Metabolomic biomarkers for (R, S)-ketamine and (S)-ketamine in treatment-resistant depression and healthy controls: A systematic review

BACKGROUND

Ketamine is increasingly used for treatment-resistant depression (TRD) while its mechanism of action is still being investigated. In this systematic review, we appraise the current evidence of metabolomic biomarkers for racemic ketamine and esketamine in patients with TRD and healthy controls (HCs).

METHODS

A comprehensive search of several databases (Ovid MEDLINE®, Embase, and Epub Ahead of Print) was performed from each database's inception to June 29, 2022, in any language, was conducted. We included studies wherein the metabolomic biomarkers for racemic ketamine or esketamine were investigated in TRD or HCs. Our main outcomes were to examine changes in metabolites among patients treated with ketamine/esketamine and explore the association with response to ketamine/esketamine.

RESULTS

A total of 1859 abstracts were screened of which 11 were included for full-text review. Of these, a total of five articles were included (N = 147), including three RCTs (n = 129) and two open-label trials (n = 18). All studies used racemic ketamine; one study additionally used esketamine. The included studies evaluated patients with treatment-resistant bipolar depression (n = 22), unipolar depression (n = 91), and HCs (n = 34). The included studies reported alteration in several metabolites including acylcarnitines, lipids, kynurenine (KYN), and arginine with ketamine in TRD. Studies suggest the involvement of energy metabolism, KYN, and arginine pathways. In HCs, acetylcarnitine decreased post-infusion, whereas inconsistent findings were observed after the ketamine infusion in TRD patients.

CONCLUSIONS

This systematic review provides preliminary evidence that ketamine may cause changes in several important pathways involved in energy metabolism and inflammation. Larger and more rigorous studies are needed.

Brain-based correlates of antidepressant response to ketamine: a comprehensive systematic review of neuroimaging studies

Ketamine is an effective antidepressant, but there is substantial variability in patient response and the precise mechanism of action is unclear. Neuroimaging can provide predictive and mechanistic insights, but findings are limited by small sample sizes. This systematic review covers neuroimaging studies investigating baseline (pre-treatment) and longitudinal (post-treatment) biomarkers of responses to ketamine. All modalities were included. We performed searches of five electronic databases (from inception to April 26, 2022). 69 studies were included (with 1751 participants). There was substantial methodological heterogeneity and no well replicated biomarker. However, we found convergence across some significant results, particularly in longitudinal biomarkers. Response to ketamine was associated with post-treatment increases in gamma power in frontoparietal regions in electrophysiological studies, post-treatment increases in functional connectivity within the prefrontal cortex, and post-treatment increases in the functional activation of the striatum. Although a well replicated neuroimaging biomarker of ketamine response was not identified, there are biomarkers that warrant further investigation.

κ-Opioid Receptor Plasma Levels Are Associated With Sex and Diagnosis of Major Depressive Disorder But Not Response to Ketamine

BACKGROUND

Preclinical evidence indicates that the κ-opioid receptor (KOR)/dynorphin pathway is implicated in depressive-like behaviors. Ketamine is believed to partly exert its antidepressant effects by modulating the opioid system. This post hoc study examined the following research questions: (1) at baseline, were there differences in KOR or dynorphin plasma levels between individuals with major depressive disorder (MDD) and healthy volunteers (HVs) or between men and women? (2) in individuals with MDD, did KOR or dynorphin baseline plasma levels moderate ketamine's therapeutic effects or adverse effects? and (3) in individuals with MDD, were KOR or dynorphin plasma levels affected after treatment with ketamine compared with placebo?

METHODS

Thirty-nine unmedicated individuals with MDD (23 women) and 25 HVs (16 women) received intravenous ketamine (0.5 mg/kg) and placebo in a randomized, crossover, double-blind trial. Blood was obtained from all participants at baseline and at 3 postinfusion time points (230 minutes, day 1, day 3). Linear mixed model regressions were used.

