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Bipolar disorder presents on a spectrum, with bipolar depression on one end and bipolar I on the other and a host of other presentations in between. In addition to its many permutations and the difficulty of differentiating between diagnoses, comorbidities, incorrect treatment, and low self-report contribute to delayed diagnoses and inappropriate or delayed treatment. Once a diagnosis is reached, the latest evidence of the safety and efficacy profiles of existing and emerging treatments adds to the complexity when developing treatment strategies for patients with bipolar disorder. As guidelines are updated and new treatments become available, developing individualized treatment regimens is key and collaboration between clinician and patient and family is critical in optimizing patient outcomes. New treatment options can reduce some of the side effect burdens associated with treating bipolar disorder, and clinicians should use measurement-based care to assess whether treatment changes are necessary, which requires engaging with the patient to monitor efficacy and manage side effects. It is important to ensure that the patient and family understand the information to foster informed decision making and create a better therapeutic alliance. Involving patients in designing their own treatment strategies according to their tolerability criteria can help combat the 90% nonadherence rate, and ultimately lead to better patient care.

Objectives Societal restrictions imposed to prevent transmission of COVID-19 may challenge circadian-driven lifestyle behaviours, particularly amongst those vulnerable to mood disorders. The overarching aim of the present study was to investigate the hypothesis that, in the routine-disrupted environment of the COVID-19, amongst a sample of people living with mood disorders, greater social rhythm disruption would be associated with more severe mood symptoms. Methods We conducted a two-wave, multinational survey of 997 participants [Formula: see text] who self-reported a mood disorder diagnosis (i.e., major depressive disorder or bipolar disorder). Respondents completed questionnaires assessing demographics, social rhythmicity (The Brief Social Rhythm Scale), depression symptoms (Patient Health Questionnaire-9), sleep quality and diurnal preference (The Sleep, Circadian Rhythms and Mood questionnaire) and stressful life events during the COVID-19 pandemic (The Social Readjustment Rating Scale). Results The majority of participants indicated COVID-19-related social disruption had affected the regularity of their daily routines to at least some extent ( n = 788, 79.1%). As hypothesised, lower social rhythmicity was associated with greater depressive symptoms when tested cross-sectionally (standardised β = −.25, t = −7.94, P = 0.000) and when tested using a 2-level hierarchical linear model across two time points ( b = −0.14, t = −3.46, df = 264, P ≤ 0.001). Conclusions These results are consistent with the social zeitgeber hypothesis proposing that mood disorders are sensitive to life events that disrupt social rhythms.

INTRODUCTION The aim of this paper was to present Social Rhythm Therapy, which has been modified from Interpersonal and Social Rhythm Therapy, by drawing on implementation science to describe a process that for integrating this into routine clinical practice. METHOD On the basis of the principles of user-centred design, we aimed to modify an existing psychosocial therapy for bipolar disorder to make this readily translatable into a range of clinical practice models which could be further modified based on feedback from end users. RESULTS Social Rhythm Therapy has been adapted from Interpersonal and Social Rhythm Therapy which has demonstrated efficacy in research settings. The adaptation was developed in order to facilitate implementation of some of the key components in routine clinical practice. It is short, relatively simple, easily learned and intended to be flexible. CONCLUSIONS Social rhythm therapy for bipolar disorder has many characteristics which may make it translatable into clinical practice in different settings. There is a need for studies into the clinical effectiveness of this intervention that has been modified from an evidence-based intervention.

The digital age poses new challenges for psychotherapy. More than four billion people worldwide use the Internet, and most of them engage with social media. Therapists are increasingly asked to help patients navigate the complex interface between online technology and relationships, but few are prepared to address this issue therapeutically. Interpersonal psychotherapy (IPT) is an evidence-based psychotherapy for depression and is focused on addressing interpersonal problems. The authors use the IPT framework to explore how therapists can discuss, during in-person sessions, the impact of technology on communication and relationships. The authors describe how therapists can preserve IPT's overarching goal of resolving interpersonal problems by adapting specific techniques to meet the needs of patients who routinely rely on technology to connect with others. Case vignettes illustrate techniques used to evaluate and modify technology-based communication, including problematic text-based interactions. Recommendations are provided for therapists seeking to meet the interpersonal needs of patients in the digital age.

