Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review

Refining Criteria for a Neurodevelopmental Subphenotype of Bipolar Disorders: A FondaMental Advanced Centers of Expertise for Bipolar Disorders Study

BACKGROUND

Bipolar disorder (BD) is a complex and heterogeneous psychiatric disorder. It has been suggested that neurodevelopmental factors contribute to the etiology of BD, but a specific neurodevelopmental phenotype (NDP) of the disorder has not been identified. Our objective was to define and characterize an NDP in BD and validate its associations with clinical outcomes, polygenic risk scores, and treatment responses.

METHODS

We analyzed the FondaMental Advanced Centers of Expertise for Bipolar Disorders cohort of 4468 patients with BD, a validation cohort of 101 patients with BD, and 2 independent replication datasets of 274 and 89 patients with BD. Using factor analyses, we identified a set of criteria for defining NDP. Next, we developed a scoring system for NDP load and assessed its association with prognosis, neurological soft signs, polygenic risk scores for neurodevelopmental disorders, and responses to treatment using multiple regressions, adjusted for age and gender with bootstrap replications.

RESULTS

Our study established an NDP in BD consisting of 9 clinical features: advanced paternal age, advanced maternal age, childhood maltreatment, attention-deficit/hyperactivity disorder, early onset of BD, early onset of substance use disorders, early onset of anxiety disorders, early onset of eating disorders, and specific learning disorders. Patients with higher NDP load showed a worse prognosis and increased neurological soft signs. Notably, these individuals exhibited a poorer response to lithium treatment. Furthermore, a significant positive correlation was observed between NDP load and polygenic risk score for attention-deficit/hyperactivity disorder, suggesting potential overlapping genetic factors or pathophysiological mechanisms between BD and attention-deficit/hyperactivity disorder.

CONCLUSIONS

The proposed NDP constitutes a promising clinical tool for patient stratification in BD.

Clinical high risk for psychosis in bipolar disorder: Clinical features, cognition and functioning

Bipolar disorder (BD) is a heterogeneous disease in terms of clinical course, neurocognitive and social-cognitive features, and functioning. Given the overlap between BD and schizophrenia, psychosis high-risk criteria that persist during euthymia may define a subgroup that differs in clinical features and functioning. In this study, we defined a subgroup of BD as ' Bipolar Disorder with Clinical High-Risk for Psychosis (BD-CHR-P)'. Our main aim was to investigate the differences in neurocognition, social cognition, psychosocial functioning, thought disorder, and clinical features in this subgroup and compare them with the BD group without this syndrome. 77 participants are included in this study. According to the Structured Interview for Prodromal Syndromes (SIPS), 25 participants were included in the BD-CHR-P group. Clinical features, cognition, functionality, thought disorder, apathy, impulsivity, and schizotypy were compared between the groups. Individuals with BD-CHR-P showed a higher rate of psychotic features in their manic episodes, and they displayed more Schneiderian symptoms in psychotic manic episodes (p = 0.049). BD-CHR-P group displayed worse functioning (F = 14.153, p < 0.001). The scores of anticipatory anhedonia (F = 5.27, p = 0.024) and positive formal thought disorder were higher in BD-CHR-P (F = 4.486, p = 0.037). In self-report evaluations impulsivity, self-report apathy, and schizotypy scores in the BD-CHR-P group were significantly higher than the BD-nonCHR-P group (F = 5.305, p = 0.024, F = 5.487, p = 0.022, F = 22.759, p < 0.001, respectively). The BD-CHR-P group exhibited poorer functioning. Further studies are needed to elucidate the mechanisms underlying the between-group differences. Moreover, cross-sectional characteristics of the BD-CHR-P group may help identify a subgroup that will develop psychotic disorders in the future.

