Associations between residual depressive symptoms, cognition, and functioning in patients with euthymic bipolar disorder: results from the FACE-BD cohort

Assessment of memory deficits in psychiatric disorders: A systematic literature review

Memory deficits are observed across psychiatric disorders ranging from the prodrome of psychosis to common mental disorders such as anxiety, depression, and dissociative disorders. Memory deficits among patients recovering from psychiatric disorders could be directly related to the primary illness or secondary to the adverse effect of a treatment such as Electroconvulsive Therapy (ECT). The trouble in the meaningful integration of working-memory and episodic memory is the most commonly affected domain that requires routine assessments. An update on the recent trends of methods of assessment of memory deficits is the first step towards understanding and correcting these deficits to target optimum recovery. A systematic literature search was conducted from October 2018 to October 2022 to review the recent methods of assessment of memory deficits in psychiatric disorders. The definition of 'Memory deficit' was operationalized as 'selective processes of memory, commonly required for activities of daily living, and affected among psychiatric disorders resulting in subjective distress and dysfunction'. We included 110 studies, most of them being conducted in western countries on patients with schizophrenia. Other disorders included dementia and mild cognitive impairment. Brief Assessment of Cognition in Schizophrenia, Cambridge Automated Neuropsychological Test Battery, California Verbal Learning Test, Trail Making Test Part A and B, Rey Auditory Verbal Learning Test, Wechsler Memory Scale, Wechsler Adults Intelligence Scale-IV were the most common neuropsychological assessments used. Mini-Mental State Examination and Montreal Cognitive Assessment were the most common bedside assessment tools used while Squire Subjective Memory Questionnaire was commonly used to measure ECT-related memory deficits. The review highlights the recent developments in the field of assessment of memory deficits in psychiatric disorders. Findings recommend and emphasize routine assessment of memory deficits among psychiatric disorders in developing countries especially severe mental illnesses. It remains interesting to see the role of standardized assessments in diagnostic systems given more than a decade of research on memory deficits in psychiatric disorders.

A systematic review and meta-analysis of global and social functioning among people at risk of bipolar disorder

BACKGROUND

Functional status could predict development of bipolar disorder (BD) or have clinical significance. The relationship between BD risk and functioning is poorly understood. We undertook a systematic review examining the global and social functioning of those at risk for BD.

METHODS

We examined observational studies comparing a risk sample with healthy controls or full-threshold BD participants, using measures of global or social functioning. Risk status included family history of BD, meeting risk criteria, or having prodromal symptomatology, or premorbid functioning of persons with BD. Medline, PsycINFO, and Embase were searched. The Newcastle-Ottawa Scale for Cross-Sectional Studies was used to assess quality. Meta-analyses were performed where possible.

RESULTS

7215 studies were screened and 40 studies were included (8474 participants). Risk samples had poorer functioning than controls, and superior functioning to participants with BD. Meta-analysis indicated poorer global functioning among persons with familial risk compared to healthy controls (mean global functional difference: 5.92; 95 % confidence interval: 7.90, 3.95; mean premorbid functioning difference: 2.31; 95 % confidence interval: 0.70, 3.92). Studies with higher proportions of female participants had slightly poorer global functioning. High heterogeneity was attributable functional measures and potentially functionally differential subgroups within the risk samples.

LIMITATIONS

Broader measures of functioning, such as neurocognition and behavioural measures, were excluded. Measures of global functioning are limited by conflating functioning and symptoms.

CONCLUSIONS

Functioning in the BD risk populations is intermediate to that of healthy controls and persons with BD, indicating their value in definitions of BD risk, in itself a likely heterogeneous state.

Neuropsychological aspects of bipolar disorder

Bipolar disorder (BD) is a chronic condition with serious consequences on the health and functionality of patients who suffer from it, with a high heritability and segregation, and aprevalence of between 1% and 2%. Neuropsychological deficits have been implicated as a very important issue related to BD prognosis, so a review was conducted of these deficits, the related factors and their functional consequences. It has been determined that the presence of neuropsychological deficits can vary in patients with BD according to their mood state, with a great influence of depressive symptoms on the cognitive variability of patients with respect to the general population and differences with respect to patients in the manic phase. In euthymic patients, the most affected cognitive domains are those of memory, attention, and executive function, associated with a more severe disease, sociodemographic vulnerability factors, and stable over time. A relationship has been found between poor cognitive performance, especially executive dysfunction, and objective functional deficit. Furthermore, cognitive differences have been outlined between BD and other serious mental illnesses that are described in this review.

Key findings on bipolar disorders from the longitudinal FondaMental Advanced Center of Expertise-Bipolar Disorder (FACE-BD) cohort

BACKGROUND

The FACE-BD cohort is an observational cohort of individuals with bipolar disorders (BD) who benefited from a systematic evaluation with evidence-based treatment recommendations and who were followed-up every year for 3 years in France. The objectives were to describe the lifetime course of BD, associated psychiatric and somatic comorbidities, and cognition profile. This cohort aims to identify clinical/biological signatures of outcomes, trajectories of functioning and transition between clinical stages. This article summarizes 10 years of findings of the FACE-BD cohort.