RESULTS

At baseline, participants with MDD had lower KOR plasma levels than HVs ( F1,60 = 13.16, P < 0.001), and women (MDD and HVs) had higher KOR plasma levels than men ( F1,60 = 4.98, P = 0.03). Diagnosis and sex had no significant effects on baseline dynorphin levels. Baseline KOR and dynorphin levels did not moderate ketamine's therapeutic or adverse effects. Compared with placebo, ketamine was not associated with postinfusion changes in KOR or dynorphin levels.

CONCLUSIONS

In humans, diagnosis of MDD and biological sex are involved with changes in components of the KOR/dynorphin pathway. Neither KOR nor dynorphin levels consistently moderated ketamine's therapeutic effects or adverse effects, nor were levels altered after ketamine infusion.

TRIAL REGISTRATION

NCT00088699 ( ClinicalTrials.gov ).

Blood-based biomarkers of antidepressant response to ketamine and esketamine: A systematic review and meta-analysis

(R,S)-ketamine (ketamine) and its enantiomer (S)-ketamine (esketamine) can produce rapid and substantial antidepressant effects. However, individual response to ketamine/esketamine is variable, and there are no well-accepted methods to differentiate persons who are more likely to benefit. Numerous potential peripheral biomarkers have been reported, but their current utility is unclear. We conducted a systematic review/meta-analysis examining the association between baseline levels and longitudinal changes in blood-based biomarkers, and response to ketamine/esketamine. Of the 5611 citations identified, 56 manuscripts were included (N = 2801 participants), and 26 were compatible with meta-analytical calculations. Random-effect models were used, and effect sizes were reported as standardized mean differences (SMD). Our assessments revealed that more than 460 individual biomarkers were examined. Frequently studied groups included neurotrophic factors (n = 15), levels of ketamine and ketamine metabolites (n = 13), and inflammatory markers (n = 12). There were no consistent associations between baseline levels of blood-based biomarkers, and response to ketamine. However, in a longitudinal analysis, ketamine responders had statistically significant increases in brain-derived neurotrophic factor (BDNF) when compared to pre-treatment levels (SMD [95% CI] = 0.26 [0.03, 0.48], p = 0.02), whereas non-responders showed no significant changes in BDNF levels (SMD [95% CI] = 0.05 [-0.19, 0.28], p = 0.70). There was no consistent evidence to support any additional longitudinal biomarkers. Findings were inconclusive for esketamine due to the small number of studies (n = 2). Despite a diverse and substantial literature, there is limited evidence that blood-based biomarkers are associated with response to ketamine, and no current evidence of clinical utility.

Neuroimaging correlates of depression after traumatic brain injury: A systematic review

Depression is the most frequent neuropsychiatric complication after traumatic brain injury (TBI) and is associated with poorer outcomes. Neuroimaging has the potential to improve our understanding of the neural correlates of depression after TBI and may improve our capacity to accurately predict and effectively treat this condition. We conducted a systematic review of structural and functional neuroimaging studies that examined the association between depression after TBI, and neuroimaging measures. Electronic searches were conducted in four databases and were complemented by manual searches. In total, 2,035 citations were identified and, ultimately, 38 articles were included totaling 1,793 individuals (median [25%-75%] sample size of 38.5 (21.8-54.3) individuals). The most frequently used modality was structural magnetic resonance imaging (MRI) (n=17, 45%), followed by diffusion tensor imaging (n=11, 29%), resting-state functional MRI (n=10, 26%), task-based functional MRI (n=4, 8%), and positron emission tomography (n=2, 4%). Most studies (n=27, 71%) were cross-sectional. Overall, depression after TBI was associated with lower grey matter measures (volume, thickness, and/or density) and greater white matter damage. However, identification of specific brain areas was somewhat inconsistent. Findings that were replicated in more than one study included reduced grey matter in the rostral anterior cingulate cortex, prefrontal cortex and hippocampus, and damage in five white matter tracts (cingulum, internal capsule, superior longitudinal fasciculi, anterior, and posterior corona radiata). This systematic review found that the available data did not converge on a clear neuroimaging biomarker for depression after TBI. However, there are promising targets that warrant further study.

