Pilar Sierra

Cardiovascular risk in patients with bipolar disorder.

BACKGROUND To date, little is known about cardiovascular risk (CVR) in terms of coronary heart disease (CHD) and cardiovascular mortality risk (CMR) in patients with bipolar disorder. This study provides data on the overall risk of any fatal or non-fatal coronary heart disease (CHD) and on the cardiovascular mortality risk (CMR) within 10 years in these patients. METHODS Naturalistic, cross-sectional, multicenter study conducted in Spain. Patients were evaluated for cardiovascular risk using the Framinghan function (CHD) and the Systematic COronary Risk Evaluation (SCORE) function (CMR). RESULTS The mean age was 46.6 years and 49% were male. Forty-six percent were in remission. Ten-year CHD risk was 7.6% (males 10.2% versus females 4.7%, p<0.001) and 10-year CMR was 1.8% (males 2.2% versus females 1.3%, p 0.161). Fifty-one percent smoked and 34% was obese. Metabolic syndrome was present in 22.4% of the sample (35.6% according to AHA and NHLBI criteria). Cardiovascular risk significantly increases with age, body mass index and presence of metabolic syndrome. LIMITATIONS The cross-sectional design of the study. CONCLUSIONS Cardiovascular risk is high in patients with bipolar disorder. It is associated with age, body mass index and metabolic syndrome. Psychiatrists should be aware of this issue and carefully monitor these patients for cardiovascular risk factors, including cigarette smoking, as part of the standard of care when treating them.

Prodromal Symptoms to Relapse in Bipolar Disorder

In a cyclical and recurring illness such as bipolar disorder, prodrome detection is of vital importance. This paper describes manic and depressive prodromal symptoms to relapse, methods used in their detection, problems inherent in their assessment, and patients’ coping strategies. A review of the literature on the issue was performed using MEDLINE and EMBASE databases (1965–May 2006). ‘Bipolar disorder’, ‘prodromes’, ‘early symptoms’, ‘coping’, ‘manic’ and ‘depression’ were entered as key words. A hand search was conducted simultaneously and the references of the articles found were used to locate additional articles. The most common depressive prodromes are mood changes, psychomotor symptoms and increased anxiety; the most frequent manic prodromes are sleep disturbances, psychotic symptoms and mood changes. The manic prodromes also last longer. Certain psychological interventions, both at the individual and psychoeducational group level, have proven effective, especially in preventing manic episodes. Bipolar patients are highly capable of detecting prodromal symptoms to relapse, although they do find the depressive ones harder to identify. Learning detection, coping strategies and idiosyncratic prodromes are elements that should be incorporated into daily clinical practice with bipolar patients.

Predictive factors of functional capacity and real-world functioning in patients with schizophrenia

PURPOSE This study was performed to identify the predictive factors of functional capacity assessed by the Spanish University of California Performance Skills Assessment (Sp-UPSA) and real-world functioning assessed by the Spanish Personal and Social Performance scale (PSP) in outpatients with schizophrenia. METHODS Naturalistic, 6-month follow-up, multicentre, validation study. Here, we report data on 139 patients with schizophrenia at their baseline visit. ASSESSMENT Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression-Severity (CGI-S), Sp-UPSA and PSP. STATISTICS Pearsons correlation coefficient (r) was used to determine the relationships between variables, and multivariable stepwise linear regression analyses to identify predictive variables of Sp-UPSA and PSP total scores. RESULTS Functional capacity: scores on the PSP and PANSS-GP entered first and second at P<0.0001 and accounted for 21% of variance (R(2)=0.208, model df=2, F=15.724, P<0.0001). Real-world functioning: scores on the CGI-S (B=-5.406), PANSS-N (B=-0.657) and Sp-UPSA (B=0.230) entered first, second and third, and accounted for 51% of variance (model df=3, F=37.741, P<0.0001). CONCLUSION In patients with schizophrenia, functional capacity and real-world functioning are two related but different constructs. Each one predicts the other along with other factors; general psychopathology for functional capacity, and severity of the illness and negative symptoms for real-world functioning. These findings have important clinical implications: (1) both types of functioning should be assessed in patients with schizophrenia and (2) strategies for improving them should be different.

