Mireia Vianna-Sulzbach

Bipolar disorder affects behavior and social skills on the Internet.

Background Bipolar disorder (BD) is a significant cause of functional, cognitive, and social impairment. However, classic studies of functioning and social skills have not investigated how BD may impact behavior on the Internet. Given that the digital age has been changing the way people communicate, this study aims to investigate the pattern of Internet use in patients with BD. Methods This cross-sectional study assessed 30 patients with BD I or II and 30 matched controls. Patients were not in an acute mood episode, according to DSM-IV. A standard protocol examined sociodemographic variables and social behavior on the Internet, assessed by Facebook number of friends (FBN) and lifetime estimated number of offline contacts (social network number, SNN). Results SNN (p<0.001) and FBN (p = 0.036) of patients with BD were significantly lower than those of controls. Also, variables related with Internet use were significantly lower in patients, e.g., close contacts on Facebook (p = 0.021), Internet experience (p = 0.020), and knowledge of terms associated with social networking sites (p = 0.042). Also, patients showed lower rates of the expected pattern of Internet use (based on their age generation), including a poorer knowledge of SNS (p = 0.018) and a lower frequency of Internet use (p = 0.010). Discussion This study suggests that patients with BD show smaller social networks both in real-world settings and on the Internet. Also, patients tend to use the Internet and social networking sites less frequently and show a poorer knowledge of Internet and social media than healthy controls, below the expected for their generation. These significant differences between patients and controls suggest that the effects of BD on social relationships and functioning extend to electronic media.

Is religiosity a protective factor against suicidal behavior in bipolar I outpatients

BACKGROUND Several risk factors have been associated with suicidal behavior (SB) in bipolar disorder (BD), but little is known regarding possible protective factors. Religiosity has been related to favorable outcomes in mental health and to a reduction in the risk of SB, although the relation between BD, religiosity and SB remains under-investigated. The objective of this study was to evaluate the association between religiosity and SB in euthymic bipolar I outpatients. METHOD In this study, 164 outpatients with BD type I with and without a history of suicide attempts were assessed and compared using a questionnaire to collect clinical and sociodemographic characteristics, the Structured Clinical Interview for DSM-IV, the Hamilton Depression Rating Scale, the Young Mania Rating Scale, the Duke Religious Index, and the Barratt Impulsivity Scale. RESULTS The suicide attempters (SA) group had more psychiatric comorbidity (p=0.007), more rapid cycling (p=0.004), higher levels of impulsivity in all domains (p=0.000), and less religious affiliation (p=0.006) compared with the non-SA group. In the multivariate analysis, after controlling for covariates, non-organizational religious activities (OR, 0.66; 95% CI, 0.50-0.86) and intrinsic religiosity (OR, 0.70; 95% CI, 0.60-0.81) were associated with less SB. LIMITATIONS A small sample size, the cross-sectional design that precluded the possibility of assessing cause and effect relationships, and the infeasibility of determining the time lapse between the last suicide attempt and the period when the patients were evaluated. CONCLUSION Non-organizational religious activities and intrinsic religiosity dimensions exert a protective effect against SB in bipolar I outpatients, even when controlling for variables that may affect the outcome in question.

Verbal memory impairment in healthy siblings of patients with schizophrenia

Cognitive deficits have been recognized as a core feature of schizophrenia (SZ) and are present in most patients. Verbal memory (VM), working memory (WM), and executive function (EF) are domains commonly impaired in patients with SZ. These latter domains have been related to the genetic risk of the disorder characterizing as possible endophenotypes. In order to study neurocognitive endophenotypes in a Brazilian population with elevated genetic risks to develop SZ, we measured VM (Hopkins Verbal Learning Test Revised), WM (Letter-Number Sequencing and Digit Span) and EF (Stroop Test) in 90 subjects (45 unaffected siblings of patients with SZ and 45 matched healthy controls). No differences were found in EF and WM (Letter-Number Sequencing and Digit Span). However, in VM, siblings of patients performed worse than controls on the immediate recall and delayed recall. Our results suggest that VM impairment could be considered an endophenotype of SZ.

Pharmacological treatment and staging in bipolar disorder: evidence from clinical practice

OBJECTIVES Staging models for medical diseases are widely used to guide treatment and prognosis. Bipolar disorder (BD) is a chronic condition and it is among the most disabling disorders in medicine. The staging model proposed by Kapczinski in 2009 presents four progressive clinical stages of BD. Our aim was to evaluate pharmacological maintenance treatment across these stages in patients with BD. METHODS One hundred and twenty-nine subjects who met DSM-IV criteria for BD were recruited from the Bipolar Disorders Program at Hospital de Clínicas de Porto Alegre, Brazil. All patients were in remission. The subjects were classified according to the staging model: 31 subjects were classified as stage I, 44 as stage II, 31 as stage III, and 23 as stage IV. RESULTS Patterns of pharmacological treatment differed among the four stages (p = 0.001). Monotherapy was more frequent in stage I, and two-drug combinations in stage II. Patients at stages III and IV needed three or more medications or clozapine. Impairment in functional status (Functioning Assessment Short Test [FAST] scale scores) correlated positively with the number of medications prescribed. CONCLUSIONS This study demonstrated differences in pharmacological treatment in patients with stable BD depending on disease stage. Treatment response can change with progression of BD. Clinical guidelines could consider the staging model to guide treatment effectiveness.

Treatment delay is associated with more episodes and more severe illness staging progression in patients with bipolar disorder.

