Morbidity In Bipolar Disorder Research Articles

A systematic review of the literature on telepsychiatry for bipolar disorder.

ObjectiveBipolar (BP) disorder is a highly morbid disorder that is often misdiagnosed or undiagnosed and affects a large number of adults and children. Due to the coronavirus disease 2019 public health emergency stay at home orders, most outpatient mental health care was provided via telepsychiatry, and the many benefits of virtual care ensure that this will continue as an ongoing practice. The main aim of this review was to investigate what is currently known about the use of telepsychiatry services in the diagnosis and treatment of BP disorder across the lifespan.MethodA systematic literature review assessing the use of telepsychiatry in BP disorder was conducted in PubMed, PsychINFO, and Medline.ResultsSix articles were included in the final review. All included articles assessed populations aged 17 years or older. The literature indicates that BP disorder was addressed in telepsychiatry services at a similar rate as in‐person services, reliable diagnoses can be made using remote interviews, satisfaction rates are comparable to in‐person services, telepsychiatry services are able to reach and impact patients with BP disorder, are sustainable, and patient outcomes can improve using a telepsychiatry intervention.ConclusionsGiven the morbidity of BP disorder, the research addressing the telepsychiatry diagnosis and treatment of BP disorder is sparse, with only emerging evidence of its reliability, effectiveness, and acceptance. There is no research assessing the safety and efficacy of telepsychiatry in pediatric populations with BP disorder. Given the morbidity associated with BP disorder at any age, further research is needed to determine how to safely and effectively incorporate telepsychiatry into clinical care for BP adult and pediatric patients.

Cariprazine for the treatment of bipolar depression: a review

ABSTRACTIntroduction: Depressive symptoms and episodes dominate the course of bipolar disorder. The morbidity of bipolar disorder is disproportionately mediated by depressive symptoms; economic costs of bipolar disorder are also disproportionately due to unremitting depressive symptoms. Relatively few treatment options have established unequivocal efficacy in the treatment of bipolar depression. Herein we review evidence regarding the efficacy of the D3 preferring D2/D3 partial agonist cariprazine in the treatment of adults with bipolar depression.Areas covered: Randomized controlled trials that sought to determine the efficacy, tolerability, and safety of cariprazine in adults with bipolar I depression.Expert opinion: The available evidence from clinical trials indicates that cariprazine is effective at treating bipolar depression wherein treatment for bipolar depression remains an unmet need in bipolar disorder. Cariprazine has demonstrated good tolerability and safety profiles in bipolar disorder. Furthermore, cariprazine may be effective in improving both anhedonia and cognitive dysfunction. Long term prevention studies in bipolar depression, as well as separate studies evaluating efficacy in adults with bipolar II depression, are needed.

Lithium and nephrotoxicity: a literature review of approaches to clinical management and risk stratification

BackgroundDespite lithium being the most efficacious treatment for bipolar disorder, its use has been decreasing at least in part due to concerns about its potential to cause significant nephrotoxicity. Whilst the ability of lithium to cause nephrogenic diabetes insipidus is well established, its ability to cause chronic kidney disease is a much more vexing issue, with various studies suggesting both positive and negative causality. Despite these differences, the weight of evidence suggests that lithium has the potential to cause end stage kidney disease, albeit over a prolonged period.MethodsA search strategy for this review was developed to identify appropriate studies, sourced from the electronic databases EMBASE, PubMed (NLM) and MEDLINE. Search terms included lithium with the AND operator to combine with nephrotoxicity or nephropathy or chronic kidney disease or nephrogenic diabetes insipidus or renal and pathophysiology.ResultsThe risks for the development of lithium induced nephropathy are less well defined but appear to include the length of duration of therapy as well as increasing age, as well as episodes of over dosage/elevated lithium levels. Whilst guidelines exist for the routine monitoring of lithium levels and renal function, it remains unclear when nephrological evaluation should occur, as well as when cessation of lithium therapy is appropriate balancing the significant attendant mental health risks as well as the potential for progression to occur despite cessation of therapy against the risks and morbidity of bipolar disorder itself.ConclusionThis paper will elucidate on the current evidence pertaining to the topic of the clinical management of lithium induced nephrotoxicity and provide a guide for clinicians who are faced with the long-term management of these patients.