Aim Symptoms of bipolar disorder (BD) include changes in mood, activity, energy, sleep and appetite. Since many of these processes are regulated by circadian function, circadian rhythm disturbance has been examined as a biological feature underlying BD. The International Society for Bipolar Disorders (ISBD) Chronobiology Task Force (CTF) was commissioned to review evidence for neurobiological and behavioural mechanisms pertinent to BD. Method Drawing upon expertise in animal models, biomarkers, physiology and behavior, CTF analyzed the relevant cross-disciplinary literature to precisely frame the discussion around circadian rhythm disruption in BD, highlight key findings, and for the first time integrate findings across levels of analysis to develop an internally consistent, coherent theoretical framework. Results Evidence from multiple sources implicates the circadian system in mood regulation, with corresponding associations with BD diagnoses and mood-related traits reported across genetic, cellular, physiological, and behavioral domains. However, circadian disruption does not appear to be specific to BD and is present across a variety of high-risk, prodromal and syndromic psychiatric disorders. Substantial variability and ambiguity among the definitions, concepts and assumptions underlying the research has limited replication and the emergence of consensus findings. Conclusions Future research in circadian rhythms and its role in BD is warranted. Well-powered studies that carefully define associations between BD-related and chronobiologically-related constructs, and integrate across levels of analysis will be most illuminating.

Social distancing/lockdown policies during the coronavirus (COVID-19) pandemic may alter social rhythms of people through imposition of restrictions on normal daily activities. This may in turn challenge circadian function, particularly in people with mood disorders. Although objective data describing the relationship between circadian disturbances and mood disorders exist, data regarding the subjective experience of circadian challenge is sparse, and its association with mood symptoms is unclear. The present qualitative study was one component of a mixed-methods multi-national project, which took advantage of widespread disruption to daily routines due to Government COVID-related lockdowns during 2020. The Behavior Emotion and Timing during COVID-19 (BEATCOVID) survey study included three open questions generating qualitative data on participants' subjective experience of social disruption due to social distancing/lockdown policies, two of which asked about the barriers and opportunities for stabilizing routines. Responses were coded and analyzed using Thematic Analysis. A total of N = 997 participants responded to at least one of the free-text questions. Four themes were identified: 1) loss of daily timed activities, 2) role of social interaction, 3) altered time perception and 4) disruption to motivation and associated psychological effects. Themes were organized into a provisional heuristic map, generating hypotheses for future research centered on the new concept of 'psychological drift.'

Fear of positive and negative evaluation is maladaptive and may result in psychosocial dysfunction. Although being diagnosed with mood disorders or experiencing childhood trauma may potentially affect fear of evaluation, previous studies examined this phenomenon mostly in social anxiety disorders. To fill this gap, we investigated the relationship between childhood trauma and fear of positive and negative evaluation in individuals with bipolar disorder (BD), depressive disorders (DD), and healthy controls (HC). 43 individuals with BD, 89 with DD, and 65 HC completed clinical interviews and self-report assessments. The relationship between participants' diagnoses and presence of trauma on fear of positive and negative evaluation was examined using ANCOVA. Independently of experiencing childhood trauma, fear of positive evaluation was significantly higher in individuals with mood disorders vs. HC. Fear of negative evaluation was significantly associated with diagnosis-by-trauma interaction. Significantly lower scores were observed in individuals with BD without childhood trauma compared to those with childhood trauma and individuals with DD. Compared to HC, more individuals with mood disorders experienced childhood trauma. While experiencing childhood trauma may increase vulnerability to mood disorders in general, it is especially detrimental for individuals with BD by increasing the risk for developing a fear of negative evaluation.

