Validity and reliability of the Cognitive Complaints in Bipolar Disorder Rating Assessment (COBRA) in Brazilian bipolar patients / Validade e fidedignidade da Escala de Disfunções Cognitivas no Transtorno Bipolar (COBRA) em pacientes bipolares brasileiros

Abstract Introduction: In Brazil, there is no valid instrument to measure subjective cognitive dysfunction in bipolar disorder. The present study analyzed the psychometric properties of the Cognitive Complaints in Bipolar Disorder Rating Assessment (COBRA) in Brazilian bipolar patients. We further investigated the relationship between the COBRA, objective cognitive measures, and illness course variables. Methods: The total sample (N=150) included 85 bipolar disorder patients and 65 healthy controls. The psychometric properties of the COBRA (e.g., internal consistency, concurrent validity, discriminative validity, factor analyses, ROC curve, and feasibility) were analyzed. Results: The COBRA showed a one-factor structure with very high internal consistency (Cronbach's alpha=0.890). Concurrent validity was indicated by a strong correlation with the cognitive domain of the FAST (r=0.811, p<0.001). Bipolar patients experienced greater cognitive complaints (mean=14.69; standard deviation [SD]=10.03) than healthy controls (mean=6.78; SD=5.49; p<0.001), suggesting discriminative validity of the instrument. No significant correlations were found between the COBRA and objective cognitive measures. Furthermore, higher COBRA scores were associated with residual depressive (r=0.448; p<0.001) and manic (r=0.376; p<0.001) symptoms, number of depressive episodes (r=0.306; p=0.011), number of total episodes (r=0.256; p=0.038), and suicide attempts (r=0.356; p=0.003). Conclusion: The COBRA is a valid instrument to assess cognitive complaints, and the combined use of subjective-objective cognitive measures enables the correct identification of cognitive dysfunctions in bipolar disorder.

Resumo Introdução: No Brasil, não existem instrumentos válidos para medir a disfunção cognitiva subjetiva no transtorno bipolar. O presente estudo analisou as propriedades psicométricas da Escala de Disfunções Cognitivas no Transtorno Bipolar (COBRA) em uma amostra brasileira de pacientes bipolares. Adicionalmente, investigamos a relação entre a COBRA, medidas cognitivas objetivas e curso da doença. Métodos: A amostra total (n=150) incluiu 85 pacientes com transtorno bipolar e 65 controles saudáveis. As propriedades psicométricas da COBRA (consistência interna, validade concorrente, validade discriminativa, análise fatorial, curva ROC e fidedignidade) foram analisadas. Resultados: A COBRA apresentou estrutura de um fator com alta consistência interna (alfa de Cronbach=0,890). A validade concorrente ficou demonstrada pela forte correlação com o domínio cognitivo da FAST (r=0,811, p<0,001). Pacientes bipolares tiveram mais queixas cognitivas [média=14,69; desvio padrão (DP)=10,03] que os controles (média=6,78; DP=5,49; p<0,001), sugerindo a validade discriminativa do instrumento. Não houve correlação significativa entre a COBRA e medidas cognitivas objetivas. Além disso, escores mais altos na COBRA estiveram associados com sintomas residuais depressivos (r=0,448; p<0,001) e maníacos (r=0,376; p<0,001), número de episódios depressivos (r=0,306; p=0,011), número de episódios totais (r=0.256; p=0.038) e tentativas de suicídio (r=0,356; p=0,003). Conclusão: A COBRA é um instrumento válido para avaliar queixas cognitivas, e o uso combinado das medidas cognitivas subjetivas-objetivas possibilita a correta identificação das disfunções cognitivas no transtorno bipolar.

Cell therapy in the treatment of bipolar mania in an animal model: a proof of concept study / Terapia celular no tratamento do transtorno bipolar: estudo piloto em um modelo animal de mania

Abstract Introduction The rationale of mesenchymal stem cells (MSCs) as a novel therapeutic approach in certain neurodegenerative diseases is based on their ability to promote neurogenesis. Hippocampal atrophy has been related to bipolar disorder (BD) in preclinical, imaging and postmortem studies. Therefore, the development of new strategies to stimulate the neurogenesis process in BD is crucial. Objectives To investigate the behavioral and neurochemical changes induced by transplantation of MSCs in a model of mania-like behavior induced by lisdexamfetamine dimesylate (LDX). Methods Wistar rats (n=65) received one oral daily dose of LDX (10 mg/kg) or saline for 14 days. On the 8th day of treatment, the animals additionally received intrahippocampal saline or MSC (1 µL containing 25,000 cells) or lithium (47.5 mg/kg) as an internal experimental control. Two hours after the last administration, behavioral and neurochemical analyses were performed. Results LDX-treated rats had increased locomotor activity compared to saline-saline rats (p=0.004), and lithium reversed LDX-related hyperactive behavior (p<0.001). In contrast, the administration of MSCs did not change hyperlocomotion, indicating no effects of this treatment on LDX-treated rats (p=0.979). We did not find differences between groups in BDNF levels (p>0.05) in the hippocampus of rats. Conclusion Even though these results suggest that a single intrahippocampal injection of MSCs was not helpful to treat hyperactivity induced by LDX and neither influenced BDNF secretion, we cannot rule out the possible therapeutic effects of MSCs. Further research is required to determine direct effects of LDX on brain structures as well as in other pathophysiological targets related to BD.

