In-person interpreters are underused, contributing to health inequities among medically complex inpatients with non-English language preference (NELP). To integrate a machine learning and informatics algorithm into clinical and language services workflows to increase the use of in-person interpreters among complex inpatients with NELP. We conducted a two-armed stepped-wedge cluster randomized trial from May 1, 2023, to June 21, 2024, at Mayo Clinic Rochester across 35 inpatient units, including hospital floors, ICUs, and emergency department. Units were randomized to transition between standard care and intervention phases every 60 days. Adult inpatients ≥ 18 years with NELP in acute care settings. We used the algorithm to identify and order inpatients with medical complexity and NELP. Among patient admissions in the intervention arm, we shared the ordered list with language services, who did targeted outreach to bedside nurses via a secure chat message. The message stated that the patient would benefit from an in-person interpreter and provided contact details to reach language services. Primary outcome was use of in-person interpreter services; secondary outcome assessed time from study entry to first interpreter visit. We enrolled 749 control and 672 intervention unique admissions. Time to receiving interpreter did not differ between groups (HR = 1.02, 95

BackgroundPatients with language barriers encounter healthcare disparities, which may be alleviated by leveraging interpreter skills to reduce cultural, language, and literacy barriers through improved bidirectional communication. Evidence supports the use of in-person interpreters, especially for interactions involving patients with complex care needs. Unfortunately, due to interpreter shortages and clinician underuse of interpreters, patients with language barriers frequently do not get the language services they need or are entitled to. Health information technologies (HIT), including artificial intelligence (AI), have the potential to streamline processes, prompt clinicians to utilize in-person interpreters, and support prioritization.MethodsFrom May 1, 2023, to June 21, 2024, a single-center stepped wedge cluster randomized trial will be conducted within 35 units of Saint Marys Hospital & Methodist Hospital at Mayo Clinic in Rochester, Minnesota. The units include medical, surgical, trauma, and mixed ICUs and hospital floors that admit acute medical and surgical care patients as well as the emergency department (ED). The transitions between study phases will be initiated at 60-day intervals resulting in a 12-month study period. Units in the control group will receive standard care and rely on clinician initiative to request interpreter services. In the intervention group, the study team will generate a daily list of adult inpatients with language barriers, order the list based on their complexity scores (from highest to lowest), and share it with interpreter services, who will send a secure chat message to the bedside nurse. This engagement will be triggered by a predictive machine-learning algorithm based on a palliative care score, supplemented by other predictors of complexity including length of stay and level of care as well as procedures, events, and clinical notes.DiscussionThis pragmatic clinical trial approach will integrate a predictive machine-learning algorithm into a workflow process and evaluate the effectiveness of the intervention. We will compare the use of in-person interpreters and time to first interpreter use between the control and intervention groups.Trial registrationNCT05860777. May 16, 2023.

Background: Prior research indicates that depression and chronic pain commonly co-exist and impact each other. Interdisciplinary pain rehabilitation programs (IPRPs) have been shown to lead to statistically and clinically significant improvements for patients who report both depressed mood and chronic pain, however there is a gap in the literature regarding the mechanisms by which these improvements occur. Methods. This two-site, distinct sample study (Study 1: N = 303, 10-week, individual format, ACT-based program; Study 2: N = 406, 3-week, group format, CBT-based program) evaluated mediators of treatment improvement in depressive symptoms among adult IPRP participants who reported elevated depressive symptoms at program admission and examined treatment mechanisms for depressive symptoms. Results: Self-reported pain self-efficacy and pain catastrophizing - particularly the helplessness domain - mediated the treatment-related change in depression among IPRP participants with elevated depressive symptoms across the two sites and samples. In one sample, full mediation was achieved while in the other sample, partial mediation was achieved. Participants in both samples showed improvement on all measures. Limitations: This study relied on self-report measures of depressive severity and not clinical diagnosis. Results may not generalize to other populations of patients with chronic pain. There was no control condition in either study. Conclusion: Increasing pain self-efficacy and decreasing a sense of helplessness are important treatment targets among IPRP participants who endorse symptoms of depression.