Alterations of subcortical structural volume in pediatric bipolar disorder patients with and without psychotic symptoms

BACKGROUND

Pediatric bipolar disorder (PBD) with psychotic symptoms may predict more severe impairment in social functioning, but the underlying biological mechanisms remain unclear. The aim of this study was to investigate alterations in subcortical structural volume in PBD with and without psychotic symptoms.

METHODS

We recruited 24 psychotic PBD (P-PBD) patients, 24 non-psychotic PBD (NP-PBD) patients, and 18 healthy controls (HCs). All participants underwent scanning with a 3.0 T Siemens Trio scanner. The FreeSurfer 7.4.0 software was employed to calculate the volume of each subcortical structure. An analysis of covariance (ANCOVA) was performed to identify brain regions with significant volume differences among the three groups, and then the inter-group comparisons were calculated. Partial correlation analyses were conducted to identify relationships between subcortical structural volumes and clinical features. Finally, receiver operating characteristic curve (ROC) analysis was employed to verify the capacity to distinguish between P-PBD and NP-PBD, P-PBD and HCs, and NP-PBD and HCs.

RESULTS

ANCOVA revealed significant differences in the volumes of bilateral lateral ventricles, third ventricle, left thalamus, and right pallidum among three groups. Compared with HC, the third ventricle volume was increased in both groups of PBD patients, whereas the left thalamus and right pallidum volumes were decreased, and the bilateral lateral ventricles were enlarged in P-PBD patients. In contrast, only the third ventricle showed further enlargement in the group of P-PBD patients compared with NP-PBD patients. Partial correlation analyses revealed that episode times were associated with the third ventricle volume in P-PBD patients. Furthermore, ROC analyses indicated that volume in the left lateral ventricle exhibited the greatest capacity to distinguish between the P-PBD and NP-PBD, and the third ventricle performed best in distinguishing both the P-PBD group from HCs and the NP-PBD group from HCs. The combined metrics demonstrated greater diagnostic value in two-by-two comparisons.

CONCLUSION

Current research suggests that PBD with psychotic symptoms may have more extensive lateral and third ventricular volume enlargement. Bilateral lateral ventricles may serve as potential neurobiomarkers to distinguish P- PBD patients from NP-PBD patients.

Gender Differences in Clinical and Biochemical Variables of Patients Affected by Bipolar Disorder

Introduction: Bipolar disorder (BD) affects over 1% of the global population and significantly impacts psychosocial functioning and life expectancy. This manuscript has the objective of investigating gender differences in the clinical and biochemical parameters of patients affected by BD. Methods: This retrospective cross-sectional study examined 672 patients diagnosed with BD in psychiatric wards in Milan and Monza. Clinical data and biochemical parameters were collected on the first day of hospitalization. Independent sample t-tests, chi-square tests and binary logistic regressions were performed to identify gender differences in BD. Results: With regard to univariate analyses, women were found to be more susceptible to psychiatric comorbidities (χ2 = 12.75, p < 0.01), medical comorbidities (χ2 = 45.38, p < 0.01), obesity (χ2 = 6.75, p = 0.01) and hypercholesterolemia (χ2 = 23.54, p < 0.01), as well as to having more mood episodes in the year prior to hospitalization (t = 5.69, p < 0.01). Men were found to be more likely to develop psychotic symptoms (χ2 = 4.40, p = 0.04), to be tobacco smokers (χ2 = 15.13, p < 0.01) and to have substance abuse disorders (χ2 = 14.66, p = <0.01). Logistic regression analyses showed that women compared to men showed more psychiatric comorbidity (p < 0.01), higher Global Assessment of Functioning (GAF) scores (p = 0.05) and higher total cholesterol plasma levels (p < 0.01); however, they also had fewer red blood cells (p < 0.01) and lower creatinine plasma levels (p < 0.01). Conclusions: Female patients (compared to males) exhibited higher levels of global functioning despite the higher frequency of psychiatric comorbidity and susceptibility to metabolic complications; consistent with earlier studies, female patients also showed higher cholesterol levels. Further studies will have to confirm the present findings and identify gender-related clinical pathways for the management of BD.

