Parting notes—An editor's perspective Chengappa, K. N. Roy
Bipolar disorders,
February 2022, 2022-02-00, 20220201, Volume:
24, Issue:
1
Journal Article
Peer reviewed
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Deprescribing, the identification and discontinuation of medications that are no longer indicated or that cause adverse effects that outweigh clinical benefit, relies on the integration of clinical ...expertise and patient values using shared decision making (SDM). This case series describes the application of SDM to the process of deprescribing in patients with serious mental illness, illustrating the ways in which SDM builds a therapeutic alliance between patient, psychiatrist, family members, and other health care professionals to collaboratively develop treatment plans.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Clozapine (CLZ) demonstrates a unique clinical efficacy relative to other antipsychotic drugs. Previous work has linked the plasma ratio of CLZ and its major metabolite, N-desmethylclozapine (NDMC), ...to an inverse relationship with cognition via putative action on the cholinergic system. However, neuroimaging correlates of CLZ/NDMC remain unknown. Here, we examined changes in basal forebrain functional connectivity with the dorsolateral prefrontal cortex, and secondly, cognition in relation to the CLZ/NDMC ratio. A cohort of nineteen chronically ill participants with treatment-resistant schizophrenia (TRS) undergoing 12 weeks of CLZ treatment were included. Measures of cognition and plasma CLZ/NDMC ratios were obtained in addition to resting-state functional neuroimaging scans, captured at baseline and after 12 weeks of CLZ treatment. We observed a significant correlation between basal forebrain-DLPFC connectivity and CLZ/NDMC ratios across CLZ treatment (p = 0.02). Consistent with previous findings, we also demonstrate a positive relationship between CLZ/NDMC ratio and working memory (p = 0.03). These findings may reflect the action of CLZ and NDMC on the muscarinic cholinergic system, highlighting a possible neural correlate of cognition across treatment.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Digital health has emerged in recent years as a tool to optimize care delivery and promote treatment adherence among individuals with first‐episode psychosis (FEP). Recent mandates for social ...distancing and sheltering in place due to the COVID‐19 pandemic have catapulted efforts to provide ongoing coordinated specialty care (CSC) on virtual platforms. While prior evidence provides support for the general implementation of virtual individual therapy, there is limited guidance and evidence for the adoption of group teletherapy. Here we describe our efforts to implement group teletherapy for two small cohorts of individuals with FEP receiving care in a coordinated specialty care clinic using methods adopted from Acceptance and Commitment Therapy. We observed high adherence with group visits as well as client satisfaction across groups. Based on our results, we have taken efforts to implement virtual group therapy more permanently in our clinic. Our experience provides guidance and a model for integration of virtual group therapy within CSC.
Practitioner points
In‐person group therapy can be adapted as an online treatment modality for individuals with first‐episode psychosis (FEP).
Group teletherapy is both accessible and satisfactory to individuals with FEP.
Group teletherapy has potential as a more standard and widespread treatment modality within coordinated specialty care for FEP.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Objectives: The presence of cognitive deficits has become increasingly appreciated across all phases of bipolar disorder. The present review sought to identify domains of cognitive dysfunction, ...methods of assessment, discrimination of iatrogenic from illness‐specific etiologies, and pharmacologic strategies to manage cognitive problems in patients with bipolar disorder.
Methods: A selective literature review was performed focusing on studies of descriptive phenomenology and pharmacologic intervention (favoring randomized comparisons when existent but open trials or case reports when not) involving cognition in bipolar disorder populations, healthy volunteers, or other clinical populations. Identification was made of (i) practical strategies for clinical assessment and management of cognitive complaints, (ii) limitations of existing intervention studies, and (iii) recommendations for the design and direction of future research.
Results: Cognitive deficits involving attention, executive function, and verbal memory are evident across all phases of bipolar disorder. Most existing treatment studies involve nonbipolar populations, prompting caution when extrapolating outcomes to individuals with bipolar disorder. Differentiating medication‐ from illness‐induced cognitive dysfunction requires comprehensive assessment with an appreciation for the cognitive domains most affected by specific medications. No current pharmacotherapies substantially improve cognition in bipolar disorder, although preliminary findings suggest some potential value for adjunctive stimulants such as modafinil and novel experimental agents.
