Major advances in bipolar disorder

Evaluation of the Effect of Memantine Supplementation in the Treatment of Acute Phase of Mania in Bipolar Disorder of Elderly Patients: A Double-blind Randomized Controlled Trial

Background:

This study aimed to evaluate the efficacy of memantine in the acute treatment of geriatric with bipolar disorder (BD) hospitalized for mania.

Materials and Methods:

This study conducted on 70 patients older than 60 years with BD in the acute phase of mania. Oral sodium valproate was prescribed in both groups. The intervention group received memantine tablet and the placebo group received a placebo tablet based on a same procedure. Severity of mania, cognitive changes, and quality of life (QoL) were assessed and recorded 4 and 8 weeks after the beginning of the study. The collected data were analyzed with SPSS (version 20) using independent samples t-test, analysis of variance in repeated observations, Chi-squared test, and Fisher's exact test.

Results:

Mania severity score had no significant difference at the beginning of the study, but 4 and 8 weeks after the intervention, it was reduced significantly in both groups (P < 0.001) that was higher in memantine group (P = 0.038). The mean increase in score of cognitive variations was 6.74 in the memantine group and 3.62 in the placebo group with a nonsignificant difference (P = 0.125). The scores of each dimension of QoL in the two groups showed that in all four dimensions, the patient's physical, psychological, social, and environmental status increased significantly by time (P < 0.001).

Conclusions:

According to the results of this study, memantine as an adjuvant to administration of sodium valproate may have a significant effect on decreasing the intensity of mania in the long run.

ALDH2 modulated changes in cytokine levels and cognitive function in bipolar disorder: A 12-week follow-up study

OBJECTIVES

We investigated the association of the aldehyde dehydrogenase 2 ( ALDH2) polymorphism (rs671), which is involved with the dopaminergic function, and with changes in cytokine levels and cognitive function, in a 12-week follow-up study in patients with bipolar disorder.

METHODS

Patients with a first diagnosis of bipolar disorder were recruited. Symptom severity and levels of plasma cytokines (tumor necrosis factor α, C-reactive protein, interleukin 6 and transforming growth factor β1) were examined during weeks 0, 1, 2, 4, 8 and 12. Neurocognitive function was evaluated at baseline and endpoint. The ALDH2 polymorphism genotype was determined.

RESULTS

A total of 541 patients with bipolar disorder were recruited, and 355 (65.6%) completed the 12-week follow-up. A multiple linear regression analysis showed a significant ( p = 0.000226) association between the ALDH2 polymorphism and changes in C-reactive protein levels. Different aspects of cognitive function improved in patients with different ALDH2 genotypes. Only patients with the ALDH2*1*1 genotype showed significant correlations between improvement of cognitive function and increased transforming growth factor -β1.

CONCLUSION

The ALDH2 gene might influence changes in cytokine levels and cognitive performance in patients with bipolar disorder. Additionally, changes in cytokine levels and cognitive function were correlated only in patients with specific ALDH2 genotypes.

Association between bipolar disorder and subsequent traumatic brain injury in patients who received inpatient treatment

Mental disorders may confer a high risk of traumatic brain injury, but only rare studies have investigated mood disorders. This nationwide cohort study compared the risk of traumatic brain injury in patients with and without bipolar disorder. We compared 1017 patients with bipolar disorder who received inpatient treatment and 9080 compared patients. The annual incidence rate of traumatic brain injury was calculated as the number of new cases divided by the total number of person-years in the available records. The incidence of subsequent traumatic brain injury was significantly higher in the bipolar group than in control group. The adjusted hazard ratio for those with multiple hospitalizations was higher than the counterpart. Except for patients in the 50-59-year age group, those in all other age groups had higher risks of traumatic brain injury. Our findings reveal a higher risk of traumatic brain injury in patients with bipolar disorder. Patients with recurrent hospitalization and multiple psychotropic use had an increased risk of traumatic brain injury. Age may modify the risk of traumatic brain injury, with a higher risk in middle-aged patients.

Can a systems approach produce a better understanding of mood disorders?

BACKGROUND

One in twenty-five people suffer from a mood disorder. Current treatments are sub-optimal with poor patient response and uncertain modes-of-action. There is thus a need to better understand underlying mechanisms that determine mood, and how these go wrong in affective disorders. Systems biology approaches have yielded important biological discoveries for other complex diseases such as cancer, and their potential in affective disorders will be reviewed.

