RSS 1.0Bipolar Disorder
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A positron emission tomography study of dopamine transporter density in patients with bipolar disorder with current mania and those with recently remitted maniaIMPORTANCE: Although dopamine is implicated in the pathophysiology of bipolar disorder (BD), the precise alterations in the dopaminergic system remain unknown. OBJECTIVE: To assess dopamine transporter (DAT) density in the striatum in patients with BD with current and recently remitted mania in comparison to healthy control individuals and its correlation with severity of manic symptoms. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study conducted in a tertiary care referral center for mood disorders in Vancouver, British Columbia, Canada, recruited 26 patients with BD (9 with current mania; 17 with recently remitted mania) and 21 matched healthy control individuals. DAT density was measured using positron emission tomography with [11C]d-threo-methylphenidate (MP). The differences between the groups in nondisplaceable binding potential (BPND) for DAT was assessed using statistical parametric mapping. The study was conducted from November 2001 to February 2007 and the data were analyzed from November 2020 to December 2021. MAIN OUTCOMES AND MEASURES: DAT density as indexed by BPND for MP across groups; manic symptom severity as measured with the Young Mania Rating Scale (YMRS) and correlated with BPND values in patients with BD. RESULTS: Of 47 total participants (mean [SD] age, 37.8 [14.4] years), 27 (57.4%) were female; 26 individuals had BD (9 with current mania and 17 with recently remitted mania) and there were 21 healthy control individuals. MP BPND was significantly lower in patients with BD in the right putamen and nucleus accumbens (mean reduction [MR] = 22%; cluster level familywise error [FWE]-corrected P < .001) as well as left putamen and caudate (MR = 24%; cluster level FWE-corrected P < .001). The reduction in BPND was more extensive and pronounced in patients with current mania, while patients with recently remitted mania had lower BPND in the left striatum but not the right. There was a significant negative correlation between YMRS scores and MP BPND in the right striatum in patients with current mania (ρ = -0.93; 95% CI, -0.99 to -0.69; P < .001) and those with recently remitted mania (ρ = 0.64; 95% CI, -0.86 to -0.23; P = .005) but not in the left striatum in either group. CONCLUSIONS AND RELEVANCE: These findings indicate that mania was associated with reduced DAT density and remitted mania was associated with DAT levels that approximated those present in individuals without BD. These results have potential implications for drug development for mania.
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Is early exposure to cannabis associated with bipolar disorder? Results from a Finnish birth-cohort studyBACKGROUND AND AIMSThere are few longitudinal studies assessing the association of cannabis use and subsequent onset of bipolar disorder. We aimed to measure the association between early cannabis exposure and subsequent bipolar disorder.DESIGN, SETTING, AND PARTICIPANTSObservational study linking a sample from the Northern Finland Birth Cohort 1986 (n=6,325) to nationwide register data to examine the association of life-time cannabis exposure at age 15/16 years and subsequent bipolar disorder until age 33 (until the end of 2018). 6,325 individuals (48.8% males) were included in the analysis.MEASUREMENTSCannabis exposure was measured via self-report. Bipolar disorder was measured via bipolar disorder-related diagnostic codes (ICD-10: F30.xx, F31.xx) collected from the Care Register for Health Care 2001-2018, the Register of Primary Health Care Visits 2011 - 2018, the medication reimbursement register of the Social Insurance Institution of Finland 2001 - 2005 and the disability pensions of the Finnish Center for Pensions 2001 - 2016. Potential confounders included demographic characteristics, parental psychiatric disorders, emotional and behavioral problems and other substance use.FINDINGS352 adolescents (5.6 %) reported any cannabis use until the age of 15-16 years. Of the whole sample, 66 (1.0 %) were diagnosed with bipolar disorder. Adolescent cannabis use was associated with bipolar disorder (hazard ratio [HR] =3.46; 95% confidence interval [CI] 1.81-6.61). This association remained statistically significant after adjusting for sex, family structure, and parental psychiatric disorders (HR =3.00; 95% CI 1.47-6.13) and after further adjusting for adolescent emotional and behavioral problems (HR =2.34; 95% CI 1.11-4.94). Further adjustments for frequent alcohol intoxications, daily smoking and lifetime illicit drug use attenuated the associations to statistically non-significant.CONCLUSIONSIn Finland, the positive association between early cannabis exposure and subsequent development of bipolar disorder appears to be confounded by other substance use.
