A multi-center naturalistic study of a newly designed 12-sessions group psychoeducation program for patients with bipolar disorder and their caregivers.

BACKGROUND: Psychoeducation (PE) for bipolar disorder (BD) has a first-line recommendation for the maintenance treatment phase of BD. Formats vary greatly in the number of sessions, whether offered individually or in a group, and with or without caregivers attending. Due to a large variation in formats in the Netherlands, a new program was developed and implemented in 17 outpatient clinics throughout the country. The current study investigated the feasibility of a newly developed 12-sessions PE group program for patients with BD and their caregivers in routine outpatient practice and additionally explored its effectiveness. METHODS: Participants in the study were 108 patients diagnosed with BD, 88 caregivers and 35 course leaders. Feasibility and acceptance of the program were investigated by measures of attendance, and evaluative questionnaires after session 12. Preliminary treatment effects were investigated by pre- and post-measures on mood symptoms, attitudes towards BD and its treatment, levels of self-management, and levels of expressed emotion. RESULTS: There was a high degree of satisfaction with the current program as reported by patients, caregivers, and course leaders. The average attendance was high and 83% of the patients and 75% of the caregivers completed the program. Analyses of treatment effects suggest positive effects on depressive symptoms and self-management in patients, and lower EE as experienced by caregivers. CONCLUSIONS: This compact 12-sessions psychoeducation group program showed good feasibility and was well accepted by patients, caregivers, and course leaders. Preliminary effects on measures of self-management, expressed emotions, and depressive symptoms were promising. After its introduction it has been widely implemented in mental health institutions throughout the Netherlands.

Investigating the association between neurocognition and psychosis in bipolar disorder: further evidence for the overlap with schizophrenia.

OBJECTIVES: In schizophrenia, a distinction is made between psychosis with developmental and cognitive impairment on the one hand and psychosis without developmental impairment and positive symptoms on the other. In this study, we investigated whether this model can be extended to bipolar disorder by testing the hypothesis that neurocognitive functioning is inversely related to positive psychotic symptoms in bipolar disorder. METHODS: Neurocognitive functioning and psychopathology were assessed in (i) 76 patients with bipolar disorder, (ii) 39 of their healthy first-degree relatives, and (iii) 61 healthy controls. Cognitive performance of bipolar patients and their first-degree relatives was investigated, taking into account the possible moderating effect of the level of expression of psychosis in patients and relatives. RESULTS: Bipolar patients showed impaired cognitive performance on multiple cognitive domains, whereas performance of their relatives was comparable to that of controls. A history of psychotic symptoms in patients was suggestive of less likelihood of cognitive alterations in relatives, and the presence of subclinical psychotic symptoms within the group of relatives predicted better cognitive performance. CONCLUSIONS: The finding of similar psychosis-cognition associations in bipolar disorder as implied by the two pathways leading to nonaffective psychotic disorders suggests that this model might be extended to the continuum spanning affective and nonaffective psychosis. This is in line with the idea of a partially overlapping vulnerability to bipolar disorder and schizophrenia and provides an explanation for the apparent differences in cognitive alterations in those at risk for the two disorders.

A pilot study of a combined group and individual functional remediation program for patients with bipolar I disorder.

BACKGROUND: Bipolar disorder has been associated with a decrease in cognitive functioning affecting the functional outcome of patients independent of mood states. However, there have only been few attempts to investigate the effects of functional remediation for patients with bipolar disorder. The current study investigates the feasibility and effectiveness of a combined group and individual functional remediation program for bipolar disorder, including both patients and their caregivers. METHODS: Twelve participants diagnosed with bipolar I disorder, and their caregivers, were treated with a combined group and individual functional remediation program. The feasibility of the program was evaluated by dropout rates and participants' evaluations of the program. The effectiveness of the program was explored through the assessment of functional outcome at baseline, immediately post-treatment, and follow-up three months later. RESULTS: The results indicate a high degree of satisfaction and a low dropout rate with the current program. Assessment of outcomes suggests improved functioning in the areas of autonomy and occupational functioning, evolving from baseline to follow-up. LIMITATIONS: Due to a small sample size and the lack of a control group the results are preliminary. CONCLUSIONS: This relatively brief intervention offers a more tailor-made approach to functional remediation and shows good feasibility, acceptability and improvement of functioning in patients with bipolar I disorder.

Implicit and explicit self-associations in bipolar disorder: a comparison with healthy controls and unipolar depressive disorder.

According to cognitive theory, negative self-schemas are involved in the occurrence of depression. Whereas implicit depressive self-associations have been found in unipolar depression, it is unknown whether impaired associations with regard to the self are also involved in Bipolar Disorder (BD). This study investigated whether a bias in self-associations is a characteristic of bipolar disorder and whether discrepancies between implicit and explicit self-evaluations may be relevant for understanding bipolar psychopathology. Implicit and explicit self-associations were assessed in patients with BD (n=99), in patients with depressive disorder (n=1236), and healthy controls (n=387). Analyses of variance and correlation analyses were used to compare bipolar patients to controls and unipolar patients on implicit self-associations and the discrepancy between implicit and explicit self-associations. Similar to unipolar patients, patients with BD showed stronger implicit depressive self-associations than controls. Specifically for bipolar patients there was no significant correlation between implicit and explicit depressive self-associations. In a similar vein, discrepancies between implicit and explicit self-associations were relatively pronounced in symptomatic bipolar patients as compared to both healthy controls and unipolar depressed patients. Thus automatic depressive self-associations were characteristic for all mood disorders whereas a lack of concordance between implicit and explicit self-associations was specific for BD.

