Richard John Porter

Objectives: To examine the relationship between irritability and mixed states in bipolar disorder to determine how subjective irritability and mixed symptoms of mania and depression manifest in patients with bipolar disorder over a period of 18 months. Methods: This exploratory analysis examined longitudinal data from a randomised controlled trial of a psychological intervention for patients with bipolar disorder. Scores of subjective irritability and mood morbidity were analysed from data sampled over ten timepoints over the trial from 82 patients. Results: Significant associations were found between the presence of irritability and mixed symptoms ( F (1, 684) = 20.468, p < 0.001). This relationship remained significant throughout the duration of the study and the administration of a psychological treatment which reduced both ratings of mood and irritability. Notably, when mixed symptoms are absent, irritability nevertheless remained for nearly half the time. Conclusions: Irritability and mixed symptoms are phenomenologically linked. The persistence of this link, regardless of the existence of mixed symptoms, suggests that irritability permeates bipolar disorder and is core to its phenomenology. Future studies should interrogate the tethering of mixed symptoms and irritability in the context of bipolar disorder as this may lead to a deeper understanding of the core characteristics of the illness—both clinically and in terms of its neurobiology.

Background Risk of new episodes is a constant concern for people living with bipolar disorder (BD). Research into sleep and circadian rhythm disruption (SCRD) suggests that relapse risk may be measurable in 24-hour rest-activity rhythms (RAR) via actigraphy. The primary aim of the Tipping Point project is to develop an algorithm forecasting relapse based on RAR. A secondary aim is to explore SCRD mechanisms linking RAR to mood dynamics in BD. The mechanistic investigation involves analysis of biological correlates of RAR, and exploration of system instability as a predictor of two types of state transition (relapse and recovery). Method Three prospective studies will enrol adults living with BD I or II. Study 1 (Australia) recruits N = 100 individuals with interepisode BD who will undergo three contiguous 26-week monitoring epochs. Each epoch commences with 14 days of actigraphy, followed by retrospective interviews at 13 and 26 weeks. RAR predictors of time to first relapse will be explored using three computational frameworks - statistical risk, probabilistic network graphs and non-linear dynamic models. Study 2 (India) replicates one of the 26-week epochs of Study 1, recruiting 25 individuals with BD and 25 matched healthy controls. Study 2 investigates the replicability of models identified in Study 1 and tests the mechanistic association between amplitude of the RAR and amplitude of clock gene expression. Study 3 (New Zealand) explores system instability as a mechanism, by investigating whether complex system indicators of relapse risk (from Study 1) also forecast recovery from acute episodes. In Study 3, actigraphy data will be collected from people experiencing a severe episode of BD depression ( N = 30) or mania ( N = 15). Discussion The Tipping Point project uses a multi-study design to develop a mechanistically-informed predictive algorithm for relapse risk in BD.

Introduction: Circadian dysfunction is involved in the pathophysiology of bipolar disorders (BD), and circadian‐based interventions are gaining recognition in their management. Moreover, basic and epidemiologic research has generated findings inspiring circadian‐informed self‐ and clinician‐management strategies. Despite these gains, many Clinical Practice Guidelines and clinical training programs have not incorporated this evidence in their recommendations and curricula. This International Society for Bipolar Disorders (ISBD) Chronobiology and Chronotherapy Task Force position paper reports a Delphi‐based expert consensus on what is essential for mental health clinicians to know about the chronobiology and chronotherapy of BD. Methods: An initial pool of statements was extracted from academic and grey literature, and experts could suggest additional statements. Statements were rated on a 5‐point scale (‘essential’; ‘important’; ‘don't know/depends’; ‘unimportant’; ‘should not be included’). Consensus was reached when statements were rated as essential or important by ≥ 80% of experts. Results: Thirty experts from 15 countries in Europe, North and South America, and the Asia Pacific participated (mean age of 55.3 years [SD = 11.8]; 40% female; 83% psychiatrists; mean clinical experience of 26 years [SD = 10.8]). Eight‐hundred‐and‐thirty‐seven statements were rated across three rounds. Consensus was reached on 342 statements spanning four major themes: basic circadian science; circadian health and disruption; chronobiology of BD; and six chronotherapies (e.g., protocols, outcomes, risks/contraindications). Conclusions: An expert consensus was obtained on the essential information about the chronobiology and chronotherapy of BD, intended to help clinicians optimise their management of BD. Dissemination of this knowledge is expected to enhance the training and efficacy of clinicians.

