A systematic review evaluating health-related quality of life, work impairment, and healthcare costs and utilization in bipolar disorder

Prevalence of multimorbidity in people with and without severe mental illness: a systematic review and meta-analysis

BACKGROUND

People with severe mental illness, such as schizophrenia-spectrum disorder and bipolar disorder, face poorer health outcomes from multiple chronic illnesses. Physical multimorbidity, the coexistence of two or more chronic physical conditions, and psychiatric multimorbidity, the coexistence of three or more psychiatric disorders, are both emerging concepts useful in conceptualising disease burden. However, the prevalence of physical and psychiatric multimorbidity in this cohort is unknown. This study aimed to estimate the absolute prevalence of both physical and psychiatric multimorbidity in people with severe mental illness, and also compare the odds of physical multimorbidity prevalence against people without severe mental illness.

METHODS

We searched CINAHL, EMBASE, PubMed, and PsycINFO from inception until Feb 15, 2024, for observational studies that measured multimorbidity prevalence. To be included, studies had to have an observational study design, be conducted in an adult population (mean age ≥18 years) diagnosed with either schizophrenia-spectrum disorder or bipolar disorder, and include a measurement of occurrence of either physical multimorbidity (≥2 physical health conditions) or psychiatric multimorbidity (≥3 psychiatric conditions total, including the severe mental illness). From control studies, a random-effects meta-analysis compared odds of physical multimorbidity between people with and without severe mental illness. Absolute prevalence of physical and psychiatric multimorbidity in people with severe mental illness was also calculated. Sensitivity and meta-regression analyses tested an array of demographic, diagnostic, and methodological variables.

FINDINGS

From 11 144 citations we included 82 observational studies featuring 1 623 773 individuals with severe mental illness (specifically schizophrenia-spectrum disorder or bipolar disorder), of which 21 studies featured 13 235 882 control individuals without severe mental illness (descriptive data for the entire pooled cohorts were not available for numbers of males and females, age, and ethnicity). This study did not feature involvement of people with lived experience. The odds ratio (OR) of physical multimorbidity between people with and without severe mental illness was 2·40 (95% CI 1·57-3·65, k=11, p=0·0009). This ratio was higher in younger severe mental illness populations (mean age ≤40 years, OR 3·99, 95% CI 1·43-11·10) compared with older populations (mean age >40 years, OR 1·55, 95% CI 0·96-2·51; subgroup differences p=0·0013). For absolute prevalence, 25% of those with severe mental illness have physical multimorbidity (95% CI 0·19-0·32, k=29) and 14% have psychiatric multimorbidity (95% CI 0·08-0·23, k=21).

INTERPRETATION

This is the first meta-analysis to estimate physical alongside psychiatric multimorbidity prevalence, showing that these are common in people with schizophrenia-spectrum disorder and bipolar disorder. The greater burden of physical multimorbidity in people with severe mental illness compared with those without is higher for younger cohorts, reflecting a need for earlier intervention. Our findings speak to the utility of multimorbidity for characterising the disease burden associated with severe mental illness, and the importance of facilitating integrated physical and mental health care.

FUNDING

None.

Association between the pharmacological treatment of bipolar disorder and risk of traumatic injuries: a self-controlled case series study

BACKGROUND

Patients with bipolar disorder (BPD) are prone to engage in risk-taking behaviours and self-harm, contributing to higher risk of traumatic injuries requiring medical attention at the emergency room (ER).We hypothesize that pharmacological treatment of BPD could reduce the risk of traumatic injuries by alleviating symptoms but evidence remains unclear. This study aimed to examine the association between pharmacological treatment and the risk of ER admissions due to traumatic injuries.

METHODS

Individuals with BPD who received mood stabilizers and/or antipsychotics were identified using a population-based electronic healthcare records database in Hong Kong (2001-2019). A self-controlled case series design was applied to control for time-invariant confounders.

RESULTS

A total of 5040 out of 14 021 adults with BPD who received pharmacological treatment and had incident ER admissions due to traumatic injuries from 2001 to 2019 were included. An increased risk of traumatic injuries was found 30 days before treatment [incidence rate ratio (IRR) 4.44 (3.71-5.31), p < 0.0001]. After treatment initiation, the risk remained increased with a smaller magnitude, before returning to baseline [IRR 0.97 (0.88-1.06), p = 0.50] during maintenance treatment. The direct comparison of the risk during treatment to that before and after treatment showed a significant decrease. After treatment cessation, the risk was increased [IRR 1.34 (1.09-1.66), p = 0.006].

CONCLUSIONS

This study supports the hypothesis that pharmacological treatment of BPD was associated with a lower risk of ER admissions due to traumatic injuries but an increased risk after treatment cessation. Close monitoring of symptoms relapse is recommended to clinicians and patients if treatment cessation is warranted.

Disability and its correlates among persons with bipolar disorder: Exploratory findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

Aim

This study aimed to evaluate the disability and its correlates in persons with Bipolar Disorder during the remission phase.

Materials and Methods

As part of the multicentric study, 773 patients with bipolar disorder, currently in clinical remission, were evaluated for disability on the Indian Disability Assessment Evaluation Scale.

Results

About one-fifth of the participants had some level of disability in the domain of self-care, one-third had some level of disability in the interpersonal domain, one-fourth had some level of disability in communication and understanding, and a maximum proportion (43.7%) had some disability in the domain of work. Overall, about one-fifth (18.4%) were considered to have a benchmark disability (i.e., disability >40%). In terms of correlates, those with a disability had a short duration of current remission, a higher number of manic and mixed episodes, a higher mean number of total episodes, spent more time in the episodes, had lower severity of the depressive episodes, higher residual depressive and manic symptoms, had overall higher manic affective morbidity, had a higher level of cognitive deficits, and had poorer insight.

Conclusion

A significant proportion of patients with bipolar disorder have disability in work domain, and the presence of residual symptoms of either polarity are associated with higher level of disability.

Association of current and remitted bipolar disorders with health-related quality of life: Findings from a nationally representative sample in the US

BACKGROUND

The associations of current and remitted bipolar disorder (BD) with health-related quality of life (HRQOL) have been under-studied, and we aim to address these gaps.

METHODS

The 2012-2013 National Epidemiological Survey on Alcohol and Related Conditions III (NESARC III) surveyed a nationally representative sample of non-institutionalized adults in the US. Using DSM-5 criteria, three groups were operationalized as: 1) adults who met criteria for BD in the past year (i.e., current BD; n = 566 unweighted); and 2) adults who met criteria for BD previously but not in the past year (i.e., BD in remission; n = 187); and 3) adults with no BD in their lifetime (n = 35,556). HRQOL and quality-adjusted life years (QALYs) were compared by these groups. Multivariable-adjusted regression analyses were used to adjust for and examine the role of covariates.

RESULTS

Overall, 1.5 % of the study sample, representing 3.6 million adults nationwide, met criteria for current BD, and 0.5 %, representing 1.3 million adults, met criteria for BD in remission. Adults with current BD and BD in remission had lower mental HRQOL and QALYs, as compared to adults who never had BD. However, these differences were no longer significant when adjusted for behavioral co-morbidities (e.g., psychiatric and substance use disorders).

CONCLUSION

Both current BD and BD in remission were adversely associated with HRQOL and QALYs, while these associations were not independent of behavioral co-morbidities. Because behavioral co-morbidities are common in individuals with current BD or those with BD in remission, they should be treated together to improve HRQOL.

Real-World Functioning in Psychiatric Outpatients: Predictive Factors

INTRODUCTION

Investigations on predictors of real-world functioning were mainly performed in patients with schizophrenia, while fewer studies have been conducted in other psychiatric disorders.

OBJECTIVE

Our objective was to identify clinical, socio-demographic, and illness-related predictors of real-world functioning during 12 months of standard treatments in outpatients with different diagnoses.

METHODS

Outpatients (n = 1019) with schizophrenia (SZ), major depressive disorder (MDD), bipolar disorder (BD), and borderline personality disorder (BPD) were evaluated with the following tools: SCID-5-CV and SCID-5-PD, CGI-S, SAT-P, DAI-10, and PSP. Change of PSP (ΔPSP) between baseline and 12 months was used as the dependent variable in multiple regression analysis.

RESULTS

Higher PSP score at baseline and the achievement of main milestones predicted better functioning after follow-up in all subgroups of patients, with the exception of BD. In the total sample, ΔPSP was related to age of onset, treatments, and quality of life, and inversely related to psychiatric anamnesis, antidepressants, and global symptoms. In SZ, ΔPSP was related to adherence and quality of life. In MDD, ΔPSP was related to psychotherapy and quality of life, and inversely related to antidepressants and global symptoms. In BD, ΔPSP was related to age of onset, antipsychotics, and quality of life, while it was inversely related to psychiatric anamnesis. In BPD, antipsychotics, mood stabilizers, psychotherapy, and quality of life were directly related to ΔPSP, while suicidal attempts and global symptoms had an inverse relation. Conclusions: Several socio-demographic and illness-related variables predicted improvement of real-world functioning, besides psychopathology and severity of the disease.

