Bipolar disorder and the metabolic syndrome: causal factors, psychiatric outcomes and economic burden

Pilot study of a ketogenic diet in bipolar disorder: a process evaluation

BACKGROUND

Bipolar disorder is a serious mental illness, which requires new strategies for prevention and management. Recent evidence suggests that a ketogenic diet may be an effective intervention. This research aimed to explore the feasibility and acceptability of a ketogenic diet intervention for bipolar disorder, fidelity to its behavioural components and the experiences of the participants and research clinicians involved.

METHODS

A mixed-methods process evaluation was conducted. Semi-structured telephone interviews were carried out with 15 participants 1-2 months after completing a 6-8 week modified ketogenic diet intervention, and 4 research clinicians from the study team following the completion of data collection. Data were thematically analysed. Fidelity checklists completed by research dietitians were analysed using descriptive count and percentage statistics. Findings are reported post-hoc, following the analysis and publication of the main pilot study findings. Reporting was guided by the COREQ checklist.

RESULTS

Five themes were identified in the qualitative data: (1) 'Encouraging entry and supporting exit' (e.g. recognising and managing participants' varied motives and expectations, including around weight loss and symptom alleviation); (2) 'Challenging but potentially transformational,' which reflects that while it can be difficult to initiate and maintain a ketogenic diet day-to-day, many participants perceived physical and psychological benefits (e.g. significant weight loss, mood stability and enhanced ability to focus); (3) 'Intervention facilitators,' including a range of behavioural (e.g. goal setting), social (e.g. family and dietitians) and technological (e.g. apps for monitoring) support mechanisms; (4) 'Intervention barriers' (e.g. dietary preferences, concerns about the diet and its impact, the testing burden and capacity of the delivery team); and (5) 'The wider context' (e.g. the cost of living and sociocultural expectations) was a crucial factor explaining differential experiences. Overall, descriptive analyses indicated moderate-to-good fidelity to the behaviour change components of the study.

CONCLUSION

We provide novel insight into the experiences of people living with bipolar disorder initiating and following a ketogenic diet, as well as those of research clinicians who support the intervention. Future trials may benefit from increased clinical research capacity, better-defined entry and exit routes, additional interpersonal support, and greater understanding of how social and societal factors impact participation.

TRIAL REGISTRATION

Study registration number: ISRCTN61613198 (02/03/22).

Pathophysiological relationships between cognitive deficit in bipolar affective disorder and metabolic syndrome

INTRODUCTION AND OBJECTIVES

Bipolar disorder (BD) has been related to various cognitive dysfunctions as well as to a high prevalence of metabolic syndrome (MS), which seems to influence the cognitive performance of patients with BD. Therefore, different hypotheses have been generated to try to explain the pathophysiological relationship between cognitive deficit in BD and MS. The objective was to review the current literature regarding the possible pathophysiological explanation of the relationship between BD and MS and its effect on cognitive performance of patients with BD.

METHODS

A bibliographic search was carried out using MEDLINE, ClinicalKey, EMBASE, Literatura Latino-Americana y del Caribe en Ciencias de la Salud [Latin American and Caribbean Literature in Health Sciences] (LILACS), APA PsycNet, Scopus and Scielo databases, and the Pan-American Medical Electronic Library; using the following search terms: "bipolar disorder"[MeSH Terms] OR "bipolar disorder"[All Fields] OR "mood disorders"[All Fields] AND "cognitive deficit"[MeSH Terms] OR "cognitive deficit"[All Fields] OR "cognitive dysfunction"[All Fields] OR "cognitive impairment"[All Fields] OR "cognitive decline"[All Fields] AND "metabolic syndrome" [MeSH Terms] OR "metabolic abnormalities"[All Fields] OR "metabolic effects"[All Fields] OR "obesity" [All Fields] OR "abdominal obesity" [All Fields] OR "overweight" [All Fields] OR "diabetes" [All Fields] OR "hypertension" [All Fields] AND "antipsychotics" [MeSH Terms] OR "antipsychotics"[All Fields] AND "antidepressants" [MeSH Terms] OR "antidepressants"[All Fields] AND "mood stabilizers" [MeSH Terms] OR "mood stabilizers"[All Fields]. Filters: free full text, full text, from 2001 to 2022. A total of 80 articles in Spanish and English, of any type of design, were selected. Selection and reading were carried out by all the authors.

RESULTS AND CONCLUSIONS

The various pathophysiological hypotheses proposed, inflammatory, endocrine, drug, environmental and social, suggest that a series of changes at the macro and microcellular level are correlated in patients with BD and MS with a negative effect on cognition of patients both globally and in specific domains, mainly executive function, memory, attention, and perceptual motor skills. Research processes should be continued to explore the various hypotheses that support the relationship between BD, MS and cognition.

Osteoporosis and low bone mass among schizophrenia and bipolar disorder: A cross-sectional study with newly diagnosed, drug-naïve subjects

BACKGROUND

A growing body of data shows that schizophrenia (SCZ) and bipolar disorder (BD) have substantial metabolic risks; however, few studies have focused on bone metabolism. This study aimed to assess the prevalence and associated influencing factors of low bone mass and osteoporosis in SCZ and BD before pharmacological effects occur.

METHODS

108 healthy controls (HCs) and drug-naïve individuals with SCZ (n = 56) and BD (n = 130) had their lumbar spine (L1-L4) and left femur (Neck/Trochanter/Ward's triangle) bone mineral density (BMD) determined using dual-energy X-ray absorptiometry. Besides, we measured bone turnover markers (BTMs) levels, including procollagen I N-terminal propeptide, osteocalcin, and C-terminal cross-linking telopeptide of type I collagen in different groups.

RESULTS

Individuals with SCZ and BD had significantly lower BMD and significantly higher prevalence of low bone mass and osteoporosis compared with HCs. In the main observation regions of the total lumbar (F = 18.368, p < 0.001) and left femur (F = 14.790, p < 0.001), BMD was lower in individuals with SCZ and BD than HCs, with SCZ showing lower BMD than BD. The osteocalcin (H = 11.421, p = 0.003) levels were significantly higher in SCZ and BD than HCs. Binary regression analysis showed that SCZ or BD was an independent risk factor for low bone mass and osteoporosis. In addition, sex, age, and BTMs also influenced the occurrence of low bone mass and osteoporosis.

LIMITATIONS

Cross-sectional study.

CONCLUSION

The results findings of the study might contribute to our understanding of the increased risk of bone metabolism in SCZ and BD.

CLINICAL TRIAL REGISTRATION

www.chictr.org.cn, identifier ChiCTR1900021379.

Increased metabolic variability in Korean patients with new onset bipolar disorder: a nationwide cohort study

Introduction

The aim of this study was to determine associations between changes of metabolic parameters and the development of BD using nationally representative data.

Methods

We used health examination data provided by the South Korean National Health Insurance System (NHIS) (n = 8,326,953). The variability of each metabolic parameter including weight circumference, blood pressure, fasting blood glucose, high-density lipoprotein cholesterol, and triglyceride levels was caculated using variability independent of mean (VIM) indices. The presence of metabolic syndrome was associated with new onset BD. Each metabolic parameter with high variability was associated with a higher risk of new onset BD compared to those with low variability after adjusting for age, sex, smoking, alcohol drinking, regular exercise, income status, baseline diabetes, hypertension, and dyslipidemia.

Results

As the number of highly variable metabolic parameters increased, the risk for new onset depression also increased even after covariates adjustment. The associations between new onset BD and metabolic variability were greater in populations with age > 50 years. In addition, these associations remained significant after adjusting for the presence of depression prior to diagnoses of BD.