Impact of childhood maltreatment on outcomes of antidepressant medication in chronic and/or recurrent depression

BACKGROUND

While childhood maltreatment (CMT) is associated with higher rates of chronicity and recurrence in depression, whether CMT results in poorer outcomes with antidepressant medication remains unclear.

METHODS

We performed secondary analyses with data from the large, representative, multisite trial Combining Medications to Enhance Depression Outcomes (CO-MED). CO-MED was a randomized, single-blinded, placebo-controlled study with 665 individuals (663 assessed for CMT) with chronic and/or recurrent Major Depressive Disorder (MDD). CMT was determined by a brief self-reported questionnaire assessing the four types of CMT defined by the Centers for Disease Control and Prevention: sexual abuse, emotional abuse, physical abuse, and neglect. Repeated measures and logistic regression analyses were used.

RESULTS

Individuals with CMT did not have a differential improvement of depressive symptoms when compared to those without CMT (adjusted p=.203 for continuous analysis; adjusted p=.320 for remission rates). Neither type of antidepressant medication (adjusted p=.302) nor the age at which CMT occurred (adjusted p=.509) affected depressive symptom outcomes. There was no difference in functional improvement between individuals with and without CMT (adjusted p=.228). A history of CMT was associated with greater antidepressant side effects (p=.009).

LIMITATIONS

This study investigated treatment-seeking individuals with chronic and/or recurrent MDD. Intensity and duration of CMT were not assessed.

CONCLUSION

In a sample of treatment-seeking outpatients with chronic and/or recurrent MDD, a history of CMT was not associated with differential symptomatic or functional response to pharmacological treatment. However, those with CMT reported greater antidepressant side effect burden.

Childhood maltreatment and impact on clinical features of major depression in adults

OBJECTIVES

This study examined: 1) the prevalence of childhood maltreatment (CMT) in individuals with chronic and/or recurrent depression, 2) the association between CMT and depressive symptoms, 3) the link between CMT and worse clinical presentation of depression, 4) the effects of accumulation of different types of CMT, and 5) the relationship between the age at CMT and depression.

METHODS

We analyzed the baseline data of 663 individuals from the CO-MED study. CMT was determined by a brief self-reported questionnaire assessing sexual abuse, emotional abuse, physical abuse, and neglect. Correlational analyses were conducted.

RESULTS

Half of the sample (n = 331) reported CMT. Those with CMT had higher rates of panic/phobic, cognitive and anhedonic symptoms than those without CMT. All individual types of maltreatment were associated with a poorer clinical presentation including: 1) earlier MDD onset; 2) more severe MDD, 3) more suiccidality, 4) worse quality of life, and functioning, and 5) more psychiatric comorbidities. Clinical presentation was worse in participants who reported multiple types of CMT.

CONCLUSIONS

In chronic and/or recurrent depression, CMT is common, usually of multiple types and is associated with a worse clinical presentation in MDD. The combination of multiple types of CMT is associated with more impairment.

Post-stroke depression: A 2020 updated review

BACKGROUND

Post-stroke depression (PSD) is common and associated with higher mortality, poorer recovery, more pronounced cognitive deficits, and lower quality of life than is stroke without depression. This manuscript will conduct an updated, comprehensive and clinically-useful review of the risk factors, pathophysiology, assessment, prevention, and treatment of PSD.

METHODS

This narrative review summarizes articles obtained on PubMed, Medline, EMBase, Google Scholar and the Cochrane Database. This review prioritized articles with a more robust level of evidence, such as original articles with longitudinal data and/or larger samples, randomized controlled trials, systematic reviews, and metaanalyses.

RESULTS

One hundred twenty-four articles were reviewed, of which 44 (35%) were published before 2016 and 80 (65%) that were published since 2016.

DISCUSSION

Rates of PSD range from 18 to 33%, yet it is vastly underdiagnosed and undertreated. Risk factors for PSD include female sex, history of psychiatric illness, large or multiple strokes, injuries in frontal/anterior areas or in the basal ganglia, stroke occurrence within the past year, poor social support, and pronounced disability. The pathophysiology of PSD is multifactorial and likely involves decreased levels of monoamines, abnormal neurotrophic response, increased inflammation with dysregulation of hypothalamic-pituitary-adrenal axis, and glutamate-mediated excitotoxicity. The evidence for preventive interventions for PSD is somewhat inconsistent and modest. The best treatment for PSD consists of the combination of pharmacological, psychosocial and stroke-focused interventions.

