Objective
This systematic review provided a critical synthesis and a comprehensive overview of guidelines on the treatment of mixed states.
Method
The MEDLINE/PubMed and EMBASE databases were ...systematically searched from inception to March 21st, 2018. International guidelines covering the treatment of mixed episodes, manic/hypomanic, or depressive episodes with mixed features were considered for inclusion. A methodological quality assessment was conducted with the Appraisal of Guidelines for Research and Evaluation‐AGREE II.
Results
The final selection yielded six articles. Despite their heterogeneity, all guidelines agreed in interrupting an antidepressant monotherapy or adding mood‐stabilizing medications. Olanzapine seemed to have the best evidence for acute mixed hypo/manic/depressive states and maintenance treatment. Aripiprazole and paliperidone were possible alternatives for acute hypo/manic mixed states. Lurasidone and ziprasidone were useful in acute mixed depression. Valproate was recommended for the prevention of new mixed episodes while lithium and quetiapine in preventing affective episodes of all polarities. Clozapine and electroconvulsive therapy were effective in refractory mixed episodes. The AGREE II overall assessment rate ranged between 42% and 92%, indicating different quality level of included guidelines.
Conclusion
The unmet needs for the mixed symptoms treatment were associated with diagnostic issues and limitations of previous research, particularly for maintenance treatment.
•Most ecological studies about lithium in drinking water report a reduction in suicide in general population, mostly in males.•Most trials, uncontrolled and controlled open label, show a reduction in ...the risk of suicide under long-term lithium use.•Evidence seems to attribute an intrinsic anti-suicidal property of lithium, independent of its efficacy as mood stabilizer.
Suicide contributes to 1–4 % of deaths worldwide every year. We conducted a systematic review aimed at summarizing evidence on the use of lithium for the prevention of suicide risk both in mood disorders and in the general population.
We followed the PRISMA methodology (keywords: “lithium”, “suicide” AND “suicidal” on Pubmed, Cochrane CENTRAL, Clinicaltrial.gov, other databases). Inclusion criteria: lithium therapy in mood disorder or found in drinking water or scalp in the general population. Exclusion criteria: no lithium administration.
From 918 screened references, 18 prospective (number of participants: 153786), 10 retrospective (number of participants: 61088) and 16 ecological studies (total sample: 2062) were included. Most of the observational studies reported a reduction in suicide in patients with mood disorders. All studies about lithium treatment’s duration reported that long-term lithium give more benefits than short-term lithium in suicide risk
The evidence seems to attribute an intrinsic anti-suicidal property of lithium, independent of its proven efficacy as a mood stabilizer.
Abstract Objective To identify clinical and neurocognitive predictors of long-term functional outcome in patients with bipolar disorder Methods A total of 32 subjects who met criteria for bipolar I ...or II disorder were recruited from the Barcelona Bipolar Disorder Program and were assessed clinically and neuropsychologically at baseline. After an average 4-year follow-up, they were interviewed with the Functioning Assessment Short Test (FAST) to assess functional outcome. Multivariate analyses were applied to identify clinical and neurocognitive predictors of functional outcome. Results The main regression model for predictors of overall psychosocial functioning identified subclinical depressive symptoms ( ß = 0.516, t = 3.51, p = 0.002), and free delayed recall in a verbal memory task ( ß = − 0.314, t = − 2.144, p = 0.041), accounting for 36% of the variance. Specific predictors of occupational functioning were, again, subthreshold depression ( ß = 0.435, t = 2.8, p = 0.009) and a measure of executive function, digits backwards ( ß = − 0.347, t = − 2.23, p = 0.034). This model explained around 28% of the variance (corrected R2 = 0.28; F = 6.38, gl = 2, p = 0.004). Conclusions Subdepressive symptomatology together with neurocognitive impairments related to verbal memory and executive functions are predictor variables of long-term functional outcome in bipolar disorder.
•COVID-19 patients with psychiatric disorders should be managed on a personalized basis.•Risks of pharmacological interaction are not absolute and should be contextualized.•Essential ...psychopharmacological ongoing treatments should be maintained.•Most psychotropic drugs should be reduced 25–50% if given with lopinavir/ritonavir.•Dose titration should be progressive and with ECG monitoring if cardiotoxic risk.