Long-term work disability due to type I and II bipolar disorder: findings of a six-year prospective study

Background

Bipolar disorder (BD) is one of the leading causes of disability worldwide. However, the prevalence and predictors of long-term work disability among patients with type I and II BD have scarcely been studied. We investigated the clinical predictors of long-term work disability among patients with BD.

Methods

The Jorvi Bipolar Study (JoBS) is a naturalistic prospective cohort study (n = 191) of adult psychiatric in- and out-patients with DSM-IV type I and II BD in three Finnish cities. Within JoBS we examined the prevalence and predictors of disability pension being granted during a six-year follow-up of the 152 patients in the labor force at baseline and collected information on granted pensions from national registers. We determined the predictors of disability pension using logistic regression models.

Results

Over the 6 years, 44% of the patients belonging to the labor force at baseline were granted a disability pension. Older age; type I BD; comorbidity with generalized anxiety disorder, post-traumatic stress disorder or avoidant personality disorder; and duration of time with depressive or mixed symptoms predicted disability pensions. Including disability pensions granted before baseline increased their total prevalence to 55.5%. The observed predictors were similar.

Conclusion

This regionally representative long-term prospective study found that about half of patients with type I or II bipolar disorder suffer from persistent work disability that leads to disability pension. In addition to the severity of the clinical course and type I bipolar disorder, the longitudinal accumulation of time depressed, psychiatric comorbidity, and older age predicted pensioning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00264-6.

Not in education, employment and training status in the early stages of bipolar I disorder with psychotic features

OBJECTIVE

There is a lack of existing research regarding young people with bipolar I disorder (BD-I) and psychotic features, who are not in education, employment, and training (NEET). Thus, the aims of the study were to: (a) establish rates of NEET at service entry to a specialist early intervention service; (b) delineate premorbid and current variables associated with NEET status at service entry and (c) examine correlates of NEET status at discharge.

METHOD

Medical file audit methodology was utilized to collect information on 118 patients with first episode psychotic mania treated at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia. NEET status was determined using the modified vocation status index (MVCI). Bivariate and multivariable logistic variables were used to examine relationships between premorbid, service entry and treatment variables, and NEET status at service entry and discharge.

RESULTS

The NEET rate was 33.9% at service entry, and 39.2% at discharge. Variables associated with NEET status at service entry were premorbid functioning and polysubstance use. NEET status at service entry was the only significant correlate of NEET status at discharge. When service entry NEET was taken out of the model, substance use during treatment was predictive of NEET status at discharge.

CONCLUSIONS

NEET status at service entry was related to a history of premorbid decline, and risk factors such as substance use and forensic issues. NEET status can decline during treatment, and utility of vocational intervention programs specifically for BD, in addition to specialist early intervention, needs to be examined.

The relations between executive functions and occupational functioning in individuals with bipolar disorder: a scoping review

Background

Patients with bipolar disorder experience impairments in their occupational functioning, despite remission of symptoms. Previous research has shown that neurocognitive deficits, especially deficits in executive functions, may persist during euthymia and are associated with diminished occupational functioning.

Objectives

The aim of this scoping review was to identify published studies that report on the relationships between executive functions and occupational functioning in BD to review current knowledge and identify knowledge gaps. In addition to traditional neuropsychological approaches, we aimed to describe executive functioning from a self-regulation perspective, including emotion regulation.

Methods

We applied the methodological framework as described by Arksey and O’Malley (Int J Soc Res Methodol Theory Pract 8:19–32, 2005) and Levac et al. (Implement Sci 5:1–9, 2010). We searched PubMed and psycINFO for literature up to November 2021, after which we screened papers based on inclusion criteria. Two reviewers independently performed the screening process, data charting process, and synthesis of results.

Results

The search yielded 1202 references after deduplication, of which 222 remained after initial screening. The screening and inclusion process yielded 82 eligible papers in which relationships between executive functions and occupational functioning are examined.

Conclusion

Neurocognitive deficits, including in executive functions and self-regulation, are associated with and predictive of diminished occupational functioning. Definitions and measurements for neurocognitive functions and occupational functioning differ greatly between studies, which complicates comparisons. Studies on functional remediation show promising results for improving occupational functioning in patients with BD. In research and clinical practice more attention is needed towards the quality of work functioning and the various contexts in which patients with BD experience deficits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00255-7.

Patient-centric characterization of multimorbidity trajectories in patients with severe mental illnesses: A temporal bipartite network modeling approach

Multimorbidity is a major factor contributing to increased mortality among people with severe mental illnesses (SMI). Previous studies either focus on estimating prevalence of a disease in a population without considering relationships between diseases or ignore heterogeneity of individual patients in examining disease progression by looking merely at aggregates across a whole cohort. Here, we present a temporal bipartite network model to jointly represent detailed information on both individual patients and diseases, which allows us to systematically characterize disease trajectories from both patient and disease centric perspectives. We apply this approach to a large set of longitudinal diagnostic records for patients with SMI collected through a data linkage between electronic health records from a large UK mental health hospital and English national hospital administrative database. We find that the resulting diagnosis networks show disassortative mixing by degree, suggesting that patients affected by a small number of diseases tend to suffer from prevalent diseases. Factors that determine the network structures include an individual's age, gender and ethnicity. Our analysis on network evolution further shows that patients and diseases become more interconnected over the illness duration of SMI, which is largely driven by the process that patients with similar attributes tend to suffer from the same conditions. Our analytic approach provides a guide for future patient-centric research on multimorbidity trajectories and contributes to achieving precision medicine.

Decreasing rate of inpatient pediatric bipolar disorder diagnosis in the US between 2004 and 2010

OBJECTIVES

Diagnosis of bipolar disorder (BD) increased substantially among youth between the mid-1990s and mid-2000s in the United States. This dramatic increase in diagnosis resulted in concern regarding the potential for misdiagnosis of BD among youth. However, the rate of BD diagnosis in the United States had not been evaluated nationally since the mid-2000s. It was unclear whether changes in diagnostic rates continued to occur. Therefore, the present study aimed to assess the pattern of longitudinal trends in the rate of national inpatient BD diagnosis subsequent to 2004.

METHODS

Data included a nationally representative dataset of inpatient hospitalizations between 1996 and 2010. De-identified data were obtained from the National Hospital Discharge Survey (NHDS) conducted annually by the National Center for Health Statistics.

RESULTS

The proportion of BD diagnoses relative to all psychiatric diagnoses increased between 1996 and 2004 among children and adolescents. The proportion of BD diagnoses then decreased between 2004 and 2010 among children but continued to increase for adolescents. However, population-adjusted rates of BD diagnosis per 10,000 individuals in the general population initially increased until the mid-2000s and then decreased until 2010 for both children and adolescents.

CONCLUSIONS

Rates of BD diagnosis substantially decreased for youth between the mid-2000s and 2010. This decline coincided with recommendations for more conservative diagnostic practices due to concerns about overdiagnosis and increasing awareness of the side effects of front-line medications used to treat BD in youth. Findings provide insight into changing trends in inpatient service utilization for BD in the United States.

Impact of bipolar disorder on health-related quality of life and work productivity: Estimates from the national health and wellness survey in Japan

BACKGROUND

Previous studies have shown that bipolar disorder (BD) patients frequently present with difficulties in interpersonal relationships, education or employment and suffer poorer quality of life. This study aimed to estimate the impact of BD on health-related quality of life (HRQOL), work productivity loss and indirect costs.

METHODS

Data was from the online, self-administered 2019 National Health and Wellness Survey. Outcomes were compared for those who self-reported a physician diagnosis of BD (N=179), major depressive disorder (MDD, N=1,549) and controls who have never experienced BD, MDD and schizophrenia (N=27,485).

RESULTS

The lifetime prevalence was estimated to be 0.60% for BD and 5.16% for MDD. Significantly lower Mental Component Summary (MCS), Role Component Summary (RCS) scores and EuroQol 5-dimension scale (EQ-5D-5L) summary index and significantly higher presenteeism, total work productivity impairment and activity impairment assessed by Work Productivity and Activity Impairment questionnaire and indirect costs for BD versus controls and BD PHQ-9≥10 versus PHQ-9<10 were observed. Compared to MDD patients, BD patients had significantly lower RCS score and greater work productivity loss and activity impairment. The national morbidity cost of BD in Japan was estimated to be Japanese yen 1,236 billion using a human-capital approach.

LIMITATIONS

The data used were self-reported and is cross-sectional in nature, thus causal relationship cannot be assumed.

CONCLUSION

BD patients and those with severe depressive symptoms experience significantly poorer HRQOL and greater work productivity loss and indirect costs. These findings highlight the importance of proper screening, diagnosis and treatment of BD and bipolar depression.

