Ethical considerations in preventive interventions for bipolar disorder

Self-Stigma in Patients with Endogenous Mental Disorders: A Cross-Sectional Comparative Study

BACKGROUND

Self-stigma remains one of the most vexing issues in psychiatry. It complicates the treatment and social functioning of patients with endogenous psychiatric disorders. Identifying the specific features of self-stigma depending on the type and duration of the endogenous mental illness can help solve this problem.

AIM

The aim of this study was to establish the level and specific features of self-stigma in patients with various types of chronic endogenous psychiatric disorders at different disease stages and to establish the correlation between the level of self-stigma and the attitude of the patient to his/her disease and treatment.

METHODS

Clinical psychopathology assessment, psychometric scales and questionnaires: "Positive and Negative Syndrome Scale" (PANSS), "Questionnaire for Self-Stigma Assessment in Mentally Ill Patients", and Russian versions of the "Insight Scale for Psychosis" (ISP), and "Drug Attitude Inventory" (DAI-10). The cross-sectional study included 86 patients with endogenous mental illnesses (bipolar affective disorder and schizophrenia spectrum disorders.

RESULTS

The analysis of the results of the "Questionnaire for Self-Stigma Assessment in Mentally Ill Patients" showed that at the initial disease stages the highest level of self-stigma is observed in patients with bipolar affective disorder (M±σ=1.22±0.73; Me [Q1; Q3]=1.10 [0.83; 1.60]), while the lowest level was observed in patients with schizophrenia spectrum disorders (M±σ=0.86±0.53; Me [Q1; Q3]=0.77 [0.31; 1.25]). Patients with schizophrenia and schizoaffective disorder and a disease duration more than five years participating in a long-term comprehensive psychosocial rehabilitation program also demonstrated high rates of self-stigma (M±σ=1.20±0.57, Me [Q1; Q3]=1.26 [0.89; 1.47]). The study groups showed differences in terms of the structure of components of self-stigma and their severity; significant correlations were uncovered between the self-stigma parameters and the attitude of patients to their disease and therapy.

CONCLUSION

The results of this study contribute to a better understanding of the specific features of self-stigma in patients with various endogenous disorders at different stages of the disease. These data can be used as part of a comprehensive psychosocial treatment program for this patient cohort, as well as for future research.

Preventing eating disorders and disordered eating in genetically vulnerable, high-risk families

OBJECTIVE

To close the chasm between theory about families containing a parent with an eating disorders (EDs) history and lack of selective or indicated prevention programming for such families with an older child or adolescent who is, genetically, at high risk.

METHOD

A search of four major databases for January 2000 through September 2022 yielded no publications that (a) identified genetically high-risk families with offspring ages 10 through 18; (b) devised a prevention program for the family; and (c) evaluated program effects on risk/protective factors. To rectify this gap, research on three lines of family-based prevention is reviewed: (1) programs for adolescents at genetic risk for depression or anxiety; (2) the Stanford-Dresden project for adolescents at high risk for anorexia nervosa; and (3) Sadeh-Sharvit et al.'s work concerning the Parent-Based Prevention program for mothers with an EDs history and a child under age 5.

RESULTS

The significant challenges for innovative prevention programming should be addressed by experts in effective EDs, depression, and anxiety prevention, and in family-based treatment (FBT) for EDs, collaborating with people from genetically vulnerable families. Innovative programming should focus on robust risk factors for EDs, adaptive expression of non-specific risk factors (e.g., temperament), and strengthening family functioning.

DISCUSSION

The field is overdue for development of prevention programs designed for older children or adolescents who are at risk because a parent has an ED. Evidence-based prevention programs for EDs and for depression and anxiety, as well as parent-based prevention informed by FBT, provide a springboard for addressing this gap.

PUBLIC SIGNIFICANCE

The foundation of theory and research is available for stakeholders to develop prevention programming that closes the huge gap between theory and research about families that are genetically vulnerable for eating disorders versus the complete lack of prevention programming for such families that have an older child or adolescent at high risk.

Ethical considerations for precision psychiatry: A roadmap for research and clinical practice

Precision psychiatry is an emerging field with transformative opportunities for mental health. However, the use of clinical prediction models carries unprecedented ethical challenges, which must be addressed before accessing the potential benefits of precision psychiatry. This critical review covers multidisciplinary areas, including psychiatry, ethics, statistics and machine-learning, healthcare and academia, as well as input from people with lived experience of mental disorders, their family, and carers. We aimed to identify core ethical considerations for precision psychiatry and mitigate concerns by designing a roadmap for research and clinical practice. We identified priorities: learning from somatic medicine; identifying precision psychiatry use cases; enhancing transparency and generalizability; fostering implementation; promoting mental health literacy; communicating risk estimates; data protection and privacy; and fostering the equitable distribution of mental health care. We hope this blueprint will advance research and practice and enable people with mental health problems to benefit from precision psychiatry.

