Longitudinal outcomes in pediatric- and adult-onset bipolar patients compared to healthy and schizophrenia controls

Mapping review of register-based cohort studies of bipolar disorder

OBJECTIVES

Register-based cohorts allow us to better understand bipolar disorder over a life course. They are inclusive and their long-term data collection provides a longer scope than most clinical trials. This mapping review provides an overview of register-based cohort studies of bipolar disorder to inform researchers of the strengths and limitations to this body of research and identify gaps for future research.

METHODS

A systematic search was performed of Medline, EMBASE, and PsycINFO databases. Cohort studies were included if they focused on bipolar disorder and had a minimum of 1 year of longitudinal data. Studies needed to be from databases that monitor the whole state or national population. A descriptive analysis of the studies' populations and methodology provides an overview of this field of study and identifies evidence gaps.

RESULTS

A hundred and forty-six studies were included. The majority were from databases in Taiwan (n = 63), Denmark (n = 38), Sweden (n = 23), and Finland (n = 11). Forty-eight studies focused on aetiological questions. Sixty prognostic studies identified cohorts with bipolar disorder and described the impact of the illness by considering comorbidity, prescribing patterns, social functioning, and mortality. Thirty-six treatment studies focused on the efficacy and adverse effects of pharmaceuticals and ECT. No studies focused on psychological treatments.

CONCLUSION

Bipolar disorder research should include register-based cohorts with greater geopolitical and cultural diversity. Custodians of health registers should consider how non-pharmaceutical interventions such as psychotherapy are captured. Register-based cohorts investigating treatments of bipolar disorder should consider long-term social outcomes alongside the usual clinical outcomes.

Osteoporosis and low bone mass among schizophrenia and bipolar disorder: A cross-sectional study with newly diagnosed, drug-naïve subjects

BACKGROUND

A growing body of data shows that schizophrenia (SCZ) and bipolar disorder (BD) have substantial metabolic risks; however, few studies have focused on bone metabolism. This study aimed to assess the prevalence and associated influencing factors of low bone mass and osteoporosis in SCZ and BD before pharmacological effects occur.

METHODS

108 healthy controls (HCs) and drug-naïve individuals with SCZ (n = 56) and BD (n = 130) had their lumbar spine (L1-L4) and left femur (Neck/Trochanter/Ward's triangle) bone mineral density (BMD) determined using dual-energy X-ray absorptiometry. Besides, we measured bone turnover markers (BTMs) levels, including procollagen I N-terminal propeptide, osteocalcin, and C-terminal cross-linking telopeptide of type I collagen in different groups.

RESULTS

Individuals with SCZ and BD had significantly lower BMD and significantly higher prevalence of low bone mass and osteoporosis compared with HCs. In the main observation regions of the total lumbar (F = 18.368, p < 0.001) and left femur (F = 14.790, p < 0.001), BMD was lower in individuals with SCZ and BD than HCs, with SCZ showing lower BMD than BD. The osteocalcin (H = 11.421, p = 0.003) levels were significantly higher in SCZ and BD than HCs. Binary regression analysis showed that SCZ or BD was an independent risk factor for low bone mass and osteoporosis. In addition, sex, age, and BTMs also influenced the occurrence of low bone mass and osteoporosis.

LIMITATIONS

Cross-sectional study.

CONCLUSION

The results findings of the study might contribute to our understanding of the increased risk of bone metabolism in SCZ and BD.

CLINICAL TRIAL REGISTRATION

www.chictr.org.cn, identifier ChiCTR1900021379.

A systematic review of the social impact of diseases in Nordic countries

BACKGROUND

We review the literature on the social impacts of diseases, defined as the social consequences of having a disease on the people around the patient, such as spouses, caregivers and offspring. The two objectives of this study are to summarise the social outcomes commonly associated with diseases and to compare the social impact across a range of diseases.

