Functional impairment in patients with mania: baseline results of the EMBLEM study

Psychosocial Impairment in Older Patients With Bipolar I Disorder

BACKGROUND

The goal of this study was to assess psychosocial functioning in older patients with bipolar I disorder compared with healthy subjects and to identify the psychopathological factors associated with poor functioning in patients.

METHODS

We recruited 68 euthymic patients with bipolar I disorder from the outpatient unit and 89 healthy controls who were older than 50 years of age. In addition to clinical variables, we used other standardized measures, including the Young Mania Rating Scale, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Functional Assessment Short Test, and the Montreal Cognitive Assessment.

RESULTS

Older patients with bipolar I disorder had poorer psychosocial functioning in general and in the domains of occupation, autonomy, and cognition than the healthy controls on the basis of previously defined Functional Assessment Short Test cutoff scores. We found that 35.3% (95% CI: 23%-47%) of the patients did not have clinically significant functional impairment, 38.2% (95% CI: 26%-50%) had mild impairment, and 26.5% (95% CI: 16%-37%) had moderate impairment. Depressive symptoms and impaired cognition were associated with poor overall functioning.

CONCLUSIONS

The level of psychosocial functioning was heterogeneous among the patients. Subsyndromal depressive symptoms, even at low levels, and impaired cognition predicted poor functioning in euthymic middle-aged and older patients with bipolar I disorder.

Assessments of functional outcomes and its determinants among bipolar disorder patients in Northwest Ethiopia comprehensive specialized hospitals: a multicenter hospital-based study

INTRODUCTION

Bipolar disorder is a severe and chronic mental illness that could continue for a lifetime. Although it is a leading cause of disability and impairments for significant numbers of patients, the levels of functional outcomes have not been studied in Ethiopia. Therefore, this study aimed to assess the functional outcome levels and associated factors among bipolar disorder patients in Northwest Ethiopia.

METHOD

Hospital-based cross-sectional study was employed among bipolar disorder patients attending psychiatric clinics, in Northwest Ethiopia, from April to June 2021. Systematic random sampling was used to get respondents. Descriptive and inferential statistics were done. Data were entered into EpiData version 4.6.02 and exported to SPSS Version 22 for analysis. Bivariable and multivariable binary logistic regression analysis was used to identify the factors associated with functional outcome levels, and p value < 0.05 was considered significant with 95% CI.

RESULT

Of the total 423 study participants approached, only 411 completed the questionnaire, with a response rate of 97.2%. The median (IQR) level of functional outcome was 6 (0-22) and 40% of the study subjects were impaired. Leisure time was the most normal functioning domain (92.2%), whereas cognitive (43.5%) and occupational (41.6%) domains were the most impaired domains. Unemployment (AOR (95%CI) = 3.9 (1.46-10.49), obesity (AOR (95% CI) = 6.5 (1.22-34.58), depressed and manic mood phases (AOR (95%CI) = 5.2 (2.84-9.35) and (AOR (95%CI) = 7.8 (3.31-18.34) respectively, medication non-adherence (AOR (95% CI) = 3.2 (1.71-6.05), and relapsed once or ≥ twice (AOR (95%CI) = 2.2 (1.25-3.98) and (AOR (95%CI) = 8.3 (2.73-25.30), respectively, were some of the important predictor variables that were significantly associated to the functional impairments levels.

CONCLUSION

The median of functional outcomes levels was found in an acceptable range; however, significant numbers of bipolar patients were functionally impaired. Moreover, patients still need unrestricted interventions in the cognitive and occupational functional domains. Socio-demographic, clinical, medication, and psychosocial variables were significantly associated with functional outcomes. Bipolar patients need to be followed and managed to improve their functional outcome and all stakeholders should be involved to achieve the recommended levels.

Pharmacotherapy exposure as a marker of disease complexity in bipolar disorder: Associations with clinical & genetic risk factors

Individuals with bipolar disorder (BD) require chronic pharmacotherapy, typically including medication switches or polypharmacy due to persisting symptoms or intolerable side effects. Here, we quantified pharmacotherapy exposure (PE) of Mayo Clinic BD Biobank participants using the number of cross-sectional (at enrollment) and lifetime BD-specific medications and medication classes, to understand the relationship between PE and markers of disease severity or treatment failure, psychiatric comorbidities, and polygenic risk scores (PRS) for six major psychiatric disorders. Being female (p < 0.05), older (p < 0.01), having history of suicide attempts (p < 0.0001), and comorbid attention-deficit/hyperactivity disorder (p < 0.05) or generalized anxiety disorder (p < 0.05) were uniformly associated with higher PE. Lifetime exposure to unique medication classes among participants with BD-I was significantly lower than for those with schizoaffective disorder (estimate = -2.1, p < 0.0001) while significantly higher than for those with BD-II (estimate = 0.5, p < 0.01). Further, higher PRS for schizophrenia (SCZ) and anxiety resulted in greater lifetime medication counts (p < 0.01), both driven by antipsychotic (p < 0.001) and anxiolytic use (p < 0.05). Our results provide initial evidence of the utility of PE as a measure of disease complexity or treatment resistance, and that PE may be predicted by higher genetic risk for SCZ and anxiety.

A systematic review of psychosocial functioning and quality of life in older people with bipolar disorder

•

The Global Assessment of Functioning (GAF; Endicott et al., 1976) is the most widely used functioning measure used with older adults with bipolar disorder.

•

Older adults with bipolar disorder demonstrate a wide range of functioning.

•

No existing validated measure assessing the psychosocial functioning or quality of life of older people with BD could be identified.

•

There is a significant lack of research in the area of older people with bipolar disorder compared to the younger population.

Background

There is evidence to suggest that older people with Bipolar Disorder (BD) are more likely to demonstrate poor levels of functioning and score lower on well-being scales compared to non-clinical controls, even when in remission (Depp et al., 2006). To our knowledge, this is the first review paper to identify how quality of life and functioning has been measured in an older adult BD population.

Methods

We conducted a systematic review of studies including a quantitative measure of psychosocial functioning or quality of life and older people over the age of 50 with a formal diagnosis of BD I or II.

Results

Eleven studies (N = 726, mean age range 59.8 to 71.1) were included in the review, demonstrating a significant lack of research in the area compered to younger people with BD. The most commonly used measure of functioning was the Global Assessment of Functioning Scale (GAF) and results indicated that older adults with BD demonstrate a wide range of functioning.

Limitations

The review used a comprehensive and systematic search strategy, however, very few eligible studies were available for review. The pooled analyses and reported means must be interpreted with caution due to the relatively small sample sizes.

Conclusions

Older people with BD present with a wide range of functioning, ranging ‘major impairment’ to ‘superior’ scores. No existing validated measure assessing the psychosocial functioning or quality of life of older people with BD could be identified. Such a tool should be developed for use in future research.

Satisfaction with antipsychotics as a medication: the role of therapeutic alliance and patient-perceived participation in decision making in patients with schizophrenia spectrum disorder

OBJECTIVES

The aim of this study was to identify independent predictors of satisfaction with antipsychotics in patients with schizophrenia spectrum disorders treated in a mental health catchment area.

METHODS

Observational analytical study of patients (n = 150) recruited through a convenience sampling method from five mental health units. Satisfaction with the antipsychotic as a medication was evaluated using the Treatment Satisfaction Questionnaire for Medication (TSQM). Therapeutic alliance was assessed by the Working Alliance Inventory Short Form (WAI-S). Patient-perceived participation in decision-making was assessed using COMRADE (Combined Outcome Measure for Risk communication And treatment Decision making Effectiveness). A multiple linear regression analysis was performed to identify variables independently associated with the TSQM 'Global Satisfaction' total score.

