Multigenerational Positive Family History of Psychiatric Disorders Is Associated With a Poor Prognosis in Bipolar Disorder

Management challenges and choices in patients with bipolar disorder: An Egyptian observational study

BACKGROUND

Patients with bipolar disorder (BD) had contributed immensely to high health service utilization. Variation in clinical practices that miss to follow the standard guidelines all with the disorder complexity, deepened the management gap. This study aimed to provide an Egyptian epidemiological database of the ongoing clinical practices that framed different diagnostic and management choices in a sample of patients with bipolar disorder. Highlighting challenges and the need for optimized clinical practices.

METHODS

Over 4 months in 2014, 20 clinicians filled in a designed sheet of their routine healthcare practice with information about; caseload /month, management guidelines knowledge background. Out of 301 patients in acute episode BD, 300 patients aged 20 to 60 years from both sexes, completed their assessment using; (1) a semi-structured interview sheet, (2) Structured Clinical Interview for DSM-IV Axis I (SCID I) for psychiatric diagnoses, (3) Global Assessment of Functioning scale for illness impact.

RESULTS

Psychiatrists received 49.5 ± 37.0 (mean ± SD) patient /month. 95% of them reported positive knowledge background on BD diagnostic guidelines and treatment recommendations (G/R), 89.6% of patients had different initial diagnosis than BD.The most commonly given initial diagnosis was major depressive disorder (33%) followed by brief psychotic disorder(20.7%) and others. The median of time taken from the initial to bipolar diagnosis was 12.3 months. Majority of patients had evident functional impairment. Atypical antipsychotics were mostly used. Drug abuse and obesity were high comorbidities.

CONCLUSION

The evident gap in practice and BD complexity have negative impact on clinical outcomes. Physician's continuous medical education programs and individually tailored standard medical care are recommended for optimized practices.

Familial load of psychiatric disorders and overall functioning in patients newly diagnosed with bipolar disorder and their unaffected first-degree relatives

BACKGROUND

Overall functioning is already impaired in patients newly diagnosed with bipolar disorder (BD) and, to a lesser degree, also in their unaffected first-degree relatives (UR). Further, aggregation of psychiatric disorders among the patients' first-degree relatives seems to be associated with higher illness burden and poorer prognosis. However, whether this aggregation of psychiatric disorders among first-degree relatives, the familial load (FL), impacts overall functioning in patients newly diagnosed with BD and their UR remains unresolved.

METHODS

In total, 388 patients newly diagnosed with BD, 144 of their UR and 201 healthy control individuals were included. Overall functioning was assessed using three different assessment methods: The interviewer based "Functioning Assessment Short Test" (FAST), the questionnaire "Work and Social Adjustment Scale" (WSAS) and six outcome measures covering the participants' socio-economic status (SES); educational achievement, employment, work ability, relationship, cohabitation and marital status. Familial load of psychiatric disorder was assessed using the "Family History Research Diagnostic Criteria" interview. Associations between FL and overall functioning in patients and UR were investigated categorically using logistic and continuously in linear regression models.

RESULTS

Contrasting with the hypotheses, the FL of psychiatric disorders was not associated with impaired overall functioning, neither in patients newly diagnosed with BD nor in their UR.

CONCLUSION

The findings indicate that impaired functioning in the early phase of BD is not associated with aggregation of psychiatric disorders among first-degree relatives. The observed functional impairment in patients newly diagnosed with BD seems driven by the personal impact of the disorder rather than the impact of having first-degree relatives with psychiatric disorders.

The pharmacotherapeutic management of comorbid bipolar disorder and alcohol use disorder

INTRODUCTION

Comorbidity of bipolar disorder (BD) and alcohol use disorder (AUD) is very frequent resulting in detrimental outcomes, including increased mortality. Diagnosis of AUD in BD and vice versa is often delayed as symptoms of one disorder mimic and obscure the other one. Evidence for pharmacotherapies for people with comorbid BD and AUD remains limited, and further proof-of-concept studies are urgently needed.

AREAS COVERED

This paper explores the currently available pharmacotherapies for AUD, BD and their usefulness for comorbid BD and AUD. It also covers to some degree the epidemiology, diagnosis, and potential common neurobiological traits of comorbid BD and AUD.