Characteristics of people with bipolar disorder I with and without auditory verbal hallucinations

BACKGROUND

Approximately half of people with bipolar disorder type I (BD-I) report the presence of psychotic symptoms at least at some point during their illness. Previous data suggest that more than 20% of people with BD-I report the presence of auditory verbal hallucinations (AVHs), or "voice-hearing" in particular. While work in other disorders with psychotic features (e.g., schizophrenia) indicates that the presence vs. absence of AVHs is associated with poorer clinical outcomes, little is known about their effects on clinical and socioeconomic features in BD-I.

METHODS

We investigated whether people with BD-I (N = 119) with AVHs (n = 36) and without AVHs (n = 83) in their lifetime differ in terms of demographic features and clinical measures. Relations with AVHs and other positive symptoms were explored.

RESULTS

People with BD-I and AVHs vs. without AVHs had higher manic and positive symptom scores (i.e., higher scores on the hallucinations, delusions, and bizarre behavior subscales). Further, a greater proportion of those with vs. without AVHs reported lower subjective socioeconomic status and tended to have higher rates of unemployment, thus, speaking to the longer-term consequences of AVH presence.

CONCLUSION

Our findings suggest that people with BD-I with AVHs exhibit more severe psychotic features and manic symptoms compared to those without. This might be associated with more socioeconomic hardship. More in-depth characterization of people with BD-I with/without AVHs is needed to fully understand this subgroup's unique challenges and needs.

LIMITATIONS

The modest sample size of the AVH group and a study population with low racial diversity/representation may limit generalizability.

Endogenous retroviruses in neurodevelopmental, psychotic and cognitive disorders

Endogenous retroviruses (ERVs) are inherited retroviral genomic elements that integrated into the mammalian genome through germline infections and insertions during evolution. Human ERVs (HERVs) comprise approximately 8 % of the human genome and are increasingly recognized to be involved in the etiology and pathophysiology of numerous brain disorders. In this narrative review, we summarize the existing evidence linking abnormal HERV expression to neurodevelopmental and psychosis-related disorders and discuss how these retroviral elements may contribute to the heterogeneity in clinical outcomes. We also review the findings suggesting that aberrant HERV expression contribute to late-onset cognitive disorders with neurodegenerative components, such as Alzheimer's disease (AD) and other forms of dementia. The evidence implicating abnormal HERV expression in neurodevelopmental, psychotic, and cognitive disorders is manifold and stems from diverse research fields, including human post-mortem brain studies, serological investigations, gene expression analyses, and clinical trials with HERV-specific pharmacological compounds. The recent establishment and use of animal models offer a complementary experimental platform that will help establish causal relationships and identify specific disease pathways affected by abnormal HERV expression. Yet, significant gaps persist in understanding the role of HERVs in neurodevelopmental, psychotic, and cognitive disorders, particularly concerning the specificity and stability of abnormal HERV expression in these conditions. Addressing these questions appears crucial for optimizing the potential benefits of therapeutic interventions aimed at targeting abnormal HERV expression across the broad spectrum of HERV-associated disorders of the central nervous system.

Early use of long-acting injectable antipsychotics in bipolar disorder type I: An expert consensus

INTRODUCTION

Long-acting injectable antipsychotics (LAIs) are not routinely offered to patients living with bipolar disorder type I (BP-I), despite widespread evidence that supports their benefits over oral antipsychotics, particularly in early disease.

METHODS

A round-table meeting of psychiatrists convened to discuss barriers and opportunities and provide consensus recommendations around the early use of LAIs for BP-I.

