Phenotypic dissection of mood disorder

The pathogenesis of affective disorders is not clearly understood and the diagnostic validity of psychiatric disorders remains unclear. The aim of this thesis was to identify sub-phenotypes in affective disorders that may be biologically validated by future molecular genetic studies. The dataset comprised over 1000 subjects meeting diagnostic criteria (DSM-IV) for bipolar I disorder (BPI) or major recurrent depression (MDDR) who were previously recruited as part of ongoing molecular genetic studies. Subjects had been assessed in detail using Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and case-note reviews. I undertook hypotheses testing and exploratory analyses in this dataset using a range of univariate and multivariate statistical tests. I found that a depressive episode at illness onset in BPI subjects was associated with a more depressive course of illness. I also found clinical characteristics of depression that were associated with a bipolar, rather than unipolar, course of illness. Using the HCL-32, I identified a substantial number of MDDR subjects (17%) who reported bipolar symptoms at a level similar to that reported by BPI subjects. I found significant differences in the clinical course of illness of MDDR and BPI subjects according to the lifetime presence of recurrent panic attacks, as well as clinical characteristics that appeared to be associated with the presence of panic attacks only in BPI subjects. In the unipolar sample, I found that within subjects psychotic episodes tended to be more severe than non-psychotic episodes. However, between subjects there was wide variation in severity in both those that did, and did not, experience psychotic episodes. In MDDR subjects, I found that episodes of postpartum depression clustered in families (p=0.015). I found no significant evidence for the familiality of reporting of life events in the MDDR sample. These studies identify sub-phenotypes that may be of use in future genetic studies

Cultural competency and mental health training for medical students: Learning from refugees and asylum seekers

Objective: Studies suggest that healthcare professionals often feel unprepared to deal with mental health issues in refugees and asylum seekers. The aim of this qualitative study was to examine the experiences of refugees and asylum seekers in relation to mental health and healthcare, to inform cultural competency training for undergraduate medical students. Method: Focus groups were conducted with 16 refugees and asylum seekers and staff from relevant charity organisations in Wales. We explored participants’ experiences in relation to mental health and healthcare, and training for healthcare professionals. The data were thematically analysed using an inductive approach. Results: Three overarching themes were identified: (1) recognition of the specific mental health needs of refugees and asylum seekers, (2) barriers preventing effective mental healthcare delivery for refugees and asylum seekers and (3) authentic learning experiences for medical students. Conclusion: To our knowledge, this is the first study to actively involve refugees and asylum seekers, along with individuals who work closely with this population, in considering the development of cultural competency training for healthcare students and professionals in relation to mental health. If we are to reduce the risks of exclusion from healthcare for refugees and asylum seekers, training in this area is essential. Findings from this study have informed the development of a guide for healthcare educators with a focus on refugee and asylum seeker mental health

Medical student attitudes to mental health and psychiatry: the use of a patient-experience short film

Background: Medical student attitudes to mental illness are significantly influenced by their undergraduate educational experience. Medical education therefore has a key role to play in challenging the stigma associated with mental illness. We developed a short educational film aimed at challenging stigmatising attitudes to mental illness and explored its effects on undergraduate medical student attitudes. We hypothesised that levels of stigmatising attitudes in medical students would reduce after students viewed the educational film. Method: We used a validated scale (Mental Illness: Clinician Attitudes, MICA) to examine undergraduate medical student attitudes to mental illness at two time points - prior to (T1) and following (T2) viewing the short film. The film focused on patient experiences and was designed to highlight personal experiences of mental illness. Results: 92 students completed the MICA before the film and 73 students at both time points. Having a personal history of mental illness was associated with less stigmatising attitudes (t=2.4, df=87, p=0.019). Stigma scores were reduced following the film viewing (t=7.101, df=72, p<0.001). Discussion: This study suggests that patient experience films, used as educational tools, can challenge student perceptions of mental illness and lead to a reduction in stigmatising attitudes, at least in the short term. Future studies are required to examine the longer-term effects of such educational interventions in terms of student perceptions and attitudes towards mental health and psychiatry

Diversity in patient and public involvement in healthcare research and education—Realising the potential