EXPERT OPINION

The authors conclude that more controlled studies are needed before evidence-based guidance can be drawn up for clinician's use. Since there are no relevant pharmacological interactions, approved medications for AUD can also be used safely in BD. For mood stabilization, lithium should be considered first in adherent persons with BD and comorbid AUD. Alternatives include valproate, lamotrigine, and some atypical antipsychotics, with partial D2/D3 receptor agonism possibly being beneficial in AUD, too.

Looking for factors affecting functioning in euthymic patients with bipolar I disorder: the importance of cognitive complaints and BDNF's Val66Met polymorphism

INTRODUCTION

Functioning in Bipolar Disorder (BD) is affected in a substantial proportion of patients. The impact of demographic, clinical, cognitive, and genetic factors on functioning has been shown individually; however, as a complex phenomenon, a global approach to identify the most relevant as well as possible interactions is needed.

METHODS

102 patients with type I BD in euthymia were invited for evaluation of demographic, clinical, and cognitive characteristics as well as genotype for Val66Met polymorphism of BDNF gene to determine those associated with poor functioning according to the FAST scale cut-off score. Clinical evaluation included assessment of residual affective symptoms and anxiety. Cognitive evaluation included the COBRA scale, verbal memory, and executive functions testing.

RESULTS

Residual depressive symptoms, anxiety, cognitive complaints and being a Met carrier were more frequent in the poor functioning group and were entered in a logistic regression model. Being a Met carrier (OR=4.46, CI=1.19-16.67) and cognitive complaints (OR=1.29, CI= 1.13-1.46) were the most important predictors of poor functioning in type I BD.

LIMITATIONS

Cross-sectional study, with select population limiting generalizability of findings.

CONCLUSIONS

A better understanding of underlying factors affecting cognition, including the possible involvement of BDNF Val66Met polymorphism, its systematic evaluation and a continued search for targeted treatment, along with recognition and attention of residual affective and anxious symptoms might improve psychosocial outcomes such as functioning in this population.

25 Years of the International Bipolar Collaborative Network (BCN)

BACKGROUND

The Stanley Foundation Bipolar Treatment Outcome Network (SFBN) recruited more than 900 outpatients from 1995 to 2002 from 4 sites in the United States (US) and 3 in the Netherlands and Germany (abbreviated as Europe). When funding was discontinued, the international group of investigators continued to work together as the Bipolar Collaborative Network (BCN), publishing so far 87 peer-reviewed manuscripts. On the 25th year anniversary of its founding, publication of a brief summary of some of the major findings appeared appropriate. Important insights into the course and treatment of adult outpatients with bipolar disorder were revealed and some methodological issues and lessons learned will be discussed.

RESULTS

The illness is recurrent and pernicious and difficult to bring to a long-term remission. Virtually all aspects of the illness were more prevalent in the US compared to Europe. This included vastly more patients with early onset illness and those with more psychosocial adversity in childhood; more genetic vulnerability; more anxiety and substance abuse comorbidity; more episodes and rapid cycling; and more treatment non-responsiveness.

CONCLUSIONS

The findings provide a road map for a new round of much needed clinical treatment research studies. They also emphasize the need for the formation of a new network focusing on child and youth onset of mood disorders with a goal to achieve early precision diagnostics for intervention and prevention in attempting to make the course of bipolar illness more benign.

Social cognition in first-degree relatives of bipolar disorder: Theory of Mind and nonverbal sensitivity

Social cognition might be impaired in first degree relatives (FDR) of BD but existing research shows controversial results about social cognitive impairments in this population. The aim of this study was to assess Theory of Mind (ToM) and nonverbal sensitivity in FDR of BD and compare the results with those of two groups of persons with remitted bipolar disorder (BD), type I and II, and a control group. Social cognitive ability was examined in first degree relatives of BD, with a biological parent, offspring or sibling diagnosed with the disorder. For this study, 37 FDRs of bipolar patients, 37 BD I, 40 BD II and 40 control participants were recruited. Social cognition was explored by means of the Reading the Mind in the Eyes Test and the MiniPONS. Results showed a significant impairment in FDR of BD in the ToM task, but not in nonverbal sensitivity. Performance of FDRs in social cognition is better than that of BDs (either type I or type II) but worse when compared with that of healthy individuals without a family history of psychiatric disorders. Nevertheless, no differences were found between BD I and BD II groups. Males and older participants showed a worse performance in all groups. Group family therapy with FDRs of BD might include training in the recognition of nonverbal cues, which might increase the understanding of their familiars with BD, in order to modify communication abilities.

