning.

METHODS

Psychosocial functioning and neurocognition were examined in 100 euthymic patients with bipolar I disorder (50 BD-P, and 50 BD-NP), compared to 50 stabilised patients with schizophrenia (SZ), and 51 healthy controls (HC).

RESULTS

1) There were no differences between BD-P and BD-NP in the GAF-F score or in the FAST total score. 2) The two groups of patients with BD had better scores than SZ both in the GAF-F, and in all measures of the FAST, except for the subscale leisure time. 3) The neurocognitive composite index, verbal memory and subclinical depressive symptoms were the variables which explained a higher percentage of the variance of functional outcome.

LIMITATIONS

The cross-sectional design, and the relatively small sample size are the main limitations.

CONCLUSIONS

A history of psychotic symptoms has no relevant impact on the level of psychosocial functioning in BD. Neurocognitive dysfunction and subclinical depressive symptoms are the variables that best explain the functional impairment. These findings have important clinical implications.

The clinical course of late-life bipolar disorder, looking back and forward

OBJECTIVES

Little is known about the course of late-life bipolar disorder (LLBD). First, we studied patients with LLBD retrospectively with regard to age at first mood episode, onset polarity, predominant polarity and episode density and its associations with other clinical variables. Next, we examined prospectively the clinical course and its associated factors.

METHODS

Data were used from a dynamic cohort (Dutch Older Bipolars [DOBi]) including 101 patients with LLBD (mean age of 68.9 years) at baseline in 2012, with 3-year follow-up measurements available for 64 of these patients. Retrospective course was assessed by diagnostic interviews, and at follow-up polarity and duration for each consecutive episode were noted. Linear and logistic analyses were performed to assess associations between relevant factors and outcome.

RESULTS

The mean age at the first episode was 33.0 years. Onset polarity was depression in 44.6% of patients, with a predominant polarity of depression in 47.5%. At 3-year follow-up, 37.5% of patients reported at least one mood episode, mainly depression. Life events, somatic illness, use of lithium and other factors were not associated with recurrence during the 3-year follow-up.

DISCUSSION

A relapse rate of 37.5% in 3 years is high, considering that LLBD patients generally have a longer history of disease and were receiving care and medication. The course of LLBD can provide important information on which clinical factors are associated with recurrence. Further phenotyping may reveal unique predictors for outcome, and both course specifiers and clinical variables should be included.