METHOD & RESULTS

We included 4422 individuals, all having a baseline assessment, among which 61.2% had at least one follow-up visit at either one, two or three years. A subsample of 1200 individuals had at least one biological sample (serum, plasma, DNA). Assessments include family history of psychiatric disorders, psychiatric diagnosis, current mood symptoms, functioning, hospitalizations, suicidal attempts, physical health, routine blood tests, treatment history, psychological dimensions, medico-economic data and a cognitive assessment. Studies from this cohort illustrate that individuals with BD display multiple coexistent psychiatric associated conditions including sleep disturbances, anxiety disorders, substance use disorders and suicide attempts as well as a high prevalence of metabolic syndrome. During follow-up, we observed a 55% reduction of the number of days of hospitalization and a significant improvement in functioning.

CONCLUSIONS

The FACE-BD cohort provides a strong research infrastructure for clinical research in BD and has a unique position among international cohorts because of its comprehensive clinical assessment and sustainable funding from the French Ministry of Health.

Activation of SIRT-1 Signalling in the Prevention of Bipolar Disorder and Related Neurocomplications: Target Activators and Influences on Neurological Dysfunctions

SIRT-1 (silent mating-type information regulation 2 homolog-1) is a protein found in neuronal nuclei, microglia, and astrocyte cells of the brain. It is sometimes referred to as NAD + -dependent deacetylase (nicotinamide adenine dinucleotide). The activation of sirtuins (SIRT-1-7) has been shown to protect against a wide range of disorders, including neurodegenerative and neuropsychiatric disorders. SIRT-1 has gained considerable interest from these families because of its early link to long-life expansion and calorie restriction involvement. SIRT-1 is necessary for gene silencing, cell cycle regulation, fat and glucose metabolism, oxidative stress, ageing, and memory formation. In this review, we investigate the role of SIRT-1 downregulation in the progression of bipolar disorder (BD) and neurological abnormalities, as well as related neurological alterations such as genetic dysfunction, neurotransmitter imbalance, oxidative stress-induced apoptosis, and mitochondrial dysfunction. BD is a psychiatric disease distinguished by extreme mood fluctuations that range from depressive lows to manic highs. BD is a complicated disorder with numerous clinical signs and neurocomplications that produce significant behavioural problems. SIRT-1 deficiency in the brain has been demonstrated to affect the activity of its transcription factors and molecular changes, including genetic defects. SIRT-1 is now being studied as a potential therapeutic target for a range of brain disorders. A recent study also found that activating SIRT-1 signalling performs a protective effect in avoiding depression and mania-like behaviours. Furthermore, this review investigates the potential mechanisms by which SIRT-1 regulates neuronal transmission and neurogenesis. As a result of our review, we revealed that SIRT-1 activators have neuroprotective potential in BD and related neurological dysfunctions.

Cognitive reserve may outperform age, mood and psychiatric comorbidities as a predictor of executive functioning in bipolar disorder and healthy adults

INTRODUCTION

Cognitive reserve plays a protective role against executive dysfunction in healthy adults and individuals with psychiatric illnesses such as bipolar disorder. However, the magnitude of the influence of cognitive reserve on specific executive functions (EFs), and its impact relative to variables such as depressive symptoms, age and psychiatric comorbidities, is unexplored. This study aimed to quantify the influence of cognitive reserve on specific EFs, and compare its impact with that of depressive symptoms, age and psychiatric comorbidities, in separate models for patients with bipolar disorder and healthy adults.

METHOD

This was a cross-sectional study of 121 adults with no mood disorders and 109 with bipolar disorder, all of whom underwent a comprehensive psychiatric assessment and evaluation of the EFs. Cognitive reserve was measured using years of education, IQ and reading and writing habits. The association between EFs and predictors (cognitive reserve, depressive symptoms, age and psychiatric comorbidities) was evaluated through structural equation modeling. Four models were constructed for each group independently (bipolar disorder and control), one each for working memory, verbal fluency, inhibition and flexibility, due to group differences in age and cognitive reserve.

RESULTS

Working memory, inhibition and flexibility were most significantly predicted by cognitive reserve and age. Verbal fluency was only predicted by cognitive reserve. Comorbidities and depressive symptoms were not significant in any of the models. Cognitive reserve had a positive influence on all EFs in models for patients with bipolar disorder and models for control participants. Age had a negative impact on three of the four EFs tested.

CONCLUSION

Fostering cognitive reserve through continued education and cognitively stimulating leisure activities may be an effective intervention for executive dysfunction in patients and non-patients alike. In some cases, the effects of these interventions may outweigh the negative cognitive impact of aging, depressive symptoms and psychiatric conditions.

Predictors of psychosocial functioning in euthymic patients with bipolar disorder: A model selection approach

BACKGROUND

Functional impairment is a major target in the treatment of bipolar disorder (BD), but the magnitude and type of functional difficulties differ across patients. Findings on predictors of overall functioning and specific functional areas are inconsistent. We aimed to characterize functional difficulties and identify factors associated with global functioning and individual domains in euthymic patients.