OBJECTIVE: Social rhythm irregularities are associated with increased bipolar disorder symptoms and suicide risk. This study was the first to examine the feasibility and acceptability of a 12-week social rhythm therapy (SRT) delivered pre-dominantly via telehealth (three in-person sessions, nine via video teleconferencing) to adolescents and young adults with bipolar disorder. The primary aim was to determine the feasibility and acceptability of SRT delivered predominantly via telehealth. Secondary aims were to explore the intervention’s impacts on social rhythm regularity, mood symptoms, and suicide propensity. METHODS: Thirteen adolescents and young adults with bipolar disorder received a modified SRT called Brain Emotion circuitry-targeted Self-Monitoring And Regulation Therapy for Daily Rhythms (BE-SMART-DR) administered mostly remotely, adjunctive to treatment as usual. Retention rates, client satisfaction, therapeutic alliance, and pre- to postintervention changes in social rhythm regularity, mood symptoms, and suicide propensity were assessed. RESULTS: BE-SMART-DR was associated with high retention rates (77%), high mean±SD scores on the Client Satisfaction Questionnaire (29.4±2.7), and high participant global scores on the Working Alliance Inventory (231.3±8.1), indicative of strong therapeutic alliance. Secondary outcome measures on social rhythm irregularities, mood symptoms, and suicide propensity decreased from pre- to posttherapy. Increased social rhythm regularity was associated with reduced suicide propensity after analyses were controlled for reductions in mood symptoms. CONCLUSIONS: These preliminary results indicate that SRT delivered largely by telemedicine is feasible and acceptable. The intervention appeared to reduce mood symptoms, and suicide propensity independent of mood symptoms, among adolescents and young adults with bipolar disorder.

Background Rhythms And You (RAY) is an online intervention for bipolar disorders (BD) based on Interpersonal and Social Rhythm Therapy. We examined RAY's feasibility and acceptability for individuals with BD recruited from primary care. Because online interventions may be more effective when paired with human support, we evaluated RAY with and without weekly brief (∼5 min) calls from clinical helpers (CH). Methods Participants (n = 47) meeting criteria for BD I, II or other specified BD, presenting for primary care, were randomly assigned to RAY, RAY-CH, or Adjunctive Reading Material (ARM) control. RAY consisted of 12 weekly online modules. ARM consisted of 12 weekly emails. Participants were assessed at baseline, 4, 8, and 12 weeks. Results RAY showed high completion rates and Client Satisfaction Questionnaire scores (36/47, 77% and 25.1 ± 5.5, respectively; no group differences). Effect sizes for RAY- CH ranged from small [Internal State Scale-Activation Subscale (ISS-ACT); d = 0.3] to large [SF-12 Mental Health Composite Score (SF-12 MHC); d = 1.3]. ARM also showed moderate effects (ISS-ACT d = 0.7; Quick Inventory of Depressive Symptoms, d = 0.8). SF-12 MHC scores showed a time*group interaction (F = 2.38, df = 6,32, p = 0.05) favoring RAY-CH. Number of logins trended toward significant association with improved social rhythm regularity (F = 4.09, df = 1, 17, p = 0.06). Limitations Sample size is small, limiting conclusions that can be drawn. Conclusions Remote delivery of RAY for individuals with BD is feasible and acceptable. More time spent engaged in RAY was associated with greater improvement in social rhythm regularity. Preliminary evidence suggests adding brief human support to RAY may yield better outcomes.

