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Summary In bipolar disorders, abnormalities of sleep patterns and of circadian rhythms of activity are observed during mood episodes, but also persist during euthymia. Shared vulnerabilities between mood disorders and abnormalities of sleep patterns and circadian rhythms of activity have been suggested. This exploratory study investigated the association between polygenic risk scores for bipolar disorder and major depressive disorder, actigraphy estimates of sleep patterns, and circadian rhythms of activity in a sample of 62 euthymic individuals with bipolar disorder. The polygenic risk score – bipolar disorder and polygenic risk score – major depressive disorder were calculated for three stringent thresholds of significance. Data reduction was applied to aggregate actigraphy measures into dimensions using principal component analysis. A higher polygenic risk score – major depressive disorder was associated with more fragmented sleep, while a higher polygenic risk score – bipolar disorder was associated with a later peak of circadian rhythms of activity. These results remained significant after adjustment for age, sex, bipolar disorder subtype, body mass index, current depressive symptoms, current tobacco use, and medications prescribed at inclusion, but not after correction for multiple testing. In conclusion, the genetic vulnerabilities to major depression and to bipolar disorder might be associated with different abnormalities of sleep patterns and circadian rhythms of activity. The results should be replicated in larger and independent samples. [ABSTRACT FROM AUTHOR]

Aim: To examine whether polygenic risk scores (PRS) for neuroticism, depression, bipolar disorder and schizophrenia are higher in individuals manifesting trans‐diagnostic risk factors for the development of major mental disorders and whether PRS enhance prediction of early onset full‐threshold disorders. Methods: Using data from the Brisbane Longitudinal Twin Study, we examined individual PRS for neuroticism, depression, bipolar disorder and schizophrenia, recorded evidence of subthreshold syndromes and family history of mood and/or psychotic disorders and noted progression to trans‐diagnostic clinical caseness (onset of major mental disorders) at follow‐up. We undertook multivariate, receiver operating curve and logistic regression analyses that were adjusted for known variables of influence (age, twin status, and so on). Results: Of 1473 eligible participants (female = 866, 59%; mean age 26.3 years), 28% (n = 409) met caseness criteria for a mood and/or psychotic disorder. All PRS were higher in cases versus non‐cases but associations with different levels of risk were inconsistent. The prediction of caseness (reported as area under the curve with 95% confidence intervals [CI]) improved from 0.68 (95% CI: 0.65, 0.71) when estimated using clinical risk factors alone up to 0.71 (95% CI: 0.69, 0.73) when PRS were added to the model. Logistic regression identified five variables that optimally classified individuals according to caseness: age, sex, individual risk characteristics, PRS for depression and mental health case status of cotwins or siblings. Conclusions: The findings need replication. However, this exploratory study suggests that combining PRS with other risk factors has the potential to improve outcome prediction in youth. [ABSTRACT FROM AUTHOR]

Summary: Insomnia is associated with fatigue, but it is unclear whether response to cognitive behaviour therapy for insomnia is altered in individuals with co‐occurring symptoms of insomnia and chronic fatigue. This is a secondary analysis using data from 1717 participants with self‐reported insomnia in a community‐based randomized controlled trial of digital cognitive behaviour therapy for insomnia compared with patient education. We employed baseline ratings of the Chalder Fatigue Questionnaire to identify participants with more or fewer symptoms of self‐reported chronic fatigue (chronic fatigue, n = 592; no chronic fatigue, n = 1125). We used linear mixed models with Insomnia Severity Index, Short Form‐12 mental health, Short Form‐12 physical health, and the Hospital Anxiety and Depression Scale separately as outcome variables. The main covariates were main effects and interactions for time (baseline versus 9‐week follow‐up), intervention, and chronic fatigue. Participants with chronic fatigue reported significantly greater improvements following digital cognitive behaviour therapy for insomnia compared with patient education on the Insomnia Severity Index (Cohen's d = 1.36, p < 0.001), Short Form‐12 mental health (Cohen's d = 0.19, p = 0.029), and Hospital Anxiety and Depression Scale (Cohen's d = 0.18, p = 0.010). There were no significant differences in the effectiveness of digital cognitive behaviour therapy for insomnia between chronic fatigue and no chronic fatigue participants on any outcome. We conclude that in a large community‐based sample of adults with insomnia, co‐occurring chronic fatigue did not moderate the effectiveness of digital cognitive behaviour therapy for insomnia on any of the tested outcomes. This may further establish digital cognitive behaviour therapy for insomnia as an adjunctive intervention in individuals with physical and mental disorders. [ABSTRACT FROM AUTHOR]

Objectives: Emerging evidence suggests a role of circadian dysrhythmia in the switch between "activation" states (i.e., objective motor activity and subjective energy) in bipolar I disorder. Methods: We examined the evidence with respect to four relevant questions: (1) Are natural or environmental exposures that can disrupt circadian rhythms also related to the switch into high‐/low‐activation states? (2) Are circadian dysrhythmias (e.g., altered rest/activity rhythms) associated with the switch into activation states in bipolar disorder? (3) Do interventions that affect the circadian system also affect activation states? (4) Are associations between circadian dysrhythmias and activation states influenced by other "third" factors? Results: Factors that naturally or experimentally alter circadian rhythms (e.g., light exposure) have been shown to relate to activation states; however future studies need to measure circadian rhythms contemporaneously with these natural/experimental factors. Actigraphic measures of circadian dysrhythmias are associated prospectively with the switch into high‐ or low‐activation states, and more studies are needed to establish the most relevant prognostic actigraphy metrics in bipolar disorder. Interventions that can affect the circadian system (e.g., light therapy, lithium) can also reduce the switch into high‐/low‐activation states. Whether circadian rhythms mediate these clinical effects is an unknown but valuable question. The influence of age, sex, and other confounders on these associations needs to be better characterised. Conclusion: Based on the reviewed evidence, our view is that circadian dysrhythmia is a plausible driver of transitions into high‐ and low‐activation states and deserves prioritisation in research in bipolar disorders. [ABSTRACT FROM AUTHOR]

