Comorbidity of bipolar disorder and borderline personality disorder: Phenomenology, course, and treatment considerations.

AIM: Bipolar disorder (BD) and borderline personality disorder (BPD) are both serious psychiatric conditions that elevate the risk for harmful outcomes. Although these conditions represent distinct diagnostic entities, existing research suggests that approximately 20% of individuals with BD meet the criteria for comorbid BPD. Individuals with comorbid BD/BPD appear to have a markedly more severe and phenomenologically distinct clinical course when compared with those with BD alone. However, treatments have generally not been tested in this specific population, and currently, no formal treatment guidelines exist for this subgroup of patients. METHOD: In the current paper, we review the epidemiological and descriptive research characterizing those with comorbid BD/BPD and discuss the impact of this comorbidity on psychosocial treatment. We also review current findings on evidence-based treatments for BD and BPD that show promise in treating those with comorbid BD/BPD. RESULTS: In our review of the literature, we highlight the importance of recognizing this comorbidity and discuss avenues for developing and integrating evidence-based treatment approaches for this understudied clinical population. CONCLUSIONS: Although formal trials of interventions targeted to comorbid BD/BPD are limited, there is promising evidence regarding the possibility of using or integrating existing evidence-based approaches for this population. There are also several areas of clinical practice improvement and future research directions that stem from this literature.

Is Ignorance Bliss? Examining the Effect of News Media Exposure on Anxiety and Depression During the COVID-19 Pandemic.

ABSTRACT: There has been a widespread increase in affective disorders after the emergence of the COVID-19 pandemic. In the current study, we investigated the effects of exposure to and perceived accuracy of news media and demographic characteristics on anxiety and depressive symptoms. We conducted an online survey of US adults (N = 480) using hierarchical linear regression models to understand the predictive roles of duration and frequency of news media exposure, as well as the perceived accuracy of COVID-19 portrayal by the news media, on anxiety and depression. Increased exposure duration predicted greater anxiety, and decreased frequency of exposure and perceived overreaction in the news media coverage of COVID-19 were linked to greater anxiety and depression. Perceived accuracy moderated the relationship of exposure frequency to both affective outcomes. Accordingly, our data support the importance of adequate levels of accurate and trusted information to help mitigate the overall mental health burden of the pandemic.

COVID-19 vaccine acceptance: influential roles of political party and religiosity.

Given recent declines in US vaccination rates and the emergence of COVID-19 vaccines, identifying sociodemographic influencers of vaccine willingness holds importance for developing effective public health campaigns aimed at enhancing nationwide COVID-19 vaccine acceptance. The present study utilized a hierarchical binary logistic regression model to assess demographic variables (age, gender, race/ethnicity, pre-existing medical conditions), political party membership, religious affiliation, level of religiosity, and fear of COVID-19 as predictors of COVID-19 vaccine acceptance ('Yes', would receive a vaccine or 'No', would not receive a vaccine) in a national sample of US adults (N = 249). Participants were recruited from Amazon's Mechanical Turk (MTurk) and completed several online questionnaires pertaining to mental health, health behaviors, and responses to the COVID-19 pandemic. Both Democratic party membership and decreased level of religiosity predicted acceptance of a COVID-19 vaccine. This investigation supports political party membership and religiosity as influencers of COVID-19 vaccine willingness and suggests that these variables could represent potential targets for public health interventions aimed at increasing vaccine adoption.

The role of fear of COVID-19 in motivation to quit smoking and reductions in cigarette smoking: a preliminary investigation of at-risk cigarette smokers.

Preliminary data suggest that cigarette smokers could have an increased mortality risk from the novel coronavirus (SARS-CoV-2), and that certain factors (e.g., increased age, medical comorbidities) can also increase risk of poor coronavirus disease (COVID-19) outcomes. Between April 30th, 2020 and May 28th, 2020, we evaluated self-reported changes in recent smoking patterns and motivation to quit smoking among current daily cigarette smokers (N = 103) on Amazon Mechanical Turk. We also assessed the relationship of these outcomes to age, medical comorbidity status, and fear of COVID-19. Most participants (68.9%) reported smoking less frequently than usual in the last 28 days. Among daily smokers, increased fear of COVID-19 predicted increased motivation to quit smoking and actual smoking reductions (ps < .05). Endorsement of one or more medical comorbidities, but not increased age, predicted increased motivation to quit smoking (p < .05). These data suggest the potentially greater relevance of psychological factors (e.g., fear of COVID-19) over external risk factors (e.g., medical comorbidity, increased age) on motivation to quit smoking and actual reductions in smoking patterns, and may reflect that the pandemic is a suitable time for offering smoking cessation intervention.