Introduction Patient satisfaction is defined as the perception that one’s general health care needs are being met. Prior research suggests that positive patient satisfaction with health care facilitates the physician–patient relationship and enhances quality of life. Objective The primary purpose of this study was to assess patient satisfaction (as measured by the Patient Satisfaction Questionnaire (PSQ-18)) of patients observed by general psychiatry residents and to examine the effects of depression and anxiety on patient satisfaction. A secondary purpose was to explore the effects of three 1-h mentalization-based skills training sessions on the PSQ-18 scores of psychiatric residents. We hypothesized that depressive and anxiety symptoms would negatively impact patient satisfaction. We hypothesized that patients’ satisfaction scores would improve after mentalization training. Methods This was a prospective case–controlled study, enrolling adult patients ( n = 157) referred for psychiatric assessment in a psychiatric resident outpatient clinic. The primary outcome was patient satisfaction as measured by the PSQ-18. This outcome was compared to anxiety and depression symptoms as measured by the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder 7-Item scale (GAD-7) questionnaires. Outcome data from the PSQ-18 were compared among residents before and after they completed mentalization training. The data were analyzed with univariate analyses and multiple linear regression. Results Overall the patients were satisfied with clinician communication and interpersonal manner (4.21 ± 0.66 and 4.15 ± 0.69, respectively). The patients score on PHQ-9 was inversely related to their scores on time spent (TS) ( p = 0.01) and accessibility/convenience (AC) ( p = 0.0009) subscales of the PSQ-18. GAD-7 score was inversely related to patients scores on AC subscale ( p = 0.01). Brief mentalization training for the providers did not impact patient satisfaction scores. Conclusions Our study reveals that depression and anxiety can negatively impact PSQ-18 patient scoring in psychiatric outpatients observed for the first time in a resident clinic. However, this study failed to show that a brief mentalization-based training could improve patient satisfaction scores that were already quite high at baseline.

