01 – Bipolar Disorder
IDENTIFY PEOPLE WHO HAVE A HIGH RISK OF DEVELOPING BIPOLAR DISORDER MAY PROVIDE AN OPPORTUNITY TO INTERVENE EARLY AND IMPROVE RESULTS.
TRANSITION TO BIPOLAR DISORDER
Bipolar disorder is a highly heritable condition, which can progress from an asymptomatic period in at-risk individuals to a potentially debilitating illness..
characterized by episodic mood changes, that is major depression and (hypo)manic episodes. According to the proposed ‘clinical staging model’, bipolar disorder is a progressive illness that evolves through successive stages: an asymptomatic period in at-risk individuals, nonspecific and subclinical hypo(manic) symptoms (prodromal) with or without syndromal depressive episodes, first threshold hypo(manic) episode, followed by a subsequent pattern of remission and recurrences and, in some patients, refractory phases.
Over the past two decades, there has been growing interest in early identification and early intervention strategies in bipolar disorder to improve outcomes and mitigate the negative consequences associated with illness progression [3]. However, data from these early intervention programmes suggest that even when evidence-based interventions are initiated shortly after the diagnosis of bipolar disorder is established, the outcomes remain far from ideal as a large subset of patients experience recurrences of mood episodes [3,4], persistent subsyndromal symptoms as well as functional disability [5] even during periods of euthymia.
In addition, once the diagnosis of bipolardisorder is established, many patients have already developed significant cognitive impairment in various domains such as executive function, memory and attention [6,7] as well as gross structural abnormalities in prefrontal and subcortical limbic brain areas [8–10]. These discouraging findings highlight the need to focus on the earliest stages of bipolar disorder by identifying those individuals who are at high genetic and/or clinical risk of developing bipolar disorder.
To know more about this topic, read the following article > Transitioning to bipolar disorder: A systematic review of prospective high-risk studies
1. Vieta E, Reinares M, Rosa AR. Staging bipolar disorder. Neurotox Res 2011; 19:279–285.
2. Berk M, Conus P, Lucas N, et al. Setting the stage: from prodrome to treatment resistance in bipolar disorder. Bipolar Disord 2007; 9:671–678.
3. Yatham LN, Kauer-Sant’Anna M, Bond DJ, et al. Course and outcome after the first manic episode in patients with bipolar disorder: prospective 12-month data from the Systematic Treatment Optimization Program For Early Mania project. Can J Psychiatry 2009; 54:105–112.
4. Gignac A, McGirr A, Lam RW, Yatham LN. Recovery and recurrence following a first episode of mania: a systematic review and meta-analysis of prospectively characterized cohorts. J Clin Psychiatry 2015; 76:1241–1248.
5. Kauer-Sant’Anna M, Bond DJ, Lam RW, Yatham LN. Functional outcomes in first-episode patients with bipolar disorder: a prospective study from the Systematic Treatment Optimization Program for Early Mania project. Compr Psychiatry 2009; 50:1–8.
6. Torres IJ, DeFreitas VG, DeFreitas CM, et al. Neurocognitive functioning in patients with bipolar I disorder recently recovered from a first manic episode. J Clin Psychiatry 2010; 71:1234–1242.
7. Lee RSC, Hermens DF, Scott J, et al. A meta-analysis of neuropsychological functioning in first-episode bipolar disorders. J Psychiatr Res 2014; 57:1–11.
8. Keramatian K, Dhanoa T, McGirr A, et al. Structural brain changes in first episode mania with and without psychosis: data from the Systematic Treatment Optimization Program for Early Mania (STOP-EM). World J Biol Psychiatry 2018; 19(Suppl 2):S30–S40.
9. Kozicky JM, Ha TH, Torres IJ, et al. Relationship between frontostriatal morphology and executive function deficits in bipolar I disorder following a first manic episode: data from the Systematic Treatment Optimization Program for EarlyMania (STOP-EM). Bipolar Disord 2013; 15:657–668.