Conclusions: Circumscribed cognitive deficits may be both iatrogenic and intrinsic to bipolar disorder. Optimal management hinges on a knowledge of illness‐specific cognitive domains as well as of the beneficial or adverse cognitive profiles of common psychotropic medications.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Cognitive impairments contribute significantly to inadequate functional recovery following illness episodes in bipolar disorder, yet data on treatment interventions are sparse. We assessed the ...cognitive effects of a standardized extract of the medicinal herb Withania somnifera (WSE) in bipolar disorder.
Sixty euthymic subjects with DSM-IV bipolar disorder were enrolled in an 8-week, double-blind, placebo-controlled, randomized study of WSE (500 mg/d) as a procognitive agent added adjunctively to the medications being used as maintenance treatment for bipolar disorder. Study enrollment and data analyses were completed between December 2008 and September 2012. Cognitive testing at baseline and 8 weeks assessed primary efficacy outcomes. Psychopathology and adverse events were monitored at scheduled visits.
Fifty-three patients completed the study (WSE, n = 24; placebo, n = 29), and the 2 groups were matched in terms of demographic, illness, and treatment characteristics. Compared to placebo, WSE provided significant benefits for 3 cognitive tasks: digit span backward (P = .035), Flanker neutral response time (P = .033), and the social cognition response rating of the Penn Emotional Acuity Test (P = .045). The size of the WSE treatment effect for digit span backward was in the medium range (Cohen d = 0.51; 95% CI, 0.25-0.77). None of the other cognitive tasks showed significant between-group differences. Mood and anxiety scale scores remained stable, and adverse events were minor.
Although results are preliminary, WSE appears to improve auditory-verbal working memory (digit span backward), a measure of reaction time, and a measure of social cognition in bipolar disorder. Given the paucity of data for improving cognitive capacity in bipolar disorder, WSE offers promise, appears to have a benign side-effects profile, and merits further study.
ClinicalTrials.gov identifier: NCT00761761.
Therapeutic options are limited for treatment-resistant bipolar depression (TRBD). Insulin resistance (IR) confers increased risk for TRBD. We investigated metformin, an insulin sensitizer, to ...reverse IR and improve clinical outcomes in TRBD.
Using a random-assignment (1:1), intent-to-treat, 2-site, quadruple-masked, parallel-group (metformin to 2,000 mg/d or placebo) clinical trial design, patients with
bipolar disorder (BD) type I or II and IR received study medication for 26 weeks (February 2016 to October 2019). The primary outcome was the change in depression rating scores (Montgomery-Asberg Depression Rating Scale MADRS) at 14 weeks between those who no longer met IR criteria (converters) and those who still did (non-converters). Additional outcomes included scores on the Global Assessment of Functioning (GAF); the Clinical Global Impressions Scale, Bipolar Disorders version (CGI-BP); and the Hamilton Anxiety Rating Scale (HAM-A) and maintenance of improved outcomes up to 26 weeks.
Forty-five BD patients were randomized to metformin (n = 20) or placebo (n = 25), and at 14 weeks or later, 11 subjects no longer met IR criteria (n = 10 with metformin, n = 1 with placebo;
= .0009). These converters experienced significant improvements in MADRS (
values ranged from .031 to .008) and GAF (
values ranged from .045 to .008) scores compared to non-converters beginning at week 6, sustained to week 26. HAM-A (
= .022 at week 14 and .019 at week 26) and CGI-BP change scores (
= .046 at 26 weeks) significantly favored converters over non-converters. Effect sizes were large for the MADRS and GAF (Cohen
> 1 at 14 and 26 weeks) and large for the HAM-A and CGI-BP at 26 weeks. Transient gastrointestinal side effects occurred under both treatment conditions.
Pending replication, this early study suggests that reversal of IR by metformin offers a path out of TRBD. Further characterization of metformin converters with TRBD will prove informative.
ClinicalTrials.gov identifier: NCT02519543.
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