METHODS

The Functional Assessment Short Test (FAST) was used to assess overall psychosocial functioning and specific functional domains in 80 euthymic participants with BD. Participants also completed a clinical interview and a cognitive assessment. Model selection with elastic net regression was performed to identify predictors of global functioning. We then examined the association of these predictors with individual functional domains using correlation.

RESULTS

FAST scores indicated moderate or severe impairment for 54% of the sample, with occupational functioning showing the highest impairment rate. Elastic net regression selected a model with three variables (higher residual depressive symptoms, lower executive functioning, more perceived cognitive deficits) as predictors of overall functioning. No significant associations were found between these predictors. Depressive symptoms were associated with interpersonal relationships and leisure time, executive skills with occupational functioning, and perceived deficits with cognitive functioning.

CONCLUSIONS

Residual depressive symptoms were the strongest predictor of overall functioning which highlights the importance of assessing and targeting subthreshold symptoms for recovery. Executive difficulties were associated with functioning, particularly occupational skills, independently of depressive symptoms. Interventions targeting these difficulties, such as cognitive and functional remediation, may be key treatment options towards facilitating functional recovery.

Reaction Time and Visual Memory in Connection to Hazardous Drinking Polygenic Scores in Schizophrenia, Schizoaffective Disorder and Bipolar Disorder

The purpose of this study was to explore the association of cognition with hazardous drinking Polygenic Scores (PGS) in 2649 schizophrenia, 558 schizoaffective disorder, and 1125 bipolar disorder patients in Finland. Hazardous drinking PGS was computed using the LDPred program. Participants performed two computerized tasks from the Cambridge Automated Neuropsychological Test Battery (CANTAB) on a tablet computer: the 5-choice serial reaction time task, or Reaction Time (RT) test, and the Paired Associative Learning (PAL) test. The association between hazardous drinking PGS and cognition was measured using four cognition variables. Log-linear regression was used in Reaction Time (RT) assessment, and logistic regression was used in PAL assessment. All analyses were conducted separately for males and females. After adjustment of age, age of onset, education, household pattern, and depressive symptoms, hazardous drinking PGS was not associated with reaction time or visual memory in male or female patients with schizophrenia, schizoaffective, and bipolar disorder.

Reaction Time and Visual Memory in Connection to Alcohol Use in Persons with Bipolar Disorder

The purpose of this study was to explore the association of cognition with hazardous drinking and alcohol-related disorder in persons with bipolar disorder (BD). The study population included 1268 persons from Finland with bipolar disorder. Alcohol use was assessed through hazardous drinking and alcohol-related disorder including alcohol use disorder (AUD). Hazardous drinking was screened with the Alcohol Use Disorders Identification Test for Consumption (AUDIT-C) screening tool. Alcohol-related disorder diagnoses were obtained from the national registrar data. Participants performed two computerized tasks from the Cambridge Automated Neuropsychological Test Battery (CANTAB) on A tablet computer: the 5-choice serial reaction time task, or reaction time (RT) test and the Paired Associative Learning (PAL) test. Depressive symptoms were assessed with the Mental Health Inventory with five items (MHI-5). However, no assessment of current manic symptoms was available. Association between RT-test and alcohol use was analyzed with log-linear regression, and eβ with 95% confidence intervals (CI) are reported. PAL first trial memory score was analyzed with linear regression, and β with 95% CI are reported. PAL total errors adjusted was analyzed with logistic regression and odds ratios (OR) with 95% CI are reported. After adjustment of age, education, housing status and depression, hazardous drinking was associated with lower median and less variable RT in females while AUD was associated with a poorer PAL test performance in terms of the total errors adjusted scores in females. Our findings of positive associations between alcohol use and cognition in persons with bipolar disorder are difficult to explain because of the methodological flaw of not being able to separately assess only participants in euthymic phase.

[Cognitive impairment in remitted patients with bipolar disorder]

OBJECTIVE

To assess the frequency and severity of cognitive impairment as well as its correlations with clinical characteristics in remitted patients with bipolar disorder (BD).

MATERIAL AND METHODS

Eighty-five patients with BD type I (64 patients) and BD type II (21 patients) in remission were examined (average age 36.6±5.7). Affective symptoms were assessed using the Hamilton Depression Rating Scale (HDRS) and Young's Mania Rating Scale (YMRS). Cognitive impairment was assessed using the Brief Neuropsychological Cognitive Examination (BNCE).

RESULTS

Cognitive impairment was revealed in 43.5% of the patients. The frequency and structure of cognitive impairment in patients with BD type I and type II did not differ. The patients with cognitive impairment were characterized by decreased speed of mental processes, decreased working memory and attention deficit. The correlation of the total BNCE score with the age of the patients, duration of the disease, total HDRS and YMRS scores was revealed.