CONCLUSION

PSD is a common, treatable condition that is associated with several negative outcomes. Early detection and proper management are critical to obtain better outcomes in individuals with PSD.

Positive and negative valence systems in major depression have distinct clinical features, response to antidepressants, and relationships with immunomarkers

BACKGROUND

Heterogeneity in major depressive disorder (MDD) is well recognized but not well understood. Core depressive features are reward and emotional symptoms, which reflect dysfunctions in the positive valence (PV) and negative valence (NV) systems, respectively. This study assessed whether PV and NV systems (based on selected symptoms) were associated with different clinical features, antidepressant response, and levels of immunomarkers in adults with MDD.

METHODS

These analyses used data from combining medications to enhance depression outcomes study (N = 665; n = 166 for immunomarkers). PV and NV symptom scores were extracted from the clinician-rated 30-item Inventory of Depressive Symptomatology. Correlational analyses were conducted.

RESULTS

PV and NV symptom scores were substantially associated with different clinical features. PV symptoms (impaired motivation, impaired energy, and anhedonia) were independently associated with female gender (p < .001), older age (p = .012), and higher cognitive and physical impairment (p < .001) according to the 7-item Cognitive and Physical Functioning Questionnaire. Conversely, NV symptoms (anxiety and interpersonal sensitivity) were independently associated with younger age (p = .013), more anxious comorbidities (p = .001 for generalized anxiety disorder and p = .002 for social phobia) and other commonly associated noncriterion symptoms (p < .001). Overall, PV symptoms were more responsive to antidepressants than NV symptoms (p < .0001; Cohen's d = .455). A PV symptom score was positively correlated with the concentration of three proinflammatory and one anti-inflammatory factor. In contrast, an NV symptom score was negatively associated with only one proinflammatory immunomarker.

CONCLUSIONS

PV and NV system functions appear to be reflected in selected clinical symptoms that differentially relate to other clinical features, treatment outcomes, and immunological function.

Aggression directed towards others vs. aggression directed towards the self: clinical differences between intermittent explosive disorder and nonsuicidal self-injury

Objective:

To investigate the clinical differences between intermittent explosive disorder (IED) (disorder of aggression primarily directed towards others) and nonsuicidal self-injury (NSSI) (disorder of aggression predominantly directed towards the self) in order to better understand the different clinical subtypes of aggression.

Methods:

We used treatment-seeking samples to compare demographic and clinical correlates between 82 participants with IED and 55 participants with NSSI.

Results:

The IED group was older, more likely to be male, in a relationship, and employed than the NSSI group. With respect to clinical variables, the NSSI group had more severe depressive symptoms and more social adjustment difficulties. Regarding psychiatric co-morbidities, the IED group had higher rates of generalized anxiety disorder. On the other hand, the NSSI group had higher rates of major depressive disorder, agoraphobia, substance use disorder, and bulimia nervosa.

Conclusions:

Individuals with NSSI may benefit from better management of psychiatric comorbidities, specifically depressive symptoms and social adjustment difficulties. Conversely, the treatment of individuals with IED may be improved by targeting comorbid generalized anxiety disorder. Our results provide important insight for the development of tailored interventions for specific subtypes of aggression.

Cognitive-behavioral group therapy for intermittent explosive disorder: description and preliminary analysis

OBJECTIVES

To evaluate the efficacy of a group therapy based on cognitive-behavioral techniques customized for intermittent explosive disorder (IED). The current report presents the preliminary results of a clinical trial comparing pre- and post-intervention scores in different anger dimensions.

METHODS

The studied sample consisted of 84 treatment-seeking subjects. The mean (standard deviation) age was 43.0 (11.9) years, and 78% were male. The therapeutic group program consisted of 15 weekly sessions plus three maintenance sessions. The sessions lasted approximately 90 minutes each.