METHODS

A systematic review of the social impact of disease in Nordic countries was conducted using PubMed, PsycINFO and Google Scholar (PROSPERO registration number CRD42022291796). All articles that met the inclusion criteria were reviewed. We tabulated all outcomes and diseases studied, and synthesised the evidence based on the perspectives of patients, spouse/caregiver and offspring.

RESULTS

A total of 135 studies met the eligibility criteria, covering 76 diseases and 39 outcomes. From the patient's perspective, diseases impact divorce and marriage rates, social functioning, likelihood of committing a crime and being a victim of crime. From the caregiver's perspective, diseases affect their health-related quality of life and physical and psychological health. From the offspring's perspective, diseases impact their development, health and social adversities in later life. Diseases generally had negative social impacts, but there were some diseases associated with positive impacts.

CONCLUSIONS

The review provides a useful summary and gross comparison of the social impact of different diseases. The social impact of diseases can be large and significant. Thus, it should be considered when policymakers are setting priorities across disease areas.

Electroconvulsive therapy following incident bipolar disorder: When, how, and for whom?

OBJECTIVE

The use of electroconvulsive therapy (ECT) in the treatment of bipolar disorder (BD) remains poorly described. Based on data from Danish registries with complete nationwide coverage, this study of patients with incident BD aimed to describe when, how, and for whom ECT is used in the context of BD.

METHODS

We identified patients receiving their first diagnosis of BD in the period from 2008 to 2018, who subsequently received ECT. Descriptive statistics were used to clarify when, how, and for whom ECT is used.

RESULTS

We identified 1338 patients with incident BD who subsequently received ECT. The median age at the first ECT session was 50.6 years (interquartile range [IQR]: 26.4), and 62% of those treated with ECT were female. The median time from the diagnosis of BD to the first ECT treatment was 0.6 years (IQR: 2.6), and 58% of the patients receiving ECT had the first treatment within the first year after being diagnosed with BD. The most common indication for the first ECT treatment was depression (mainly non-psychotic depression), followed by mania (mainly psychotic mania). The first ECT session was typically provided to inpatients (97%), upon patient consent (98%) and with bilateral electrode placement (60%).

CONCLUSIONS

A substantial proportion of the patients with incident BD who receive ECT require this treatment within the first year after the diagnosis. The most common indication for ECT is depression followed by (psychotic) mania. Inpatient voluntary ECT using bilateral electrode placement is the most common form of administration.

Prevalence and 5-year trend of incidence for medical illnesses after the diagnosis of bipolar disorder: A nationwide cohort study

OBJECTIVE

Medical comorbidities are prevalent in patients with bipolar disorder. Evaluating longitudinal trends of the incidence of medical illnesses enables implementation of early prevention strategies to reduce the high mortality rate in this at-risk population. However, the incidence risks of medical illnesses in the early stages of bipolar disorder remain unclear. This study investigated the incidence and 5-year trend of medical illnesses following bipolar disorder diagnosis.

METHODS

We identified 11,884 patients aged 13-40 years who were newly diagnosed as having bipolar disorder during 1996-2012 and 47,536 age- and sex-matched controls (1:4 ratio) who represented the general population from Taiwan's National Health Insurance Research Database. We estimated the prevalence and incidence of individual medical illnesses yearly across the first 5 years after the index date. The adjusted incidence rate ratio was calculated to compare the occurrence of specific medical illnesses each year between the bipolar disorder group and control group using the Poisson regression model.

RESULTS

Apart from the prevalence, the adjusted incidence rate ratios of most medical illnesses were >1.00 across the first 5-year period after bipolar disorder diagnosis. Cerebrovascular diseases, ischaemic heart disease, congestive heart failure, other forms of heart disease, renal disease and human immunodeficiency virus infection exhibited the highest adjusted incidence rate ratios during the first year. Except for that of renal disease, the 5-year trends of the adjusted incidence rate ratios decreased for cerebrovascular diseases, cardiovascular diseases (e.g. ischaemic heart disease, other forms of heart disease, and vein and lymphatic disease), gastrointestinal diseases (e.g. chronic hepatic disease and ulcer disease) and communicable diseases (e.g. human immunodeficiency virus infection, upper respiratory tract infection and pneumonia).