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Service user experiences of care recommendations from the 2014 NICE guideline for bipolar disorder: a surveyClinical guidelines for mental health disorders produced by the National Institute of Care Excellence (NICE) emphasise a recovery-based approach clinical care with collaborative decision-making. The aim of the study was to explore service user experience of collaborative decision-making and recovery focussed care in relation to a NICE clinical guideline for bipolar disorder four years after publication. Participants with a clinical diagnosis of bipolar disorder were recruited from adult mental health services in four specialist mental health NHS Trusts through health professional or self-referral following advertisement. An online or written survey was designed with service user input to cover 40 NICE recommendations on recovery based or collaborative care. Participants completed the survey anonymously and independent of any health professional involvement. Of 222 participants, 72 (33.5%) reported to a great extent care was delivered in line with a positive recovery message; 55 (25.5%) reported that not much or no care was recovery based. Only four items (10%) on medication or the offer of crisis services were endorsed as collaborative decision-making with a health professional by >70% service users. Most decision-making in relation to the NICE clinical guideline for bipolar disorder was not delivered collaboratively and only some care was recovery focussed.
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Characterization of hemodynamic alterations in schizophrenia and bipolar disorder and their effect on resting-state fMRI functional connectivityCommon and distinct neural bases of Schizophrenia (SZ) and bipolar disorder (BP) have been explored using resting-state fMRI (rs-fMRI) functional connectivity (FC). However, fMRI is an indirect measure of neural activity, which is a convolution of the hemodynamic response function (HRF) and latent neural activity. The HRF, which models neurovascular coupling, varies across the brain within and across individuals, and is altered in many psychiatric disorders. Given this background, this study had three aims: quantifying HRF aberrations in SZ and BP, measuring the impact of such HRF aberrations on FC group differences, and exploring the genetic basis of HRF aberrations. We estimated voxel-level HRFs by deconvolving rs-fMRI data obtained from SZ (N = 38), BP (N = 19), and matched healthy controls (N = 35). We identified HRF group differences (P < .05, FDR corrected) in many regions previously implicated in SZ/BP, with mediodorsal, habenular, and central lateral nuclei of the thalamus exhibiting HRF differences in all pairwise group comparisons. Thalamus seed-based FC analysis revealed that ignoring HRF variability results in false-positive and false-negative FC group differences, especially in insula, superior frontal, and lingual gyri. HRF was associated with DRD2 gene expression (P < .05, 1.62 < |Z| < 2.0), as well as with medication dose (P < .05, 1.75 < |Z| < 3.25). In this first study to report HRF aberrations in SZ and BP, we report the possible modulatory effect of dopaminergic signalling on HRF, and the impact that HRF variability can have on FC studies in clinical samples. To mitigate the impact of HRF variability on FC group differences, we suggest deconvolution during data preprocessing.
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The extent of user involvement in the design of self-tracking technology for bipolar disorder: Literature reviewBACKGROUNDThe number of self-monitoring apps for bipolar disorder (BD) is increasing. The involvement of users in human-computer interaction (HCI) research has a long history and is becoming a core concern for designers working in this space. The application of models of involvement, such as user-centered design, is becoming standardized to optimize the reach, adoption, and sustained use of this type of technology.OBJECTIVEThis paper aims to examine the current ways in which users are involved in the design and evaluation of self-monitoring apps for BD by investigating 3 specific questions: are users involved in the design and evaluation of technology? If so, how does this happen? And what are the best practice ingredients regarding the design of mental health technology?METHODSWe reviewed the available literature on self-tracking technology for BD and make an overall assessment of the level of user involvement in design. The findings were reviewed by an expert panel, including an individual with lived experience of BD, to form best practice ingredients for the design of mental health technology. This combines the existing practices of patient and public involvement and HCI to evolve from the generic guidelines of user-centered design and to those that are tailored toward mental health technology.RESULTSFor the first question, it was found that out of the 11 novel smartphone apps included in this review, 4 (36%) self-monitoring apps were classified as having no mention of user involvement in design, 1 (9%) self-monitoring app was classified as having low user involvement, 4 (36%) self-monitoring apps were classified as having medium user involvement, and 2 (18%) self-monitoring apps were classified as having high user involvement. For the second question, it was found that despite the presence of extant approaches for the involvement of the user in the process of design and evaluation, there is large variability in whether the user is involved, how they are involved, and to what extent there is a reported emphasis on the voice of the user, which is the ultimate aim of such design approaches. For the third question, it is recommended that users are involved in all stages of design with the ultimate goal of empowering and creating empathy for the user.CONCLUSIONSUsers should be involved early in the design process, and this should not just be limited to the design itself, but also to associated research ensuring end-to-end involvement. Communities in health care-based design and HCI design need to work together to increase awareness of the different methods available and to encourage the use and mixing of the methods as well as establish better mechanisms to reach the target user group. Future research using systematic literature search methods should explore this further.
