Accurate diagnosis of bipolar disorder (BPD) is difficult in clinical practice, with an average delay between symptom onset and diagnosis of about 7 years. A depressive episode often precedes the first manic episode, making it difficult to distinguish BPD from unipolar major depressive disorder (MDD).

We use genome-wide association analyses (GWAS) to identify differential genetic factors and to develop predictors based on polygenic risk scores (PRS) that may aid early differential diagnosis.

Based on individual genotypes from case–control cohorts of BPD and MDD shared through the Psychiatric Genomics Consortium, we compile case–case–control cohorts, applying a careful quality control procedure. In a resulting cohort of 51 149 individuals (15 532 BPD patients, 12 920 MDD patients and 22 697 controls), we perform a variety of GWAS and PRS analyses.

Although our GWAS is not well powered to identify genome-wide significant loci, we find significant chip heritability and demonstrate the ability of the resulting PRS to distinguish BPD from MDD, including BPD cases with depressive onset (BPD-D). We replicate our PRS findings in an independent Danish cohort (iPSYCH 2015, N = 25 966). We observe strong genetic correlation between our case–case GWAS and that of case–control BPD.

We find that MDD and BPD, including BPD-D are genetically distinct. Our findings support that controls, MDD and BPD patients primarily lie on a continuum of genetic risk. Future studies with larger and richer samples will likely yield a better understanding of these findings and enable the development of better genetic predictors distinguishing BPD and, importantly, BPD-D from MDD.

Postpartum psychosis is a rare psychiatric emergency, occurring days to weeks after 1-2 per 1000 deliveries. Its low prevalence makes it difficult to recruit enough participants to investigate the underlying pathophysiology. It is epidemiologically linked to bipolar disorder, which one study also found it to resemble in genetic susceptibility for psychiatric disorders (Di Florio et al. Lancet Psych 2021; 8: 1045–52).

In this study we aim to investigate polygenic liability for psychiatric disorders in two new Swedish postpartum psychosis cohorts.

Cases with postpartum psychosis, defined as a psychiatric hospitalization within 6 weeks after delivery, and/or receiving a diagnosis of F53.1 (ICD 10) or 294.40 (ICD 8.), parous women with severe mental illness without postpartum psychosis, and healthy parous controls were identified in two Swedish genetic studies: the Swedish bipolar collection (SWEBIC) and Predictors for ECT (PREFECT). Polygenic risk scores (PRS) were calculated from summary statistics from genome wide studies on bipolar disorder (Mullins et al. Nat Genet 2021; 53 817-829), schizophrenia (Trubetskoy et al. Nature 2022; 604 502-508) and major depression (Wray et al. Nat Genet. 2018; 50 668-681). The p-value thresholds best predicting their respective phenotype were used in logistic regression analyses with the first six principal components and genotyping platform as confounders.

We identified 176 patients with postpartum psychosis and genetic information (N(SWEBIC)=126, N(PREFECT)=50). Compared with healthy parous women, patients with postpartum psychosis had significantly higher PRS for bipolar disorder (SWEBIC: odds ratio [OR] 2.6 (95% confidence interval [CI] 1.9-3.5), PREFECT: OR 2.4 (95% CI 1.8-3.2), Figure 1.) and schizophrenia (SWEBIC: OR 1.6 (95% CI 1.2-2.2), PREFECT: OR 1.8 (95%; CI 1.3-2.5)). Patients with postpartum psychosis had significantly higher PRS for bipolar disorder (SWEBIC: OR 1.4 (95% CI 1.2-1.8), PREFECT: OR 1.5 (95% CI 1.1-2)) compared with parous women with severe mental illness without postpartum psychosis. We found no associations with major depression PRS in either cohort.

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We replicated previous findings of significantly higher PRS for bipolar disorder and schizophrenia in postpartum psychosis compared with healthy controls. In contrast to previous research, we find postpartum psychosis cases to have higher PRS for bipolar disorder than bipolar disorder cases. Our findings highlight the genetic influence in postpartum psychosis and support previous genetic and epidemiological evidence that postpartum psychosis lies on the bipolar spectrum.

None Declared

The aim of this study was to determine possible differences in psychiatric care contact and the type of contact in the year prior to suicide by migrant status and region of origin compared to Swedish persons.

A population-based open cohort design, using linked national registers, to study all individuals aged 20–64 years who died by suicide between 1 January 2006 and 31 December 2016 in Sweden (N = 12 474). The primary exposure was migrant status compared to the Swedish majority population in the following categories: non-refugee migrants, refugee migrants and children of migrants. The secondary exposure was region of origin in seven regions: Sweden, other Nordic countries, Europe, Sub-Saharan Africa, the Middle East and North Africa, Asia, the Americas and Oceania. The four outcomes were psychiatric in- and outpatient care, prescribed and purchased psychotropic medication and a variable composing the other variables, all measured the year before death. Logistic regression models adjusted for age, sex, income and marital status estimated the likelihood of psychiatric care utilisation by type of care within the year prior to death by migrant status and region of origin (individually and combined).