RESULTS

Two variables - age and higher level of self-perceived participation in treatment decision-making - were directly, significantly, and independently associated (β coefficient values: 0.209 and 0.432, respectively) with a higher TSQM Global satisfaction score. In addition, the severity of psychotic symptoms was inversely associated with satisfaction (β coefficient value: -0.205) (R² = 0.355; R² adj. = 0.291; F(13) = 5.554; p < 0.01).

CONCLUSIONS

These findings suggest that involving the patient in treatment decision-making and optimising the treatment to reduce symptoms, especially in younger patients, could increase satisfaction with antipsychotic treatment.Key PointsPatient involvement in shared decision-making is relevant for treatment satisfaction.Current evidence suggests that improving the doctor-patient relationship optimises antipsychotics outcomes.Self-perceived participation in decision-making predicts satisfaction with antipsychotic medication.Types of antipsychotics do not determine consistent differences in satisfaction.

Impact of Childhood Trauma and Attachment on Resilience in Remitted Patients with Bipolar Disorder

BACKGROUND

Childhood trauma has been reported to be associated with severe course of illness, insecure attachment, and lower resilience in bipolar disorder. We aimed to examine the impact of childhood trauma on resilience and possible mediating role of attachment on this impact in bipolar disorder.

METHODS

The study group comprised of 110 remitted patients with bipolar disorder. Hamilton Depression Rating Scale (HAM-D) and Young Mani Rating Scale (YMRS) are administered to verify remission. Childhood trauma questionnaire (CTQ-SF), Experiences in Close Relationships-revised (ECR-R), and Resilience Scale for Adults (RSA) scales administered to all patients.

RESULTS

More than half of patients in bipolar disorder group reported childhood trauma. HAM-D scores were positively associated with childhood trauma total scores and emotional abuse scores, negatively associated with resilience, with attachment-related anxiety. Total childhood trauma scores were associated with lower scores of resilience, higher scores of attachment-related anxiety and avoidance. Resilience scores were negatively associated with attachment-related anxiety and avoidance. Impact of childhood trauma on resilience was partly mediated by attachment-related anxiety and avoidance, respectively.

LIMITATIONS

The cross-sectional design of this study is a limitation in terms of determining causality of the identified relationships.

CONCLUSIONS

Childhood traumas are associated with lower resilience and higher attachment-related anxiety and avoidance. Attachment-related anxiety and avoidance partly mediated the negative effect of childhood trauma on resilience. Since resilience is associated with increased quality of life in bipolar disorder, it might be helpful to develop attachment-informed psychosocial interventions to ameliorate the detrimental effect of childhood trauma on resilience.

Risk and Protective Factors Associated With Health-Related Quality of Life of Parents With Mental Illness

Purpose: Health-related quality of life (HRQoL) can be reduced in parents with mental illness (mental illness) who face the dual demands of disabling symptoms and their impact on family, social, and occupational life. This study aimed at analyzing the influence of various factors on HRQoL in parents with mental illness. Method: Baseline data of the German randomized controlled multicenter project CHIMPS (children of parents with mental illness) was used for analyses. The final sample consisted of n = 208 parents with mental illness and n = 197 children and adolescents aged 8-18 years. HRQoL was assessed with the EQ-5D. Results: Parents with mental illness reported significantly lower global and specific HRQoL than the German reference population. They were least satisfied with aspects that relate to anxiety and depression followed by usual activities, pain and discomfort. Better global HRQoL was primarily associated with self-reported physical and mental health, as well as adaptive coping behavior. Associations with mobility, self-care, usual activity, pain and discomfort, anxiety and depression were analyzed and discussed. Conclusions: HRQoL in parents with mental illness is reduced. Clinical interventions should focus on the alleviation of mental health symptoms and probably somatic symptoms and promote adaptive coping skills.

Work impairment in bipolar disorder patients – results from a two-year observational study (EMBLEM)

Objectives

To explore factors associated with work impairment at 2 years following an acute episode.

Methods

European Mania in Bipolar disorder Longitudinal Evaluation of Medication (EMBLEM) is a prospective, observational study on the outcomes of patients with a manic/mixed episode. Work impairment was measured using a Longitudinal Interval Follow-up Evaluation (slice of LIFE) item and patients were categorised with either low or high work impairment at each observation. Baseline factors associated with work impairment at 2 years were assessed using multivariate modelling.

Results

At baseline (n = 2289), 69% of patients had high work impairment. At 2 years (n = 1393), high impairment reduced to 41%. Modelling identified rapid cycling as the strongest disease-related factor associated with high work impairment at 2 years, although high work impairment at baseline had the strongest association overall. Lower levels of education, recent admissions, CGI-BP overall severity in the 12 months prior to baseline and CGI-BP mania at baseline all predicted higher work impairment. Living together in a relationship and independent housing were both significantly associated with having low work impairment at 2 years.

Conclusions

Work impairment in bipolar disorder is maintained over long periods, and is strongly associated with relationship status, living conditions and various disease-related factors.

Executive functioning but not IQ or illness severity predicts occupational status in bipolar disorder

Background

Bipolar disorder is associated with significant functional deficits including occupational functioning. Despite the high rates of unemployment and sick leave in the patient population, only a limited number of studies have examined factors associated with occupational functioning in bipolar disorder. The aim of the study was to investigate the relative importance of demographic, clinical, and neuropsychological factors on occupational dysfunction in bipolar disorder.

Methods

A sample of 120 partially or fully remitted bipolar disorder I and II patients were included in the study. Patients were stratified into an active and an inactive group based on the number of hours per week working or studying. Active (n = 86) and inactive (n = 34) patients were compared with respect to demographic factors, clinical characteristics, medication, measures of psychosocial functioning, and cognitive functioning (i.e., IQ and executive functions). No other cognitive domains were examined.

Results

Univariate analyses revealed better overall cognitive function in active patients in terms of IQ and executive functioning. However, only executive functioning accounted for a significant amount of the variance in occupational status when other significant predictors were taken into account.

Conclusions

Executive functioning was a more powerful predictor of occupational status in bipolar disorder patients than IQ and other clinical factors, including illness severity.

Psychiatric Epidemiology of Transgender and Nonbinary Adult Patients at an Urban Health Center

PURPOSE

Transgender and nonbinary people have an increased burden of psychiatric problems compared with the general population. Data are needed to understand factors associated with psychiatric diagnoses, acuity in terms of suicide attempts and level-of-care escalation, and outpatient engagement among transgender and nonbinary adults.

METHODS

We conducted a retrospective review of records from 201 transgender and nonbinary adults who presented for primary care at a health center. Regression models were fit to examine factors associated with psychiatric diagnoses, substance use disorders (SUDs), acuity, and outpatient behavioral health engagement.

RESULTS

Male sex assignment at birth was associated with decreased odds of a psychiatric diagnosis (odds ratio [OR] 0.40, 95% confidence interval [CI]: 0.20-0.81). Increased odds of SUDs were associated with later hormone initiation (OR 1.04, 95% CI: 1.01-1.08) and suicide attempt (OR 5.79, 95% CI: 2.08-16.15). Increased odds of higher acuity were associated with alcohol use disorder (OR 31.54, 95% CI: 5.73-173.51), post-traumatic stress disorder (OR 18.14, 95% CI: 2.62-125.71), major depressive disorder (MDD) (OR 6.62, 95% CI: 1.72-25.44), and absence of psychiatrist integration into primary medical care (OR 4.52, 95% CI: 1.26-16.22). Increased odds of outpatient behavioral health engagement were associated with case management utilization (OR 10.73, 95% CI: 1.32-87.53), anxiety disorders (OR 15.84, 95% CI: 2.00-125.72), and MDD (OR 10.45, 95% CI: 2.28-47.98).