RESULTS

No differences were found in demographic profile and pre-treatment status between subjects who completed treatment (n=59) and dropouts (n=25). Comparison of State-Trait Anger Expression Scale (STAXI) scores pre- and post-treatment showed statistically significant changes in all anger scales and subscales of the questionnaire.

CONCLUSION

This preliminary report is a significant addition to currently scarce clinical data. Our findings provide further evidence that structured cognitive-behavioral group therapy, with a focus on anger management and cognitive coping, may be a promising approach to the treatment of IED.

Gambling disorder and obsessive-compulsive personality disorder: A frequent but understudied comorbidity

Background and aims Epidemiological data have suggested that the prevalence of co-occurring personality disorders is particularly high in people with gambling disorder (GD). Among the personality disorders, obsessive-compulsive personality disorder (OCPD) appears to be the most common problem. The objective of this study was to investigate the clinical presentation of GD with and without co-occurring OCPD. Methods We studied 25 subjects with current GD and lifetime diagnosis of OCPD. They were matched for age and gender with 25 individuals with current GD but no lifetime diagnosis of any personality disorder. Results Subjects with GD and OCPD demonstrated (a) lower severity of gambling symptoms, (b) slower progression from recreational gambling to full-blown GD, (c) preferred individual forms of betting, (d) identified more triggers to gambling (specially the availability of money and stress); and (e) reported less negative impact on relational problems due to GD. Conclusions Our research provides further insight on GD co-occurring with OCPD, such as increasing social support and improvement of coping skills, especially to deal with financial difficulties and stress. Our findings may lead to more customized and effective therapeutic approaches to this frequent comorbidity.

How to measure monetary losses in gambling disorder? An evidence-based refinement

Diverse monetary measures have been utilized across different studies in gambling disorder (GD). However, there are limited evidence-based proposals regarding the best way to assess financial losses. We investigated how different variables of monetary losses correlate with validated assessments of gambling severity and overall functioning in a large sample of subjects with GD (n = 436). We found that relative monetary variables (i.e. when financial losses were evaluated in relation to personal income) showed the most robust correlations with gambling severity and overall psychosocial functioning. Percentage of monthly income lost from gambling was the variable with the best performance.

Bipolar disorder and tobacco smoking: Categorical and dimensional clinical correlates in subjects from the Brazilian bipolar research network

BACKGROUND

People with bipolar disorder (BD) have high rates of smoking. However, the scientific literature examining the association between clinical outcomes in BD and tobacco smoking is still limited and there are conflicting results. The objective of the current study was to comprehensively investigate associations between BD and tobacco smoking in a large Brazilian sample.

METHODS

This study evaluated 336 outpatients from the Brazilian Bipolar Research Network, which is a collaboration between three large academic centers in Brazil.

MAIN FINDINGS

Regarding the categorical analysis (i.e. current smokers versus non-smokers), tobacco smokers showed: 1) a higher percentage of individuals identifying as Non-Caucasians; 2) a longer duration of illness; 3) a longer duration of untreated illness; 4) more severe manic symptoms; 4) a stronger family history of mood disorder; and 6) a higher current prevalence of alcohol/substance use disorder. The dimensional analysis in smokers (i.e. number of cigarettes per day versus clinical variables) found a positive correlation between number of cigarettes per day and a) age, b) age at onset of BD, c) duration of illness, and d) current diagnosis of panic disorder.

CONCLUSION

This study found important clinical correlates of tobacco smoking in BD subjects. We observed that the variables associated with current smoker status (categorical approach) are not necessarily correlated with number of cigarettes per day (dimensional approach). Duration of illness appears to be a particularly relevant clinical variable in the association between BD and tobacco smoking.

Major depressive disorder and depressive symptoms in intermittent explosive disorder

It is estimated that between 1.7 and 2.6 million people have had intermittent explosive disorder (IED) during their life in the United States alone. Co-occurring psychiatric disorders are very common in IED, being major depressive disorder arguably the most common. The objective of this study was to examine the clinical correlates of IED and depressive manifestations in 74 treatment-seeking subjects. After controlling for confounders, there were associations between major depressive disorder and severity of depressive symptoms, and (a) higher assault scores, (b) more severe hostile behavior and (c) worse social adjustment. Management of depressive symptoms may be an important for IED treatment.