SCOPE OF REVIEW

This review will provide a general background to affective disorders, plus an outline of experimental and computational systems biology. The current application of these approaches in understanding affective disorders will be considered, and future recommendations made.

MAJOR CONCLUSIONS

Experimental systems biology has been applied to the study of affective disorders, especially at the genome and transcriptomic levels. However, data generation has been slowed by a lack of human tissue or suitable animal models. At present, computational systems biology has only be applied to understanding affective disorders on a few occasions. These studies provide sufficient novel biological insight to motivate further use of computational biology in this field.

GENERAL SIGNIFICANCE

In common with many complex diseases much time and money has been spent on the generation of large-scale experimental datasets. The next step is to use the emerging computational approaches, predominantly developed in the field of oncology, to leverage the most biological insight from these datasets. This will lead to the critical breakthroughs required for more effective diagnosis, stratification and treatment of affective disorders.

ECT and lithium in old age depression - cause or treatment of rapid cycling?

OBJECTIVE

This article presents the case of an elderly woman experiencing a depressive phase of Bipolar Affective Disorder 1 (BPAD1), who required electroconvulsive therapy (ECT), prior to which her lithium was ceased, and who developed ultra-ultra-rapid cycling (UURC) and ultra-rapid cycling (URC). This resolved with the recommencement of lithium and continuation of ECT.

METHOD

Case report and review of the relevant literature.

RESULTS

The patient's mood stabilized with recommencement of lithium and continuation of ECT.

CONCLUSIONS

Ceasing lithium prior to ECT may carry a risk of URC or UURC in BPAD1.

A qualitative investigation of hypomania and depression in bipolar II disorder

Psychological treatments may have differential impacts on bipolar (BP) sub-types, yet little is known about psychological processes in BP II disorder. We explored cognitive processes and behaviors mediating hypomania and depression in participants diagnosed with BP II disorder. Semi-structured interviews with 13 participants were analysed using interpretative phenomenological analysis. The majority were able to detect hypomanic and depressive prodromes, and describe behavioral responses to these mood states. Qualitative analyses revealed four theme clusters. Hypomania ascent beliefs described beliefs regarding identity, positioning hypomania as an enjoyable state preferable to depression. Hypomania descent beliefs referred to hypomania as a signal for depression, causing interpersonal difficulties. Beliefs about depression positioned depression as an abnormal, fearful state, impacting negatively interpersonally, occupationally and on self-perceptions. Finally, The impact of chronicity referred to shifts in coping strategies over time, moving from maladaptive to adaptive behavioral responses. Themes were interpreted within the framework of a cognitive model of BP disorder. Clinical implications for BP II disorder were discussed.

The DRD2/ANKK1 gene is associated with response to add-on dextromethorphan treatment in bipolar disorder

Dextromethorphan (DM) is a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist that may be neuroprotective for monoamine neurons. We hypothesized that adding DM to valproate (VPA) treatment would attenuate bipolar disorder (BP) symptoms. We evaluated in BP patients the association between the DRD2/ANKK1 TaqIA polymorphism with treatment response to VPA+add-on DM and to VPA+placebo. This double-blind, stratified, randomized study ran from January 2007 through December 2010. BP patients undergoing regular VPA treatments were randomly assigned to groups given either add-on DM (60 mg/day) (n=167) or placebo (n=83) for 12 weeks. The Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale (HDRS) were used to evaluate clinical response. The genotypes of the DRD2/ANKK1 TaqIA polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis. To adjust within-subject dependence over repeated assessments, multiple linear regression with generalized estimating equation methods was used to analyze the effects of the DRD2/ANKK1 TaqIA polymorphism on clinical performance. Both groups showed significantly decreased YMRS and HDRS scores after 12 weeks of treatment; the differences between groups were non-significant. Decreases in YMRS scores were greater in patients with the A1A1 (P=0.004) genotypes than with the A2A2 genotype. We conclude that the DRD2/ANKK1 TaqIA polymorphism influenced responses to DM by decreasing manic symptoms in BP patients.

Gray matter reduction of the superior temporal gyrus in patients with established bipolar I disorder

BACKGROUND

Functional abnormalities of the superior temporal gyrus (STG) have been implicated in the pathophysiology of bipolar disorder, but magnetic resonance imaging (MRI) studies of this region have yielded inconsistent findings.