Understanding the Barriers and Facilitators to Employment for People with Bipolar Disorder

People with Bipolar Disorder (BD) consistently report a desire for employment; however, this is not reflected in employment figures. Individuals' perceptions of barriers to employment, along with endorsement of facilitators to employment remain under-investigated. We aimed to address this limitation by: (i) first examining differences in employed versus unemployed individuals (demographic, clinical, functioning); then (ii) identifying barriers and/or facilitators to employment, perception of same, and subsequent impact on employment. We assessed demographics, functioning, and illness-related characteristics in 35 participants with BD (19 employed, 16 unemployed). Participants were asked to indicate perception of common barriers and facilitators to employment. Groups did not differ regarding demographic or clinical variables. High levels of absenteeism, termination of last role and commonly perceived barriers were attributed to mental ill-health. 93.3% of unemployed participants reportedly desired employment, and more perceived barriers were observed in the unemployed group. Identified facilitators included increased support and flexible work strategies. A comprehensive understanding of perceptions of limiting and helpful factors related to employment for people with BD was obtained. These findings have implications for service provision, encouraging targeted discussion, and tailored treatment approaches to individual's unique perceptions of factors related to employment.

Impulsivity and sleep and circadian rhythm disturbance predict next-day mood symptoms in a sample at high risk for or with recent-onset bipolar spectrum disorder: An ecological momentary assessment study

BACKGROUND

Impulsivity and sleep and circadian rhythm disturbance are core features of bipolar spectrum disorders (BSDs) that are antecedents to onset and persist even between mood episodes; their pervasive presence in BSD suggests that they may be particularly relevant to understanding BSD onset and course. Considerable research demonstrates bidirectional associations between impulsivity and sleep disturbance in healthy individuals; thus, it is important to examine how these features interact to impact BSD symptomatology.

METHODS

Young adults (N = 107, 55% female, M age = 21.82 years) at high risk for developing BSD (based on high self-reported reward sensitivity) or with recent-onset BSD participated in ecological momentary assessment (EMA) to examine relationships between impulsivity, sleep and circadian rhythm alterations, and mood symptoms in everyday life. Impulsivity was measured via self-report/behavioral task, sleep was measured via actigraphy, circadian rhythms were measured via dim light melatonin onset (DLMO) time, and mood symptoms were measured three times daily via self-report.

RESULTS

Multi-level modeling revealed that less total sleep time predicted increased next-day mood symptoms. Moreover, DLMO, total sleep time, and sleep onset latency moderated the relationship between impulsivity and EMA-assessed mood symptoms. Fewer minutes of sleep and later DLMO strengthened the positive relationship between impulsivity and mood symptoms.

LIMITATIONS

Mood symptoms in our sample were mild; future studies should replicate findings in populations with more severe mood symptoms.

CONCLUSIONS

This multi-method assessment of dynamic relationships revealed novel associations between impulsivity, sleep and circadian rhythm disturbance, and symptoms within individuals at high-risk for or with recent-onset BSD.

Lurasidone in the long-term treatment of Japanese patients with bipolar I disorder: a 52 week open label study

BACKGROUND

The current study evaluated the long-term (52 week) safety and impact on symptom measures of lurasidone (with or without lithium or valproate) for the treatment of bipolar I disorder in Japanese patients.

METHODS

Bipolar patients for this open-label flexibly dosed lurasidone (20-120 mg/day) study were recruited from those with a recent/current depressive episode who completed an initial 6 week, double-blind, placebo-controlled, lurasidone study (depressed group), and those with a recent/current manic, hypomanic, or mixed episode (non-depressed group) who agreed to enroll directly into the long-term study. Measures of adverse events and safety included treatment-emergent adverse events, vital signs, body weight, ECG, laboratory tests, and measures of suicidality and extrapyramidal symptoms. Symptom measures included Montgomery Åsberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS).

RESULTS

The most common adverse events associated with lurasidone were akathisia (30.7%), nasopharyngitis (26.6%), nausea (12.1%), and somnolence (12.1%). Minimal changes in lipids and measures of glycemic control occurred. Mean change in body weight was + 1.0 kg in the non-depressed group and - 0.8 kg in the depressed group. MADRS total scores declined by a mean (SD) of 2.0 (14.7) points from long-term baseline to endpoint in the depressed group who had received placebo in the prior 6 week trial. The depressed group that had received lurasidone during the prior 6 week study maintained their depressive symptom improvements. For the non-depressed group, YMRS total scores decreased over time.

LIMITATIONS

No control group was included, treatment was open-label, and 49.7% of patients completed the 52 week study.

CONCLUSIONS

Long-term treatment with lurasidone 20-120 mg/day for Japanese patients with bipolar disorder maintained improvements in depressive symptoms for depressed patients who were treated in a prior 6 week trial and led to improvements in manic symptoms among a newly recruited subgroup of patients with a recent/current manic, hypomanic, or mixed episode. Few changes in weight or metabolic parameters were evident.

CLINICAL TRIAL REGISTRATION

JapicCTI-132319, clinicaltrials.gov-NCT01986114.

Help-Seeking Patterns Among the General Population in Singapore: Results from the Singapore Mental Health Study 2016

This study aimed to establish lifetime mental health service utilisation among the general population of Singapore. The sociodemographic correlates of those seeking help from different service provider groups and changes in lifetime mental health service utilisation between 2010 and 2016 among those with mental disorders were also explored. A population-based cross-sectional epidemiological household survey of the Singapore resident population aged 18 years and above was conducted from 2016 to 2018, using the World Mental Health Composite International Diagnostic Interview (CIDI) version 3.0. Data from two cross-sectional population-based studies were used for comparison of lifetime mental health service utilisation in 2010 (n = 6616) and 2016 (n = 6126). Chi square test and multiple logistic regression were used to analyse the data. A total of 6126 respondents completed the study in 2016. Overall 9.3% of the total sample, 32.0% of those with mental disorders, and 5.7% of those not meeting criteria for mental disorders, ever sought help for their mental health issues in their lifetime, from any treatment service sectors. Several sociodemographic characteristics were found to be correlated with different service provider groups. There was no change in mental health service utilisation between 2010 and 2016 for all mental disorders included in this study, with the exception of a significant increase in help sought from professionals in social services, among those with alcohol abuse. Even though the overall help-seeking rates are low, it is encouraging that those seeking help did so from mental health professionals and professionals working in the social services.

Association Between Medicaid Prescription Drug Limits and Access to Medications and Health Care Use Among Young Adults With Disabilities

Question

Are policies that cap monthly prescriptions in Medicaid associated with access to medication and health care use among young adults with disabilities in Arkansas and Texas?

Findings

In this cohort study using difference-in-differences analysis of 28 046 young adults with disabilities, including 8214 in states with a 3-drug limit at age 21 years, the 3-drug limit was associated with lower monthly prescriptions for medications used to treat mental health conditions and higher inpatient admissions among all individuals with disabilities in states with the drug cap policy compared with those in states without this policy.

Meaning

In this study, state drug cap policies in Medicaid were associated with lower access to medications and higher use of inpatient care.

Importance

Prescription drugs are necessary for managing complex physical and mental health conditions for more than 10 million Medicaid beneficiaries with disabilities. However, some state Medicaid programs limit the number of prescription drugs that beneficiaries can obtain monthly, which may decrease access to essential medications.

Objective

To examine the association between exposure to the 3-drug limit at age 21 years in Arkansas and Texas and prescription drug and health care use among beneficiaries with disabilities enrolled in Medicaid.

Design, Setting, and Participants

In this cohort study of 28 046 young adults with disabilities, difference-in-differences analysis was performed using Medicaid Analytic eXtract claims data from January 1, 2007, to December 31, 2012. Analyses were completed December 1, 2020. The analyses included Medicaid beneficiaries with disabilities in Arkansas and Texas (ie, drug cap states) or 15 comparison states without drug cap policies who became age 21 years during the study period and were continuously enrolled in fee-for-service Medicaid in the year before and after that point.

Exposures

Exposure to the 3-drug prescription limit at age 21 years in 2 drug cap states.

Main Outcomes and Measures

Monthly total prescriptions and prescriptions for drugs to treat mental health conditions, total prescription drug spending, and inpatient and emergency department visits and spending in the 12 months before and after becoming age 21 years.