Discussion

Our results suggest possibility of metabolic variability as an independent environmental risk factor for BD even after adjusting for the presence of metabolic syndrome.

The concept of "metabolic jet lag" in the pathophysiology of bipolar disorder: implications for research and clinical care

Bipolar disorder (BD) is a potentially chronic mental disorder marked by recurrent depressive and manic episodes, circadian rhythm disruption, and changes in energetic metabolism. "Metabolic jet lag" refers to a state of shift in circadian patterns of energy homeostasis, affecting neuroendocrine, immune, and adipose tissue function, expressed through behavioral changes such as irregularities in sleep and appetite. Risk factors include genetic variation, mitochondrial dysfunction, lifestyle factors, poor gut microbiome health and abnormalities in hunger, satiety, and hedonistic function. Evidence suggests metabolic jet lag is a core component of BD pathophysiology, as individuals with BD frequently exhibit irregular eating rhythms and circadian desynchronization of their energetic metabolism, which is associated with unfavorable clinical outcomes. Although current diagnostic criteria lack any assessment of eating rhythms, technological advancements including mobile phone applications and ecological momentary assessment allow for the reliable tracking of biological rhythms. Overall, methodological refinement of metabolic jet lag assessment will increase knowledge in this field and stimulate the development of interventions targeting metabolic rhythms, such as time-restricted eating.

Prevalence of eating disorders in patients with bipolar disorder: a scoping review of the literature

BACKGROUND

Eating disorder (ED) and bipolar disorder (BD) exhibit certain phenomenological similarities rooted in eating behavior and emotional regulation. However, despite the growing body of research on the comorbidity of ED and BD, scientific data on the concurrent course of these disorders has remained poorly systematized.

AIM

To conduct a scoping review of published data on the prevalence of various types of ED among patients with BD types I and II in the context of the sex and clinical features of the concurrent course of these disorders.

METHODS

The analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The search was conducted in the MEDLINE electronic database. Studies were included if they were focused samples of patients diagnosed with BD and ED, and the Diagnostic and Statistical Manual of Mental Disorders, fourth and fifth editions (DSM-IV, DSM-5), or International Statistical Classification of Diseases and Related Health Problems, tenth Revision (ICD-10), were used for the verification of the ED and BD diagnoses. The descriptive analysis method was used to summarize the review findings.

RESULTS

A total of 41 studies were selected for the review. Lifetime ED in patients with BD ranged from 2.2% to 31.1%, and the prevalence rates of BD among patients with ED varied from 11.3% to 68.1%. ED nominally had a higher prevalence among individuals with BD type II and females. Additionally, the presence of ED in patients with BD was associated with earlier onset of mood disorder, a higher number of depressive episodes, higher levels of atypical depressive symptoms, suicide attempts, as well as a higher frequency of comorbid obsessive-compulsive and anxiety disorders, addictions, and various metabolic disorders.

CONCLUSION

Despite the high degree of volatility in the results, the prevalence rates of a concurrent course of ED and BD are rather high. For this reason, screening for ED in patients with BD and vice versa holds significant value in the accurate diagnosis and selection of the most effective therapy. The patterns of comorbidity among different types of ED and BD, depending on gender, need further exploration in future research.

Genetic Pathways and Functional Subnetworks for the Complex Nature of Bipolar Disorder in Genome-Wide Association Study

Bipolar disorder is a complex psychiatric trait that is also recognized as a high substantial heritability from a worldwide distribution. The success in identifying susceptibility loci for bipolar disorder (BPD) has been limited due to its complex genetic architecture. Growing evidence from association studies including genome-wide association (GWA) studies points to the need of improved analytic strategies to pinpoint the missing heritability for BPD. More importantly, many studies indicate that BPD has a strong association with dementia. We conducted advanced pathway analytics strategies to investigate synergistic effects of multilocus within biologically functional pathways, and further demonstrated functional effects among proteins in subnetworks to examine mechanisms underlying the complex nature of bipolarity using a GWA dataset for BPD. We allowed bipolar susceptible loci to play a role that takes larger weights in pathway-based analytic approaches. Having significantly informative genes identified from enriched pathways, we further built function-specific subnetworks of protein interactions using MetaCore. The gene-wise scores (i.e., minimum p-value) were corrected for the gene-length, and the results were corrected for multiple tests using Benjamini and Hochberg’s method. We found 87 enriched pathways that are significant for BPD; of which 36 pathways were reported. Most of them are involved with several metabolic processes, neural systems, immune system, molecular transport, cellular communication, and signal transduction. Three significant and function-related subnetworks with multiple hotspots were reported to link with several Gene Ontology processes for BPD. Our comprehensive pathway-network frameworks demonstrated that the use of prior knowledge is promising to facilitate our understanding between complex psychiatric disorders (e.g., BPD) and dementia for the access to the connection and clinical implications, along with the development and progression of dementia.

Increased prevalence of metabolic syndrome in patients with bipolar disorder compared to a selected control group-a Northern Netherlands LifeLines population cohort study

OBJECTIVES

Metabolic syndrome (MetS) is highly prevalent among patients with bipolar disorder (BD). The aims of this cross-sectional study were to determine the prevalence of MetS in Dutch BD subjects and compare it with a control group, to examine the association of demographic and clinical characteristics with MetS in BD, and to determine the extent to which metabolic dysregulation is treated in those patients.

METHODS

493 Dutch adult patients (≥ 18 years) with BD receiving psychotropic drugs and 493 matched control subjects were compared using data from the biobank Lifelines. We determined MetS according to the National Cholesterol Education Program Adult Treatment Panel III-Adapted (NCEP ATP III-A) criteria. The difference in the prevalence of MetS and the associations with characteristics were analyzed with logistic regression.

RESULTS

BD subjects (30.6%) showed a significantly higher prevalence of MetS compared to the control group (14.2%) (p < .001, OR:2.67, 95% CI:1.94-3.66). Univariate analysis showed that smoking, body mass index (BMI) and antidepressant drug use were associated with MetS. Multivariate analysis showed that smoking (OR:2.01) was independently associated with MetS in BD. For hypertension, hyperglycemia and lipid disorder pharmacological treatment was provided to respectively 69.5%, 24% and 18.4% of the BD subjects in our sample.

LIMITATIONS

Duration of illness of BD subjects was unknown.

CONCLUSIONS

This study demonstrated a higher prevalence of MetS in Dutch BD subjects compared to persons without BD. In addition, a remarkable undertreatment of some of the components of MetS was found.

Lithium therapy and weight change in people with bipolar disorder: A systematic review and meta-analysis

Lithium remains the gold standard maintenance treatment for Bipolar Disorder (BD). However, weight gain is a side effect of increasing relevance due to its metabolic implications. We conducted a systematic review and meta-analysis aimed at summarizing evidence on the use of lithium and weight change in BD. We followed the PRISMA methodology, searching Pubmed, Scopus and Web of Science. From 1003 screened references, 20 studies were included in the systematic review and 9 included in the meta-analysis. In line with the studies included in the systematic review, the meta-analysis revealed that weight gain with lithium was not significant, noting a weight increase of 0.462 Kg (p = 0158). A shorter duration of treatment was significantly associated with more weight gain. Compared to placebo, there were no significant differences in weight gain. Weight gain was significantly lower with lithium than with active comparators. This work reveals a low impact of lithium on weight change, especially compared to some of the most widely used active comparators. Our results could impact clinical decisions.