Objectives Limited prospective data, mostly focused on bipolar I disorder, suggests that pro-inflammatory cytokines are elevated in abnormal mood states. We evaluated whether treatment normalizes peripheral markers of inflammation in bipolar II disorder. Methods Using data from a randomized clinical trial of Interpersonal and Social Rhythm Therapy (IPSRT) + quetiapine vs. IPSRT + placebo for bipolar II depression, we examined whether these treatments for bipolar II depression impact inflammatory cytokines and whether observed changes in cytokines are associated with changes in depressive symptomatology as measured by the Hamilton Rating Scale for Depression (HRSD-17). Results Cytokine values were available for 33 participants who completed baseline and 20-week follow-up visits. After excluding those with CRP values > = 10 mg/L, there were 27 patients available for analysis (IPSRT + quetiapine N = 10, IPSRT + placebo N = 17). Baseline measure of inflammation did not appear to moderate treatment response, nor was change in HRSD-17 score correlated with changes in cytokines. Those who received IPSRT + quetiapine had significantly greater increases in IL-6 (p = 0.02) and TNF-α (p = 0.04), even after adjusting for changes in body mass index, than the IPSRT alone group. Descriptively, the quetiapine group showed increases in pro-inflammatory and decreases in anti-inflammatory cytokines and the psychotherapy group showed reduced pro-inflammatory cytokines. Conclusions Despite both groups showing depression improvement, this small study suggests a more pro-inflammatory cytokine profile over time with quetiapine plus psychotherapy compared to psychotherapy alone. Elevated risk of cardiovascular morbidity and mortality among those with bipolar II disorder underscores the importance of delivering treatments that do not exacerbate these risk factors.

Bipolar II disorder causes significant suffering among patients and their families, some of which may be alleviated by psychotherapy alone or as an adjunct to pharmacotherapy. Psychotherapies may be more effective if modified to meet the specific needs of patients with bipolar II disorder.

Background Interpersonal Psychotherapy (IPT) is an affect- and relationally focused, time-limited treatment supported by research spanning >4 decades. IPT focuses on stressful interpersonal experiences of loss, life changes, disputes, and social isolation. It emphasizes the role of relationships in recovery. This scoping review describes, within a historical perspective, IPT's evolution as an evidence-supported treatment of psychiatric disorders. Methods English-language publications (n = 1119) identified via EMBASE, MEDLINE, PsycINFO, and Web of Science databases (1974-2017), augmented with manual reference searches, were coded for clinical focus, population demographics, format, setting, publication type, and research type. Quantitative and qualitative analyses identified IPT publications' characteristics and trends over four epochs of psychotherapy research. Results IPT literature primarily focused on depression (n = 772 articles; 69%), eating disorders (n = 135; 12%), anxiety disorders (n = 68; 6%), and bipolar disorder (n = 44; 4%), with rising publication rates and numbers of well-conducted randomized, controlled trials over time, justifying inclusion in consensus treatment guidelines. Research trends shifted from efficacy trials to effectiveness studies and population-based dissemination initiatives. Process research examined correlates of improvement and efficacy moderators. Innovations included global initiatives, prevention trials, and digital, web-based training and treatment. Conclusion Sparked by clinical innovations and scientific advances, IPT has evolved as an effective treatment of psychiatric disorders across the lifespan for diverse patients, including underserved clinical populations. Future research to elucidate mechanisms of change, improve access, and adapt to changing frameworks of psychopathology and treatment planning is needed. IPT addresses the universal centrality of relationships to mental health, which is as relevant today as it was over 40 years ago.

Discerning distinct neurobiological characteristics of related mood disorders such as bipolar disorder type-II (BD-II) and unipolar depression (UD) is challenging due to overlapping symptoms and patterns of disruption in brain regions. More than 60% of individuals with UD experience subthreshold hypomanic symptoms such as elevated mood, irritability, and increased activity. Previous studies linked bipolar disorder to widespread white matter abnormalities. However, no published work has compared white matter microstructure in individuals with BD-II vs. UD vs. healthy controls (HC), or examined the relationship between spectrum (dimensional) measures of hypomania and white matter microstructure across those individuals. This study aimed to examine fractional anisotropy (FA), radial diffusivity (RD), axial diffusivity (AD), and mean diffusivity (MD) across BD-II, UD, and HC groups in the white matter tracts identified by the XTRACT tool in FSL. Individuals with BD-II (n = 18), UD (n = 23), and HC (n = 24) underwent Diffusion Weighted Imaging. The categorical approach revealed decreased FA and increased RD in BD-II and UD vs. HC across multiple tracts. While BD-II had significantly lower FA and higher RD values than UD in the anterior part of the left arcuate fasciculus, UD had significantly lower FA and higher RD values than BD-II in the area of intersections between the right arcuate, inferior fronto-occipital and uncinate fasciculi and forceps minor. The dimensional approach revealed the depression-by-spectrum mania interaction effect on the FA, RD, and AD values in the area of intersection between the right posterior arcuate and middle longitudinal fasciculi. We propose that the white matter microstructure in these tracts reflects a unique pathophysiologic signature and compensatory mechanisms distinguishing BD-II from UD.