CONCLUSION

Psychiatric disorders were highly prevalent among transgender and nonbinary adult patients. Novel findings include associations of lack of psychiatrist integration into primary care with acuity and of case management utilization with outpatient behavioral health engagement.

Psychiatric symptoms and related dysfunction in a general population sample

Background

Along with the key clinical features of major psychiatric disorders such as psychosis, mania, and depression, these disorders are also associated with cognitive, social, and functional deficits. A growing body of evidence suggests that these disorders exist at the extreme end of a continuum of symptoms rather than as binary entities, so it is plausible that the associated cognitive, social, and functional deficits assume a similar pattern. Consistent with this approach, we sought to determine whether adults in the general population with psychiatric symptoms also demonstrate milder forms of the cognitive, social, and functional deficits that are often associated with the psychiatric disorders.

Methods

Using data from the Study of Resilience and Environmental Adversity in Midlife Health (STREAM), which includes survey responses of 811 individuals, we compared early academic achievement and self-reported social and functional outcomes between respondents who reported psychotic symptoms, manic symptoms, depressive symptoms, or no psychiatric symptoms (controls).

Results

Adults with psychotic symptoms had significantly poorer early academic performance (p = .04) and social and functional outcomes (self-reported marital status, p = .021, income, p = .001, and health, p < .001) than controls. Adults with depressive symptoms had significantly lower early academic performance and income and poorer health than controls (p's = 0.033, 0.037, 0.013 respectively), and adults with manic symptoms also reported significantly lower rates of marriage than controls (p = .006).

Conclusions

The results are consistent with the continuum view of the etiology of psychiatric disorders in which psychiatric disorders are dimensional and experienced in varying degrees of severity across the general and clinical population. Importantly, the results highlight the potential impact of psychiatric symptomatology on functional outcomes in the population.

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.

Functional impairment in adult bipolar disorder with ADHD

BACKGROUND

It is well established that patients with either bipolar disorder (BD) or attention-deficit/hyperactivity disorder (ADHD) present functional impairment even when in remission. Nevertheless, research on functional impairment with adult patients with bipolar disorder comorbid to ADHD (BD+ADHD) is very scarce. The main objective of the current report was to evaluate the overall and specific domains of functioning, in patients with BD+ADHD compared to patients with pure bipolar disorder (pBD) and healthy controls (HCs).

METHOD

162 subjects from 3 groups were compared: 63 pBD, 23 BD+ADHD and 76 HCs. All the patients with BD had been euthymic for at least 6 months and they were recruited at the Hospital Clinic of Barcelona. All the participants were assessed with the 17-item Hamilton Depression Rating Scale (HAM-D), the Young Mania Rating Scale (YMRS) and the Functioning Assessment Short Test (FAST). Clinical, and sociodemographic data were also recorded.

RESULTS

Clinical groups, pBD and BD+ADHD, showed lower overall functioning (p < 0.001) in each domain of the FAST scale compared to the HCs. Moreover, the Tukey post hoc test revealed that the BD+ADHD group showed a worse score than pBD in the cognitive domain of the FAST. However, after controlling for potential confounding variables, only the HDRS scores (p < 0.026) remained significant for the cognitive domain of the FAST.

LIMITATIONS

The small sample size of the comorbid BD+ADHD group.

CONCLUSIONS

Adult patients with BD+ADHD showed the worst scores in functioning compared with the HCs, but did not show more severe functional impairment than the pBD group except for the cognitive domain. Therefore our findings suggest that depressive symptoms in adults with BD+ADHD may negatively influence cognitive functioning. Further studies are needed to confirm our findings for the management of BD+ADHD.

Bipolar Disorder and Cognitive Dysfunction: A Complex Link

The aim of this article was to describe the current evidence regarding phenomenon of cognitive functioning and dementia in bipolar disorder (BD). Cochrane Library and PubMed searches were conducted for relevant articles, chapters, and books published before 2016. Search terms used included "bipolar disorder," "cognitive dysfunction," and "dementia." At the end of the selection process, 159 studies were included in our qualitative synthesis. As result, cognitive impairments in BD have been previously considered as infrequent and limited to the affective episodes. Nowadays, there is evidence of stable and lasting cognitive dysfunctions in all phases of BD, including remission phase, particularly in the following domains: attention, memory, and executive functions. The cause of cognitive impairment in BD raises the question if it subtends a neurodevelopmental or a neurodegenerative process. Impaired cognitive functioning associated with BD may contribute significantly to functional disability, in addition to the distorted affective component usually emphasized.

Age-at-onset subsets of bipolar I disorders: A critical insight into admixture analyses

Gaussian mixture analysis is frequently used to model the age-at-onset (AAO) in bipolar I disorder and identify homogeneous subsets of patients. This study aimed to examine whether, using admixture analysis of AAO, cross-sectional designs (which cause right truncation), unreliable diagnosis for individuals younger than 10 years old (which causes left truncation) and the selection criterion used for admixture analysis impact the number of identified subsets. A simulation study was performed. Different criteria - the likelihood ratio test (LRT), the Akaike information criterion (AIC), and the Bayesian information criterion (BIC) - were compared using no, left and/or right truncation simulated data. The error rate of each criterion (percentage of erroneous number of detected subsets) was estimated. An application to two real databases, including 2,876 and 1,393 patients, is provided. Without data truncation and regardless of the distribution of AAO, the LRT and the AIC had much higher error rates (12% and 33%, respectively) than the BIC (1%). For a homogeneous population, the error rate increased with the introduction of left truncation. This study shows that the number of subsets identified using admixture analysis may depend on the sample size, the selection criterion, and the study design.

Functional Impairment in Older Adults With Bipolar Disorder

Data describing bipolar disorder in older adults people are scarce, particularly with regard to functional status. This observational, comparative study assessed psychosocial functioning in 33 euthymic older adults with bipolar disorder compared with 30 healthy controls. In addition, we evaluated the association between clinical variables and poor functioning in the patient group. The mean age of the group was 68.70 years. Patients with bipolar disorder experienced poorer psychosocial functioning (19.15 ± 11.36) than healthy controls (5.17 ± 3.72; p = 0.0001), as assessed using the Functioning Assessment Short Test. Significant differences between the groups were found for specific domains of functioning: autonomy, occupational functioning, cognitive functioning, financial issues, and interpersonal relationships (p = 0.0001, respectively). The largest variation was observed in overall functioning (Cohen's d = 0.63). The number of previous hospitalizations was strongly associated with poor overall functioning (F = 7.217, p = 0.002). Older patients with bipolar disorder had a greater functional impairment than the healthy control group. Implementation of novel rehabilitation models is critical to help patients manage their illness.

Anticonvulsants and suicide attempts in bipolar I disorders

OBJECTIVE

To identify risk factors for suicide attempts (SA) in individuals commencing treatment for a manic or mixed episode.

METHOD

A total of 3390 manic or mixed cases with bipolar disorder (BD) type I recruited from 14 European countries were included in a prospective, 2-year observational study. Poisson regression models were used to identify individual and treatment factors associated with new SA events. Two multivariate models were built, stratified for the presence or absence of prior SA.