Insulin Resistance and Blood-Brain Barrier Dysfunction Underlie Neuroprogression in Bipolar Disorder

Bipolar disorder (BD) often progresses to a more chronic and treatment resistant (neuroprogressive) course. Identifying which patients are at risk could allow for early intervention and prevention. Bipolar disorder is highly comorbid with metabolic disorders including type II diabetes mellitus (T2DM), hypertension, obesity, and dyslipidemia. Our studies have shown that insulin resistance (IR) is present in over 50% of patients with BD and that IR might underlie the progression of BD. While no confirmed predictors exist for identifying which patients with BD are likely to develop a more chronic course, emerging evidence including our own studies suggest that IR and related inflammatory pathways lead to impairments in blood-brain barrier (BBB) functioning. For the first time in living psychiatric patients, we have shown that the severity of BBB leakage is proportional to BD severity and is associated with IR. In this hypothesis paper we (i) highlight the evidence for a key role of IR in BD, (ii) show how IR in BD relates to shared inflammatory pathways, and (iii) hypothesize that these modulations result in BBB leakage and worse outcomes in BD. We further hypothesize that (iv) reversing IR through lifestyle changes or the actions of insulin sensitizing medications such as metformin, or optimizing BBB function using vascular protective drugs, such as losartan, could provide novel strategies for the prevention or treatment of neuroprogressive BD.

Relationship Between Serum Agouti-Related Peptide Levels and Metabolic Syndrome in Euthymic Bipolar Patients

INTRODUCTION

Agouti-Related Peptide (AgRP) is expressed primarily in the hypothalamic arcuate nucleus, stimulates appetite and decreases metabolism and energy expenditure. The aim of our study is to evaluate the relationship between serum Agouti-Related Peptide (AgRP) levels and metabolic syndrome in euthymic bipolar patients.

METHODS

Forty euthymic bipolar patients who used only mood stabilizer for at least three months and 40 healthy volunteers as control group were included in the study. We measured fasting blood glucose levels and serum levels of AgRP, total cholesterol, triglyceride, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) of all participants. The main outcome measure was the difference between patients and control groups in terms of metabolic syndrome frequency and the relationship between serum AgRP level and metabolic syndrome is also investigated.

RESULTS

The metabolic syndrome was significantly more common in euthymic bipolar patients than in control group (p=0.039). Additionally, levels of blood glucose and triglyceride were significantly higher in the patient group than in the control group (p=0.006 and 0.01 respectively). Serum AgRP levels did not differ between the patient and control groups (p=0.35). Also, in euthymic bipolar patients, there was no significant difference in serum AgRP levels between patients with metabolic syndrome and those without (p=0.754).

CONCLUSION

We found significantly higher frequency of metabolic syndrome in euthymic bipolar patients than in the control group. However, there was no significant difference in the levels of serum AgRP between bipolar patients with and without metabolic syndrome in either study groups.

Mood disorders comorbidity in obese bariatric patients: the role of the emotional dysregulation

BACKGROUND

Obese patients seeking bariatric surgery are known to show high rates of mental disorders, mainly mood and eating disorders. The aim of the present study is to evaluate psychiatric comorbidities, affective temperamental dimensions, emotional dysregulation and impulsivity in a sample of obese bariatric patients, exploring the differences between obese patients with and without mood disorders (MD).

METHODS

A total of 69 obese patients were consecutively enrolled between March and November 2019 during the presurgical evaluation routinely performed before the bariatric intervention. Sociodemographic and clinical features were collected by psychiatrists during a single consultation. Affective temperaments, emotional dysregulation and impulsivity were also investigated through self-report questionnaires. Epidemiological and clinical variables were compared between patients with and without MD.

RESULTS

In our sample, almost 3 out of 4 patients presented a lifetime psychiatric disorder, mainly MD (n=33, 48%), binge eating disorder (BED) (n=34, 49%) and anxiety disorders (n=30, 43%). Compared to N-MD patients, those with MD showed higher rates of psychiatric comorbidity with BED, bulimia and panic disorder. In addition, obese patients with MD showed more frequently cyclothymic, depressive and anxious temperaments, and higher mean scores on the psychometric questionnaires assessing emotional dysregulation and impulsivity compared to obese subjects without MD.

LIMITATIONS

the small sample size, the retrospectively assessment of psychiatric disorders and the self-report questionnaires.

CONCLUSIONS

A subgroup of obese patients, especially among those with MD, show high emotional dysregulation, affective lability and impulsiveness that could represent suitable substrates for the development of compulsive and addictive eating habits.

Prolonged functional cerebral asymmetry as a consequence of dysfunctional parvocellular paraventricular hypothalamic nucleus signaling: An integrative model for the pathophysiology of bipolar disorder

Approximately 45 million people worldwide are diagnosed with bipolar disorder (BD). While there are many known risk factors and models of the pathologic processes influencing BD, the exact neurologic underpinnings of BD are unknown. We attempt to integrate the existing literature and create a unifying hypothesis regarding the pathophysiology of BD with the hope that a concrete model may potentially facilitate more specific diagnosis, prevention, and treatment of BD in the future. We hypothesize that dysfunctional signaling from the parvocellular neurons of the paraventricular hypothalamic nucleus (PVN) results in the clinical presentation of BD. Functional damage to this nucleus and its signaling pathways may be mediated by myriad factors (e.g. immune dysregulation and auto-immune processes, polygenetic variation, dysfunctional interhemispheric connections, and impaired or overactivated hypothalamic axes) which could help explain the wide variety of clinical presentations along the BD spectrum. The neurons of the PVN regulate ultradian rhythms, which are observed in cyclic variations in healthy individuals, and mediate changes in functional hemispheric lateralization. Theoretically, dysfunctional PVN signaling results in prolonged functional hemispheric dominance. In this model, prolonged right hemispheric dominance leads to depressive symptoms, whereas left hemispheric dominance correlated to the clinical picture of mania. Subsequently, physiologic processes that increase signaling through the PVN (hypothalamic-pituitaryadrenal axis, hypothalamic- pituitary-gonadal axis, and hypothalamic-pituitary-thyroid axis activity, suprachiasmatic nucleus pathways) as well as, neuro-endocrine induced excito-toxicity, auto-immune and inflammatory flairs may induce mood episodes in susceptible individuals. Potentially, ultradian rhythms slowing with age, in combination with changes in hypothalamic axes and maturation of neural circuitry, accounts for BD clinically presenting more frequently in young adulthood than later in life.

A miRNome analysis of drug-free manic psychotic bipolar patients versus healthy controls

The lifetime presence of psychotic symptoms is associated with more clinical severity, poorer outcome and biological changes in patients affected by bipolar disorder (BD). Epigenetic mechanisms have been evoked to explain the onset of psychotic symptoms in BD as well as the associated biological changes. The main objective of the present study was to evaluate the expression profiles of circulating microRNAs (miRNAs) in drug-free manic psychotic bipolar patients versus healthy controls (HC), to identify possible non-invasive molecular markers of the disorder. 15 drug-free manic psychotic bipolar patients and 9 HC were enrolled and 800 miRNAs expression profile was measured by Nanostring nCounter technology on plasma samples and validated through qPCR. Overall, twelve miRNAs showed a significantly altered expression between the two groups (p < 0.05). Functional annotation of predicted miRNAs targets by MultiMIR R tool showed repression in bipolar patients of genes with a role in neurodevelopment and neurogenesis, and upregulation of genes involved in metabolism regulation. We identified a signature of circulating miRNA characteristic of manic psychotic bipolar patients, suggesting a possible role in neurodevelopment and metabolic processes regulation.