Emotion regulation and motives for illicit drug use in opioid-dependent patients.

Refining the mechanisms behind illicit drug use is an important factor for improving the quality of clinical care. Research in alcohol, marijuana, and nicotine use disorders have linked coping motives (e.g. using substances to ameliorate negative emotional states) to problematic substance use. We evaluated the link between emotion regulation difficulties (as assessed via the difficulties in emotion regulation scale [DERS]) and motives for drug use (as assessed via the Drug Use Motives Questionnaire) among individuals (n = 68) with opioid use disorders who were in methadone maintenance treatment. We found that the DERS total score was significantly associated with coping motives for use. Nonacceptance of emotional responses was the only DERS domain that offered nonredundant prediction of coping motives. These findings highlight the relevance of specific emotion regulation deficits in motives for illicit drug use among individuals with opioid use disorders and may help inform targeted cognitive-behavioral treatments in this population.

Treating Circadian Rhythm Disruption in Bipolar Disorder.

PURPOSE OF REVIEW: Disruptions in circadian rhythms are believed to underlie the illness course of bipolar disorder (BD). This review evaluates recent studies on the treatment of circadian dysfunction in BD. RECENT FINDINGS: Targeted social rhythm therapy may be useful for bipolar depression though some studies suggest that a non-targeted psychosocial or pharmacological intervention may be just as efficacious. Lithium holds potential for addressing circadian dysfunction in BD. Blue-blocking therapy may be useful for mania and midday bright light therapy may relieve depression. CONCLUSIONS: Psychosocial, pharmacological, and light-based approaches are promising avenues for treating circadian dysfunction in BD.

MoodNetwork: An Innovative Approach to Patient-centered Research.

INTRODUCTION: Research has often been viewed as a passive process by which participants enroll in studies developed by researchers. It is becoming clearer that to understand the nuances of mood episodes and how to prevent them, we need to conduct large clinical trials that have the power to investigate moderators and mediators, or catalysts and mechanisms of change. MoodNetwork, the first online, patient-centered research community for individuals with mood disorders, aims to change the way that traditional research has been conducted by involving patients, their caregivers, and advocates in the process of research. The aim of this report is to share lessons learned from developing MoodNetwork. METHODS: Participants enroll by completing a demographic survey and consent form. Once enrolled, participants are encouraged to complete optional surveys about their mood disorders and areas of research priority. Stakeholder and advocacy partners developed the website, web-based surveys, and recruitment materials. RESULTS: MoodNetwork has enrolled 4103 participants to date. Of this sample, 96.9% report experiencing depression and 79.7% endorse symptoms of mania or hypomania. Participants rated reducing stigma and alleviating symptoms as their 2 largest research priorities. Recruitment has been slower than expected. Recruiting a diverse sample has been challenging, and this impacts the Network's ability to conduct comparative effectiveness research studies. DISCUSSION: We discuss lessons learned from recruiting individuals with mood disorders to MoodNetwork, an innovative approach to conducting clinical trials. We identify and review 5 strategies for increasing enrollment as well as future directions.

Substance use comorbidity in bipolar disorder: A qualitative review of treatment strategies and outcomes.

BACKGROUND AND OBJECTIVES: Substance use disorders (SUDs) are present in up to 70% of patients with bipolar disorder (BD) and contribute to high rates of disability, morbidity, and treatment non-adherence. Despite this prevalence, few trials have investigated targeted psychosocial interventions for comorbid BD and SUDs. METHODS: Using PubMed and PsycINFO, we conducted a search of the literature up to January 2018 for psychosocial interventions targeted to patients with comorbid BD and SUDs. We identified eight total trials. Of these studies, four randomized and two open trials targeted the types of substance use (alcohol and illicit drugs) of primary concern to mood stability; the remaining two studies, both open trials, targeted smoking cessation. RESULTS: None of the randomized trials provided consistent evidence for management of both mood symptoms and substance use though integrated group therapy (IGT) demonstrated consistent beneficial effects on substance use outcomes. Other treatments showed benefit for mood symptoms without benefits for alcohol or illicit substance use. Small pilot studies of combined treatments for smoking cessation provided some initial promise. CONCLUSIONS: At present, IGT is the most-well validated and efficacious approach if substance use is targeted in an initial treatment phase. For a subsequent phase, additional psychosocial BD treatments may be needed for mood and functioning benefits. SCIENTIFIC SIGNIFICANCE: This review synthesizes the psychosocial interventions that have been conducted in comorbid BD and SUDs while also providing a perspective on which intervention elements are helpful for addressing substance use versus mood symptoms in patients with these co-occurring conditions. (Am J Addict 2018;27:188-201).