RESULTS

A total of 302 SA were recorded prospectively; the peak incidence was 0-12 weeks after commencing treatment. In cases with a prior history of SA, risk of SA repetition was associated with younger age of first manic episode (P = 0.03), rapid cycling (P < 0.001), history of alcohol and/or substance use disorder (P < 0.001), number of psychotropic drugs prescribed (P < 0.001) and initiation of an anticonvulsant at study entry (P < 0.001). In cases with no previous SA, the first SA event was associated with rapid cycling (P = 0.02), lifetime history of alcohol use disorder (P = 0.02) and initiation of an anticonvulsant at study entry (P = 0.002).

CONCLUSION

The introduction of anticonvulsants for a recent-onset manic or mixed episode may be associated with an increased risk of SA. Further BD studies must determine whether this link is causal.

Treatment of Functional Impairment in Patients with Bipolar Disorder

Traditionally, functional impairment has received little attention in bipolar disorder, despite the fact that many patients experience significant impairments in daily life. In the last decade, research has changed its focus from clinical remission to functional recovery in bipolar patients as a priority. A literature review of this topic will allow us provide an overview of the relevance of functional impairment as well as the potential factors that can predict or contribute to low functioning in bipolar disorder (BD). Treatment approaches should consider not only euthymia as a goal but also cognitive and functional improvement of patients with such a complex disorder. Functional remediation and psychoeducation among psychological interventions may help to enhance functioning. The combination of cognitive enhancers and cognitive/functional remediation programs may help in improving cognitive and functional impairments. Early interventions are essential to prevent cognitive deficits and disability.

Meta-Analysis of the Risk of Subsequent Mood Episodes in Bipolar Disorder

BACKGROUND

Reported relapse and recurrence rates in bipolar disorder (BD) differ significantly between studies. Most data originate from highly selective patients participating in sponsored randomized controlled trials with narrow inclusion criteria. To estimate the true risk of a subsequent mood episode (SME) under real-world conditions, we conducted a meta-analysis of rates of SME as reported in naturalistic BD studies.

METHODS

PubMed, ScienceDirect, Scopus, and Web of Knowledge were searched until July 2015. Studies reporting the time until the emergence of an SME, from which individual data or Kaplan-Meier plots with censors marked could be retrieved, were included.

RESULTS

Twelve studies comprising 5,837 patients met the inclusion criteria. The median time to an SME in adults after an index episode was 1.44 years. The risk of an SME was 44% during the first year. Not having a SME during this first year lowered this risk to 19% in the second year. The risk was higher in bipolar II disorder (BD-II) than in bipolar I disorder (BD-I; HR = 1.5). In BD-I, the risk of a subsequent manic, mixed, or depressive mood episode was higher after an index episode of the same polarity (HR = 1.89-5.14). The overall risk of an SME was higher in patients with persisting subsyndromal symptoms (HR = 2.17).

CONCLUSIONS

The data from this study provide a more reliable estimate of the risk of an SME in BD in real-world settings. Further research into the longitudinal course of BD-II is warranted to confirm its role as a risk factor for SME.

Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990-2015: Systematic review and meta-analysis

BACKGROUND

Comorbidity between substance use disorders (SUDs) and bipolar disorder (BD) is highly prevalent to the extent it may almost be regarded the norm. This systematic review and meta-analysis aimed to estimate the prevalence rates of SUDs in treatment seeking patients diagnosed with BD in both inpatient and outpatient settings.

METHODS

A comprehensive literature search of Medline, EMBASE, psychINFO and CINAHL databases was conducted from 1990 to 2015. Prevalence of co-morbid SUDs and BD were extracted and odds ratios (ORs) were calculated using random effects meta-analysis.

RESULTS

There were 151 articles identified by electronic searches that yielded 22 large, multi-site studies and 56 individual studies describing comorbid rates of SUDs amongst community dwelling, BD inpatients or outpatients. The SUDs with the highest prevalence in BD were alcohol use (42%) followed by cannabis use (20%) and other illicit drug use (17%). Meta-analysis showed males had higher lifetime risks of SUDs compared to females. BD and comorbid SUDS were associated with earlier age of onset and slightly more hospitalisations than non-users.

LIMITATIONS

The results do not take into account the possibility that individuals may have more than one comorbid disorder, such as having more than one SUD, anxiety disorder, or other combination. Some of the meta-analyses were based on relatively few studies with high rates of heterogeneity. Most included studies were cross-sectional and therefore causality cannot be inferred.

CONCLUSIONS

This systematic review shows comorbidity between SUDs and bipolar illness is highly prevalent in hospital and community-based samples. The prevalence of SUDs was similar in patients with bipolar I and bipolar II disorders. This study adds to the literature demonstrating that SUDs are common in BD and reinforces the need to provide better interventions and properly conducted treatment trials to reduce the burden conferred by comorbid SUD and BD.

Social Aspect of Functioning Deteriorates More Than Individual Aspect in Patients with Remitted Bipolar Disorder

INTRODUCTION

Many studies have demonstrated that patients with bipolar disorder (BD) suffer from significant functional impairment, even during remission periods. This study aimed to assess the levels of overall functioning and specific areas of functioning in remitted patients with BD compared with those in healthy controls.

METHODS

Eighty completely remitted patients with BD and 80 healthy controls were included in the study. The Bipolar Disorder Functioning Questionnaire (BDFQ), Young Mania Rating Scale, and Beck Depression Inventory were used.

RESULTS

There were fewer married and employed cohorts in the BD group than in the control group. Compared with healthy controls, patients with BD exhibited a worse functioning in terms of intellectual and sexual functioning, feelings of stigmatization, social withdrawal, household relationships, relationships with friends, and participation in social activities. There was no difference between the groups in terms of emotional functioning, daily activities and hobbies, taking initiative and self-sufficiency, and occupation. The total BDFQ scores of patients were lower than those of healthy controls. A better functionality was observed in patients using only a mood stabilizer than in patients using three or more drugs.

CONCLUSION

Remarkably, remitted patients with BD tended to perform daily activities well when these activities were not in a social context. Stigma-oriented interpersonal approaches can be particularly beneficial for these patients.

Disparities in Treatment and Service Utilization Among Hispanics and Non-Hispanic Whites with Bipolar Disorder

OBJECTIVES

Due to the serious and recurrent nature of bipolar disorder, continuous long-term medication treatment is typically recommended. Little is known about whether these treatment recommendations are effectively implemented for Hispanics. This study examined differences in mood stabilizer use and mental health service utilization between adult English-speaking Hispanic and non-Hispanic white respondents with bipolar disorder.

METHODS

The sample included 163 participants with lifetime bipolar I and II disorders in the National Comorbidity Survey Replication. Demographics, symptom presentation, and acculturation were examined as covariates.

RESULTS

None of the 26 Hispanic respondents were taking mood-stabilizing medication, compared to 21 % of non-Hispanic whites, and Hispanics were less likely to receive medications for emotional problems, see a professional for manic episodes, or attend psychotherapy. Even after accounting for differences in symptom profiles and sociodemographics, ethnicity continued to be a significant predictor of mood stabilizer use and psychotherapy attendance. There was a non-significant trend toward lower acculturation among Hispanics being associated with even poorer service utilization.

CONCLUSIONS

No Hispanics were receiving minimally adequate treatment for their bipolar disorder. Future research should focus on identifying the barriers that lead to these stark ethnic disparities in treatment.