Considering a Potential Role of Linalool as a Mood Stabilizer for Bipolar Disorder

Epidemiologic studies suggest that the lifetime prevalence of bipolar spectrum disorders ranges from 2.8 to 6.5 percent of the population. To decrease morbidity and mortality associated with disease progression, pharmacologic intervention is indicated for the majority of these patients. While a number of effective treatment regimens exist, many conventional medications have significant side effect profiles that adversely impact patients' short and long-term well-being. It is thus important to continue advancing and improving therapeutic options available to patients. This paper reviews the limitations of current treatments and examines the chemical compound Linalool, an alcohol found in many plant species, that may serve as an effective mood stabilizer. While relatively little is known about Linalool and bipolar disorder, the compound has been shown to have antiepileptic, anti-inflammatory, anxiolytic, anti-depressive, and neurotrophic effects, with mechanisms that are comparable to current bipolar disorder treatment options.

The association between leptin and adiponectin, and metabolic syndrome components and serum levels of lipid peroxidation in bipolar disorder patients treated with lithium and valproic acid

BACKGROUND

The aim of study is to assess a relation between the adiponectin and leptin levels, and metabolic syndrome components and lipid peroxidation treated with Li and VPA in bipolar disorder patients and compared with controls.

MATERIALS AND METHODS

56 patients and 31 healthy controls were enrolled. The ATP III criteria were used to determine metabolic syndrome components. Leptin, adiponectin, lipid peroxidation and lipid profiles were measured.

RESULTS

Malondialdehyde in Li patients was higher than VPA patients. BMI, waist circumference (WC), triglyceride, malondialdehyde and adiponectin levels were increased, whereas HDL-cholesterol (VPA treated patients) and leptin were decreased in patients compared with controls. Leptin and adiponectin were correlated with WC, triglyceride and malondialdehyde in both groups. Adiponectin was correlated with HDL-cholesterol in VPA patients.

CONCLUSION

Patients should be checked metabolic syndrome components, serum leptin and adiponectin level occasionally to prevent possible deficiency or pathologic increase of these parameters.

Higher Prevalence of Metabolic Syndrome in Child-adolescent Patients with Bipolar Disorder

Objective

Previous studies have indicated a convergent and bidirectional relationship between metabolic syndrome (MetS) and bipolar disorder (BD). As most of these studies focused mainly on adults diagnosed with BD, our study aims to investigate and characterize metabolic disturbances in child-adolescents diagnosed with BD.

Methods

We retrospectively examined the medical records of psychiatric hospitalizations with admitting diagnosis of BD in child-adolescents (age < 18 years). Body mass index (BMI), lipid profile, fasting blood glucose, and blood pressure were primary variables. National Cholesterol Education Program criteria were used to define MetS. Reference group data was obtained from the National Health and Nutrition Examination Survey study. Statistical analyses included ttests, chi-square tests, and Fisher’s exact tests.

Results

We identified 140 child-adolescent patients with BD (mean age = 15.12 ± 1.70 years, 53% male). MetS was significantly more common in BD compared to the reference group: 14% (95% confidence interval [95% CI] 8−20) vs. 6.7% (95% CI 4.1−9.2), p = 0.001 with no significant difference by sex. MetS components were higher in the BD group, particularly BMI ≥ 95% (25% vs. 11.8%, p < 0.001) and high blood pressure (17% vs. 8%, p = 0.05). Moreover, female patients had lower odds of high blood pressure (odds ratio = 0.24 [95% CI 0.08−0.69], p = 0.005).

Conclusion

Compared with the general child-adolescent population, the prevalence of MetS was significantly higher in patients with BD of same age. This reiterates the notion of an increased risk of MetS in patients diagnosed with BD; and thus, further exploration is warranted.

Neuroinflammation in Bipolar Depression

Bipolar disorder (BD) is a leading cause of worldwide disability among mood disorders. Pathological mechanisms are still vastly unclear, and current treatments with conventional medications are often unsatisfactory in maintaining symptoms control and an adequate quality of life. Consequently, current research is focusing on shedding new light on disease pathogenesis, to improve therapeutic effectiveness. Recent evidence has suggested a prominent role of inflammation in mood disorders. Elevated levels of peripheral proinflammatory mediators have been reported in BD, as well as in other mood disorders, and people with systemic autoimmune diseases have an increased risk of developing BD. These immunological alterations are stable, and current medications are unable to alter peripheral concentrations even when clinical improvement is evident. These findings have also been replicated in the central nervous system (CNS) milieu, whereas genetic studies have shown that these immune alterations are not due to the disorder itself, being detectable before the illness onset. Moreover, these inflammatory modifications seem to be affected by and linked to other biomarkers of the disorder, such as alterations of white matter (WM) microstructure, metabolism, kynurenine pathway, and circadian rhythmicity. Finally, these immune variations seem to be useful as predictors of therapeutic responsiveness to medications, and in discriminating between clinically different outcomes. The objective of this review is to summarize available evidence on the connection between inflammation and BD, focusing on peripheral inflammatory markers and recent findings on their connection with other typical features of BD, to outline a general overview of the disorder. Moreover, it is meant to analyze the issues with data gathering and interpretation, given the partially contradictory and inconsistent nature of results.

Total gray matter volume is reduced in individuals with bipolar disorder currently treated with atypical antipsychotics

BACKGROUND/AIMS

Recent evidence indicates that the intake of atypical antipsychotics (AAP) is associated with gray matter abnormalities in patients with psychiatric disorders. We explored if patients with bipolar disorder (BD) who are medicated with AAP exhibit total gray matter volume (TGV) reduction compared to BD individuals not medicated with AAP and healthy controls (HC).

METHODS

In a cross-sectional design, 124 individuals with BD and 86 HC underwent 3T-MRI of the brain and clinical assessment as part of our BIPFAT-study. The TGV was estimated using Freesurfer. We used univariate covariance analysis (ANCOVA) to test for normalized TGV differences and controlled for covariates.

RESULTS

ANCOVA results indicated that 75 BD individuals taking AAP had significantly reduced normalized TGV as compared to 49 BD not taking AAP (F = 9.995, p = .002., Eta = 0.084) and 86 HC (F = 7.577, p = .007, Eta = 0.046).

LIMITATIONS

Our cross-sectional results are not suited to draw conclusions about causality. We have no clear information on treatment time and baseline volumes before drug treatment in the studied subjects. We cannot exclude that patients received different psychopharmacologic medications prior to the study point. We did not included dosages into the calculation. Many BD individuals received combinations of psychopharmacotherapy across drug classes. We did not have records displaying quantitative alcohol consumption and drug abuse in our sample.

CONCLUSIONS

Our data provide further evidence for the impact of AAP on brain structure in BD. Longitudinal studies are needed to investigate the causal directions of the proposed relationships.

Cognitive Development in Patients with Bipolar Disorder and Metabolic Syndrome

OBJECTIVE

To describe and discuss current evidence on the relationship between cognitive performance, Bipolar Affective Disorder (BAD) and Metabolic Syndrome (MS).

METHODS

We searched for related articles in different bibliographic databases (MEDLINE, EMBASE, Scielo) and performed a narrative review of the literature with the selected articles.

RESULTS

To date, evidence has not been conclusive and the effect of MS on BD has not been widely studied, but important correlations have been observed with individual metabolic variables. It is suggested that obesity in patients with BAD is associated wotj worse performance in verbal memory, psychomotor processing speed, and sustained attention. Hypertriglyceridemia in patients with BAD appears to be associated with a lower score in executive function tasks; hypertension appears to be associated with impairment in overall cognitive function.

CONCLUSIONS

Despite the associations between MS and poor cognitive performance in patients suffering from BAD, more studies are required to precisely determine how these variables are related to each other.

High Prevalence of Metabolic Syndrome Among Adolescents and Young Adults With Bipolar Disorder

OBJECTIVE

Despite abundant literature demonstrating increased metabolic syndrome (MetS) prevalence and important clinical correlates of MetS among middle-age adults with bipolar disorder, little is known about this topic among adolescents and young adults early in their course of bipolar disorder. We therefore examined this topic in the Course and Outcome of Bipolar Youth (COBY) study.