Childhood maltreatment and adult medical morbidity in mood disorders: comparison of unipolar depression with bipolar disorder.

The medical burden in mood disorders is high; various factors are thought to drive this pattern. Little research has examined the role of childhood maltreatment and its effects on medical morbidity in adulthood among people with unipolar depression and bipolar disorder.AimsThis is the first study to explore the association between childhood maltreatment and medical morbidity in bipolar disorder and in unipolar depression, and examine whether the impact of abuse and neglect are distinct or combined. The participants consisted of 354 psychiatrically healthy controls, 248 participants with recurrent unipolar depression and 72 with bipolar disorder. Participants completed the Childhood Trauma Questionnaire and received a validated medical history interview. Any type of childhood maltreatment, child abuse and child neglect were significantly associated with the medical burden in bipolar disorder, but not unipolar depression or for controls. These associations worked in a dose-response fashion where participants with bipolar disorder with a history of two or more types of childhood maltreatment had the highest odds of having a medical illness relative to those without such history or those who reported one form. No such significant dose-response patterns were detected for participants with unipolar depression or controls. These findings suggest that childhood maltreatment may play a stronger role in the development of medical illnesses in individuals with bipolar disorder relative to those with unipolar depression. Individuals who had been maltreated with a mood disorder, especially bipolar disorder may benefit most from prevention and intervention efforts surrounding physical health.Declaration of interestNone.

Childhood maltreatment and the medical morbidity in bipolar disorder: a case\u2013control study

BackgroundChildhood maltreatment (abuse and neglect) can have long-term deleterious consequences, including increased risk for medical and psychiatric illnesses, such as bipolar disorder in adulthood. Emerging evidence suggests that a history of childhood maltreatment is linked to the comorbidity between medical illnesses and mood disorders. However, existing studies on bipolar disorder have not yet explored the specific influence of child neglect and have not included comparisons with individuals without mood disorders (controls). This study aimed to extend the existing literature by examining the differential influence of child abuse and child neglect on medical morbidity in a sample of bipolar cases and controls.MethodsThe study included 72 participants with bipolar disorder and 354 psychiatrically healthy controls (average age of both groups was 48 years), who completed the Childhood Trauma Questionnaire, and were interviewed regarding various medical disorders.ResultsA history of any type of childhood maltreatment was significantly associated with a diagnosis of any medical illness (adjusted OR = 6.28, 95% confidence intervals 1.70–23.12, p = 0.006) and an increased number of medical illnesses (adjusted OR = 3.77, 95% confidence intervals 1.34–10.57, p = 0.012) among adults with bipolar disorder. Exposure to child abuse was more strongly associated with medical disorders than child neglect. No association between childhood maltreatment and medical morbidity was detected among controls.ConclusionsTo summarise, individuals with bipolar disorder who reported experiencing maltreatment during childhood, especially abuse, were at increased risk of suffering from medical illnesses and warrant greater clinical attention.

Infectious and immunogenetic factors in bipolar disorder.

ObjectiveDespite the evidence supporting the association between infection and bipolar disorder (BD), the genetic vulnerability that mediates its effects has yet to be clarified. A genetic origin for the immune imbalance observed in BD, possibly involved in the mechanisms of pathogen escape, has, however, been suggested in recent studies.MethodHere, we present a critical review based on a systematic literature search of articles published until December 2016 on the association between BD and infectious/immunogenetic factors.ResultsWe provide evidence suggesting that infectious insults could act as triggers of maladaptive immune responses in BD and that immunogenetic vulnerability may amplify the effects of such environmental risk factors, increasing susceptibility to subsequent environmental encounters. Quality of evidence was generally impaired by scarce attempt of replication, small sample sizes and lack of high‐quality environmental measures.ConclusionInfection has emerged as a potential preventable cause of morbidity in BD, urging the need to better investigate components of the host–pathogen interaction in patients and at‐risk subjects, and thus opening the way to novel therapeutic opportunities.