Objectives: To examine the time delay between the age at onset of symptoms or episodes of bipolar disorders (BD) and the age at diagnosis of and/or receipt of clinical practice guideline recommended interventions for BD. Methods: Systematic search of five databases to identify publications from January 2000 to July 2022 that reported one or more of the following reliable and valid estimates of latency: delay in help seeking (DHS), delay in diagnosis (DD) and duration of untreated BD (DUB). Eligible studies were included in random effects meta‐analyses and multivariate meta‐regression was used to assess factors associated with each latency construct. Results: Screening of 1074 publications identified 59 eligible studies (reported in 66 publications) of >40,000 individuals that estimated DHS (8 studies), DD (20 studies) and/or DUB (45 studies). The median DHS, DD and DUB were 3.5 (IQR: 2.8, 8.48), 6.7 (IQR: 5.6, 8.9) and 5.9 years (IQR: 1.1, 8.2), respectively. Key factors associated with shorter DD included older age and residing outside North America; shorter DUB was associated with psychotic or manic onset and access to early intervention services. Conclusions: Greater consensus on definitions of latency constructs and better‐quality targeted research is required regarding DHS, DD and DUB. This review suggests that, while the peak age at onset of BD is 15–25, diagnosis and guideline recommended interventions (e.g., mood stabilizers) are likely to be delayed until age 25–35 years except for a minority of individuals with access to early intervention services. [ABSTRACT FROM AUTHOR]

Summary: Using data from 1721 participants in a community‐based randomized control trial of digital cognitive behavioural therapy for insomnia compared with patient education, we employed linear mixed modelling analyses to examine whether chronotype moderated the benefits of digital cognitive behavioural therapy for insomnia on self‐reported levels of insomnia severity, fatigue and psychological distress. Baseline self‐ratings on the reduced version of the Horne–Östberg Morningness–Eveningness Questionnaire were used to categorize the sample into three chronotypes: morning type (n = 345; 20%); intermediate type (n = 843; 49%); and evening type (n = 524; 30%). Insomnia Severity Index, Chalder Fatigue Questionnaire, and Hospital Anxiety and Depression Scale were assessed pre‐ and post‐intervention (9 weeks). For individuals with self‐reported morning or intermediate chronotypes, digital cognitive behavioural therapy for insomnia was superior to patient education on all ratings (Insomnia Severity Index, Chalder Fatigue Questionnaire, and Hospital Anxiety and Depression Scale) at follow‐up (p‐values ≤ 0.05). For individuals with self‐reported evening chronotype, digital cognitive behavioural therapy for insomnia was superior to patient education for Insomnia Severity Index and Chalder Fatigue Questionnaire, but not on the Hospital Anxiety and Depression Scale (p = 0.139). There were significant differences in the treatment effects between the three chronotypes on the Insomnia Severity Index (p = 0.023) estimated difference between evening and morning type of −1.70, 95% confidence interval: −2.96 to −0.45, p = 0.008, and estimated difference between evening and intermediate type −1.53, 95% confidence interval: −3.04 to −0.03, p = 0.046. There were no significant differences in the treatment effects between the three chronotypes on the Chalder Fatigue Questionnaire (p = 0.488) or the Hospital Anxiety and Depression Scale (p = 0.536). We conclude that self‐reported chronotype moderates the effects of digital cognitive behavioural therapy for insomnia on insomnia severity, but not on psychological distress or fatigue. [ABSTRACT FROM AUTHOR]

Aims: We explored lifetime comorbidities in clinical subsamples with a diagnosis of Psychosis (N = 143), bipolar (BD = 511), and unipolar disorders (UP = 861). Methods: We analyzed trajectories and patterns of comorbidities using novel metrics, namely bubble plots and density of antecedent events per year of illness exposure per individual. Results: Age at onset (AAO) of most comorbidities was similar to epidemiological studies, but cumulative rates were higher in clinical cases. There were some between group differences in patterns or burden of comorbidities, for example, Psychosis showed the earliest AAO of any mental disorder; UP showed the latest AAO of the index diagnosis. The relative risk of multimorbidity was lower in UP compared with other diagnoses, however, the goodness of fit for the illness trajectory path was lowest for BD. Conclusions: Bubble plots offer a useful representation of timing, sequence, cumulative probability and of comorbidities, the added value of reporting density measures was less obvious. [ABSTRACT FROM AUTHOR]

Summary: Sleep disturbances are typical symptoms of acute episodes of bipolar disorder (BD) and differentiate euthymic BD cases from healthy controls (HC). Researchers often employ objective recordings to evaluate sleep patterns, such as actigraphy, whilst clinicians often use subjective ratings, such as the Pittsburgh Sleep Quality Index (PSQI). As evidence suggests the measures may disagree, we decided to compare subjective (PSQI) and objective (3 weeks of actigraphy) sleep profiles in BD cases and HC (n = 154). We examined whether a dimensional approach helps to illustrate different patterns of sleep disturbances and whether the concordance between subjective and objective recordings varies according to clinical status (BD versus HC). Principal component analysis (PCA) extracted two factors from the PSQI, and separate PCAs of actigraphy recordings extracted two factors for mean values of sleep parameters and one factor for intra‐individual variability. Correlational and linear regression analyses of PCA‐derived dimensions demonstrated that, in both BD and HC, a PSQI "Sleep duration‐efficiency" factor was significantly correlated with an actigraphy "Sleep initiation‐duration" factor. Furthermore, in BD cases only, the PSQI total score and a PSQI "Sleep Impairments" factor were each significantly correlated with an actigraphy "Sleep Variability" factor. Overall, we found that subjective experiences of sleep may be modulated by different components of objectively recorded sleep in BD compared with HC. Also, the use of PCA enabled us to consider the multi‐dimensional nature of subjective sleep, whilst the inclusion of intra‐individual sleep variability afforded a more subtle evaluation of objective sleep. [ABSTRACT FROM AUTHOR]

Background: Adolescents and young adults undertake internet searches before and after attending mental health consultations, but they express concerns about how they can identify reliable online mental health information (OMHI). This action research project examines how clinicians might direct young people towards credible OMHI by analysing which search strategies are most helpful for developing an 'internet prescription' targeted at a youth audience. Methods: Recently qualified doctors undertook searches for OMHI about the diagnosis and treatment of seven mental health conditions. Rankings of websites in search results were compared with reliability and quality ratings derived from established evaluation instruments [the Brief DISCERN and the 12‐item Health on the Net (HoN) tool]. Results: Of 140 websites identified through seven Google searches, only 15% of those evaluated were categorized as high quality. About 17% of websites were selling a treatment or service and about 25% were regarded as untrustworthy. Also, higher rankings in the search results were not indicative of better quality OMHI (Wilcoxon signed rank test: Z = −5.28; p <.001). Although the HoN and DISCERN tools provided useful insights into the credibility of OMHI, investigators did not think either instrument could be recommended for independent use by youth. Conclusions: Our findings suggest that clinical services should take responsibility for identifying a range of credible sources of OMHI. The next step in translating the research strategy into clinical practice involves collaboration with young people to select those platforms most orientated to their needs and to develop rating instruments that enable youth to evaluate OMHI. [ABSTRACT FROM AUTHOR]