Trichotillomania and its clinical relationship to depression and anxiety

OBJECTIVE

Trichotillomania (TTM) is associated with high rates of co-occurring depression and anxiety disorders. What the co-occurrence of TTM, depression or anxiety disorders means clinically and cognitively, however, has garnered little research attention.

METHODS

About 530 adults with TTM were examined on a variety of clinical measures including symptom severity, psychosocial measures of functioning, psychiatric comorbidity and neurocognitive testing assessing motor inhibition and cognitive flexibility. Clinical features and cognitive functioning were compared between TTM patients with current comorbid major depressive disorder (MDD), a current anxiety disorder, both MDD and an anxiety disorder, or neither.

RESULTS

Of 530 participants, 58 (10.3%) had MDD only, 97 (18.3%) had an anxiety disorder only, 58 (10.3%) had both MDD and an anxiety disorder, and 317 (59.8%) had neither. For almost all clinical measures, those with MDD only reported worse symptoms than those with an anxiety disorder only, and the combination of MDD and an anxiety disorder reported the worst level of symptom severity.

CONCLUSIONS

These results suggest that adults with TTM and co-occurring MDD and anxiety disorders exhibit unique clinical differences. The clinical differences may also have treatment implications.

A cross-cultural clinical comparison between subjects with obsessive-compulsive disorder from the United States and Brazil

Although OCD is a global problem, the literature comparing, in a direct and standardized way, the manifestations across countries is scarce. Therefore, questions remain as to whether some important clinical findings are replicable worldwide, especially in the developing world. The objective of this study was to perform a clinical comparison of OCD patients recruited in the United States (U.S.) and Brazil. Our sample consisted of 1187 adult, treatment-seeking OCD outpatients from the U.S. (n=236) and Brazil (n=951). With regards to the demographics, U.S. participants with OCD were older, more likely to identify as Caucasian, had achieved a higher educational level, and were less likely to be partnered when compared to Brazilians. Concerning the clinical variables, after controlling for demographics the two samples presented largely similar profiles. Brazilian participants with OCD, however, endorsed significantly greater rates of generalized anxiety disorder and post-traumatic stress disorder, whereas U.S. subjects were significantly more likely to endorse a lifetime history of addiction (alcohol-use and substance-use disorders). This is the largest direct cross-cultural comparison to date in the OCD field. Our results provide much needed insight regarding the development of culture-sensitive treatments.

Gambling disorder: Association between duration of illness, clinical, and neurocognitive variables

Background and aims Gambling disorder (GD) may have its onset in a wide range of ages, from adolescents to old adults. In addition, individuals with GD tend to seek treatment at different moments in their lives. As a result of these characteristics (variable age at onset and variable age at treatment seeking), we find subjects with diverse duration of illness (DOI) in clinical practice. DOI is an important but relatively understudied factor in GD. Our objective was to investigate clinical and neurocognitive characteristics associated with different DOI. Methods This study evaluated 448 adults diagnosed with GD. All assessments were completed prior to treatments being commenced. Results Our main results were: (a) there is a negative correlation between DOI and lag between first gambling and onset of GD; (b) lifetime history of alcohol use disorder (AUD) is associated with a longer duration of GD; (c) the presence of a first-degree relative with history of AUD is associated with a more extended course of GD; and (d) there is a negative correlation between DOI and quality of life. Discussion This study suggests that some important variables are associated with different DOI. Increasing treatment-seeking behavior, providing customized psychological interventions, and effectively managing AUD may decrease the high levels of chronicity in GD. Furthermore, research on GD such as phenomenological studies and clinical trials may consider the duration of GD in their methodology. DOI might be an important variable when analyzing treatment outcome and avoiding confounders.

