Neuropsychological profiles of adult bipolar disorder patients with and without comorbid attention-deficit hyperactivity disorder

Neurocognitive and psychosocial functioning profiles in bipolar disorder and comorbid attention deficit hyperactivity disorder: A systematic review and meta-analysis

Bipolar disorder (BD) and attention deficit hyperactivity disorder (ADHD) are chronic psychiatric conditions with significant impacts on neurocognitive and psychosocial functioning. Co-occurrence of BD and ADHD (BD-ADHD) presents unique clinical challenges and could exacerbate cognitive and functional impairments. This systematic review and meta-analysis aimed to provide an updated synthesis of the differences in neurocognitive and psychosocial functioning between patients with BD-ADHD, BD, ADHD, and healthy controls (HC). A comprehensive systematic search identified 5639 records, with 34 studies meeting the inclusion criteria for a systematic review and 31 for the meta-analysis. There were no significant differences in cognitive performance across none of the evaluated cognitive domains between BD-ADHD and BD patients. BD-ADHD patients exhibited significantly lower visual memory (SMD=-0.29, 95 % CI=-0.53,-0.04; p = 0.022) compared to ADHD patients. Compared to HC, BD-ADHD patients showed poorer performance in processing speed (SMD=-0.54, 95 % CI= -0.86,-0.22; p < 0.001), sustained attention (SMD=-0.40, 95 % CI=-0.62, -0.19; p < 0.001), visual memory (SMD=-0.47, 95 % CI=-0.69,-0.26; p < 0.001), working memory (SMD=-0.79, 95 % CI=-1.13,-0.44; p < 0.001), cognitive flexibility and higher-order executive functions (SMD=-0.52, 95 % CI=-0.84,-0.20; p = 0.001), and verbal memory (SMD=-0.95, 95 % CI=-1.43,-0.47; p < 0.001). Psychosocial functioning was significantly worse in BD-ADHD patients compared to BD (SMD=-0.46; p < 0.001), ADHD (SMD=-1.00; p < 0.001), and HC (SMD=-3.54; p < 0.001). Our results suggest that the co-occurrence of BD and ADHD is associated with significant neurocognitive and psychosocial impairments. These findings underscore the need for targeted interventions to address the unique challenges of this comorbid condition, informing clinical practice and guiding future research.

Web-based cognitive screening in bipolar disorder: validation of the Internet-based Cognitive Assessment Tool in remote administration settings

BACKGROUND

Cognitive impairments are prevalent during remission in bipolar disorder (BD), but existing cognitive screening tools are time- and resource-intensive. Digital, web-based options can facilitate detection and monitoring of these impairments across clinical and research settings.

METHODS

This cross-sectional study investigated psychometric properties of the Internet-based Cognitive Assessment Tool (ICAT) when self-administered in home-based settings. Newly diagnosed, remitted outpatients with BD and healthy controls (HC) underwent cognitive testing with the standard paper-pencil tool Screen for Cognitive Impairment in Psychiatry (SCIP) in-clinic and ICAT at-home as part of baseline assessments for an intervention trial (ClinicalTrials ID: 2021-000862-14).

RESULTS

Data were analyzed for 31 BD patients and 29 HC. We demonstrated a strong positive correlation between at-home ICAT and in-clinic SCIP total scores within patients with BD (r(29) = 0.66, p < .001), which survived subsyndromal mood symptoms adjustment (partial r(25) = 0.67, p < .001), indicating adequate concurrent validity. There was a moderate positive correlation between ICAT and SCIP total scores across the entire sample (r(54) = 0.56, p < .001) and between subtest scores (r = 0.29-0.61, ps ≤ .03), except the executive functions tasks (p = .1). BD patients exhibited no impaired performance compared to HC on ICAT or SCIP (ps ≥ .08).

CONCLUSIONS

ICAT is a valid and feasible online tool for remote cognitive screening in remitted patients with BD. Web-based screening constitutes an accessible and efficient approach for implementing systematic cognitive screening in BD.

Efficacy and safety of established and off-label ADHD drug therapies for cognitive impairment or attention-deficit hyperactivity disorder symptoms in bipolar disorder: A systematic review by the ISBD Targeting Cognition Task Force

BACKGROUND

Abnormalities in dopamine and norepinephrine signaling are implicated in cognitive impairments in bipolar disorder (BD) and attention-deficit hyperactivity disorder (ADHD). This systematic review by the ISBD Targeting Cognition Task Force therefore aimed to investigate the possible benefits on cognition and/or ADHD symptoms and safety of established and off-label ADHD therapies in BD.

METHODS

We included studies of ADHD medications in BD patients, which involved cognitive and/or safety measures. We followed the procedures of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 statement. Searches were conducted on PubMed, Embase and PsycINFO from inception until June 2023. Two authors reviewed the studies independently using the Revised Cochrane Collaboration's Risk of Bias tool for Randomized trials.