Objective: Chronobiological models postulate that abnormalities in circadian rest/activity rhythms (CRAR) are core phenomena of bipolar disorders (BDs). We undertook a meta‐analysis of published studies to determine whether self‐ or observer ratings of CRAR differentiate BD cases from comparators (typically healthy controls [HCs]). Method: We undertook systematic searches of four databases to identify studies for inclusion in random effects meta‐analyses and meta‐regression analyses. Effect sizes (ES) for pooled analyses of self‐ and observer ratings were expressed as standardized mean differences with 95% confidence intervals (CIs). Results: The 30 studies meeting eligibility criteria included 2840 cases and 3573 controls. Compared with HC, BD cases showed greater eveningness (ES: 0.33; 95% CI: 0.12–0.54), lower flexibility of rhythms (ES: 0.36; 95% CI: 0.06–0.67), lower amplitude of rhythms (ES: 0.55; 95% CI: 0.39–0.70) and more disturbances across a range of CRAR (ES of 0.78–1.12 for general and social activities, sleep and eating patterns). Between study heterogeneity was high (I2 > 70%) and evidence indicated a potential publication bias for studies using the Biological Rhythms Interview of Assessment in Neuropsychiatry. Meta‐regression analyses suggested significantly larger ES were observed in studies using observer ratings or including BD cases with higher levels of depressive symptoms. Conclusion: This meta‐analysis demonstrates that BD is associated with higher levels of self‐ or observer‐rated CRAR disturbances compared with controls. However, further studies should examine the respective performance of individual instruments when used alone or in combination, to clarify their applicability and utility in clinical practice. [ABSTRACT FROM AUTHOR]

Aim: Symptoms of bipolar disorder (BD) include changes in mood, activity, energy, sleep, and appetite. Since many of these processes are regulated by circadian function, circadian rhythm disturbance has been examined as a biological feature underlying BD. The International Society for Bipolar Disorders Chronobiology Task Force (CTF) was commissioned to review evidence for neurobiological and behavioral mechanisms pertinent to BD. Method: Drawing upon expertise in animal models, biomarkers, physiology, and behavior, CTF analyzed the relevant cross‐disciplinary literature to precisely frame the discussion around circadian rhythm disruption in BD, highlight key findings, and for the first time integrate findings across levels of analysis to develop an internally consistent, coherent theoretical framework. Results: Evidence from multiple sources implicates the circadian system in mood regulation, with corresponding associations with BD diagnoses and mood‐related traits reported across genetic, cellular, physiological, and behavioral domains. However, circadian disruption does not appear to be specific to BD and is present across a variety of high‐risk, prodromal, and syndromic psychiatric disorders. Substantial variability and ambiguity among the definitions, concepts and assumptions underlying the research have limited replication and the emergence of consensus findings. Conclusions: Future research in circadian rhythms and its role in BD is warranted. Well‐powered studies that carefully define associations between BD‐related and chronobiologically‐related constructs, and integrate across levels of analysis will be most illuminating. [ABSTRACT FROM AUTHOR]

Background: Online searches about anxiety and depression are recorded every 3–5 s. As such, information and communication technologies (ICT) have enormous potential to enable or impair help‐seeking and patient‐professional interactions. Youth studies indicate that ICT searches are undertaken before initial mental health consultations, but no publications have considered how this online activity affects the first steps of the patient journey in youth mental health settings. Methods: State‐of‐the‐art review using an iterative, evidence mapping approach to identify key literature and expert consensus to synthesize and prioritise clinical and research issues. Results: Adolescents and young adults are more likely to seek health advice via online search engines or social media platforms than from a health professional. Young people not only search user‐generated content and social media to obtain advice and support from online communities but increasingly contribute personal information online. Conclusions: A major clinical challenge is to raise professional awareness of the likely impact of this activity on mental health consultations. Potential strategies range from modifying the structure of clinical consultations to ensure young people are able to disclose ICT activities related to mental health, through to the development and implementation of 'internet prescriptions' and a youth‐focused 'toolkit'. [ABSTRACT FROM AUTHOR]

Objectives: Clinical staging is widely used in medicine to map disease progression, inform prognosis, and guide treatment decisions; in psychiatry, however, staging remains a hypothetical construct. To facilitate future research in bipolar disorders (BD), a well‐defined nomenclature is needed, especially since diagnosis is often imprecise with blurred boundaries, and a full understanding of pathophysiology is lacking. Methods: Under the auspices of the International Society of Bipolar Disorders, a Task Force of international experts was convened to review, discuss, and integrate findings from the scientific literature relevant to the development of a consensus staging model and standardize a terminology that could be used to advance future research including staging of BD and related disorders. Results: Consensus opinion and areas of uncertainty or difference were identified in regard to terms referring to staging as it may apply to BD, to at‐risk status and subthreshold stages, and to various clinical stages of BD as it is currently diagnosed. Conclusion: The use of a standardized nomenclature about the clinical stages of BD will facilitate communication about research on clinical and pathological components of this heterogeneous group of disorders. The concepts presented are based on current evidence, but the template provided allows for further refinements as etiological advances come to light. [ABSTRACT FROM AUTHOR]

Objectives: Network analysis is increasingly applied to psychopathology research. We used it to examine the core phenomenology of emerging bipolar disorder (BD I and II) and 'at risk' presentations (major depression with a family history of BD). Methodology: The study sample comprised a community cohort of 1867 twin and nontwin siblings (57% female; mean age ~26) who had completed self‐report ratings of (i) depression‐like, hypomanic‐like and psychotic‐like experiences; (ii) family history of BD; and (iii) were assessed for mood and psychotic syndromes using the Composite International Diagnostic Interview (CIDI). Symptom networks were compared for recent onset BD versus other cohort members and then for individuals at risk of BD (depression with/without a family history of BD). Results: The four key symptoms that differentiated recent onset BD from other cohort members were: anergia, psychomotor speed, hypersomnia and (less) loss of confidence. The four key symptoms that differentiated individuals at high risk of BD from unipolar depression were anergia, psychomotor speed, impaired concentration and hopelessness. However, the latter network was less stable and more error prone. Conclusions: We are encouraged by the overlaps between our findings and those from two recent publications reporting network analyses of BD psychopathology, especially as the studies recruited from different populations and employed different network models. However, the advantages of applying network analysis to youth mental health cohorts (which include many individuals with multimorbidity) must be weighed against the disadvantages including basic issues such as judgements regarding the selection of items for inclusion in network models. [ABSTRACT FROM AUTHOR]