Abstract Background Patients taking chronic opioids are at high risk of opioid induced adrenal insufficiency (OIAI). Previously, we showed that the prevalence of OIAI was 9% based on low morning cortisol, corticotropin (ACTH), and dehydroepiandrosterone sulfate (DHEAS). Data on the overnight metyrapone test to diagnose OIAI are sparse. We aimed to determine the prevalence of OIAI using overnight metyrapone test and identify changes in the steroid metabolome of patients treated with opioids. Methods Cross-sectional study of adult patients treated with opioid therapy of at least 20 morphine milligram equivalents (MME)/day for at least 3 months. Measurements included ACTH, cortisol, and DHEAS. Overnight metyrapone test was administered in all patients, and 24h urine steroid profiling was optional (25 steroids measured by liquid chromatography mass spectrometry1). All patients completed the quality-of-life survey (AddiQoL). Prevalence of OIAI was defined as sum of post-metyrapone 11-deoxycortisol and cortisol of <15 mcg/dL. Result: In 22 patients (median age 59 years [range, 38-74], 9, 41% women), median MME was 33 (20-161) mg, and median cumulative opioid exposure was 245 (10-2550) mg*years. Following the overnight metyrapone test, 7 (32%) patients were diagnosed with OIAI. Patients with OIAI had lower DHEAS concentrations (median of 21 mcg/dL[ 5-113] vs 54 [22-173], p =0. 03), but not cortisol (median 10[5.3-16] mcg/dL vs 13[5.3-22], p=0. 06) or ACTH (median 27[8.1-51] pg/mL vs 26[5.9-55], p=0.8). Patients with OIAI were treated with higher daily MME (100 mg[30-150] vs 30[20-161], p=0. 03) and had a higher cumulative exposure to opioids (median, 660 mg*years [250-2250] vs 150 [10-1288], p =0. 01). AddiQol scores were similar between groups (median of 68[56-84] vs 73[48-83], p= 0.97). Urine steroid profiling was performed in 18 patients. Patients with OIAI demonstrated 4 times lower total urine glucocorticoids (16334 mcg/24h vs 4377 mcg/24h, p=0. 003), all <10% of the reference range, and 3 times lower total urinary androgens (median of 805 mcg/24h vs 2320 mcg/24h, p=0.14). Conclusion Prevalence of OIAI using overnight metyrapone test is high at 32%. Patients diagnosed with OIAI were treated with higher doses of MME/day and had a higher cumulative exposure to opioids when compared to those without OIAI. Applying 24h urine steroid profiling we showed that total glucocorticoids are 4 times lower in those with OIAI (and all <10% of reference ranges) as opposed to those without OIAI. We showed that baseline measurements of ACTH, DHEAS, and cortisol may incorrectly exclude OIAI, and a dynamic test, such as overnight metyrapone test is needed when suspicion for OIAI is high. | 1. Hines JM, Bancos I, Bancos C, et al. High-Resolution, Accurate-Mass (HRAM) Mass Spectrometry Urine Steroid Profiling in the Diagnosis of Adrenal Disorders. Clin Chem. 2017;63(12): 1824-1835. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Coronavirus disease 2019 (COVID-19) has caused unprecedented changes in how health care institutions care for patients, disproportionately impacting the provision of health care among vulnerable populations. Furthermore, COVID-19 has highlighted health and health care disparities among minorities,1Hooper M.W. Nápoles A.M. Pérez-Stable E.J. COVID-19 and racial/ethnic disparities.JAMA. 2020; 323: 2466-2467Crossref PubMed Scopus (1520) Google Scholar many of whom have language barriers or limited English proficiency (LEP).1Hooper M.W. Nápoles A.M. Pérez-Stable E.J. COVID-19 and racial/ethnic disparities.JAMA. 2020; 323: 2466-2467Crossref PubMed Scopus (1520) Google Scholar Patients with LEP are defined as individuals who do not speak English as their primary language and have a limited ability to read, write, speak, or understand English.2LEP.gov. Commonly Asked Questions and Answers Regarding Limited English Proficient (LEP) Individuals. https://www.lep.gov/sites/lep/files/media/document/2020-03/042511_QA_LEP_General_0.pdf. Accessed Noveber 12, 2020.Google Scholar A mandate compels US institutions accepting federal funding to provide interpretation services to patients with LEP enhancing bidirectional communication to mitigate disparities during health care interactions.3VanderWielen L.M. Enurah A.S. Rho H.Y. et al.Medical interpreters: improvements to address access, equity, and quality of care for limited-English-proficient patients.Acad Med. 2014; 89: 1324-1327Crossref PubMed Scopus (37) Google Scholar It is vital during COVID-19 when populations with LEP are at increased risk of hospitalization to bolster trustworthy and accurate interpretation. Mayo Clinic Rochester (MCR) needed to preserve personal protective equipment for frontline clinicians during COVID-19; therefore, in-person interpretation for patients with confirmed COVID-19 or COVID-19 rule-outs (positivity uncertain) was discontinued. Mayo Clinic Rochester continued normal interpreter practice for non–COVID-19 patients. MCR is one of three institutions in the United States with an established program for providing complex care to international patients. Therefore, global travel restrictions impacting international patients' ability to reach the United States substantially impacted MCR's usual inpatient population. Additionally, with increasing COVID-19 regional referrals, MCR admitted larger numbers of Spanish-speaking patients with severe COVID-19.4O'Horo J.C. Cerhan J.R. Cahn E.J. et al.Outcomes of COVID-19 With the Mayo Clinic.Model of Care and Research. 2021; 96: 601-618Google Scholar Similar to other institutions, MCR could not meet the demand for Spanish interpretation and increasingly adopted outside telephone and video interpretation to meet language needs (using programs such as Language Line and Insight).5LanguageLine SolutionsLanguageLine and Insight.https://www.languageline.comGoogle Scholar Before COVID-19, fixed tablets were installed in high-acuity patient rooms such as in the intensive care units, emergency department, and some acute care units to facilitate video consultations (using a program such as Intouch).6Intouch Health and InDemand Interpreting Partnership Enables Clinicians to Connect With Interpreters.https://intouchhealth.com/indemand-interpreting-partners-with-intouch-health/Google Scholar Although not previously implemented, with COVID-19, video-enabled interpretation using Intouch was integrated into interpretation services connecting remote interpreters to inpatients. If an Intouch screen was not available in the patient's room, interpreters connected via other applications such as Zoom or Insight to patient and family smartphones or hospital iPads. With visitor restrictions, patients with LEP are isolated and susceptible to poor communication and lack of advocacy at the bedside while hospitalized. The role of the interpreter may assume broader significance including as an advocate, cultural broker, or simply a language-concordant person with whom a patient with LEP can relate more easily.7Suarez N.R.E. Urtecho M. Jubran S. et al.The roles of medical interpreters in intensive care unit communication: a qualitative study.Patient Educ Couns. 2021; 104: 1100-1108Crossref PubMed Scopus (17) Google Scholar Without being present, it is challenging for an interpreter to do this. To compound the issue of remote interpretation, it is also likely that with severe and critical illness admissions related to COVID-19, interpreters were required to conduct especially challenging conversations to guide complex decision-making and therapeutic management. Several ethical considerations deserve attention. In-person interpretation is considered superior by most, especially during critical and serious illness conversations. Much work has examined clinician duty of care during pandemics. Although they are members of the health care team, interpreters do not have the same duty of care; however, they do have other ethical obligations to patients. Institutions have a responsibility to address the language needs of patients with LEP while simultaneously ensuring the safety of their employees, including interpreters. Empirical work to explore patient, caregiver, clinician, and interpreter experiences during COVID-19 would be helpful as institutions evaluate their responsibilities, quality of care, and systems issues that may impact the delivery of effective language services to patients with LEP.

