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The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management

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Roger S McIntyre, Martin Alda, Ross J Baldessarini, Michael Bauer, Michael Berk, Christoph U Correll, Andrea Fagiolini, Kostas Fountoulakis, Mark A Frye, Heinz Grunze, Lars V Kessing, David J Miklowitz, Gordon Parker, Robert M Post, Alan C Swann, Trisha Suppes, Eduard Vieta, Allan Young, Mario Maj

Original languageEnglish
Pages (from-to)364-387
Number of pages24
JournalWorld Psychiatry
Volume21
Issue number3
DOIs
Published1 Oct 2022

Bibliographical note

Funding Information: R. McIntyre has received a research grant support from CIHR/GACD/Chinese National Natural Research Foundation. M. Berk is supported by a National Health and Medical Research Senior Principal Research Fellowship (grant no. 1156072). R.J. Baldessarini is supported by a grant from the B.J. Anderson Foundation. Publisher Copyright: © 2022 World Psychiatric Association.

King's Authors

Abstract

Bipolar disorder is heterogeneous in phenomenology, illness trajectory, and response to treatment. Despite evidence for the efficacy of multimodal-ity interventions, the majority of persons affected by this disorder do not achieve and sustain full syndromal recovery. It is eagerly anticipated that combining datasets across various information sources (e.g., hierarchical "multi-omic" measures, electronic health records), analyzed using advanced computational methods (e.g., machine learning), will inform future diagnosis and treatment selection. In the interim, identifying clinically meaningful subgroups of persons with the disorder having differential response to specific treatments at point-of-care is an empirical priority. This paper endeavours to synthesize salient domains in the clinical characterization of the adult patient with bipolar disorder, with the overarching aim to improve health outcomes by informing patient management and treatment considerations. Extant data indicate that characterizing select domains in bipolar disorder provides actionable information and guides shared decision making. For example, it is robustly established that the presence of mixed features - especially during depressive episodes - and of physical and psychiatric comorbidities informs illness trajectory, response to treatment, and suicide risk. In addition, early environmental exposures (e.g., sexual and physical abuse, emotional neglect) are highly associated with more complicated illness presentations, inviting the need for developmentally-oriented and integrated treatment approaches. There have been significant advances in validating subtypes of bipolar disorder (e.g., bipolar I vs. II disorder), particularly in regard to pharmacological interventions. As with other severe mental disorders, social functioning, interpersonal/family relationships and internalized stigma are domains highly relevant to relapse risk, health outcomes, and quality of life. The elevated standardized mortality ratio for completed suicide and suicidal behaviour in bipolar disorder invites the need for characterization of this domain in all patients. The framework of this paper is to describe all the above salient domains, providing a synthesis of extant literature and recommendations for decision support tools and clinical metrics that can be implemented at point-of-care.

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