RESULTS

LAIs are rarely prescribed to treat BP-I unless a patient has severe symptoms, sub-optimal adherence to oral antipsychotics, or has experienced multiple relapses. Beyond country-specific accessibility issues (e.g., healthcare infrastructure and availability/approval status), primary barriers to the effective use of LAIs were identified as attitudinal and knowledge/experience-based. Direct discussions between healthcare providers and patients about treatment preferences may not occur due to a preconceived notion that patients prefer oral antipsychotics. Moreover, as LAIs have historically been limited to the treatment of schizophrenia and the most severe cases of BP-I, healthcare providers might be unaware of the benefits LAIs provide in the overall management of BP-I. Improved treatment adherence associated with LAIs compared to oral antipsychotics may support improved outcomes for patients (e.g., reduced relapse and hospitalization). Involvement of all stakeholders (healthcare providers, patients, and their supporters) participating in the patient journey is critical in early and shared decision-making processes. Clinical and database studies could potentially bridge knowledge gaps to facilitate acceptance of LAIs.

CONCLUSION

This review discusses the benefits of LAIs in the management of BP-I and identifies barriers to use, while providing expert consensus recommendations for potential solutions to support informed treatment decision-making.

Systematic review of risk factors for violence in psychosis: 10-year update

BACKGROUND

Understanding risk factors for violence in people with psychosis can inform risk management and violence prevention. However, much of the evidence comes from cross-sectional studies, and previous reviews require updating.

AIMS

To synthesise evidence from longitudinal studies on risk factors for violence in people with schizophrenia-spectrum disorders, bipolar disorder or other affective psychoses.

METHOD

We searched five bibliographic databases up to June 2022. We identified longitudinal studies reporting risk factors for violence in individuals diagnosed with schizophrenia or other psychoses using DSM or ICD criteria. If ≥3 independent samples reported a risk factor, we conducted random-effects meta-analyses to provide a pooled estimate. We also meta-analysed risk factors by major domains.

RESULTS

We identified 47 longitudinal studies on risk factors for violence in psychosis, representing 41 independent samples - 21 from the original and 20 from the updated review - and 203 297 individuals. A total of 30 risk factors were present in ≥3 independent samples. Criminal history factors were associated with the greatest risk of violent outcomes (pooled odds ratio 3.50, 95% CI = 2.37, 5.16), followed by substance misuse factors (odds ratio 2.36, 95% CI = 1.99, 2.80). Many treatment-related factors were protective (odds ratio 0.54, 95% CI = 0.34, 0.85). Effect estimates were attenuated in inpatient settings. We also identified novel risk factors, including cannabis use, in a secondary analysis (odds ratio 3.34, 95% CI = 2.32, 4.82).

CONCLUSIONS

Using longitudinal evidence, we have validated comorbid substance misuse and criminal history as major risk factors for violence in psychosis. Novel factors such as cannabis use need further replication. Several identified factors are possible intervention targets if associations are found to be causal.

Machine learning for the diagnosis accuracy of bipolar disorder: a systematic review and meta-analysis

Background

Diagnosing bipolar disorder poses a challenge in clinical practice and demands a substantial time investment. With the growing utilization of artificial intelligence in mental health, researchers are endeavoring to create AI-based diagnostic models. In this context, some researchers have sought to develop machine learning models for bipolar disorder diagnosis. Nevertheless, the accuracy of these diagnoses remains a subject of controversy. Consequently, we conducted this systematic review to comprehensively assess the diagnostic value of machine learning in the context of bipolar disorder.

Methods

We searched PubMed, Embase, Cochrane, and Web of Science, with the search ending on April 1, 2023. QUADAS-2 was applied to assess the quality of the literature included. In addition, we employed a bivariate mixed-effects model for the meta-analysis.

Results

18 studies were included, covering 3152 participants, including 1858 cases of bipolar disorder. 28 machine learning models were encompassed. Sensitivity and specificity in discriminating between bipolar disorder and normal individuals were 0.88 (9.5% CI: 0.74~0.95) and 0.89 (95% CI: 0.73~0.96) respectively, and the SROC curve was 0.94(95% CI: 0.92~0.96). The sensitivity and specificity for distinguishing between bipolar disorder and depression were 0.84 (95%CI: 0.80~0.87) and 0.82 (95%CI: 0.75~0.88) respectively. The SROC curve was 0.89 (95%CI: 0.86~0.91).