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Explaining why childhood abuse is a risk factor for poorer clinical course in bipolar disorder: a path analysis of 923 people with bipolar I disorderBACKGROUNDChildhood abuse is a risk factor for poorer illness course in bipolar disorder, but the reasons why are unclear. Trait-like features such as affective instability and impulsivity could be part of the explanation. We aimed to examine whether childhood abuse was associated with clinical features of bipolar disorder, and whether associations were mediated by affective instability or impulsivity.METHODSWe analysed data from 923 people with bipolar I disorder recruited by the Bipolar Disorder Research Network. Adjusted associations between childhood abuse, affective instability and impulsivity and eight clinical variables were analysed. A path analysis examined the direct and indirect links between childhood abuse and clinical features with affective instability and impulsivity as mediators.RESULTSAffective instability significantly mediated the association between childhood abuse and earlier age of onset [effect estimate (θ)/standard error (SE): 2.49], number of depressive (θ/SE: 2.08) and manic episodes/illness year (θ/SE: 1.32), anxiety disorders (θ/SE: 1.98) and rapid cycling (θ/SE: 2.25). Impulsivity significantly mediated the association between childhood abuse and manic episodes/illness year (θ/SE: 1.79), anxiety disorders (θ/SE: 1.59), rapid cycling (θ/SE: 1.809), suicidal behaviour (θ/SE: 2.12) and substance misuse (θ/SE: 3.09). Measures of path analysis fit indicated an excellent fit to the data.CONCLUSIONSAffective instability and impulsivity are likely part of the mechanism of why childhood abuse increases risk of poorer clinical course in bipolar disorder, with each showing some selectivity in pathways. They are potential novel targets for intervention to improve outcome in bipolar disorder.
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Treatment-resistant and multi-therapy criteria for bipolar depression: A consensus definitionIntroduction: Most people with bipolar disorder (BD) spend a significant percentage of their life experiencing either sub-syndromal depressive symptoms or major depressive episodes, which contribute greatly to the high levels of disability and mortality associated with BD. Despite the importance of bipolar depression, there are only a small number of treatment options available. Consecutive treatment failures can quickly exhaust these options leading to treatment-resistant bipolar depression (TRBD). Few studies have evaluated TRBD and those available lack a comprehensive definition of multi-therapy resistant bipolar depression (MTRBD). The aim of this study was to reach consensus regarding threshold definitions criterion for TRBD and MTRBD. Method(s): Based on the evidence of standard treatments available in the latest BD treatment guidelines, TRBD and MTRBD criteria were agreed by a representative panel of BD experts using a modified Delphi method. Result(s): TRBD criteria in bipolar depression was defined as failure to reach sustained remission for 8 consecutive weeks after two different treatment trials, at adequate therapeutic doses, with at least two recommended monotherapy treatments or at least one monotherapy treatment and another combination treatment. MTRBD included the same definition as TRBD, with the addition of failure of at least one antidepressant trial, a psychological treatment and a course of electroconvulsive therapy. Conclusion(s): The proposed TRBD and MTRBD criteria may provide an important signpost to help clinicians and researchers in judging when to consider new non-standard treatments. However, some challenging diagnostic and therapeutic issues were identified in the consensus process which need further evaluation and research.
