Elevated Familial Cardiovascular Burden Among Adolescents With Familial Bipolar Disorder

Systematic review and meta-analysis of retinal microvascular caliber in bipolar disorder, major depressive disorder, and schizophrenia

BACKGROUND

Individuals with a severe mental illness (SMI), such as bipolar disorder (BD), major depressive disorder (MDD), and schizophrenia (SZ), have increased rates of cardiovascular and cerebrovascular disease. Interestingly, it has been reported that retinal microvessels, a proxy cerebrovascular measure, non-invasively assessed via retinal imaging, predict future cardiovascular disease, with some studies also showing anomalous retinal microvascular caliber in SMI. Therefore, this review and meta-analysis evaluated whether retinal microvascular caliber differs between individuals with SMI vs controls and summarized current findings.

METHODS

A systematic literature search for retinal microvascular caliber and SMI was conducted in Embase and MEDLINE. Studies needed to be published in English before 2022 December 1st and examine retinal microvascular caliber in individuals diagnosed with a SMI. Finally, a meta-analysis of arteriolar and venular caliber in SMI case-controlled studies was also conducted.

RESULTS

The search yielded 65 unique articles, 11 were included in the review and 6 in the meta-analysis. The meta-analysis found that the SMI group had significantly wider venules than controls (SMD = -0.53; 95 % CI = 0.24, 0.81; p = 0.0004) but not arterioles (SMD = 0.07; 95 % CI = -0.29, 0.44; p = 0.70). Additionally, the systematic review found that poorer retinal microvascular health is associated with greater illness severity.

LIMITATIONS

Large heterogeneity of findings and small sample size.

CONCLUSION

This systematic review and meta-analysis found that SMI, specifically SZ, is associated with wider retinal venules. Retinal imaging, a fast, cost-effective, and non-invasive assay of cerebrovascular health, may provide insight into the pathophysiological processes of SMI. However, future longitudinal studies investigating these findings are warranted.

[Psychosomatic medicine: old resources and new technologies]

Two primary research directions closely coexist in psychosomatic medicine. One is the most traditional, associated with an assessment of the psychological aspects of the connection, interconnection and mutual impact of mental and somatic pathology. The second, based on the rapid development of biological medicine in the last decade, studies causal associations and looks for shared mechanisms. In our review, we consider the previous main stages in the psychosomatic medicine and the prospective approaches to its further study. Evaluation of the etiopathogenesis of the entire set of mental and somatic symptoms in their interaction and dynamics can help identify individual subpopulations of patients with shared pathobiochemical and neurophysiological disorders. The recent interpretation of the biopsychosocial model is mainly related to the etiology and pathogenesis of mental disorders and also provides a good perspective for research on these issues. Today, there are sufficient opportunities to study all three domains of the model. Productive study of the biological, personal and social domains is also possible on the base of evidence-based design using modern research technologies.

A scoping review of near infrared spectroscopy studies employing a verbal fluency task in bipolar disorder

BACKGROUND

Deficits in cognitive functioning, including attention, memory, and executive functions, along with impairments in language production, are present in patients with bipolar disorder (BD) patients during mood phases, but also during euthymia.Verbal fluency tasks (VFTs), being able to evaluate integrity of a wide range of cognitive domains and represent, can be used to screen for these disturbances. Neuroimaging studies, including Near-InfraRed Spectroscopy (NIRS), have repeatedly showed widespread alterations in the prefrontal and temporal cortex during the performance of VFTs in BD patients. This review aims to summarize the results of NIRS studies that evaluated hemodynamic responses associated with the VFTs in prefrontal and temporal regions in BD patients.

METHODS

We performed a scoping review of studies evaluating VFT-induced activation in prefrontal and temporal regions in BD patients, and the relationship between NIRS data and various clinical variables.

RESULTS

15 studies met the inclusion criteria. In BD patients, compared to healthy controls, NIRS studies showed hypoactivation of the dorsolateral prefrontal cortex, ventrolateral prefrontal cortex and anterior temporal regions. Moreover, clinical variables, such as depressive and social adaptation scores, were negatively correlated with hemodynamic responses in prefrontal and temporal regions, while a positive correlation were reported for measures of manic symptoms and impulsivity.

LIMITATIONS

The heterogeneity of the studies in terms of methodology, study design and clinical characteristics of the samples limited the comparability of the findings.