Aim: Subthreshold syndromes (STS) frequently precede the onset of full‐threshold syndromes (FTS) of the corresponding mental disorder (homotypic continuity). This study examines whether subthreshold conditions are comorbid and whether there is heterotypic continuity also between STS and FTS. Methods: Data were extracted from the Brisbane "19Up" cohort study of twins and siblings (N = 1838; 56% female) on individuals who (i) completed self‐report ratings of depression‐like (DLE), hypomanic‐like (HMLE) and psychotic‐like experiences (PLE) and (ii) were assessed for mood and psychotic FTS using the Composite International Diagnostic Interview (CIDI). Associations between STS and FTS were estimated using adjusted prevalence ratios (APR) and 95% confidence intervals (CI). Results: STS are prevalent, with 22% reporting DLE, 14% HMLE and 5% PLE; 7% reported >1 STS, with PLE most likely to demonstrate comorbidity. Individuals with DLE were likely to meet CIDI criteria for depression (APR: 3.71, 95% CI: 2.83, 4.89), hypo/mania (APR: 3.62, 95% CI: 2.21, 5.94) and psychotic disorders (APR: 1.74, 95% CI 1.08, 2.83). Individuals with HMLE were likely to meet CIDI criteria for depression (APR: 2.29, 95% CI: 1.58, 3.31) and hypo/mania (APR: 2.51, 95% CI: 1.29, 4.91); those with PLE were likely to meet criteria for hypo/mania (APR: 5.8, 95% CI: 1.90, 17.70) and psychotic disorders (APR: 17.27, 95% CI: 7.54, 39.65). Conclusions: The findings suggest that STS are common among young adults and show heterotypic as well as homotypic continuity with FTS and support the need for more trans‐diagnostic research on the evolution of major mental disorders. [ABSTRACT FROM AUTHOR]

Introduction: Although clinical practice guidelines (CPG) identify first, second‐ and third‐line mood stabilizer (MS) treatments, they rarely define clinical response to prophylaxis or the core issues to be considered. This project aimed to develop a template for describing how clinical response may be classified and a framework to assist decision‐making and monitoring of response in day‐to‐day practice. Method: A scoping exercise was undertaken followed by narrative synthesis of (a) qualitative and quantitative definitions of MS response applied in clinical and research practice and (b) potential confounders (eg, non‐adherence; tolerability issues) of relevance to routine practice, for example, the concepts are applicable to individuals with bipolar disorder for whom sustained remission is a less realistic goal. Expert consensus was employed to develop a taxonomy of response and key concepts that inform clinical judgements about MS response. Results: Five core constructs can be used to systematize clinical judgements regarding MS response and its monitoring: (a) quantitative, qualitative and/or patient‐reported outcome measures (PROMS), (b) personalized assessment of the acceptable benefit‐to‐harm ratio of a proposed treatment, (c) adequacy of treatment exposure (dose, duration, therapeutic monitoring and adherence), (d) illness activity pre‐ and post‐MS initiation, and (e) other potential confounders (co‐prescription of MS; polypharmacy) or protective factors (eg, psychosocial factors). Conclusions: This heuristic framework might be used as a teaching aid or by clinicians who wish to take a more systematic approach to developing shared criteria for judging MS response that better match patient expectations and preferences. Heuristic approaches also allow seamless introduction of new evidence. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to advance understanding of stage of illness in bipolar disorder (BD), by interrogating the literature for evidence of an influence of stage of illness on functional (ie non‐symptom) outcomes following psychosocial intervention. Methods: A systematic literature search following PRISMA guidelines was conducted to identify empirical studies of psychosocial interventions for established BD. To investigate stage as a predictor of three functional outcomes (general/social functioning, cognitive functioning and quality of life [QoL]), study samples were dichotomised into earlier and later stage using proxy measures identified in existing staging models. Findings were integrated using data‐based convergent synthesis. Results: A total of 88 analyses from 62 studies were identified. Synthesis across studies suggested that psychosocial intervention was more likely to be effective for general functioning outcomes earlier in the course of established BD. No stage‐related differences were found for cognitive or QoL outcomes. Exploratory investigations found some evidence of an interaction between specific intervention type and stage of illness in predicting outcomes. Conclusions: A novel systematic review provided preliminary evidence that benefits general/social functioning may be more pronounced in earlier versus later stages of established BD. The review also generated hypotheses about a potential three‐way interaction, whereby specific psychosocial interventions may be best placed to target functional outcomes in earlier versus later stage BD. The strength of conclusions is limited by the overall low‐quality and significant heterogeneity of studies. Further research is urgently required to understand the impact of illness stage on the effectiveness of psychosocial interventions. [ABSTRACT FROM AUTHOR]

Background: Interest in biological clock pathways in bipolar disorders (BD) continues to grow, but there has yet to be an audit of circadian measurement tools for use in BD research and practice. Procedure: The International Society for Bipolar Disorders Chronobiology Task Force conducted a critical integrative review of circadian methods that have real‐world applicability. Consensus discussion led to the selection of three domains to review—melatonin assessment, actigraphy, and self‐report. Results: Measurement approaches used to quantify circadian function in BD are described in sufficient detail for researchers and clinicians to make pragmatic decisions about their use. A novel integration of the measurement literature is offered in the form of a provisional taxonomy distinguishing between circadian measures (the instruments and methods used to quantify circadian function, such as dim light melatonin onset) and circadian constructs (the biobehavioral processes to be measured, such as circadian phase). Conclusions: Circadian variables are an important target of measurement in clinical practice and biomarker research. To improve reproducibility and clinical application of circadian constructs, an informed systematic approach to measurement is required. We trust that this review will decrease ambiguity in the literature and support theory‐based consideration of measurement options. [ABSTRACT FROM AUTHOR]

Objectives: The Retrospective Assessment of the Lithium Response Phenotype Scale (Alda scale) is the most widely used clinical measure of lithium response phenotypes. We assess its performance against recommended psychometric and clinimetric standards. Methods: We used data from the Consortium for Lithium Genetics and a French study of lithium response phenotypes (combined sample >2500) to assess reproducibility, responsiveness, validity, and interpretability of the A scale (assessing change in illness activity), the B scale, and its items (assessing confounders of response) and the previously established response categories derived from the Total Score for the Alda scale. Results: The key findings are that the B scale is vulnerable to error measurement. For example, some items contribute little to overall performance of the Alda scale (eg, B2) and that the B scale does not reliably assess a single construct (uncertainty in response). Machine learning models indicate that it may be more useful to employ an algorithm for combining the ratings of individual B items in a sequence that clarifies the noise to signal ratio instead of using a composite score. Conclusions: This study highlights three important topics. First, empirical approaches can help determine which aspects of the performance of any scale can be improved. Second, the B scale of the Alda is best applied as a multidimensional index (identifying several independent confounders of the assessment of response). Third, an integrated science approach to precision psychiatry is vital, otherwise phenotypic misclassifications will undermine the reliability and validity of findings from genetics and biomarker studies. [ABSTRACT FROM AUTHOR]