Randomized controlled trial of a mindfulness-based intervention in adolescents from the general population: The Mindfulteen neuroimaging study protocol

AIM

Adolescence is a period of vulnerability to stress. Increased anxiety during this period has been associated with the later development of mental disorders, hence the growing interest for interventions that could decrease stress reactivity and improve cognitive control in adolescents. Mindfulness-based interventions have demonstrated their efficacy on stress reactivity and anxiety in adults, but evidence is lacking in youth.

METHODS

The Mindfulteen Study is a 3-year longitudinal cohort with a nested randomized controlled trial examining the effectiveness of mindfulness-based interventions for adolescents. Young adolescents from the general population, aged between 13 and 15 years old, with no history of current mental health disorder (apart from past mood disorders or current anxiety disorders) are included and stratified into low or high anxiety based on trait anxiety scores before being randomized to early or late 8-week intervention groups. Primary outcomes are based on neuroimaging data (i.e., structural and functional measures in the cortico-limbic network) while secondary outcomes are psychological (i.e., anxiety and stress-associated dimensions) and biological (i.e., cortisol, inflammatory and redox markers). Assessments are performed at baseline, immediately after intervention or waiting time and after 18 months of intervention.

CONCLUSION

To the best of our knowledge, this is the first randomized controlled trail examining the effect of a mindfulness-based intervention in young adolescents from the general population based on the measurement and analyses of psychological, neuroimaging and biological data.

My child's future mental health: Carer's engagement with risk identification in an intervention study for youth with at-risk mental states

AIM

Prevention and early intervention efforts of serious mental illnesses has yielded promising results. However, alongside benefits, several ethical concerns have been raised, including the effects of being identified as being at-risk. In these debates, the voice of parents or carers is conspicuously absent. This is especially concerning as several at-risk interventions are trialled in under-age youth where parents consent on behalf of young people. Therefore, this study aimed to understand carer's experiences of their teenager being identified as at risk for psychosis.

METHODS

Semi-structured interviews were conducted with seven carers who had provided consent for their teenager to participate in a stepped intervention study for youth at-risk for psychosis. Questions explored their experiences regarding having their teenager being identified as at-risk. Transcripts were analysed using thematic analysis.

RESULTS

We identified five main themes from seven female carers' experiences of risk identification including: (a) recall of risk information was limited, or variable, (b) goal of risk disclosure was perceived to be positive, (c) negative emotions were associated with knowledge of risk, (d) relief from uncertainty and helplessness and (e) effects of risk disclosure were mediated by individual circumstance.

CONCLUSION

Overall, the results demonstrate that carers' experience of risk disclosure varied with factors surrounding their individual circumstances, and the process of disclosure. Whilst participants acknowledged potential adverse effects associated with risk disclosure, many still adopted a positive outlook. Tailoring safe and effective disclosure of risk to suit the needs of youth and carers could outweigh the potential risks.

[Early intervention in bipolar affective disorders: Why, when and how]

OBJECTIVES

Bipolar disorder (BD) is a chronic and severe psychiatric disease. There are often significant delays prior to diagnosis, and only 30 to 40 % of patients will experience complete remission. Since BD occurs most often at a young age, the disorder can seriously obstruct future socio-professional development and integration. Vulnerability-stress model of BD is considered to be the result of an interaction between vulnerability genes and environmental risk factors, which leads to the onset of the disorder most often in late adolescence or early adulthood. The clinical "staging" model of BD situates the subject in a clinical continuum of varying degrees of severity (at-risk status, first episode, full-blown BD). Given the demonstrated effectiveness of early intervention in the early stages of psychotic disorder, we posit that early intervention for early stages of BD (i.e. at-risk status and first episode mania or hypomania) would reduce the duration of untreated illness and optimize the chances of therapeutic response and recovery.

METHODS

We conducted a narrative review of the literature to gather updated data on: (1) features of early stages: risk factors, at-risk symptoms, clinical specificities of the first manic episode; (2) early screening: targeted populations and psychometric tools; (3) early treatment: settings and therapeutic approaches for the early stages of BD.