CONCLUSIONS

Given its non-invasiveness, good time-resolution and no need of posturalconstraint, NIRS technique could represent a useful tool for the evaluation of prefrontal and temporal haemodynamic correlates of cognitive performances in BD patients.

Bipolar disorder: Treatment strategies for women of childbearing age

PURPOSE

Bipolar disorder is associated with increased rates of morbidity and mortality, magnified in women of childbearing age. The purpose of this paper is to provide an overview of the differential diagnosis and management of bipolar disorder in women of childbearing age.

CONCLUSIONS

Differential diagnoses for bipolar disorder include depressive disorders, anxiety disorders, trauma-related disorders, attention-deficit/hyperactivity disorder, and personality disorders. Pharmacotherapeutic options for the treatment of bipolar disorder include lithium, anti-epileptic medications, and atypical antipsychotics. In regard to women of childbearing age, consideration of risks, benefits, and alternative therapies is needed before initiating therapy.

PRACTICE IMPLICATIONS

Caring for patients with bipolar disorder, particularly women of childbearing age, requires careful differentiation of bipolar disorder from other mental health problems, and prudent consideration of pharmacotherapeutic options.

Mini-review: The anti-aging effects of lithium in bipolar disorder

The medical use of lithium has grown since its initial introduction in the 1800s as a treatment for gout. Today, the divalent cation remains as the pharmacological gold standard in treatment of bipolar disorder (BD) with strong mood stabilizing effects. Lithium has demonstrated efficacy in the treatment of acute affective episodes, in the reduction of affective episode recurrence, and in significantly decreasing the risk of suicide in patients. BD has been consistently associated with clinical signs of accelerated aging, including increased rates of age-related diseases such as cardiovascular diseases, malignancies, and diabetes mellitus. This clinical scenario parallels accelerated aging mechanisms observed on a molecular basis, with studies reporting shortened telomeres, increased oxidative stress, and accelerated epigenetic aging in patients with BD compared to controls. Lithium has proved useful as a potential agent in slowing down this accelerated aging process in BD, potentially reversing effects induced by the disorder. This mini-review summarizes findings of anti-aging mechanisms associated with lithium use and provides a discussion of the clinical implications and perspectives of this evolving field. Despite many promising results, more studies are warranted in order to elucidate the exact mechanism by which lithium may act as an anti-aging agent and the extent to which these mechanisms are relevant to its mood stabilizing properties in BD.

Markedly increased prevalence of migraine headaches in adolescents with bipolar disorder

OBJECTIVE

There is substantial evidence of increased prevalence of migraines, and negative psychiatric correlates of migraines, in adults with bipolar disorder (BD). Given the paucity of data on this topic in youth, we investigated the prevalence and correlates of migraine in a large sample of adolescents with BD.

METHOD

The study included 165 adolescents with BD-I, -II, or -not otherwise specified (NOS), diagnosed via the KSADS-PL semi-structured interview, and 89 healthy controls (HCs). Non-migraine headache and migraine headache was evaluated using the validated ID-Migraine 3-item screener.

RESULTS

Although the prevalence of non-migraine headaches did not differ between adolescents with BD (24.2%) and HCs (32.6%; P = .15), migraine was significantly more prevalent among adolescents with BD (38.2%) compared to HCs (3.4%; adjusted odds ratio 14.76, 95% confidence interval 4.39-49.57; P < .001). Within BD, migraine was associated with female sex, BD-II/-NOS subtype, less severe worst past functioning, higher past depression severity, higher self-reported affective lability, higher body mass index, and less use of lithium and second-generation antipsychotics.

DISCUSSION

Migraine is much more prevalent among adolescents with BD compared to HCs; the magnitude of this association exceeds what has been reported in adult samples. Correlates of migraine in youth BD are similar to those found for adults, including the link with the depressive polarity of BD. Future prospective studies are warranted to evaluate temporal associations between migraine and mood symptoms, and to evaluate neurobiological and cardiovascular underpinnings of these associations.

A nation-wide population-based longitudinal study mapping physical diseases in patients with bipolar disorder and their siblings

BACKGROUND

Patients with bipolar disorder may have increased risk of physical diseases due to genetic and environmental factors, but no study has systematically mapped all physical comorbidities in such subjects. The aim was to map rates of all physical diseases among patients and siblings to patients with bipolar disorder.