Early-onset bipolar disorder, stress, and coping responses of mothers: A comparative study

BACKGROUND

Providing care and nurturance to a child with bipolar disorder (BPAD) is a challenging task for parents, especially mothers. In Indian contexts, mothers are the primary caregivers of ailing children and they have to keep intrafamily situation stable, which makes their role more stressful.

OBJECTIVES

The objective of the study was to assess maternal stress and coping in mothers of adolescents with BPAD.

MATERIALS AND METHODS

This study was a comparative one and carried out on sixty mothers of adolescents; of which thirty were adolescents with BPAD, and the remaining thirty were the mothers of normal adolescents. The participants were selected purposively as per the mothers' age and education level, and the socioeconomic status of the families they belong to. Sociodemographic and clinical data sheet, Parenting Stress Index/Short Form (PSI/SF), and Brief COPE were applied on the mothers for data collection.

RESULTS

Mothers' of the BPAD adolescents reported higher scores in the both PSI/SF and Brief COPE.

CONCLUSION

Mothers of the adolescents with BPAD tend to perceive high level of stress and they also use maladaptive coping more in dealing with stressful situations.

The effect of mental health on social capital: An instrumental variable analysis

Although a large body of literature has examined the effect of social capital on health and theoretical models suggest a reciprocal relationship between the two variables, there are relatively few studies that have investigated the effect of mental health on social capital. This paper evaluates the impact of mental health on the stock of social capital using data from the cross-sectional 2012 (N = 21,844) and 2002 (N = 31,089) Canadian Community Health Survey - Mental Health editions. Mental health was measured retrospectively as self-rated mental health, past year mental health conditions, and past 30-day psychological distress. Given the reciprocal relationship, we used an instrumental variable approach with family history of mental health problems as the instrument and examined forms of social capital - sense of belonging and workplace social support - that are largely measures of social capital provided by non-family members in the community and workplace. The analysis suggests there are large and significant associations between measures of mental health and both outcomes, which persist in the instrumental variable analyses. These findings highlight the urgent need for policy makers to implement greater prevention and treatment of poor mental health, and provide greater support for individuals with poor mental health so they can build and maintain their social capital.

Comorbid Bipolar and Alcohol Use Disorder-A Therapeutic Challenge

Comorbidity rates in Bipolar disorder rank highest among major mental disorders, especially comorbid substance use. Besides cannabis, alcohol is the most frequent substance of abuse as it is societally accepted and can be purchased and consumed legally. Estimates for lifetime comorbidity of bipolar disorder and alcohol use disorder are substantial and in the range of 40-70%, both for Bipolar I and II disorder, and with male preponderance. Alcohol use disorder and bipolarity significantly influence each other's severity and prognosis with a more complicated course of both disorders. Modern treatment concepts acknowledge the interplay between these disorders using an integrated therapy approach where both disorders are tackled in the same setting by a multi-professional team. Motivational interviewing, cognitive behavioral and socio- therapies incorporating the family and social environment are cornerstones in psychotherapy whereas the accompanying pharmacological treatment aims to reduce craving and to optimize mood stability. Adding valproate to lithium may reduce alcohol consumption whereas studies with antipsychotics or naltrexone and acamprosate did not affect mood fluctuations or drinking patterns. In summary, there is a continuous need for more research in order to develop evidence-based approaches for integrated treatment of this frequent comorbidity.

Double jeopardy in the United States: Early onset bipolar disorder and treatment delay

BACKGROUND

Evidence is emerging that early onset bipolar disorder and the duration of the delay to first treatment are both risk factors for poor treatment outcome. We report on the incidence and implications of these two risk factors in patients from the United States (US) versus Europe.