Out of all who had died by suicide, 81% had had psychiatric care of any type in the year before death by suicide. Among refugees the prevalence of psychiatric care before death by suicide was 88%. Compared with the Swedish reference group, non-refugees and persons from Asia and Sub-Saharan Africa had a lower likelihood of utilising psychiatric care prior to suicide driven by a lower use of prescribed psychotropic medication. Persons from the Middle East and North Africa had a higher likelihood, driven by higher use of psychiatric outpatient care and prescribed psychotropic medication. Non-refugees' likelihood of utilising care before death by suicide was lower within the first 5 years of living in Sweden.

A large share of those who die by suicide use psychiatric care the year before they die. Non-refugee migrants and persons from Asia and Sub-Saharan Africa have a lower likelihood of utilising psychiatric care prior to suicide compared to Swedish, whereas persons from the Middle East and North Africa have a higher likelihood. Health care and policy makers should consider both migrant status, region of origin and time in the new country for further suicide prevention efforts.

Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.

To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.

Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.

Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.

AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.

Psychotic disorders often cause a drastic change in the life situation of the affected individual. Personality is an aspect that can affect the symptoms and social function in psychotic disorders.

No study has examined stability of personality traits exceeding five years in patients with schizophrenia. The aim of this study was to investigate the stability of personality traits over a 13-year period among patients with psychotic disorder and healthy individuals and to evaluate case-control differences.

At three occasions during a 13-year period patients with psychotic disorders (n=28) and non-psychotic individuals (n=57) completed Swedish universities Scales of Personality (SSP). For all the individuals within- and between-subject analyses were performed at three occasions for all 13 subscales and the three overall factors of SSP. Correlations, means and SDs were calculated.

Tests of within-subject correlations showed differences in two subscales: Lack of Assertiveness, which were influenced by age and Physical Trait Aggression, where patients ratings were stable, whereas controls rated themselves less aggressive at higher age. Between-subjects correlations showed differences regarding any of the parameters diagnosis, time, age, gender or age x gender in nine of the 13 subscales as well as in factor Neuroticism.

Long term follow-up showed a generally high stability of personality traits measured with SSP, especially among patients. Between-subject analyses over the 13 years showed that patients differed compared to controls for the SSP factor Neuroticism as well as the subscale Detachment, which is in accordance with previous studies.

The cognitive profile of the older depressed person includes impairments in executive functioning, episodic memory and processing speed. When in remission, executive functioning impairment may still remain. It is not known whether these impairments also exist in self-reported depression and if so, whether there are any performance differences between currently and remitted depression.

To examine differences in cognitive functioning between self-reported nondepressed, depressed, and remitted persons in young and older old.

Data were collected using interviews and cognitive testing (executive functioning, episodic memory, and processing speed) in the Swedish National study of Aging and Care in Kungsholmen (SNAC-K). All non-demented participants (n = 2727) were categorized according to age (60–77 years, n = 1626, and +78 years, n = 1101), and depression status, 1) never depressed (n = 2200), 2) current depression (n = 214), and 3) remitted depression (n = 313).

A 2 (age) × 3 (depression) MANOVA showed significant main effects of age, depression and a significant interaction effect. Younger outperformed older on all tests. Depression showed an effect on Trail Making Test B, where nondepressed outperformed currently depressed, and the remitted outperformed the currently depressed on free recall. Furthermore, an interaction effect was found for recognition, suggesting that decline in episodic memory is more pronounced in persons with self-reported depression when aging.

Self-reported depression in an older population affects executive functioning and episodic memory, but not processing speed. For persons in remission, we found remaining deficits in episodic memory, rather than executive functioning.

Early environmental risk factors have a role in the development of violent behaviour in adulthood.

The aim of the study was to assess the impact of childhood trauma, expressed violent behaviour as a child, co morbid personality disorder and substance abuse on self reported interpersonal violence as an adult in suicide attempters.

A total of 161 suicide attempters were diagnosed with SCID I and II and assessed with the Karolinska Interpersonal Violence Scale (KIVS) measuring exposure to violence and expressed violent behaviour in childhood (between 6-14 years of age) and during adult life (15 years or older). A standard linear regression analyses was conducted with the two predictive KIVS subscales exposure to violence as a child and expressed violent behaviour as a child, Axis 1 mood and anxiety disorder diagnosis, co morbid substance abuse diagnosis, co morbid personality disorder diagnosis, age and gender as predictors of expressed interpersonal violence as an adult.

The regression model was significant with adjusted R square 0.22, F ratio 7.2, DF=7, p< 0.0001. Expressed violent behaviour as a child and personality disorder were significant predictors of expressed interpersonal violence as an adult. Broken down by gender expressed violent behaviour as a child was a significant predictor of violence as an adult in both men and women, whereas exposure to violence as a child and personality disorder predicted violence as an adult only in men.

It is important to take into account expressed violent behaviour in childhood in violence risk assessments.

Cognitive symptoms in depression are associated with high distress, poor functional outcome and more relapses. Variability in cognitive deficits in depression is often reported, and may originate from numerous factors; one rarely examined factor is psychiatric history.

To assess the effects of depression and severe psychiatric history on old-age cognitive performance.