METHOD

We used MRI to examine the volumes of the STG and its gray matter subregions [planum polare (PP), Heschl gyrus (HG), planum temporale (PT), and lateral STG (rostral and caudal regions)] in 26 patients with established bipolar I disorder (8 males and 18 females, mean age=38.4 years) and 24 age and gender-matched healthy controls (7 males and 17 females, mean age=38.7 years).

RESULTS

Bipolar patients had significantly smaller volumes of the PT and caudal STG compared with controls in the left hemisphere. The STG white matter volume did not differ between the groups. There was no association between the STG volume and number of manic/depressive episodes, family history, or clinical subtype (i.e., psychotic and nonpsychotic), but daily dosage of lithium treatment at the time of scanning was positively correlated with right PP and right rostral STG volumes.

LIMITATIONS

Entire clinical data (e.g., lifetime medication, symptomatology) were not available.

CONCLUSIONS

These findings implicate a role for the STG gray matter, especially its left posterior regions, in the neurobiology of bipolar disorder. Our findings may also support the notion of lithium-induced gray matter expansion.

Memantine efficacy and safety in patients with acute mania associated with bipolar I disorder: a pilot evaluation

OBJECTIVE

Evaluate the efficacy and tolerability of memantine (20, 30, and 40 mg/d) in the acute treatment of adults with bipolar I disorder hospitalized for mania.

METHODS

This multicenter, open-label, pilot trial included adults with bipolar I disorder (manic or mixed episode, with and without psychotic features). Patients were assigned to 21 days of treatment: cohort 1, 20 mg/d (range, 20-30 mg/d); cohort 2, 30 mg/d (range, 30-40 mg/d); cohort 3, 40 mg/d (range, 30-50 mg/d). Efficacy measures included the Young Mania Rating Scale (YMRS) and the Mania Rating Scale (>or=50% reduction in total score from baseline). The change from baseline was also assessed using the Positive and Negative Syndrome Scale in patients with psychiatric symptoms, Positive and Negative Syndrome Scale-Excited Component, Clinical Global Impression Severity and Improvement scores, and Montgomery Asberg Depression Rating Scale.

RESULTS

A total of 35 patients were enrolled; 33 patients received at least 1 dose of memantine and had at least 1 postbaseline assessment using YMRS. Greatest improvement occurred in cohort 1 where half of the patients responded to memantine based on YMRS and Mania Rating Scale. At day 21, a response was observed in all patient cohorts. Treatment-emergent adverse events were reported in 19 patients (54.3%). The most frequently reported adverse events (>or=4 patients) included constipation, nausea, and headache.

CONCLUSIONS

The response to memantine combined with its tolerability support conducting large-sized randomized controlled trials to investigate further the use of memantine monotherapy in the treatment of mania.

Recognizing and treating common psychiatric disorders in multiple sclerosis

BACKGROUND

The rate of depression and other psychiatric disorders is greater in multiple sclerosis (MS) than in other chronic conditions or neurologic diseases. This means that clinical neurologists seeing MS patients will frequently be engaged in the diagnosis and treatment of psychiatric distress.

REVIEW SUMMARY

This review provides a summary of what is known about psychiatric dysfunction in MS. It offers information about the current views on the link between various psychiatric disorders and MS. More important, it offers suggestions on how the knowledge from existing research can be integrated into real-world practice.

CONCLUSION

Clinicians need to understand the factors that influence the development of psychiatric disorders in MS, the relationship between disease-modifying therapies and psychiatric distress, and the issues surrounding the treatment of psychiatric conditions in MS. Thorough knowledge of psychiatric dysfunction and MS will allow the clinician to design an effective treatment regimen that helps patients cope with their disease.

Self-reported care needs of outpatients with a bipolar disorder in the Netherlands

The care needs of patients with a bipolar disorder have not been studied to date. In the present research, the care needs, care received and unmet care needs for a population of outpatients with a bipolar disorder in the Netherlands are described. The participants (n = 157) completed the Need for Care Questionnaire and a questionnaire addressing various demographic and clinical characteristics. The results show the care needs to mainly involve the domains of psychological help, psychiatric help and social functioning. Unmet needs are frequently reported for all domains and found to be particularly frequent for needs on social functioning. Some significant associations between source of income, number of hospitalizations and involvement of community psychiatric nurses, on the one hand, and reported care needs, on the other hand, are identified and discussed. Incorporation of needs assessment into the treatment process is recommended in the form of structured questionnaires which can also then be used to guide and evaluate the treatment process. Future research should focus on the identification of the specific risk factors for particular care needs and thereby work to minimize the occurrence of such risk factors and promote early intervention efforts to reduce the burden on patients and their relatives.