CONCLUSION

The results demonstrate the affective nature of cognitive deficit in the patients. Cognitive impairment in remitted patients with BD is a significant therapeutic target.

Longitudinal relationships between cognition and functioning over 2 years in euthymic patients with bipolar disorder: a cross-lagged panel model approach with the FACE-BD cohort

BACKGROUND

Longitudinal studies of the relationship between cognition and functioning in bipolar disorder are scarce, although cognition is thought to be a key determinant of functioning. The causal structure between cognition and psychosocial functioning in bipolar disorder is unknown.

AIMS

We sought to examine the direction of causality between cognitive performance and functional outcome over 2 years in a large cohort of euthymic patients with bipolar disorder.

METHOD

The sample consisted of 272 adults diagnosed with bipolar disorder who were euthymic at baseline, 12 and 24 months. All participants were recruited via the FondaMental Advanced Centers of Expertise in Bipolar Disorders. We used a battery of tests, assessing six domains of cognition at baseline and 24 months. Residual depressive symptoms and psychosocial functioning were measured at baseline and 12 and 24 months. The possible causal structure between cognition and psychosocial functioning was investigated with cross-lagged panel models with residual depressive symptoms as a covariate.

RESULTS

The analyses support a causal model in which cognition moderately predicts and is causally primary to functional outcome 1 year later, whereas psychosocial functioning does not predict later cognitive performance. Subthreshold depressive symptoms concurrently affected functioning at each time of measure.

CONCLUSIONS

Our results are compatible with an upward causal effect of cognition on functional outcome in euthymic patients with bipolar disorder. Neuropsychological assessment may help specify individual prognoses. Further studies are warranted to confirm this causal link and evaluate cognitive remediation, before or simultaneously with functional remediation, as an intervention to improve functional outcome.

Neuropsychological Aspects of Bipolar Disorder

Bipolar disorder (BD) is a chronic condition with serious consequences on the health and functionality of patients who suffer from it, with a high heritability and segregation, and a prevalence of between 1% and 2%. Neuropsychological deficits have been implicated as a very important issue related to BD prognosis, so a review was conducted of these deficits, the related factors and their functional consequences. It has been determined that the presence of neuropsychological deficits can vary in patients with BD according to their mood state, with a great influence of depressive symptoms on the cognitive variability of patients with respect to the general population and differences with respect to patients in the manic phase. In euthymic patients, the most affected cognitive domains are those of memory, attention, and executive function, associated with a more severe disease, sociodemographic vulnerability factors, and stable over time. A relationship has been found between poor cognitive performance, especially executive dysfunction, and objective functional deficit. Furthermore, cognitive differences have been outlined between BD and other serious mental illnesses that are described in the review.

Neurocognitive effects of six ketamine infusions and the association with antidepressant effects in treatment-resistant bipolar depression: a preliminary study

Objective

The N-methyl-D-aspartate subtype glutamate receptor antagonist ketamine has rapid antidepressant and antisuicidal effects in treating treatment-resistant bipolar depression (TRBD). The neurocognitive effects of repeated ketamine infusions in TRBD are not known.

Methods

Six intravenous infusions of ketamine (0.5 mg/kg over 40 min) were administered on a Monday–Wednesday–Friday schedule during a 12-day period on 16 patients with TRBD followed by a 2-week observational period. The assessment of neurocognitive function was conducted using the MATRICS Consensus Cognitive Battery at baseline, 13 and 26 days. Tasks were designed to test speed of processing, working memory, visual learning and verbal learning.

Results

A significant improvement was found only in scores of speed of processing (F = 9.9, p = 0.001) after a 2-week observational period, which was accounted for by the improvement of depression symptoms. There were no significant changes over time in terms of working memory, visual learning and verbal learning. Pearson correlation analysis showed that the improvement of depression symptoms through six ketamine infusions was greater among TRBD patients with lower working memory at baseline (r = 0.54, p = 0.03). In multiple regression analysis, the significant correlation was still maintained (beta = 0.67, t = 2.2, p = 0.04).

Conclusion

This preliminary study indicated that six ketamine infusions were not harmful but were slightly beneficial for speed of processing in TRBD. However, this change was mainly accounted for the improvement of depression symptoms over time. Lower baseline working memory appears to be associated with greater antidepressant response after completion of six ketamine infusions in patients with TRBD.

"Influence of modifiable and non-modifiable variables on functioning in bipolar disorder: a path analytical study"

OBJECTIVE

The aim of this study was to investigate the influence of modifiable (mood, cognitive reserve, cognitive performance) and non-modifiable factors (diagnosis, suicide attempts, substance use, age) on self-reported functioning in BD.

METHODS

103 adults with no mood disorders and 95 individuals with BD completed the WHODAS 2.0, in addition to a neuropsychological battery and diagnostic assessments. Path analysis was then used to analyse the relationships between modifiable and non-modifiable predictors of functioning in the sample.