Processing of Facial Emotion in Bipolar Depression and Euthymia

Previous studies of facial emotion processing in bipolar disorder (BD) have reported conflicting findings. In independently conducted studies, we investigate facial emotion labeling in euthymic and depressed BD patients using tasks with static and dynamically morphed images of different emotions displayed at different intensities. Study 1 included 38 euthymic BD patients and 28 controls. Participants completed two tasks: labeling of static images of basic facial emotions (anger, disgust, fear, happy, sad) shown at different expression intensities; the Eyes Test (Baron-Cohen, Wheelwright, Hill, Raste, & Plumb, 2001), which involves recognition of complex emotions using only the eye region of the face. Study 2 included 53 depressed BD patients and 47 controls. Participants completed two tasks: labeling of "dynamic" facial expressions of the same five basic emotions; the Emotional Hexagon test (Young, Perret, Calder, Sprengelmeyer, & Ekman, 2002). There were no significant group differences on any measures of emotion perception/labeling, compared to controls. A significant group by intensity interaction was observed in both emotion labeling tasks (euthymia and depression), although this effect did not survive the addition of measures of executive function/psychomotor speed as covariates. Only 2.6-15.8% of euthymic patients and 7.8-13.7% of depressed patients scored below the 10th percentile of the controls for total emotion recognition accuracy. There was no evidence of specific deficits in facial emotion labeling in euthymic or depressed BD patients. Methodological variations-including mood state, sample size, and the cognitive demands of the tasks-may contribute significantly to the variability in findings between studies.

Predictors of functional outcome after a manic episode

BACKGROUND

The identification of functional outcome predictors after acute episodes of bipolar disorders (BD) may allow designing appropriate treatment aiming at restoring psychosocial functioning. Our objective was to identify the best functional outcome predictors at a 6-month follow-up after an index manic episode.

METHODS

We conducted a naturalistic trial (MANACOR) focusing on the global burden of BD, with special emphasis on manic episode-associated costs. We observed patients with BD seen in services of four hospitals in Catalonia (Spain).The total sample included 169 patients with chronic DSM-IV-TR BD I suffering from an acute manic episode who were followed-up for 6 months. In this subanalysis we report the results of a stepwise multiple regression conducted by entering in the model those clinical and sociodemographic variables that were identified through preliminary bivariate Pearson correlations and using total scores on the Functioning Assessment Short Test (FAST) at the 6-month follow-up as the dependent variable.

RESULTS

Number of previous depressive episodes (Beta=3.25; t=3.23; p=0.002), presence of psychotic symptoms during the manic index episode (Beta=7.007; t=2.2; p=0.031) and the Body Mass Index (BMI) at baseline (Beta=0.62; t=2.09; p=0.041) were best predictors of functional outcome after a manic episode.

LIMITATIONS

The main limitations of this study include the retrospective assessment of the episodes, which can be a source of bias, and the 6-month follow-up might have been too short for assessing the course of a chronic illness.

CONCLUSIONS

Psychotic symptoms at index episode, number of past depressive episodes, and BMI predict worse outcome after 6 months follow-up after a manic episode, and may constitute the target of specific treatment strategies.

Cannabis and bipolar disorder: does quitting cannabis use during manic/mixed episode improve clinical/functional outcomes?

OBJECTIVE

To examine whether bipolar disorder patients who stop cannabis use during a manic/mixed episode have better clinical and functional outcomes than continued use or never use.

METHOD

Data from the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM), a 2-year prospective observational study in adults with a manic/mixed episode of bipolar disorder, was used. Three cannabis use groups were: current use (between 12-week and 24-month visits); no current but previous use (during first 12 weeks); and never use. Associations between cannabis use and outcomes were analyzed using regression models.

RESULTS

Of 1922 patients analyzed, 6.9% were current users, 4.6% previous users, and 88.5% never users. Clinical outcomes differed between groups (P<0.019): previous users had highest rates of remission (68.1%) and recovery (38.7%), and lowest rates of recurrence (42.1%) and relapse (29.8%). Logistic regression showed previous users had similar outcomes to never users (all P>0.05), whereas current users had lower recovery (P=0.004) and remission (P=0.014), higher recurrence (P=0.014), greater work impairment (P=0.016), and were more likely not to be living with partner (P=0.006) than never users.

CONCLUSION

Bipolar patients who stop using cannabis during manic/mixed episode have similar clinical and functional outcomes to never users, while continued use is associated with higher risk of recurrence and poorer functioning.

Two years' outcome of acute mania in bipolar disorder: different effects of age and age of onset

BACKGROUND

Information about differences between younger and older patients with bipolar disorder and between older patients with early and late age of onset of illness during long-term treatment is scarce.

OBJECTIVES

This study aimed to investigate the differences in treatment and treatment outcome between older and younger manic bipolar patients and between early-onset bipolar (EOB) and late-onset bipolar (LOB) older patients.

METHOD

The European Mania in Bipolar Longitudinal Evaluation of Medication study was a 2-year prospective, observational study in 3459 bipolar patients on the treatment and outcome of patients with an acute manic or mixed episode. Patients were assessed at 6, 12, 18, and 24 months post-baseline. We calculated the number of patients with a remission, recovery, relapse, and recurrence and the mean time to achieve this.

RESULTS

Older patients did not differ from younger bipolar patients in achieving remission and recovery or suffering a relapse and in the time to achieve this. However, more older patients recurred and in shorter time. Older patients used less atypical antipsychotics and more antidepressants and other concomitant psychiatric medication. Older EOB and LOB patients did not differ in treatment, but more older LOB patients tended to recover than older EOB patients.

CONCLUSION

Older bipolar manic patients did not differ from younger bipolar patients in short-term treatment outcome (remission and recovery), but in the long term, this may be more difficult to maintain. Distinguishing age groups in bipolar study populations may be useful when considering treatment and treatment outcome and warrants further study.

Parental relationships and behavioral approach system dysregulation in young adults with bipolar disorder

OBJECTIVES

Expressed emotion (EE), or the presence of criticism/hostility/emotional overinvolvement in a family relationship, predicts poorer outcomes in bipolar disorder; however, the mechanism of this is unclear. The present study investigated whether, in a sample of young adults (aged 18-40 years) with bipolar disorder, parental criticism was associated with Behavioral Approach System (BAS) dysregulation, including emotional reactivity to negative feedback and cognitive schemas of self-criticism/perfectionism.

METHOD

Twenty-two young adults with bipolar I disorder and 22 matched control participants completed an interview, questionnaires, and a computer-based task with false negative feedback; emotional reactivity to this feedback was assessed.

RESULTS

Compared to control participants, clinical participants exhibited higher levels (p = 0.001) of self-criticism, and a trend towards a greater decrease in positive affect after negative feedback (p = 0.053), even when controlling for mood symptoms. Among clinical participants, perceived criticism from paternal caregivers was associated with self-criticism and perfectionism, and low perceived paternal care was associated with decrease in positive affect.

CONCLUSION

Strain in parental relationships may be associated with BAS dysregulation for individuals with bipolar disorder.

Impulsivity predicts time to reach euthymia in adults with bipolar disorder

OBJECTIVES

Specific demographic and illness characteristics have been identified as predictors of overall morbidity and treatment course among individuals with bipolar disorder. However, the role of specific cognitive limitations on disease severity and treatment response is unclear. The present study evaluated whether impulsiveness during acute mania was a significant predictor of achieving euthymia within one year following psychiatric hospitalization.

METHODS

Participants were 94 adult inpatients (60 manic) with bipolar I disorder. Baseline symptom severity was assessed using the Young Mania Rating Scale and the Montgomery-Åsberg Depression Rating Scale. Impulsivity was measured with the Stop Signal Task, Degraded Stimulus Continuous Performance Task, Delayed Response Task, and Barratt Impulsiveness Scale-11.

RESULTS

Individual predictors of time to reach euthymia included fewer depressive symptoms and better impulse control at baseline, later age at illness onset, shorter illness duration, and the absence of comorbid attention-deficit hyperactivity disorder. Self-reported impulsivity was a significant independent predictor of time to euthymia, even after accounting for relevant clinical variables.