Cognitive processes and attitudes in bipolar disorder: a study into personality, dysfunctional attitudes and attention bias in patients with bipolar disorder and their relatives.

BACKGROUND: Research in cognitive processes and attitudes in bipolar disorder is scarce and has provided mixed findings, possibly due to differences in current mood state. It is unclear whether alterations in cognitive processes and attitudes are only related to the depressive mood states of bipolar patients or also represent a vulnerability marker for the development of future (depressive) episodes. This was investigated in the current study. METHODS: Both implicit (attentional bias for emotional words) and explicit (dysfunctional attitudes and personality characteristics) measures of cognitive processes and attitudes were assessed in 77 bipolar patients with varying levels of depressive symptoms (depressed=17, euthymic n=60), their healthy first-degree relatives (n=39) and a healthy control group (n=61). Analyses of variance were used to investigate differences between groups. RESULTS: Mildly depressed patients with bipolar disorder demonstrated an attentional bias away from positive emotional words and showed increased dysfunctional attitudes and higher levels of neuroticism. Euthymic patients were largely comparable to healthy controls and only differed from controls in higher levels of neuroticism. Relatives were similar to controls on all measures, although they significantly differed from bipolar patients in displaying less neuroticism and more extraversion. LIMITATIONS: No firm conclusions regarding causality can be drawn from the associations that were found between cognitive processes and attitudes and the evolution of mood symptoms in bipolar disorder. CONCLUSION: Alterations in cognitive processes and attitudes in bipolar patients appear to be mostly related to the expression of mood symptomatology rather than to the vulnerability for bipolar disorder.

Is the lack of association between cognitive complaints and objective cognitive functioning in patients with bipolar disorder moderated by depressive symptoms?

OBJECTIVES: To investigate the association between cognitive complaints and objective cognitive functioning in bipolar patients, with a focus on the moderating role of depressive symptoms. METHODS: The association between cognitive complaints (measured by the total score and four subscales of the Cognitive Failure Questionnaire; CFQ) and objective cognitive functioning (domains of psychomotor speed, speed of information processing, attentional switching, verbal memory, visual memory and executive functioning/working memory, and the total score) was assessed in 108 euthymic (n=45) or mildly to moderately depressed bipolar patients (n=63). We studied potential moderation of this association by depressive symptoms (total score of the Inventory of Depressive Symptomatology-self rating). Analyses were performed using Pearson correlations and multiple linear regression. RESULTS: Cognitive complaints were not associated with objective cognitive functioning, except for CFQ 'memory for names' which was positively correlated with speed of information processing (r=0.257, p=0.007). Although depressive symptoms were positively associated with cognitive complaints (total score and three subscales; p<0.01), the association between cognitive complaints and objective cognitive functioning was not moderated by depressive symptoms (p for interaction 0.054 to 0.988). LIMITATIONS: It can be argued whether the retrospective questionnaire (CFQ) is sufficiently accurate to measure the type of cognitive dysfunctions seen in bipolar patients. CONCLUSIONS: Cognitive complaints are not associated with objective cognitive functioning, irrespective of depressive symptoms. However, cognitive complaints are indicative for depressive symptoms. Clinicians should be to be alert to depressive symptoms rather than objective cognitive problems in patients expressing cognitive complaints.

Co-occurring manic symptomatology as a dimension which may help explaining heterogeneity of depression.

BACKGROUND: The dichotomous distinction between unipolar and bipolar disorders may be challenged by heterogeneity within diagnoses and overlap between different diagnoses. A broad mood disorder category in which patients differ as a result of variation along separate manic and depressive mood dimensions can be proposed. To test this, it is hypothesized that heterogeneity in clinical and other features of subjects selected for unipolar depression can be partly explained by coexisting manic symptoms. METHODS: A cohort selected for unipolar depressive disorder was followed up for two years at which time co-occurring manic symptoms were assessed, yielding four groups with increasing manic symptomatology: i) pure unipolar depressive disorder (n=1598), ii) unipolar depressive disorder with subthreshold manic symptomatology (n=64), iii) bipolar II disorder (n=39), and iv) bipolar I disorder (n=86). Multivariate logistic regression and analyses of covariance controlled for depression severity were used to investigate whether patients with increasing manic symptomatology could be differentiated from patients with pure depressive disorder. RESULTS: Male gender, a lower age at first episode, a history of suicide attempts and increased aggressive cognitions were independently associated with an increase in manic symptoms. The additional presence of (hypo)mania was associated with greater depression severity and more disability than pure depressive disorder. LIMITATIONS: The groups with manic symptomatology (subthreshold, hypomania and mania) were considerably smaller compared to the pure depression group. CONCLUSIONS: The heterogeneity in depressive illness can be partly explained by the coexisting variation along the manic symptom dimension. Co-occurring manic symptoms should be taken into account in depression and a symptom dimensional approach of mood disorders may provide phenotypes that are more informative than current mood disorder categories.