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Treatment-resistant and multi-therapy-resistant criteria for bipolar depression: Consensus definitionBACKGROUNDMost people with bipolar disorder spend a significant percentage of their lifetime experiencing either subsyndromal depressive symptoms or major depressive episodes, which contribute greatly to the high levels of disability and mortality associated with the disorder. Despite the importance of bipolar depression, there are only a small number of recognised treatment options available. Consecutive treatment failures can quickly exhaust these options leading to treatment-resistant bipolar depression (TRBD). Remarkably few studies have evaluated TRBD and those available lack a comprehensive definition of multi-therapy-resistant bipolar depression (MTRBD).AimsTo reach consensus regarding threshold definitions criteria for TRBD and MTRBD.METHODBased on the evidence of standard treatments available in the latest bipolar disorder treatment guidelines, TRBD and MTRBD criteria were agreed by a representative panel of bipolar disorder experts using a modified Delphi method.RESULTSTRBD criteria in bipolar depression was defined as failure to reach sustained symptomatic remission for 8 consecutive weeks after two different treatment trials, at adequate therapeutic doses, with at least two recommended monotherapy treatments or at least one monotherapy treatment and another combination treatment. MTRBD included the same initial definition as TRBD, with the addition of failure of at least one trial with an antidepressant, a psychological treatment and a course of electroconvulsive therapy.CONCLUSIONSThe proposed TRBD and MTRBD criteria may provide an important signpost to help clinicians, researchers and stakeholders in judging how and when to consider new non-standard treatments. However, some challenging diagnostic and therapeutic issues were identified in the consensus process that need further evaluation and research.Declaration of interestIn the past 3 years, M.B. has received grant/research support from the NIH, Cooperative Research Centre, Simons Autism Foundation, Cancer Council of Victoria, Stanley Medical Research Foundation, MBF, NHMRC, Beyond Blue, Rotary Health, Geelong Medical Research Foundation, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Meat and Livestock Board, Organon, Novartis, Mayne Pharma, Servier, Woolworths, Avant and the Harry Windsor Foundation, has been a speaker for Astra Zeneca, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Janssen Cilag, Lundbeck, Merck, Pfizer, Sanofi Synthelabo, Servier, Solvay and Wyeth and served as a consultant to Allergan, Astra Zeneca, Bioadvantex, Bionomics, Collaborative Medicinal Development, Eli Lilly, Grunbiotics, Glaxo SmithKline, Janssen Cilag, LivaNova, Lundbeck, Merck, Mylan, Otsuka, Pfizer and Servier. A.C. has received fees for lecturing from pharmaceutical companies namely Lundbeck and Sunovion. A.J.C. has in the past 3 years received honoraria for speaking from Astra Zeneca and Lundbeck, honoraria for consulting from Allergan, Janssen, Lundbeck and LivaNova and research grant support from Lundbeck. G.M.G. holds shares in P1Vital and has served as consultant, advisor or CME speaker for Allergan, Angelini, Compass pathways, MSD, Lundbeck, Otsuka, Takeda, Medscape, Minervra, P1Vital, Pfizer, Servier, Shire and Sun Pharma. J.G. has received research funding from National Institute for Health Research, Medical Research Council, Stanley Medical Research Institute and Wellcome. H.G. received grants/research support, consulting fees or honoraria from Gedeon Richter, Genericon, Janssen Cilag, Lundbeck, Otsuka, Pfizer and Servier. R.H.M.-W. has received support for research, expenses to attend conferences and fees for lecturing and consultancy work (including attending advisory boards) from various pharmaceutical companies including Astra Zeneca, Cyberonics, Eli Lilly, Janssen, Liva Nova, Lundbeck, MyTomorrows, Otsuka, Pfizer, Roche, Servier, SPIMACO and Sunovion. R.M. has received research support from Big White Wall, Electromedical Products, Johnson and Johnson, Magstim and P1Vital. S.N. received honoraria from Lundbeck, Jensen and Otsuka. J.C.S. has received funds for research from Alkermes, Pfizer, Allergan, J&J, BMS and been a speaker or consultant for Astellas, Abbott, Sunovion, Sanofi. S.W has, within the past 3 years, attended advisory boards for Sunovion and LivaNova and has undertaken paid lectures for Lundbeck. D.J.S. has received honoraria from Lundbeck. T.S. has reported grants from Pathway Genomics, Stanley Medical Research Institute and Palo Alto Health Sciences; consulting fees from Sunovion Pharamaceuticals Inc.; honoraria from Medscape Education, Global Medical Education and CMEology; and royalties from Jones and Bartlett, UpToDate and Hogrefe Publishing. S.P. has served as a consultant or speaker for Janssen, and Sunovion. P.T. has received consultancy fees as an advisory board member from the following companies: Galen Limited, Sunovion Pharmaceuticals Europe Ltd, myTomorrows and LivaNova. E.V. received grants/ research support, consulting fees or honoraria from Abbott, AB-Biotics, Allergan, Angelini, Dainippon Sumitomo, Ferrer, Gedeon Richter, Janssen, Lundbeck, Otsuka and Sunovion. L.N.Y. has received grants/research support, consulting fees or honoraria from Allergan, Alkermes, Dainippon Sumitomo, Janssen, Lundbeck, Otsuka, Sanofi, Servier, Sunovion, Teva and Valeant. A.H.Y. has undertaken paid lectures and advisory boards for all major pharmaceutical companies with drugs used in affective and related disorders and LivaNova. He has also previously received funding for investigator-initiated studies from AstraZeneca, Eli Lilly, Lundbeck and Wyeth. P.R.A.S. has received research funding support from Corcept Therapeutics Inc. Corcept Therapeutics Inc fully funded attendance at their internal conference in California USA and all related expenses. He has received grant funding from the Medical Research Council UK for a collaborative study with Janssen Research and Development LLC. Janssen Research and Development LLC are providing non-financial contributions to support this study. P.R.A.S. has received a presentation fee from Indivior and an advisory board fee from LivaNova.