RESULTS

Cognitive reserve and age had an indirect influence on individual functioning, mediated by cognitive performance. The influence of diagnosis and depressive symptoms on functioning was partly direct, and partly mediated by cognition. The presence of psychiatric comorbidities in addition to BD also had a significant influence on individual functioning.

CONCLUSIONS

Initiatives focussed on modifiable factors such as depressive symptoms and cognitively stimulating activities, which increase cognitive reserve, may be a useful complement to existing treatments and help patients achieve functional recovery. KEY POINTS Individual functioning was influenced by cognitive performance, cognitive reserve, age, diagnosis and depressive symptoms. Executive functioning mediated the influence of age and cognitive reserve on individual functioning. Interventions focussed on depressive symptoms and cognitive stimulation may help patients achieve functional recovery.

Functioning in euthymic patients with bipolar disorder: A systematic review and meta-analysis using the Functioning Assessment Short Test

OBJECTIVES

Systematically review the prevalence of functional impairment (FI) in euthymic patients with bipolar disorder (BD), as assessed only with the Functioning Assessment Short Test (FAST), explore the prevalence of this impairment among all the domains, identify the most compromised of them and the clinical variables associated with low functioning in this population.

METHODS

Meta-analyses were performed, searching for relevant papers published from 2007 to 2019 in Medline, Embase, Cochrane, PsycINFO databases and via hand-searching, without language restrictions. 1128 studies were initially identified, 13 of which were ultimately chosen based on the eligibility criteria. A two-step meta-analysis was performed using the mean difference with a 95% confidence interval for continuous variables and proportion estimation with a fixed-effects model for categorical variables.

RESULTS

In the first step, all FAST domains showed worse FI in patients than in healthy controls, with significant differences between groups. In the second step, the prevalence of FI domains were as follows: global, 58.6%; occupational, 65.6%; cognitive, 49.2%; autonomy, 42.6%; interpersonal relationships, 42.1%; leisure, 29.2%; and financial issues, 28.8%. Residual depressive symptoms were the most frequently cited variable associated with FI.

CONCLUSIONS

This study reinforces the relevant functional impact of BD in this population and suggests that the occupational domain may be the most impaired. Greater efforts should be directed toward targeting functioning in patient care, as it constitutes the most meaningful endpoint of response to treatment, especially with occupational and cognitive rehabilitation, thus allowing patients to overcome the course of illness and carry fulfilling lives.

Minimum clinically important differences for the Functioning Assessment Short Test and a battery of neuropsychological tests in bipolar disorders: results from the FACE-BD cohort

AIMS

Establishing the minimum clinically important difference (MCID) in functioning and cognition is essential to the interpretation of the research and clinical work conducted in bipolar disorders (BD). The present study aimed to estimate the MCID for the Functioning Assessment Short Test (FAST) and a battery of neuropsychological tests in BD.

METHODS

Anchor-based and distributive methods were used to estimate the MCID for the FAST and cognition using data from a large, multicentre, observational cohort of individuals with BD. The FAST and cognition were linked with the Clinical Global Impressions Scale-Severity (CGI-S) and Global Assessment of Functioning (GAF) using an equipercentile method. The magnitude of the standard error measurement (s.e.m.) provided another estimate of the MCID.

RESULTS

In total, 570 participants were followed for 2 years. Cross-sectional CGI-S and GAF scores were linked to a threshold ⩽7 on the FAST for functional remission. The MCID for the FAST equalled 8- or 9-points change from baseline using the CGI-S and GAF. One s.e.m. on the FAST corresponded to 7.6-points change from baseline. Cognitive variables insufficiently correlated with anchor variables (all ρ <0.3). One s.e.m. for cognitive variables corresponded to a range of 0.45 to 0.93-s.d. change from baseline.

CONCLUSIONS

These findings support the value of the estimated MCID for the FAST and cognition and may be a useful tool to evaluate cognitive and functional remediation effects and improve patient functional outcomes in BD. The CGI-S and GAF were inappropriate anchors for cognition. Further studies may use performance-based measures of functioning instead.

Cognitive enhancement interventions for people with bipolar disorder: A systematic review of methodological quality, treatment approaches, and outcomes

BACKGROUND

Patients with bipolar disorder (BD) suffer from cognitive deficits across several domains. The association between cognitive performance and psychosocial functioning has led to the emergence of cognition as a treatment target.

OBJECTIVE

This study reviews the existing literature on cognitive enhancement interventions for people with BD, focusing on different treatment approaches and methodological quality.

METHODS

We conducted a systematic search following the PRISMA guidelines. Sample characteristics and main outcomes for each study and treatment characteristics for each approach were extracted. Study quality was assessed using the Clinical Trials Assessment Measure (CTAM) and Cochrane Collaboration's Risk of Bias tool by independent raters.

RESULTS

Eleven articles reporting data from seven original studies were identified encompassing 471 participants. Two treatment approaches were identified, cognitive and functional remediation. For controlled studies, methodological quality was modest (average CTAM score = 60.3), while the overall risk of bias was considered moderate. Beneficial effects on cognitive or functional outcomes were reported in the majority of studies (91%), but these findings were isolated and not replicated across studies. Key methodological limitations included small sample sizes, poor description of randomization process, high attrition rates, and participant exclusion from the analysis.