Conclusions

Machine learning methods can be employed for discriminating and diagnosing bipolar disorder. However, in current research, they are predominantly utilized for binary classification tasks, limiting their progress in clinical practice. Therefore, in future studies, we anticipate the development of more multi-class classification tasks to enhance the clinical applicability of these methods.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023427290, identifier CRD42023427290.

Distinguished Frontal White Matter Abnormalities Between Psychotic and Nonpsychotic Bipolar Disorders in a Pilot Study

BACKGROUND/OBJECTIVES

Recent studies indicate extensive shared white matter (WM) abnormalities between bipolar disorder (BD) and schizophrenia (SZ). However, the heterogeneity of WM in BD in terms of the presence of psychosis remains a critical issue for exploring the boundaries between BD and SZ. Previous studies comparing WM microstructures in psychotic and nonpsychotic BDs (PBD and NPBD) have resulted in limited findings, probably due to subtle changes, emphasizing the need for further investigation.

METHODS

Diffusion tensor imaging measures were obtained from 8 individuals with PBD, 8 with NPBD, and 22 healthy controls (HC), matched for age, gender, handedness, and educational years. Group comparisons were conducted using tract-based spatial statistics (TBSS). The most significant voxels showing differences between PBD and HC in the TBSS analyses were defined as a TBSS-ROI and subsequently analyzed.

RESULTS

Increased radial diffusivity (RD) in PBD compared to NPBD (p < 0.006; d = 1.706) was observed in TBSS-ROI, distributed in the confined regions of some WM tracts, including the body of the corpus callosum (bCC), the left genu of the CC (gCC), and the anterior and superior corona radiata (ACR and SCR). Additionally, NPBD exhibited significant age-associated RD increases (R2 = 0.822, p < 0.001), whereas the greater RD observed in PBD compared to NPBD remained consistent across middle age.

CONCLUSIONS

Preliminary findings from this small sample suggest severe frontal WM disconnection in the anterior interhemispheric communication, left fronto-limbic circuits, and cortico-striatal-thalamic loop in PBD compared to NPBD. While these results require replication and validation in larger and controlled samples, they provide insights into the pathophysiology of PBD, which is diagnostically located at the boundary between BD and SZ.

Acute Behavioral and Neurochemical Effects of Sulpiride in Adult Zebrafish

Affective and psychotic disorders are highly prevalent and severely debilitating mental illnesses that often remain untreated or treatment-resistant. Sulpiride is a common antipsychotic (neuroleptic) drug whose well-established additional (e.g., antidepressant) therapeutic effects call for further studies of a wider spectrum of its CNS effects. Here, we examined effects of acute 20-min exposure to sulpiride (50-200 mg/L) on anxiety- and depression-like behaviors, as well as on brain monoamines, in adult zebrafish (Danio rerio). Overall, sulpiride exerted overt anxiolytic-like effects in the novel tank test and showed tranquilizing-like effects in the zebrafish tail immobilization test, accompanied by lowered whole-brain dopamine and its elevated turnover, without affecting serotonin or norepinephrine levels and their turnover. Taken together, these findings support complex behavioral pharmacology of sulpiride in vivo and reconfirm high sensitivity of zebrafish-based screens to this and, likely, other related clinically active neuroleptics.