METHODS

Age of onset and age at first treatment for depression or mania was assessed in 967 outpatients with bipolar disorder who gave informed consent for participation and filling out a detailed questionnaire. Age at onset and treatment delay were compared in the 675 patients from the US and 292 from the Netherlands and Germany (abbreviated as Europe). Both were then graphed and analyzed.

RESULTS

Age of onset of bipolar disorder was earlier in the US than in Europeans by an average of 6-7 years with similar results in those with first onsets of depression or of mania. Delay to first treatment was strongly inversely related to age of onset and was twice as long in the US than in Europe, and especially different for mania in adolescents. The longer delay to treatment in the US was not solely due to earlier age of onset.

CONCLUSIONS

Treatment delay is a remedial risk factor and could be shortened with better recognition of the higher incidence of early onset bipolar disorder in the US, which also associated with more genetic and environmental vulnerability factors compared to Europe. New treatment and research initiatives are needed to address these liabilities so that children with bipolar achieve more positive long-term outcomes.

Predictors of 1-year rehospitalization in inpatients with bipolar I disorder treated with atypical antipsychotics

Bipolar disorder (BPD) is debilitating disorder, and patients can experience multiple relapses and subsequent hospitalizations. Since pharmacotherapy is the mainstay of treatment for patients with BPD, investigations on the effects of atypical antipsychotics (AAP) on reducing rehospitalization risk are crucial. The objective of study is to explore predictors of 1-year rehospitalization in patients with bipolar I disorder treated with AAP. A retrospective chart review on inpatients with bipolar I disorder was conducted. All participants were followed up for 1 year, and they were subdivided into three AAP treatment groups (olanzapine, risperidone, and quetiapine group). Kaplan-Meier survival analysis was implemented to detect time to rehospitalization due to any mood episodes within 1 year after discharge. Cox proportional regression model was adopted to find predictors of 1-year hospitalization in patients who experienced rehospitalization. One hundred thirty-eight participants were included in the study, and a 1-year rehospitalization rate was 18.1%. Time to rehospitalization did not differ between three AAP treatment groups. Predictors of rehospitalization due to any episode within 1 year were family history of depression and number of previous admission. Our findings can be conducive to understanding prognosis, and predicting rehospitalization risk in patients with BPD on AAP.

Familial severe psychiatric history in bipolar disorder and correlation with disease severity and treatment response

BACKGROUND

Bipolar disorder is a heritable disorder, and we aimed to assess the impact of family history of mental disorders in first-degree relatives on the severity and course of bipolar disorder.

METHODS

The Bipolar CHOICE (lithium versus quetiapine) and LiTMUS (optimized treatment with versus without lithium) comparative effectiveness studies were similar trials among bipolar disorder outpatients studying four different randomized treatment arms for 24 weeks. Patients self-reported on six severe mental disorders among first-degree relatives. We performed ANOVA and linear regression regarding disease severity measures, sociodemographic and cardiometabolic markers and mixed effects linear regression to evaluate treatment response.

RESULTS

Among 757 patients, 644 (85.1%) reported at least one first-degree relative with a severe mental disorder (mean=2.8; standard deviation=2.2; range=0-13). Depression (67.1%), alcohol abuse (51.0%) and bipolar disorder (47.0%) were the most frequently reported disorders. Familial psychiatric history correlated with several disease severity measures (hospitalizations, suicide attempts, and earlier onset) and sociodemographic markers (lower education and household income) but not with cardiometabolic markers (e.g. cholesterol or waist circumference) or cardiovascular risk scores, e.g. the Framingham risk score. Patients with familial psychiatric history tended to require more psychopharmacological treatment (p=0.054) but responded similarly (all p>0.1) to all four treatment arms.

CONCLUSIONS

Our findings indicate that familial psychiatric history is common among outpatients with bipolar disorder and correlates with disease severity and sociodemographic measures. Patients with a greater familial psychiatric load required more intense treatment but achieved similar treatment responses compared to patients without familial psychiatric history.

