Executive function impairments in depression and bipolar disorder: association with functional impairment and quality of life

BACKGROUND

The neuropsychological correlates of major depressive (MDD) and bipolar disorder (BD), and their association with quality of life (QOL) and functioning, have not been sufficiently studied in the literature. The present study aimed to compare executive functions, attention, processing speed, QOL and disability between patients with BD type I, BD type II, MDD and healthy controls.

METHOD

205 participants (n=37 BDI, 81% female; n=35 BDII, 80% female; n=45 MDD, 69% female; n=89C, 46% female) aged between 18 and 67 years were administered an extensive neurocognitive battery consisting of widely used standardized measures such as the Trail Making Test, the Stroop Color-Word Test and a modified version of the Wisconsin Card Sorting Task. Z-scores were compared between groups by ANCOVA. The prevalence of impairments on each measure (Z-score<1.5) was compared between groups using chi-square tests. The associations between cognition, quality of life and functioning were evaluated through correlational analysis.

RESULTS

Patients with MDD showed poor selective and sustained attention, and exhibited impairments in timed tasks, suggesting low efficiency of executive processing. Patients with BDI displayed more widespread cognitive impairment than the remaining groups, and performed worse than subjects with MDD on measures of sustained attention and inhibitory control. Decision-making ability and attentional control were able to distinguish between patients with BDI and BDII. QOL and disability were most impaired in patients with BDI, and more closely associated with cognitive impairment than in the remaining groups.

LIMITATIONS

No control of pharmacological variables, clinical or demographic characteristics.

CONCLUSIONS

Our results provide important information regarding the nature and severity of the cognitive alterations associated with different mood disorders, and may contribute to the diagnosis, rehabilitation and treatment of these conditions.

Quality of life, functioning and cognition in bipolar disorder and major depression: A latent profile analysis

This study aimed to identify profiles of functioning and quality of life (QOL) in depression (MDD), bipolar disorder (BD) and healthy adults, as well as the clinical, demographic and cognitive variables associated with each of these profiles. Participants completed the WHODAS 2.0 and WHOQOL-BREF, which were submitted to latent profile analysis. The four cluster solution provided the best fit for our data. Cluster 1 consisted mostly of healthy adults, and had the highest functioning and QOL. Clusters 2 contained older patients with subclinical depressive symptoms and psychiatric comorbidities, whose impairments in QOL and functioning were associated with mood symptoms and several cognitive abilities. Patients with MDD, BDI or BDII with mild to moderate depression, such as those in cluster 3, may benefit more significantly from interventions in cognitive flexibility, inhibition, planning, and sustained attention. Lastly, patients with mood disorders and clinically significant levels of depression, as well as a history of suicide attempts, like those in cluster 4, may benefit from interventions aimed at working memory, inhibitory control, and cognitive flexibility; that is, the three core executive functions. These findings should be further investigated, and used to guide treatments for patients with mood disorders and different patterns of functional impairment.

Self-reported inhibition predicts history of suicide attempts in bipolar disorder and major depression

BACKGROUND

Studies have reliably identified an association between suicide attempts and executive functions such as decision making (DM) and inhibitory control (IC) in patients with mood disorders. As such, the present study aimed to investigate the association between inhibition, DM, impulsivity and the history of suicide attempts in individuals with bipolar (BD) or major depressive disorder (MDD), identifying which assessment instruments may be most strongly associated with suicide in clinical samples.

METHODS

The sample included 80 control subjects and two groups of patients with BD and MDD, matched by age and education (26 with a history of suicide attempts [MD+], and 26 with no such history [MD-]). Participants completed behavioral and self-report measures of DM and IC, which were compared between groups using ANCOVA, followed by logistic regression for patients with mood disorders only, and the presence or absence of a history of suicide as the outcome.

RESULTS

Cognitive performance did not differ between groups. The MD+ group showed significantly higher motor and attentional impulsivity on the BIS-11 than the MD- and control groups. A regression analysis containing these scores showed that motor impulsivity was the only significant predictor of a history of suicide (OR = 1.14; 95%CI 1.00-1.30).