METHODS

A cross-sectional, retrospective study was conducted of 162 adolescents and young adults (mean ± SD age = 20.8 ± 3.7 years; range, 13.6-28.3 years) with bipolar disorder (I, II, or not otherwise specified, based on DSM-IV) enrolled in COBY between 2000 and 2006. MetS measures (blood pressure, glucose, high-density lipoprotein cholesterol [HDL-C], triglycerides, and waist circumference), defined using the International Diabetes Federation criteria, were obtained at a single timepoint. Mood, comorbidity, and treatment over the 6 months preceding the MetS assessment were evaluated using the Longitudinal Interval Follow-Up Evaluation.

RESULTS

The prevalence of MetS in the sample was 19.8% (32/162). Low HDL-C (56.5%) and abdominal obesity (46.9%) were the most common MetS criteria. MetS was nominally associated with lower lifetime global functioning at COBY intake (odds ratio [OR] = 0.97, P = .06). MetS was significantly associated with percentage of weeks in full-threshold pure depression (OR = 1.07, P = .02) and percentage of weeks receiving antidepressant medications (OR = 1.06, P = .001) in the preceding 6 months. MetS was not associated with manic symptoms or medications other than antidepressants.

CONCLUSIONS

The prevalence of MetS in this sample was at least double compared to the general population. Moreover, MetS is associated with increased burden of depression symptoms in this group. Management of early-onset bipolar disorder should integrate strategies focused on modifying MetS risk factors.

Adiponectin levels in patients with bipolar disorder: A systematic review and meta-analysis

Bipolar disorder (BD) is associated with high prevalence rates of obesity-related conditions and subclinical inflammation. Adiponectin is produced by adipose tissue and exerts anti-inflammatory activities. We aimed to perform a systematic review and meta-analysis of studies investigating adiponectin levels in BD patients and healthy controls. Electronic databases were searched from their inception until 15th Jan 2019. Random-effects models with the Hedges' g as the effect size (ES) estimate were used. We included 11 studies, representing 477 patients and 380 controls. Pooled data analysis revealed no significant differences in adiponectin levels between BD patients and controls (ES = 0.28, 95%CI: -0.34 - 0.90, p = 0.372). The levels of adiponectin were significantly higher during euthymia (ES = 1.09, 95%CI: 0.03-2.16, p = 0.044). The levels of adiponectin in depressed patients were lower, but this result did not reach statistical significance (ES = -0.90, 95%CI: -1.85 - 0.05, p = 0.063). Due to low number of studies, the subgroup analysis of manic patients was not performed; however, a severity of manic symptoms was not associated with the ES estimates. Longer illness duration and a higher percentage of BD type I (BD-I) patients were associated with higher ES estimates. A higher severity of depressive symptoms was associated with lower ES estimates. Heterogeneity was significant in all analyses. Results of the Egger's test were insignificant, showing no publication bias. Our results indicate that adiponectin might be a state marker of BD as it appears to be elevated in euthymia and decreased in depression. Illness progression and a diagnosis of BD-I might contribute to higher adiponectin levels.

Neurococognitive and neuroimaging correlates of obesity and components of metabolic syndrome in bipolar disorder: a systematic review

BACKGROUND

Individuals with bipolar disorder (BD) have a higher prevalence of obesity and metabolic syndrome (MetS) compared with the general population. Obesity and MetS are associated with cognitive deficits and brain imaging abnormalities in the general population. Obesity and components of MetS might potentially associate with neuroimaging and neurocognitive findings in BD.

METHODS

A literature search of studies investigating the association between obesity (and other components of MetS) and neurocognitive and neuroimaging findings in BD was conducted. In addition to a systematic review, a random-effects meta-analysis was conducted when sufficient data were available.

RESULTS

Twenty-three studies were included in the current systematic review. Overweight/obese patients were significantly associated with impaired neurocognition compared normal weight individuals with BD (d = 0.37). The most robust association between obesity and cognitive deficits in BD was observed in the cognitive subdomain of executive functions (d = 0.61). There was also evidence for a significant relationship between cognitive impairment in BD and other components of MetS including hypertension, dyslipidemia, and diabetes. Overweight/obese individuals with BD had more pronounced brain imaging abnormalities than normal weight individuals with BD.

CONCLUSIONS

Obesity and related cardiovascular risk factors significantly are associated with more severe cognitive and brain imaging abnormalities in BD. Medical co-morbidities can potentially contribute to functional decline observed in some patients throughout the course of BD.

Impaired glucose metabolism in bipolar patients and response to mood stabilizer treatments

BACKGROUND

Metabolic dysfunctions in patients with bipolar disorder (BD) are critical factors that interfere with outcome, but only one study evaluated the influence of glucose dysmetabolism on the response to treatment with lithium. We aimed to investigate the potential impact of glucose metabolic status on clinical characteristics of BD patients and their response to treatment with different mood stabilizers in monotherapy or in combination.

METHODS

45 BD patients with insulin resistance (IR) or type 2 diabetes mellitus (DM2) and 46 patients with normal glucose metabolism, treated with mood stabilizers for at least one year were assessed by diagnostic and rating instruments. Their clinical characteristics were compared and an ordinal logistic regression model was adopted to identify possible predictors of response to mood stabilizer treatments.

RESULTS

Compared to patients with normal glucose metabolism, BD patients with impaired glucose metabolism showed a worse clinical presentation of their psychiatric illness and a worse response to mood stabilizers. Ordinal logistic regression analysis evidenced that impaired glucose metabolism was the only predictor of poor response to mood stabilizers (OR 4.3; 95% CI: 1.7-11.1; p < 0.002).

LIMITATIONS

Cross-sectional design and the relatively small sample size, are the main limitations of our study.

CONCLUSIONS

Our findings expand literature data suggesting that BD patients with impaired glucose metabolism are at a greater risk of not responding to lithium as well as to different mood stabilizer treatments.

Dynamic Changes of the Mitochondria in Psychiatric Illnesses: New Mechanistic Insights From Human Neuronal Models

Mitochondria play a crucial role in neuronal function, especially in energy production, the generation of reactive oxygen species, and calcium signaling. Multiple lines of evidence have suggested the possible involvement of mitochondrial deficits in major psychiatric disorders, such as schizophrenia and bipolar disorder. This review will outline the current understanding of the physiological role of mitochondria and their dysfunction under pathological conditions, particularly in psychiatric disorders. The current knowledge about mitochondrial deficits in these disorders is somewhat limited because of the lack of effective methods to dissect dynamic changes in functional deficits that are directly associated with psychiatric conditions. Human neuronal cell model systems have been dramatically developed in recent years with the use of stem cell technology, and these systems may be key tools for overcoming this dilemma and improving our understanding of the dynamic changes in the mitochondrial deficits in patients with psychiatric disorders. We introduce recent discoveries from new experimental models and conclude the discussion by referring to future perspectives. We emphasize the significance of combining studies of human neuronal cell models with those of other experimental systems, including animal models.

Health status and mobility limitations are associated with residential and employment status in schizophrenia and bipolar disorder

INTRODUCTION

Schizophrenia (SCZ) and bipolar disorder (BP) are linked to multiple impairments in everyday functioning which share cognitive and symptom risk factors. Other risk factors for critical aspects of every day functioning (e.g., gainful employment; residential independence) such as physical health have not been evaluated, despite poor health in SCZ and BP.