Introduction Over 5.8?million people in the US are currently living with Alzheimer's disease (AD), the most common form of neurodegenerative dementia. More than 90% of individuals with AD experience neuropsychiatric symptoms (NPS), such as agitation, apathy, and depression. Agitation is one of the most common NPS, which not only accounts for 12% of health and social care costs but also increases the risk of mortality and caregiver burden. The most common treatments for agitation include psychotropic medications, used off-label, along with behavioral management strategies. Though the prevalence of AD is projected to rise to 13.8?million by 2050, there are no FDA-approved treatments for the severe agitation associated with this condition. Recent case series and prospective naturalistic reports have demonstrated evidence that electroconvulsive therapy (ECT), used widely for severe episodes of Major Depression in older adults, may be effective for reducing severe agitation in moderate to severe stages of Alzheimer's dementia. We describe an NIA funded study comparing the efficacy of ECT plus usual care (ECT + UC) versus simulated ECT plus usual care (S-ECT + UC) in decreasing agitation symptoms for individuals with AD. In order to minimize the potential for adverse cognitive effects associated with ECT, such as memory impairment, the present study has taken into consideration treatment modality, treatment modification, and treatment discontinuation to minimize adverse effects of ECT on cognition and the development of delirium. Methods The ECT-AD study aims to randomize 200 patients with a diagnosis of AD, severe agitation and a history of at least three prior failed trials of psychotropic medication. The patients will be admitted to the inpatient psychiatry units at Emory Wesley Woods Hospital, McLean Hospital, Mayo Clinic, Pine Rest Christian Mental Health Center, and Northwell Health. The consent will be provided by an authorized health care representative and assent will be obtained from patients. Subjects will be randomized to up to 9 ultra-brief pulse Right Unilateral (UB-RUL) ECT treatments plus usual care or simulated ECT plus usual care, blinding the inpatient treatment team to the study arm allocation. Previous research has not only established the comparability in regards to the safety and efficacy of UB-RUL ECT with more commonly practiced treatment modalities (i.e., brief pulse bitemporal (BP-BT) or BP-bifrontal (BP-BF)), but also demonstrated that there is reduced evidence for memory impairment associated with UB-RUL ECT than with either BP-BT or BP-BF. To mitigate the risk of cognitive side effects, this study will initiate UB-RUL for all patients. Seizures threshold will be established at treatment one, and subsequent treatments will be given at 6 x seizure threshold. Treatment modifications for this study include a switch from UB-RUL ECT to BP-BT ECT after the 6th ECT treatment if the patient has not demonstrated improvement. The treatment parameters will be switched to BP-BT for sessions 7 through 9, and charge dose would be determined using the half-age method. We established discontinuation procedures to minimize cognitive side effects, such as discontinuation due to change in eligibility (i.e., no longer meets agitation criteria on Cohen Mansfield Agitation Inventory (CMAI), development of delirium measured by the Confusion Assessment Method (CAM), or development of a cognitive adverse event as determined by persistent decreases on measures of the Severe Impairment Battery (SIB-8) or the Barthel Index (BI). Results A recent retrospective chart review of sixty patients with dementia and agitation from Emory suggests that UB-RUL ECT is safe and effective in reducing agitation in AD as measured by the Pittsburgh Agitation Scale (PAS), Global Assessment of Functioning (GAF) and number of psychotropic medications. The baseline PAS total was 9.3+/-3.7 and it decreased significantly after three (2.5+/-2.8) and six (1.5+/-2.3,) ECT treatments. No significant ECT-related medical complications were observed except transient confusion. There was a reduction in the number of psychotropic medications prescribed along with an increase in the global assessment of function (GAF) score after the ECT treatment course. We hypothesize that ECT+UC will be more efficacious in reducing severe agitation in AD subjects than S-ECT+UC. The primary efficacy outcome measure is the CMAI. The secondary efficacy outcome measures are the Neuropsychiatric Inventory – Clinician Version (NPI-C), Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change Scale (ADCS-CGIC), and PAS. Safety and tolerability will be assessed with the Severe Impairment Battery – 8 items (SIB-8) for cognitive decline, the CAM for the development of delirium, and adverse event monitoring. For subjects who exhibit floor effects on the SIB-8 at baseline, the Barthel Index (BI) will be used as a proxy measure of cognitive function. Conclusions The present study aims to demonstrate the safety and efficacy of ECT for treating severe agitation in individuals with AD using a randomized-controlled method while minimizing cognitive side effects through established baseline treatment parameters and treatment modification protocols. Results from this study will likely guide further research and help clinicians more effectively address severe agitation in patients with AD, including an improvement in quality of life for individuals with AD while decreasing caregiver burden and healthcare costs. This research was funded by: National Institute of Aging R01 AG061100-01