Effects of Fish Oil Monotherapy on Depression and Prefrontal Neurochemistry in Adolescents at High Risk for Bipolar I Disorder: A 12-Week Placebo-Controlled Proton Magnetic Resonance Spectroscopy Trial

Objectives: To evaluate the clinical and neurochemical effects of 12-week fish oil, a source of omega-3 polyunsaturated fatty acids (n-3 PUFAs), in depressed adolescents with a family history of bipolar I disorder. Methods: Adolescents with a current Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision diagnosis of Major Depressive Disorder or Depressive Disorder not otherwise specified, a Childhood Depression Rating Scale-Revised (CDRS-R) Version raw score of ≥40, and at least one biological parent with bipolar I disorder were randomized to double-blind treatment with fish oil (2100 mg/day) or placebo for 12 weeks. The primary outcome measure was change in CDRS-R total score, and secondary outcomes measures were change in manic symptoms (Young Mania Rating Scale), global symptom and functioning measures (Clinical Global Impression-Severity [CGI-S] /CGI Improvement [CGI-I], Children's Global Assessment Scale, and Child Behavior Checklist), safety and laboratory measures, and anterior cingulate cortex (ACC) and bilateral ventrolateral prefrontal cortex neurometabolite concentrations using proton magnetic resonance spectroscopy at 4 T. Results: Fifty-six patients were randomized, and 42 completed the 12-week trial (placebo: n = 21; fish oil, n = 21). Subjects randomized to fish oil, but not placebo, exhibited a significant baseline to endpoint increase in erythrocyte n-3 PUFAs. Reductions in CDRS-R scores did not differ between treatment groups (p = 0.15), and similar remission (p = 0.58) and response (p = 0.77) rates were observed. Fish oil produced a significantly greater decrease in CGI-S (p = 0.0042) and CGI-I (p = 0.036) scores compared with placebo. Baseline to endpoint change in ACC creatine (p = 0.004) and ACC choline (Cho) (p = 0.024) differed significantly between groups. Baseline ACC Cho levels were inversely correlated with baseline and baseline to endpoint change in CDRS-R scores, and baseline to endpoint change in ACC Cho correlated with baseline-endpoint change in CDRS-R scores and n-3 PUFA. There were no group differences in safety and tolerability ratings or laboratory measures. Conclusions: Fish oil monotherapy was not superior to placebo for reducing depressive symptoms in high-risk youth as assessed by the CDRS-R, but was safe and well tolerated and superior to placebo on clinician ratings of global symptom improvement. Associations among ACC Cho levels, depression symptom severity, and n-3 PUFA warrant additional investigation.

Elevated Familial Cardiovascular Burden Among Adolescents With Familial Bipolar Disorder

Background: Bipolar disorder (BD) is one of the most heritable medical conditions, and certain phenotypic characteristics are especially familial in BD. BD is also strongly associated with elevated and premature cardiovascular disease (CVD) morbidity and mortality. Thus, far, little is known regarding the familiality of cardiovascular risk in BD. We therefore examined the extent of CVD-related conditions among relatives of: adolescents with BD with a family history of BD (familial BD), adolescents with BD without a family history of BD (non-familial BD) and healthy controls (HC). Materials and Methods: The sample included 372 adolescents; 75 with familial BD, 96 with non-familial BD, and 201 HC. Parents of the adolescents completed the CARDIA Family Medical History interview regarding the adolescents' first- and second- degree adult relatives. We computed a "cardiovascular risk score" (CRS) for each relative, based on the sum of the presence of diabetes, hypertension, obesity, dyslipidemia, stroke, angina, and myocardial infarction (range 0-7). Primary analyses examined for group differences in mean overall CRS scores among first and second- degree relatives combined, controlling for age, sex, and race. Secondary analyses examined first- and second-degree relatives separately, controlling for age, sex, and race. Results: There were significant between-group differences in CRS in first- and second- degree relatives combined, following the hypothesized ordering: CRS was highest among adolescents with familial BD (1.14 ± 0.78), intermediate among adolescents with non-familial BD (0.92 ± 0.79) and lowest in HC (0.76 ± 0.79; F = 6.23, df = 2, p = 0.002, ηp 2 = 0.03). There was a significant pairwise difference between adolescents with familial BD and HC (p = 0.002, Cohen's d = 0.49). A similar pattern of between-group differences was identified when first-degree and second-degree relatives were examined separately. Limitations: familial cardiovascular burden was determined based on parent interview, not evaluated directly. Conclusions: Adolescents with BD with a family history of BD have elevated rates of CVD-related conditions among their relatives. This may be related to genetic overlap between BD and CVD-related conditions, shared environmental factors that contribute to both BD and CVD-related conditions, or a combination of these factors. More research is warranted to better understand the interaction between familial risk for BD and CVD, and to address this risk using family-wide preventive approaches.