Background: Patient and public involvement (PPI) is an increasing priority in health‐related research and education. Attracting and supporting people from different demographic groups to give up their time and get involved is important to help ensure that all parts of society are empowered, represented and their voices heard in decisions that may affect their health and quality of life. Objectives: (1) To determine if a demographically diverse cross‐section of society would be interested in contributing to healthcare research and education. (2) To understand factors that can act as barriers and enablers to effective and diverse PPI. Method: PPI survey data was collected via engagement events, with the aim of scoping interest in PPI from a diverse public. A Focus Group study involving members of the public, academic and professional service staff, was then conducted to gain a deeper understanding around the barriers and enablers of diversity within PPI. Results: 71% of a diverse rich public indicated they would like to get involved in healthcare research and teaching. 76% of survey respondents indicated that they would be happy to share a personal or family experience of healthcare. The two biggest factors impacting on our cohort getting involved are’ availability of time’ and ‘being aware of PPI opportunities’. These factors may disproportionally affect specific groups. Shared and individual PPI enablers and barriers were identified across all stakeholder groups within the Focus Group Study, as well as generic and novel factors that would impact on an institutions’ ability to improve PPI diversity. Conclusion: These data points confirm a demographically diverse public's appetite to get involved in academic health research and teaching. This needs to be recognised and harnessed to ensure public contributor networks are representative of society. Equality Impact Assessments should be undertaken in relation to all PPI opportunities. There is a need to recognise the investment of time and resources required to build mutually beneficial relationships with diverse communities as well as the development of inclusive ‘fit for purpose’ PPI infrastructures to support the uptake of diverse PPI contributors. Public Contribution: This study involved members of the public responding to a short survey. Public contributors made up one of the three focus groups. The School of Medicine lead public contributor was also involved in the preparation of this manuscript

Investigation of relationships between bipolar disorder phenotypes and genome-wide significant loci from PGC2 schizophrenia

Background Schizophrenia (SZ) and Bipolar disorder (BD) show evidence for partial overlap in phenotypic and genetic influences based on family, twins, adoption and Psychiatric Genetic Consortium (PGC) studies. They have lifetime prevalence of about 1% and 2.4%, and heritability estimates of 60-80% and 40-70%, respectively. In the last decade BD has been investigated using dimensional structuring of psychoses based on symptomatic-functional checklists that provides reliable approach to phenotypic assessment. Recent research suggests moving towards developing Phenotype-based Genetic Association Studies. In this approach, patients will only be put into groups consisting of others with symptoms similar to their own. Canonical Correlation Analysis (CCA) is statistical technique designed to identify relationships (usually hidden) between two sets of variables. We use CCA to combine genotypic and phenotypic variables and measure correlation between those sets. This analysis estimates canonical correlation between psychotic symptoms measured using validated item check list (OPCRIT), and genome-wide significant (GWS) loci from PGC2 schizophrenia. Methods For our analysis we used phenotype and genetic data for 5,507 BD cases. Imputation of genetic data was performed with 1000Genomes (Phase 3, 2014) then quality control was applied (INFO>0.8, HWE>1e-6, MAF>0.01). Additional quality control was performed on phenotypic symptom coverage. CCA was employed as implemented in R, using package “CCA” with GWS loci from PGC2 SZ and OPCRIT items. SNPs were standardised and adjusted for 10 population covariates calculated from imputed data using principal component approach prior to CCA. Results Canonical correlation analysis was run on 4422 cases on 89 available GWS PGC2 SZ SNPs or their proxies (with r2>0.6). 60 phenotypic variables were taken from OPCRIT measurements including mood disturbance, biological indices, atypical depression, substance use, psychosis and social functioning. We found no significant canonical correlations indicating absence of hidden sub-clusters at individual symptom level of BD associated with SZ GWS loci. Discussion Our analysis was focused to find correlation from bipolar phenotype by using OPCRIT questionnaire and GWS SZ loci from PGC2. We have shown that there were no significant canonical correlation coefficients suggesting that there is no direct association between SZ associated genetic loci and BP at individual symptom level. CCA is canonical correlation analysis is one of potential of data-driven approaches to identify hidden genotype-phenotype relationships. It provides opportunities to generate and test different hypotheses and understand more about complex architecture of psychiatric disorders. In the next stage we plan to extend our analysis to more fine grained systematic descriptors of BD and test for correlation with genetic profiles from a number of co-morbid disorders, as well as the full range of phenotypic and genetic data that are available

Psychosis and the level of mood incongruence in Bipolar Disorder are related to genetic liability for Schizophrenia