CONCLUSIONS

Findings are promising but preliminary. Quality studies were few and mostly underpowered. Heterogeneity in sample characteristics, outcome measures, and treatment approaches further limit the ability to generalize findings. Adequately powered trials are required to replicate initial findings, while moderators of treatment response and mechanisms of transfer need to be explored.

Shared and dissociable features of apathy and reward system dysfunction in bipolar I disorder and schizophrenia

BACKGROUND

Bipolar disorder I (BD-I) is defined by episodes of mania, depression and euthymic states. These episodes are among other symptoms characterized by altered reward processing and negative symptoms (NS), in particular apathy. However, the neural correlates of these deficits are not well understood.

METHODS

We first assessed the severity of NS in 25 euthymic BD-I patients compared with 25 healthy controls (HC) and 27 patients with schizophrenia (SZ). Then, we investigated ventral (VS) and dorsal striatal (DS) activation during reward anticipation in a Monetary Incentive Delayed Task and its association with NS.

RESULTS

In BD-I patients NS were clearly present and the severity of apathy was comparable to SZ patients. Apathy scores in the BD-I group but not in the SZ group correlated with sub-syndromal depression scores. At the neural level, we found significant VS and DS activation in BD-I patients and no group differences with HC or SZ patients. In contrast to patients with SZ, apathy did not correlate with striatal activation during reward anticipation. Explorative whole-brain analyses revealed reduced extra-striatal activation in BD-I patients compared with HC and an association between reduced activation of the inferior frontal gyrus and apathy.

CONCLUSION

This study found that in BD-I patients apathy is present to an extent comparable to SZ, but is more strongly related to sub-syndromal depressive symptoms. The findings support the view of different pathophysiological mechanisms underlying apathy in the two disorders and suggest that extra-striatal dysfunction may contribute to impaired reward processing and apathy in BD-I.

Predictors of quality of life in bipolar disorder: A path analytical study

Quality of life (QoL) is an important outcome in psychiatric illnesses like bipolar disorder (BD). However, little is known about the variables that affect it, and therefore contribute to prognosis and treatment outcomes in these populations. This study aimed to explore QoL in BD and investigate its relationship with modifiable (cognitive reserve, cognitive ability, mood symptoms) and non-modifiable factors (diagnosis, previous suicide attempts, substance misuse, age). The WHOQOL-bref was administered to 121 control participants and 109 patients with BD, who also underwent clinical and neuropsychological assessments. Factor analysis was used to identify latent constructs underlying WHOQOL-bref domains, and structural equation models were used to examine predictors of each latent construct. Two latent constructs were identified in the WHOQOL-bref, and labeled 'Personal' and 'Social' QoL. Both were directly predicted by depression symptoms and a diagnosis of BD, and indirectly predicted by (hypo)manic symptoms. Cognitive reserve was a stronger predictor of social QoL than a diagnosis of BD. Our findings suggest that the management of depression symptoms and fostering of cognitive reserve may improve QoL in BD. A diagnosis of BD and/or substance use disorders were risk factors for poor QoL, and may signal the need for preventive interventions to promote well-being.

Improved functioning following computerized working memory training (COGMED®) in euthymic patients with bipolar disorder and cognitive complaints: An exploratory study

BACKGROUND

Patients with bipolar disorder (BD) frequently have cognitive deficits even when euthymic. These deficits are considered one of the main drivers of functional disability in BD. This study investigated whether computerized working memory training using the COGMED® program in patients with BD can improve global functioning, therapeutic compliance, and subjective quality of life.

METHODS

For this naturalistic prospective study, 40 patients with BD and cognitive complaints were recruited. Sociodemographic, clinical, neurocognitive and functional data were collected before starting the remediation intervention (baseline). At home, patients used the web-based working memory training program COGMED® that included a battery of interactive games (daily sessions, five days per week for five weeks), supported by weekly phone-based feedback. The clinical, neurocognitive and functional assessment was repeated four weeks after the intervention end and compared with the baseline data.

RESULTS

Thirty-two patients completed the study. Compared with baseline, general functioning was improved after the working memory training program, as indicated by a mean reduction of 6.78 (SD 4.65) points in the Functioning Assessment Short Test (p<0.001). This result remained significant after controlling for depressive symptomatology improvement. Similarly, the scores of neuropsychological tests for cognitive complaints, as well as verbal and visuospatial working memory components were significantly different before and after the intervention (p<0.05). Conversely, the subjective quality of life and therapeutic compliance did not change.

LIMITATIONS

The naturalistic open-label, non-controlled design of this study precludes the conclusion regarding causality.

CONCLUSIONS

In patients with BD, global functioning is improved by computerized working memory remediation.