CONCLUSIONS

Self-reported motor impulsivity was a significant predictor of suicide. These findings underscore the importance of self-report measures in neuropsychological assessment, and their contributions to the management and prognosis of patients with mood disorders. Lastly, they point to the role of impulsivity as a target for interventions and public policy on suicide prevention.

Behavioural effects of acute tryptophan depletion in healthy male volunteers

Acute tryptophan depletion (ATD) studies have been used to assess the role of the serotonergic system in various aspects of human behaviour. Changes in mood have already been described in selected groups of individuals submitted to ATD. The present study was a randomized, double-blind, cross-over trial designed to evaluate the effects of ATD on mood, memory, attention and induced anxiety in normal male volunteers. Twelve healthy male volunteers were submitted to two separate sessions of ATD, 1 week apart. Drinks containing either a balanced mixture of amino acids (B) or a similar mixture devoid of tryptophan (T-) were administered in each session. Mood was assessed using self-rating scales. Attention and memory were assessed using a battery of psychological tests. Anxiety induction was carried out using a simulation of public speaking. Blood levels of tryptophan were assessed before and after the B and T- drinks. Results showed that ATD markedly decreased plasma tryptophan (p < 0.0001). Mood ratings, memory and attention were not changed by the T- drink. There was no difference among the anxiety levels measured under T- or B mixtures. These data supports the notion that ATD does not change mood and cognitive function in healthy subjects.

Assessment of the psychometric properties of the 17- and 6-item Hamilton Depression Rating Scales in major depressive disorder, bipolar depression and bipolar depression with mixed features

Assessing therapeutic response in depression requires scales that adequately measure the core symptoms of depressive symptomatology. The main goal of this study was to assess the psychometric properties of the 17-item Hamilton Depression Rating Scale (HAM-D17) and the 6-item Hamilton Depression Rating Scale (HAM-D6) in patients with Major Depressive Disorder (MDD), bipolar depression and bipolar depression with mixed features. We conducted a reanalysis of a pragmatic clinical trial in an outpatient clinic for mood disorders that included eight weeks of follow-up. A Mokken analysis was performed to evaluate the unidimensionality of the HAM-D17 and HAM-D6, and the Spearman correlation was used to assess concurrent validity between the HAM-D17, the HAM-D6 and quality of life scale (SF-36 and WHOQOL-BREF) scores. A total of 237 patients with a mean age of 40.2 years (±11.7) were included. According to the DSM-IV criteria, 58 (24.5%) were diagnosed with MDD and 73 (30.8%) were diagnosed with bipolar depression. Bipolar depression with mixed features was diagnosed in 106 (44.7%) patients according to the DSM-IV and supplemented by the Cincinnati criteria. Only the HAM-D6 scale proved to be unidimensional, showing strong homogeneity for evaluating MDD, moderate homogeneity for bipolar depression and weak homogeneity for bipolar depression with mixed features. Both the HAM-D17 and the HAM-D6 had inverse, significant correlations at baseline with SF-36 and WHOQOL-BREF scores. This is the first study to include bipolar depression patients with mixed features in an assessment of HAM-D6 unidimensionality.

The predictive role of daily cognitive stimulation on executive functions in bipolar disorder

This study aimed to estimate the predictive role of clinical and demographic variables on the three core executive functions (EF) - working memory (WM), inhibitory control (IC) and cognitive flexibility (CF) - in bipolar disorder (BD). The sample consisted of 38 patients with BD type I, 39 with BD type II, and 106 control participants with no mood disorders. Subjects completed the Hayling Test, Trail Making Test, Digit Span Backwards, Sentence Word Span Test, and Stroop Color-Word Test. Composite scores for WM, IC and CF were calculated, and their correlations with clinical and demographic variables were analyzed. Stepwise hierarchical regression models including all significant correlates, gender, and diagnosis, revealed that the frequency of reading and writing habits (FRWH), IQ and diagnosis predicted 38.1% of the variance in IC. Diagnosis and IQ predicted 24.9% of the variance in WM scores. CF was predicted by the FRWH only, which accounted for 7.6% of the variance in this construct. These results suggest that daily cognitive stimulation through reading and writing make a significant positive contribution to executive functioning in BD, even in the absence of continued education. These and other forms of routine cognitive stimulation should be further emphasized in intervention programs for BD.