Early intervention for adolescents at-risk for bipolar disorder: A pilot randomized trial of Interpersonal and Social Rhythm Therapy (IPSRT)

OBJECTIVE

To conduct a pilot randomized trial of Interpersonal and Social Rhythm Therapy plus Data-Informed Referral (IPSRT + DIR) versus DIR-alone for adolescents at-risk for bipolar disorder (BP).

METHOD

Eligible participants included youth (12-18) with a BP parent; youth with BP were excluded. Participants (n = 42) were randomized to receive IPSRT + DIR to treat any psychiatric disorders present at baseline, or DIR-alone. A blind evaluator assessed outcomes at baseline, 3- and 6-months. Participants wore an actigraph to measure sleep/wake patterns for 7 days at baseline and 6-months. Primary outcomes included mood and non-mood symptoms and sleep disturbance.

RESULTS

Youth randomized to IPSRT + DIR attended approximately half of scheduled IPSRT sessions. Although 33% of DIR-alone youth were referred for mental health services at intake (another 33% were already engaged in services), none initiated new services over follow-up. No youth developed new-onset mood disorder over follow-up. Self- and parent-reported mood and non-mood psychiatric symptoms did not distinguish the groups, although youth in DIR-alone tended to have higher baseline scores on most measures. Per clinician ratings, 1 youth receiving IPSRT + DIR displayed subthreshold hypo/manic symptoms, versus 2 receiving DIR-alone (OR = 14.7, p = 0.03), possibly signaling less subthreshold hypo/manic symptoms, and for fewer weeks (χ²= 11.06, p = 0.0009), over 6-months with IPSRT + DIR. We found a small effect for youth in the IPSRT + DIR group to evidence more WASO at pre-treatment, but less at follow-up (cohen's d = 0.28).

LIMITATIONS

Small sample size limits statistical power, and we are unable to definitively attribute group differences to IPSRT versus greater clinical contact. Ability to examine distal/rare (i.e., BP onset) outcomes was limited.

CONCLUSIONS

Adolescents at-risk for BP present challenges to psychosocial treatment engagement and retention. IPSRT merits further study as an acceptable intervention for at-risk youth, though necessary frequency and intensity to affect outcomes should be examined. The potential to delay or prevent subthreshold hypo/manic symptoms via enhanced sleep continuity is an area for further examination. Future studies with larger samples and extended follow-up can help determine whether IPSRT may delay or prevent syndromal hypo/mania in youth at-risk.

Multigenerational transmission of liability to psychiatric illness in offspring of parents with bipolar disorder

INTRODUCTION

Instead of the typical assessment of risk of illness in the offspring based on a parent with bipolar disorder, we explored the potential multigenerational conveyance across several disorders of the vulnerability to illness in the offspring of a patient with bipolar disorder.

METHODS

A total of 968 outpatients (average age 41 years) with bipolar illness gave informed consent and filled out a detailed questionnaire about a family history in their parents, grandparents, and offspring of: depression; bipolar disorder; alcohol abuse; substance abuse; suicide attempt; or "other" illness. Of those with children, 346 were from the USA and 132 were from Europe. Amount and type of illness in progenitors in two and three previous generations were related to offspring illness.

RESULTS

The type of illness seen in both prior generations was associated with the same type of illness in the offspring of a bipolar patient, including depression, bipolar disorder, alcohol and substance abuse and "other" illness, but not suicide attempts. There was an impact of multiple generations, such that depression in grandparents and/or great-grandparents increased the risk of depression in the offspring from 12.6% to 41.4%.