CONCLUSIONS

Better trait impulse control may be associated with better treatment responsiveness among adults with bipolar disorder.

Unexplored areas of psychotherapy in bipolar disorder

Several psychological interventions-including group psychoeducation, family-focused psychoeducation, and interpersonal social-rhythm therapy-have demonstrated prophylactic efficacy as an adjunct to medication in bipolar disorders (BDs). The field of psychological interventions for BD has experienced impressive progress over the last 15 years. Certain unexplored areas, however, require further research in order to establish the full potential of psychological interventions for BD. Such research should focus, among other things, on cognitive impairment associated with BD, BD in the elderly, comorbid anxiety disorders and other comorbidities, the treatment of BD in pregnant women, and the improvement of patients' overall physical health.

Age at onset in bipolar I affective disorder in the USA and Europe

OBJECTIVE

To test for differences in reported age at onset (AAO) of bipolar I affective disorder in clinical samples drawn from Europe and the USA.

METHODS

Admixture analysis was used to identify the model best fitting the observed AAO distributions of two large samples of bipolar I patients from Europe and USA (n = 3616 and n = 2275, respectively). Theoretical AAO functions were compared between the two samples.

RESULTS

The model best fitting the observed distribution of AAO in both samples was a mixture of three Gaussian distributions. The theoretical AAO functions of bipolar I disorder differed significantly between the European and USA populations, with further analyses indicating that (i) the proportion of patients belonging to the early-onset subgroup was higher in the USA sample (63 vs. 25%) and (ii) mean age at onset (±SD) in the early-onset subgroup was lower for the USA sample (14.5 ± 4.9 vs. 19 ± 2.7 years).

CONCLUSIONS

The models best describing the reported AAO distributions of European and USA bipolar I patients were remarkably stable. The intermediate- and late-onset subgroups had similar characteristics in the two samples. However, the theoretical AAO function differed significantly between the USA and European samples due to the higher proportion of patients in the early-onset subgroup and the lower mean age-at-onset in the USA sample.

The impact of repeated manic episodes and executive dysfunction on work adjustment in bipolar disorder

The aim of this study was to study the clinical and neurocognitive variables that best explain poor work adjustment in a sample of bipolar I euthymic patients. Eighty-five euthymic patients at the Hospital Clinic of Barcelona were assessed for this study by means of a comprehensive neuropsychological battery and a work-focused interview to determine work adjustment. Clinical and sociodemographic variables were also collected. Direct logistic regression was performed to assess the impact of demographic, clinical and neuropsychological variables on the likelihood of presenting poor work adjustment. The model that best fitted contained five variables (Hamilton Depression Rating scores, number of manic episodes, number of perseverative errors in the Wisconsin Card Sorting Test (WCST), number of depressive episodes and Trail Making Test-part B). However, only two out of these variables made a unique statistically significant contribution to the model, which were number of manic episodes (OR 1.401; CI 1.05-1.86; p = 0.021) and number of perseverative errors in the WCST (OR 1.062; CI 1.00-1.12; p = 0.044). The model explained up to 36 % of the variance in work adjustment. This study highlights the role of manic relapses and neurocognitive impairment, specifically the role of executive function, in work adjustment.

Pharmacogenomics of bipolar disorder

Bipolar disorder (BD) is a lifelong severe psychiatric condition with high morbidity, disability and excess mortality. The longitudinal clinical trajectory of BD is significantly modified by pharmacological treatment(s), both in acute and in long-term stages. However, a large proportion of BD patients have inadequate response to pharmacological treatments. Pharmacogenomic research may lead to the identification of molecular predictors of treatment response. When integrated with clinical information, pharmacogenomic findings may be used in the future to determine the probability of response/nonresponse to treatment on an individual basis. Here we present a selective review of pharmacogenomic findings in BD. In light of the evidence suggesting a genetic effect of lithium reponse in BD, we focused particularly on the pharmacogenomic literature relevant to this trait. The article contributes a detailed overview of the current status of pharmacogenomics in BD and offers a perspective on the challenges that can hinder its transition to personalized healthcare.

Mood instability and functional recovery in bipolar disorders

OBJECTIVE

The aim of this study was to identify psychopathological factors associated with long-term functional outcome in euthymic bipolar disorder patients and to test new measures of mood instability and symptoms intensity.

METHOD

Fifty-five patients with more than 12 months of follow-up were included. In addition to traditional clinical variables, the time spent ill was documented using a modified life-charting technique based on NIHM life-charting method. New measures, Mood Instability Factor, and Mood Intensity Factor were defined and assessed. Functioning Assessment Short Test (FAST) was used to assess disability.

RESULTS

The follow-up period was 3.00 ± 1.51 years. Weeks with subsyndromal depressive symptoms (β = 0.133, t = 2.556, P = 0.014), weeks with mild manic symptoms (β = 1.441, t = 3.10, P = 0.003), and the Mood Instability Factor (β = 0.105, t = 3.593, P = 0.001) contributed to approximately 46% of the FAST total score variance.

CONCLUSION

New methodologies including subsyndromal symptoms and mood instability parameters might contribute to understand the worse long-term functional outcome that affects a considerable percentage of BD patients even after episode remission. Concerns about therapeutic approaches are discussed.

The Relationship between Impulsivity and Quality of Life in Euthymic Patients with Bipolar Disorder

OBJECTIVE

Bipolar disorder (BD) is characterized by elevated impulsivity, even during periods of remission. Many recovered BD patients have functional impairments, which can lead to poor quality of life (QoL). The aim of this study was to investigate the association between impulsivity and QoL in euthymic BD patients.

METHODS

A total of 56 remitted or recovered patients with type I or II BD, diagnosed based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, were recruited. Psychiatrists administered the Clinical Global Impression (CGI) for BD and the Global Assessment of Functioning (GAF) scales and then interviewed the subjects to assess clinical variables. Patients completed the Barratt Impulsiveness Scale (BIS-11) and the World Health Organization Quality of Life Assessment Instrument-Brief Form (WHOQoL-BREF). Pearson correlations, univariate regression analyses, and multiple linear regression analyses were performed.

RESULTS

The BIS-11 total score was significantly correlated with the WHOQoL-BREF total score (r=-0.55, p<0.01) and with the WHOQoL-BREF subscales. After controlling for GAF score and other clinical variables, the BIS-11 total score (β=-0.43, p=0.001) was independently associated with overall QoL. Additionally, the BIS-11 total score was particularly strongly associated with the physical, psychological, and social domains of the multi-dimensional QoL scale.

CONCLUSION

Our results suggest that high impulsivity is related to low QoL in euthymic BD patients. Further studies are needed to examine whether interventions for high impulsivity effectively improve QoL in patients with BD.

Patient satisfaction with psychotropic drugs: Validation of the PAtient SAtisfaction with Psychotropic (PASAP) scale in patients with bipolar disorder

PURPOSE

The PAtient SAtisfaction with Psychotropic (PASAP) scale is a self-completed questionnaire measuring satisfaction with psychotropic medication. The aim of the study was to describe its development in French and its psychometric properties.

MATERIALS AND METHODS

Scale construction was based on an extensive search of the literature. The item reduction process required semi-structured interviews of psychiatric outpatients (n=30). The final version of the PASAP is a 9-item, 5-point Likert-type scale, covering the scope of effectiveness and adherence. To assess the psychometric properties of the scale, French patients with an acute manic episode (n=314) from a large European observational cohort completed the PASAP scale 3 months after psychotropic treatment initiation/change. Internal validity and reliability were assessed using principal component analysis (PCA). Concurrent validity was assessed using comparisons to physician-rated satisfaction with life, illness severity, mood relapse, compliance and side effects.