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Reducing relapse and suicide in bipolar disorder: practical clinical approaches to identifying risk, reducing harm and engaging service users in planning and delivery of care - the PARADES (Psychoeducation, Anxiety, Relapse, Advance Directive Evaluation and Suicidality) programmeBACKGROUND: Bipolar disorder (BD) costs pound5.2B annually, largely as a result of incomplete recovery after inadequate treatment. OBJECTIVES: A programme of linked studies to reduce relapse and suicide in BD. DESIGN: There were five workstreams (WSs): a pragmatic randomised controlled trial (RCT) of group psychoeducation (PEd) versus group peer support (PS) in the maintenance of BD (WS1); development and feasibility RCTs of integrated psychological therapy for anxiety in bipolar disorder (AIBD) and integrated for problematic alcohol use in BD (WS2 and WS3); survey and qualitative investigations of suicide and self-harm in BD (WS4); and survey and qualitative investigation of service users' (SUs) and psychiatrists' experience of the Mental Capacity Act 2005 (MCA), with reference to advance planning (WS5). SETTING: Participants were from England; recruitment into RCTs was limited to certain sites [East Midlands and North West (WS1); North West (WS2 and WS3)]. PARTICIPANTS: Aged >/= 18 years. In WS1-3, participants had their diagnosis of BD confirmed by the Structural Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. INTERVENTIONS: In WS1, group PEd/PS; in WS3 and WS4, individual psychological therapy for comorbid anxiety and alcohol use, respectively. MAIN OUTCOME MEASURES: In WS1, time to relapse of bipolar episode; in WS2 and WS3, feasibility and acceptability of interventions; in WS4, prevalence and determinants of suicide and self-harm; and in WS5, professional training and support of advance planning in MCA, and SU awareness and implementation. RESULTS: Group PEd and PS could be routinely delivered in the NHS. The estimated median time to first bipolar relapse was 67.1 [95% confidence interval (CI) 37.3 to 90.9] weeks in PEd, compared with 48.0 (95% CI 30.6 to 65.9) weeks in PS. The adjusted hazard ratio was 0.83 (95% CI 0.62 to 1.11; likelihood ratio test p = 0.217). The interaction between the number of previous bipolar episodes (1-7 and 8-19, relative to 20+) and treatment arm was significant (chi(2) = 6.80, degrees of freedom = 2; p = 0.034): PEd with one to seven episodes showed the greatest delay in time to episode. A primary economic analysis indicates that PEd is not cost-effective compared with PS. A sensitivity analysis suggests potential cost-effectiveness if decision-makers accept a cost of pound37,500 per quality-adjusted life-year. AIBD and motivational interviewing (MI) cognitive-behavioural therapy (CBT) trials were feasible and acceptable in achieving recruitment and retention targets (AIBD: n = 72, 72% retention to follow-up; MI-CBT: n = 44, 75% retention) and in-depth qualitative interviews. There were no significant differences in clinical outcomes for either trial overall. The factors associated with risk of suicide and self-harm (longer duration of illness, large number of periods of inpatient care, and problems establishing diagnosis) could inform improved clinical care and specific interventions. Qualitative interviews suggested that suicide risk had been underestimated, that care needs to be more collaborative and that people need fast access to good-quality care. Despite SUs supporting advance planning and psychiatrists being trained in MCA, the use of MCA planning provisions was low, with confusion over informal and legally binding plans. LIMITATIONS: Inferences for routine clinical practice from WS1 were limited by the absence of a 'treatment as usual' group. CONCLUSION: The programme has contributed significantly to understanding how to improve outcomes in BD. Group PEd is being implemented in the NHS influenced by SU support. FUTURE WORK: Future work is needed to evaluate optimal approaches to psychological treatment of comorbidity in BD. In addition, work in improved risk detection in relation to suicide and self-harm in clinical services and improved training in MCA are indicated. TRIAL REGISTRATION: Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 6, No. 6. See the NIHR Journals Library website for further project information.