CONCLUSIONS

A family history of illness burden in prior generations was previously related to an earlier age of onset of bipolar illness in our adult patients with bipolar disorder and is now also found to be related to the incidence of multiple psychiatric illnesses in their offspring. Genetic and epigenetic mechanisms deserve consideration for this multigenerational conveyance of illness vulnerability, and clinical and public health attempts to prevent or slow this transmission are indicated.

The Child Network for Parents to Track Their Child's Mood and Behavior

INTRODUCTION

A wide range of psychiatric disorders are common in young children, especially in those at high risk because of a parent with a unipolar or bipolar mood disorder in the United States. Yet in part because most children are seen in primary care, these illnesses are often not recognized or treated in a timely fashion. To begin to address this problem, we started the Child Network.

METHODS

The Child Network is for parents of children age 2-12 with mood or behavioral symptoms or at high risk for them. The parents rate the severity of symptoms of depression, anxiety, attention-deficit/hyperactivity disorder (ADHD), oppositional behavior, and mania on a once a week basis on a secure website under a Johns Hopkins Intramural Review Board (IRB)-approved protocol. These ratings can then be printed out along with any treatments given to aide in visualization of symptom course. A demographics form, which includes diagnoses given to the child in the community, and a symptom checklist are filled out upon Network entry. We report on the retrospective diagnoses and prospective treatment of the first 65 parents to join the Network.

RESULTS

The most common diagnoses were anxiety disorders and ADHD followed by disruptive behavioral disorders and bipolar spectrum disorders. Prospective ratings of two or more consecutive weeks of moderate to severe rating in any of the five symptom domains paralleled these diagnoses given in the community. Atypical antipsychotics, anticonvulsant mood stabilizers, and medications for ADHD were among the most widely used drugs. An illustrated example of symptom course is presented.

DISCUSSION

Many children continued to show substantial symptom severity despite treatment with an average of 2.2 medications. The Child Network provides a useful longitudinal approach to visualize the course of symptoms, which should help lead to earlier and more effective treatment.

More childhood onset bipolar disorder in the United States than Canada or Europe: Implications for treatment and prevention

Evidence of a high or increasing incidence of childhood onset bipolar disorder in the United States (US) has been viewed skeptically. Here we review evidence that childhood onsets of bipolar disorder are more common in the US than in Europe, treatment delays are longer, and illness course is more adverse and difficult. Epidemiological data and studies of offspring at high risk also support these findings. In our cohort of outpatients with bipolar disorder, two of the major vulnerability factors for early onset - genetics and environmental adversity in childhood - were also greater in the US than in Europe. An increased familial loading for multiple psychiatric disorders was apparent in 4 generations of the family members of the patients from the US, and that familial burden was linked to early onset bipolar disorder. Since both early onset and treatment delay are risk factors for a poor outcome in adulthood, new clinical, research, and public health initiatives are needed to begin to address and ameliorate this ongoing and potentially devastating clinical situation.

Illnesses in siblings of US patients with bipolar disorder relate to multigenerational family history and patients severity of illness

BACKGROUND

Patients with bipolar disorder from the US have more early-onset illness and a greater familial loading for psychiatric problems than those from the Netherlands or Germany (abbreviated here as Europe). We hypothesized that these regional differences in illness burden would extend to the patients siblings.

METHODS

Outpatients with bipolar disorder gave consent for participation in a treatment outcome network and for filling out detailed questionnaires. This included a family history of unipolar depression, bipolar disorder, suicide attempt, alcohol abuse/dependence, drug abuse/dependence, and "other" illness elicited for the patients' grandparents, parents, spouses, offspring, and siblings. Problems in the siblings were examined as a function of parental and grandparental problems and the patients' adverse illness characteristics or poor prognosis factors (PPFs).

RESULTS

Each problem in the siblings was significantly (p<0.001) more prevalent in those from the US than in those from Europe. In the US, problems in the parents and grandparents were almost uniformly associated with the same problems in the siblings, and sibling problems were related to the number of PPFs observed in the patients.

LIMITATIONS

Family history was based on patient report.

CONCLUSIONS

Increased familial loading for psychiatric problems extends through 4 generations of patients with bipolar disorder from the US compared to Europe, and appears to "breed true" into the siblings of the patients. In addition to early onset, a variety of PPFs are associated with the burden of psychiatric problems in the patients' siblings and offspring. Greater attention to the multigenerational prevalence of illness in patients from the US is indicated.