Maternity blues in Brazilian women

In this prospective study, a sample of 86 postpartum women was compared with a sample of 75 women from a random period of 8 consecutive days out of puerperium. Symptoms were evaluated each day using the Blues Questionnaire. Postpartum women and women out of puerperium showed a different distribution of percentile scores on the scale on the third, fourth and fifth days. The postpartum symptom peak occurred on the fifth day. Symptoms more significantly associated with the third, fourth and fifth postpartum days were overemotionalism and oversensitivity. It is concluded that maternity blues in Brazilian women appear to be characterized by maternal mental state alterations occurring on the third, fourth and fifth days postpartum. MB seems to be better defined as an emotional oversensitivity syndrome of cross-cultural dimension than as depression.

Evaluating response to mood stabilizers in patients with mixed depression: A study of agreement between three different mania rating scales and a depression rating scale

BACKGROUND

The aim of the present study was to evaluate agreement between three pairs formed by one of three mania scales (Young Mania Rating Scale [YMRS], Bech-Rafaelsen Mania Scale [BRMS], or the Clinician-Administered Rating Scale for Mania [CARS-M]) and a single depression scale (21-item Hamilton Depression Rating Scale [21-HAM-D]) for evaluation of response to mood stabilizers in patients with mixed bipolar disorder.

METHODS

Between 2010 and 2014, 68 consecutive bipolar type I and II outpatients with mixed depression as per DSM-IV-TR and Cincinnati criteria were included in this 8-week open-label trial to randomly receive carbamazepine, lithium carbonate, or valproic acid as monotherapy.

RESULTS

Patterns of response (defined as a reduction of at least 50% in one of the mania scales and on the 21-HAM-D) were strikingly similar: 21-HAM-D+YMRS=22.1%, 21-HAM-D+BRMS=20.6%, and 21-HAM-D+CARS-M=23.5% (p<0.368). Assessment of agreement revealed very high kappa coefficients: 21-HAM-D+YMRS vs. 21-HAM-D+CARS-M, kappa=0.87; 21-HAM-D+YMRS vs. 21-HAM-D+BRMS, kappa=0.78; 21-HAM-D+CARS-M vs. 21-HAM-D+BRMS, kappa=0.91 (p<0.001).

LIMITATIONS

The decision to combine a depression rating scale with any one mania rating scale to assess treatment response in patients with mixed depression is questionable.

CONCLUSIONS

The present study suggests that any one of the three tested mania rating scales (YMRS, BRMS, and CARS-M) can be combined with the 21-HAM-D to assess treatment response in patients with mixed bipolar disorder. This should give clinicians an added measure of confidence in using this strategy until valid, and specific instruments are developed for assessment of mixed states.

[Historical evolution of the concept of posttraumatic stress disorder]

The authors elaborate on the historical evolution of the concept of Posttraumatic Stress Disorder (PTSD). The authors quote the French scholars, mainly Charcot and Janet, as the first to connect traumatic events and symptoms of hysteria. The contributions of Freud are described with enphasis on his effort into integrating the intra-psychic and environmental dimensions. Kardiner is referred as the author who coined the concept of 'war neurosis', which was deemed as an important one during the Second World War and Vietnam War. In conclusion, the authors highlight that the concept of PTSD used in the Diagnostic and Statistical Manual of Mental Disorders (DSM) by the American Psychiatric Association assess, at the same time, how treatening was the traumatic event and the list of symptoms presented by the patients.

Cognitive reserve may outperform age, mood and psychiatric comorbidities as a predictor of executive functioning in bipolar disorder and healthy adults

INTRODUCTION

Cognitive reserve plays a protective role against executive dysfunction in healthy adults and individuals with psychiatric illnesses such as bipolar disorder. However, the magnitude of the influence of cognitive reserve on specific executive functions (EFs), and its impact relative to variables such as depressive symptoms, age and psychiatric comorbidities, is unexplored. This study aimed to quantify the influence of cognitive reserve on specific EFs, and compare its impact with that of depressive symptoms, age and psychiatric comorbidities, in separate models for patients with bipolar disorder and healthy adults.