Structure-function coupling in macroscale human brain networks

Precisely how the anatomical structure of the brain gives rise to a repertoire of complex functions remains incompletely understood. A promising manifestation of this mapping from structure to function is the dependency of the functional activity of a brain region on the underlying white matter architecture. Here, we review the literature examining the macroscale coupling between structural and functional connectivity, and we establish how this structure-function coupling (SFC) can provide more information about the underlying workings of the brain than either feature alone. We begin by defining SFC and describing the computational methods used to quantify it. We then review empirical studies that examine the heterogeneous expression of SFC across different brain regions, among individuals, in the context of the cognitive task being performed, and over time, as well as its role in fostering flexible cognition. Last, we investigate how the coupling between structure and function is affected in neurological and psychiatric conditions, and we report how aberrant SFC is associated with disease duration and disease-specific cognitive impairment. By elucidating how the dynamic relationship between the structure and function of the brain is altered in the presence of neurological and psychiatric conditions, we aim to not only further our understanding of their aetiology but also establish SFC as a new and sensitive marker of disease symptomatology and cognitive performance. Overall, this Review collates the current knowledge regarding the regional interdependency between the macroscale structure and function of the human brain in both neurotypical and neuroatypical individuals.

Challenges in the Treatment of Psychotic Bipolar Depression

BACKGROUND

Psychotic bipolar depression (PBD) is a prevalent yet understudied psychiatric illness, and there are no specific guidelines or Food and Drug Administration-approved medications for its treatment. Recent studies suggest that some antipsychotics and mood stabilizers may be effective in managing bipolar depression; however, their effectiveness for PBD remains unclear. Given the urgent need for more focused research for managing PBD, we conducted a literature review to summarize the existing literature on PBD.

METHODS

We conducted an electronic literature search from the 1960s to 2023, utilizing PubMed, MEDLINE, EMBASE, and Google, and selected studies based on their relevance to PBD.

FINDINGS

PBD is a complex disorder, with 50%-75% of patients with bipolar disorder exhibiting psychotic features. This likelihood increases among those with a history of psychotic mania. Treatment guidelines often recommend a combination of mood stabilizers, antipsychotics, or electroconvulsive therapy, but they do not specify a first-line treatment. PBD symptoms can be masked by mixed high mood and energy feelings, potentially delaying diagnosis and treatment while increasing suicide risk. Limited research has evaluated outcomes of various treatments for PBD, and despite the lack of evidence for superior efficacy, in clinical practice, antipsychotics are frequently prescribed. Notably, combining an antipsychotic with selective noradrenaline reuptake inhibitors or tricyclic antidepressants may be effective, but including a mood stabilizer is necessary.

CONCLUSION

PBD poses a significant challenge in mental health due to its severity and the lack of consensus on optimal treatment approaches. There is a critical need for more dedicated clinical trials and research to answer key questions about the effective treatment of acute PBD, ideal follow-up care, traits of responders to different therapies, and decision models for subsequent treatments.

Advances in the understanding of the pathophysiology of schizophrenia and bipolar disorder through induced pluripotent stem cell models

The pathophysiology of schizophrenia and bipolar disorder involves a complex interaction between genetic and environmental factors that begins in the early stages of neurodevelopment. Recent advancements in the field of induced pluripotent stem cells (iPSCs) offer a promising tool for understanding the neurobiological alterations involved in these disorders and, potentially, for developing new treatment options. In this review, we summarize the results of iPSC-based research on schizophrenia and bipolar disorder, showing disturbances in neurodevelopmental processes, imbalance in glutamatergic-GABAergic transmission and neuromorphological alterations. The limitations of the reviewed literature are also highlighted, particularly the methodological heterogeneity of the studies, the limited number of studies developing iPSC models of both diseases simultaneously, and the lack of in-depth clinical characterization of the included samples. Further studies are needed to advance knowledge on the common and disease-specific pathophysiological features of schizophrenia and bipolar disorder and to promote the development of new treatment options.