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Users' experiences of an online intervention for bipolar disorder: Important lessons for design and evaluationBACKGROUNDThe evidence base for digital interventions for physical and mental health, including severe and enduring mental health difficulties, is increasing. In a feasibility trial, web-based Enhanced Relapse Prevention (ERPonline) for bipolar disorder demonstrated high recruitment and retention rates. Relative to participants in the waitlist control group, those who received ERPonline showed increased monitoring for early warning signs of relapse and had developed more positive illness models.OBJECTIVETo understand users' motivations and barriers for taking part in an online/telephone-based trial, and for engagement with ERPonline.METHODSParticipants from the trial who had been allocated to receive ERPonline were purposively sampled to participate in telephone-based, in-depth qualitative interviews about their experiences. Interviews (n=19) were analysed using framework analysis to identify themes relevant to study aims.FINDINGSParticipants took part due to the convenient, flexible and rewarding aspects of the trial design, as well as a desire to improve the mental health of themselves and others. Barriers included extensive assessments, practical difficulties and mood. ERPonline was was generally considered to be accessible, relevant and straightforward, but there were individual preferences regarding design, content and who it was for. Several participants reported positive changes, but there was a sense that digital interventions should not replace routine care.CONCLUSIONSThere are a number of barriers and facilitators to consider when evaluating and implementing digital interventions. Individual preferences and human contact were key factors for both trial design and engagement with an online intervention.CLINICAL IMPLICATIONSDigital interventions should be co-produced, personalised, interactive and embedded as one component in a broader package of care.TRIAL REGISTRATION NUMBERISRCTN56908625; Post-results.
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The epidemiology of bipolar affective disorder; a review of the literature and introduction to work in progressThe past 20 years have seen much research into affective disorders, reflecting advances in both pharmacological and psychological treatments. However, there has been little basic epidemiological research into bipolar illness. This is particularly apparent regarding its basic occurrence and possible epigenetic causes. This presentation will attempt to bring together and integrate the available evidence regarding the basic epidemiology of bipolar disorder, define areas where further research is needed, and outline a large epidemiological study including bipolar affective disorder that has been supported by the Stanley Foundation.
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Aggressive behaviour at first contact with services: Findings from the AESOP First Episode Psychosis StudyBackground: Aggressive behaviour is increased among those with schizophrenia but less is known about those with affective psychoses. Similarly, little is known about aggressive behaviour occurring at the onset of illness. Method: The main reasons for presentation to services were examined among those recruited to a UK-based first episode psychosis study. The proportion of individuals presenting with aggressive behaviour was determined and these individuals were compared to those who were not aggressive on a range of variables including sociodemographic, clinical, criminal history, service contact, and symptom characteristics. Among the aggressive group, those who were physically violent were distinguished from those who were not violent but who were still perceived to present a risk of violence to others. Results: Almost 40% (n = 194) of the sample were aggressive at first contact with services; approximately half of these were physically violent (n = 103). Younger age, African-Caribbean ethnicity and a history of previous violent offending were independently associated with aggression. Aggressive behaviour was associated with a diagnosis of mania and individual manic symptoms were also associated with aggression both for the whole sample and for those with schizophrenia. Factors differentiating violent from non-violent aggressive patients included male gender, lower social class and past violent offending. Conclusions: Aggressive behaviour is not an uncommon feature in those presenting with first episode psychosis. Sociodemographic and past offending factors are associated with aggression and further differentiate those presenting with more serious violence. A diagnosis of mania and the presence of manic symptoms are associated with aggression. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
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Incidence of bipolar affective disorder in three UK cities: Results from the ÆSOP studyBackground: There has been a relative dearth of epidemiological research into bipolar affective disorder. Furthermore, incidence studies of bipolar disorder have been predominantly retrospective and most only included hospital admission cases. Aims: To determine the incidence of operationally defined bipolar disorder in three areas of the UK and to investigate any differences in gender and ethnicity. Method: All patients who contacted mental health services with first-episode psychosis or non-psychotic mania between September 1997 and August 1999 were identified and diagnosed according to ICD-10 criteria. Incidence rates of bipolar affective disorder were standardised for age and stratified by gender and ethnic group across the three areas. Results: The incidence rate per 100 000 per year in south-east London was over twice that in Nottingham and Bristol. There was no significant difference in the rates of disorder in men and women. Incidence rates of bipolar disorder in the combined Black and minority ethnic groups in all three areas were significantly higher than those of the comparison White groups. Conclusions: The incidence of bipolar disorder was higher in south-east London than in the other two areas, and was higher among Black and minority ethnic groups than in the White population. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