Early clinical predictors and correlates of long-term morbidity in bipolar disorder

ObjectivesIdentifying factors predictive of long-term morbidity should improve clinical planning limiting disability and mortality associated with bipolar disorder (BD). MethodsWe analyzed factors associated with total, depressive and mania-related long-term morbidity and their ratio D/M, as %-time ill between a first-lifetime major affective episode and last follow-up of 207 BD subjects. Bivariate comparisons were followed by multivariable linear regression modeling. ResultsTotal % of months ill during follow-up was greater in 96 BD-II (40.2%) than 111 BD-I subjects (28.4%; P=0.001). Time in depression averaged 26.1% in BD-II and 14.3% in BD-I, whereas mania-related morbidity was similar in both, averaging 13.9%. Their ratio D/M was 3.7-fold greater in BD-II than BD-I (5.74 vs. 1.96; P<0.0001). Predictive factors independently associated with total %-time ill were: [a] BD-II diagnosis, [b] longer prodrome from antecedents to first affective episode, and [c] any psychiatric comorbidity. Associated with %-time depressed were: [a] BD-II diagnosis, [b] any antecedent psychiatric syndrome, [c] psychiatric comorbidity, and [d] agitated/psychotic depressive first affective episode. Associated with %-time in mania-like illness were: [a] fewer years ill and [b] (hypo)manic first affective episode. The long-term D/M morbidity ratio was associated with: [a] anxious temperament, [b] depressive first episode, and [c] BD-II diagnosis. ConclusionsLong-term depressive greatly exceeded mania-like morbidity in BD patients. BD-II subjects spent 42% more time ill overall, with a 3.7-times greater D/M morbidity ratio, than BD-I. More time depressed was predicted by agitated/psychotic initial depressive episodes, psychiatric comorbidity, and BD-II diagnosis. Longer prodrome and any antecedent psychiatric syndrome were respectively associated with total and depressive morbidity.

A longitudinal mirror-image assessment of morbidity in bipolar disorder

BackgroundEvidence about the clinical course of bipolar disorder is inconsistent and limited. The aim of this study was to assess changes in morbidity in patients with bipolar disorder along a mean follow-up period of 80months. MethodsBased on a mirror-image design, the follow-up period of each patient was divided into two halves. Then, three measures of morbidity — number of affective episodes, time spent ill, and cycle length — were recorded and compared between each half of the follow-up period. ResultsOn average, there was a trend to a smaller amount of time spent with subclinical symptomatology during the second half of the follow-up period. In contrast, there were no differences in terms of number of episodes, time spent with clinical symptoms, or cycle length between the first and second half of the follow-up period. A subgroup analysis identified 21.9% of patients with consistent data of a worsening during follow-up. ConclusionsThe results suggest that, on average, there is stability or slight improvement of clinical morbidity over the course of BD. Then, worsening of the clinical course may be a feature of a subgroup of patients rather than an inherent characteristic of the disorder. These subgroups or patient profiles could represent an opportunity for further studies to assess clinical, pathophysiologic, and therapeutic features associated with them.

Physical and mental health burden in cases of bipolar disorder classified as current, former, or non-tobacco smokers

BackgroundTobacco smoking increases the global burden of bipolar disorder (BD). We examined markers of physical and mental health that are associated with tobacco smoking, controlling for confounders that have not always been considered in previous studies of BD. MethodsOver 600 individuals with BD I or II referred to the French Network for bipolar disorder (FACE-BD) who completed standardized assessments, and could be reliably classified as current (CS) or former smokers (FS), were compared with those who were never smokers (NS) on: BD symptom load and psychiatric comorbidities; prevalence of alcohol and substance use disorders (ASUD); medication usage; functioning and physical health parameters. The bivariate and multivariate analyses took into account age and gender. Results300 cases (49%) were CS, 78 (13%) FS and 238 (39%) had never smoked. Rates were similar across genders regardless of BD subtype. Compared with NS, CS were more likely to have an ASUD (Odds Ratio (OR) 5.18), BD I (OR 2.09), and lower abdominal obesity (OR 0.97), and FS were more likely to have an ASUD (OR 6.32) and higher abdominal obesity (OR 1.03). LimitationsThe sample comprised of white Europeans; the FS subgroup was relatively small and we did not apply any statistical correction for the bivariate analyses. ConclusionsThe increased risk of physical and mental health burden in CS and FS compared to NS represents avoidable morbidity in BD. This study offers support to the argument that individuals with BD should be routinely offered support to prevent or stop tobacco smoking.