Resumo Introdução Células-tronco mesenquimais (CTMs) têm emergido como um promissor tratamento em diversas doenças neurodegenerativas devido a sua plasticidade e capacidade de regenerar tecidos. Estudos pré-clínicos, clínicos e de neuroimagem têm demonstrado a presença de atrofia hipocampal no transtorno bipolar (TB). Portanto, o desenvolvimento de tratamentos capazes de regenerar tecido lesado e estimular a neurogênese poderia ser útil. Objetivos Investigar mudanças comportamentais e neuroquímicas induzidas pelo transplante de CTMs no hipocampo de ratos em um modelo animal de mania induzido por dimesilato de lisdexanfetamina (LDX). Métodos Ratos Wistar (n=65) receberam LDX (10 mg/kg) ou solução salina por via oral durante 14 dias. No oitavo dia, os animais foram transplantados com injeção de CTMs ou solução salina (1 µL contendo 25.000 células) ou lítio (47,5 mg/kg) como controle interno do experimento. Duas horas após a última dose, foram realizadas análises comportamentais e neuroquímicas. Resultados Animais que receberam LDX tiveram um aumento da atividade locomotora comparados ao grupo que recebeu solução salina (p=0,004); já o lítio reverteu a hiperatividade locomotora desses animais (p<0,001). Os animais que receberam CTMs não apresentaram alterações no comportamento, indicando ausência de efeitos sobre hiperatividade locomotora. Os níveis de BDNF hipocampais não diferiram entre os grupos (p>0.05). Conclusão Não foi possível demonstrar efeitos neuroprotetores das CTMs, administradas em dose única, em um modelo animal de mania induzido por LDX. No entanto, não se pode descartar os possíveis efeitos terapêuticos das CTMs. Mais estudos são necessários para determinar os efeitos das CTMs em estruturas cerebrais e outros alvos fisiopatológicos relacionados ao TB.

Challenges and developments in research of the early stages of bipolar disorder

Recently, attention in the field of bipolar disorder (BD) has focused on prevention, including early detection and intervention, as these strategies have the potential to delay, lessen the severity, or even prevent full-blown episodes of BD. Although knowledge of the neurobiology of BD has advanced substantially in the last two decades, most research was conducted with chronic patients. The objective of this paper is to comprehensively review the literature regarding the early stages of BD, to explore recent discoveries on the neurobiology of these stages, and to discuss implications for research and clinical care. The following databases were searched: PubMed, PsycINFO, Cochrane Library, and SciELO. Articles published in English from inception to December 2015 were retrieved. Several research approaches were used, including examination of offspring studies, retrospective studies, prospective studies of clinical high-risk populations, and exploration of the progression after the first manic episode. Investigations with neuroimaging, cognition assessments, and biomarkers provide promising (although not definitive) evidence of alterations in the neural substrate during the at-risk stage. Research on BD should be expanded to encompass at-risk states and aligned with recent methodological progress in neuroscience.

Cognitive performance and psychosocial functioning in patients with bipolar disorder, unaffected siblings, and healthy controls

Objective: To assess cognitive performance and psychosocial functioning in patients with bipolar disorder (BD), in unaffected siblings, and in healthy controls. Methods: Subjects were patients with BD (n=36), unaffected siblings (n=35), and healthy controls (n=44). Psychosocial functioning was accessed using the Functioning Assessment Short Test (FAST). A sub-group of patients with BD (n=21), unaffected siblings (n=14), and healthy controls (n=22) also underwent a battery of neuropsychological tests: California Verbal Learning Test (CVLT), Stroop Color and Word Test, and Wisconsin Card Sorting Test (WCST). Clinical and sociodemographic characteristics were analyzed using one-way analysis of variance or the chi-square test; multivariate analysis of covariance was used to examine differences in neuropsychological variables. Results: Patients with BD showed higher FAST total scores (23.90±11.35) than healthy controls (5.86±5.47; p < 0.001) and siblings (12.60±11.83; p 0.001). Siblings and healthy controls also showed statistically significant differences in FAST total scores (p = 0.008). Patients performed worse than healthy controls on all CVLT sub-tests (p < 0.030) and in the number of correctly completed categories on WCST (p = 0.030). Siblings did not differ from healthy controls in cognitive tests. Conclusion: Unaffected siblings of patients with BD may show poorer functional performance compared to healthy controls. FAST scores may contribute to the development of markers of vulnerability and endophenotypic traits in at-risk populations.