The association of unipolar depression (UD), relative to healthy controls (HC), with cortical myelin is underexplored, despite growing evidence of associations with white matter tract integrity. We characterized cortical myelin in the 360 Glasser atlas regions using the T1w/T2w ratio in 39 UD and 47 HC participants (ages=19-44, 75% female). A logistic elastic net regularized regression with nested cross-validation and a subsequent linear discriminant analysis conducted on held-out samples were used to select brain regions and classify UD vs. HC. True-label model performance was compared against permuted-label model performance. Cortical myelin distinguished UD from HC with 68% accuracy (p

BackgroundDepression and obesity often co-occur but the underlying neural mechanisms for this bidirectional link are not well understood. Using fMRI, we examined how the relationship between Body Mass Index (BMI) and dimensional lifetime depression severity was associated with brain activation during food anticipation and pleasant/unpleasant rating.Methods90 participants (48 healthy controls, 42 with unipolar depression (UD), 69 female, age=28.5±6.6) were fMRI-scanned while performing the Food and Object Cued Encoding task consisting of food/object anticipation and food/object pleasant/unpleasant rating phases.ResultsThe analysis across all participants revealed a significant BMI-by-lifetime depression severity interaction on RIFG activation during food anticipation (pConclusionsThe IFG is involved in emotion regulation and response inhibition necessary to control appetitive behavior. Greater RIFG activation during pleasant/unpleasant rating of food coupled with low ratings of food liking and wanting could be associated with inhibition of cognitive and emotional response to food in UD. This process may be cognitively challenging and stressful thus putting affected individuals with UD at risk for weight gain and worsening of depression.

Distinguishing bipolar disorder (BD) from major depressive disorder (MDD) is clinically challenging, especially during depressive episodes. While both groups are characterized by aberrant working memory and anticipatory processing, the role of these processes in discriminating BD from MDD remains unexplored. In this study, we examine how brain activation corresponding to anticipation of and performance on easy vs. difficult working memory tasks with emotional stimuli contributes to discrimination among BD, MDD, and healthy controls (HC). Depressed individuals with BD (n = 18), MDD (n = 23), and HC (n = 23) were scanned while performing a working memory task in which they had to first anticipate performance on 1-back (easy) or 2-back (difficult) tasks with happy, fearful, or neutral faces, and then, perform the task. Anticipation-related and task-related brain activation was measured in the whole brain using functional magnetic resonance imagining. We used an elastic-net regression for variable selection, and a random forest classifier for BD vs. MDD classification. The former selected the activation differences (1-back minus 2-back) in the lateral and medial prefrontal cortices (PFC) during task anticipation and performance on the working memory tasks with fearful and neutral faces as variables relevant for BD vs. MDD classification. BD vs. MDD were classified with 70.7% accuracy (p