RESULTS

(1) Features of early stages: among genetic risk factors, we highlighted the diagnosis of BD in relatives and affective temperament including as cyclothymic, depressive, anxious and dysphoric. Regarding prenatal environmental risk, we identified peripartum factors such as maternal stress, smoking and viral infections, prematurity and cesarean delivery. Later in the neurodevelopmental course, stressful events and child psychiatric disorders are recognized as increasing the risk of developing BD in adolescence. At-risk symptoms could be classified as "distal" with early but aspecific expressions including anxiety, depression, sleep disturbance, decreased cognitive performance, and more specific "proximal" symptoms which correspond to subsyndromic hypomanic symptoms that increase in intensity as the first episode of BD approaches. Specific clinical expressions have been described to assess the risk of BD in individuals with depression. Irritability, mixed and psychotic features are often observed in the first manic episode. (2) Early screening: some individuals with higher risk need special attention for screening, such as children of people with BD. Indeed, it is shown that children with at least one parent with BD have around 50 % risk of developing BD during adolescence or early adulthood. Groups of individuals presenting other risk factors, experiencing an early stage of psychosis or depressive disorders should also be considered as targeted populations for BD screening. Three questionnaires have been validated to screen for the presence of at-risk symptoms of BD: the Hypomanic Personality Scale, the Child Behavior Checklist-Paediatric Bipolar Disorder, and the General Behavior Inventory. In parallel, ultra-high risk criteria for bipolar affective disorder ("bipolar at-risk") distinguishing three categories of at-risk states for BD have been developed. (3) Early treatment: clinical overlap between first psychotic and manic episode and the various trajectories of the at-risk status have led early intervention services (EIS) for psychosis to reach out for people with an early stage of BD. EIS offers complete biopsychosocial evaluations involving a psychiatric examination, semi-structured interviews, neuropsychological assessments and complementary biological and neuroimaging investigations. Key components of EIS are a youth-friendly approach, specialized and intensive care and client-centered case management model. Pharmaceutical treatments for at-risk individuals are essentially symptomatic, while guidelines recommend the use of a non-antipsychotic mood stabilizer as first-line monotherapy for the first manic or hypomanic episode. Non-pharmacological approaches including psychoeducation, psychotherapy and rehabilitation have proven efficacy and should be considered for both at-risk and first episode of BD.

CONCLUSIONS

EIS for psychosis might consider developing and implementing screening and treatment approaches for individuals experiencing an early stage of BD. Several opportunities for progress on early intervention in the early stages of BD can be drawn. Training first-line practitioners to identify at-risk subjects would be relevant to optimize screening of this population. Biomarkers including functional and structural imaging measures of specific cortical regions and inflammation proteins including IL-6 rates constitute promising leads for predicting the risk of transition to full-blown BD. From a therapeutic perspective, the use of neuroprotective agents such as folic acid has shown particularly encouraging results in delaying the emergence of BD. Large-scale studies and long-term follow-up are still needed to achieve consensus in the use of screening and treatment tools. The development of specific recommendations for the early stages of BD is warranted.

Lithium as a Neuroprotective Agent for Bipolar Disorder: An Overview

Lithium (Li⁺) is a first option treatment for adult acute episodes of Bipolar Disorder (BD) and for the prophylaxis of new depressed or manic episodes. It is also the preferred choice as maintenance treatment. Numerous studies have shown morphological abnormalities in the brains of BD patients, suggesting that this highly heritable disorder may exhibit progressive and deleterious changes in brain structure. Since treatment with Li⁺ ameliorates these abnormalities, it has been postulated that Li⁺ is a neuroprotective agent in the same way atypical antipsychotics are neuroprotective in patients diagnosed with schizophrenia spectrum disorders. Li⁺'s neuroprotective properties are related to its modulation of nerve growth factors, inflammation, mitochondrial function, oxidative stress, and programmed cell death mechanisms such as autophagy and apoptosis. Notwithstanding, it is not known whether Li⁺-induced neuroprotection is related to the inhibition of its putative molecular targets in a BD episode: the enzymes inositol-monophosphatase, (IMPase), glycogen-synthase-kinase 3β (GSK3), and Protein kinase C (PKC). Furthermore, it is uncertain whether these neuroprotective mechanisms are correlated with Li⁺'s clinical efficacy in maintaining mood stability. It is expected that in a nearby future, precision medicine approaches will improve diagnosis and expand treatment options. This will certainly contribute to ameliorating the medical and economic burden created by this devastating mood disorder.

At-risk studies and clinical antecedents of psychosis, bipolar disorder and depression: a scoping review in the context of clinical staging

Identifying young people at risk of developing serious mental illness and identifying predictors of onset of illness has been a focus of psychiatric prediction research, particularly in the field of psychosis. Work in this area has facilitated the adoption of the clinical staging model of early clinical phenotypes, ranging from at-risk mental states to chronic and severe mental illness. It has been a topic of debate if these staging models should be conceptualised as disorder-specific or transdiagnostic. In order to inform this debate and facilitate cross-diagnostic discourse, the present scoping review provides a broad overview of the body of literature of (a) longitudinal at-risk approaches and (b) identified antecedents of (homotypic) illness progression across three major mental disorders [psychosis, bipolar disorder (BD) and depression], and places these in the context of clinical staging. Stage 0 at-risk conceptualisations (i.e. familial high-risk approaches) were identified in all three disorders. However, formalised stage 1b conceptualisations (i.e. ultra-high-risk approaches) were only present in psychosis and marginally in BD. The presence of non-specific and overlapping antecedents in the three disorders may support a general staging model, at least in the early stages of severe psychotic or mood disorders.