Anxiety, Gambling Activity, and Neurocognition: A Dimensional Approach to a Non-Treatment-Seeking Sample

Background and aims Previous analyses have highlighted significant associations between gambling disorder (GD)/subsyndromal GD and increased rates of anxiety symptoms and anxiety disorders relative to the general population. However, less is known about how anxiety symptoms influence the clinical presentation of gambling problems. The objective of this study was to evaluate the association between anxiety symptoms, gambling activity, and neurocognition across the spectrum of gambling behavior. Methods The sample consisted of 143 non-treatment-seeking young adults (aged 18-29 years), in which 63 individuals (44.1%) were classified as recreational gamblers, 47 (32.9%) as having subsyndromal GD, and 33 (23.1%) met criteria for GD. Results The main findings were: (a) there was a positive correlation between anxiety severity and gambling severity measured by the number of DSM-5 GD criteria met; (b) there was a positive correlation between anxiety severity and attentional impulsiveness; (c) subjects with suicidality presented higher levels of anxiety; and (d) the severity of anxiety symptoms was negatively correlated with the quality of life. Discussion and conclusions This study suggests that anxiety may be associated with relevant clinical variables in the broad spectrum of gambling activity. Therefore, proper management of anxiety symptoms might improve the clinical presentation of gamblers in different areas.

A cross-cultural study of gambling disorder: a comparison between women from Brazil and the United States

OBJECTIVE

To perform a cross-cultural comparison of gambling disorder (GD) in women from Brazil and the United States, two countries with pronounced social and cultural differences. We hoped to produce insight into the impact of cultural influences on the presentation of GD in women, which may be useful for the development of culturally-sensitive interventions.

METHOD

We assessed 681 women with GD: 406 from a Brazilian sample and 275 from a U.S.

SAMPLE

We assessed demographic and gambling behavior variables in addition to co-occurring psychiatric disorders.

RESULTS

Fewer Brazilian participants were Caucasian (73.3 vs. 91.3%; p = 0.022). Also, Brazilian women had lower levels of education (59.9% with high school or less vs. 44.4%; p < 0.001), and were more likely to have a current partner (54.9 vs. 43.4%; p = 0.003). Brazilian gamblers also reported lower urge scores (6.6±4.3 vs. 11.6±2.4; p < 0.001) and higher chasing rates (89.1 vs. 80.0%; p = 0.002). Brazilian gamblers reported higher rates of bingo gambling (19.2 vs. 5.7%; p < 0.001), but lower rates of card game gambling (5.8 vs. 23.1%; p < 0.001). Finally, Brazilian gamblers were more likely to endorse a history of major depressive disorder (36.9 vs. 24.4%; p = 0.001).

CONCLUSIONS

This study reinforces the need for further general cross-cultural research on GD and particularly for studies investigating how gender mediates these differences. Finally, the differences noted in this analysis suggest that the findings of predominantly Anglo-Saxon cultures may not be generalizable to other world populations.

Association between duration of untreated bipolar disorder and clinical outcome: data from a Brazilian sample

Objective:

Bipolar disorder (BD) is often left untreated for long periods, and this delay in treatment correlates with unfavorable prognosis. The present study sought to assess the magnitude of duration of untreated bipolar disorder (DUB) in Brazil. We hypothesized that DUB would be longer in Brazil than in developed countries, and would be associated with poor clinical outcomes.

Methods:

One hundred and fifty-two psychiatric outpatients were evaluated for BD diagnosis, demographics, DUB, and clinical outcomes.

Results:

The mean age and mean DUB were, respectively, 38.9±10.8 and 10.4±9.8 years. An extended DUB was associated with early onset of BD (p < 0.001), depression as first mood episode (p = 0.04), and presence of BD in a first-degree relative (p = 0.012). Additionally, a longer DUB was associated with poorer clinical outcomes, such as elevated rates of rapid cycling (p = 0.004) and anxiety disorders (p = 0.016), as well as lower levels of current full remission (p = 0.021).

Conclusion:

As DUB may be a modifiable variable, better medical education regarding mental health, more structured medical services, and population-wide psychoeducation might reduce the time between onset and proper management of BD, thus improving outcome.