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Shared white-matter dysconnectivity in schizophrenia and bipolar disorder with psychosisBackground: There is an appreciable overlap in the clinical presentation, epidemiology and treatment response of the two major psychotic disorders - schizophrenia and bipolar disorder. Nevertheless, the shared neurobiological correlates of these two disorders are still elusive. Using diffusion tensor imaging (DTI), we sought to identify brain regions which share altered white-matter connectivity across a clinical spectrum of psychotic disorders.; Method: A sample of 41 healthy controls, 62 patients in a clinically stable state of an established psychotic disorder (40 with schizophrenia, 22 with bipolar disorder) were studied using DTI. Tract-based spatial statistics (TBSS) was used in order to study group differences between patients with psychosis and healthy controls using fractional anisotropy (FA). Probabilistic tractography was used in order to visualize the clusters that showed significant differences between these two groups.; Results: The TBSS analysis revealed five clusters (callosal, posterior thalamic/optic, paralimbic, fronto-occipital) with reduced FA in psychosis. This reduction in FA was associated with an increase in radial diffusivity and a decrease in mode of anisotropy. Factor analysis revealed a single white-matter integrity factor that predicted social and occupational functioning scores in patients irrespective of the diagnostic categorization.; Conclusions: Our results show that a shared white-matter dysconnectivity links the two major psychotic disorders. These microstructural abnormalities predict functional outcome better than symptom-based diagnostic boundaries during a clinically stable phase of illness, highlighting the importance of seeking shared neurobiological factors that underlie the clinical spectrum of psychosis.;
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Ten-year outcomes in first episode psychotic major depression patients compared with schizophrenia and bipolar patientsWe aimed to investigate long-term outcomes in psychotic major depression patients compared to schizophrenia and bipolar/manic psychosis patients, in an incidence sample, while accounting for diagnostic change. Based on Aetiology and Ethnicity in Schizophrenia and Other Psychoses (ÆSOP and ÆSOP-10), a first episode psychosis cohort was followed-up 10years after first presentation. The Schedules for Clinical Assessment in Neuropsychiatry, WHO Life Chart and Global Assessment of Functioning were used to assess clinical, social and service use outcomes. Seventy-two PMD patients, 218 schizophrenia patients and 70 psychotic bipolar disorder/mania patients were identified at baseline. Differences in outcome between PMD and bipolar patients based on baseline and lifetime diagnosis were minimal. Differences in clinical, social and service use outcomes between PMD and schizophrenia were more substantial with PMD patients showing better outcomes on most variables. However, there was some weak evidence (albeit not quite statistically significant at p<0.05) based on lifetime diagnoses that PMD patients were more likely to attempt suicide (OR 2.31, CI 0.98-5.42, p0.055) and self-harm (OR 2.34, CI 0.97-5.68, p0.060). PMD patients have better social and service use outcomes compared to people with schizophrenia, but may be more likely to attempt suicide or self-harm. This unique profile is important for clinicians to consider in any risk assessment.; Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.
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Bipolar at-risk criteria: An examination of which clinical features have optimal utility for identifying youth at risk of early transition from depression to bipolar disordersA clinical and research challenge is to identify which depressed youth are at risk of "early transition to bipolar disorders (ET-BD)." This 2-part study (1) examines the clinical utility of previously reported BD at-risk (BAR) criteria in differentiating ET-BD cases from unipolar depression (UP) controls; and (2) estimates the Number Needed to Screen (NNS) for research and general psychiatry settings. Fifty cases with reliably ascertained, ET-BD I and II cases were matched for gender and birth year with 50 UP controls who did not develop BD over 2 years. We estimated the clinical utility for finding true cases and screening out non-cases for selected risk factors and their NNS. Using a convenience sample (N = 80), we estimated the NNS when adjustments were made to account for data missing from clinical case notes. Sub-threshold mania, cyclothymia, family history of BD, atypical depression symptoms and probable antidepressant-emergent elation, occurred significantly more frequently in ET-BD youth. Each of these "BAR-Depression" criteria demonstrated clinical utility for screening out non-cases. Only cyclothymia demonstrated good utility for case finding in research settings; sub-threshold mania showed moderate utility. In the convenience sample, the NNS for each criterion ranged from ~4 to 7. Cyclothymia showed the optimum profile for case finding, screening and NNS in research settings. However, its presence or absence was only reported in 50% of case notes. Future studies of ET-BD instruments should distinguish which criteria have clinical utility for case finding vs screening. © The Author 2016. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.