To mark the 10th Anniversary of BJPsych Open, we explore the contributions of papers published in BJPsych Open to advance cultural psychiatry practice and policy. In our overview of papers published in BJPsych Open, we found examples of good practice where authors detailed the translation methods and interpretation models in the research. The task facing clinicians and public health practitioners is to evolve applied, locally relevant, culturally competent interventions in which specific adaptations are shaped by the potential beneficiaries, alongside theoretical and practical issues of cultural adaptation. Researchers and clinicians will need to provide evidence of acceptability and effectiveness of adapted interventions, alongside considering financial and implementation realities.

Objective: Estimate and compare rates of cardiometabolic blood screening, elevated results and clinical follow-up actions for Māori and non-Māori mental health service users with psychosis in Canterbury, Aotearoa New Zealand. Methods: A retrospective cohort study ( N = 3840) with dynamic entry was conducted with people aged 18–64 years with a psychosis diagnosis in Canterbury Specialist Mental Health Service (1 August 2012 to 31 December 2019). Linked administrative data captured lipid and HbA1c screening within 1 year of study entry, elevated results (triglycerides > 2.2 mmol/L; total cholesterol:high-density lipoprotein cholesterol > 5; HbA1c > 40 mmol/mol) from individual study entry to 31 December 2023, and clinical actions (repeat test; statin/metformin dispensing) within 1 year following an elevated result. Results: 887/3840 (23%) of Canterbury Specialist Mental Health Service users with psychosis were Māori. First-year screening rates were modest (31–44%), similar by ethnicity and broadly higher among clozapine/olanzapine users. Māori had higher odds of both elevated lipids and HbA1c. About one-third of elevated results were followed up with re-testing within 1 year. Rates of follow-up testing and medication dispensing were broadly similar for Māori and non-Māori, except Māori were more likely to receive repeat HbA1c testing after an elevated result (odds ratio = 1.71 [1.16, 2.50]). Conclusions: Findings highlight large gaps in cardiometabolic screening and follow-up actions among Māori and non-Māori Specialist Mental Health Service users with psychosis. Māori presented with psychosis 4 years younger, had significantly higher rates of elevated cardiometabolic risk markers and were more likely to receive HbA1c re-testing following an elevated result.

Purpose: Changes in facial emotion processing were examined over the course of anti-androgen treatment in women with PCOS. We also explored whether these changes in emotion processing correlated with changes in mood and anxiety symptoms over treatment. Methods: Thirty-three women with PCOS received 12 weeks of naturalistic treatment based on clinical presentation. Facial emotion processing was assessed at baseline and 12-weeks on the Reading the Mind in the Eyes Test, and a computerised Facial Expression Recognition (FER) Task, which measured accuracy and response time in recognising facial expressions (happiness, sadness, fear, disgust, anger, neutral), and neutral misinterpretation bias. The Hospital Anxiety and Depression Scale was completed at the same time-points. Outcomes were compared with a control group of 40 healthy women. Results: Women with PCOS (mean age = 29 years) were treated with a variety of medications, mainly spironolactone ( n = 22) and oral contraceptives ( n = 16). Within the PCOS group, significant improvement was found for 10 of 19 FER variables over treatment, and in depression and anxiety symptoms. When comparing the PCOS and control groups over time, the PCOS group became significantly faster in responding to disgusted and neutral expressions, and reduced in their tendency to misinterpret neutral faces as angry. Improved depression and anxiety symptoms correlated significantly with improved accuracy in recognising fearful expressions, but not with any other FER variables. Conclusions: In this preliminary study, anti-androgen treatment improved some aspects of facial emotion processing in women with PCOS, which has implications for understanding the mental health aspects of PCOS.

Summary: Lithium is the only true mood stabiliser as it is able to both treat and prevent mania and depression. In practice, its popularity has declined despite discovering it has anti-suicidal and neuroprotective properties. Here, we argue for recognition of its benefits and advocate for its clinical use more widely.