From a sample of non-demented participants (60+ years) in a population-based study receiving neuropsychological testing, three groups were formed based on information from the Swedish national inpatient register (1969-2005): current unipolar depression (ICD-10)/no psychiatric history (n=49), current unipolar depression/psychiatric history (n=16; F10-F45, F31-31.9 excluded), remission/history of mood disorders (n=35, F31-31.9 excluded). In addition, a group of healthy controls (n=98) was randomly selected.

Currently depressed participants without psychiatric history performed at a lower level compared to healthy controls in processing speed, attention, executive function, verbal fluency, episodic free recall and vocabulary. However, remitted participants performed at the same level as healthy controls, and outperformed currently depressed with psychiatric history in verbal fluency. No group differences were observed for short term memory, episodic recognition, general knowledge or spatial ability.

Currently depressed without psychiatric history consistently performed at the lowest level. The proportion receiving psychopharmacological treatment in this group was low, 6.1% compared to 56.2% and 37.1%, which may partially account for this finding. Additional factors potentially explaining why remitted participants and healthy controls perform at the same level cognitively will be examined. These findings may have important implications for preventing residual cognitive deficits in depression.

Our understanding of the complex relationship between schizophrenia symptomatology and etiological factors can be improved by studying brain-based correlates of schizophrenia. Research showed that impairments in value processing and executive functioning, which have been associated with prefrontal brain areas [particularly the medial orbitofrontal cortex (MOFC)], are linked to negative symptoms. Here we tested the hypothesis that MOFC thickness is associated with negative symptom severity.

This study included 1985 individuals with schizophrenia from 17 research groups around the world contributing to the ENIGMA Schizophrenia Working Group. Cortical thickness values were obtained from T1-weighted structural brain scans using FreeSurfer. A meta-analysis across sites was conducted over effect sizes from a model predicting cortical thickness by negative symptom score (harmonized Scale for the Assessment of Negative Symptoms or Positive and Negative Syndrome Scale scores).

Meta-analytical results showed that left, but not right, MOFC thickness was significantly associated with negative symptom severity (βstd = −0.075; p = 0.019) after accounting for age, gender, and site. This effect remained significant (p = 0.036) in a model including overall illness severity. Covarying for duration of illness, age of onset, antipsychotic medication or handedness weakened the association of negative symptoms with left MOFC thickness. As part of a secondary analysis including 10 other prefrontal regions further associations in the left lateral orbitofrontal gyrus and pars opercularis emerged.

Using an unusually large cohort and a meta-analytical approach, our findings point towards a link between prefrontal thinning and negative symptom severity in schizophrenia. This finding provides further insight into the relationship between structural brain abnormalities and negative symptoms in schizophrenia.

The increased occurrence of obstetric complications (OCs) in patients with schizophrenia suggests that alterations in neurodevelopment may be of importance to the aetiology of the illness. Abnormal cortical folding may reflect subtle deviation from normal neurodevelopment during the foetal or neonatal period. In the present study, we hypothesized that OCs would be related to cortical folding abnormalities in schizophrenia patients corresponding to areas where patients with schizophrenia display altered cortical folding when compared with healthy controls.

In total, 54 schizophrenia patients and 54 healthy control subjects underwent clinical examination and magnetic resonance image scanning on a 1.5 T scanner. Information on OCs was collected from original birth records. An automated algorithm was used to calculate a three-dimensional local gyrification index (lGI) at numerous points across the cortical mantle.

In both schizophrenia patients and healthy controls, an increasing number of OCs was significantly related to lower lGI in the left pars triangularis (p<0.0005) in Broca's area. For five other anatomical cortical parcellations in the left hemisphere, a similar trend was demonstrated. No significant relationships between OCs and lGI were found in the right hemisphere and there were no significant case–control differences in lGI.

The reduced cortical folding in the left pars triangularis, associated with OCs in both patients and control subjects suggests that the cortical effect of OCs is caused by factors shared by schizophrenia patients and healthy controls rather than factors related to schizophrenia alone.

Communication and information are cornerstones of management during major incidents and disasters. To support medical command and control, the Web-based support system called Paratus Major Incident can be used. The Paratus Major Incident system can provide management staff with online information from the incident area, and support management and patient handling at both single and mass-casualty incidents. The purpose of the Web-based information technology (IT) system is to ensure communication and information between the medical management at the scene, hospital management, and regional medical command and control (gold level).

In the region of Östergötland, Sweden, Paratus Major Incident system is used in operating topics such as: (1) information dissemination from the incident area; (2) communication between prehospital, regional, and hospital management; (3) continuous updates between the dispatch centre and medical commanders at all levels; (4) digital log-files for medical management and patient records; (4) database used for follow-up studies and quality control.

During 2,161 incidents, 746 “first incident reports” from ambulance on scene were sent to regional medical command and control within 2 minutes. Four hundred and fifty-six “verification reports” were sent within 10 minutes. During 15 incidents, the designated duty officer on regional level confirmed “major incident” directly via the digital system, thereby notifying all arriving ambulance resources and involved medical managements.

This Web-based IT system successfully has been used daily within prehospital management since 2005. The system includes medical command and control at the regional level and all involved hospitals in a major incident.