Bipolar disorder is a recurrent psychiatric disorder marked by waxing and waning affective symptoms and impairment in functioning. Some of the morbidity and mortality associated with the illness may be reduced with evidence-based psychotherapies (EBPs) along with pharmacotherapy. To enhance clinicians’ understanding of which therapy modalities have evidence supporting their use, the authors conducted a systematic literature review to identify randomized controlled trials (RCTs) of psychotherapy for adults with bipolar disorder. A strong evidence base exists for psychoeducation, cognitive-behavioral therapy, family-focused therapy, interpersonal and social rhythm therapy, and peer-support programs. Promising modalities include functional remediation, mindfulness-based cognitive therapy, illness management and recovery, and technology-assisted strategies. RCTs demonstrate a consistent advantage of these psychotherapies plus pharmacotherapy, compared with the use of pharmacotherapy alone. Adjunctive EBPs hasten time to remission, delay time to recurrence, and improve functional outcomes. EBPs play an important role in helping individuals develop skills needed to manage the persistent and lifelong psychosocial, neurocognitive, vocational, and interpersonal consequences of bipolar disorder. Continued efforts to improve the effectiveness of EBPs for adults with bipolar disorder are warranted.

Objective Treatment of maternal depression with psychotherapy has been shown to confer indirect benefits to school-age offspring with psychiatric disorders. The current study sought to understand mechanisms by which improvement in depressed mothers, with and without histories of trauma and treated with psychotherapy, produce changes in children who struggle with psychiatric illnesses themselves. We hypothesized that maternal history of childhood trauma would moderate the relationship between maternal and child outcomes and that increased positive and decreased negative parenting behaviors would mediate the relationship between maternal and child outcomes. We also examined whether maternal history of trauma would moderate the mediational effects of parenting behaviors. Methods Participants were dyads (n = 62) of mothers with major depressive disorder and their children, ages 7–18, with at least one internalizing disorder. Mothers were treated with nine sessions of psychotherapy and children were treated openly in the community. Dyads were evaluated every three months over one year. Results Maternal improvement in depressive symptoms was associated, in a lagged fashion, with child improvement in functioning six months later. There was a significant interaction of time and change in maternal symptoms [F(1, 45) = 5.84, p = 0.02], where change in maternal depressive symptoms from baseline to six months was robustly associated with change in child functioning from baseline to 12 months (β = 0.49, p = 0.0002). Maternal history of childhood sexual abuse moderated the association between change in maternal and child depressive symptoms [F(1,87) = 5.8, p = 0.02], and maternal history of physical neglect moderated the relationship between improvement in maternal depression and improvement in child functioning [F(1,36) = 4.34, p = 0.04], where significant associations between maternal and child outcomes were only found in mothers without histories of sexual abuse or physical neglect. Increase in positive parenting strategies (acceptance) by mothers mediated 6-month lagged associations between maternal and child outcomes, but reduction in negative parenting strategies (psychological control) did not. Maternal history of childhood emotional neglect moderated the mediational model, such that improved positive parenting did not explain lagged improvement in child depression among the subset of mothers with childhood histories of emotional neglect. Conclusions In dyads comprised of depressed mothers and school-age children with internalizing disorders, children improved when mothers improved, but not among those whose mothers who had histories of sexual abuse or physical neglect. Increased use of positive parenting strategies among mothers accounted for lagged relationships between improvement in maternal depressive symptoms and improvement in child functioning. This pattern was not, however, observed among mothers with childhood histories of emotional neglect. Interventions that directly enhance positive parenting and more rapidly change these behaviors may hasten improvement in offspring. Offspring of depressed mothers with histories of early trauma are at high risk for poor outcomes, even when their mothers receive depression treatment.

Objective Social relationships play important roles in emotional health, and are common targets of psychotherapeutic interventions. To better evaluate social relationship structure and function in the context of psychotherapy trials, this study introduces and psychometrically evaluates the Social Network Quality (SNQ) scales, which supplement the Social Network Index (SNI). The original SNI evaluates social network structure (i.e., extent of participation in diverse social roles and number of social relationships). The SNQ adds two social network quality scales evaluating levels of: (a) positivity/support, and (b) negativity/stress, within and across specific social roles. Method Participants included 168 depressed mothers of psychiatrically-ill children participating in a psychotherapy treatment trial utilizing interpersonal therapy (IPT) and brief supportive therapy (BSP). The SNI, SNQ, and measures of social functioning and psychopathology were collected at baseline and at 3-month intervals over a one-year period. Results SNQ scores showed meaningful concurrent relationships with measures of social support and interpersonal distress, as well as incremental utility in explaining variance in relationship and mood outcomes above and beyond the SNI. SNQ scores also detected global and relationship-specific changes in social relationship quality following psychotherapy treatment. Conclusion This report demonstrates that SNQ scales reliably assess psychotherapy-induced changes in relationship quality.