RESULTS

Participation rate was 68.4%. PCA was in favour of uni-dimensionality. Cronbach's α coefficient was 0.85 (95%CI 0.83-0.88). All five concurrent measures were significantly associated with the PASAP score.

CONCLUSION

The PASAP scale showed good psychometric properties in a large bipolar population and thus seems adequate for evaluating treatment satisfaction. Its short length and good acceptability makes it suitable for clinical research.

Occupational disability in bipolar disorder: analysis of predictors of being on severe disablement benefit (PREBIS study data)

OBJECTIVE

Patients diagnosed with bipolar disorder (BD) are reported to have significant work impairment during interepisode intervals. This study was carried out to assess potential predictors of occupational disability in a longitudinal follow-up of euthymic patients.

METHOD

We included 327 euthymic patients diagnosed with BD type I or type II, 226 of whom were employed and 101 were receiving a severe disablement benefit (SDB). Sociodemographic data were studied and episode recurrence was assessed along a 1-year follow-up. Logistic regression analysis was applied to determine predictors of receiving SDB. Cox regression was built to study recurrences.

RESULTS

Predictors of receiving SDB were: axis II comorbidity [Odds Ratio (OR) = 2.94, CI: 1.26-6.86, P = 0.013], number of manic episodes (OR = 1.21, CI: 1.10-1.34, P < 0.001), being without stable partner (OR = 2.44, CI: 1.34-4.44, P = 0.004) and older age (OR = 1.08, CI: 1.05-1.12, P < 0.001). Bipolar patients receiving SDB presented more episodic recurrences regardless of polarity than employed bipolar patients (P = 0.002). The time until recurrence in 25% of the bipolar patients receiving SDB was 6.08 months (CI: 4.44-11.77) being 13.08 months (CI: 9.60 to -) in the employed group.

CONCLUSION

Occupational disability in bipolar patients is associated with axis II comorbidity, more previous manic episodes, not having a stable relationship, older age, and more recurrences at 1-year follow-up.

Mixed states with predominant manic or depressive symptoms: baseline characteristics and 24-month outcomes of the EMBLEM cohort

BACKGROUND

While factors associated with mixed states have been extensively studied, data are scant regarding the clinical heterogeneity of mixed states. The EMBLEM study was a prospective, observational study on patients with manic and mixed states. We describe and compare baseline characteristics and 24-month clinical course of mixed states with predominant depressive symptoms (MSDS) and mixed states with predominant manic symptoms (MSMS).

METHODS

Adult inpatients/outpatients with bipolar disorder were enrolled within the standard course of care if they initiated or changed oral medication for acute mania or mixed states. A logistic regression was used to identify the baseline factors associated with each polarity. Comparisons with mixed episode without symptom predominance (OMS) were performed for informational purpose only.

RESULTS

About 573 mixed patients were analyzed (23.7% of the cohort): 59.5% (n=341) had MSMS, 11.9% (n=68) had MSDS, and 28.6% (n=164) had OMS. At baseline, hallucinations/delusions during the index episode, inpatient status, high CGI-BP overall score, and low education level were more often associated with MSMS versus MSDS. Alcohol abuse or dependence and selective serotonin reuptake inhibitor (SSRI) or benzodiazepine use at inclusion were significantly more frequent with MSDS. MSDS had a significantly lower 24-month recurrence rate than MSMS; MSMS experienced more switches to mania whereas MSDS switched more to depression.

LIMITATIONS

The post hoc dimensional definitions in the study require caution in the interpretation of the results.

CONCLUSION

These results present evidence of clinical heterogeneity within mixed states. Predominant manic or depressive symptoms within mixed episode could influence clinicians' decisions in term of hospitalization, treatment, and perception of bipolar severity.

Development of the International Classification of Functioning, Disability and Health core sets for bipolar disorders: results of an international consensus process

PURPOSE

The International Classification of Functioning, Disability and Health (ICF) is a tool of the World Health Organization (WHO) designed to be a guide to identify and classify relevant domains of human experience affected by health conditions. The purpose of this article is to describe the process for the development of two Core Sets for bipolar disorder (BD) in the framework of the ICF. The Comprehensive ICF Core Set for BD intends to be a guide for multidisciplinary assessment of patients diagnosed with this condition, while the Brief ICF Core Set for BD will be useful when rating aspects of patient's experience for clinical practice or epidemiological studies.

METHODS

An international consensus conference involving a sample of experts with different professional backgrounds was performed using the nominal group technique. Various preparatory studies identified a set of 743 potential ICF categories to be included in the Core Sets.

RESULTS

A total of 38 ICF categories were selected to be included in the Comprehensive Core Set for BD. A total of 19 ICF categories from the Comprehensive Core Set were chosen as the most significant to constitute the Brief Core Set for BD.

CONCLUSIONS

The formal consensus process integrating evidence and expert opinion on the ICF led to the formal adoption of the ICF Core Sets for BD. The most important categories included are representative of the characteristics usually associated with BD. The next phase of this ICF project is to conduct a formal validation process to establish its applicability in clinical settings. Implications for Rehabilitation Bipolar disorder (BD) is a prevalent condition that has a great impact on people who suffer it, not only in health but also in daily functioning and quality of life. No standard has been defined so far regarding the problems in functioning of persons with BDs. The process described in this article defines the set of areas of functioning to be addressed in clinical assessments of persons with BD and establish the starting point for the development of condition-specific outcome measures.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2012 on the long-term treatment of bipolar disorder

OBJECTIVES

These guidelines are based on a first edition that was published in 2004, and have been edited and updated with the available scientific evidence up to October 2012. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the long-term treatment of bipolar disorder in adults.

METHODS

Material used for these guidelines are based on a systematic literature search using various data bases. Their scientific rigor was categorised into six levels of evidence (A-F) and different grades of recommendation to ensure practicability were assigned.

RESULTS

Maintenance trial designs are complex and changed fundamentally over time; thus, it is not possible to give an overall recommendation for long-term treatment. Different scenarios have to be examined separately: Prevention of mania, depression, or an episode of any polarity, both in acute responders and in patients treated de novo. Treatment might differ in Bipolar II patients or Rapid cyclers, as well as in special subpopulations. We identified several medications preventive against new manic episodes, whereas the current state of research into the prevention of new depressive episodes is less satisfactory. Lithium continues to be the substance with the broadest base of evidence across treatment scenarios.

CONCLUSIONS

Although major advances have been made since the first edition of this guideline in 2004, there are still areas of uncertainty, especially the prevention of depressive episodes and optimal long-term treatment of Bipolar II patients.

Young Mania Rating Scale: how to interpret the numbers? Determination of a severity threshold and of the minimal clinically significant difference in the EMBLEM cohort

The aim of this analysis was to identify Young Mania Rating Scale (YMRS) meaningful benchmarks for clinicians (severity threshold, minimal clinically significant difference [MCSD]) using the Clinical Global Impressions Bipolar (CGI-BP) mania scale, to provide a clinical perspective to randomized clinical trials (RCTs) results. We used the cohort of patients with acute manic/mixed state of bipolar disorders (N = 3459) included in the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) study. A receiver-operating characteristic analysis was performed on randomly selected patients to determine the YMRS optimal severity threshold with CGI-BP mania score ≥ "Markedly ill" defining severity. The MCSD (clinically meaningful change in score relative to one point difference in CGI-BP mania for outcome measures) of YMRS, was assessed with a linear regression on baseline data. At baseline, YMRS mean score was 26.4 (±9.9), CGI-BP mania mean score was 4.8 (±1.0) and 61.7% of patients had a score ≥ 5. The optimal YMRS severity threshold of 25 (positive predictive value [PPV] = 83.0%; negative predictive value [NPV] = 66.0%) was determined. In this cohort, a YMRS score of 20 (typical cutoff for RCTs inclusion criteria) corresponds to a PPV of 74.6% and to a NPV of 77.6%, meaning that the majority of patients included would be classified as severely ill. The YMRS minimal clinically significant difference was 6.6 points.

