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IntroductionPostpartum 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).ObjectivesIn this study we aim to investigate polygenic liability for psychiatric disorders in two new Swedish postpartum psychosis cohorts.MethodsCases 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.ResultsWe 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.Image:ConclusionsWe 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.Disclosure of InterestNone Declared

Arousal and vigilance are essential for survival and relevant regulatory neural circuits lie within the brainstem, hypothalamus and forebrain. The nucleus incertus (NI) is a distinct site within the pontine periventricular gray, containing a substantial population of GABAergic neurons with long-range, ascending projections. Existing neuroanatomical data and functional studies in anesthetized rats, suggest the NI is a central component of a midline behavioral control network well positioned to modulate arousal, vigilance and exploratory navigation, yet none of these roles have been established experimentally. We used a chemogenetic approach—clozapine-N-oxide (CNO) activation of virally delivered excitatory hM3Dq-DREADDs—to activate the NI in rats and examined the behavioral and physiological effects, relative to effects in naïve rats and appropriate viral-treated controls. hM3Dq activation by CNO resulted in long-lasting depolarization of NI neurons with action potentials, in vitro. Peripheral injection of CNO significantly increased c-Fos immunoreactivity in the NI and promoted cortical electroencephalograph (EEG) desynchronization. These brain changes were associated with heightened arousal, and increased locomotor activity in the homecage and in a novel environment. Furthermore, NI activation altered responses in a fear conditioning paradigm, reflected by increased head-scanning, vigilant behaviors during conditioned fear recall. These findings provide direct evidence that the NI promotes general arousal via a broad behavioral activation circuit and support early hypotheses, based on its connectivity, that the NI is a modulator of cognition and attention, and emotional and motivated behaviors.

Although evidence for mitochondrial dysfunction in the pathogenesis of bipolar disorder (BD) has been reported, the precise biological basis remains unknown, hampering the search for novel biomarkers. In this study, we performed metabolomics of cerebrospinal fluid (CSF) from male BD patients ( n =54) and age-matched male healthy controls ( n =40). Subsequently, post-mortem brain analyses, genetic analyses, metabolomics of CSF samples from rats treated with lithium or valproic acid were also performed. After multivariate logistic regression, isocitric acid (isocitrate) levels were significantly higher in the CSF from BD patients than healthy controls. Furthermore, gene expression of two subtypes ( IDH3A and IDH3B ) of isocitrate dehydrogenase (IDH) in the dorsolateral prefrontal cortex from BD patients was significantly lower than that of controls, although the expression of other genes including, aconitase ( ACO1 , ACO2 ), IDH1 , IDH2 and IDH3G , were not altered. Moreover, protein expression of IDH3A in the cerebellum from BD patients was higher than that of controls. Genetic analyses showed that IDH genes ( IDH1 , IDH2 , IDH3A , IDH3B ) and ACO genes ( ACO1 , ACO2 ) were not associated with BD. Chronic (4 weeks) treatment with lithium or valproic acid in rats did not alter CSF levels of isocitrate, and mRNA levels of Idh3a , Idh3b , Aco1 and Aco2 genes in the rat brain. These findings suggest that abnormality in the metabolism of isocitrate by IDH3A in the mitochondria plays a key role in the pathogenesis of BD, supporting the mitochondrial dysfunction hypothesis of BD. Therefore, IDH3 in the citric acid cycle could potentially be a novel therapeutic target for BD.

Emerging evidence suggests that inflammation has a key role in depression and suicidal behavior. The kynurenine pathway is involved in neuroinflammation and regulates glutamate neurotransmission. In the cerebrospinal fluid (CSF) of suicidal patients, levels of inflammatory cytokines and the kynurenine metabolite quinolinic acid (QUIN), an N -methyl- d -aspartate receptor agonist, are increased. The enzyme amino-β-carboxymuconate-semialdehyde-decarboxylase (ACMSD) limits QUIN formation by competitive production of the neuroprotective metabolite picolinic acid (PIC). Therefore, decreased ACMSD activity can lead to excess QUIN. We tested the hypothesis that deficient ACMSD activity underlies suicidal behavior. We measured PIC and QUIN in CSF and plasma samples from 137 patients exhibiting suicidal behavior and 71 healthy controls. We used DSM-IV and the Montgomery-Åsberg Depression Rating Scale and Suicide Assessment Scale to assess behavioral changes. Finally, we genotyped ACMSD tag single-nucleotide polymorphisms (SNPs) in 77 of the patients and 150 population-based controls. Suicide attempters had reduced PIC and a decreased PIC/QUIN ratio in both CSF ( P <0.001) and blood ( P =0.001 and P <0.01, respectively). The reductions of PIC in CSF were sustained over 2 years after the suicide attempt based on repeated measures. The minor C allele of the ACMSD SNP rs2121337 was more prevalent in suicide attempters and associated with increased CSF QUIN. Taken together, our data suggest that increased QUIN levels may result from reduced activity of ACMSD in suicidal subjects. We conclude that measures of kynurenine metabolites can be explored as biomarkers of suicide risk, and that ACMSD is a potential therapeutic target in suicidal behavior.