Introduction. Despite research evidence supporting adjunctive psychological treatment for bipolar disorder, there is often a failure in translation to routine clinical care. This study aimed to determine the feasibility of implementing social rhythm therapy, a brief intervention with potential for adoption within Specialist Mental Health Services for individuals with bipolar disorder. Method. Case managers from two community mental health teams were trained to deliver social rhythm therapy to clients with bipolar disorder on their case load. Feasibility was based on qualitative and quantitative data addressing acceptability of training, ability to deliver therapy as part of a caseload, and adherence and fidelity for case managers, and acceptability of therapy including recruitment and retention for case managers and clients. Descriptive analyses were used for quantitative data and thematic analysis for qualitative data. Results. Ten case managers were trained with eight delivering the therapy. Of 37potential clients with bipolar disorder, 10 began therapy (27% uptake),with five completing (50% completion). Qualitative findings demonstrated acceptability of training with implementation challenges associated with engaging clients and balancing case management requirements with high workplace demands. Limitations included the small sample size and significant gaps in data, especially reflecting the clients’ perspectives. Conclusion. The feasibility of implementing of social rhythm therapy in Specialist Mental Health Services was impacted by low level of uptake and systemic barriers, primarily related to the requirements inherent in the case manager role. Effective implementation requires addressing the systemic issues and enhancing engaging individuals with bipolar disorder in psychological treatment approaches.

Background: Sunlight has profound impacts on physical and mental health, beyond vision, including effects on circadian rhythms, alertness, mood, and sleep. A family history of any mood disorders is strongly associated with psychiatric disorders including bipolar disorder. The purpose of this study was to evaluate the association between a family history of any mood disorder in patients with bipolar I disorder and solar insolation at varied international onset locations. Methods: Data for this analysis were available from 5842 patients with a diagnosis of bipolar I disorder obtained at 83 collection sites in both hemispheres. This included 4752 patients from 71 collection sites in the northern hemisphere and 1090 patients from 12 collection sites in the southern hemisphere. Patient data variables were obtained from records or interviews. Solar insolation data were obtained from The National Aeronautics and Space Administration (NASA) Power database for each onset location, and the ratio of the mean monthly minimum/mean monthly maximum solar insolation was calculated. Typically, the ratio is largest near the equator (little yearly change in solar insolation) and smallest near the poles (large yearly change in solar insolation). Results: A significant relationship was found between a family history of any mood disorder, the ratio of the mean monthly minimum/mean monthly maximum solar insolation, and gender. The odds of a family history of mood disorder increased as patient location nears the poles and decreased near the equator. Female gender also increased the odds of having a family history of a mood disorder. Conclusions: This study highlighted the association between family history, solar insolation, and gender in international patients with bipolar I disorder. Given the profound effects of sunlight on human health, the family of patients with bipolar disorder who live in the same location with the same solar insolation, and especially females, may be at increased risk for a mood disorder.

Background: The Consensus on subdomains and measures of Affective and Social cognition for research on Bipolar Disorder (CAS‐BD) project aimed to formulate preliminary consensus‐based recommendations for assessing affective and social cognition in BD. Methods: Three sequential surveys administered to experts on affective and social cognition in BD were conducted using the Delphi process. Experts responded to questions regarding affective and social cognition subdomains and rated their importance to research on BD. Experts also nominated measures, rated them for suitability, and ranked them by preference for use. Consensus was defined as ≥ 80% agreement. Results: 31 experts completed the initial survey, with 20–23 completing subsequent surveys. Consensus was obtained for the subdomain structure of both affective cognition and social cognition , and the definition of each subdomain within. Explicit emotion regulation was ranked as being of highest priority for further research on affective cognition, and theory of mind as highest priority for further research on social cognition. The top‐preferenced measures of all affective cognition subdomains were considered by consensus to be suitable for use in BD research. Agreement that the top‐preferenced measures of social cognition were suitable ranged from 71.5% to 95.3%. Discussion: Expert consensus on subdomains and measures of affective and social cognition for research on BD was obtained via a staged approach. Prior familiarity may have influenced some experts' rankings, but generally there was a notable lack of consistency in the use of available measures by BD experts. This reaffirms the need for more specific guidance and validated batteries of social and affective cognition to direct the field and allow for more consistency and replication of research in the future.