Treatment and outcomes of an Australian cohort of outpatients with bipolar I or schizoaffective disorder over twenty-four months: implications for clinical practice

BACKGROUND

The Bipolar Comprehensive Outcomes Study (BCOS) is a 2-year, prospective, non-interventional, observational study designed to explore the clinical and functional outcomes associated with 'real-world' treatment of participants with bipolar I or schizoaffective disorder. All participants received treatment as usual. There was no study medication.

METHODS

Participants prescribed either conventional mood stabilizers (CMS; n = 155) alone, or olanzapine with, or without, CMS (olanzapine ± CMS; n = 84) were assessed every 3 months using several measures, including the Young Mania Rating Scale, 21-item Hamilton Depression Rating Scale, Clinical Global Impressions Scale - Bipolar Version, and the EuroQol Instrument. This paper reports 24-month longitudinal clinical, pharmacological, functional, and socioeconomic data.

RESULTS

On average, participants were 42 (range 18 to 79) years of age, 58%; were female, and 73%; had a diagnosis of bipolar I. Polypharmacy was the usual approach to pharmacological treatment; participants took a median of 5 different psychotropic medications over the course of the study, and spent a median proportion of time of 100%; of the study on mood stabilizers, 90%; on antipsychotics, 9%; on antidepressants, and 5%; on benzodiazepines/hypnotics. By 24 months, the majority of participants had achieved both symptomatic and syndromal remission of both mania and depression. Symptomatic relapse rates were similar for both the CMS alone (65%;) and the olanzapine ± CMS (61%;) cohorts.

CONCLUSIONS

Participants with bipolar I or schizoaffective disorder in this study were receiving complex medication treatments that were often discordant with recommendations made in contemporary major treatment guidelines. The majority of study participants demonstrated some clinical and functional improvements, but not all achieved remission of symptoms or syndrome.

Stigma experiences in bipolar patients: the impact upon functioning

The aim of this study was to investigate the impact of self-rated stigma and functioning in patients with bipolar disorder in South Brazil. This is a cross-sectional study. Sixty participants with bipolar disorder were recruited from an outpatient Bipolar Disorder Program. Experiences with and impact of perceived stigma were evaluated using the Inventory of Stigmatizing Experiences. Functional impairment was assessed with the Functioning Assessment Short Test (FAST). Higher scores of self-perceived stigma were correlated with higher FAST scores, indicating more disability. After linear correlation analysis, current depressive symptoms, age at onset of treatment, age at diagnosis and functioning were correlated with self-perceived stigma. The study demonstrated a correlation between stigma and poor functioning in bipolar disorder. Perceived stigma is really important to individuals with bipolar disorder, both to how they experience their illness and to its results on functioning. Potential consequences of such results for mental health care professionals are discussed. Differential clinical features, sociocultural factors and the sample size limit the generalization of the present findings.

Determinants of treatment satisfaction of schizophrenia patients: results from the ESPASS study

BACKGROUND

Knowing the determinants of treatment satisfaction can provide better understanding of patient expectations in schizophrenia. The aim of this study was to determine which treatment-related factors were associated with treatment satisfaction, independently of patient-related or illness-related factors, in schizophrenia patients.

METHODS

A cross-sectional study of data collected nationwide in France between 2005 and 2006 was conducted. 5500 adult patients with non-acute schizophrenia and requiring a switch of antipsychotic drug were included by 995 psychiatrists. Treatment satisfaction was assessed using the "PAtient SAtisfaction with Psychotropics" (PASAP) self-report questionnaire. Linear mixed model was used to explore the association between treatment satisfaction and treatment-related factors-including the current antipsychotic drug (none, first or second-generation antipsychotic) and psychosocial therapy-independently of patient-related and illness-related factors.

FINDINGS

3630 (66%) patients filled in the PASAP questionnaire. Main treatment-related determinants of higher levels of satisfaction were: (1) being on second-generation antipsychotics compared to first-generation antipsychotics (olanzapine: ß=1.2; CI95%=[0.5; 2.0], risperidone: ß=0.9; CI95%=[0.1; 1.6], clozapine: ß=2.5; CI95%=[0.6; 4.3] and amisulpride: ß=1.2; CI95%=[0.3; 2.1]) and (2) participating in psychosocial therapy (ß=0.9; CI95%=[0.3; 1.5]).

CONCLUSION

Treatment satisfaction in non-acute schizophrenia was related to the more recent antipsychotic agents and psychosocial therapy, which may reflect expectations of more pro-active care.

Bipolar disorder: "pure" versus mixed depression over a 1-year follow-up

OBJECTIVES

To compare two samples of Bipolar (BD) patients presenting "pure" (D) and mixed (Mx) depression to assess any difference in terms of clinical outcome, social functioning and quality of life during a 1-year follow-up.

METHODS

A total of 114 depressed outpatients (HDRS > 13) were included. "Pure" depressed (D, n = 76) were divided from "mixed" depressed (Mx, n = 38) by the number of concomitant manic symptoms. All patients were evaluated by the Hamilton Depression Rating Scale (HDRS), the Hamilton Anxiety Rating Scale (HARS), the Young Mania Rating Scale (YMRS), the Global Assessment of Functioning (GAF), the Social Adjustment Self-reported Scale (SASS) and the Quality of Life Scale (QoL), at baseline and after 1, 3, 6 and 12 months of treatment.

RESULTS

Mx patients were significantly younger at the onset of BD. Manic features persisted significantly higher in Mx than in D patients all over the follow-up period. Axis I comorbidities had a negative impact on the course of social functioning over the medium term period, while Mx patients showed a faster improvement in social adjustment than "pure" depressed patients.

CONCLUSIONS

Mixed features may persist relatively stable throughout a depressive episode, having a negative impact over clinical and functional outcome, but not on social adjustment.

One-year psychosocial functioning in patients in the early vs. late stage of bipolar disorder

OBJECTIVE

The aim of this 1-year follow-up study was to compare functional outcome as well as clinical differences between patients with first- and multiple-episode bipolar disorder.

METHOD

Bipolar disorder patients with first (n = 60) and multiple episodes (n = 59) were recruited from two hospitals in Spain. The Functioning Assessment Short Test (FAST) was used to assess functioning. The Hamilton Depression Rating Scale (HAMD) and the Young Mania Rating Scale (YMRS) were administered to assess mood symptoms.

RESULTS

As expected, patients with first episode experienced a greater functioning compared to patients with multiple episodes (11.26 ± 10.94 vs. 26.91 ± 13.96; t = 6.436, P < 0.001). There were significant demographic and clinical differences between both groups. Baseline depressive symptoms (F = 9.553, df = 4, 102; P < 0.001) and age (F = 14.145, df = 4, 103; P < 0.001) were significantly associated with poor functional recovery at 6-month and 12-month assessment, respectively, in a group of patients with multiple episodes.

CONCLUSION

Our data give support to the model of staging in bipolar disorder, showing that the enduring neurotoxicity of repeated episodes may contribute to sustained impairment in multiple areas of psychosocial functioning.