There have been reports of long-term subjective memory worsening after electroconvulsive therapy (ECT). To study the prevalence and risk factors of long-term subjective memory worsening among patients receiving ECT in routine clinical practice. Patients (n = 535, of whom 277 were included in the final analysis) were recruited from eight Swedish hospitals. Participants' subjective memory impairment was assessed before ECT and a median of 73 days after ECT using the memory item from the Comprehensive Psychopathological Rating Scale. Participants also rated their pre-ECT expectations and post-ECT evaluations of the effect of ECT on memory on a 7-point scale. We used ordinal regression to identify variables associated with subjective memory worsening and negative evaluations of the effect of ECT on memory. Comparisons of pre- and post-ECT assessments showed that subjective memory worsened in 16.2% of participants, remained unchanged in 52.3% and improved in 31.4%. By contrast, when asked to evaluate the effect of ECT on memory after treatment 54.6% reported a negative effect. Subjective memory worsening was associated with negative expectations before ECT, younger age and shorter duration of follow-up. Although subjective memory improved more often than it worsened when assessed before and after ECT, a majority of patients reported that ECT had negative effects on their memory when retrospectively asked how ECT had affected it. This might suggest that some patients attribute pre-existing subjective memory impairment to ECT. Clinicians should be aware that negative expectations are associated with subjective worsening of memory after ECT.

Sheet metal forming in the car industry is a highly competitive area. The use of digital techniques and numerical methods are therefore of high interest for reduced costs and lead times. One method for reducing the try-out phase is virtual rework of die surfaces. The virtual rework is based on Finite Element (FE) simulations and can reduce and support manual rework. The elastic behaviour of dies and presses must be represented in a reliable way in FE-models to be able to perform virtual rework. CAD-models exists for nearly all dies today, but not for press lines. A full geometrical representation of presses will also yield very large FE- models. This paper will discuss and demonstrate a strategy for measuring and characterizing a press table for inclusion in FE-models. The measurements of the elastic press deformations is carried out with force transducers and an ARAMIS 3D optical measurement system. The press table is then inverse modelled by topology optimization using the recorded results as boundary conditions. Finally, the press table is coupled with a FE-model of a die to demonstrate its influence on the deformations. This indicates the importance of having a reliable representation of the press deformations during virtual rework.

Succinate is identified as a metabolite in innate immune signalling, which leads to enhanced interleukin-1β production during inflammation. Succinate is an innate immunity signal The bacterial endotoxin lipopolysaccharide activates macrophages, as part of the innate immunity response, by inducing a shift from oxidative to glycolytic metabolism. Gillian Tannahill et al . show here that lipopolysaccharide increases levels of the tricarboxylic acid cycle intermediate succinate in macrophages through a metabolic process not previously reported in macrophages, the 'GABA shunt'. Succinate in turn drives the key pro-inflammatory cytokine interleukin-1β. Macrophages activated by the Gram-negative bacterial product lipopolysaccharide switch their core metabolism from oxidative phosphorylation to glycolysis 1 . Here we show that inhibition of glycolysis with 2-deoxyglucose suppresses lipopolysaccharide-induced interleukin-1β but not tumour-necrosis factor-α in mouse macrophages. A comprehensive metabolic map of lipopolysaccharide-activated macrophages shows upregulation of glycolytic and downregulation of mitochondrial genes, which correlates directly with the expression profiles of altered metabolites. Lipopolysaccharide strongly increases the levels of the tricarboxylic-acid cycle intermediate succinate. Glutamine-dependent anerplerosis is the principal source of succinate, although the ‘GABA (γ-aminobutyric acid) shunt’ pathway also has a role. Lipopolysaccharide-induced succinate stabilizes hypoxia-inducible factor-1α, an effect that is inhibited by 2-deoxyglucose, with interleukin-1β as an important target. Lipopolysaccharide also increases succinylation of several proteins. We therefore identify succinate as a metabolite in innate immune signalling, which enhances interleukin-1β production during inflammation.