The Impact of Subsyndromal Bipolar Symptoms on Patient's Functionality and Quality of Life

Subsyndromal symptoms have rarely been in the focus of bipolar research. This may be, in part, due to the fact that there is neither a uniform definition nor do they constitute an indication of regulatory and commercial interest. Nevertheless, they do have a decisive impact on the long-term course of bipolar disorder (BD), and the degree of functionality and quality of life (QoL) is more likely determined by their presence or absence than by acute episodes. Summarizing the literature an estimated 20-50% of patients suffer inter-episodically or chronically from subsyndromal BD. The most prominent symptoms that interfere with functionality are subsyndromal depression, disturbances of sleep, and perceived cognitive impairment, whereas anxiety negatively impacts on QoL. In the absence of evidence-based pharmacological treatments for subsyndromal BD, clinical practice adopts guidelines designed for treatment-resistant full-blown episodes of BD, supplemented by cognitive-behavioral, family focused or social-rhythm-based psychotherapies.

[Exploring Early Maladaptative Schema (EMS) in adults with bipolar disorder: A systematic review of the scientific literature]

OBJECTIVES

Clinical heterogeneity during euthymic states is a crucial issue in bipolar disorders. Indeed, actual data are not sufficient to understand why some patients are unharmed by subthreshold symptoms and have functional impairments whereas others have a functional remission but have subthreshold symptoms. Based on the Ball model, cognitive and schematic vulnerability interact with genetic vulnerability and trigger affective symptoms with the intervention of stressful life events. Furthermore, according to this model, adjustment and adaptation to illness assessed by functional outcome and illness experience are associated with this cognitive and schematic vulnerability. So, theoretical arguments support that childhood adversity and temperamental deregulation characterize patients with bipolar disorders. Thus, the aim of this study is to systematically review studies of Early Maladaptive Schemas in bipolar disorder, to determine whether Early Maladaptive Schemas have specificity in bipolar disorder in comparison with other populations, and to identify which Early Maladaptive Schemas could be activated. The challenge of this review is to identify if the taking of early maladaptive schemas into account could allow us to better identify, understand and manage bipolar disorders.

METHODS

This systematic review was led according to the Preferred Reporting Items for Systematic review and Meta-Analysis statement on the electronic databases Cochrane, PsycArticles, Psychology and Behavioral Sciences Collection, PsycInfo, PubMed, ScienceDirect and Scopus with « early maladaptive schemas » AND « bipolar disorder » as keywords. Only studies meeting eligibility criteria concerning publication status, language, population and outcomes were included after several screenings on basis of title, abstract and full-text. Then, we carried out data extraction in accordance with criteria defined in principle (about characteristics of participants, objectives, materiel and methods, principle results and bias).

RESULTS

Among 39 records identified, a total of 10 studies met eligibility criteria for inclusion in this review. Synthesizing findings across the studies revealed three important topics. First, early maladaptive schemas appear as potential cognitive characteristics that clinicians have to investigate in clinical practice. Indeed, patients with bipolar disorders present greater activation of the early maladaptive schemas in comparison with people who have no disorder. This point supports the first part of Ball's theoretical model that considers schemas as a vulnerability to bipolarity. Secondly, early maladaptive schemas are relevant to distinguish bipolar disorders from unipolar depression and borderline personality disorder. A greater and a lower activation are respectively identified among bipolar disorders. Thirdly, supporting the second part of Ball's model, early maladaptive schemas play a key role in recovery regarding their impact on the course of bipolarity, in particular on suicidality and functional impairment. Finally, these dysfunctional schemas allow us to understand the clinical heterogeneity of bipolar disorder, and among others, about the type of bipolarity. These results have several implications, but there are some limits in this systematic review. First, no French study has been done. Then, reduced sample sizes in these studies increased the risk to conclude wrongly to an activation difference between groups. Furthermore, probably due to the variety of methods and populations, we could not identify an homogeneous pattern of early activated maladaptive schemas. Overall, scientific approaches used in these studies are based on statistical models using mean and standard deviation. These types of statistical analyses are the main limit because they cannot represent the heterogeneity of early maladaptive schemas profiles.

CONCLUSIONS

Schema theory proves to be a relevant approach in bipolar disorders, and early maladaptive schemas appear to be important to take into account in clinical practice. Nevertheless, in order to propose schemas therapy appropriately, it is necessary to specify if early maladaptive schemas are activated and to specify therapeutic indications because of clinical heterogeneity. Moreover, data do not yet allow us to understand the disparity of profiles during the inter-episode period. Indeed, a French research perspective is being considered that will prefer a person-oriented approach.