METHODS

We analyzed 20-year follow-up data from the Suffolk County Mental Health Project cohort of consecutive first admissions with a psychotic disorder to 12 psychiatric facilities in Suffolk County, NY, between September 1989 and December 1995. Both 20-year symptom, health, and cognition data, and the 20-year course of weight gain were included as predictors of employment and residence status.

RESULTS

The analysis sample consisted of 122 participants with SCZ ad BP, with SCZ participants less likely to work or live independently. Correlational analyses showed symptoms and cognition predicted vocational outcomes in both samples. The effect of diagnosis was significant for both gainful employment and independence in residence. After consideration of diagnosis, mobility and negative symptoms predicted gainful employment in both samples, but there were no additional predictors of residential independence. Prospective analysis of BMI found that baseline BMI, but not changes during the 20-year follow up, predicted labor force participation.

DISCUSSION

Health status limitations were associated with residential and, particularly, employment status independent from other, previously established predictors of everyday outcomes, including cognition and symptoms. The importance of health status limitations for predicting outcome was confirmed in both SCZ and BP, with schizophrenia representing the more impaired group.

Twenty-year progression of body mass index in a county-wide cohort of people with schizophrenia and bipolar disorder identified at their first episode of psychosis

OBJECTIVE

There is an increased prevalence of obesity in schizophrenia and bipolar disorder, leading to a disproportionate risk of adverse health conditions. Prospective, long-term weight gain data, however, are scarce.

METHODS

We analyzed data from the Suffolk County Mental Health Project cohort of consecutive first admissions with psychosis recruited from September 1989 to December 1995 and subsequently followed for 20 years, focusing on people with schizophrenia (n=146) and bipolar disorder (n=87). The time course of weight gain was examined using a 2 (group)×5 (time) mixed-model repeated measures ANOVA, and body mass index (BMI) scores at the first (6 months) and second (2 years) assessments were compared to examine whether early overweight predicted later obesity.

RESULTS

There was a statistically significant effect of time (F(1,210)=68.06, P<.001) and diagnosis (F(1,210)=29.18, P<.001) on BMI, but not the interaction of time×diagnosis (F(1,210)=0.88, P=.48). Most participants had normal BMIs at the first two assessments. Early overweight was a predictor of eventual obesity for both groups. At the 20-year follow-ups, approximately 50% of the bipolar and 62% of the schizophrenia sample were obese, with a greater prevalence of obesity in schizophrenia at each assessment (all P<.02), except for years 4 (P=.12) and 20 (P=.27).

CONCLUSIONS

Nearly two-thirds of the participants with schizophrenia and over half of those with bipolar disorder were obese 20 years after first hospitalization for psychosis, considerably higher than the rate for adults in New York State (27%). Early intervention may be required to prevent long-term consequences of obesity-related morbidity and mortality.

The role of tryptophan metabolism and food craving in the relationship between obesity and bipolar disorder

BACKGROUND & AIMS

Individuals with bipolar disorder (BD) have a significantly increased risk of obesity-related conditions. The imbalance between food intake and energy expenditure is assumed to be a major risk factor for obesity in BD. This study analyzed food craving in relation to anthropometric, metabolic, and neurobiological parameters in a well-characterized cohort of euthymic individuals with BD.

METHODS

One-hundred-thirty-five patients completed the Food-Craving Inventory assessing four categories of food craving (fat, fast-food, sweets and carbohydrate craving). Additionally, clinical, metabolic and anthropometric parameters were assessed.

RESULTS

Higher levels of fat craving were observed in males, versus females, with BD. High levels of carbohydrate craving positively correlated with kynurenine and the kynurenine-to-tryptophan ratio. Higher serum nitrite and neopterin levels were related to fat craving. Parameters of fat metabolism (triglycerides, high-density lipoprotein) were associated with fat and fast-food craving. Anthropometric measures of obesity (e.g. body mass index, waist-to-hip-ratio) were not related to food craving.

CONCLUSIONS

Overweight/obese individuals with BD show an increased driving of tryptophan down the kynurenine pathways, as indicated by an increase in the serum kynurenine-to-tryptophan ratio. The driving of tryptophan down the kynurenine pathway is mediated by immune-inflammatory activity and stress. The correlation of increased kynurenine with food craving, especially carbohydrate craving, probably indicates a regulatory deficit in the maintenance of chronic inflammatory processes in obesity and BD. Food craving seems to be of clinical importance in the treatment of metabolic disturbances in BD, although not associated with anthropometric measures of obesity. Rather, food craving correlates with blood metabolic parameters and an increased activation of the kynurenine pathway, both of which are linked to higher affective symptomatology and the development of cardiovascular diseases.

Prevalence of metabolic syndrome and its clinical correlates among patients with bipolar disorder

OBJECTIVE

To assess the prevalence of metabolic syndrome (MetS) in patients with bipolar disorder (BD) and examine the clinical correlates of MetS.

METHODS

Sixty-seven patients with BD were evaluated for presence for MetS. The consensus definition was used to define MetS. The clinical variables were recorded on the basis of information provided by the patients, accompanying caregivers and review of treatment records. The symptoms severity of present depressive and manic episode was assessed by using Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) respectively.

RESULTS

The prevalence of MetS was 53.7%. Patients with MetS were older than the patients with BD alone (P=0.001). Increased waist circumference was the most common abnormal parameter (74.6%) followed by low high density lipoprotein (HDL) (71.6%) and raised triglycerides (64.2%). High blood pressures were recorded in 35.8% with high fasting blood glucose levels were seen in 33.3%. MetS was associated with greater number of life time episodes (p=0.010), longer duration of illness (p=0.010), greater numbers of lifetime depressive episodes (p<0.001). Substance use (alcohol and nicotine) associated with significantly higher prevalence of high blood pressure among MetS patients (p<0.001) while abnormal triglyceride level shown associated with substance use (p=0.010). Age of the patients, number of lifetime depressive episodes and use of Olanzapine were found to predictive of the development of MetS.

CONCLUSIONS

Patients with BD have high prevalence of MetS and its presence correlates with clinical variables.

Medical comorbidity in bipolar disorder: The link with metabolic-inflammatory systems

BACKGROUND

Bipolar disorder (BD) is associated with chronic low-grade inflammation, several medical comorbidities and a decreased life expectancy. Metabolic-inflammatory changes have been postulated as one of the main links between BD and medical comorbidity, although there are few studies exploring possible mechanisms underlying this relationship. Therefore, the aims of the current narrative review were 1) synthesize the evidence for metabolic-inflammatory changes that may facilitate the link between medical comorbidity and BD and 2) discuss therapeutic and preventive implications of these pathways.

METHODS

The PubMed and Google Scholar databases were searched for relevant studies.

RESULTS

Identified studies suggested that there is an increased risk of medical comorbidities, such as autoimmune disorders, obesity, diabetes and cardiovascular disease in patients with BD. The association between BD and general medical comorbidities seems to be bidirectional and potentially mediated by immune dysfunction. Targeting the metabolic-inflammatory-mood pathway may potential yield improved outcomes in BD; however, further study is needed to determine which specific interventions may be beneficial.

LIMITATIONS

The majority of identified studies had cross-sectional designs, small sample sizes and limited measurements of inflammation.

CONCLUSIONS

Treatment and prevention of general medical comorbidities in mood disorders should include preferential prescribing of metabolically neutral agents and adjunctive lifestyle modifications including increased physical activity, improved diet and decreased substance abuse. In addition, the use of anti-inflammatory agents could be a relevant therapeutic target in future research.

Metabolic syndrome and adverse clinical outcomes in patients with bipolar disorder

BACKGROUND

Metabolic syndrome (MetS) is highly prevalent among patients with bipolar disorder. MetS may cause complications in the brain, but studies investigating MetS-associated clinical psychiatric outcomes remain scant.