Aim: To systematically review evidence that objectively assessed level of physical fitness is associated with future risk of adverse mental health outcomes during the peak age range for onset of adult mental disorders. Methods: Searches of Electronic databases (EBSCOhost, SPORTDISCUS, EMBASE, MedLINE, Cochrane database, CINAHL, PsychInfo, and Dissertation Abstracts), supplemented by hand searches of journals, conference proceedings and citations. Random‐effects meta‐analysis models were used to pool the intervention effects. Results: Eight studies of adolescents and young adults were included in the qualitative review and six studies derived from four independent cohorts were included in the statistical analyses. Most publications reported on large samples (including >1 million), but male conscripts were over‐represented in the study cohorts; quality of included studies was modest, and heterogeneity was significant. Meta‐analytic estimates were conducted for different adverse mental health outcomes, but all showed an inverse association between fitness and incidence of mental disorders or suicidality. Overall, higher level of physical fitness was associated with lower rates of onset of mental health problems (odds ratio: 0.59; 95% confidence intervals: 0.54, 0.65). Conclusions: All eligible studies were undertaken since 2010, suggesting this is an emerging but unfinished field of research. The study design and methodological limitations indicate that the reported results should be treated with caution. However, if the meta‐analytic findings are reliably replicated for new cohorts of males and females, they have implications for research into the prevention of non‐communicable diseases, as our review suggests that interventions should target physical and mental health in equal measure. [ABSTRACT FROM AUTHOR]

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people. [ABSTRACT FROM AUTHOR]

The article presents a prospective study focusing on whether youth at high risk of illness progression can be identified by measures of rumination, depression and sleep-wake disturbance. Topics include the use of clinical staging to investigate and identify risk factors for illness progression, and the tendency for common dimensions between rumination and sleep-wake disturbance to indicate illness progression in youth.

Given that evidence that vaccination against other diseases is often required, for example for travel to the Indian sub-continent, it has been argued that this is a potentially helpful way to increase uptake of COVID-19 vaccinations. Managing the infodemic about COVID-19: Strategies for clinicians and researchers The obvious nudge to behaviours related to COVID-19 is that several countries are considering whether tourists will require "vaccination passports" in the future. [Extracted from the article]

Background: Studies of potential interventions for asymptomatic individuals at risk of severe mental disorders (ie, clinical stage 0) have focused on genetic counselling or the views of adults with established disease. No study has interviewed youth at risk of bipolar disorders (BD). Methods: Qualitative analysis of interviews with asymptomatic adolescent offspring of adults with BD (OSBD = 7) and unrelated parents with bipolar disorders (PBD = 6) to examine manifest and latent themes in the dialogue. Results: Core themes in both groups were ignorance regarding the magnitude of risk of BD onset in offspring and greater concerns for the health of other family members than for oneself. Parents expressed anxieties in coping with the uncertainty about whether their children would inherit BD and their desire to reduce this risk was partly driven by guilt and their sense of responsibility; PBD favoured the introduction of specialized clinical OSBD services. In contrast, the priority for OSBD was advice on coping with a parent with BD; OSBD favoured access to generic non‐clinical peer group support, which they perceived as less stigmatizing than specialist services. Conclusion: The study highlights that youth at risk of BD should be allowed to express their ideas on what interventions they believe are likely to be most beneficial for them, as their views may differ from other advocates who are routinely consulted, such as PBD. A noteworthy finding was that OSBD thought that being included in the clinical dialogue about their parents' BD would decrease rather than increase their stress levels. [ABSTRACT FROM AUTHOR]

Objectives We investigated the feasibility and acceptability of an integrated group therapy (called HABIT) for comorbid bipolar disorder (BD) and alcohol and substance use disorders (ASUD) (BD-ASUD), a disabling clinical presentation for which no specific treatment has been validated. The 14-session HABIT programme employs psychoeducation-oriented cognitive-behaviour therapy (CBT) followed by mindfulness-based relapse prevention (MBRP) therapy. Method Potential group participants were recruited from adult clients with a DSM-IV diagnosis of BD and an ASUD who were referred by their treating clinician. Observer-rated changes in mood symptoms and ASUD, attendance rates and subjective feedback are reported. Results Eight of 12 clients referred to the programme initially agreed to join the group, six attended the first group session and five clients completed the programme. Group mean scores for mood symptoms improved over time, with slightly greater reductions in depression during the first module. About 50% of individuals showed clinically significant improvement (≥30% reduction) in alcohol and substance use. Attendance rates showed some variability between individuals and across sessions, but the average attendance rate of the group was marginally higher for the first module (86%) as compared with the second module (77%). Most clients reported high levels of general satisfaction with a group specifically targeted at individuals with BD-ASUD. Conclusion This small pilot study suggests our intensive group therapy is acceptable and feasible. If findings are replicated, we may have identified a therapy that, for the first time, leads to improvement in both mood and substance use outcomes in clients with difficult-to-treat comorbid BD-ASUD. Copyright © 2016 John Wiley & Sons, Ltd. Key Practitioner Message Comorbidity between bipolar and alcohol and substance use disorders (BD-ASUD) is frequent and highly disabling;, Therapeutic research on approaches that can simultaneously help BD and ASUD is lacking;, Previous research highlights the need for integrated treatment of both conditions but showed improvements limited to either element of the comorbid disorder;, This pilot study supports the feasibility and acceptability of an intensive, 14-session group therapy programme that integrates CBT and mindfulness approaches. [ABSTRACT FROM AUTHOR]

Aim To examine whether clinical stage of illness and current diagnosis influence appointment behaviour in a specialized primary-level youth mental health service. Methods Factors associated with attendance at 8697 appointments made by 828 young people (females = 497) aged 12-25 years over a 1-year period were analysed. Results The number of appointments made did not correlate with the rates of attendance. However, those with more severe psychiatric morbidity made significantly more appointments and missed significantly more appointments than those with less severe presentations. Impaired social functioning was the best predictor of female attendance rates, whereas age and clinical stage of illness best predicted male attendance rates. Current diagnosis rather than functional impairment appeared to influence the level of input offered by clinicians. Conclusions Age, gender, severity of illness, functioning and psychological distress had differential associations with both planned treatment intensity and attendance rates. These differences are likely to have implications for service provision in this youth population. [ABSTRACT FROM AUTHOR]