RESULTS

Seventeen studies were identified (N = 2136), investigating armodafinil (k = 4, N = 1581), methylphenidate (k = 4, N = 84), bupropion (k = 4, n = 249), clonidine (k = 1, n = 70), lisdexamphetamine (k = 1, n = 25), mixed amphetamine salts (k = 1, n = 30), or modafinil (k = 2, n = 97). Three studies investigated cognition, four ADHD symptoms, and 10 the safety. Three studies found treatment-related ADHD symptom reduction: two involved methylphenidate and one amphetamine salts. One study found a trend towards pro-cognitive effects of modafinil on some cognitive domains. No increased risk of (hypo)mania was observed. Five studies had low risk of bias, eleven a moderate risk, and one a serious risk of bias.

CONCLUSIONS

Methylphenidate or mixed amphetamine salts may improve ADHD symptoms in BD. However, there is limited evidence regarding the effectiveness on cognition. The medications produced no increased mania risk when used alongside mood stabilizers. Further robust studies are needed to assess cognition in BD patients receiving psychostimulant treatment alongside mood stabilizers.

Adults with both bipolar disorder and ADHD

ADHD and bipolar disorder (BP) commonly coexist, and both share key symptoms, depending on affective state and emotional dysregulation. The overlap poses diagnostic challenges and may lead to underdiagnoses. Comorbid cases exhibit worsened symptom burden, increased psychiatric morbidity, admissions, and suicide attempts. Treating BP before ADHD is recommended. Stimulant use combined with mood stabilisers may be effective and relatively safe; however, this review finds that well-designed randomised controlled studies in the area is warranted.

Bipolar-ADHD comorbidity: screening for differences in neurocognition and virtual reality-based cognitive performance

OBJECTIVES

Identification of comorbid attention-deficit/hyperactivity disorder (ADHD) in patients with bipolar disorder (BD) is complicated by overlapping cognitive symptoms and methodological challenges. This cross-sectional study investigated whether virtual reality (VR)-based cognitive assessment that mimics daily life cognitive challenges can aid in the detection of sustained attention impairment in BD individuals with comorbid ADHD (BD + ADHD).

METHODS

Forty-nine fully or partially remitted outpatients with BD, of whom 14 (24%) had BD + ADHD, were assessed with the Cognition Assessment in Virtual Reality (CAVIR) test, including a sustained attention test that involves distractions, and the Screen for Cognitive Impairment in Psychiatry (SCIP). Patients were also rated for mood symptoms and functioning and completed questionnaires assessing subjective cognition and quality of life. Patients' cognitive impairment on the SCIP was estimated with reference to n = 100 demographically comparable healthy control participants.

RESULTS

BD + ADHD participants exhibited more pronounced performance deficits on the CAVIR sustained attention test (t(48) = 2.15, p = .037, d = .66). Notably, deficits on this test were proportional to self-reported daily life concentration difficulties in BD + ADHD individuals. Exploratory analyses revealed that BD + ADHD participants also displayed greater impairment on the SCIP working memory- and delayed verbal learning subtests and greater subjective cognitive complaints than BD patients without this comorbidity (p-levels < .001), but only the difference in subjective cognition survived correction for multiple comparisons (F(1,47) = 14.13, p = .005, np2 = 0.24).

CONCLUSION

Screening for deficits in sustained attention with an ecologically valid VR test involving distracting stimuli may be useful for identifying BD + ADHD individuals.

Objective methods for matching neuropsychological patterns: Formulas and comparisons

INTRODUCTION

Objective neuropsychology test score pattern matching methods can help to identify data similarities and differences with comparison groups which can help the clinician in diagnosis and in identifying treatment options.

MATERIALS AND METHODS

The current study examines five methods of matching a data set: Correlation, Configuration, Kullback-Leibler (KL) Divergence, Pooled Effect Size (Cohen's d), and a new method called MNB (Meyers Neuropsychological Battery) Code. Thirty data sets diagnosed with Traumatic Brain Injury (TBI) were compared with four Comparison Group data sets consisting of TBI, Depression, Anxiety and Attention Deficit/Hyperactivity Disorder.

RESULTS

The Correlation Method was correct 90% (27/30) and Configuration was correct 86% (26/30). The KL Divergence was correct 76% (23/30) and the MNB Code was correct 73% (22/30). The Effect Size Method was correct 70% (21/30). When using a simple majority of all the matching methods, the classification rate was 90+ percent.

CONCLUSIONS

The results of this study demonstrate that there are statistical methods that can identify patterns of cognitive strengths and weaknesses. Multiple matching methods and a simple majority of agreement between the different comparisons suggests the best matching profile for diagnosis. In some cases, more than one pattern may be present.

Clinical correlates of comorbid attention deficit hyperactivity disorder in adults suffering from bipolar disorder: A meta-analysis

OBJECTIVE

Attention deficit hyperactivity disorder is a frequent comorbid condition in adults with bipolar disorder. We performed a meta-analysis aimed at assessing sociodemographic and clinical correlates of attention deficit hyperactivity disorder in bipolar disorder.