Age of onset of bipolar disorder: Combined effect of childhood adversity and familial loading of psychiatric disorders

BACKGROUND

Family history and adversity in childhood are two replicated risk factors for early onset bipolar disorder. However, their combined impact has not been adequately studied.

METHODS

Based on questionnaire data from 968 outpatients with bipolar disorder who gave informed consent, the relationship and interaction of: 1) parental and grandparental total burden of psychiatric illness; and 2) the degree of adversity the patient experienced in childhood on their age of onset of bipolar disorder was examined with multiple regression and illustrated with a heat map.

RESULTS

The familial loading and child adversity vulnerability factors were significantly related to age of onset of bipolar and their combined effect was even larger. A heat map showed that at the extremes (none of each factor vs high amounts of both) the average age of onset differed by almost 20 years (mean = 25.8 vs 5.9 years of age).

LIMITATIONS

The data were not based on interviews of family members and came from unverified answers on a patient questionnaire.

CONCLUSIONS

Family loading for psychiatric illness and adversity in childhood combine to have a very large influence on age of onset of bipolar disorder. These variables should be considered in assessment of risk for illness onset in different populations, the need for early intervention, and in the design of studies of primary and secondary prevention.

Epigenetic basis of sensitization to stress, affective episodes, and stimulants: implications for illness progression and prevention

OBJECTIVES

The process of sensitization (increased responsivity) to the recurrence of stressors, affective episodes, and bouts of substance abuse that can drive illness progression in the recurrent affective disorders requires a memory of and increased reactivity to the prior exposures. A wealth of studies now supports the postulate that epigenetic mechanisms underlie both normal and pathological memory processes.

METHODS

We selectively reviewed the literature pertinent to the role of epigenetics in behavioral sensitization phenomena and discuss its clinical implications.

RESULTS

Epigenetics means above genetics and refers to environmental effects on the chemistry of DNA, histones (around which DNA is wound), and microRNA that change how easily genes are turned on and off. The evidence supports that sensitization to repeated stressor, affective episodes, and substance is likely based on epigenetic mechanisms and that these environmentally based processes can then become targets for prevention, early intervention, and ongoing treatment. Sensitization processes are remediable or preventable risk factors for a poor illness outcome and deserve increased clinical, public health, and research attention in the hopes of making the recurrent unipolar and bipolar affective disorders less impairing, disabling, and lethal by suicide and increased medical mortality.

CONCLUSIONS

The findings that epigenetic chemical marks, which change in the most fundamental way how genes are regulated, mediate the long-term increased responsivity to recurrent stressors, mood episodes, and bouts of substance abuse should help change how the affective disorders are conceptualized and move treatment toward earlier, more comprehensive, and sustained pharmacoprophylaxis.

More illness in offspring of bipolar patients from the U.S. compared to Europe

BACKGROUND

Evidence suggests that patients with bipolar disorder from the United States have an earlier age of onset and a more difficult course of illness than those from Germany and the Netherlands. These characteristics were related to a greater family burden of psychiatric illness and the experience of more psychosocial adversity in childhood. We hypothesized that this greater illness burden would extend to the offspring of the US patients.

METHODS

968 outpatients (average age 41) with bipolar illness gave informed consent for participation in a treatment outcome network and filled out a detailed questionnaire about their illness and family history of illness, including whether their offspring had a diagnosis of depression, bipolar disorder, alcohol or substance abuse, suicide attempt or "other" illness. Of those with children, 356 were from the US and 132 were from Europe.

RESULTS

Compared to the Europeans, offspring of patients from the US had significantly (p<0.001) more depression, bipolar disorder, drug abuse, and "other" illnesses. The number of illnesses in the offspring was related to the bipolar parent being from the US, having had childhood adversity, more than 20 prior episodes, and more parental psychiatric illness.

CONCLUSIONS

While the findings are limited by their basis on self report, the distribution of the percentages in the US offspring are similar to those of Axelson et al. (2015) who used direct interviews. The higher burden of illness in the offspring and their in direct progenitors from the US compared to Europe warrant new attempts at better treatment and prevention.