Association of subthreshold manic symptoms and cognitive impairments in euthymic patients with bipolar disorder I

Cognitive impairments exist during the euthymic period of bipolar disorder (BD). However, the impact of clinical factors (e.g., subthreshold symptoms and body mass index) on cognitive function in euthymic patients with bipolar disorder I is inconsistent. This cross-sectional study included 83 patients with euthymic BD I and 115 healthy controls. The Repeatable Battery for the Assessment of Neuropsychological Status indices were used to assess cognitive function. We assessed the relationship between cognitive function and clinical impact factors. Performance in language abilities, attention, and immediate memory was worse in euthymic BD I. Spearman's correlation revealed that indices for immediate memory and attention were negatively correlated with subthreshold manic symptoms, and indices for delayed memory were positively correlated with years of education. Linear regressions indicated that subthreshold manic symptoms were the best predictors of immediate memory and attention. Years of education predicted performance in most cognitive domains, except immediate memory. Individuals with euthymic BD I exhibited cognitive deficits in language learning, attention, and immediate memory. Our study highlights the importance of the effect of subthreshold manic symptoms on cognitive function in remitted BD; these symptoms should receive more attention and be targeted in personalized clinical therapeutic interventions.

The use of component-wise gradient boosting to assess the possible role of cognitive measures as markers of vulnerability to pediatric bipolar disorder

BACKGROUND AND AIMS

Cognitive impairments are primary hallmarks symptoms of bipolar disorder (BD). Whether these deficits are markers of vulnerability or symptoms of the disease is still unclear. This study used a component-wise gradient (CGB) machine learning algorithm to identify cognitive measures that could accurately differentiate pediatric BD, unaffected offspring of BD parents, and healthy controls.

METHODS

59 healthy controls (HC; 11.19 ± 3.15 yo; 30 girls), 119 children and adolescents with BD (13.31 ± 3.02 yo, 52 girls) and 49 unaffected offspring of BD parents (UO; 9.36 ± 3.18 yo; 22 girls) completed the CANTAB cognitive battery.

RESULTS

CGB achieved accuracy of 73.2% and an AUROC of 0.785 in classifying individuals as either BD or non-BD on a dataset held out for validation for testing. The strongest cognitive predictors of BD were measures of processing speed and affective processing. Measures of cognition did not differentiate between UO and HC.

CONCLUSIONS

Alterations in processing speed and affective processing are markers of BD in pediatric populations. Longitudinal studies should determine whether UO with a cognitive profile similar to that of HC are at less or equal risk for mood disorders. Future studies should include relevant measures for BD such as verbal memory and genetic risk scores.

Prevalence and determinants of cognitive impairment in the euthymic phase of bipolar disorders: results from the FACE-BD cohort

BACKGROUND

Cognitive deficits are a well-established feature of bipolar disorders (BD), even during periods of euthymia, but risk factors associated with cognitive deficits in euthymic BD are still poorly understood. We aimed to validate classification criteria for the identification of clinically significant cognitive impairment, based on psychometric properties, to estimate the prevalence of neuropsychological deficits in euthymic BD, and identify risk factors for cognitive deficits using a multivariate approach.

METHODS

We investigated neuropsychological performance in 476 euthymic patients with BD recruited via the French network of BD expert centres. We used a battery of tests, assessing five domains of cognition. Five criteria for the identification of neuropsychological impairment were tested based on their convergent and concurrent validity. Uni- and multivariate logistic regressions between cognitive impairment and several clinical and demographic variables were performed to identify risk factors for neuropsychological impairment in BD.

RESULTS

One cut-off had satisfactory psychometric properties and yielded a prevalence of 12.4% for cognitive deficits in euthymic BD. Antipsychotics use were associated with the presence of a cognitive deficit.

CONCLUSIONS

This is the first study to validate a criterion for clinically significant cognitive impairment in BD. We report a lower prevalence of cognitive impairment than previous studies, which may have overestimated its prevalence. Patients with euthymic BD and cognitive impairment may benefit from cognitive remediation.

Neurocognition and functional outcome in patients with psychotic, non-psychotic bipolar I disorder, and schizophrenia. A five-year follow-up

Background:

Bipolar disorder (BD) and schizophrenia (SZ) are characterized by neurocognitive and functional deficits with marked heterogeneity. It has been suggested that BD with a history of psychotic symptoms (BD-P) could constitute a phenotypically homogeneous subtype characterized by greater neurocognitive and functional impairments, or by a distinct trajectory of such deficits. The aim of this study was to compare the neurocognitive and functional course of euthymic BD-P, euthymic BD patients without a history of psychosis (BD-NP), stabilized patients with schizophrenia and healthy subjects, during a five-year follow-up.

Methods:

Neurocognitive and psychosocial function was examined in 100 euthymic patients with BD (50 BD-P, 50 BD-NP), 50 stabilized patients with schizophrenia (SZ), and 51 healthy controls (HC) at baseline (T1), and after a 5-year follow-up (T2).

Results:

The course of both neurocognitive performance and functional outcome of patients with SZ and BD (BD-P and BD-NP) is stable. The profile of neurocognitive impairment of patients with SZ or BD (BD-P and BD-NP), is similar, with only quantitative differences circumscribed to certain domains, such as working memory. The subgroup of patients with BD-NP does not show functional deterioration.

Conclusions:

We have not found evidence of progression in the neurocognitive or psychosocial impairment in any of the three groups of patients, although it cannot be dismissed the possibility of a subset of patients with a progressive course. Other longitudinal studies with larger samples and longer duration are necessary to confirm these findings.