METHOD

We searched main electronic databases up to June 2021. Random-effects meta-analyses, with relevant meta-regression and quality-based sensitivity analyses, were carried out to estimate the association between attention deficit hyperactivity disorder and putative correlates, grading the quality of evidence.

RESULTS

We included 43 studies, based on 38 independent samples. Attention deficit hyperactivity disorder participants were more likely to be males (odds ratio = 1.46; p < 0.001) and unemployed (odds ratio = 1.45; p = 0.045), and less likely to be married (odds ratio = 0.62; p = 0.014). They had an earlier onset of bipolar disorder (standardized mean difference = -0.36; p < 0.001); more mood episodes (standardized mean difference = 0.35; p = 0.007), particularly depressive (standardized mean difference = 0.30; p = 0.011) and mixed (standardized mean difference = 0.30; p = 0.031) ones; higher odds of using antidepressants (odds ratio = 1.80; p = 0.024) and attempted suicides (odds ratio = 1.83; p < 0.001) and lower odds of psychotic features (odds ratio = 0.63; p = 0.010). Moreover, they were more likely to have generalized anxiety disorder (odds ratio = 1.50; p = 0.019), panic disorder (odds ratio = 1.89; p < 0.001), social phobia (odds ratio = 1.61; p = 0.017), eating disorders (odds ratio = 1.91; p = 0.007), antisocial personality disorder (odds ratio = 3.59; p = 0.004) and substance (odds ratio = 2.29; p < 0.001) or alcohol (odds ratio = 2.28; p < 0.001) use disorders. Quality of the evidence was generally low or very low for the majority of correlates, except for bipolar disorder onset and alcohol/substance use disorders (high), and suicide attempts (moderate).

CONCLUSION

Comorbid bipolar disorder/attention deficit hyperactivity disorder may have some distinctive clinical features including an earlier onset of bipolar disorder and higher comorbid alcohol/substance use disorder rates. Further research is needed to identify additional clinical characteristics of this comorbidity.

Attention Deficit Hyperactivity Disorder and Bipolar Disorder: Diagnosis, Treatments, and Clinical Considerations: A Narrative Review

Attention-deficit Hyperactivity Disorder is one of the most common childhood mental health disorders, affecting about 5.6% of the population worldwide. Several studies have specifically shown a high prevalence of comorbid mood disorders, such as depression and bipolar disorder (BD), in those diagnosed with ADHD. Several common symptoms of ADHD are also found in BD, which are characterized by alternating periods of euthymia and mood disturbances. The inattention and impulsivity of ADHD can be seen in manic and hypomanic episodes of BD. Over the past decade, there has been an increased interest in research between the correlation of ADHD and pediatric bipolar disorder (PBD) in children. Some experts hypothesize that more children are comorbidly diagnosed with ADHD and PBD because of how many clinicians treat children with ADHD. Other factors, which may affect the dual diagnoses of ADHD and PBD, are overlapping diagnostic criteria for the two disorders, the inevitable biases seen when one disorder is diagnosed without the other, and related risk factors leading to prodromal relationships. By examining clinical trials, a better understanding of whether ADHD and PBD have a stepwise progression or if other factors influence these comorbidities, such as blurred lines of diagnostic criteria. Those with ADHD are also at an increased risk of impairment at work and in social settings. This manuscript explores both progression of this disease and its clinical connections to other disorders.

Neurocognitive Functions in Bipolar Disorder in Relation to Comorbid ADHD

Introduction

Bipolar disorder (BD) and attention deficit hyperactivity disorder (ADHD) often co-occur in adult population. Both conditions present various neurocognitive and behavioral problems. We aimed to examine neurocognitive functions in adult patients with comorbid BD and ADHD (BD+ADHD) in comparison to patients with only BD, only ADHD and healthy controls (HCs).

Method

An extensive cognitive battery which evaluates verbal learning and memory, visual memory, processing speed, attention, executive functions, working memory and verbal fluency, was used to assess neurocognitive functions respectively in adult (age 18-65 years) patients with BD (n=37), ADHD (n=43), BD+ADHD (n=20) in comparison to HCs (n=51). The Multivariate Analysis of Covariance models, where age, level of education and total BIS-11 scores were included as covariates, were used for comparing neurocognitive scores among groups.

Results

Both BD and BD+ADHD groups showed significantly poorer performance than HCs in processing speed, attention, executive functions, and verbal fluency domains. The BD group had additional significant deficits in executive functions, verbal learning and memory domains. There were no significant differences between BD and BD+ADHD groups with regards to verbal learning and memory, visual memory, processing speed, attention, executive functions, working memory and verbal fluency domains. Patients with only ADHD showed significantly poorer performance than HCs in verbal fluency domain.

Conclusions

Our results show similarities in the neurocognitive functions of adults with BD and BD+ADHD across a wide range of cognitive domains. The findings point to the need for further exploration of diverging and converging neurodevelopmental trajectories of BD and ADHD.

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

Background

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

Methods

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

Results

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

Conclusions

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