Is melatonin an adjunctive stabilizer

A 61-YEAR-OLD WOMAN with Alzheimer’s dementia (AD) was admitted semi-mutistic having ceased eating, drinking, and taking oral medications over 2 weeks before. DSMIV-TR criteria for major depression were not met. Hostile/ aggressive features as well as any signs of emotional distress were unapparent. Thus, upon admission, apathy syndrome was diagnosed with indolence, requirement of prompts to initiate physical and mental activity and a complete lack of goaldirected behavior. Medical and neurological examination revealed tachycardia and clinical signs of dehydration but she was otherwise normal. Laboratory work-up was normal. A computed tomography scan showed no acute pathological findings. Intravenous fluid and electrolyte replacement was installed. Treatment with intramuscular lorazepam (1 mg b.i.d.) and haloperidol (5 mg q.d.) had no effect and was discontinued after 5 days. Intravenous administration of citalopram 20 mg q.d. was started after 5 drug-free days. Three days later, responsiveness increased, and spontaneous speech and emotional reactions occurred. After 8 days, the patient ate and drank. She was switched successfully to oral citalopram 40 mg q.d. after 14 days. Although emotional blunting persisted, she became accessible and cooperative. Her Mini Mental State Examination score was 15/30, consistent with moderate dementia. After 30 days of oral citalopram, she was referred to a nursing home with sufficient daily food and fluid intake, having gained 1.9 kg of bodyweight. Apathy is one of the most common behavioral symptoms in AD representing a significant burden to patients and caregivers. Severe forms, such as the reported case, with distinct key symptoms as highlighted above are well separable from other AD-related behavioral disturbances, above all, depression. Treatment options include psychostimulants and dopaminergics which, however, are not available for parenteral administration and bear the risk of other behavioral complications. Selective serotonin reuptake inhibitors (SSRI), such as citalopram or sertraline, are well tolerated in geriatric populations. However, most likely due to differentially impaired neural pathways, they appear not to be effective in depression in AD. Nevertheless, SSRI have shown efficacy for treating irritability and psychotic symptoms in AD. Furthermore, cholinergic and glutamatergic disturbances, a profound alteration of serotonergic (5-HT) activity, for example via 5-HT1A receptor and/or 5-HT transporter reduction in AD, has been demonstrated and linked to the aforementioned neurobehavioral symptoms. Thus, and given the possibility of parenteral administration, SSRI should be considered as an alternative treatment option for such conditions over less well-tolerated drug classes. Our case suggests that intravenous citalopram may be a treatment option in severe AD-related apathy.

Comparative neurocognitive effects of lithium and anticonvulsants in long-term stable bipolar patients

BACKGROUND The aim of choosing a mood-stabilizing drug (lithium or anticonvulsants) or a combination of them with minimal neurocognitive effects is to stimulate the development of criteria for a therapeutic adequacy, particularly in Bipolar Disorder (BD) patients who are clinically stabilized. METHOD Three groups of BD patients were established according to their treatment: (i) lithium monotherapy (n=29); (ii) lithium together with one or more anticonvulsants (n=28); and (iii) one or more anticonvulsants (n=16). A group of healthy controls served as the control (n=25). The following tests were applied: Wechsler Adult Intelligence Scale, Trail Making Test, Wechsler Memory Scale, Rey Complex Figure Test, Stroop color-word test, Wisconsin Card Sorting Test, Tower of Hanoi, Frontal Assessment Battery, and Reading the Mind in the Eyes Test. RESULTS Relative to healthy controls, BD patients showed the following: (i) those on lithium monotherapy, but not other BD groups, had preserved short-term auditory memory, long-term memory, and attention; (ii) those who took only anticonvulsants showed worse findings in short-term visual memory, working memory, and several executive functions; and (iii) all BD patients showed worse performance in processing speed, resistance to interference, and emotion recognition. LIMITATIONS Medication alone cannot explain why all BD patients showed common cognitive deficits despite different pharmacological treatment. CONCLUSION The impairment on some executive functions and emotion recognition is an inherent trait in BD patients, regardless of their pharmacological treatment. However, while memory, attention, and most of the executive functions are preserved in long-term stable BD patients, these cognitive functions are impaired in those who take anticonvulsants.

Understanding Bipolar Disorder in Late Life Clinical and Treatment Correlates of a Sample of Elderly Outpatients

AbstractThe aim of this study was to examine the demographic, clinical, and treatment correlates of bipolar disorder (BD) in outpatients 65 years or older and to compare patients with BD subtype I (BD-I) versus BD subtype II (BD-II) and patients with early onset (EO; ⩽50 years old) versus late onset (LO; >50 years old) of the illness. Sixty-nine consecutive outpatients with BD were included. Diagnosis was delayed for a mean of 14.1 years, significantly longer in patients with EO (18.6 years) than with LO (3.3 years). Mild to moderate depressive symptoms were detected in 29% of the patients. The patients were receiving a mean of 3 different psychotropic medications. Antidepressantswere more frequently prescribed to patients with BD-II than to patients with BD-I (75.80% vs. 48.60%) and to patients with EO (71.7%) than to LO (35.3%). Geriatric BD has similar clinical characteristics with those of younger ages, and these do not seem to greatly differ with subtype or age of onset.

Cuál es la relevancia real y el manejo de las principales alteraciones tiroideas en los pacientes bipolares

Thyroid disfunction affects negatively emotional stability and worsens the clinical course of bipolar affective disorder. The main stabilizer used in this illness, lithium carbonate has numerous effects on the physiology of the thyroid, with the most significant being the inhibition of thyroid hormone release that may occur at therapeutic levels. These dysfunctions have also been reported most frequently in bipolar patients not undergoing treatment with lithium, and was not completely explained by the effects of this drug. Apart from the numerous medical complications and mood disturbances, the cognitive or perceptual system may also be affected. In fact, the presence of thyroid disease increases the rates of obsessive compulsive disorder, phobias, panic disorder, major depressive disorder, cyclothymia, or bipolar disorder. In severe cases of hypothyroidism, the clinical symptoms and signs can be similar to a melancholic depression or dementia. It is therefore important to know well all these possible complications in daily clinical practice. This review will cover the main thyroid dysfunctions present in bipolar patients, whether ot not produced by treatment with lithium carbonate, and will provide a series of recommendations for clinical management.