: The management of coronavirus disease 2019 (COVID-19) in patients with comorbid psychiatric disorders poses several challenges, especially regarding drug interactions.
: We report three representative case-scenarios on patients with psychiatric disorders and COVID-19 to provide a practical approach based on the existing literature and the clinical experience of an expert team in consultation-liaison psychiatry.
: Psychopharmacological ongoing treatments should be prioritized and most doses should be reduced 25–50% of original dose if the patient receives lopinavir/ritonavir, with some exceptions including quetiapine, asenapine, olanzapine, sertraline, lamotrigine, bupropion, and methadone. If the psychopharmacological usual doses are in the low-to-median range levels, a dose change during COVID-19 drugs co-administration is not recommended, but only ECG and clinical monitoring of adverse effects and drug levels if required. Furthermore, when introducing a psychopharmacological drug, dose titration should be progressive, with ECG monitoring if cardiotoxic interactions are present.
(A) In agitated delirium, olanzapine is recommended as first-line antipsychotic and quetiapine should be avoided.
(B) In severe mental illness (SMI), essential treatments should be maintained.
(C) In non-SMI with depressive/anxiety symptoms, psychological support should be provided and symptoms identified and treated.
: Most recommendations on pharmacological interactions provide only a limited qualitative approach and quantitative recommendations are lacking.
: Patients with psychiatric disorders and COVID-19 should be managed on a personalized basis considering several clinical criteria and, should not be excluded from receiving COVID-19 treatments. Risks of pharmacological interaction are not absolute and should be contextualized, and most psychopharmacological treatments should include an ECG with special attention to QTc interval.
IntroductionEmotion dysregulation (ED) is a multidimensional construct involving the lack of awareness, understanding and acceptance of emotions, a reduced access to adaptive and appropriate ...strategies to modulate the intensity or duration of emotional responses, and the inability to control behaviors in accordance with desired goals when experiencing negative emotions. ED is outlined in the general population and several psychiatric disorders, including bipolar disorder (BD), and influences its clinical course and management, quality of life, and daily social functioning.ObjectivesThe objective of this systematic review was to examine the correlations between maladaptive (i.e., positive and negative rumination, negative focus, risk taking behaviors, suppression, and dampening) and adaptive (i.e., cognitive reframing, adaptive coping, and acceptance) strategies of emotion regulation (ER) and depressive and manic symptoms of BD.MethodsWe searched the literature from inception to April 12, 2022, and included studies focusing on ER/ED assessed with a validated scale. We conducted multiple pairwise meta-analyses for correlations between ED dimension (or overall ED) and the measures of depressive and manic symptoms of BD, and separate Bayesian network meta-analyses to examine which aspects of emotion regulation were most closely associated with depressive and manic symptoms of BD. The Pearson’s r coefficients were adjusted using sample-size weights and Fisher’s r-to-z transformed was conducted.ResultsA total of 13,826 records was identified and, after duplicate removal and title/abstract evaluation, 442 were explored at the full text. Sixteen studies were finally included. Results from pairwise meta-analyses are shown in Figure 1, results from network meta-analyses in Figure 2 and 3. Both depressive and manic BD symptomatology were found to be related to maladaptive ER strategies, with the only difference of positive rumination, associated only to manic symptoms. Negative rumination and risk-taking behaviors were the strategies more correlated to both manic and depressive symptoms, as confirmed by both pairwise metanalyses and network metanalyses. On the other hand, depressive symptomatology appeared more correlated with decreased adaptive strategies than manic symptomatology.Image:Image 2:Image 3:ConclusionsED has a significant correlation with BD symptomatology, therefore it should be explicitly considered during clinical assessment, diagnosis, and intervention on BD, and specific treatments should be implemented. More studies, and with longitudinal design, are needed to better explore these associations and their causal direction. In addition, future studies should mainly focus on the complex interactions between cognitive, social, and cultural aspects, and biological correlates to improve knowledge on a topic that is still