METHODS

We used Danish nation-wide population-based longitudinal register linkage to identify 19.955 patients with bipolar disorder, their 13.923 siblings and 20 sex, age and calendar matched control individuals from the general population. Follow-up was from 1995 to 2017.

RESULTS

Bipolar disorder was associated with increased rates of all physical disease categories compared with rates for control individuals, except for cancer. Further, bipolar disorder was associated with increased rates of separate disorders including ischemic heart disease, diabetes, dementia, hypertension, hypercholesterolemia and hyperlipidemia, hypothyroidism and infections. In contrast, siblings to patients with bipolar disorder who were unaffected by bipolar disorder had increased rates of certain disorders, only, comprising infectious and parasitic diseases, and diseases of the nervous system, digestive system and genitourinary system.

LIMITATIONS

Underdetection of physical disorders is likely because data are not available for persons who do not seek help for their disorders.

CONCLUSIONS

Bipolar disorder was associated with increased rates of all physical diseases categories, except cancer, and with separate disorders, likely involving inflammatory components in the pathogenesis. In contrast, unaffected siblings to patients with bipolar disorder had increased rates of certain disorders, only.

High Risk and Trajectories of Physical Illnesses before the Diagnosis of Bipolar Disorder

OBJECTIVE

The authors investigated the distributions and trajectories of physical illnesses preceding the diagnosis of bipolar disorder with comparison to schizophrenia and general populations.

METHODS

Using data from the Taiwan National Health Insurance Research Database entered from 1996 to end of 2012, we identified 13,079 patients newly diagnosed as having bipolar disorder between the age of 13 and 40 years (ie, cases). For each case with bipolar disorder, two age- and sex- and diagnosis year- schizophrenia comparisons (n=26,158)(n=26,158) and four age- and sex-matched comparisons representing the general population (n=52,316)(n=52,316) were randomly selected from the cohort. Multivariate conditional logistic regression analyses were conducted to estimate the risk of physical illness before the diagnosis (index date). Variables exhibiting a powerful association (p<0·001) were retained in the final model.

RESULTS

During the year before diagnosis, patients with newly diagnosed bipolar disorder had a higher risk of numerous physical illnesses across the cardiovascular, respiratory, gastrointestinal, endocrine/metabolic, and musculoskeletal/integument systems compared with those with schizophrenia and the general population. Trends in the risk of specific physical illnesses, mainly hypertension, heart disease, asthma, ulcer disease, hyperlipidemia, and connective tissue disease, were increased across the 3-year prodromal phase of bipolar disorder relative to schizophrenia.

CONCLUSIONS

Intriguingly, physical illnesses before the diagnosis of bipolar disorder are pervasive with higher risk. Moreover, the trajectories of physical illnesses markedly differ from those of schizophrenia before full manifestation.

Cardiometabolic disease risk among siblings of patients with major depressive disorder

Studies have suggested an association between metabolic and cerebrocardiovascular diseases and major depressive disorder (MDD). However, the risk of metabolic and cerebrocardiovascular diseases in the unaffected siblings of patients with MDD remains uncertain. Using the Taiwan National Health Insurance Research Database, 22,438 unaffected siblings of patients with MDD and 89,752 age-/sex-matched controls were selected and followed up from 1996 to the end of 2011. Individuals who developed metabolic and cerebrocardiovascular diseases during the follow-up period were identified. Compared with the controls, the unaffected siblings of patients with MDD had a higher prevalence of metabolic diseases, such as hypertension (5.0% vs. 4.5%, p = 0.007), dyslipidemia (5.6% vs. 4.8%, p < 0.001), and obesity (1.7% vs. 1.5%, p = 0.028), and cerebrocardiovascular diseases, such as ischemic stroke (0.6% vs. 0.4%, p < 0.005) and ischemic heart disease (2.1% vs. 1.7%, p < 0.001). Logistic regression analyses revealed that the unaffected siblings of patients with MDD were more likely to develop hypertension, dyslipidemia, ischemic stroke, and ischemic heart diseases during the follow-up period than the controls. Our study revealed a familial coaggregation between MDD and metabolic and cerebrocardiovascular diseases. Additional studies are required to investigate the shared pathophysiology of MDD and metabolic and cerebrocardiovascular diseases.