The impact of substance use disorders on recovery from bipolar depression: Results from the Systematic Treatment Enhancement Program for Bipolar Disorder psychosocial treatment trial.

OBJECTIVE: Up to 60% of patients with bipolar disorder develop a substance use disorder during their lifetime. The purpose of this paper was to assess the impact of substance use disorders on depression recovery among bipolar patients randomly assigned to different psychotropic medications and psychosocial interventions. We hypothesized that patients with a comorbid substance use disorder would benefit less from psychotherapy regardless of treatment intensity/length compared to patients without a comorbid substance use disorder. METHOD: We conducted post hoc analyses among bipolar disorder patients ( n = 270) with and without comorbid substance use disorders enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder randomized psychosocial intervention trial. All patients entered during or shortly after the onset of a bipolar depressive episode. Logistic regression and Cox proportional hazard models were used to assess whether current or past substance use disorders moderated the response of patients to intensive psychosocial intervention or brief psychoeducation with collaborative care, operationalized as full recovery from an episode of bipolar depression. RESULTS: Current comorbid substance use disorders significantly predicted likelihood of recovery (odds ratio = 2.25, p = 0.025) and time to recovery (odds ratio = 1.71, p = 0.006) from bipolar depression. We found that 74.5% of patients with a current substance use disorder, compared to 56.5% without a current substance use disorder, recovered from bipolar depression. Past substance use disorders did not predict likelihood of recovery or time to recovery. Current substance use disorders did not significantly moderate response to intensive psychotherapy versus collaborative care. CONCLUSION: Contrary to our hypotheses, bipolar disorder participants with a current comorbid substance use disorder were more likely to recover from psychosocial treatment for bipolar depression than patients without a current comorbid substance use disorder. If this finding is replicated, it has implications for the ordering of treatment for patients with comorbid bipolar disorder and substance use disorders.

A randomized, placebo-controlled proof-of-concept trial of adjunctive topiramate for alcohol use disorders in bipolar disorder.

BACKGROUND AND OBJECTIVES: Topiramate is effective for alcohol use disorders (AUDs) among non-psychiatric patients. We examined topiramate for treating comorbid AUDs in bipolar disorder (BD). METHODS: Twelve participants were randomized to topiramate or placebo for 12 weeks. RESULTS: The topiramate group, with two out of five participants (40%) completing treatment, experienced less improvement in drinking patterns than the placebo group, with five out of seven participants (71%) completing treatment. DISCUSSION AND CONCLUSIONS: Topiramate did not improve drinking behavior and was not well-tolerated. This study failed to recruit adequately. Problems surrounding high attrition, a small study sample, and missing data preclude interpretation of study findings. SCIENTIFIC SIGNIFICANCE: This is the first randomized, placebo-controlled trial of topiramate for AUDs in BD.

Why now and not later? An exploration into the neurocognitive correlates of delay discounting in bipolar disorder.

Increased delay discounting is evident in bipolar disorder, though there is minimal research on the factors that impact delay discounting in this population. We evaluated neurocognitive correlates of delay discounting among relatively euthymic participants with bipolar disorder (N = 76) with (n = 31) and without (n = 45) past-year substance use disorders. There were no significant differences in the mean delay discounting value between the bipolar disorder group and the comorbid bipolar disorder and past-year substance use disorders group (p = .082, Cohen's d = 0.41). Using multiple regression, we evaluated the most important predictors of the delay discounting value. Impairments in executive functioning (per number of categories completed on the Wisconsin Card Sorting Test) and visuospatial construction (per the Rey-Osterrieth Complex Figure Test Copy Raw Score), as well as decreased years of education (all ps < .05), offered the best neurocognitive characterization of increased delay discounting in this sample.

A New Treatment Program: Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD).

