Bipolar Disorder Mood Cycling: Why Women Are More Prone

What’s happening – The prevalence of bipolar disorder is a growing concern, with women disproportionately affected. To understand sex differences in bipolar rates, researchers conducted an analysis of 10 large-scale studies (with 1,000-plus participants) conducted over the past decade. Their findings, which appear in the International Review of Bipolar Disorder (Dell’Osso B et al), reveal that females seem to be increasingly likely to have a bipolar diagnosis and to experience rapid cycling (defined as four or more mood episodes – mania or hypomania followed by depression – over the course of 1 year) as well as other symptoms.

One noted possible explanation for this disparity among females is that the medical community has become better at diagnosing bipolar disorder and at recognizing how it presents in women, so fewer cases are being missed. The researchers also mention the need for further studies delving deeper into the prevalence of sex-specific bipolar disorder.

Why it’s complicated — The mood changes that occur with bipolar disorder can present in different ways, making it difficult to diagnose no matter the sex of the patient. In very recent years, clinicians have increasingly recognized this variability. According to Chris Aiken, MD, medical director of the Mood Treatment Center in Winston-Salem, NC, one of the most controversial presentations is ultradian cycling, also called ultra-ultra rapid cycling, which is when mood episodes change in less than a 24-hour period. There is also ultra-rapid cycling, which involves four mood swings within 1 month, or rapid cycling when the mood differences occur four or more times in a year. Recognizing these distinctions is key to properly diagnosing and treating patients (see how below in our Psy-Q challenge).

Conversation & Perspectives –

  • A trial published in the Journal of Clinical Psychiatry looked at the effectiveness of adding citalopram to standard mood stabilizers to treat bipolar depression and found that it did not make a significant difference. Further, in those with rapid cycling, this medication seemed to worsen manic symptoms when used as a maintenance treatment.
  • An expert opinion piece published in Neuropsychiatric Disease and Treatment explored the limitations of current treatments for bipolar depression and pointed out the potential for substances such as ketamine and N-acetyl cysteine (NAC) that focus on neurotransmitter pathways and inflammatory processes to help fill in some of the gaps.
  • The International Bipolar Foundation shared stories of three individuals with bipolar disorder who experience different levels of rapid cycling.
  • Amazon Prime recently streamed stories taken from a New York Times column called “Modern Love” – one episode was based on an entertainment attorney with ultradian bipolar disorder.
  • An older case study in the Journal of Affective Disorders outlines the successful treatment of a patient with ultra-ultra-rapid cycling.
  • @IntlBipolar (International Bipolar Foundation) refers to another study on gender and rapid cycling in the following tweet: “Hospitalization, prevalent polarity, and female sex were found to increase the risk for rapid cycling in bipolar disorder, according to a study published in European Psychiatry…”
  • @stress_2020 (7th International Conference on Stress, Mindfulness, Meditation and Resilience) tweets: “According to the latest research, Bipolar disorder shows inequalities. They are associated both with socioeconomic factors and with gender …”

In practice – How to differentiate between unipolar and bipolar depression. How to diagnose BPD, below with Chris Aiken, MD.

Psy-Q: This Week's Challenge

What is the most difficult aspect of diagnosing bipolar disorder? Chris Aiken, MD, answers.

Get the Answer

Alzheimer’s and Parkinson’s Related Dementia: COVID Infection and Cognition

What’s happening – In recent years, scientists have been on the hunt to better understand the role of different brain pathways and impairments in common diseases that are associated with age. Such insights can be essential to find new forms of prevention and treatment strategies for disorders such as Alzheimer’s.

Liselotte De Wit and colleagues conducted a systemic review to better understand the impact of Alzheimer’s disease (AD) dementia or amnestic Mild Cognitive Impairment (aMCI) on procedural learning. Their findings, published in Neuropsychology Review, reveal that, of those studies (there are few) that have compared differences in procedural learning between healthy adults and those with AD dementia or an MCI, only small, insignificant differences were noted. They concluded that procedural learning is not affected in people with these conditions.

Another study led by D. Hansen in the UK, which appeared in Neuropathology and Applied Neurobiology, explored the clinical and neuropathological symptoms experienced by people with dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD). They sought to understand the role of cerebral amyloid angiopathy (CAA) in the disease course and discovered that CAA is more likely to be found, and to be more severe, in people with DLB compared to those with PDD. Individuals with DLB also had symptoms that progress more rapidly than those with PDD and, thus, had worse outcomes.

Another review appearing in Nature Reviews Neurology looked at the relationship between AD and inflammatory markers and discovered that microglia plays a key role in neuroinflammation related to the progression of AD. This finding calls attention to the potential for modulating these cells in order to treat the disease.

Why it’s complicated — recent studies show that current and future infection by COVID-19 may also have an impact on dementia.