Abstract Importance Bipolar disorder (BD) overlaps schizophrenia in its clinical presentation and genetic liability. Alternative approaches to patient stratification beyond current diagnostic categories are needed to understand the underlying disease processes/mechanisms. Objectives To investigate the relationship between common-variant liability for schizophrenia, indexed by polygenic risk scores (PRS) and psychotic presentations of BD, using clinical descriptions which consider both occurrence and level of mood-incongruent psychotic features. Design Case-control design: using multinomial logistic regression, to estimate differential associations of PRS across categories of cases and controls. Settings & Participants 4399 BDcases, mean [sd] age-at-interview 46[12] years, of which 2966 were woman (67%) from the BD Research Network (BDRN) were included in the final analyses, with data for 4976 schizophrenia cases and 9012 controls from the Type-1 diabetes genetics consortium and Generation Scotland included for comparison. Exposure Standardised PRS, calculated using alleles with an association p-value threshold < 0.05 in the second Psychiatric Genomics Consortium genome-wide association study of schizophrenia, adjusted for the first 10 population principal components and genotyping-platform. Main outcome measure Multinomial logit models estimated PRS associations with BD stratified by (1) Research Diagnostic Criteria (RDC) BD subtypes (2) Lifetime occurrence of psychosis.(3) Lifetime mood-incongruent psychotic features and (4) ordinal logistic regression examined PRS associations across levels of mood-incongruence. Ratings were derived from the Schedule for Clinical Assessment in Neuropsychiatry interview (SCAN) and the Bipolar Affective Disorder Dimension Scale (BADDS). Results Across clinical phenotypes, there was an exposure-response gradient with the strongest PRS association for schizophrenia (RR=1.94, (95% C.I. 1.86, 2.01)), then schizoaffective BD (RR=1.37, (95% C.I. 1.22, 1.54)), BD I (RR= 1.30, (95% C.I. 1.24, 1.36)) and BD II (RR=1.04, (95% C.I. 0.97, 1.11)). Within BD cases, there was an effect gradient, indexed by the nature of psychosis, with prominent mood-incongruent psychotic features having the strongest association (RR=1.46, (95% C.I. 1.36, 1.57)), followed by mood-congruent psychosis (RR= 1.24, (95% C.I. 1.17, 1.33)) and lastly, BD cases with no history of psychosis (RR=1.09, (95% C.I. 1.04, 1.15)). Conclusion We show for the first time a polygenic-risk gradient, across schizophrenia and bipolar disorder, indexed by the occurrence and level of mood-incongruent psychotic symptoms

Symptom profile of postpartum and non-postpartum manic episodes in bipolar I disorder: a within-subjects study

The relationship of postpartum mania to episodes of mania occurring outside the perinatal period among women with bipolar disorder remains controversial. Previous studies have used between-subjects designs to compare the clinical presentations of these episodes meaning the differences, in part, may reflect between-group differences. To overcome this we have undertaken within-subject comparisons of the symptom profile of postpartum and non-postpartum manic episodes in 50 women with DSM-IV bipolar I disorder. For each woman detailed symptom information on a postpartum episode of mania and a comparison non-postpartum manic episode was collected. The occurrence of manic, psychotic and depressive symptoms in these episodes were compared. Postpartum manic episodes had a significantly higher incidence of perplexity and excessive self-reproach. Classic manic symptoms, specifically pressured speech and increased sociability, were significantly less frequent in postpartum manic episodes. Overall there were significantly fewer manic symptoms and significantly more depressive symptoms in the postpartum episodes than in the non-postpartum episodes. The mixed presentation of postpartum manic episodes suggests childbirth may act as a pathoplastic trigger in women with bipolar disorder. The differences in symptom profiles suggests further research is warranted into whether differences in treatment response exist among women experiencing postpartum and non-postpartum manic episodes

Genome-wide association study identifies 30 loci associated with bipolar disorder.

Bipolar disorder is a highly heritable psychiatric disorder. We performed a genome-wide association study (GWAS) including 20,352 cases and 31,358 controls of European descent, with follow-up analysis of 822 variants with P &lt; 1 × 10-4 in an additional 9,412 cases and 137,760 controls. Eight of the 19 variants that were genome-wide significant (P &lt; 5 × 10-8) in the discovery GWAS were not genome-wide significant in the combined analysis, consistent with small effect sizes and limited power but also with genetic heterogeneity. In the combined analysis, 30 loci were genome-wide significant, including 20 newly identified loci. The significant loci contain genes encoding ion channels, neurotransmitter transporters and synaptic components. Pathway analysis revealed nine significantly enriched gene sets, including regulation of insulin secretion and endocannabinoid signaling. Bipolar I disorder is strongly genetically correlated with schizophrenia, driven by psychosis, whereas bipolar II disorder is more strongly correlated with major depressive disorder. These findings address key clinical questions and provide potential biological mechanisms for bipolar disorder

Comorbid medical illness in bipolar disorder

Background Individuals with a mental health disorder appear to be at increased risk of medical illness. Aims To examine rates of medical illnesses in patients with bipolar disorder (n = 1720) and to examine the clinical course of the bipolar illness according to lifetime medical illness burden. Method Participants recruited within the UK were asked about the lifetime occurrence of 20 medical illnesses, interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and diagnosed according to DSM-IV criteria. Results We found significantly increased rates of several medical illnesses in our bipolar sample. A high medical illness burden was associated with a history of anxiety disorder, rapid cycling mood episodes, suicide attempts and mood episodes with a typically acute onset. Conclusions Bipolar disorder is associated with high rates of medical illness. This comorbidity needs to be taken into account by services in order to improve outcomes for patients with bipolar disorder and also in research investigating the aetiology of affective disorder where shared biological pathways may play a role