Shortened telomere length in bipolar disorder: a comparison of the early and late stages of disease

Objective: Bipolar disorder (BD) has been associated with increased rates of age-related diseases, such as type II diabetes, metabolic syndrome, osteoporosis, and cardiovascular disorders. Several biological findings have been associated with age-related disorders, including increased oxidative stress, inflammation, and telomere shortening. The objective of this study was to compare telomere length among participants with BD at early and late stages and age- and gender-matched healthy controls. Methods: Twenty-six euthymic subjects with BD and 34 healthy controls were recruited. Genomic DNA was extracted from peripheral blood and mean telomere length was measured using real-time quantitative polymerase chain reaction. Results: Telomere length was significantly shorter in both the early and late subgroups of BD subjects when compared to the respective controls (p = 0.002 and p = 0.005, respectively). The sample size prevented additional subgroup analyses, including potential effects of medication, smoking status, and lifestyle. Conclusion: This study is concordant with previous evidence of telomere shortening in BD, in both early and late stages of the disorder, and supports the notion of accelerated aging in BD.

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. .

Níveis séricos do Fator neurotrófico derivado do cérebro e citocinas e a duração da amamentação em crianças e adolescentes / Serum levels of brain-derived neurotrophic factor and cytokines and duration of breastfeeding in children adolescents

INTRODUÇÃO: O Fator Neurotrófico Derivado do Cérebro (BDNF) é uma importante neurotrofina que está presente no tecido cerebral e periférico. O leite materno é considerado o alimento “padrão ouro” para o desenvolvimento cerebral, tornando o desmame precoce um fator de risco no desenvolvimento infantil. OBJETIVO: Avaliar a concentração de BDNF, IL6, IL10, TNF-α em crianças e correlacionar com a duração da amamentação. MÉTODOS: Trinta e sete crianças foram recrutadas e classificadas de acordo com a duração do aleitamento materno: < 6 meses (desmame precoce) e ≥ 6 meses. Foram realizadas duas consultas: a consulta basal em 2007 (T0) e a consulta de seguimento em 2011 (T1). Os níveis séricos de BDNF foram avaliados por ELISA sanduíche e os de citocinas por citometria de fluxo. RESULTADOS: Níveis séricos de BDNF em T0 foram significativamente menores no grupo amamentado por ≥ 6 meses (p=0,025), sendo que este não teve diferença entre os grupos em T1 (p=0,863). Níveis de IL6 apresentaram-se aumentados significativamente em T0 no grupo de desmame precoce (p=0,016). O IMC em T1 foi maior no grupo de desmame precoce (p=0,007). E em relação aos níveis de IL10 e TNF-α não houve diferenças significativas entre os grupos. CONCLUSÃO: Os resultados deste estudo mostraram semelhanças entre os níveis séricos de BDNF medidos a longo prazo, entre crianças amamentadas por < 6 meses e ≥ 6 meses, sugerindo que futuros estudos são necessários, com dosagens durante o período de amamentação para investigar o papel de marcadores neuroquímicos na duração do aleitamento materno e suas implicações no estado nutricional e cognição das crianças amamentadas.

BACKGROUND: The Brain-Derived Neurotrophic Factor (BDNF) is an important neurotrophin found in the brain and peripheral tissues. Breast milk is considered to be the “gold standard” food for brain development, making early weaning a risk factor in child development. AIM: To evaluate the concentration of BDNF, IL6, IL10, TNF-α in children and its correlation with the duration of breastfeeding. METHODS: Thirty-seven children were recruited and classified according to the duration of breastfeeding: <6 months (early weaning) and ≥ 6 months. There were two visits: the baseline interview in 2007 (T0) and the follow-up visit in 2011 (T1). BDNF levels were assayed using a sandwich ELISA, and cytokines were assayed with flow cytometry. RESULTS: Serum BDNF levels at T0 were significantly lower in the group breastfed for ≥ 6 months (p = 0.025), and they did not differ between groups at T1 (p = 0.863). IL-6 levels were significantly increased in the early weaning group at T0 (p = 0.016). Body mass index at T1 was higher in the early weaning group (p = 0.007). There was no significant difference in IL10 and TNF-α levels between groups. CONCLUSION: The results of this study showed similarities in serum BDNF levels over time between children who had been breastfed <6months and ≥ 6 months. This suggests that further studies, with measurements taken during the breastfeeding period, are needed to investigate the role of neurochemical markers in the duration of breastfeeding and its implications on nutritional status and cognition of breastfed children.