A Risk Calculator to Predict the Individual Risk of Conversion From Subthreshold Bipolar Symptoms to Bipolar Disorder I or II in Youth

OBJECTIVE

Youth with subthreshold mania are at increased risk of conversion to bipolar disorder (BP) I/II. Predictors for conversion have been published for the group as a whole. However, risk factors are heterogeneous, indicating the need for personalized risk assessment.

METHOD

One hundred forty youth with BP not otherwise specified (BP-NOS; 6-17 years old) followed through the Course and Outcome of Bipolar Youth (COBY) study with at least 1 follow-up assessment before conversion to BP-I/II were included. Youths were assessed on average every 7 months (median 11.5 years) using standard instruments. Risk predictors reported in the literature were used to build a 5-year risk calculator. Discrimination was measured using the time-dependent area under the curve after 1,000 bootstrap resamples. Calibration was evaluated by comparing observed with predicted probability of conversion. External validation was performed using an independent sample of 58 youths with BP-NOS recruited from the Pittsburgh Bipolar Offspring Study.

RESULTS

Seventy-five (53.6%) COBY youths with BP-NOS converted to BP-I/II, of which 57 (76.0%) converted within 5 years. Earlier-onset BP-NOS, familial hypomania/mania, and high mania, anxiety, and mood lability symptoms were important predictors of conversion. The calculator showed excellent consistency between the predicted and observed risks of conversion, good discrimination between converters and non-converters (area under the curve 0.71, CI 0.67-0.74), and a proportionally increasing rate of converters at each successive risk class. Discrimination in the external validation sample was good (area under the curve 0.75).

CONCLUSION

If replicated, the risk calculator would provide a useful tool to predict personalized risk of conversion from subsyndromal mania to BP-I/II and inform individualized interventions and research.

Ethical considerations in bipolar disorders

The implications of biomedical ethics principles extend to both medical care and biomedical research. They are particularly relevant for psychiatry in which pathologies are often chronic and disabling. Bipolar disorders impact the ability to make judgements and to take decisions during mood episodes and remain a stigmatised condition. Early interventions, even those in the prodromal phase, pose ethical questions for both clinicians and researchers. The degree of patients' autonomy in their clinical care must also now be considered from a biomedical ethics perspective.

Is "early intervention" in bipolar disorder what it claims to be?

BACKGROUND

The notion of early intervention is understandably appealing for conditions such as bipolar disorder (BD), a chronic life-long illness that increases risk of suicide and diminishes quality of life. It is purported that intervening early in the course of the illness with suitable interventions could substantially alter the trajectory of BD and improve outcomes. However, while there are obvious benefits to the prompt commencement of treatment, it is important to consider the gaps in our understanding regarding the aetiopathogenesis of bipolar disorder-upon which the paradigm of early intervention is predicated.

METHODS

A literature search was undertaken using recognized search engines: PubMed, PsycINFO Medline, and Scopus, along with auxiliary manual searches.

RESULTS

This review first examines how the unpredictable nature of BD creates substantial difficulties when determining an optimal therapeutic target for early intervention. Second, the challenges with identifying appropriate populations and apposite times for early intervention strategies is discussed. Finally, the risks associated with intervening early are examined, highlighting the potential harmful effects of initiating medication.

CONCLUSION

Early intervention for BD is a potentially useful strategy that warrants investigation, but until the emergence and trajectory of the illness are definitive, and a clear view of key targets is achieved, a more conservative approach to treating nascent BD and its antecedent symptoms is needed.

Five indicators were developed to assess the quality of reviews on preventive interventions

OBJECTIVES

The objective of the study was to develop quality indicators for preventive effectiveness and to evaluate their use with Cochrane Reviews of primary preventive interventions.

STUDY DESIGN AND SETTING

Based on the quality of care framework, we searched the literature to develop a set of quality indicators. Two authors applied the quality indicators independently to a sample of Cochrane systematic reviews of primary prevention.

RESULTS

Five quality indicators were developed: sample size, directness of evidence, adherence, harm, and costs. We applied the quality indicators to a random sample of 84 of a total of 264 Cochrane reviews of primary preventive interventions. Only 70% reviews (n = 59) complied with the indicator sample size, whereas 61% (n = 51) complied with directness of the outcome, 48% (n = 40) with adherence, 76% (n = 64) with harm, and 46% (n = 39) with the indicator cost.

CONCLUSION

Applying the five quality indicators is feasible. The quality of evidence in reviews of primary prevention can be substantially improved. Trialists and review authors should provide more information especially on adherence, costs, and indirectness of the outcome. Methodological research is needed on how to incorporate cost information in systematic reviews and how to better deal with indirectness.