On the Asymmetric Relationship Between Physician Mental Health Disorders on Quality of Healthcare Under the COVID-19 Pandemic in Taiwan: Quantile on Quantile Regression Analyses

Purpose

When examining the nexus of physician mental health disorders and healthcare quality from the empirical perspective, mental health disorders are frequently associated with cyclical patterns corresponding to cyclic seasonality, mood swings, emission of air pollution and business cycles, the potential asymmetric effects of physician mental health disorders on healthcare quality have not received adequate attention from researchers. Therefore, the purpose of this study is to explore the asymmetric relationship between physician mental health disorders and healthcare quality during the pandemic outbreak in Taiwan.

Methods

Daily data for care quality indicators and physician mental health disorders were collected from the National Insurance Research Database in Taiwan, and the quantile-on-quantile regression model was applied to proceed with our analyses.

Results

Our results indicated that the overall aggregate effects of each quantile of physician mental health disorders on the cumulative quantiles of healthcare quality are negative (positive) for the 14-day readmission rate (preventable hospitalization rate and non-urgent ED-visit rate). Positively (negatively) cumulative effects of each quantile of physician mental health disorders were detected in the middle (low and high) quantiles of the preventable hospitalization rate. The cumulative effects of each quantile of physician mental health disorders on the high (low and middle) quantiles of the 14-day readmission rate are negative (positive), but the cumulative effects on various quantiles of the non-urgent ED-visit rate exhibit the opposite pattern.

Conclusion

The observed variation in the relationship between physician mental health disorders and different quantiles of healthcare quality suggests the need for tailored strategic interventions based on distinct levels of healthcare quality when addressing the higher risk of physician mental health disorders during the pandemic outbreak conditions.

Are There Any Differences in Clinical and Biochemical Variables between Bipolar Patients with or without Lifetime Psychotic Symptoms?

INTRODUCTION

Psychotic symptoms occur in more than half of patients affected by Bipolar Disorder (BD) and are associated with an unfavorable course of the disorder. The objective of this study is to identify the differences in the clinical and biochemical parameters between bipolar patients with or without psychotic symptoms.

METHODS

A total of 665 inpatients were recruited. Demographic, clinical, and biochemical data related to the first day of hospitalization were obtained via a screening of the clinical charts and intranet hospital applications. The two groups identified via the lifetime presence of psychotic symptoms were compared using t tests for quantitative variables and χ2 tests for qualitative ones; binary logistic regression models were subsequently performed.

RESULTS

Patients with psychotic BD (compared to non-psychotic ones) showed a longer duration of hospitalization (p < 0.001), higher Young Mania Rating Scale scores (p < 0.001), lower Global Assessment of Functioning scores (p = 0.002), a less frequent history of lifetime suicide attempts (p = 0.019), less achievement of remission during the current hospitalization (p = 0.028), and a higher Neutrophile to Lymphocyte Ratio (NLR) (p = 0.006), but lower total cholesterol (p = 0.018) and triglycerides (p = 0.013).

CONCLUSIONS

Patients with psychotic BD have a different clinical and biochemical profile compared to their counterparts, characterized by more clinical severity, fewer metabolic alterations, and a higher grade of inflammation. Further multi-center studies have to confirm the results of this present study.

Older age bipolar disorder

PURPOSE OF REVIEW

Older age bipolar disorder (OABD) refers to patients with bipolar disorder aged 50 years and over. There is a paucity of evidence-based guidelines specific to OABD, but in recent years, several studies have been published on OABD. The current review synthesizes previous literature (up to January 1, 2021) as well as most recent literature on OABD (since January 1, 2021).

RECENT FINDINGS

This review covers the following themes: diagnosis and specifiers, clinical course, psychosocial functioning, cognition, physical comorbidities, and pharmacotherapy. On the basis of the latest data, specific clinical recommendations are proposed for each theme.