The purpose of this study was to estimate the extent of potential antidepressant overprescribing in a geographically defined U.S. population, and to determine the indications and factors that account for it. We conducted a cohort study of new antidepressant prescriptions for elderly residents of Olmsted County, Minnesota, 2005-2012, using the Rochester Epidemiology Project medical records-linkage system. Indications for antidepressants were abstracted from health records for all cohort members. Potential antidepressant overprescribing was defined based on regulatory approval, the level of evidence identified from a standardized drug information database, and multidisciplinary expert review. Predictors of potential antidepressant overprescribing were investigated using logistic regression models, stratified by general antidepressant indication (general medical indication, specific psychiatric diagnosis, and non-specific psychiatric symptoms). Potential antidepressant overprescribing occurred in 24% of 3199 incident antidepressant prescriptions during the study period, and involved primarily newer antidepressants that were prescribed for non-specific psychiatric symptoms and subthreshold diagnoses. Potential antidepressant overprescribing was associated with nursing home residence, having a higher number of comorbid medical conditions and outpatient prescribers, taking more concomitant medications, having greater use of urgent or acute care services in the year preceding the index antidepressant prescription, and being prescribed antidepressants via telephone, e-mail, or patient portal. In conclusion, potential antidepressant overprescribing occurred in elderly persons and involved mainly newer antidepressants used for non-specific psychiatric symptoms and subthreshold diagnoses, and was associated with indicators of higher clinical complexity or severity and with prescribing without face-to-face patient contact.

Background: Item 9 of the Patient Health Questionnaire (PHQ) evaluates passive thoughts of death or self-injury within the last two weeks, and is often used to screen depressed patients for suicide risk. We aimed to validate the PHQ-9 item 9 with a brief electronic version of the Columbia Suicide Severity Rating Scale (eC-SSRS). Methods: We analyzed data from 841 patients enrolled in the National Network of Depression Centers Clinical Care Registry. We performed a validation analysis of PHQ-9 item 9 for suicide risk and ideation, using the eC-SSRS as a gold standard (defined as positive response to suicidal ideation with intent to act or recent suicidal behavior). Results: Of the 841 patients, 13.4% and 41.1% were assessed as being positive for suicide risk by the eC-SSRS and PHQ-9 item 9, respectively. For the overall cohort, sensitivity was 87.6% (95% CI 80.2-92.5%), specificity was 66.1% (95% CI 62.6-69.4%), PPV was 28.6% (95% CI 24.1-33.6%), and NPV was 97.2% (95% CI 95.3-98.3%) for the PHQ-9 suicide item. These performance measures varied within subgroups defined by demographic and clinical characteristics. In addition, the validity of PHQ-9 item 9 (cutoff score of 1) with eC-SSRS-defined suicide ideation showed overall poor results. Limitations: The gold standard used in our study was a surrogate measure of suicidality based on eC-SSRS scores. Conclusions: The results of our study suggest that item 9 of the PHQ-9 is an insufficient assessment tool for suicide risk and suicide ideation, with limited utility in certain demographic and clinical subgroups that requires further investigation.