METHOD

This was a cross-sectional study of 121 adults with no mood disorders and 109 with bipolar disorder, all of whom underwent a comprehensive psychiatric assessment and evaluation of the EFs. Cognitive reserve was measured using years of education, IQ and reading and writing habits. The association between EFs and predictors (cognitive reserve, depressive symptoms, age and psychiatric comorbidities) was evaluated through structural equation modeling. Four models were constructed for each group independently (bipolar disorder and control), one each for working memory, verbal fluency, inhibition and flexibility, due to group differences in age and cognitive reserve.

RESULTS

Working memory, inhibition and flexibility were most significantly predicted by cognitive reserve and age. Verbal fluency was only predicted by cognitive reserve. Comorbidities and depressive symptoms were not significant in any of the models. Cognitive reserve had a positive influence on all EFs in models for patients with bipolar disorder and models for control participants. Age had a negative impact on three of the four EFs tested.

CONCLUSION

Fostering cognitive reserve through continued education and cognitively stimulating leisure activities may be an effective intervention for executive dysfunction in patients and non-patients alike. In some cases, the effects of these interventions may outweigh the negative cognitive impact of aging, depressive symptoms and psychiatric conditions.

Development and application of the mania rating guide (MRG)

In this article we present the development and application of the Mania Rating Guide (MRG), a semi-structured interview. This guide was created in order to assist the filling of three mania Scales: Mania Rating Scale, Bech-Rafaelsen Mania Scale and Clinician-Administered Rating Scale for Mania. The MRG consists of twenty-one Psychopathological Dimensions, that correspond to the Items of the original Scales, and are structured in Questions. The guide was applied to fifteen manic patients admitted in the Psychiatric Unit of the Clinical Hospital of Porto Alegre. A psychiatrist interviewed them using the MRG, and the interviews were videotaped. Afterwards, three independent raters scored the Mania scales based on the films. The impression of the raters was that the MRG allows not only to easily score all the Items of the Scales but also to cover the wide spectrum of the symptomatological presentation of a manic syndrome.

Predictors of quality of life in bipolar disorder: A path analytical study

Quality of life (QoL) is an important outcome in psychiatric illnesses like bipolar disorder (BD). However, little is known about the variables that affect it, and therefore contribute to prognosis and treatment outcomes in these populations. This study aimed to explore QoL in BD and investigate its relationship with modifiable (cognitive reserve, cognitive ability, mood symptoms) and non-modifiable factors (diagnosis, previous suicide attempts, substance misuse, age). The WHOQOL-bref was administered to 121 control participants and 109 patients with BD, who also underwent clinical and neuropsychological assessments. Factor analysis was used to identify latent constructs underlying WHOQOL-bref domains, and structural equation models were used to examine predictors of each latent construct. Two latent constructs were identified in the WHOQOL-bref, and labeled 'Personal' and 'Social' QoL. Both were directly predicted by depression symptoms and a diagnosis of BD, and indirectly predicted by (hypo)manic symptoms. Cognitive reserve was a stronger predictor of social QoL than a diagnosis of BD. Our findings suggest that the management of depression symptoms and fostering of cognitive reserve may improve QoL in BD. A diagnosis of BD and/or substance use disorders were risk factors for poor QoL, and may signal the need for preventive interventions to promote well-being.

"Influence of modifiable and non-modifiable variables on functioning in bipolar disorder: a path analytical study"

OBJECTIVE

The aim of this study was to investigate the influence of modifiable (mood, cognitive reserve, cognitive performance) and non-modifiable factors (diagnosis, suicide attempts, substance use, age) on self-reported functioning in BD.

METHODS

103 adults with no mood disorders and 95 individuals with BD completed the WHODAS 2.0, in addition to a neuropsychological battery and diagnostic assessments. Path analysis was then used to analyse the relationships between modifiable and non-modifiable predictors of functioning in the sample.