Objectives Converging evidence identifies that the offspring of parents with bipolar disorder ( BD), individuals at clinical high risk of BD, and young people with recent onset BD may differ from other clinical cases or healthy controls in terms of sleep-wake profiles. However, it is possible that these differences may reflect current mental state, subtype of mood disorder, or familial traits. This study aimed to determine objective and subjective sleep-wake profiles in individuals aged 15-25 years with a current major depressive episode, in relation to familial traits. Methods Frequency matching was employed to ensure that each individual with a confirmed family history of BD ( FH+) could be compared to four controls who did not have a familial mood disorder ( FH-). Pre-selected objective actigraphy and subjective Pittsburgh Sleep Quality Index ( PSQI) ratings were compared using one-way analysis of variance ( ANOVA) and applying the Benjamini-Hochberg ( BH) correction for false discoveries. Results The sample comprised 60 individuals with a mean age of 19 years. The FH+ (n=12) and FH- groups (n=48) differed on three key sleep parameters: mean sleep duration on week nights ( P=.049), variability in waking after sleep onset ( P=.038), and daily disturbances ( PSQI dimension of sleep disturbance and daytime dysfunction; P=.01). Conclusions The sleep profiles we identified in this study, especially the daily disturbances phenotype, provide support for research into endophenotypes for BD. Also, the findings may offer the opportunity for more tailored, personalized interventions that target specific components of the sleep-wake cycle in individuals with a family history of BD. [ABSTRACT FROM AUTHOR]

Background Inpatient alcohol detoxifications are only proposed after motivational outpatient encounters because detoxification directly from the emergency department (ED) is believed to be associated with early dropout and poor adherence to outpatient follow-up. The aim of this prospective follow-up study was to test the feasibility of unscheduled (UP) alcohol detoxification directly from the ED and to compare the 1-year follow-up of these patients to that of scheduled (SP) patients. Methods A quasi-naturalistic prospective follow-up study of 120 patients: 60 consecutively admitted patients referred directly by the ED for alcohol detoxification ( UP) were compared to 60 consecutively admitted patients who had undergone the usual preparation for an inpatient detoxification program ( SP). The length of hospitalization (in days) and attendance to postdischarge outpatient visits during the first year was compared. Results UP patients were older, less frequently employed, and had more somatic comorbidities compared with SP patients. The UP length of stay was significantly longer (20 ± 16 vs. 14 ± 6, p = 0.04). No difference in their postdischarge attendance was observed; the number of patients attending 1 session (57% UP vs. 65% SP, p = 0.227) and 5 sessions (22% UP vs. 32% SP, p = 0.151) and the mean number of postdischarge visits attended were comparable between the UP and SP groups (2.7 ± 6 vs. 4.5 ± 6; Mann-Whitney U = 1,517, p = 0.124). Conclusions We did not find that UP patients who had been admitted for alcohol detoxification had a significantly higher dropout rate or lower postdischarge addiction treatment attendance. Because they may have several advantages, detoxification programs directly linked with EDs should be further evaluated. [ABSTRACT FROM AUTHOR]

The article discusses the need for reliable criteria to detect and manage at-risk states for bipolar disorders. The pre-onset phenotype of bipolar disorder is characterized by non-specific symptoms that overlap with other high prevalence disorders. Presentations of manic-like experiences are the most robust predictors of early transition to full-threshold mania. Genetic factors and phenomenology, such as depression with atypical symptoms, can also be used to detect the prodrome. Various instruments and approaches have been developed to detect at-risk states, but further research is needed to validate their effectiveness. Early intervention and tailored therapies are important for managing individuals at risk for bipolar disorder. [Extracted from the article]

An introduction is presented in which the editor discusses various reports within the issues on topics including randomized controlled trials, pharmacotherapy and the evolution of evidence-based therapies.

Objectives Gender-specific rates of unipolar and bipolar disorders are well established for cases with post-pubertal onset. However, there is less certainty about these rates in pre-pubertal children. We undertook a systematic review of community studies that report gender-specific rates for unipolar and bipolar disorders in young children, particularly cases of major depression and mania. Method Computer databases (Medline, EMBASE, Index to Theses, and PsychInfo) were searched for non-clinical observational studies using recognized diagnostic criteria to identify unipolar and bipolar disorders in children aged ≤12 years. A meta-analysis was undertaken to calculate pooled odds ratios ( ORs) for caseness for major depression by gender. The limited data on bipolar disorder were summarized. Results Analysis of 12 studies (>15,000 children), indicated that the community prevalence of unipolar disorders was higher in boys (1.3%) than in girls (0.8%). Rates of major depression were low (0.61%), but boys were significantly more likely to meet diagnostic criteria than girls ( OR = 1.61; 95% confidence interval: 1.11-2.35). Five studies, assessing >5,000 children, identified only one case with a probable diagnosis of mania. Conclusions This systematic review suggests that boys aged ≤12 years are significantly more likely to experience major depression than girls. However, in younger children, community rates of major depression are low, and it is frequently suggested (but not proven) that most cases are comorbid. The absence of mania suggests either that childhood bipolar phenotypes do not resemble post-pubertal onset cases or that there are problems of case ascertainment. [ABSTRACT FROM AUTHOR]

Make lithium great again - Precisely! 2019; 7 (1). 4 Scott J, Etain B, Bellivier F. Can an integrated science approach to precision medicine research improve lithium treatment in bipolar disorders? Before highlighting factors that may optimise lithium use, we wish to remind readers that lithium is cheap, uniquely effective and a prime candidate for developing precision prescribing in psychiatry. [Extracted from the article]

Morriss R, Yang M, Chopra A, Bentall R, Paykel E, Scott J. Differential effects of depression and mania symptoms on social adjustment: prospective study in bipolar disorder. Bipolar Disord 2013: 15: 80-91. © 2013 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd. Objectives: Previous studies of social adjustment in bipolar disorder have been cross-sectional and small in sample size, have examined a limited number of roles, or were not controlled for baseline mood and other clinical, social, or treatment confounders. We aimed to prospectively explore the strength and stability of correlations between depression and mania-type symptoms and impairment in a broad range of social adjustment roles and domains. Methods: Multilevel modeling analysis of correlation coefficients between depression and mania-type symptoms with roles and domains of the modified social adjustment scale (overall, work, social/leisure, extended family, marital, parental social adjustment roles, performance, interpersonal behavior, friction, dependency, overactivity domains) was used. Interview assessments were made at eight-week intervals beginning at eight weeks and continuing through 72 weeks after baseline in 253 patients in a multicenter randomized controlled trial. Results: After controlling for baseline mood episodes, and other clinical, social, and treatment variables, depression symptoms showed strong and stable correlations over time with performance, overall social adjustment, and the work role; and a moderate but stable relationship with interpersonal behavior. The relationships of depression symptoms with the other roles were weak, non-significant, or not stable. For mania-type symptoms, only the correlation with interpersonal friction was moderately strong and reasonably stable over time. Mood episodes, substance use disorder, and borderline/antisocial personality disorder increased role impairment, while employment and marriage mildly decreased it. Conclusions: Depression and mania-type symptoms have specific effects on social adjustment in bipolar I disorder. Depression symptoms are correlated strongly with performance and moderately with interpersonal behavior, while mania-type symptoms are correlated moderately with interpersonal friction. [ABSTRACT FROM AUTHOR]