Onset of bipolar disorder (BD) in childhood is common and often associated with extraordinarily long delays to specific treatment. Perlis et al. in the STEP-BD study found that 66% of their cohort had onset in childhood or adolescence (until the age of 18) (Perlis et al., 2004). They also reported that early onset was associated with more comorbid substance abuse and anxiety, greater number of mood episodes and suicide attempts. To corroborate this idea, Post et al. reported that treatment delay was associated with a persistent adverse course of illness rated prospectively in adults (Post et al., 2010). The staging model proposed by Kapczinski for BD assumes 1 latent and 4 clinical stages, based on the biological, functional and clinical neuroprogression (Kapczinski et al., 2009). According to this model, in stage I, patients have well-defined periods of euthymia and no cognitive impairment; in stage II, they have interepisodic symptoms due to comorbidities and transient cognitive impairment; in stage III, marked cognitive and functional impairment; and in stage IV, cognitive and functional impairment prevents autonomous living. Adverse courses of illness presumably show more rapid neuroprogression, and it is possible that patients with treatment delay have more severe illness staging classification. The aim of this study is to examine the association between time to the first correct treatment for BD, measured in years, and the clinical stages among patients with BD. Two hundred forty-three outpatients with BD from Hospital de Clínicas de Porto Alegre, Brazil, were screened for this study. Out of those, 127 met inclusion criteria: (1) Age 418 years; (2) fulfilling DSM-IV-TR criteria for BD Type I, according to the Structured Clinical Interview for DSM-IV-TR; (3) meeting remission criteria (Young Mania Rating Scale and the 17 items Hamilton Depression Scale both less than 7 points in the last month); (4) absence of comorbid mental retardation/severe intellectual disabilities; (5) absence of severe unstable medical comorbidities; and (6) being able to comprehend and give informed consent. Sociodemographic and clinic variables were evaluated by the research protocol. Disease onset was defined as the first DSM-IV-TR mood episode. Classification in the 4 clinical stages was performed by experienced psychiatrists using a semistructured interview assessing clinical, social, laboral and functional history. Data was checked with family and the assistant psychiatrist (Rosa et al., 2014). The local ethics committee approved the study and all participants gave written informed consent. The sample consisted in 31 stage I patients, 43 stage II, 31 stage III and 22 stage IV, 72% of them female. The mean age was 44.6 (SD1⁄412.8), and mean age of illness onset was 28.7 (SD1⁄412.5) years. Thirty-two percent of patients had illness onset in childhood or adolescence. Sample was stratified regarding previous mood episodes in three groups (o5 episodes, 5–10 episodes, and 410 episodes). Treatment delay in years was different between stratification groups (Anova F1⁄44.399, df1⁄42, p1⁄40.014), greater in the 410 episodes group compared to the o5 episodes group (Tukey post-hoc, p1⁄40.010). Anova test also showed differences in the magnitude of treatment delay among BD clinical stages (F1⁄42.806, df1⁄43, p1⁄40.043). Tukey post-hoc analyses showed less delay in treatment in Stage I, compared to later stages (Io II1⁄4 III1⁄4 IV, p1⁄40.041). These results converge with previous evidence that treatment delay in BD is associated with episode recurrence and a more adverse course of illness. Our study amplifies existing evidence towards the idea of staging, showing that earlier detection and more effective early intervention could help preventing disorder progression. Early detection and intervention could also maintain patients living with minimum or no cognitive and functional impairments. A longer duration of untreated BD is also correlated with the number of medical comorbidities, such as hypertension and metabolic disorders (Maina et al., 2013); reinforcing the idea of mood episode toxicity (Kapczinski et al., 2010, 2011). Comorbidities increase disease burden, lead to a worse course of illness and, finally, accelerates neuroprogression to later stages (Kapczinski et al., 2009; Maina et al., 2013). Studies with longitudinal designs and with a broader investigation of risk factors for progression to later stages of BD are of vital importance. Nonetheless, our results have implications for understanding neuroprogression hypothesis of mood disorders and help the argument for examining the mood symptoms impact on neurobiological and clinical outcomes.

Right hippocampus size is negatively correlated with leptin serum levels in bipolar disorder

Obesity is more frequent in bipolar disorder. Adipokines are associated with depression and obesity via the inflammatory process. Twenty-six DSM-IV patients with BD and 39 controls were enrolled to assess the relationship between serum leptin and adiponectin with hippocampal volumes. Among patients, there was a significant negative correlation between right hippocampal volume and serum leptin levels. This result sum for the hypothesis of a pro-inflammatory state associated with BD and the prevalent co-morbid obesity.

Volumetric brain magnetic resonance imaging predicts functioning in bipolar disorder: A machine learning approach

Neuroimaging studies have been steadily explored in Bipolar Disorder (BD) in the last decades. Neuroanatomical changes tend to be more pronounced in patients with repeated episodes. Although the role of such changes in cognition and memory is well established, daily-life functioning impairments bulge among the consequences of the proposed progression. The objective of this study was to analyze MRI volumetric modifications in BD and healthy controls (HC) as possible predictors of daily-life functioning through a machine learning approach. Ninety-four participants (35 DSM-IV BD type I and 59 HC) underwent clinical and functioning assessments, and structural MRI. Functioning was assessed using the Functioning Assessment Short Test (FAST). The machine learning analysis was used to identify possible candidates of regional brain volumes that could predict functioning status, through a support vector regression algorithm. Patients with BD and HC did not differ in age, education and marital status. There were significant differences between groups in gender, BMI, FAST score, and employment status. There was significant correlation between observed and predicted FAST score for patients with BD, but not for controls. According to the model, the brain structures volumes that could predict FAST scores were: left superior frontal cortex, left rostral medial frontal cortex, right white matter total volume and right lateral ventricle volume. The machine learning approach demonstrated that brain volume changes in MRI were predictors of FAST score in patients with BD and could identify specific brain areas related to functioning impairment.