CONCLUSION

Incidence risks of medical illnesses are increased in the first year after bipolar disorder diagnosis. Clinicians must carefully evaluate medical illnesses during this period because the mortality rates from medical illnesses are particularly high in people with bipolar disorder.

Brain-derived neurotrophic factor in bipolar disorder: Associations with age at onset and illness duration

Bipolar disorder (BD) is a heterogeneous disorder that contains neurodevelopmental differences. Defining homogeneous subgroups of BD patients by using age at onset (AAO) as a specifier may promote the classification of biomarkers. This study compares peripheral BDNF levels between pediatric and adult BD patients to investigate the associations between BDNF levels, AAO, and illness duration. We enrolled two groups of euthymic patients, those with pediatric BD (n = 39) and those with adult BD (n = 31), as well as a group of healthy controls (HCs) (n = 90). Participants were assessed using clinical measures and BDNF serum levels were obtained using ELISA. We observed that BDNF levels were comparable between adult BD and HCs, but were clearly lower in pediatric BD than in HCs. In adult BD with AAO ≥30 years, BDNF levels were significantly higher than in adult BD with AAO <30 years. In pediatric BD, patients with prepubertal-onset had higher BDNF levels than those with pubertal-onset. BDNF levels demonstrated the accuracy of being able to distinguish pediatric BD from healthy controls in a receiver operating characteristic (ROC) curve analysis (area under the curve [AUC] = 0.792). In adult BD, higher BDNF levels were associated with later disease onset, but this was not the case in pediatric BD. Finally, reduced BDNF levels were associated with illness duration in adult BD. The findings indicate that BDNF levels in BD patients are associated with AAO. BDNF may, therefore, potentially serve as a developmental marker in BD, when AAO is taken into account.

Diagnostic stability in children and adolescents with bipolar disorder, a nationwide register-based study

Background

Diagnostic stability of bipolar disorder (BD) in children and adolescents, beyond the first contact has been investigated sparsely. The aim of this study was to investigate the diagnostic stability of BD in children and adolescents using over two decades of nationwide register-based data, and to examine factors associated with change from BD to schizophrenia (ICD-10: F20.x), schizoaffective disorder (ICD-10: F25.x) or other primary psychotic disorders (ICD-10 F23.x–24.x and F28.x–29.x).

Methods

Danish register-based data for all incident BD patients diagnosed prior to age 18 years, between January 1st 1995 and December 31st 2014 (N = 519). We graphically illustrated diagnostic change at different follow-up times and studied variables associated with diagnostic change after 3-year follow-up using Poisson regression with robust standard error estimates.

Results

The diagnosis of incident BD was relatively stable. The diagnosis did not change for 93% of those followed for at least 6 months, and remained unchanged for 86% and 73% of those followed at least 3 years and 10 years, respectively. In patients followed for at least 3 years after index BD (N = 478), the risk of diagnostic change was 61% higher in males versus females. The risk of diagnostic change for patients diagnosed during hospitalization was 74% higher compared to patients diagnosed at outpatient clinics/emergency rooms. The risk of diagnostic change for patients abusing substances other than alcohol and cannabis was 173% higher compared to patients not abusing such substances. The risk of diagnostic change for patients previously diagnosed with schizophrenia or related diagnosis was 257% higher compared to patients not having been diagnosed with such diagnosis previously, while the risk of diagnostic change in offspring of parents with schizophrenia or related diagnosis was 126% higher compared to patients who did not have parents diagnosed with such disorders.

Conclusion

Overall, the stability of the BD diagnosis in the Danish nationwide healthcare registers was high. Factors associated with risk of diagnostic change within 3 years of the initial diagnosis were being male, diagnosis given during hospitalization, substance abuse other than alcohol and cannabis, and a prior diagnosis of schizophrenia or related diagnosis in the patient or in their parents.