10. Keramatian K, Chakrabarty T, Saraf G, et al. Grey matter abnormalities in first episode mania: a systematic review and meta-analysis of voxel-based morphometry studies. Bipolar Disord 2020; 23:228–240.
BIPOLAR DISORDERS AND DIABETES MELLITUS TYPE 2
Bipolar disorder is a chronic and often severe psychiatric disorder that affects approximately 1-4% of the world's population. There are three types of TB, including bipolar I disorder (TB-I), bipolar II disorder (TB-II), and cyclothymic disorder. All three types involve clear changes in mood, energy, and activity levels [1]. At a systemic level, TB is not only associated with strong individual suffering and a higher probability of suicide, but also with physical complications such as hypertension, diabetes, autoimmune diseases, immunological alterations, cancer and accelerated aging [2]. In recent years, long-term BD has frequently led to long-lasting cognitive and functional impairment and is associated with an increased risk of dementia, which has been linked to low-grade stress, inflammation, and structural alterations in the brain [ 3 ].
Type 2 diabetes mellitus (T2DM) is a medical condition that frequently co-occurs with bipolar disorders and is associated with brain abnormalities similar to those seen in bipolar disorders. A recent cross-sectional study among 121 adults with bipolar disorders found that 13% of participants reported a personal history of T2DM. After systematic evaluation, this number increased to 21%, indicating that in 40% of cases, psychiatrists were the first to make the diagnosis of T2DM [4]. Additionally, an additional 32.2% of subjects suffered from prediabetes (insulin resistance or glucose intolerance) and none of the participants were aware of these conditions. Overall, upon systematic evaluation, 40% of all patients in this sample had previously unidentified metabolic disturbance [4]. These findings are concerning and clinically relevant.
High rates of T2DM in bipolar disorders may contribute to the disproportionately high cardiovascular mortality reported in bipolar disorders [5,6] and the fact that bipolar disorders are considered a level II moderate risk condition for cardiovascular disease even among young people. [7].
To know more about this topic, read the following article > Bipolar disorders, type 2 diabetes mellitus, and the brain
1. McIntyre RS, Berk M, Brietzke E, et al. Bipolar disorders. Lancet 2020; 396:1841–1856.
2. Mariano A, Di Lorenzo G, Jannini TB, et al. Medical comorbidities in 181 patients with bipolar disorder vs. schizophrenia and related psychotic disorders findings from a single-center, retrospective study from an acute inpatients psychiatric unit. Front Psychiatry 2021; 12:702789.
3. Van Rheenen TE, Lewandowski KE, Bauer IE, et al. Current understandings of the trajectory and emerging correlates of cognitive impairment in bipolar disorder: an overview of evidence. Bipolar Disord 2020; 22:13–27.
4. Calkin CV, Ruzickova M, Uher R, et al. Insulin resistance and outcome in bipolar disorder. Br J Psychiatry 2015; 206:52–57. The study showed a negative association between T2DM or insulin resistance and response to Li and suggests that insulin resistance is an important prognostic factor for adverse clinical outcomes in bipolar disorders.
5. Hayes JF, Miles J, Walters K, et al. A systematic review and meta-analysis of premature mortality in bipolar affective disorder. Acta Psychiatr Scand 2015; 131:417–425. The study demonstrates the strength and robustness of the evidence for elevated mortality in bipolar disorders.
6.Kessing LV, Vradi E, McIntyre RS, Andersen PK. Causes of decreased life expectancy over the life span in bipolar disorder. J Affect Disord 2015; 180:142–147. A population study among 5.4 million people showing that bipolar disorders is associated with lower life expectancy and that natural causes of death are the main reason for lost life years.
7. Goldstein BI, Carnethon MR, Matthews KA, et al. Major depressive disorder and bipolar disorder predispose youth to accelerated atherosclerosis and early cardiovascular disease: a scientific statement from the American Heart Association. Circulation 2015; 132:965–986. A position paper demonstrating that bipolar disorder among youth meets criteria for Expert Panel tier II moderate-risk condition for cardiovascular morbidity.