  • An article in Molecular Neurobiology looked at commonalities between COVID-19 and Alzheimer’s, both of which can affect memory and disrupt learning. The authors point out that both conditions have similarities in regard to angiotensin-converting enzyme 2 (ACE2) receptors and pro-inflammatory markers; addressing these factors may lead to more effective treatments both for COVID-19 and AD.
  • The American Journal of Geriatric Psychiatry included an article that suggests ways to mitigate the impact of COVID-19 on people with AD and other forms of dementia, including addressing risks of getting sick, access to treatment, strain on caregivers, and delays in research, among other key areas.
  • Researchers discuss the widespread impacts of COVID-19 on vulnerable elderly populations, including increased risk of cognitive impairment in older people with dementia. Their findings, published in Frontiers in Aging Neuroscience, also stress the need for providers to conduct period cognitive and neuropsychiatric assessments in COVID and beyond, along with ensuring people have access to needed services

Conversation & Perspectives —

  • @ForumExtendCare (institutional pharmacy and consulting services) tweets: “Dementia doubles the risk of COVID-19, according to an analysis of 61 million adults. These findings highlight the need to protect patients with dementia as part of an ongoing strategy to control COVID-19.”
  • @neuroeon (neuroscience training) shares: “The impact of COVID-19 pandemic has been HUGE. Deaths resulted from dementia and Alzheimer’s have increased by 16% during the pandemic! And we have not named the implications of other cognitive disorders here…”
  • @HindawiBioSci (science communication) shares an opinion piece: “Andrei Surguchov, Chief Editor of #Biochemistry Research International, reflects on the impact the #COVID-19 has had on the epidemic of neurodegenerative disease and #dementia.”

In practice – See our special report on the COVID pandemic and the ongoing mental health needs of long-term care residents.

Treating Alcohol Use Disorder in Adults Experiencing Homelessness: New Approaches Needed

What’s happening – Alcohol addiction among the homeless is a serious problem, yet most attention is directed toward treating drug addiction in this population. Further, many efforts that do address alcohol use disorder (AUD) in the homeless tend to rely on a therapeutic community model that, ironically, can pose challenges for people experiencing homelessness. A newly published study in The Lancet Psychiatry takes a closer look at approaches that may work.

Researchers led by Susan E. Collins at the University of Washington and Washington State University followed just over 300 individuals with AUD who had experienced homelessness over the prior 12 months. (It’s important to note that participants were not required to agree to abstain from alcohol in order to participate.) Each person was placed into one of three treatment groups:

  • harm reduction treatment for alcohol abuse alone (behavioral treatment)
  • harm reduction treatment and medication with extended-release naltrexone (behavioral and pharmacological treatment)
  • harm reduction treatment and placebo

Over a 12-week period, the participants who received combined treatment – harm reduction and naltrexone medication – experienced significant reductions in alcohol use (59% reduction in drinks compared to their heaviest drinking days pre-treatment) and also in health and wellbeing, including a 43% reduction in harm from alcohol use, 29% less frequent drinking, and 10% increase in how people viewed their own health.

Why it’s complicated – The differences in results between the groups that participated in harm reduction treatment alone and those that received medication were not as consistent. Therefore, the researchers are not sure just how much benefit is associated with taking the extended-release naltrexone. The team suggested that an integrated approach (behavioral and pharmacological) should be further investigated and recommended that future research examine whether a “maintenance treatment approach could extend the positive outcome trajectories.”

Conversation & Perspectives –

  • An announcement from Washington State University points out that the study findings prove that abstinence is not necessary for people with AUD to experience drinking reduction and health improvements. The findings hold promise for people who are not experiencing homelessness as well.
  • An article from the Addiction Center network shares data from the National Coalition that says 38% of people experiencing homelessness are alcohol dependent. The authors point out that the difficulty of living on the streets can contribute to addiction.
  • A study on Health Affairs reveals that COVID-19 has called attention to the serious problem of housing insecurity and its link to many social determinants of health, thus calling attention to the need for more safety nets and effective policies.
  • @capitalandmain (online publication) comments on another study focused on addiction and homelessness in Los Angeles, CA, tweeting: “A study found drug and alcohol overdose as one of the key drivers of homeless deaths in the first half of 2020. Overdose deaths increased by 33% during the first seven months of 2020.”
  • @jamie_daw (assistant professor of health policy and management at Columbia SPH) also looks at another ground-breaking research effort, the New Leaf Project: “A Canadian study gave $7,500 to homeless people. What happened? They moved into stable housing faster, saved money, decreased spending on drugs, tobacco, and alcohol and increased spending on food, clothes, and rent.”
  • @VACtrHomeless talks about a related study among veterans, sharing: “Researchers at VISN6 MIRECC and @VACtrHomeless @jtsailab examine alcohol use among veterans with PTSD. Upstream of homelessness? ….”

In practice – Our clinical primers help mental health professionals understand the nuances of addiction, relapse, and the drive-reward system, and how to treat alcohol use disorder using MAT. Psychiatrist Michael McGee shares his personal experience with the homeless population and mental health. See also the American Psychiatric Association’s recent “Homelessness and Mental Health” curated collection by Lilanthi Balasuriya, MD, and Lisa B. Dixon, MD, MPH.

Last Updated: May 7, 2021