METHODS

We enrolled clinically stable outpatients with bipolar disorder aged 18-65 years and performed anthropometric and fasting biochemical assessments to investigate MetS prevalence. We then performed clinical assessments by using the Young Mania Rating Scale for manic symptoms, the Montgomery-Åsberg Depression Rating Scale for depressive symptoms, the Positive and Negative Symptom Scale for psychotic symptoms, the Involuntary Movement Scale for tardive dyskinesia, the Barnes Akathisia Rating Scale for akathisia, the Udvalg for Kliniske Undersogelser for general side effects, the Schedule for Assessment of Insight for insight, the Global Assessment of Functioning scale for global functioning, and the Wisconsin Card Sorting Test (WCST) for cognitive executive function.

RESULTS

In total, 143 patients were enrolled and had a MetS prevalence of 29.4%. The patients treated with atypical antipsychotics plus mood stabilizers (36.3%) and atypical antipsychotics alone (36.0%) had a significantly higher prevalence of MetS than did those treated with mood stabilizers alone (10.5%; p = 0.012). According to multivariate regression analyses adjusted for age, sex, smoking status, bipolar disorder subtype (I or II), pharmacological treatment duration, and psychiatric medication, compared with patients without MetS, those with MetS had significantly more previous hospitalizations (p = 0.036), severer tardive dyskinesia (p = 0.030), poorer insight (p = 0.036), poorer global function (p = 0.046), and more impaired executive function (conceptual level response on the WCST; p = 0.042).

CONCLUSIONS

Our results indicated that patients with comorbid bipolar disorder and MetS have more adverse clinical outcomes than those without, with more hospitalizations, severer tardive dyskinesia, poorer insight, poorer global function, and more impaired executive function. Monitoring MetS is crucial for assessing not only physical burden, but also psychiatric outcomes.

Uric acid levels in subjects with bipolar disorder: A comparative meta-analysis

Previous research has hypothesised increased uric acid levels, possibly because of an amplified purinergic metabolism and a reduced adenosine activity, in subjects with bipolar disorder. This systematic review and meta-analysis aimed at estimating if individuals with bipolar disorder had uric acid levels higher than both healthy controls and subjects with major depression (trait marker hypothesis). It also tested if uric acid levels could differ in different phases of bipolar disorder (state marker hypothesis). Meta-analyses were carried out generating pooled standardized mean differences (SMDs), using random-effects models. Heterogeneity between studies was estimated using the I(2) index. Relevant sensitivity and meta-regression analyses were conducted. We searched main Electronic Databases, identifying twelve studies that met our inclusion criteria. Meta-analyses showed increased uric acid levels in individuals with bipolar disorder as compared with both healthy controls (SMD = 0.65, p < 0.001, I(2) = 82.9%) and those with major depression (SMD = 0.46, p < 0.001; I(2) = 68.7%). However, meta-regression analyses confirmed this association only as compared with healthy controls. Finally, though uric acid levels were higher in manic/mixed phases as compared with depressive ones (SMD = 0.34; p = 0.04, I(2) = 58.8%), a sensitivity analysis did not confirm the association. In sum, our meta-analysis shows that subjects with bipolar disorder have uric acid levels higher than healthy controls. The potential role of factors that might clarify the nature of this association deserves additional research.

Abdominal obesity is associated with impaired cognitive function in euthymic bipolar individuals

OBJECTIVES

Overweight/obesity has been implicated to play a role in cognitive deficits in bipolar disorder (BD). This study aims to identify the relationship between body fat distribution and different domains of cognition in BD during euthymia.

METHODS

A sample of 100 euthymic individuals with BD was measured with a cognitive test battery (i.e., Trail Making Test-A-B/TM-A/B, d2 Test of Attention, Stroop test, California Verbal Learning Test/CVLT) and an anthropometric measures set (body mass index, waist circumference, hip circumference, waist-to-hip-ratio, waist-to-height-ratio, and lipometry). Patient data were compared with a healthy control group (n = 64).

RESULTS

Results show that overweight patients with BD exhibit lower performance in the TMT-A/B as well as in the free recall performance of the CVLT compared to normal-weight patients with BD and controls. In bipolar individuals, (abdominal) obesity was significantly associated with a poor cognitive performance. In bipolar females, associations with measures of verbal learning and memory were found; in bipolar males, associations with poor performance in the TMT-A/B and in the Stroop interference task were demonstrated. In controls, no associations were found.

CONCLUSIONS

There are several possible pathways moderating the association between obesity and cognition in BD. Anthropometric and lipometry data underline the substantial mediating impact of body fat distribution on cognition in BD.

The development of lurasidone for bipolar depression

Bipolar disorder is a chronic, recurrent illness that ranks among the top 10 causes of disability in the developed world. As the illness progresses, major depressive episodes increasingly predominate. However, few treatment options are available that have demonstrated efficacy in the treatment of bipolar depression, either as monotherapy or adjunctive therapy in combination with mood stabilizers. Lurasidone is an atypical antipsychotic drug that was initially developed for the treatment of schizophrenia. Since no previous atypical antipsychotic development program had proceeded directly from work on schizophrenia to bipolar depression, the decision to focus on this indication represented an innovation in central nervous system drug development and was designed to address a clinically significant unmet need. The current review summarizes key results of a clinical development program undertaken to characterize the efficacy and safety of lurasidone in patients diagnosed with bipolar depression. Lurasidone is currently the only treatment for bipolar depression approved in the United States as both a monotherapy and an adjunctive therapy with lithium or valproate. The approval of lurasidone expands available treatment options for patients with bipolar depression and provides a therapy with an overall favorable risk-benefit profile.

Lifestyle interventions targeting dietary habits and exercise in bipolar disorder: A systematic review

BACKGROUND

Bipolar disorder (BD) is a serious mental illness associated with a high risk of medical comorbidities, long-term disability and premature death. This systematic review examined the current literature on therapeutic interventions targeting nutrition, physical activity and wellness in BD and collecting health-related measures such as mood and course of illness.

METHODS

Scopus (all databases), Pubmed and Ovid Medline were systematically searched with no language or year restrictions, up to June 2015, for studies focusing on lifestyle interventions in BD. Search terms were related to bipolar disorder, nutrition, physical activity, wellbeing, psychosocial interventions and course of illness. We hand searched content pages of Bipolar Disorders and Journal of Affective Disorders and checked references of relevant reviews and dissertations to identify additional papers.

RESULTS

After applying inclusion and exclusion criteria to identified hits, this literature search retrieved six papers. Overall findings point towards a beneficial role of lifestyle interventions on mood, weight, blood pressure, lipid profile, physical activity and overall wellbeing. Methodological limitations include small sample size, gender ratio imbalance, inconsistencies in terms of laboratory measures, and lack of randomized controlled trials and absence of follow-up and longitudinal studies to determine the benefits of these factors on clinical and functional outcomes over time

CONCLUSIONS

Lifestyle interventions in BD targeting nutrition, exercise, wellbeing alongside beliefs, coping strategies and attitudes towards health show promise in reducing the risk of comorbid ailments in BD. There is still a strong need for studies a) developing interventions which are informed by the patient's input and b) examining the effectiveness of such interventions targeting general wellness using well-controlled trials.

High H1-affinity antidepressants and risk of metabolic syndrome in bipolar disorder

RATIONALE

Metabolic syndrome (MetS) is common in patients with bipolar disorder, with a relative risk of 1.6-2 compared to the general population. The increased risk is believed to be due to unhealthy lifestyles and use of medications. Although antipsychotics and mood stabilizers have been associated with weight gain and MetS, the impact of antidepressants has not been comprehensively evaluated.

