A disfunção do sistema imune inato e a neuroinflamação tem sido cada vez mais reconhecidas como elementos importantes na fisiopatologia do transtorno bipolar (TB). Como componentes essenciais da imunidade inata, os macrófagos tem múltiplas funções tanto na inibição como na promoção da proliferação celular e na reparação tecidual, sendo a diversidade e a plasticidade características marcantes deste tipo celular. A polarização M1 clássica e a polarização alternativa M2 de macrófagos representam dois extremos de um estado dinâmico na mudança da ativação dos mesmos. Os macrófagos do tipo M1 sintetizam citocinas próinflamatórias que inibem a proliferação de células circundantes e danificam tecidos, enquanto os macrófagos do fenótipo M2 liberam citocinas antiinflamatórias que podem promover reparo tecidual. Um desequilíbrio da polarização M1-M2 dos macrófagos é frequentemente associado a várias doenças ou condições inflamatórias. O objetivo desta tese foi, além de revisar a importância da inflamação sistêmica na modulação da resposta inflamatória da microglia/macrófagos e consequentemente seu potencial envolvimento na fisiopatologia do TB, avaliar o perfil de polarização M1/M2 em cultura de macrófagos de sujeitos com TB comparados a indivíduos saudáveis. Monócitos foram isolados a partir de sangue periférico de dez sujeitos com TB e dez indivíduos saudáveis e diferenciados em macrófagos através da adição de fator estimulante de colônia de macrófagos (MCSF) ao meio de cultura. Para induzir a polarização M1 ou M2, as culturas foram incubadas com IFN-y e LPS ou IL-4 respectivamente. Após a incubação, recolheram-se os sobrenadantes e mediram-se as citocinas (IL-1β, IL-6, IL-10 e TNF-α) por ensaio multiplex. A secreção das citocinas IL-1β, TNF-α e IL-6 características do protótipo M1 e citocinas IL-10 do protótipo M2 foram semelhantes entre os pacientes e os controles. Utilizou-se a razão TNF-α / IL-10 do fenótipo M1 para refletir o estado inflamatório dos participantes. Não foi observada diferença entre os grupos (p=0,627). Duas hipóteses diferentes poderiam explicar esses resultados: todos os pacientes incluídos neste estudo representam um estágio inicial da doença como evidenciado pela pontuação FAST total inferior a 11. De acordo com o modelo de estadiamento em TB, as alterações biológicas (incluindo a inflamação) parecem estar relacionadas com os episódios de humor e progressão da doença. Juntamente com estudos anteriores, os nossos dados sugerem que os pacientes nos estágios iniciais ainda preservam a função do sistema imunológico sem apresentar um desequilíbrio a favor do perfil de macrófagos M1 como tem sido observado em pacientes no estágio tardio, destacando a relevância da intervenção precoce no TB. Ainda, estes pacientes estavam em tratamento com estabilizadores de humor e é plausível especular que esses fármacos exerçam efeitos sobre a polarização de macrófagos. Estudos futuros em pacientes drug-free são essenciais para avaliar esta questão. Em conclusão, nossos achados sugerem que os pacientes TB não apresentam desequilíbrio na polarização dos macrófagos em favor do fenótipo pró-inflamatório M1. O fato de todos estes pacientes estarem em estágios iniciais da doença reforça os efeitos protetores da intervenção precoce no TB na prevenção de alterações do sistema imune e, consequentemente, na progressão da doença. / Innate immune system dysfunction and neuroinflammation have been recognized as important elements in the pathophysiology of bipolar disorder (BD). As essential players of innate immunity, macrophages have multiple roles in inhibition and promotion of cell proliferation and tissue repair. The classical M1 polarization and the M2 alternative polarization of macrophages represent two extremes of a dynamic state in their change of activation. M1 macrophages synthesize proinflammatory cytokines that inhibit the proliferation of surrounding cells and damage tissues, whereas macrophages of the M2 phenotype release antiinflammatory cytokines that may promote tissue repair. An imbalance of the M1-M2 polarization of macrophages is often associated with various diseases or inflammatory conditions. The aim of this thesis was to review the importance of systemic inflammation in modulating the inflammatory response of microglia/ macrophages and consequently their potential involvement in the pathophysiology of BD, and also evaluate the M1/M2 polarization profile in macrophages of patients with BD compared to healthy individuals. Blood monocytes were obtained from ten BD patients and ten healthy controls. These cells were activated/polarized into the M1 (IFNγ + LPS) or M2(IL-4) phenotype. Supernatants were collected and the cytokines (IL-1β, IL-6, IL-10 and TNF-α) were measured by multiplex assay. Secretion of the IL- 1β, TNF-α, IL-6 and IL-10 were similar between patients and controls. The TNF-α/IL- 10 ratio of the M1 phenotype was used to reflect the inflammatory state of the participants. There was no difference between groups (p = 0.627). Two hypotheses could explain these results: all patients included in this study represent an early stage of disease as evidenced by the FAST score below 11. According to the BD staging model, biological changes (including inflammation) appear to be related to mood episodes and disease progression. Together with previous studies, our data suggest that patients in early stages of BD still preserve immune system function without presenting an imbalance in favor of M1 macrophages as has been observed in latestage patients, highlighting the relevance of early intervention. Moreover, these patients were under treatment with mood stabilizers and it is plausible to speculate that these drugs have effects on macrophage polarization. Future studies in drug-free patients are essential to assess this issue. In conclusion, our findings suggest that BD patients do not present imbalance in macrophage polarization in favor of the M1 proinflammatory phenotype. The fact that all these patients are in the early stages of the disease reinforces the protective effects of early intervention in BD to prevent changes in the immune system and, consequently, prevent the progression of the disease.