RESULTS

Cognitive reserve and age had an indirect influence on individual functioning, mediated by cognitive performance. The influence of diagnosis and depressive symptoms on functioning was partly direct, and partly mediated by cognition. The presence of psychiatric comorbidities in addition to BD also had a significant influence on individual functioning.

CONCLUSIONS

Initiatives focussed on modifiable factors such as depressive symptoms and cognitively stimulating activities, which increase cognitive reserve, may be a useful complement to existing treatments and help patients achieve functional recovery. KEY POINTS Individual functioning was influenced by cognitive performance, cognitive reserve, age, diagnosis and depressive symptoms. Executive functioning mediated the influence of age and cognitive reserve on individual functioning. Interventions focussed on depressive symptoms and cognitive stimulation may help patients achieve functional recovery.

A longitudinal study of cognition, functional outcome and quality of life in bipolar disorder and major depression

OBJECTIVE

Cognitive impairments are known to be a frequent cause of disability in bipolar disorder (BD) and major depression (MDD). Yet there is no consensus regarding the particular cognitive functions whose impairments can lead to disability in each domain of functioning. The aim of this study was to perform a longitudinal evaluation of working memory, inhibition, cognitive flexibility and attention in BD and MDD, investigate the relationship of these cognitive functions to disability and quality of life, and evaluate the impact of variables related to cognitive reserve (education and daily cognitive stimulation) on cognitive performance.

METHOD

31 participants (MDD = 12; BD = 19) were evaluated at baseline and after an average time of 2 years.

RESULTS

the BD group showed improvements in attention while patients with MDD improved on measures of attention and working memory. In BD working memory performance was associated with the cognition and mobility domains of functioning, and with physical and environmental quality of life. In MDD, cognitive flexibility was related to social relationships and environmental quality of life.

CONCLUSION

working memory and cognitive flexibility may be an interesting target for interventions aiming to improve everyday functioning and quality of life in BD and MDD.

Cognitive abilities underlying performance on the modified card sorting test: novel and traditional scores

The Modified Card Sorting Test (MCST) is a widely used variation of the Wisconsin Card Sorting Test. It is faster to administer, less frustrating for respondents and less ambiguous in its scoring but has been criticized for its task impurity and low discriminability between control participants and clinical groups prone to executive dysfunction. This study aimed to examine the executive functions (EF) underlying traditional (number of categories completed, perseverative errors) and novel scores for the MCST, and compare their ability to differentiate between control and clinical samples. Novel and traditional MCST scores were compared between 94 control participants, 87 with bipolar disorder and 64 with major depression. The relationship between MCST scores and traditional EF tasks was examined through correlation and regression analyses. All MCST scores were associated with at least one measure of EF, the most common of which were the Trail Making or Hayling Tests. IQ predicted most scores on the MCST, save for nonperseverative errors and categorizing efficiency. Traditional and novel scores differentiated between clinical and control groups. These findings support the utility of the MCST in detecting executive dysfunction and highlight the importance of new scoring methods in increasing the specificity and interpretability of this task.

Early-life trauma, impulsivity and suicide attempt: a systematic review and meta-analysis

INTRODUCTION

Suicide is a worldwide health concern and up to date there is no good predictor of it except a previous suicide attempt. Therefore, there are increasing efforts in the understanding of which factors, genetic or environmental, are associated with suicide behaviour.

OBJECTIVE

To review evidence of the effect of childhood trauma and impulsivity on suicidal behavior through a systematic review and meta-analysis.

METHODS

Searches were conducted on the 12th of June 2021 in the PubMed, Scopus, and Web of Science databases. Two reviewers evaluated each record for eligibility and discussed upon disagreement, when no consensus was reached, a third reviewer was involved to make a decision.

RESULTS

A total of 11,530 records were identified through the searches. After duplicates were removed, 6,595 records remained to be screened. The full text was sought for 1,561 records. Our qualitative synthesis included 22 studies, from which 9 were included in the meta-analyses. We found a significant effect of sexual abuse, physical abuse, emotional abuse and physical neglect on suicide attempts in the prisoners, and Substance Use Diorder (SUD) subgroups. Moreover, there was a significant effect of Childhood Trauma Questionnaire (CTQ) total score and emotional neglect dimension for all the subgroups.