Co-occurring manic symptomatology influences HPA axis alterations in depression.

Although dysfunctioning of the HPA axis is considered to be a core pathophysiological process in mood disorders, the evidence with regard to depression remains conflicting. This could partly be due to the large heterogeneity within mood disorders, since HPA axis abnormalities may also be associated with the extent of co-occurring manic symptomatology as is seen in bipolar disorder. In this study, patients with depressive disorder and bipolar spectrum disorders were studied with regard to their HPA axis functioning. In 304 healthy controls, 1,134 patients with pure unipolar depressive disorder (UP), and 133 bipolar spectrum disorder patients (BD spectrum), cortisol was measured in 7 saliva samples to determine the 1 h cortisol awakening response (CAR), evening cortisol levels and cortisol suppression after a 0.5 mg dexamethasone suppression test. Both patient groups had overall higher CAR levels compared to controls, but only UP patients showed a higher increase over time in the CAR. A linear association was found between increasing bipolarity and cortisol diurnal slope: BD spectrum patients had a significantly higher diurnal slope than UP patients. Dexamethasone suppression did not differ between mood disorder diagnoses. The heterogeneity in HPA axis functioning in patients with depression can partially be explained by co-existing manic symptomatology, since an increase in the CAR appears to be more specific for pure depression whereas the presence of bipolarity is associated with an increase in the diurnal slope of cortisol.

Neurocognitive functioning as intermediary phenotype and predictor of psychosocial functioning across the psychosis continuum: studies in schizophrenia and bipolar disorder.

OBJECTIVE: Neurocognitive functioning may represent an indicator of genetic risk and poor outcome in both schizophrenia and bipolar disorder. In this study, shared and nonshared characteristics in the cognitive domain in both disorders were analyzed to determine to what degree neurocognitive functioning may represent a predictor of the familial vulnerability and poor functioning that schizophrenia spectrum disorders and bipolar disorder share. METHOD: Neurocognition, psychopathology, and psychosocial functioning were assessed in samples of patients with a schizophrenia spectrum disorder (n = 345) and bipolar disorder (n = 76) meeting DSM-IV criteria, first-degree relatives of both patient groups (n = 331 and n = 37, respectively), and healthy controls (n = 260 and n = 61, respectively). Multiple regression models were used to investigate the effect of group status on neurocognition and to explore associations between cognition, symptoms, and psychosocial functioning in the 2 groups. The schizophrenia spectrum study sample was recruited between September 2004 and January 2008, and the bipolar study sample was recruited between June 2004 and July 2007. RESULTS: Cognitive deficits were more severe and more generalized in patients with a schizophrenia spectrum disorder compared to patients with bipolar disorder; cognitive alterations were present in relatives of patients with schizophrenia spectrum disorders but not in relatives of bipolar patients. The association between neurocognitive dysfunction and psychosocial functioning was more generalized in schizophrenia spectrum disorders than in bipolar disorder; for both disorders, associations were only partly mediated by symptoms. CONCLUSIONS: The evidence for cognitive dysfunction as a marker of familial vulnerability is stronger for schizophrenia than for bipolar disorder. Although the presence of multiple cognitive deficits is shared by the 2 groups, the severity of cognitive deficits and its consequences appear to partly differ between schizophrenia and bipolar disorder, which is in line with a model that implies the specific presence of a neurodevelopmental impairment in the former but not in the latter.

Is processing speed predictive of functional outcome in psychosis?

OBJECTIVE: To investigate the contribution of processing speed in the prediction of various domains of outcome in psychosis. METHOD: Data were drawn from the UK700 Case Management Trial of 708 patients with chronic psychotic illness. Regression analyses were applied to investigate cross-sectional and longitudinal associations between processing speed at baseline and measures of service use, social outcome and subjective outcome, taking into account current psychopathology and adjusting for baseline values of the outcome measure. RESULTS: Cross-sectionally, processing speed was associated with all three domains of outcome, although only associations in the social and subjective outcome domain remained significant after controlling for psychopathology and the effects differed between and within domains of outcome. Prospectively, only the subjective outcome measure of number of met and unmet needs (CAN) was weakly associated with baseline neurocognitive performance after adjustment for baseline needs. Other associations disappeared after adjustment for the baseline measure of outcome and/or baseline psychopathology. CONCLUSION: The finding of weak cross-sectional associations in the absence of specific and unconfounded longitudinal associations suggests that processing speed is an independent dimension of disease severity rather than a causal factor impacting on social outcome. Nevertheless, longitudinal change in patient reported needs may be weakly sensitive to baseline cognitive impairment.