Background The Sense of Coherence (SOC) scale was designed to measure an individual’s ability to perceive life as comprehensible, manageable, and meaningful. While low SOC is associated with various psychiatric disorders, its association with bipolar disorder remains unclear. This study explores SOC in individuals with bipolar disorder, its associations with clinical characteristics, and its stability and predictive value over 14 years. Methods We included 248 individuals with bipolar disorder and 113 healthy controls from the St. Göran Bipolar Project. SOC was assessed using Antonovsky’s 29-item scale at baseline and after 14 years. Clinical measures included the Montgomery-Åsberg Depression Rating Scale (MADRS), Sheehan Disability Scale, and comorbid psychiatric diagnoses. SOC’s predictive value for relapse, suicide attempts, and self-harm was evaluated using data from a 7-year follow-up visit. Results SOC scores were lower in individuals with bipolar disorder than in healthy controls ( p  < 0.001). Lower SOC correlated with greater functional impairment, residual depressive symptoms, and comorbid anxiety disorders. SOC was stable over 14 years, with modest increases in both groups. In the bipolar disorder group, baseline SOC predicted self-harm during the initial 7-year follow-up ( p  = 0.012) but was not associated with mood episode relapse or suicide attempts. Conclusion Although individuals with bipolar disorder exhibit lower SOC than healthy controls, the difference probably reflects broader psychopathology rather than core bipolar symptoms. SOC predicted self-harm during the 7-year follow-up period, but not mood episode relapse or suicide attempts. Targeting SOC in interventions may benefit comorbid conditions, but is unlikely to impact bipolar-specific outcomes.

Background Accumulating evidence suggests that the brain's nitric oxide (NO) signalling system may be involved in the pathophysiology of schizophrenia and could thus constitute a novel treatment target. The study was designed to investigate the benefit of L-lysine, an amino acid that interferes with NO production, as an add-on treatment for schizophrenia. Methods L-lysine, 6 g/day, was administered to 10 patients with schizophrenia as an adjunctive to their conventional antipsychotic medication. The study was designed as a single-blinded, cross-over study where patients were randomly assigned to initial treatment with either L-lysine or placebo and screened at baseline, after four weeks when treatment was crossed over, and after eight weeks. Results L-lysine treatment caused a significant increase in blood concentration of L-lysine and was well tolerated. A significant decrease in positive symptom severity, measured by the Positive And Negative Syndrome Scale (PANSS), was detected. A certain decrease in score was also observed during placebo treatment and the effects on PANSS could not unequivocally be assigned to the L-lysine treatment. Furthermore, performance on the Wisconsin Card Sorting Test was significantly improved compared to baseline, an effect probably biased by training. Subjective reports from three of the patients indicated decreased symptom severity and enhanced cognitive functioning. Conclusions Four-week L-lysine treatment of 6 g/day caused a significant increase in blood concentration of L-lysine that was well tolerated. Patients showed a significant decrease in positive symptoms as assessed by PANSS in addition to self-reported symptom improvement by three patients. The NO-signalling pathway is an interesting, potentially new treatment target for schizophrenia; however, the effects of L-lysine need further evaluation to decide the amino acid's potentially beneficial effects on symptom severity in schizophrenia. Trial registration NCT00996242

Individuals with bipolar disorder are at increased risk for cardiovascular diseases. Most studies have described increases in cardiometabolic risk indicators (CMRIs) using clinical cut-off values. Further, there are no longitudinal studies on CMRIs. We aimed to investigate continuous measures of CMRIs in individuals with bipolar disorder and controls using both cross-sectional and longitudinal data. We used data from the Swedish St. Göran Bipolar project. Study individuals were examined at baseline and after a median of 6 and 7 years for the control and patient group, respectively. Data were collected December 2005–December 2020. The cohort included 281 individuals with bipolar disorder (mean age 39 years, 59% women) and 114 controls (mean age 38 years, 55% women). Of those, 155 patients and 74 controls also provided follow-up data. At baseline, individuals with bipolar disorder had significantly higher mean values of waist-to-hip ratio (WHR) (β = 0.142, p = 0.001), body mass index (β = 0.150, p = 0.006), plasma triacylglycerol (TAG) (β = 0.218, p < 0.001), total/plasma high-density lipoprotein-cholesterol (TChol/HDL-C) ratio (β = 0.103, p = 0.03), TAG/HDL-C ratio (β = 0.151, p = 0.006), and non-HDL-C (β = 0.168, p = 0.001) than controls. Most CMRIs remained higher in the patient group at follow-up. The difference between patients and controls increased over time for WHR (0.005 unit/year, p < 0.001), and systolic (1.1 mm Hg/year, p = 0.002) and diastolic (0.8 mm Hg/year, p < 0.001) blood pressure. Individuals with bipolar disorder displayed persistently higher levels of nearly all included CMRIs. Over time, a subset of CMRIs worsened in patients relative to controls. This suggests that active measures to counter cardiovascular risk in persons with bipolar disorder should be considered.