poorly investigated.Disclosure of InterestV. Oliva: None Declared, M. De Prisco: None Declared, G. Fico Grant / Research support from: “La Caixa” Foundation (ID 100010434 - fellowship code LCF/BQ/DR21/11880019), Consultant of: Angelini, Janssen-Cilag and Lundbeck, A. Murru Grant / Research support from: Spanish Ministry of Science and Innovation (PI19/00672) integrated into the Plan Nacional de I+D+I and co-financed by the ISCIII-Subdirección General de Evaluación and the Fondo Europeo de Desarrollo Regional (FEDER), Consultant of: Angelini, Idorsia, Lundbeck, Pfizer, Takeda, M. Fornaro: None Declared, A. Serretti Consultant of: Abbott, Abbvie, Angelini, AstraZeneca, Clinical Data, Boehringer, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Innovapharma, Italfarmaco, Janssen, Lundbeck, Naurex, Pfizer, Polifarma, Sanofi, Servier, and Taliaz, J. Radua Grant / Research support from: Spanish Ministry of Science and Innovation (PI19/00394, CPII19/00009) integrated into the Plan Nacional de I+D+I and co-financed by the ISCIII-Subdirección General de Evaluación and the Fondo Europeo de Desarrollo Regional (FEDER) and the Instituto de Salud Carlos III, E. Vieta Grant / Research support from: Spanish Ministry of Science and Innovation (PI18/00805, PI21/00787) integrated into the Plan Nacional de I+D+I and co-financed by the ISCIII-Subdirección General de Evaluación and the Fondo Europeo de Desarrollo Regional (FEDER); the Instituto de Salud Carlos III; the CIBER of Mental Health (CIBERSAM); the Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement (2017 SGR 1365), the CERCA Programme, and the Departament de Salut de la Generalitat de Catalunya for the PERIS grant SLT006/17/00357. Thanks the support of the European Union Horizon 2020 research and innovation program (EU.3.1.1. Understanding health, wellbeing and disease: Grant No 754907 and EU.3.1.3. Treating and managing disease: Grant No 945151), Consultant of: AB-Biotics, AbbVie, Angelini, Biogen, Boehringer-Ingelheim, Celon Pharma, Dainippon Sumitomo Pharma, Ethypharm, Ferrer, Gedeon Richter, GH Research, Glaxo-Smith Kline, Janssen, Lundbeck, Medincell, Novartis, Orion Corporation, Organon, Otsuka, Rovi, Sage, Sanofi-Aventis, Sunovion, Takeda, and Viatris
IntroductionCognitive impairment has been commonly found in patients with bipolar disorder (BD).(1) Recent evidence supports the view that global and cognitive functioning decrease as a function of ...number of prior mood episodes, but the relationship is still not clear. (2)ObjectivesWe conducted a cross-sectional study to explore the associations between the lifetime number of affective episodes and functioning, in particular, cognitive functioning in a cohort of patients with BD.MethodsAdult patients with BD were recruited if euthymic for at least 3 months. Socio-demographic and clinical variables were recollected at the baseline evaluation. Functioning was evaluated at baseline with the functioning assessment short test (FAST). The strength of the association between the lifetime number of affective episodes and FAST subscores was explored with Spearman’s correlation test. Linear regression was computed using cognitive functioning as the dependent variable and a set of clinically relevant variables including the lifetime number of affective episodes as independent variables after controlling for illness duration.Results261 BD patients were recruited. Patients with a higher number of lifetime affective episodes showed a significant positive correlation with higher FAST global score (r=0.334, p<0.001) and FAST cognitive functioning subscore (r=0.331, p<0.001). At the linear regression, a higher number of affective episodes was associated to worse cognitive functioning (b=0.037, 95%CI 0.011-0.064, p=0.005).ConclusionsPoor cognitive functioning in BD could be the result of multiple affective relapses. A timely diagnosis with subsequent effective prophylactic treatment may prevent poor functional outcomes in real-world patients with BD.Disclosure of InterestNone Declared
Introduction
When completing the medical record of a patient with bipolar disoder (BD), hardly anything is more impacting than a family history of completed suicide (FHS). In fact, FHS is a main risk ...factor for personal suicide attempts and death in this population. There are few modifiable protective factors against suicide in BD, such as lithium treatment and absence of substance abuse.
Objectives
We aimed to explore the relationship between a FHS and clinical characteristics in patients with BD. Given the impact that FHS has on the individual and on healthcare professionals, we hypothesized that it would modify behaviors towards a higher prevalence of the modifiable protective factors against suicide, namely more treatment with lithium and less drug addiction.