OBJECTIVE: Bipolar disorder (BD) is complicated by a dynamic, chronic course along with multiple comorbid psychiatric and medical conditions, making it challenging for clinicians to treat and patients to thrive. To efficiently manage the complexity of BD and help patients recover, we developed a Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD). The purpose of this paper is to describe how we developed this clinic and the lessons we learned. METHODS: We developed FITT-BD by integrating strategies from stepped care, collaborative care, and learning health care systems. We describe the rationale, details, and lessons learned in developing FITT-BD. RESULTS: By integrating stepped care, collaborative care, and a learning health care system approach, FITT-BD aims to reduce barriers to care, leverage the expertise of a multidisciplinary treatment team, ensure patient-centeredness, and use assessments to inform and continuously improve outcomes in real time. We learned that there are challenges in the creation of a web-based application that tracks the treatment of patients within a network of hospitals. CONCLUSIONS: The success of FITT-BD will be determined by the degree to which it can increase treatment access, improve treatment adherence, and help individuals with BD achieve their treatment goals. We expect that FITT-BD will improve outcomes in the context of ongoing clinical care. PUBLIC HEALTH SIGNIFICANCE: The treatment of BD is challenging and complex. We propose a new treatment model for BD: FITT-BD. We expect that this program will be a patient-centered approach that improves outcomes in the context of ongoing clinical care for patients with BD.

Healthy hearts healthy minds: A randomized trial of online interventions to improve physical activity.

INTRODUCTION: Depressed individuals are more likely to die from cardiovascular disease (CVD) than those without depression. People with CVD have higher rates of depression than those without and have higher mortality rates if they have comorbid depression. While physical activity (PA) improves both, few people engage in enough. We compared self-guided internet-based cognitive behavior therapy (CBT) + Fitbit or mindfulness-based cognitive therapy (MBCT) + Fitbit, with Fitbit only to increase daily steps for participants with depression who have low PA. METHODS: Adult participants (N = 340) were recruited from two online patient-powered research networks and randomized to one of three study interventions for 8 weeks with an additional 8 weeks of follow-up. Using linear mixed effects models, we evaluated the effect of the intervention on average daily steps (NCT03373110). RESULTS: Average daily steps increased 2.8 steps per day in MBCT+Fitbit, 2.9 steps/day in CBT + Fitbit, but decreased 8.2 steps/day in Fitbit Only. These changes were not statistically different between the MBCT+Fitbit and CBT + Fitbit groups, but were different from Fitbit Only across the initial 8-week period. Group differences were not maintained across follow-up. Exploratory analyses identified comorbid anxiety disorders, self-reported PA, and employment status as moderators. DISCUSSION: Changes in daily steps over both 8- and 16-week periods-regardless of intervention group-were minimal. The results emphasize the limits of using self-guided web-based psychotherapy with an activity tracker to increase PA in participants with a history of depression and low PA.

Impaired risk avoidance in bipolar disorder and substance use disorders.

Comorbid substance use disorders are highly prevalent in bipolar disorder, and research suggests that individuals with the comorbid presentation typically have worse outcomes than individuals with bipolar disorder without this comorbidity. However, psychosocial treatments for the comorbid presentation have not demonstrated effectiveness for both mood and substance use symptom domains, suggesting novel treatments are needed. An alternative path to treatment development is to identify mechanisms that underlie comorbid bipolar disorder and substance use disorders that can subsequently be targeted in treatment. We evaluated neurocognitive markers for impairments in risk avoidance (the tendency to engage in a persistent pattern of problematic behaviors despite negative outcomes resulting from such behaviors) as potential mechanistic variables underlying negative illness outcomes in the comorbid population. Participants with bipolar disorder (n = 45) or comorbid bipolar disorder and substance use disorders (n = 31) in a relatively euthymic mood state completed clinical risk behavior assessments, task-based risk avoidance assessments, and neurocognitive assessments. Results indicated a lack of notable between-group differences in the clinical risk composite score, task-based risk avoidance assessments, and neurocognitive assessments, with the exception of self-reported executive dysfunction which was elevated among the comorbid sample. Collapsing across group, we found that increased discounting of delayed rewards, older age, and an earlier age of (hypo)mania onset predicted an increased clinical risk composite score. These findings underscore the potential importance of delay discounting as a novel mechanistic target for reducing clinical risk behaviors among individuals with bipolar disorder both with and without comorbid substance use disorders.

Skin conductance levels and responses in Asian and White participants during fear conditioning✰.

Fear conditioning paradigms are frequently used in the translational study of anxiety and fear-related disorders. Accordingly, it is important to understand whether the measurement of fear conditioning responses is systematically influenced by an individual's race. Studies have found increased pain sensitivity and smaller physiological startle responses in Asian individuals, compared to White individuals; to our knowledge, no studies have evaluated whether skin conductance response (SCR) outcomes differ between Asian and White individuals. In a series of secondary data analyses, we investigated potential differences in skin conductance level (SCL), orienting SCR, unconditioned SCR, SCR to CS+ and CS-, differential SCR, and differential SCR non-responder status. In sample 1, Asian participants (n = 97) demonstrated a significantly smaller mean differential SCR compared to White participants (n = 86). No other between group differences were observed. In sample 2, there was no difference in mean differential SCR between Asian (n = 52) and White (n = 62) participants, although more Asian participants failed to show adequate skin conductance levels for study entry. To our knowledge, this is the first study to evaluate differences between Asian and White samples using skin conductance outcomes in a fear conditioning paradigm. We detected only subtle evidence for SCR differences between Asian and White samples, unlikely to reach significance outside large studies.