Objectives:  Randomized trials of adjunctive psychotherapy for bipolar disorder are reviewed, in tandem with discussion of cost-effectiveness, mediating mechanisms, and moderators of effects. Methods:  Systematic searches of the MEDLINE and PSYCHLIT databases yielded 19 randomized controlled trials of individual family and group therapies. Outcome variables included time to recovery, relapse or recurrence, symptom severity, medication adherence, and psychosocial functioning. Results:  Meta-analyses consistently show that disorder-specific psychotherapies [cognitive-behavioral therapy (CBT), interpersonal, family, and group] augment mood stabilizers in reducing rates of relapse (OR = 0.57; 95% CI: 0.39–0.82) over 1–2 years. Specific mediating mechanisms include, but are not limited to, increasing medication adherence, teaching self-monitoring and early intervention with emergent episodes, and enhancing interpersonal functioning and family communication. All therapies have strengths and weaknesses. One group psychoeducation trial, demonstrated effect sizes for recurrence that are at least equivalent to individual therapies, but findings await replication. Family interventions have been successfully administered in both single and multi-family formats, but no studies report the comparative cost-effectiveness of these formats. The best-studied psychotherapy modality, CBT, can have beneficial effects on depression, but findings are inconsistent across studies and vary with sample characteristics and comparison treatments. Conclusions:  Adjunctive psychotherapies can be cost-effective when weighed against observed reductions in recurrence, hospitalization and functional impairments. Future trials need to (i) clarify which populations are most likely to benefit from which strategies; (ii) identify putative mechanisms of action; (iii) systematically evaluate costs, benefits, and generalizability; and (iv) record adverse effects. The application of psychosocial interventions to young-onset populations deserves further study. [ABSTRACT FROM AUTHOR]

Objectives: To determine the effects of mood and additional clinical variables on different domains of current interviewer-rated social adjustment reflecting the reported behaviour of patients with bipolar disorder (BD). Method: Multi-center cross-sectional study employing multiple linear regression to investigate whether mood and other clinical features, previously linked to self-rated social adjustment, were associated with eight domains of interviewer-rated social adjustment in 253 BD patients. Baseline variables were entered sequentially in blocks representing current mood, demographic, current other psychiatric, past psychiatric and current treatment variables. Results: Mood episode or symptoms together with five other variables (borderline/antisocial personality disorder, male gender, living alone, hypnotic drug and drugs for physical illness) were associated with impairment on two or more domains of interviewer-rated social adjustment. They explained up to 31% of the variance in social adjustment, although friction, dependence and overactivity were associated with a different pattern of variables. Hypomanic symptoms were associated with increased friction and worse social adjustment with the extended family in the whole sample but improved performance and social and leisure activities in patients who were not in acute bipolar episode. Conclusion: Clinicians may determine up to about 30% of outcome in current social adjustment in BD patients from the patient's current mood episode or symptoms and a small number of other clinical or demographic variables. Hypomanic episodes and symptoms usually worsen friction and overall social adjustment, but in patients who are not in acute episode, hypomanic symptoms can increase performance and social and leisure activities. [ABSTRACT FROM AUTHOR]

Background: Evidence indicates that social outcomes in bipolar disorders (BP) are poorer than previously assumed. This study explores determinants of the quality and quantity of social activity. Methods: Seventy-seven subjects with BP completed self-report and observer-rated questionnaires assessing demographic and clinical factors, personality and social functioning. Results: Quality of functioning and spectrum of activity were found to be independent. The best determinants of the quality of functioning, accounting for 33% of the variance, were premorbid neuroticism and the current level of depressive symptoms. Only 30% of subjects were active in all social domains, and the quantity of social activity was largely explained by social circumstances, namely, living with someone else and later age of illness onset. Conclusions: The implications of these findings are discussed in this paper. We suggest that future studies need to differentiate between factors associated with the quality of functioning as compared with the quantity of social activity. [ABSTRACT FROM AUTHOR]

Scott J, Gutierrez MJ. The current status of psychological treatments in bipolar disorders: a systematic review of relapse prevention.Bipolar Disord 2004: 6: 498–503.© Blackwell Munksgaard, 2004This paper reviews published randomized-controlled treatment trials of psychological therapies added to standard psychiatric treatment versus medication and standard psychiatric treatment alone to explore whether adjunctive psychotherapy reduces relapse rates in individuals with bipolar disorders (BDs).Relapse rates were calculated for individual trials that met inclusion criteria and then pooled odds ratios were calculated using meta-analytic techniques.The majority of studies quoted demonstrate that individuals receiving psychological treatments had significantly fewer relapses. The length of therapy required was between 10 and 20 h over 6–9 months and the models of effective therapies had many shared characteristics in terms of style and content.Adjunctive psychological treatments for individuals with BDs are acceptable and feasible and reduce relapse risk. There are relatively few differences in the benefits that accrue from the different therapy models. It is now important to explore whether they have added value in terms of additional health gains and social functioning compared with standard treatment approaches. [ABSTRACT FROM AUTHOR]

Objectives: To assess the acceptability and feasibility of concordance therapy (CCT) in improving adherence with lithium prophylaxis in individuals with bipolar disorder. Methods: Ten subjects with bipolar I disorder and self-reported problems with lithium adherence were recruited. Eight participated in a 6-month study of CCT delivered by an expert in cognitive therapy. Reliable and valid assessments of self-reported adherence with lithium, attitudes towards, and knowledge of lithium and serum plasma lithium levels were measured pre- and post-intervention. Subjects' views of CCT were also recorded. Results: Statistically significant improvements in attitudes towards lithium (mean score baseline = 6.8; follow up = 4.1; Effect size = 1.6) were associated with improvements in self-reported adherence. Laboratory results demonstrated statistically significant increases in serum plasma lithium levels (mean increased from 0.41 to 0.6; effect size 1.7). Subjects viewed CCT as an acceptable intervention. However, only four of the 10 subjects completed all seven half-hour therapy sessions and homework tasks. Conclusions: This small open study suggests that CCT may represent a useful addition to the ‘stepped care’ package of treatment for individuals with bipolar disorders. Research is underway to assess its efficacy and to establish whether novice therapists can also apply the model effectively. [ABSTRACT FROM AUTHOR]

Examines the role of homework in therapy for depression. Difficulties in designing assignments for depressed individuals; Importance of homework in the process of cognitive therapy; Aspects of cognitive therapy.