Screening for bipolar disorders using a French version of the Mood Disorder Questionnaire (MDQ)

BACKGROUND

Bipolar disorders remain much too often unrecognized and subsequently inappropriately treated. This paper presents the translation into French and validation of the MDQ, a screening instrument for bipolar spectrum disorders, in an adult psychiatric sample. Modifications of its criteria for a positive screening as well as its test-retest reliability are also addressed.

METHODS

A sample of 96 patients, attending outpatient treatment programs and suffering from mood disorders, completed the MDQ before being interviewed according to the mood module of the structured clinical interview for DSM-IV (SCID). They completed the MDQ a second time 1 month later, in order to examine its stability over time.

RESULTS

According to the SCID interview, 54 patients were suffering from bipolar disorder and 42 from unipolar disorder. Among the bipolar sample, the MDQ identified 74.1% of them, with higher sensitivity in bipolar I (90.3%) than bipolar II (52.4%) and 90.5% specificity. Lowering the level of impairment required for positive screening led to improved sensitivity for bipolar II patients (76.2%). The French MDQ demonstrated adequate internal consistency (Cronbach alpha=0.89). Its test-retest reliability proved to be satisfactory, with a kappa coefficient of 0.79. Similar stability over a 1-month interval was obtained for bipolar type I and type II (kappa=0.75 and 0.77, respectively).

LIMITATIONS

Similarly to the American version, the French MDQ has lower sensitivity for bipolar II disorders.

CONCLUSIONS

The performance of the French MDQ is comparable to the one reported in the original American study conducted with a similar patient population. In a psychiatric outpatient sample, the French MDQ proves to be a feasible and reliable screening instrument.

A typical mood stabilizers: a "typical role for atypical antipsychotics

OBJECTIVE

To assess the potential role of atypical antipsychotics as mood stabilizers.

METHOD

A MedLine, PsychLIT, PubMed, and EMBASE literature search of papers published up to December 2004 was conducted using the names of atypical antipsychotics and a number of key terms relevant to bipolar disorder. Additional articles were retrieved by scrutinizing the bibliographies of review papers and literature known to the authors. Data pertinent to the objective was reviewed according to the various phases of bipolar disorder.

RESULTS

The data is most substantive for the use of atypical antipsychotics in mania, to the extent that an argument for a class effect of significant efficacy can be made. This does not extend to bipolar depression, however, good data is now emerging for some agents and will need to be considered for each individual agent as it accumulates. As regards mixed states and rapid cycling the evidence is thus far sparse and too few maintenance studies have been conducted to make any firm assertions. However, with respect to long-term therapy the atypical antipsychotics do have clinically significant side-effects of which clinicians need to be aware.

CONCLUSION

Based on the evidence thus far it is perhaps premature to describe the atypical antipsychotics as mood stabilizers. Individual agents may eventually be able to claim this label, however, much further research is needed especially with respect to maintenance and relapse prevention.

Genetics and genomics of depression

Depressive disorders are among the most common psychiatric diseases, with prevalence estimates ranging from 5% to a maximum of 20%. Despite their high prevalence and socioeconomic impact, little is known about their etiology. Heritability estimates demonstrate up to a 50% genetic component based on family aggregation and contrasting monozygotic and dizygotic twin studies. The low relative risk to siblings ( lambda sib <1.5) makes the search for their genetic determinants very tedious. Gene-environment interaction has been recognized for a long time in the pathophysiology of depression, and its best biological substratum at present is represented by the serotonin transporter (5-HTT) gene, where several copies of its short allele culminate in depression and suicide in response to lifelong stress events. Many total genome scans have been performed with variable results, the most authoritative being the one of Utah pedigrees with a strong family history of major depression. It identified a locus on chromosome 12 encompassing a gene cluster and sex-specific predisposition. Nevertheless, recent genome scan meta-analysis yielded somewhat disappointing conclusions with a relatively low significance for quantitative trait loci on chromosomes 9, 10, 14, and 18. Studies on animal models have contributed to the chromosomal mapping of many behavioral traits, including anxiety, the stress response, and depression. Although F2 crosses constitute a classical approach, novel models of recombinant inbred strain and recombinant congenic strain animals allow for a rapid initial localization of any traits. This type of analysis has led us to uncover significant loci for the stress response and anxiety in rats and mice.