Evaluating the Interactive Effect of COVID-19 Worry and Loneliness on Mental Health Among Young Adults.

BACKGROUND: Young adults are overrepresented in terms of adverse mental health problems related to COVID-19. Emerging work has identified worry about the consequences and trajectory of COVID-19 and loneliness as important factors in mental health during the pandemic. However, the main and interactive effects of worry about COVID-19 and loneliness have not been explored in one overarching model in relation to mental health problems among young adults. METHODS: The present study therefore evaluated loneliness and COVID-19 related worry in terms of anxiety, stress, and depression among young adults (209 college students, 76.1% female, M age = 22.99 years, SD = 5.25) recruited to participate in an online survey study. RESULTS: Results indicated a significant interaction between COVID-19 worry and loneliness for each criterion variable (depression: b = .01, SE = .003, t = 2.86, p = .01; anxiety: b = .01, SE = .002, t = 2.36, p = .02; stress: b = .01, SE = .003, t = 2.54, p = .01), such that worry was more strongly related to each mental health outcome among those that endorsed higher levels of loneliness. CONCLUSION: The current findings suggest loneliness is related to negative mental health symptoms among young adults experiencing COVID-19 related worry. The current findings provide initial empirical evidence for the impact of COVID-19 worry on mental health among young adults experiencing loneliness. Future research may benefit from exploring how COVID-19 worry and loneliness interplay over time.

Stage models for major depression: Cognitive behavior therapy, mechanistic treatment targets, and the prevention of stage transition.

Stage models encourage a longitudinal perspective on the care of those with major depression: supporting vigilance to the risk for stage progression and the selection of interventions to address that risk. A central goal for this article is to evaluate the role of cognitive-behavior therapy (CBT) in addressing stage progression in the treatment of major depression. We summarize the evidence supporting depression-focused CBT for: (1) preventing depression onset, (2) treating syndromal depression, (3) treating residual symptoms, (4) preventing relapse, and (5) addressing pharmacologic treatment resistance. In addition, consistent with the goal of aiding prevention and intervention development by refining mechanistic treatment targets, we evaluate the role of two specific risk-factors for stage progression: insomnia and rumination. These risk factors have a feed-forward relationship with stress, both being amplified by stress and amplifying the negative consequences of stress. Moreover, each of these risk factors predict depression stage transmissions across multiple stages, and both are modifiable with treatment. Accordingly, insomnia and rumination appear to serve as excellent mechanistic targets for the prevention of depression stage progression. These findings are discussed in relation to current limitations and future research directions for targeting these risk factors and furthering the effective treatment of depression.

The relationship between suicidal thoughts and well-being among individuals with a history of depression and cardiovascular risk.

Prior work demonstrates a relationship between suicidal behavior and mood disorders, as well as between suicidal behavior and cardiovascular risk. When cardiovascular risk and mood disorders co-occur, people with these comorbid conditions tend to experience worse outcomes than people with only one of these conditions. As such, given the relevance of suicidal thoughts and behaviors among those with cardiovascular risk and mood disorders, suicidal thoughts and behaviors may be of particular concern in the comorbid population. However, the factors that differentiate those with or without suicidal thoughts or behaviors are unknown. Self-reported well-being is one factor that is shown to hold a relationship with suicidal risk, and may be relevant in the comorbid population. Thus, we evaluated whether different levels of well-being relate to suicidal thoughts and behaviors among individuals (N = 340) with lifetime mood disorders and cardiovascular risk who participated in a 16-week online exercise study. Participants completed self-report assessments of lifetime (per the MINI International Neuropsychiatric Interview) and current (per the Patient Health Questionnaire-9) suicidal thoughts and behaviors, as well as a self-report assessment of well-being (per the WHO-5 Well-Being Index). We found that individuals with lifetime and current suicidal thinking had lower total WHO-5 scores over the study period. These data suggest that, among those with a history of depression and who have or are at-risk for cardiovascular disease, the risk of current or lifetime suicidal thoughts and behaviors may be increased for those who experience decreased well-being.