Psychotherapists routinely use both specific and non-specific strategies to deliver empirically supported treatments (ESTs). Psychotherapy adherence monitoring has traditionally focused on assessing therapist use of EST-specific strategies (to distinguish between ESTs), paying less attention to non-specific techniques common to multiple psychotherapies. This study used the Collaborative Study Psychotherapy Rating Scale (CSPRS) to evaluate therapist use of both specific and non-specific techniques in two affect-focused ESTs for depression. Blinded raters evaluated 180 recorded sessions of interpersonal psychotherapy (IPT) and brief supportive psychotherapy (BSP). Because IPT and BSP both emphasize attention to affective states and developing a warm therapy relationship, we expected overlap across scales measuring therapist warmth, empathy, and focus on feelings. In contrast, we expected differences in scales measuring therapist directiveness, as well as IPT- and BST-specific interventions. Results showed raters displayed good inter-rater reliability on primary subscales and could discriminate between two treatments with considerable overlap. Both IPT and BSP therapists used similarly high levels of non-specific, facilitative interventions. Expectedly, IPT therapists were more directive and used more IPT-specific strategies, while BSP therapists utilized more non-directive, supportive strategies. Unexpectedly, BSP therapists showed greater focus on feelings than IPT therapists. Exploratory analyses suggested that greater focus on feelings in early sessions was associated with greater depressive symptom reduction in the first eight weeks of treatment for both ESTs. Additional treatment adherence research is needed to investigate both shared and distinctive features of ESTs, as well as the effect of the relative use of specific versus non-specific interventions on psychotherapy outcomes.

Bipolar disorder among pregnant women has deleterious effects on birth and child outcomes and is currently under-detected, not addressed effectively, or exacerbated through inappropriate treatment. The goal of this study was to identify perspectives of pregnant and postpartum women with bipolar disorder on barriers and facilitators to psychiatric treatment during pregnancy. In-depth interviews were conducted with pregnant and postpartum women who scored ≥ 10 on the Edinburgh Postnatal Depression Scale and met DSM-IV criteria for bipolar disorder I, II or not otherwise specified using the Mini International Neuropsychiatric Interview version 5.0. Interviews were transcribed, and resulting data were analyzed using a grounded theory approach to identify barriers and facilitators to bipolar disorder treatment access in pregnancy. Participant identified barriers included perception that psychiatric providers lack training and experience in the treatment of psychiatric illness during pregnancy, are reluctant to treat bipolar disorder among pregnant women, and believe that pharmacotherapy is not needed for psychiatric illness during pregnancy. Facilitators included participants' perception that providers' acknowledge risks associated with untreated or undertreated psychiatric illness during pregnancy and provide psycho-education about the risks, benefits and alternatives to pharmacotherapy. Psychiatric providers are critically important to the treatment of bipolar disorder and need knowledge and skills necessary to provide care during the perinatal period. Advancing psychiatric providers' knowledge/skills may improve access to pharmacotherapy for pregnant women with bipolar disorder.