Methods
This is a cross-sectional study that included all patients with BD that were followed up in a specialised unit between 1998 and 2020. Only subjects with complete information on FHS were retained for the analysis. We assessed sociodemographic and clinical data and described it with measures of frequency, central tendency and dispersion. Differences between subjects with and without FHS were calculated with χ², Fisher’s exact test and Student’s t-test as appropriate. We set the significance level at p≤0.05. All tests were two-tailed.
Results
The sample consisted of 480 subjects with a mean age of 45.9 years (standard deviation 14.4, range 18-88), of which 54.4% (n=261) were women. 69.2% (n=332) had a diagnosis of BD type I and 30.8% (n=148) of BD type II. 77 subjects (16%) had a FHS. Regarding differences between groups, those with relatives who had committed suicide did not show statistically significant differences in terms of sociodemographic variables (age, gender, civil status, employment) or key clinical features (type of BD, illness duration, psychotic features, predominant polarity, rapid cycling, number of lifetime manic and depressive episodes, comorbid personality disorder), neither did they have a higher use of lithium (55.8% vs 59.3%, p=0.572) nor lower substance use disorder (10.9% vs 15.5%, p=0.34). Predictably, people with FHS had a higher prevalence of family history of mental and affective disorders (96.1% vs 70.9%, p<0.001; 86.3% vs 56.3%, p<0.001) and of stressful life events (71.6% vs 58.9%, p=0.05). Personal lifetime suicide attempts also tended to be higher (36.4% vs 26.7%, p=0.088).
Conclusions
Contrary to our hypothesis, in our sample of subjects with BD a FHS was not associated with a higher prevalence of the modifiable protective factors against suicide. Therefore, although suicide has a major impact both in families and healthcare professionals, our results suggest it does not modify attitudes towards prevention in a real-life scenario. The main limitation of our study is its cross-sectional design, which does not allow for causal inference. In conclusion, there is room for improvement in the fight against suicide.
Disclosure of Interest
None Declared
The coronavirus disease 2019 (COVID-19) outbreak is putting healthcare professionals, especially those in the frontline, under extreme pressures, with a high risk of experiencing physical exhaustion, ...psychological disturbances, stigmatization, insomnia, depression and anxiety. We report the case of a general practitioner, without relevant somatic or psychiatric history that experienced a “brief reactive psychosis (298.8)” under stressful circumstances derived from COVID-19. She presented with delusional ideas of catastrophe regarding the current pandemic situation, delusions of self-reference, surveillance and persecution, with high affective and behavioural involvement. Physical examination and all further additional investigations did not reveal any secondary causes. She was administered olanzapine 10 mg with significant psychopathological improvement being later discharged with indications to maintain the treatment. To our knowledge this is the first reported case of severe mental illness in a healthcare professional without previous psychiatric history due to COVID-19 outbreak. Around 85% of patients presenting a brief psychotic disorder will develop a potentially disabling serious psychotic illness in the long-term. This case represents the potentially serious mental health consequences on healthcare professionals throughout the COVID-19 crisis and emphasizes the need to implement urgent measures to maintain staff mental health during the current pandemic.
Sleep alterations are frequent occurrence in Bipolar Disorder (BD), both in acute and interepisodic phases. Sleep alterations have been also described both long before BD onset, as aspecific risk ...syndromes, or as immediate prodromes of BD onset. The aim of the present study is to systematically review the relationship between sleep alterations anticipating for the full-blown onset of BD, both in general and according to specific polarities of onset.
A systematic literature research according to PRISMA statement and considering: 1. prospective studies about BD patients' offspring with sleep alterations who later developed BD. 2. prospective studies assessing patients with sleep disorders who later developed BD. 3. retrospective studies on BD patients where sleep alterations before BD onset of the disease were reported.
A total of 16 studies were included in this review. Sleep disturbances may frequently appear 1 year before the onset of BD or more, often during childhood or adolescence. A decreased need for sleep may precede the onset of the illness, specially a manic episode, while insomnia appears to anticipate either a manic or a depressive episode. Hypersomnia seems to precede bipolar depressive episodes.
Sleep alterations frequently appear long before the onset of BD, and appear to be related specifically to the polarity of the index episode. The detection and treatment of sleep alterations in special high risk populations may help achieving an earlier detection of the illness.
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