SUMMARY

OABD forms a more complex subgroup of bipolar disorder, with an increased risk of cognitive deficits, physical comorbidities, impaired psychosocial functioning, and premature death. The distinctions between BD-I and BD-II and between EOBD and LOBD do not clinically represent relevant subtypes for OABD patients. Mental healthcare professionals should treat all OABD patients with an integrative care model that takes into account cognitive and physical comorbidities and that contains elements aimed at improvement of psychosocial functioning and quality of life. Older age itself should not be a reason to withhold lithium treatment. Future research should collect data on essential data domains using validated measurement scales.

Differential characteristics of bipolar I and II disorders: a retrospective, cross-sectional evaluation of clinical features, illness course, and response to treatment

BACKGROUND

The distinction between bipolar I and bipolar II disorder and its treatment implications have been a matter of ongoing debate. The aim of this study was to examine differences between patients with bipolar I and II disorders with particular emphasis on the early phases of the disorders.

METHODS

808 subjects diagnosed with bipolar I (N = 587) or bipolar II disorder (N = 221) according to DSM-IV criteria were recruited between April 1994 and March 2022 from tertiary-level mood disorder clinics. Sociodemographic and clinical variables concerning psychiatric and medical comorbidities, family history, illness course, suicidal behavior, and response to treatment were compared between the bipolar disorder types.

RESULTS

Bipolar II disorder patients were more frequently women, older, married or widowed. Bipolar II disorder was associated with later "bipolar" presentation, higher age at first (hypo)mania and treatment, less frequent referral after a single episode, and more episodes before lithium treatment. A higher proportion of first-degree relatives of bipolar II patients were affected by major depression and anxiety disorders. The course of bipolar II disorder was typically characterized by depressive onset, early depressive episodes, multiple depressive recurrences, and depressive predominant polarity; less often by (hypo)mania or (hypo)mania-depression cycles at onset or during the early course. The lifetime clinical course was more frequently rated as chronic fluctuating than episodic. More patients with bipolar II disorder had a history of rapid cycling and/or high number of episodes. Mood stabilizers and antipsychotics were prescribed less frequently during the early course of bipolar II disorder, while antidepressants were more common. We found no differences in global functioning, lifetime suicide attempts, family history of suicide, age at onset of mood disorders and depressive episodes, and lithium response.

CONCLUSIONS

Differences between bipolar I and II disorders are not limited to the severity of (hypo)manic syndromes but include patterns of clinical course and family history. Caution in the use of potentially mood-destabilizing agents is warranted during the early course of bipolar II disorder.

Status of Type II vs. Type I Bipolar Disorder: Systematic Review with Meta-Analyses

LEARNING OBJECTIVES AFTER PARTICIPATING IN THIS CME ACTIVITY, THE PSYCHIATRIST SHOULD BE BETTER ABLE TO

• Analyze and compare the different bipolar disorder (BD) types.• Identify markers that distinguish BD types and explain how the DSM-IV defines the disorder.

ABSTRACT

Since the status of type II bipolar disorder (BD2) as a separate and distinct form of bipolar disorder (BD) remains controversial, we reviewed studies that directly compare BD2 to type I bipolar disorder (BD1). Systematic literature searching yielded 36 reports with head-to-head comparisons involving 52,631 BD1 and 37,363 BD2 patients (total N = 89,994) observed for 14.6 years, regarding 21 factors (with 12 reports/factor). BD2 subjects had significantly more additional psychiatric diagnoses, depressions/year, rapid cycling, family psychiatric history, female sex, and antidepressant treatment, but less treatment with lithium or antipsychotics, fewer hospitalizations or psychotic features, and lower unemployment rates than BD1 subjects. However, the diagnostic groups did not differ significantly in education, onset age, marital status, [hypo]manias/year, risk of suicide attempts, substance use disorders, medical comorbidities, or access to psychotherapy. Heterogeneity in reported comparisons of BD2 and BD1 limits the firmness of some observations, but study findings indicate that the BD types differ substantially by several descriptive and clinical measures and that BD2 remains diagnostically stable over many years. We conclude that BD2 requires better clinical recognition and significantly more research aimed at optimizing its treatment.