The importance of anxiety states in bipolar disorder.

Anxiety symptoms and syndromes are common in bipolar disorders, occurring in over half of all subjects with bipolar disorder type I. Despite methodological and diagnostic inconsistencies, most studies have shown a robust association between the presence of a broadly defined comorbid anxiety disorder and important indices of clinical morbidity in bipolar disorder, including a greater number of depressive episodes, worse treatment outcomes, and elevated risk of attempting suicide. Anxiety symptoms and/or syndromes often precede the onset of bipolar disorder and may represent a clinical phenotype of increased risk in subjects with prodromal symptoms. Although the causal relationship between anxiety and bipolar disorders remains unresolved, the multifactorial nature of most psychiatric phenotypes suggests that even with progress towards more biologically valid phenotypes, the "phenomenon" of comorbidity is likely to remain a clinical reality. Treatment studies of bipolar patients with comorbid anxiety have begun to provide preliminary evidence for the role of specific pharmacological and psychotherapeutic treatments, but these need to be confirmed in more definitive trials. Hence, there is an immediate need for further research to help guide assessment and help identify appropriate treatments for comorbid conditions.

Antecedents of manic versus other first psychotic episodes in 263 bipolar I disorder patients

As initial episode type can predict later morbidity in bipolar disorder, we tested the hypothesis that clinical antecedents might predict initial episode types. We studied 263 first-episode, adult, DSM-IV-TR type I bipolar disorder (BD-I) subjects within the McLean-Harvard-International First-Episode Project. Based on blinded assessments of antecedents from SCID examinations and clinical records, we compared first lifetime manic vs. other (mixed, depressive, or non-affective) major psychotic episodes. We identified 32 antecedents arising at early, intermediate or later times, starting 12.3±10.7 years prior to first lifetime major psychotic episodes. Based on multivariate modeling, antecedents associated significantly and independently with other (n=113) more than manic (n=150) first lifetime major psychotic episodes ranked by odds ratio: more early attentional disturbances, more late depression, more early perplexity, more detoxification, more early unstable mixed affects, more antidepressants, more early dysphoria, more intermediate depression, more early impulsivity, more late anhedonia, longer early-to-intermediate intervals, more intermediate substance abuse, more family history of major depression, and younger at earliest antecedents. Antecedents selectively preceding manic more than other first psychotic episodes included more late behavioral problems and more risk of familial BD-I. Clinical antecedents in adult, BD-I patients, beginning a decade before first major episodes and progressing through sequential stages were dissimilar in manic vs. other first psychotic episodes.

Existential Despair and Bipolar Disorder: The Therapeutic Alliance as a Mood Stabilizer

The major clinical morbidity of bipolar disorder is chronic depression. Yet this depression, which is resistant to our best pharmacological treatments, may represent something else. We suggest it may involve existential despair, as a consequence of the losses incurred by this illness, as well as the result of our treatment approaches. Such chronic depressive symptoms may be seen as existential, rather than biological, consequences of the failed hopes of mania. Contrary to traditional psychoanalytic views, we suggest that psychotherapeutic work can be done with manic patients through existential and interpersonal methods to develop a strong therapeutic alliance with the manic patient. We draw on the existential work of Karl Jaspers and the counter projective methods of Harry Stack Sullivan to lay out these approaches. An existentially oriented therapeutic alliance can be seen as a mood-stabilizing treatment in patients with bipolar disorder, which augments the benefits of mood stabilizing medications.

HIGHLIGHTS IN THIS ISSUE

This issue features papers on community care, neuropsychological abnormalities in antisocial personality disorder, schizophrenia and other disorders, pharmacological aspects of affective disorders including effects of carbamazepine and lithium on inter-episode morbidity in bipolar disorder, and effects of tryptophan depletion in the relatives of bipolars.