Objectives: The purpose of this study was to identify clinical and psychosocial factors involved in transitioning hospitalized patients receiving electroconvulsive therapy (ECT) from the inpatient to the outpatient setting and to propose an algorithm to guide clinicians with this process. Methods: A retrospective chart review was completed for adult patients discharged from a psychiatric hospital from 2002 to 2012 who had an acute course of ECT that was initiated in the hospital and completed as an outpatient. We reviewed demographic and clinical information and outcomes, including ECT treatments. Results: Among the 277 patients who were identified, the mean age was 52.2 years, 60% were women, and 66% were married. The mean length of hospital stay was 12.9 days, and the mean number of ECT treatments was 4.9 as an inpatient and 3.1 as an outpatient. The most frequent primary diagnosis was depression. Most patients (81%) had a responsible adult at home. Patients had good cognitive functioning at both baseline and discharge, and showed improved functional status at discharge ( P <0.001 for change in scores on the Global Assessment of Functioning from admission to discharge). Conclusions: Factors such as improved cognitive and functional status from admission to discharge, a medically uncomplicated course, and a responsible adult at home were observed among patients transitioned from inpatient to outpatient ECT. On the basis of these study results, a review of the literature, and clinical experience, an algorithm to assist clinical decisions for ECT transitioning was developed.

Objectives This naturalistic prospective observation study examines the efficacy of electroconvulsive therapy (ECT) in treating dementia-related agitation. Methods Patients with dementia-related agitation who received ECT were compared with patients with the same condition who did not receive ECT using Cohen-Mansfield Agitation Inventory (CMAI), Neuropsychiatric Inventory (NPI)—nursing home version, and Clinical Global Impression Scale (CGI). Outcomes were compared between ECT-treated and non–ECT-treated patients. Results A total of 9 patients were included in the study. Six received ECT, and 3 did not. Patients in the ECT and non–ECT-treated groups had comparable baseline scores (CMAI, P = 0.880; NPI, P = 0.814; and CGI, P = 0.445). The CMAI, NPI, and CGI scores were lower on final assessment in both groups with no statistically significant difference (CMAI, P = 0.771; NPI, P = 0.243; and CGI, P = 0.519). Conclusions Electroconvulsive therapy should be considered as a treatment option in the management of severe treatment refractory dementia-related agitation.

As patients receiving maintenance electroconvulsive therapy (MECT) age, many will acquire medical illnesses that may complicate their course of ECT and the treatment of their underlying psychiatric conditions. In this study, we present 7 cases of patients receiving MECT whose medical illnesses resulted in clinical reassessment of whether or not MECT should be continued. We discuss clinical implications and considerations for treating medically ill patients with MECT.

Introduction: Identifying clinical and genetic risk factors associated with antidepressant-induced mania (AIM) may improve individualized treatment strategies for bipolar depression. Method: From 2009 to 2012, bipolar depressed patients, confirmed by DSM-IV-TR-structured interview, were screened for AIM. An AIM+ case was defined as a manic/hypomanic episode within 60 days of starting or changing dose of antidepressant, while an AIM-control was defined as an adequate (>= 60 days) exposure to an antidepressant with no associated manic/hypomanic episode. 591 subjects (205 AIM+ and 386 AIM-) exposed to an antidepressant and a subset of 545 subjects (191 AIM+ and 354 AIM-) treated with a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) were used to evaluate the association of AIM with phenotypic clinical risk factors previously published. 295 white subjects (113 AIM+ cases, 182 AIM-controls) were genotyped for 3 SLC6A4 variants: the 5-HTTLPR, single nucleotide polymorphism (SNP) rs25531, and the intron 2 variable number of tandem repeats (VNTR). Tests of association with AIM were performed for each polymorphism and the haplotype. Results: The only clinical risk factors associated with AIM in the overall and the SSRI + SNRI analysis was bipolar I subtype. The S allele of 5-HTTLPR was not significantly associated with AIM; however, a meta-analysis combining this sample with 5 prior studies provided marginal evidence of association (P = .059). The L-A-10 haplotype was associated with a reduced risk of AIM (P = .012). Discussion: Narrowly defined, AIM appears to be at greatest risk for bipolar I patients. Our haplotype analysis of SLC6A4 suggests that future pharmacogenetic studies should not only focus on the SLC6A4 promotor variation but also investigate the role of other variants in the gene. (C) Copyright 2015 Physicians Postgraduate Press, Inc.