Results

Among 28 046 young adults with disabilities, 8214 (29.3%) resided in drug cap states and were subject to the 3-drug limit at age 21 years. Most individuals were male (drug cap states: 61.4%, comparison states: 60.6%), and the minority were White individuals (drug cap states: 36.7%, comparison states: 49.4%). More than one-half of individuals with disabilities were diagnosed with a mental health condition before age 21 years (drug cap states: 57.0%, comparison states: 60.0%). In the year before the analyzed individuals became aged 21 years, the mean (SD) number of prescriptions per beneficiary per month was 1.58 (2.16) in drug cap states vs 1.82 (1.91) in comparison states. The drug cap policy was associated with 19.6% (95% CI, −21.3% to −17.8%; P < .001) fewer monthly prescriptions and 16.5% (95% CI, −21.9% to −10.8%; P < .001) fewer prescriptions for drugs for mental health conditions but was not associated with total prescription drug spending. The drug cap policy was associated with 13.6% (95% CI, 1.9% to 26.6%; P = .02) more inpatient admissions.

Conclusions and Relevance

In this cohort study of young adults with disabilities, drug cap policies were associated with lower rates of access to important medications and higher rates of hospitalization among individuals in states with drug cap policies vs those without these policies.

Cognitive impairment and consumption of mental healthcare resources in outpatients with bipolar disorder

Cognitive dysfunction is a major predictor of functional outcomes, and loss of occupational functioning is usually linked with a higher cost of illness. However, the association between cognitive impairment and consumption of health resources has not been studied in bipolar disorder to date. This study aims to examine this relationship. This is an observational, retrospective study of a representative sample of euthymic outpatients between 18 and 55 years, fulfilling DSM 5 criteria for bipolar disorder and recruited at a catchment area in Spain. Cognitive performance was screened with the Spanish version of the Screen for Cognitive Impairment in Psychiatry (SCIP-S), and several variables of health resources consumption during the previous year were registered. A total of 72 patients were assessed. Cognitive impairment according to the SCIP-S was significantly associated with the number of scheduled clinical appointments (p < 0.005) and hospital admissions (p < 0.04) but not with other health resources consumption variables. These results need to be interpreted with caution given that neither a control group nor a comprehensive, objective neuropsychological battery were used. However, despite these limitations, this study shows that in euthymic outpatients with bipolar disorder, those with suspected cognitive impairment had consumed a higher number of health resources over the previous year. These preliminary results may foster similar studies on the relationship between mental healthcare resource use and cognitive dysfunction in bipolar disorder and other psychiatric disorders.

A Real-World Study of the Association between a Brief Group Psychoeducation and the Course of Bipolar Disorder

Although pharmacotherapy is considered the first-line treatment for bipolar disorders (BD), adjunctive psychoeducation has proven its effectiveness in improving self-management of the disease and reducing relapse rates. Few studies have evaluated the effect of brief group psychoeducation on pragmatic variables, such as the number of hospitalizations. The aim of the present study was to assess the mid-term effect of a four-session group psychoeducation on course-related variables in BD. Thirty-two individuals with BD were included in the study. Sixteen were exposed to psychoeducation and were matched to sixteen nonexposed individuals who received their usual treatment. Both groups were compared on insight, treatment adherence, change in the number of hospitalizations and visits to the emergency services, occurrence rate after intervention, and time to the first psychiatric hospitalization and the first urgent attendance. There was a significant reduction in the mean number of hospitalizations and urgent attendances in the exposed group in comparison to the nonexposed group. The first urgent attendance was significantly sooner in the nonexposed cohort. There were no differences between groups in any of the other variables. This intervention has shown benefits for pragmatic variables of the disease course and may be a feasible and cost-effective intervention to routinely implement in the management of BD.

Comparison of Cerebellar Grey Matter Alterations in Bipolar and Cerebellar Patients: Evidence from Voxel-Based Analysis

The aim of this study was to compare the patterns of cerebellar alterations associated with bipolar disease with those induced by the presence of cerebellar neurodegenerative pathologies to clarify the potential cerebellar contribution to bipolar affective disturbance. Twenty-nine patients affected by bipolar disorder, 32 subjects affected by cerebellar neurodegenerative pathologies, and 37 age-matched healthy subjects underwent a 3T MRI protocol. A voxel-based morphometry analysis was used to show similarities and differences in cerebellar grey matter (GM) loss between the groups. We found a pattern of GM cerebellar alterations in both bipolar and cerebellar groups that involved the anterior and posterior cerebellar regions (p = 0.05). The direct comparison between bipolar and cerebellar patients demonstrated a significant difference in GM loss in cerebellar neurodegenerative patients in the bilateral anterior and posterior motor cerebellar regions, such as lobules I-IV, V, VI, VIIIa, VIIIb, IX, VIIb and vermis VI, while a pattern of overlapping GM loss was evident in right lobule V, right crus I and bilateral crus II. Our findings showed, for the first time, common and different alteration patterns of specific cerebellar lobules in bipolar and neurodegenerative cerebellar patients, which allowed us to hypothesize a cerebellar role in the cognitive and mood dysregulation symptoms that characterize bipolar disorder.

Lurasidone in the Long-Term Treatment of Bipolar I Depression: A 28-week Open Label Extension Study

BACKGROUND

Lurasidone has demonstrated efficacy for short-term treatment of bipolar depression in a diverse ethnic population including Japanese. This study evaluated the long-term safety and effectiveness of open-label lurasidone treatment in these patients.

METHODS

Patients for this 28-week extension study were recruited from those who completed a 6-week double-blind study of lurasidone, 20-60 mg/day, lurasidone 80-120 mg/day, and placebo. In the extension study, lurasidone was flexibly dosed (20 to 120 mg/day). Safety was evaluated in terms of change from extension-phase baseline to endpoint including adverse events, vital signs, body weight, ECG, laboratory tests, and measures of suicidality and extrapyramidal symptoms. Effectiveness was determined by Montgomery Åsberg Depression Rating Scale (MADRS) and other measures.

RESULTS

303 of 413 (73.3%) subjects completed the extension study. Discontinuation due to a treatment-emergent adverse event occurred for 11.4% of those who received placebo, and 8.9% of those who received lurasidone, in the prior 6-week trial. The most common treatment-emergent adverse event was akathisia. Minimal changes were evident on body weight and metabolic parameters. Long-term treatment with lurasidone further reduced mean MADRS total scores from long-term baseline to week 28 (or endpoint) for both those who had received prior placebo (-11.3), and those who had receive prior lurasidone (-8.9), in the 6-week double-blind trial.

LIMITATIONS

There was no placebo control and treatment was not double-blind.

CONCLUSIONS

Long-term treatment with lurasidone (20-120 mg/day) was well-tolerated with no new safety concerns and associated with continued improvement in depressive symptoms in this international sample of patients with bipolar depression.

CLINICAL TRIAL REGISTRATION

JapicCTI-132319, clinicaltrials.gov - NCT01986114.

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.

The Quality of Life in Bipolar Disorder (QoL.BD) questionnaire a decade on - A systematic review of the measurement of condition-specific aspects of quality of life in bipolar-disorder

BACKGROUND

Condition-specific quality of life (QoL) instruments are more representative of the priorities of people with lived experience. As such, the development of the first and only bipolar disorder (BD) specific measurement instrument, the Quality of Life in Bipolar Disorder (QoL.BD) questionnaire, marked an important step forward for the literature. The present systematic review aims to characterise applications of the QoL.BD in the BD literature and review empirical findings obtained from studies using this measure.

METHODS

A systematic search identified 37 peer-reviewed publications which reported original empirical data using the QoL.BD in a BD population. No restrictions were placed on language/study type.

RESULTS

Adaptations to the QoL.BD displayed appropriate psychometric properties. Although clinical trials were typically underpowered, promising effect sizes for a number of treatment modalities were reported. QoL.BD scores were moderately correlated with depressive symptoms; a number of candidate predictors were identified.

LIMITATIONS

Due to resource limitations, the present review used one database (Google Scholar), and a single author reviewed articles for eligibility. On balance the risks of missing relevant studies were deemed minimal.

CONCLUSION

A sizeable, international body of evidence now exists regarding the measurement, presentation, and treatment of condition-specific aspects of QoL in BD. Key avenues for future research include large scale, randomized control clinical trials using the QoL.BD as a primary outcome, and granular exploration of potential correlates of QoL.BD domain scores. Finally, longer follow-up periods are required to inform understanding of the dynamic relationship between clinical variables and condition-specific aspects of QoL in BD.

Double-blind, placebo-controlled study of lurasidone monotherapy for the treatment of bipolar I depression

AIM

Previous studies conducted primarily in the USA and Europe have demonstrated the efficacy and safety of lurasidone 20-120 mg/day for the treatment of bipolar I depression. The aim of the current study was to evaluate the efficacy and safety of lurasidone monotherapy for the treatment of bipolar I depression among patients from diverse ethnic backgrounds, including those from Japan.

METHODS

Patients were randomly assigned to double-blind treatment for 6 weeks with lurasidone, 20-60 mg/day (n = 184) or 80-120 mg/day (n = 169), or placebo (n = 172). The primary end-point was change from baseline to Week 6 on the Montgomery-Åsberg Depression Rating Scale (MADRS).