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Psychological models of mood disordersA number of psychological models for depression and bipolar disorder have at least some empirical support, are in common use and spawned effective psychological treatments for mood disorder. The article will discuss cognitive behaviour therapy and life events and social support models for unipolar depressive episodes, and more briefly review psychodynamic and medication adherence models for depression, and the development of psychological models in bipolar disorder. These models fit well with the view of many patients that their mood disorder is at least in part psychologically and socially caused. They also promote active self-management of their condition rather than passive compliance with treatment. As a result, these psychological approaches tend to improve the outcomes from medication. Effective care plans can be based on a formulation of cases with mood disorders using these psychological models without employing a formal course of psychological treatment. However, people who do not improve with such a plan may require a formal course of psychological treatment based on these models from an experienced therapist. Since these models tend to utilize information from the past that often cannot be verified, they are open to reporting and recall bias. Also, severely ill or immature patients may not be able to utilize these techniques. However, in suitable patients the use of these psychological models in addition to optimal prescribing of medication and continuity of care probably represent the current gold standard of care for mood disorders. © 2006 Elsevier Ltd. All rights reserved.
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Psychological management of mood disordersEvidence-based psychological treatments for adults with unipolar depressive disorder and bipolar disorder are reviewed. There is most empirical evidence for cognitive behavioural therapy (CBT), which is examined in terms of what it is and its evidence base in unipolar depression, including severe, chronic, and treatment-resistant cases. The evidence base for the combination of CBT plus antidepressant treatment, including where continuation CBT may be usefully employed, reveals greater effectiveness than antidepressant treatment with continuing clinical support or other forms of psychotherapy in patients with severe, chronic, and treatment-resistant depression or depression with co-morbid personality disorder. Briefer descriptions and evidence for the role of mindfulness-based cognitive therapy, behaviour therapy, problem-solving, interpersonal therapy, psychodynamic therapy and cognitive analytical therapy are reviewed. All of these have some evidence for effectiveness and the roles of some of these treatments are starting to become clearer. Simple psychological treatments for bipolar disorder, such as medication adherence and early warning symptoms interventions, can improve some types of clinical outcome, but longer psychological interventions delivered by highly skilled therapists such as CBT and group psycho-education may have more comprehensive evidence of effectiveness. There is some preliminary evidence for the effectiveness of some psychological treatments in bipolar depression. Overall, the effectiveness of psychological treatments for unipolar depressive disorder and bipolar disorder is now well established and an understanding is starting to be obtained as to when they may be employed most usefully. © 2009 Elsevier Ltd. All rights reserved.
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National survey and analysis of barriers to the utilisation of the 2005 mental capacity act by people with bipolar disorder in England and WalesBACKGROUND: The Mental Capacity Act (2005) (MCA) provides a legal framework for advance planning for both health and welfare in England and Wales for people if they lose mental capacity, for example, through mania or severe depression. AIMS: To determine the proportion of people with bipolar disorder (BD) who utilise advance planning, their experience of using it and barriers to its implementation. METHODS: National survey of people with clinical diagnosis of BD of their knowledge, use and experience of the MCA. Thematically analysed qualitative interviews with maximum variance sample of people with BD. RESULTS: A total of 544 respondents with BD participated in the survey; 18 in the qualitative study. 403 (74.1%) believed making plans about their personal welfare if they lost capacity to be very important. A total of 199 (36.6%) participants knew about the MCA. A total 54 (10%), 62 (11%) and 21 (4%) participants made advanced decisions to refuse treatment, advance statements and lasting power of attorney, respectively. Barriers included not understanding its different forms, unrealistic expectations and advance plans ignored by services. CONCLUSION: In BD, the demand for advance plans about welfare with loss of capacity was high, but utilisation of the MCA was low with barriers at service user, clinician and organisation levels.