Background Maternal depression is associated with increased risk of psychiatric illness in offspring. While risk may relate to depressed mothers’ difficulties regulating emotions in the context of interacting with offspring, physiological indicators of emotion regulation have rarely been examined during mother–child interactions—and never among mother–adolescent dyads in which both mother and adolescent have histories of major depressive disorder (MDD). Methods We examined changes in high-frequency heart rate variability (HF-HRV), an indicator of parasympathetic (vagal) function that has been related to depression, stress, social engagement, and emotion regulation, in 46 mother–daughter dyads (23 in which both mother and daughter had an MDD history and 23 never-depressed controls). Hierarchical linear models evaluated changes in HF-HRV while mother–daughter dyads engaged in discussions about shared pleasant events and relationship conflicts. Results While control dyads displayed positive slopes (increases) in HF-HRV during both discussions, MDD dyads displayed minimal change in HF-HRV across discussions. Among controls, HF-HRV slopes were positively correlated between mothers and daughters during the pleasant events’ discussion. In contrast, HF-HRV slopes were negatively correlated between MDD mothers and daughters during both discussions. Conclusions Vagal responses observed in control mother–daughter dyads suggest a pattern of physiological synchrony and reciprocal positive social engagement, which may play a role in adolescent development of secure social attachments and healthy emotion regulation. In contrast, MDD mothers and daughters displayed diminished and discordant patterns of vagal responsiveness. More research is needed to understand the development and consequences of these patterns of parasympathetic responses among depressed mother–daughter dyads.

There are substantial gaps in understanding near-term precursors of suicidal ideation in bipolar II disorder. We evaluated whether repeated patient-reported mood and energy ratings predicted subsequent near-term increases in suicide ideation.Secondary data were used from 86 depressed adults with bipolar II disorder enrolled in one of 3 clinical trials evaluating Interpersonal and Social Rhythm Therapy and/or pharmacotherapy as treatments for depression. Twenty weeks of daily mood and energy ratings and weekly Hamilton Depression Rating Scale (HDRS) were obtained. Penalized regression was used to model trajectories of daily mood and energy ratings in the 3 week window prior to HDRS Suicide Item ratings.Participants completed an average of 68.6 (sd=52) days of mood and energy ratings. Aggregated across the sample, 22% of the 1675 HDRS Suicide Item ratings were non-zero, indicating presence of at least some suicidal thoughts. A cross-validated model with longitudinal ratings of energy and depressed mood within the three weeks prior to HDRS ratings resulted in an AUC of 0.91 for HDRS Suicide item2, accounting for twice the variation when compared to baseline HDRS ratings. Energy, both at low and high levels, was an earlier predictor than mood.Data derived from a heterogeneous treated sample may not generalize to naturalistic samples. Identified suicidal behavior was absent from the sample so it could not be predicted.Prediction models coupled with intensively gathered longitudinal data may shed light on the dynamic course of near-term risk factors for suicidal ideation in bipolar II disorder.

Aims To systematically review the literature on the efficacy and tolerability of the major chronotherapeutic treatments of bipolar disorders (BD)-bright light therapy (LT), dark therapy (DT), treatments utilizing sleep deprivation (SD), melatonergic agonists (MA), interpersonal social rhythm therapy (IPSRT), and cognitive behavioral therapy adapted for BD (CBTI-BP)-and propose treatment recommendations based on a synthesis of the evidence. Methods PRISMA-based systematic review of the literature. Results The acute antidepressant (AD) efficacy of LT was supported by several open-label studies, three randomized controlled trials (RCTs), and one pseudorandomized controlled trial. SD showed rapid, acute AD response rates of 43.9%, 59.3%, and 59.4% in eight case series, 11 uncontrolled, studies, and one RCT, respectively. Adjunctive DT obtained significant, rapid anti-manic results in one RCT and one controlled study. The seven studies on MA yielded very limited data on acute antidepressant activity, conflicting evidence of both antimanic and maintenance efficacy, and support from two case series of improved sleep in both acute and euthymic states. IPSRT monotherapy for bipolar II depression had acute response rates of 41%, 67%, and 67.4% in two open studies and one RCT, respectively; as adjunctive therapy for bipolar depression in one RCT, and efficacy in reducing relapse in two RCTs. Among euthymic BD subjects with insomnia, a single RCT found CBTI-BP effective in delaying manic relapse and improving sleep. Chronotherapies were generally safe and well-tolerated. Conclusions The outcome literature on the adjunctive use of chronotherapeutic treatments for BP is variable, with evidence bases that differ in size, study quality, level of evidence, and non-standardized treatment protocols. Evidence-informed practice recommendations are offered.