RESULTS

Lurasidone treatment significantly reduced mean MADRS total scores from baseline to Week 6 for the 20-60-mg/day group (-13.6; adjusted P = 0.007; effect size = 0.33), but not for the 80-120-mg/day group (-12.6; adjusted P = 0.057; effect size = 0.22) compared with placebo (-10.6). Treatment with lurasidone 20-60 mg/day also improved MADRS response rates, functional impairment, and anxiety symptoms. The most common adverse events associated with lurasidone were akathisia and nausea. Lurasidone treatments were associated with minimal changes in weight, lipids, and measures of glycemic control.

CONCLUSION

Monotherapy with once daily doses of lurasidone 20-60 mg, but not 80-120 mg, significantly reduced depressive symptoms and improved functioning in patients with bipolar I depression. Results overall were consistent with previous studies, suggesting that lurasidone 20-60 mg/day is effective and safe in diverse ethnic populations, including Japanese.

The impact of a new affective episode on psychosocial functioning, quality of life and perceived stress in newly diagnosed patients with bipolar disorder: A prospective one-year case-control study

BACKGROUND

Bipolar disorder (BD) has been associated with impaired functioning during periods of euthymia. This prospective one-year case-control study investigated the impact of a new affective episode on psychosocial functioning, quality of life (QoL) and perceived stress in newly diagnosed patients with BD in euthymia.

METHODS

Clinically evaluated psychosocial functioning (Functioning Assessment Short Test, FAST), self-reported QoL (WHOQoL-BREF scale) and stress (Cohens' Perceived Stress Scale) were collected from 87 patients with BD with (BD-E) (n=38) and without (BD-NE) (n=44) clinical relapse and 44 age and gender matched healthy control (HC) individuals at baseline (T0), following an episode if it occurred (T2) and at one-year follow-up (T3).

RESULTS

Patients with BD presented with poorer functioning compared to HC individuals at T0 and T3. There was no statistically significantly difference in the changes in FAST (-1.2, adjusted-p=0.82), PSS (0.34, adjusted-p=0.93) or WHOQoL (-0.67, adjusted-p=0.93) between BD-E and BD-NE during the one-year follow-up. The subgroup BD-E had statistically significantly higher FAST and stress scores and lower WHOQoL-scores compared to BD-NE at both T0 and T3.

LIMITATIONS

Modest sample size.

CONCLUSION

Functioning is impaired in newly diagnosed patients with BD in a euthymic state, however, a new affective episode does not affect functioning during subsequent euthymia at one-year follow-up. Patients with BD-E presented with overall most impaired functioning, highlighting the importance of early intervention strategies as essential to identify and treat patients at high risk of relapse and poor outcome.

Expanding the search for emerging mental ill health to safeguard student potential and vocational success in high school: A narrative review

AIM

Young people experiencing mental ill health are more likely than their healthy aged peers to drop out of high school. This can result in social exclusion and vocational derailment. Identifying young people at risk and taking action before an illness is established or school dropout occurs is an important goal. This study aimed to examine evidence for the risk markers and at risk mental states of the clinical staging model (stage 0-1b) and whether these risk states and early symptoms impact school participation and academic attainment.

METHOD

This narrative review assembles research from both the psychiatry and education literature. It examines stage 0 to stage 1b of the clinical staging model and links the risk states and early symptoms to evidence about the academic success of young people in high school.

RESULTS

In accordance with the clinical staging model and evidence from education literature, childhood trauma and parental mental illness can impact school engagement and academic progress. Sleep disturbance can result in academic failure. Undifferentiated depression and anxiety can increase the risk for school dropout. Subthreshold psychosis and hypomanic states are associated with functional impairment and high rates of Not in Employment, Education, or Training (NEET) but are not recognized in the education literature.

CONCLUSION

Risk markers for emerging mental ill health can be identified in education research and demonstrate an impact on a student's success in high school. Clear referral protocols need to be embedded into school life to reduce risk of progression to later stages of illness and support school participation and success.

Economic evaluations of non-pharmacological interventions and cost-of-illness studies in bipolar disorder: A systematic review

Background Bipolar disorder (BD) is associated with substantial societal burden. Therefore, economic studies in BD are becoming increasingly important. The goal of the current study is three-fold: (1) summarize the evidence regarding economic evaluations (EEs) of non-pharmacological interventions for BD, (2) summarize cost-of-illness studies (COIs) for BD published 2012 or later and (3) assess the quality of the identified studies. Methods A systematic search was conducted in MedLine, EMBASE and PsycINFO. For both EEs and COIs, quality assessments were conducted and general and methodological characteristics of the studies were extracted. Outcomes included incremental-cost-effectiveness ratios for EEs and direct and indirect costs for COIs. Results Eight EEs and ten COIs were identified. The included studies revealed high heterogeneity in general and methodological characteristics and study quality. All interventions resulted in improved clinical outcomes. Five studies additionally concluded decreased total costs. For COIs, we found a wide range of direct ($881-$27,617) and indirect cost estimates per capita per year ($1,568-$116,062). Limitations High heterogeneity in terms of interventions, study design and outcomes made it difficult to compare results across studies. Conclusions Interventions improved clinical outcomes in all studies and led to cost-savings in five studies. Findings suggest that non-pharmacological intervention for BD might be cost-effective. Studies on the costs of BD revealed that BD has a substantial economic burden. However, we also found that the number of EEs was relatively low and methodology was heterogenous and therefore encourage future research to widen the body of knowledge in this research field and use standardized methodology.

Linguistic analysis of autobiographical narratives in unipolar and bipolar mood disorders in light of multiple code theory

BACKGROUND

Discriminating bipolar disorder (BD) from unipolar disorder (UD) is crucial in diagnosing mood disorders. Neurophysiological studies have identified different correlates of emotional regulation in BD and UD. According to the Multiple Code Theory, bodily modifications relate to linguistic styles, as highlighted by studies on the language of depression. Our purpose is to verify the existence in the Italian language of linguistic features of depression differentiating BD from UD to provide tools for clinicians to use beyond self-report measures.

METHODS

The sample included 20 BD, 20 UD (all diagnosed using DSM-5), and 20 Control Group (CG) participants. Participants completed the Profile of Mood States (POMS) and an audio-recorded Relationship Anecdotes Paradigm Interview, transcribed and analyzed by the Discourse Attributes Analysis Program for Referential Process Linguistic Measures.

RESULTS

One-way ANOVAs confirmed that specific linguistic features characterized BD, UD and CG. The use of Sensory-Somatic words was significantly different in the groups: higher in BD, intermediate in UD, and lower in CG. Individuals with BD produced higher scores on the Referential Activity Intensity Index and the use of singular pronoun "I". Negative Affect, as well as several POMS subscales, distinguished UD and BD from CG.

LIMITATIONS

Narrow sample size, use of a single self-report instrument and treatment effects on measures in the clinical groups are limitations of the study.

CONCLUSION

Individuals with UD and BD appear to use sensory-somatic language in predictably different patterns from each other and from the non-clinical population. Observation and assessment of linguistic features could improve diagnostic accuracy.

Association of antipsychotic treatment switching in patients with schizophrenia, bipolar, and major depressive disorders

Aims: To evaluate the association of relapse and healthcare resource utilization in patients with schizophrenia (SZ), bipolar disorder (BD), or major depressive disorder (MDD) who switched antipsychotic medication versus those who did not.Materials and methods: Medicaid claims from six US states spanning six years were retrospectively analyzed for antipsychotic switching versus non-switching. For all patients with SZ, BD, or MDD, and for the subset of patients who also had ≥1 extrapyramidal symptoms (EPS) diagnosis at baseline, times to the following outcomes were analyzed: underlying disease relapse, other psychiatric relapse, all-cause emergency room (ER) visit, all-cause inpatient (IP) admission, and EPS diagnosis.Results: Switchers (N = 10,548) had a shorter time to disease relapse, other psychiatric relapse, IP admissions, ER visits, and EPS diagnosis (all, log-rank p < .001) than non-switchers (N = 31,644). Switchers reached the median for IP admission (21.50 months) vs non-switchers (not reached) and for ER visits (switchers, 9.07 months; non-switchers, 13.35 months). For disease relapse, other psychiatric relapse, and EPS diagnosis, <50% of patients had an event during the two-year study period. Subgroup analysis of those with ≥1 EPS diagnosis revealed similar associations.Limitations: Only association, not causation, may be inferred, and there may be differences between the patient groups in parameters not evaluated.Conclusions: These results show that disease and other psychiatric relapse, all-cause ER visits, IP admissions, and EPS diagnosis occurred earlier for patients who switched antipsychotics than for those who did not, suggesting that switching is associated with an increased risk of relapse in patients with SZ, BD, and MDD. This may be attributed to more-severely ill patients being less responsive than those with less-severe illness, which, in turn, may require more episodes of switching.