OBJECTIVE

The objective of the study is to assess the risk of MetS in patients exposed to different types of antidepressants.

METHODS

In this cross-sectional study, 294 patients with bipolar disorder were consecutively recruited. MetS was diagnosed according to NCEP ATP-III modified criteria. Antidepressants used by the patients were classified according to the usual nomenclature (SSRI, TCA, SNRI, and other antidepressants) and a pharmacodynamic classification taking into account histamine 1-receptor (H1-R) affinity.

RESULTS

Use of antidepressants in general was not associated with MetS (prevalence ratio [PR], 1.08; 95% confidence interval, 0.73 to 1.62; p = 0.70). However, subjects using H1-R high-affinity antidepressants (N = 15) showed a substantial increase in the prevalence of MetS (PR, 2.17; 95 % confidence interval, 1.24 to 3.80; p = 0.007). When we included the inhibition constant (Ki) as a continuous covariate in the models, we found an inverse association between Ki and prevalence of MetS (p = 0.004).

CONCLUSION

We observed for the first time in a clinical setting that a pharmacodynamic-based classification of antidepressants could be more useful than the traditional one to predict the risk of MetS in patients with bipolar disorder. Clinical consequences may be relevant. However larger studies are warranted to generalize these results.

Eating behavior and obesity in bipolar disorder

OBJECTIVES

Individuals with bipolar disorder are more frequently overweight or obese than the general population, but the reasons for this association are unknown. The aim of this study is to further understand the etiology of overweight and obesity in bipolar disorder.

METHODS

We invited patients in a specialty outpatient bipolar clinic to complete the Eating Inventory. Patients provided self-reported restraint, disinhibition, and perceived hunger as well as general perceptions of dietary intake.

RESULTS

Sixty-two individuals (37 female) between the ages of 18 and 67 (M = 41.5, SD = 13.38) and with an average body mass index (BMI) of 27.18 (SD = 5.71) completed the survey. Disinhibition and perceived hunger were positively correlated with BMI and self-reported difficulty eating healthy foods. Restraint was positively correlated with healthy eating (ps < .05). Stepwise linear regressions revealed that hunger was the most significant predictor of BMI (F(1) = 8.134, p = .006). Those participants with bipolar I or II disorder reported greater hunger scores (p < .01) and difficulty eating healthily (p < .05) than those without a full diagnosis.

CONCLUSIONS

These results suggest that disinhibition and perception of hunger may be linked to the disproportionately high rate of obesity in bipolar disorder.

Body fat distribution and associations with metabolic and clinical characteristics in bipolar individuals

Overweight and obesity differentially affect bipolar disorder (BD) and are associated with a poorer prognosis. Herein, we sought to evaluate body fat distribution in a well-characterized BD sample. Anthropometric measures (i.e., body mass index, waist-to-hip ratio, waist-to-height ratio, waist circumference, hip circumference, and lipometry) of 100 BD individuals were compared with data of 57 matched mentally healthy controls. Additionally, fasting serum parameters including metabolic parameters and monoamines were analyzed. Findings indicate that similar to US BD cohorts, Austrian patients exhibit an increased central body fat accumulation (i.e., higher subcutaneous adipose tissue at upper abdomen) accompanying with the harmful IDF-defined metabolic syndrome. In addition, positive associations between epinephrine as well as staging and fat parameters were detected.

Cost-of-illness studies for bipolar disorder: systematic review of international studies

BACKGROUND AND OBJECTIVES

Bipolar disorder (BD) may result in a greater burden than all forms of cancer, Alzheimer's disease and epilepsy. Cost-of-illness (COI) studies provide useful information on the economic burden that BD imposes on a society. Furthermore, COI studies are pivotal sources of evidence used in economic evaluations. This study aims to give a general overview of COI studies for BD and to discuss methodological issues that might potentially influence results. This study also aims to provide recommendations to improve practice in this area, based on the review.

METHODS

A search was performed to identify COI studies of BD. The following electronic databases were searched: MEDLINE, EMBASE, PsycInfo, Cochrane Database of Systematic Reviews, HMIC and openSIGLE. The primary outcome of this review was the annual cost per BD patient. A narrative assessment of key methodological issues was also included. Based on these findings, recommendations for good practice were drafted.

RESULTS

Fifty-four studies were included in this review. Because of the widespread methodological heterogeneity among included studies, no attempt has been made to pool results of different studies. Potential areas for methodological improvement were identified. These were: description of the disease and population, the approach to deal with comorbidities, reporting the rationale and impact for choosing different cost perspectives, and ways in which uncertainty is addressed.

CONCLUSIONS

This review showed that numerous COI studies have been conducted for BD since 1995. However, these studies employed varying methods, which limit the comparability of findings. The recommendations provided by this review can be used by those conducting COI studies and those critiquing them, to increase the credibility and reporting of study results.

Lurasidone: a review of its use in adult patients with bipolar I depression

Lurasidone (Latuda(®)), a benzisothiazole derivative antipsychotic, is approved in the USA and Canada for the treatment of adults with major depressive episodes (MDE) associated with bipolar I disorder; this article reviews studies of lurasidone in this indication. In two 6-week, placebo-controlled trials in adults with bipolar I depression, lurasidone 20-120 mg/day reduced depressive symptoms, either as monotherapy or as an adjunct to lithium or valproate. Lurasidone reduced the mean Montgomery-Åsberg Depression Rating Scale (MADRS) total score from baseline (primary endpoint) by >50 %; the reductions in scores were significantly greater than with placebo. The treatment effects were small to medium and the numbers needed to treat to obtain an additional MDE response (≥50 % reduction from baseline in the MADRS total score) were ≤7 across the lurasidone groups. In a third, similarly designed trial of lurasidone 20-120 mg/day adjunctive to lithium or valproate, there was no significant between-group difference in the change in the mean MADRS total score at week 6 (primary endpoint), although significant differences favouring lurasidone were observed from week 2 to week 5. Across trials, the most frequently occurring adverse events included akathisia, extrapyramidal symptoms and somnolence. Lurasidone had a favourable profile with respect to weight gain and metabolic disturbances, known to occur with some other antipsychotics. Thus, lurasidone offers a valuable addition to the therapies available for adult patients with bipolar depression, either as monotherapy or as an adjunct to lithium or valproate.

Treatment implications of predominant polarity and the polarity index: a comprehensive review

BACKGROUND

Bipolar disorder (BD) is a serious and recurring condition that affects approximately 2.4% of the global population. About half of BD sufferers have an illness course characterized by either a manic or a depressive predominance. This predominant polarity in BD may be differentially associated with several clinical correlates. The concept of a polarity index (PI) has been recently proposed as an index of the antimanic versus antidepressive efficacy of various maintenance treatments for BD. Notwithstanding its potential clinical utility, predominant polarity was not included in the DSM-5 as a BD course specifier.

METHODS

Here we searched computerized databases for original clinical studies on the role of predominant polarity for selection of and response to pharmacological treatments for BD. Furthermore, we systematically searched the Pubmed database for maintenance randomized controlled trials (RCTs) for BD to determine the PI of the various pharmacological agents for BD.

RESULTS

We found support from naturalistic studies that bipolar patients with a predominantly depressive polarity are more likely to be treated with an antidepressive stabilization package, while BD patients with a manic-predominant polarity are more frequently treated with an antimanic stabilization package. Furthermore, predominantly manic BD patients received therapeutic regimens with a higher mean PI. The calculated PI varied from 0.4 (for lamotrigine) to 12.1 (for aripiprazole).

CONCLUSIONS

This review supports the clinical relevance of predominant polarity as a course specifier for BD. Future studies should investigate the role of baseline, predominant polarity as an outcome predictor of BD maintenance RCTs.