Objective: The aim of this paper is to review the prevalence, predictors and methods for improving medication adherence in unipolar and bipolar affective disorders. Method: Studies were identified through Medline and PsycLit searches of English language publications between 1976 and 2001. This was supplemented by a hand search and the inclusion of selected descriptive articles on good clinical practice. Results: Estimates of medication non-adherence for unipolar and bipolar disorders range from 10 to 60% (median 40%). This prevalence has not changed significantly with the introduction of new medications. There is evidence that attitudes and beliefs are at least as important as side-effects in predicting adherence. The limited number of empirical studies of how to reduce non-adherence offer encouraging evidence that, if recognized, the problem can be overcome. Conclusion: Only 1–2% of all publications on the treatment of affective disorders explore factors associated with medication non-adherence. This is disappointing as research and clinical data highlight the importance of extended courses of medication in improving the long-term prognosis of affective disorders. [ABSTRACT FROM AUTHOR]

Objective: To explore the clinical characteristics of familial and non-familial bipolar disorder. Method: Twenty subjects with bipolar disorder, who also had a family history of bipolar disorder in a first degree relative, were matched for current age, age of first onset of bipolar disorder and gender with 20 subjects with bipolar disorder who had no family history of any psychiatric disorders in first or second degree relatives. Results: Fourteen subjects in each group were female. The mean age at interview was 45.2 years and the mean age at first admission was 26 years. Although familial and non-familial probands had an equivalent number of illness episodes, familial probands were significantly more likely to experience mixed states as compared to non-familial probands. The latter experienced significantly more depressive episodes and had significantly higher neuroticism (N) scores on the Eysenck Personality Inventory (EPI; Eysenck H, Eysenck S. Manual of the Eysenck Personality Inventory. London: University of London Press, 1964.). Conclusions: If the results are replicated, they have important implications. For example, such data may aid decisions about the targeting of additional psychosocial interventions in high N score cases. Researchers will wish to investigate whether mixed states show a stronger association with early age of onset or family history of BD. [ABSTRACT FROM AUTHOR]

This study reviews referrals of elderly medically ill patients to a psychogeriatric team in a district general hospital. Sociodemographic variables, medical diagnosis, source and reasons for referral, and primary DSM III diagnosis were determined. The impact on referral patterns of the introduction of a pscychogeriatric liaison attachment to complement the existing consultation service was also asscessed. In three years, 217 patients were referred, the majority from the general medical specialities. The median age of the sample was 79.5 years, more than half were female and over 60% demonstrated multiple physical pathology, particularly cerebrovascular and cardiovascular disorders. The most prevalent psychiatric diagnoses were dementia, delirium and depression. The pattern of referrals changed significantly with the introduction of the consultation- liaison service. The number of referrals increased by over 100% and there was a significant increase in the recognition and referral of functional psychiatric disorders, especially depression. The role of the geriatricians and the liaison psychiatry attachment in promoting these changes and the clinical, teaching and research advantages of this type of collaboration are discussed. [ABSTRACT FROM AUTHOR]

Seventy-three elderly patients (38 with Alzheimer-type dementia (ATD) and 35 with major depressive disorder) were followed up 2–5 years after an index admission during which a dexamethasone suppression test (DST) had been performed. Clinical state, cognitive function, neurological status and repeat DST were assessed where possible. The death rate was high in both groups (greater in the ATD group) but was not influence by original DST In either group, but DST non-suppression in the depressed group was associated with significant cognitive rate and abnormal neurological features. Possible mechanisms of the association are discussed. [ABSTRACT FROM AUTHOR]

The author discusses early intervention in bipolar disorders (BD). It explains the difference between primary, secondary and tertiary prevention of BD. The risk factors for BD are mentioned. The author believes that the important issue in early intervention in BD is to strike a balance between the desire to reduce acute distress and prevent or delay relapse versus the need to engender hope and to decatastrophize the fact that the existence of BD will have an impact on the patient's future.

Objectives: The study aims to generate an immunological age (IA) trait on the basis of immune cell differentiation parameters, and to test whether the IA is related to age and disease characteristics. Methods: Forty‐four euthymic type I bipolar disorder patients were included in this study. Five immunosenescence‐related parameters were assessed: proportions of late‐differentiated cells (e.g., CD3+CD8+CD28‐CD27‐ and CD3‐CD19+IgD‐CD27‐), and the expression of CD69, CD71, and CD152 after stimulation. Confirmatory factor analysis was applied to generate an IA trait underling the 5 measures. Results: The best‐fit model was constituted by 4 parameters that were each related to an underlying IA trait, with 1 cell population positively correlated (CD3+CD8+CD28‐CD27‐ [λ = 0.544, where λ represents the loading of the parameter onto the IA trait] and 3 markers negatively correlated (CD69 [λ = −0.488], CD71 [λ = −0.833], and CD152 [λ = −0.674]). The IA trait was associated with chronological age (β = 0.360, p = .013) and the number of previous mood episodes (β = 0.426, p = .006). In a mediation model, 84% of the effect between manic episodes, and IA was mediated by body mass index. Conclusion: In bipolar disorder type I, premature aging of the immune system could be reliably measured using an index that validated against chronological age, which was related to adverse metabolic effects of the disease course. [ABSTRACT FROM AUTHOR]

The authors reflects on the fifth edition of the "Diagnostic and statistical manual of mental disorders" (DSM-5) classification system releasing in May 2013, and highlights uncertainty over DSM improving clinical care for mental disorders. They emphasizes clinical staging as a diagnostic practice for improved clinical care, and outlines clinical staging model. They also mention that the clinical staging focuses on the benefits of intervening earlier in life-threatening illnesses.

The author discusses the results of various studies on the diagnosis and treatment of bipolar disorder (BD). According to a World Bank study, at least 20% of working-age adults with early onset unipolar cases will convert to BP over 5 to 8 years, which implies that BP could become more debilitating and costly than most major medical disorders. The significance of a study that examined the range and complexity of factors to be considered when devising interventions that meet the needs of individuals affected by the onset of BP is also explored.