Impairment in psychosocial functioning in patients with different subtypes of eating disorders / O prejuízo no funcionamento psicossocial de pacientes com diferentes subtipos de transtorno alimentar

OBJECTIVE: To examine psychosocial functioning in eating disorder (ED) patients with restrictive and purgative subtypes. METHOD: Forty-four adult female patients with a diagnosis of ED were divided into restrictive (RP) and purgative (PP) groups according the presence of purgative symptoms. Functioning was assessed using the Functioning Assessment Short Test (FAST) and the Global Assessment of Functioning Scale (GAF). RESULTS: No differences were found in total FAST scores or in specific domains between the RP (39.58±11.92) and PP (45.75±11.75) groups (p = 0.19). However, PP showed more severe functional impairment than RP in the financial domain (p < 0.01). There were no differences in comorbidity with mood disorders, depressive symptoms, or general psychiatric symptoms between the two ED subtypes. CONCLUSIONS: The similarities found between PP and PR in overall functioning and in autonomy, cognition, work, interpersonal relationships, and leisure seem to reflect the use of an objective scale that corresponds to the clinical impression. In fact, the assessment of psychosocial functioning in ED patients using self-report instruments requires careful consideration because results may reflect the egosyntonic nature of symptoms commonly observed in these patients, particularly in the restrictive subtype

OBJETIVO: Avaliar o funcionamento psicossocial de pacientes com subtipos restritivo e purgativo de transtorno alimentar (TA). MÉTODOS: Quarenta e quatro pacientes adultas com TA foram divididas em grupos restritivo (RP) e purgativo (PP) conforme a presença de sintomas purgativos. O funcionamento foi avaliado com a Functioning Assessment Short Test (FAST) e a Global Assessment of Functioning Scale (GAF). RESULTADOS: Não houve diferenças nos escores totais nem nos domínios da FAST entre os grupos RP (39,58±11,92) e PP (45,75±11,75) (p = 0,19). No entanto, o grupo PP demonstrou maior prejuízo funcional no domínio finanças (p < 0,01). RP e PP foram semelhantes em comorbidade com transtornos de humor, sintomas depressivos e sintomas psiquiátricos em geral. CONCLUSÕES: As semelhanças encontradas entre os grupos PP e RP no funcionamento geral e nos domínios autonomia, cognição, trabalho, relacionamentos interpessoais e lazer parecem refletir o uso de uma escala objetiva que corresponde à impressão clínica. De fato, é necessário cautela ao avaliar funcionamento psicossocial em pacientes com TA com escalas autoaplicáveis, porque estas costumam refletir a natureza egossintônica dos sintomas comumente observados nesses pacientes, especialmente no subtipo restritivo

Cognitive impairment in a Brazilian sample of patients with bipolar disorder / Prejuízo cognitivo em uma amostra brasileira de pacientes com transtorno do humor bipolar

OBJECTIVE: Persistent neurocognitive deficits have been described in bipolar mood disorder. As far as we are aware, no study have examined whether the cognitive impairment is presented in the same way in a Brazilian sample. METHOD: Cognitive function of 66 patients with bipolar disorder (32 with depressive symptoms and 34 euthymic) and 28 healthy subjects was examined using a complete cognitive battery. RESULTS: Patients with bipolar disorder presented a significantly poorer performance in eight of the 12 subtests when compared to healthy subjects. There was no significant difference between the subgroups of patients. These patients showed impairment in both verbal and non-verbal cognitive function. CONCLUSION: Cognitive impairment was found in both groups of patients with bipolar disorder. The findings described here suggest an overall impairment of cognitive function, independent of mood symptoms. This is in line with data showing that cognitive deficits may be a persistent characteristic of bipolar disorder.

OBJETIVO: Déficits neurocognitivos persistentes têm sido descritos no transtorno do humor bipolar; entretanto, não há estudos em amostras brasileiras para avaliar se o prejuízo se apresenta da mesma forma. MÉTODO: Foi realizada uma avaliação cognitiva em 66 pacientes bipolares (32 com sintomas depressivos e 34 eutímicos) e 28 controles, utilizando-se uma bateria cognitiva completa. RESULTADOS: Em oito dos 12 subtestes avaliados os pacientes apresentaram desempenho significativamente inferior em relação aos controles. Não houve diferença significativa entre os grupos de pacientes. Foram encontrados prejuízos cognitivos tanto na área verbal como na área não verbal da cognição. CONCLUSÃO: Foi observada uma performance inferior em ambos os grupos de pacientes com transtorno bipolar. As dificuldades cognitivas encontradas apontam para um prejuízo global no funcionamento cognitivo, independente da presença de sintomas, sugerindo estabilidade ou cronicidade dos déficits cognitivos.