Incorporating Risk Stratification Into the Practice of Pediatric Preventive Cardiology

Atherosclerosis in its earliest stages is associated with the same traditional cardiovascular disease (CVD) risk factors as are associated with manifest CVD events in adulthood. Clustering of risk factors is associated with exponential increases in atherosclerotic burden from a young age. Some medical conditions and risk behaviours occurring in children can either increase the likelihood of higher levels of risk factors (such as chronic kidney disease) or the presence of risk factor clustering (such as obesity and cardiometabolic syndrome) or are associated with acquired coronary artery pathology (such as Kawasaki disease). This creates a milieu for-or increases the impact of-accelerated atherosclerosis that, in turn, increases the likelihood of premature CVD. This review highlights the importance of considering the total risk factor and risk-condition profile of pediatric patients. An algorithm is provided for stratifying patients into high-, moderate-, and at-risk categories, and practical examples are provided as to how the evaluation and management of 1 risk factor or risk condition might need to be intensified in the context of additional risk factors or risk conditions. For example, for treatment of an adolescent with familial hypercholesterolemia, the target low-density lipoprotein cholesterol level might be lowered by the concomitant presence of low high-density lipoprotein cholesterol or elevated lipoprotein(a) levels. As awareness of cardiovascular risk and atherosclerosis in pediatric patients increases, new at-risk conditions that warrant consideration are emerging. The identification and management of high-risk individuals is an important part of the overall practice of pediatric preventive cardiology.

Call to action regarding the vascular-bipolar link: A report from the Vascular Task Force of the International Society for Bipolar Disorders

OBJECTIVES

The association of bipolar disorder with early and excessive cardiovascular disease was identified over a century ago. Nonetheless, the vascular-bipolar link remains underrecognized, particularly with regard to how this link can contribute to our understanding of pathogenesis and treatment.

METHODS

An international group of experts completed a selective review of the literature, distilling core themes, identifying limitations and gaps in the literature, and highlighting future directions to bridge these gaps.

RESULTS

The association between bipolar disorder and vascular disease is large in magnitude, consistent across studies, and independent of confounding variables where assessed. The vascular-bipolar link is multifactorial and is difficult to study given the latency between the onset of bipolar disorder, often in adolescence or early adulthood, and subsequent vascular disease, which usually occurs decades later. As a result, studies have often focused on risk factors for vascular disease or intermediate phenotypes, such as structural and functional vascular imaging measures. There is interest in identifying the most relevant mediators of this relationship, including lifestyle (eg, smoking, diet, exercise), medications, and systemic biological mediators (eg, inflammation). Nonetheless, there is a paucity of treatment studies that deliberately engage these mediators, and thus far no treatment studies have focused on engaging vascular imaging targets.

CONCLUSIONS

Further research focused on the vascular-bipolar link holds promise for gleaning insights regarding the underlying causes of bipolar disorder, identifying novel treatment approaches, and mitigating disparities in cardiovascular outcomes for people with bipolar disorder.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk of cardiometabolic diseases among siblings of patients with bipolar disorder

BACKGROUND

Cardiometabolic diseases are suggested to be associated with bipolar disorder. However, the risk of metabolic disorders in unaffected siblings of patients with bipolar disorder remains unclear.

METHODS

From the Taiwan National Health Insurance Research Database, 7,225 unaffected siblings of bipolar probands and 28,900 age-/sex-/income-/residence-matched control individuals were included and followed until the end of 2011. Individuals who developed metabolic disorders during the follow-up period were identified.

RESULTS

The unaffected siblings of bipolar probands had a higher prevalence of dyslipidemia (5.4% vs. 4.5%, p = 0.001), younger age at diagnosis of type 2 diabetes mellitus (34.81 vs. 37.22, p = 0.024), and higher prevalence of any stroke (1.5% vs. 1.1%, p = 0.007) than the controls. Moreover, only male siblings of bipolar probands had an increased risk of dyslipidemia (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.10-1.48) and higher rates of any stroke (OR: 1.38, 95% CI: 1.02-1.85) and ischemic stroke (OR: 2.43, 95% CI: 1.60-3.70) during the follow-up compared with the controls.

DISCUSSION

Unaffected siblings of bipolar patients, particularly brothers, had a higher prevalence of dyslipidemia and ischemic stroke compared with the controls. The result suggests the familial association between cardiometabolic diseases and bipolar disorder. Further research may be necessary to identify this shared etiology between the disorders.