Impact of integrated mental health care on food insecurity of households of people with severe mental illness in a rural African district: a community-based, controlled before-after study

OBJECTIVES

To evaluate the impact of integrated mental health care upon food insecurity (FI) in households of people with severe mental illness (SMI) in a rural Ethiopian district, and to investigate mediation by improved work impairment and discrimination.

METHODS

A community-based, controlled before-after study was conducted. People with probable SMI were identified in the community, diagnosed by primary healthcare workers, with diagnostic confirmation from a psychiatric nurse. Households of a person with SMI were matched to control households. District-wide integration of mental health care was implemented. Change in FI status over 12 months of follow-up was measured using the Household Food Insecurity Access Scale. Multivariable models were used to assess improvement in FI. Direct and indirect mediators of change in FI status were modelled using path analysis.

RESULTS

A total of 239 (81.8%) people with SMI and 273 (96.5%) control households were assessed after 12 months. Maintenance of food security or improvement in food insecurity status was observed in 51.5% of households of a person with SMI vs. 39.7% of control households (adjusted risk ratio 1.41: 95% CI 1.11, 1.80). Reduction in symptom severity was indirectly associated with improved FI status via an impact on reducing work impairment and discrimination (P < 0.001).

CONCLUSIONS

Improving access to mental health care may reduce food insecurity in households of people with SMI. Optimising engagement in care and adding interventions to improve work functioning and tackle discrimination may further reduce food insecurity.

Similar and Different Regional Homogeneity Changes Between Bipolar Disorder and Unipolar Depression: A Resting-State fMRI Study

OBJECTIVE

To investigate the regional homogeneity (ReHo) between unipolar depression (UD) and bipolar disorder (BD), and to search for brain imaging markers for distinguishing UD and BD.

METHODS

A total of 58 patients who met the diagnosis criteria of UD in DSM-Ⅳ, 40 patients who met the diagnosis criteria of BD in DSM-Ⅳ and 54 healthy controls (HC) completed the resting-state functional magnetic resonance (rs-fMRI) scans. The ReHo of the three groups was compared and Pearson correlation analysis was performed between the ReHo values and the clinical symptoms.

RESULTS

(1) Significant differences were found in the right hippocampus, right parahippocampal gyrus, right Inferior orbitofrontal gyrus, right superior temporal gyrus, right inferior temporal gyrus, and right middle occipital gyrus across the three groups. (2) Compared to HC, the ReHo in the right parahippocampal gyrus in UD significantly increased. (3) When compared to HC, the ReHo in the right hippocampus in BD significantly increased. The ReHo in the right middle occipital gyrus decreased. (4) Compared to UD, BD exhibited significantly decreased ReHo in the right inferior temporal gyrus. No correlations were observed between the scores of 24-item Hamilton Depression Rating Scale (HDMD-24), Hamilton Anxiety Scale (HAMA), Young Mania Rating Scale (YMRS), and the ReHo values of altered brain regions between BD and UD.

CONCLUSION

The results suggest that there was a considerable difference in the ReHo of brain among UD, BD, and HCs. ReHo in the right inferior temporal gyrus showed significant differences between BD and UD that might serve as neuroimaging markers to identify BD and UD.

FKBP5 Gene Variants May Modulate Depressive Features in Bipolar Disorder

BACKGROUND

Previous evidence suggested the possible association of FK506 binding protein 5 (FKBP5) gene variants in bipolar disorder (BPD).

OBJECTIVE

Given the need of refinement of the findings obtained in large but poorly phenotyped samples, this study investigated the possible role of variants within FKBP5 in a small but deeply phenotyped BPD sample.

METHODS

A sample (N = 131) of bipolar patients were investigated with 10 polymorphisms within the FKBP5 gene. A control sample (N = 65) was also used for the analyses. Treatment response and remission of symptoms were evaluated using of the Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), and Young Mania Rating Scale (YMRS). The same analyses were also performed on the depressive subsample of BPD (D.BPD).

RESULTS

rs3800373 was associated with disorder risk in the depressive BPD subsample with the G allele being more frequent in subjects with a D.BPD phenotype. This was the only association that survived statistical correction.

CONCLUSIONS

rs3800373 FKBP5 may increase the risk of developing predominantly depressed BPD, probably through the creation of an enhancer consensus sequence in the 3'UTR of the gene, thus potentially increasing its expression. This finding seems to be partially supported by literature data, which evidenced increased levels of FKBP5 in psychiatric subjects.

Assessment of the Functioning Levels and Related Factors in Patients with Bipolar Disorder during Remission

Introduction

The course of bipolar disorder (BD) is characterized by relapse and remission periods. Although the symptoms show a significant and sometimes almost complete improvement during remission, the patients' functioning levels may be lower compared to the premorbid period. This study aimed to compare the functional levels between patients with BD during remission period and healthy controls and to evaluate the factors related to the functional status of the patients.

Methods

In this cross-sectional study, functioning levels of the BD-I patients, who were in remission for three months or longer, were compared with those of the healthy controls. Young Mania Rating Scale and Hamilton Depression Rating Scale were used to determine remission status, and Bipolar Disorder Functioning Questionnaire (BDFQ) was used to determine the level of functioning.

Results

The study included 165 BD-I patients during remission and 63 healthy controls. The BDFQ scores of the patients including intellectual functioning, sexual functioning, feeling of stigmatization, introversion, relationships with friends, participation in social activities, daily activities and hobbies, and taking initiative were found to be statistically significantly lower than those of the controls. When the functioning comparisons were carried out within the patients considering the drugs they were using, the functioning levels including domestic functioning and introversion domains were found to be significantly impaired in those who use at least one antipsychotic in addition to the mood stabilizers than in those who use only mood stabilizers.

Conclusion

In BD, the impairments within multiple functioning domains are observed even during remission periods. Besides targeting remission through pharmacological treatment, psychosocial interventions for functioning are also important in the treatment of these patients.

Psychometric properties and utility of the Responses to Positive Affect questionnaire (RPA) in a sample of people with bipolar disorder

Objectives

To evaluate the psychometric properties of the Responses to Positive Affect (RPA) questionnaire in a sample of persons with bipolar disorder (BD).

Method

Cross‐sectional survey study with 107 persons with BD. The original 3‐factor model of the RPA was compared with a 2‐factor model. Construct validity was determined with measures of well‐being, personal recovery, social role participation, and psychopathology and incremental validity was evaluated.

Results

The fit of the 3‐factor model was acceptable for most fit indices. Subscores of the RPA revealed a significant relationship with aspects of well‐being, personal recovery, and psychopathology. Dampening and self‐focused positive rumination explained additional variance in personal recovery above and beyond well‐being.

Conclusions

The RPA is an internally consistent and valid tool to assess positive emotion regulation processes in persons with BD. Specifically, the processes of dampening and emotion‐focused positive rumination seem to play an important role in BD.

Measuring personal recovery in people with bipolar disorder and exploring its relationship with well‐being and social role participation

The relevance of personal recovery receives increasing attention in mental health care and is also important for people with bipolar disorder (BD). There is a need for reliable and valid instruments measuring personal recovery. Therefore, the current study evaluated the psychometric properties of a Dutch translation of the Questionnaire about the Process of Recovery (QPR) in a sample of people with BD and explored the relationship with constructs of well‐being, social role participation, and psychopathology. A cross‐sectional survey study was conducted in which 102 people diagnosed with BD completed the QPR. Factor structure of the QPR was evaluated by conducting confirmatory factor analyses (CFA), and internal consistency was assessed by calculating reliability coefficients. Convergent validation measures assessed well‐being, social role participation, and symptomatology. Incremental validity was determined by evaluating the ability of the QPR to explain variance in symptomatology above and beyond well‐being. Findings of the CFA supported a unidimensional factor structure, and internal consistency estimates were excellent. Scores of the QPR showed strong correlations with convergent measures, but were only weakly associated with manic symptomatology. Moreover, personal recovery explained additional variance in symptoms of depression and anxiety above and beyond well‐being, indicating incremental validity. The QPR appears to be a reliable and valid tool to assess personal recovery in people with BD. Our findings underline the importance of personal recovery in the context of treatment of BD. Personal recovery demonstrates a substantial overlap with well‐being.