ObjectivesTo determine whether clinical features of bipolar disorder, such as history of psychosis, and cardiovascular disease (CVD) risk factors contribute to a higher risk of CVD among patients with bipolar disorder.MethodsThis cross‐sectional study included a sample of 988 patients with bipolar I or bipolar II disorder or schizoaffective bipolar type confirmed by the Structured Clinical Interview for DSM‐IV‐TR disorders (SCID). Medical comorbidity burden was quantified utilizing the Cumulative Illness Severity Rating Scale (CIRS). This 13‐item organ‐based scale includes cardiac disease severity quantification. Confirmed by medical record review, patients who scored 1 (current mild or past significant problem) or higher in the cardiac item were compared by logistic regression to patients who scored 0 (no impairment), adjusting for CVD risk factors that were selected using a backwards stepwise approach or were obtained from the literature.ResultsIn a multivariate model, age [odds ratio (OR) = 3.03, 95% confidence interval (CI): 1.66–5.54, p < 0.0001], hypertension (OR = 2.43, 95% CI: 1.69–3.55, p < 0.0001), and history of psychosis (OR = 1.48, 95% CI: 1.03–2.13, p = 0.03) were associated with CVD. When CVD risk factors from the literature were added to the analysis, age (OR = 3.19, 95% CI: 1.67–6.10, p = 0.0005) and hypertension (OR = 2.46, 95% CI: 1.61–3.76, p < 0.01) remained significant, with psychosis being at the trend level (OR = 1.43, 95% CI: 0.96–2.13, p = 0.08).ConclusionsThe phenotype of psychotic bipolar disorder may reflect higher illness severity with associated cardiac comorbidity. Further studies are encouraged to clarify the effect of the disease burden (i.e., depression), lifestyle, and treatment interventions (i.e., atypical antipsychotics) on this risk association.

Background: We aimed to establish a bipolar disorder biobank to serve as a resource for clinical and biomarker studies of disease risk and treatment response. Here, we describe the aims, design, infrastructure, and research uses of the biobank, along with demographics and clinical features of the first participants enrolled.Methods: Patients were recruited for the Mayo Clinic Bipolar Biobank beginning in July 2009. The Structured Clinical Interview for DSM-IV was used to confirm bipolar diagnosis. The Bipolar Biobank Clinical Questionnaire and Participant Questionnaire were designed to collect detailed demographic and clinical data, including clinical course of illness measures that would delineate differential phenotypes for subsequent analyses. Blood specimens were obtained from participants, and various aliquots were stored for future research.Results: As of September 2014, 1363 participants have been enrolled in the bipolar biobank. Among these first participants, 69.0 % had a diagnosis of bipolar disorder type I. The group was 60.2 % women and predominantly white (90.6 %), with a mean (SD) age of 42.6 (14.9) years. Clinical phenotypes of the group included history of psychosis (42.3 %), suicide attempt (32.5 %), addiction to alcohol (39.1 %), addiction to nicotine (39.8 %), obesity (42.9 %), antidepressant-induced mania (31.7 %), tardive dyskinesia (3.2 %), and history of drug-related serious rash (5.7 %).Conclusions: Quantifying phenotypic patterns of illness beyond bipolar subtype can provide more detailed clinical disease characteristics for biomarker research, including genomic-risk studies. Future research can harness clinically useful biomarkers using state-of-the-art research technology to help stage disease burden and better individualize treatment selection for patients with bipolar disorder.

Lithium as a gold standard therapy for bipolar disorder is well known to have a number of medical comorbidities that impact renal, parathyroid, and thyroid function. Despite these medical comorbidities, there remains a group of lithium-responsive lithium-treated patients who have maintained mood stability for decades. The risk/benefit ratio of end organ toxicity/mood stability must be evaluated in each individual case.