Impulsividad, búsqueda de sensaciones y agresividad en pacientes bipolares tipo I y II

OBJECTIVE Although impulsivity may seem to be strongly linked to bipolar disorder, few studies have directly measured this phenomenon. To determine its implications for the prognosis of this illness, we studied the relationship between impulsivity and other aspects that are probably related, such as sensation seeking and aggressiveness, and different clinical variables of bipolar disorder. METHOD Sixty-nine (type I, n=42; type II, n=27) outpatients from a unit specifically for bipolar patients in remission completed the Barratt Impulsiveness Scale (BIS), the Sensation Seeking Scale (SSS), the Buss-Durkee Hostility Inventory (BDHI) and the Bipolar Eating Disorder Scale (BEDS). Sociodemographic and clinical data were obtained. RESULTS Type II bipolar patients scored significantly higher on the BIS and the BDHI physical aggression subscale. Patients with predominant depressive polarity also obtained significantly higher global scores on the BDHI. No differences were found relating to prior suicide attempts or psychiatric admissions. Smoking patients scored significantly higher on the BIS non-planning subscale and the SSS disinhibition subscale. LIMITATIONS As patients with substance use disorder (SUD) were excluded, the sample of this study may represents a subgroup of patients with bipolar disorder with probably low levels of impulsivity. CONCLUSIONS Impulsivity and aggressiveness are relevant aspects of bipolar disorders that could significantly increase comorbidity, especially in type II bipolar patients. Adequate diagnosis and treatment are, therefore, important factors in improving the clinical course of this illness.

Gender differences in C-reactive protein and homocysteine modulation of cognitive performance and real-world functioning in bipolar disorder

BACKGROUND Cognitive and psychosocial impairment has been associated with increased levels of C-reactive protein (CRP) and homocysteine in bipolar disorder, but gender differences have seldom been studied. METHODS Two hundred and twenty-four bipolar outpatients were included. Cognitive performance was assessed through the Screen for Cognitive Impairment in Psychiatry (SCIP). Psychosocial functioning was evaluated using the Functioning Assessment Short Test (FAST) and the General Assessment of Functioning (GAF). Homocysteine and CRP levels were determined. Separate analyses were performed by gender. Partial correlations were calculated to test for associations between biomarkers and cognitive and psychosocial functioning. Hierarchical multiple regression was used to assess factors predicting cognitive and psychosocial functioning. Covariates were: age, education, duration of illness, hospital admissions, depressive symptoms, tobacco consumption, and BMI. RESULTS A better performance was noted in women in delayed verbal learning (p = 0.010), along with better occupational functioning (p = 0.027) and greater leisure time impairment (p = 0.034). In men, CRP and homocysteine levels were associated with psychosocial dysfunction (interpersonal relationships and financial functioning, respectively). In women, CRP levels correlated with cognitive performance (SCIP total raw score, immediate and delayed verbal learning, and verbal fluency). CRP was a predictor of cognitive performance in women only. LIMITATIONS The choice of the cognitive scale and covariates and the lack of a control group may be the main limitations. CONCLUSIONS A gender difference was found in biomarker modulation of cognition and psychosocial functioning. A gender-based approach to cognition and real-world functioning should be considered in bipolar disorder to ensure an optimal outcome.

Are affective temperaments determinants of quality of life in euthymic patients with bipolar disorder

BACKGROUND Bipolar disorder (BD) is a disabling illness that is associated with low quality of life (QoL). This low QoL goes further than mood episodes, which suggests that stable traits, such as affective temperaments, can cause functional impairment. OBJECTIVE Our study analyses the impact of affective temperaments on the Physical Component Summary (PCS) and Mental Component Summary (MCS) of QoL in euthymic BD patients. METHODS A multicentre study was conducted in 180 euthymic BD patients and 95 healthy controls. Firstly, statistical analyses were performed to compare QoL and affective temperaments between the two groups. Secondly, Adaptive Lasso Analysis was carried out to identify the potential confounding variables and select the affective temperaments as potential predictors on the PCS and MCS of QoL in BD patients, as well as the control group. RESULTS QoL scores in terms of PCS and MCS in BD patients were significantly lower than in healthy individuals. Whereas anxious temperament, anxiety disorder comorbidity, and age were the best predictors of PCS impairment in BD patients, anxious temperament, subclinical depressive symptoms, and age were the best predictors of MCS impairment. LIMITATIONS Further longitudinal studies with unaffected high-risk relatives are needed to examine the potential interaction between affective temperament and psychopathology. CONCLUSIONS Anxious temperament has an impact on QoL in BD in terms of both the physical component and the mental component. Systematic screening of temperament in BD would give clinicians better knowledge of QoL predictors. Further research should allow more individualized treatment of BD patients based on temperamental factors.