Differentiating between bipolar and unipolar depression in functional and structural MRI studies

Distinguishing depression in bipolar disorder (BD) from unipolar depression (UD) solely based on clinical clues is difficult, which has led to the exploration of promising neural markers in neuroimaging measures for discriminating between BD depression and UD. In this article, we review structural and functional magnetic resonance imaging (MRI) studies that directly compare UD and BD depression based on neuroimaging modalities including functional MRI studies on regional brain activation or functional connectivity, structural MRI on gray or white matter morphology, and pattern classification analyses using a machine learning approach. Numerous studies have reported distinct functional and structural alterations in emotion- or reward-processing neural circuits between BD depression and UD. Different activation patterns in neural networks including the amygdala, anterior cingulate cortex (ACC), prefrontal cortex (PFC), and striatum during emotion-, reward-, or cognition-related tasks have been reported between BD and UD. A stronger functional connectivity pattern in BD was pronounced in default mode and in frontoparietal networks and brain regions including the PFC, ACC, parietal and temporal regions, and thalamus compared to UD. Gray matter volume differences in the ACC, hippocampus, amygdala, and dorsolateral prefrontal cortex (DLPFC) have been reported between BD and UD, along with a thinner DLPFC in BD compared to UD. BD showed reduced integrity in the anterior part of the corpus callosum and posterior cingulum compared to UD. Several studies performed pattern classification analysis using structural and functional MRI data to distinguish between UD and BD depression using a supervised machine learning approach, which yielded a moderate level of accuracy in classification.

Whole-exome sequencing identifies variants associated with structural MRI markers in patients with bipolar disorders

BACKGROUND

Bipolar disorder (BD) is one of the most heritable psychiatric disorders. A growing number of whole-exome sequencing (WES) studies for BD has been performed, however, no research has examined the association between single nucleotide variants (SNVs) from WES and structural magnetic resonance imaging (MRI) data.

METHODS

We sequenced whole-exomes in 53 patients with BD and 82 healthy control participants at an initial discovery stage and investigated the impacts of SNVs in risk genes from WES analysis on the cortical gray-matter thickness and integrity of white matter tracts and in the following stage. Cortical thickness and white matter integrity were investigated using the FreeSurfer and TRACULA (Tracts Constrained by UnderLying Anatomy).

RESULTS

We identified 122 BD-related genes including KMT2C, AHNAK, CDH23, DCHS1, FRAS1, MACF1 and RYR3 and observed 27 recurrent copy number alteration regions including gain on 8p23.1 and loss on 15q11.1 - q11.2. Among them, single nucleotide polymorphism (SNP) rs4639425 in KMT2C gene, which regulates histone H3 lysine 4 (H3K4) methylation involved in chromatin remodeling, was associated with widespread alterations of white matter integrity including the cingulum, uncinate fasciculus, cortico-spinal tract, and superior longitudinal fasciculus.

LIMITATION

The small sample size of patients with BD in the genome data may cause our study to be underpowered when searching for putative rare mutations.

CONCLUSION

This study first combined a WES approach and neuroimaging findings in psychiatric disorders. We postulate the rs4639425 may be associated with BD-related microstructural changes of white matter tracts.

Development of a Novel Staging Model for Affective Disorders Using Partial Least Squares Bootstrapping: Effects of Lipid-Associated Antioxidant Defenses and Neuro-Oxidative Stress

Although, staging models gained momentum to stage define affective disorders, no attempts were made to construct mathematical staging models using clinical and biomarker data in patients with major depression and bipolar disorder. The aims of this study were to use clinical and biomarker data to construct statistically derived staging models, which are associated with early lifetime traumata (ELTs), affective phenomenology, and biomarkers. In the current study, 172 subjects participated, 105 with affective disorders (both bipolar and unipolar) and 67 controls. Staging scores were computed by extracting latent vectors (LVs) from clinical data including ELTs, recurring flare ups and suicidal behaviors, outcome data such as disabilities and health-related quality of life (HR-QoL), and paraoxonase (PON)1 actvities and nitro-oxidative stress biomarkers. Recurrence of episodes and suicidal behaviors could reliably be combined into a LV with adequate composite reliability (the "recurrence LV"), which was associated with female sex, the combined effects of multiple ELTs, disabilities, HR-QoL, and impairments in cognitive tests. All those factors could be combined into a reliable "ELT-staging LV" which was significantly associated with nitro-oxidative stress biomarkers. A reliable LV could be extracted from serum PON1 activities, recurrent flare ups, disabilities, and HR-QoL. Our ELT-staging index scores the severity of a relevant affective dimension, shared by both major depression and bipolar disorder, namely the trajectory from ELTs, a relapsing course, and suicidal behaviors to progressive disabilities. Patients were classified into three stages, namely an early stage, a relapse-regression stage, and a suicidal-regression stage. Lowered lipid-associated antioxidant defenses may be a drug target to prevent the transition from the early to the later regression stages.

Hippocampal subfield volumes in major depressive disorder and bipolar disorder

BACKGROUND

The hippocampus is not a uniform structure, but rather consists of multiple, functionally specialized subfields. Few studies have explored hippocampal subfield volume difference in the same sample of major depressive disorder (MDD) and bipolar disorder (BD) cases. We aimed to investigate the difference of hippocampal subfield volume between patents with MDD and BD and healthy controls (HCs).

METHODS

A total of 102 MDD and 55 BD patients and 135 HCs were recruited and underwent T1-weighted image. Hippocampal subfield volume was calculated by automated segmentation and volumetric procedures developed by Iglesias et al. and implemented in FreeSurfer. Volume differences between the groups were analyzed using the analysis of covariance and controlling for age, sex, and total intracranial cavity volume.

RESULTS

Patients with MDD had significantly reduced volumes in the bilateral cornu ammonis 1 (CA1), CA4, the granule cell layer (GCL), molecular layer (ML), whole hippocampus, the left CA2/3, and right presubiclum and subiculum. Patients with BD had significantly reduced volumes in the right CA1, GCL, and the whole hippocampus as compared to HCs. No significant volume differences were observed between the MDD and BD groups. Illness duration was negatively correlated with volumes of the left CA1, CA4, ML, presubiculum, subiculum, and the whole hippocampus in patients with BD.

CONCLUSION

We observed hippocampal subfield volume reductions in both MDD and BD, a finding which more prominent in MDD. The inverse correlation between BD illness duration and hippocampal subfield volume may evidence the neuroprogressive nature of BD.

Bipolar disorder in primary care: a qualitative study of clinician and patient experiences with diagnosis and treatment

OBJECTIVE

To understand primary care patients' and clinicians' experiences with diagnosis and treatment of patients with bipolar disorder in primary care.

METHODS

We conducted a qualitative study using thematic content analysis of individual interviews with nine primary care clinicians and six patients from Federally Qualified Health Centers to understand their experiences with the diagnosis and treatment of bipolar disorder.

RESULTS

Themes of bipolar disorder detection, referral to specialty mental health care and medication treatment emerged from individual interviews with primary care patients and clinicians. Clinicians and patients faced challenges deciding to continue with care in primary care that is easier to access, but less intensive, than specialty care that can be harder to access but at times of higher quality.

CONCLUSIONS

Potential next steps in research include identifying ways to support primary care clinicians in detection of patients with bipolar disorder, and strategies to support treatment of patients in primary care with easier access to specialty care including consultation in primary care or co-management with specialty care.

Abnormal cerebellum-DMN regions connectivity in unmedicated bipolar II disorder

OBJECTIVE

Bipolar disorder (BD) is a common psychiatric disease. Previous studies have found abnormalities in structural and functional brain connectivity in BD patients. However, few studies have focused on the functional connectivity (FC) of the cerebellum and its sub-regions in patients with BD. The present study aimed to examine the FC of cerebellum-default mode network (DMN) regions in patients with BD II.

METHOD

Ninety patients with unmedicated BD II depression and 100 healthy controls (HCs) underwent resting-state functional magnetic resonance imaging. We selected three pairs of subregions of the cerebellum that are DMN-related (the bilateral Crus I, Crus II, and lobule IX) as seed regions and calculated the whole brain FC for each subregion.

RESULTS

Compared with the HCs, the patients with BD II depression showed increased connectivity between the right Crus I and bilateral precuneus and decreased connectivity between the left Crus II and bilateral medial prefrontal cortex (mPFC) and between the left Crus II and right medial frontal gyrus (MFG). There was no significant difference in the whole FC of the left Crus I and bilateral lobule IX between the BD II depression group and the HCs group.

LIMITATIONS

This study was cross-sectional and did not examine data from euthymic BD patients.

CONCLUSIONS

The findings showed impaired FC of cerebellum-DMN regions in BD; partial FC between the Crus I and precuneus and the Crus II and prefrontal cortex suggests the importance of abnormal cerebellum-DMN regions FC in the pathophysiology of BD.

Depression and quality of life in adults perceiving exposure to parental alienation behaviors

Background

The current study is aimed at examining the relationship between exposure to parental alienation (PA) behaviors, depression, and health-related quality of life (HRQoL) in Italian adults.

Methods

Four hundred ninety-one adults were tested. Participants filled out the following self-rating scales: The Baker Strategy Questionnaire (BSQ), the Beck Depression Inventory – II (BDI-II) and its brief version (6-item version of the BDI-II), the Short-Form 36 (SF-36) Health Survey for measuring HRQoL and its brief version including 3 items (WHO-3) of the 5-item World Health Organization Well-Being Index.