CONCLUSION

The present study has provided an overview of the state-of-the-art research on childhood trauma and impulsivity and their association with suicidal behavior and quantified their effects on suicide attempts. Hopefully this evidence will be considered in future research and harnessed for clinical gain in detection and treatment of suicide behaviour.

The symptomatology of Attention-Deficit/Hyperactivity Disorder and the genetic control of vitamin D levels

OBJECTIVES

Vitamin D deficiency has been associated with psychiatric disorders and behavioral phenotypes such as Attention-Deficit/Hyperactivity Disorder (ADHD). Considering that vitamin D levels are polygenic, we aim to evaluate the overall effects of its genetic architecture on symptoms of inattention, hyperactivity, and impulsivity and on the serum levels of vitamin D in two independent samples of adults, as well as the specific effects of five relevant polymorphisms in vitamin D-related genes.

METHODS

We evaluated 870 subjects from an ADHD sample (407 cases and 463 controls) and 319 subjects from an academic community (nutrigenetic sample). Vitamin D serum levels were obtained through Elisa test and genetic data by TaqMan™ allelic discrimination and Infinium PsychArray-24 BeadChip genotyping. Polygenic Scores (PGS) were calculated on PRSice2 based on the latest GWAS for Vitamin D and statistical analyses were conducted at Plink and SPSS software.

RESULTS

Vitamin D PGSs were associated with inattention in the ADHD sample and with hyperactivity when inattention symptoms were included as covariates. In the nutrigenetic sample, CYP2R1 rs10741657 and DHCR7 rs12785878 were nominally associated with impulsivity and hyperactivity, respectively, and both with vitamin D levels. In the clinical sample, RXRG rs2134095 was associated with impulsivity.

DISCUSSION

Our findings suggest a shared genetic architecture between vitamin D levels and ADHD symptoms, as evidenced by the associations observed with PGS and specific genes related to vitamin D levels. Interestingly, differential effects for vitamin D PGS were found in inattention and hyperactivity, which should be considered in further studies involving ADHD.

Diagnosis of bipolar and major depressive disorders: The appropriateness of MINI compared to the clinical interview in a sample of patients with mood disorders in tertiary mental health care

OBJECTIVE

The Mini International Neuropsychiatric Interview (MINI) is one of the most used instruments for the assessment of Mental Disorders, playing an essential role in psychiatric research and in clinical and hospital practice. Despite this, the accuracy of the MINI, when used by a psychiatrist, is poorly studied, particularly in relation to Bipolar Disorder (BD). The early diagnosis of BD and Major Depressive Disorder (MDD) is extremely important, as it provides an opportunity for intervention that can reduce the impact on the patient's daily life and functionality. As such, this study assesses the suitability of MINI for diagnosing BD or MDD in a sample of patients with mood disorders.

METHOD

Agreement between the MINI and the clinical interview was assessed in a sample of 347 outpatients by calculating Cohen's kappa, sensitivity, specificity, positive predictive value, negative predictive value, and the area under the curve (AUC).

RESULTS

The sample consisted of 347 patients with mood disorders. 279 were women (80.40%), 105 (30.3%) were diagnosed with MDD and 242 (69.7%) with BD from the assessment performed in the clinical interview. In the MINI assessment, 97 individuals (28%) were classified with a diagnosis of MDD and 250 (72%) with BD. We found a sensitivity of 87.2% and specificity of 62.8% for the MINI in the diagnosis of BD and a Cohen's kappa between the MINI and the clinical interview of 0.51. The AUC was 0.75.

CONCLUSIONS

MINI has greater sensitivity (87.2%) for the diagnosis of BD and greater specificity (87.2%) for the diagnosis of MDD. In addition, the moderate Cohen kappa (0.51) and AUC (0.75) values between the MINI and the clinical interview are acceptable when considering most available psychiatric diagnostic tools.