Results

Findings revealed statistically significant differences between participants who reported PA and those who did not. Participants who reported exposure to PA behaviors had higher scores on the original BDI-II and its 6-item version (p < 0.05, p < 0.01, respectively); they had also lower levels of HRQoL as resulting from 6 of the 8 SF-36 domains (at least p < 0.05), including lower scores on the WHO-3 (p < 0.01). Perceiving an exposure to PA behaviors significantly increased the likelihood of being above the clinical cut-off on the BDI-II (p < 0.01), the 6-item version of the BDI-II (p < 0.05), and the WHO-3 (p < 0.05). Moreover, perceiving an exposure to PA increased the odds of diminished HRQoL (OR = 2.43 and OR = 1.92 for general health and social functioning domains, respectively).

Conclusions

Childhood exposure to PA was related to higher likelihood of depressive symptoms and diminished HRQoL in adulthood. Our findings suggest the need for preventive and clinical interventions to protect vulnerable children involved in PA from negative outcomes.

Evaluation of the Effect of Memantine Supplementation in the Treatment of Acute Phase of Mania in Bipolar Disorder of Elderly Patients: A Double-blind Randomized Controlled Trial

Background:

This study aimed to evaluate the efficacy of memantine in the acute treatment of geriatric with bipolar disorder (BD) hospitalized for mania.

Materials and Methods:

This study conducted on 70 patients older than 60 years with BD in the acute phase of mania. Oral sodium valproate was prescribed in both groups. The intervention group received memantine tablet and the placebo group received a placebo tablet based on a same procedure. Severity of mania, cognitive changes, and quality of life (QoL) were assessed and recorded 4 and 8 weeks after the beginning of the study. The collected data were analyzed with SPSS (version 20) using independent samples t-test, analysis of variance in repeated observations, Chi-squared test, and Fisher's exact test.

Results:

Mania severity score had no significant difference at the beginning of the study, but 4 and 8 weeks after the intervention, it was reduced significantly in both groups (P < 0.001) that was higher in memantine group (P = 0.038). The mean increase in score of cognitive variations was 6.74 in the memantine group and 3.62 in the placebo group with a nonsignificant difference (P = 0.125). The scores of each dimension of QoL in the two groups showed that in all four dimensions, the patient's physical, psychological, social, and environmental status increased significantly by time (P < 0.001).

Conclusions:

According to the results of this study, memantine as an adjuvant to administration of sodium valproate may have a significant effect on decreasing the intensity of mania in the long run.

Early Life Trauma Predicts Affective Phenomenology and the Effects are Partly Mediated by Staging Coupled with Lowered Lipid-Associated Antioxidant Defences

Background Early life trauma (ELT) may drive mood disorder phenomenology, nitro-oxidative pathways and impairments in semantic memory. There are no data regarding the impact of ELT on affective phenomenology and whether these pathways are mediated by staging or lowered lipid-associated antioxidant defences. Methods This study examined healthy controls (n=54) and patients with affective disorders including major depression, bipolar disorder and anxiety disorders (n=118). ELT was assessed using the Child Trauma Questionnaire. In addition, we measured affective phenomenology and assayed advanced oxidation protein products; malondialdehyde, paraoxonase 1 (CMPAase) activity, high-sensitivity C-reactive protein (hsCRP), and high-density lipoprotein (HDL) cholesterol. Results ELT was associated into with increased risk for mood and comorbid anxiety disorders and a more severe phenomenology, including staging characteristics, depression and anxiety severity, suicidal behaviours, type of treatments, disabilities, body mass index, smoking behaviour and hsCRP, as well as lowered health-related quality of life, antioxidant defences and semantic memory. The number of mood episodes and CMPAase/HDL-cholesterol levels could be reliably combined into a new vulnerability staging-biomarker index, which mediates in part the effects of ELT on affective phenomenology and oxidative stress. Moreover, the effects of female sex on mood disorders and affective phenomenology are mediated by ELT. Discussion The cumulative effects of different ELT drive many aspects of affective phenomenology either directly or indirectly through effects of staging and/or lipid-associated antioxidant defences. The results show that children, especially girls, with ELT are at great risk to develop mood disorders and more severe phenotypes of affective disorders.

Cognitive and functional deficits in bipolar disorder and schizophrenia as a function of the presence and history of psychosis

OBJECTIVES

Schizophrenia and bipolar disorder overlap considerably. Schizophrenia is a primary psychotic disorder, whereas approximately half of people with bipolar disorder will experience psychosis. In this study, we examined the extent to which cognitive and functional impairments are related to the presence and history of psychosis across the two disorders.

METHOD

A total of 633 participants with bipolar disorder I, schizophrenia, and schizoaffective disorder were recruited for a study on the genetics of cognition and functioning in bipolar disorder and schizophrenia. Participants were classified into five groups: bipolar disorder with current psychosis (N = 30), bipolar disorder with a history of psychosis (N = 162), bipolar disorder with no history of psychosis (N = 92), schizophrenia with current psychosis (N = 245), and schizophrenia with past psychosis (N = 104).

RESULTS

Cognitive profiles of all groups were similar in pattern; however, both current psychosis (P < .02) and a diagnosis of schizophrenia (P < .03) were associated with greater impairment. Schizophrenia with current psychosis was also associated with a superimposed severe impairment in processing speed. Both psychosis (P < .03) and schizophrenia diagnosis (P < .01) were associated with poorer functional competence. Individuals with bipolar disorder and schizophrenia experienced similar impairments in real-world functioning if they were experiencing current psychosis (P = .32).

CONCLUSION

The presence of active psychosis is an important cross-diagnostic factor in cognition and functioning in both schizophrenia and bipolar disorder. Characterization and treatment of cognition and functional deficits in bipolar disorder should consider the effects of both current and history of psychosis.

Menorraghia's impact on quality of life: A case control study from a teaching Hospital in Lahore

Background and Objective:

Menorrhagia is one of the common complaints presenting in gynaecology outdoor and clinics. Menorrhagia is defined as excessive uterine bleeding occurring at regular intervals or prolonged uterine bleeding lasting for more than seven days. This is a very distressing condition effecting almost all ages, and has multiple causes. The objective of this study was to determine effect of menorrhagia on quality of life of a woman.

Methods:

It was a case control study, conducted at Arif Memorial Teaching Hospital Lahore from January 2017 to December 2017. It included 230 women. Out of these, 150 women who had menorrhagia were included in Group A (cases). Group B included 80 women accompanying them and have normal menstrual cycles (controls).

Results:

The mean age of the participants was 35.56±8.85 years. Duration of menorrhagia was more than 4 years in 11% of the patients, 22% had menorrhagia for 1-2 years and 1.2% for three months. Among all age groups, quality of life was better in female without menorrhagia as compared to female with menorrhagia (p-value <0.001).

Conclusion:

Health care providers should have knowledge to treat patients with menorrhagia, also future qualitative studies should be done to determine perception of patients regarding treatment and management of menorrhagia.

B-positive: a randomized controlled trial of a multicomponent positive psychology intervention for euthymic patients with bipolar disorder - study protocol and intervention development

BACKGROUND

Bipolar disorder (BD) is characterized by recurrent (hypo)manic and depressive episodes, alternating with euthymic states in which patients are relatively symptom free. Besides clinical recovery, it is important to also strive for improvement of mental well-being and personal recovery. One prominent field focussing on the improvement of well-being is positive psychology. However, studies assessing the effects of positive psychology or personal recovery interventions for people with BD are scarce and have used weak methodological designs. The study described in this protocol article aims to assess the effectiveness of a multicomponent positive psychology intervention ("Living well with bipolar disorder") adjusted for people with BD in the euthymic phase to improve well-being and personal recovery.

METHOD

The study concerns a pragmatic randomized multicenter trial. The principle objective of the study is to assess whether the positive psychology intervention offered to BD patients in remission in addition to usual care (CAU) is more effective than CAU. The study will include 112 participants randomized to either the experimental condition receiving the intervention in addition to CAU or the control condition receiving CAU. The study population are patients with BD I or II in the euthymic phase. The inclusion criteria are 1) diagnosis of BD I or BD II, 2) between the ages of 18-65, 3) four or more supportive sessions in the last year, and 4) only residual depressive or manic symptoms. Patients are excluded if they are in a depressive or manic episode, have current addiction problems or have optimal levels of well-being. Measurements take place at baseline, post-intervention and follow-up 6 and 12 months from baseline. Outcomes of measures include positive well-being, personal recovery, psychopathology, self-compassion, positive relationships, dampening of positive affect and relapse.

DISCUSSION

The outlined study will be the first RCT examining the effects of a multicomponent positive psychology intervention for patients with bipolar disorder. Several limitations, including generalizability of the results and possible attrition issues, are discussed in advance.

TRIAL REGISTRATION

This study has been registered in the Netherlands Trial Register ( NTR6729 ) on 12 October 2017.