Background: Suicide prevention strategies recognise the need to address suicide in high-risk groups, such as people with psychiatric illness. People with bipolar disorder are known to be at particularly high risk of suicide and self-harm, with around half of people diagnosed with bipolar disorder making at least one suicide attempt during their lifetime. It is important that clinicians can identify who is most at risk among people with bipolar disorder so that interventions that meet the needs of this high risk group can be implemented. Method: A multiple-methods approach was used to explore suicidal behaviour in bipolar disorder. Descriptive analysis, case-control methods, and survival analysis were used on data held by The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI), and the Manchester Self-Harm (MaSH) Project, to identify characteristics and risk factors associated with suicide in bipolar disorder. Semi-structure interviews were carried out with people who had a range of experiences of suicidal behaviour in bipolar disorder, and these data were analysed using Thematic Analysis to add context and depth to the quantitative results. Results: Suicidal behaviours were common in people with bipolar disorder, accounting for around 10% of all psychiatric suicide deaths in England; this rate was fairly stable over time. Characteristics associated with suicidal behaviour in bipolar disorder included; being aged 45 to 64 years old, experiencing negative life events, comorbid alcohol use, multiple inpatient admissions; there was a particularly strong association with a history of self-harm. It is clinically important that people with bipolar disorder were often seen by services in the 24 hours before they died. This both emphasises the weaknesses in current risk assessment, and highlights the potential for successful intervention if risk can be determined more accurately. Key issues identified in the interview study included being able to access care rapidly during time periods when risk was elevated, the importance of obtaining a correct diagnosis of bipolar disorder, and the potential benefits of including family in the care of people with bipolar disorder. Conclusion: Suicidal behaviours are common in people with bipolar disorder. People with bipolar disorder who die by suicide tend to have several markers that may indicate a more severe (e.g. multiple inpatient admission, history of self-harm) and complex course of illness (e.g. comorbid alcohol use, personality disorder). Diagnosis-specific risk assessment is needed to better identify risk of suicide in an illness that is often characterised by fluctuating mood states. Family involvement in care may aid detection of increased suicide risk.

There is still a great deal that is unknown about various depressive conditions, though it is a very common affliction and cause of disability throughout the world. Not only do the underlying mechanisms of various types of depression remain uncertain, but the mystery of how different treatment options work and who will respond to them also persists. The aim of this study was to identify potential non-invasive biomarkers, to predict responsiveness to electroconvulsive therapy. Two hypotheses were investigated in this study. The first was that patient improvement from baseline on the neurocognitive, computer based pattern separation task prior to the third ECT treatment will correlate with a clinical antidepressant response. The second was that increased prefrontal slowing relative to baseline will correlate with a decrease in depressive symptoms. As a first step to validate this approach, a healthy control group performed both the pattern separation and EEG tasks once per week over the course of three weeks. Patient participants completed both tasks before their first ECT treatment, prior to their third treatment, and prior to their last treatment. A spectral analysis of EEG data was then conducted. Results indicated good test-retest reliability for the pattern separation task and EEG measurements across all three trials in the healthy control group. Results from patient data are inconclusive, but indicates that there is a change from baseline to subsequent trials for at least the EEG measurements. However, a larger sample size is needed to determine this. The limited results from this small patient sample suggest that these measurements may have clinical value in refining ECT treatment, and merit further study.

Suicidal behavior represents the most severe, yet inherently preventable, outcome of psychiatric disease. Despite tremendous efforts to improve the awareness and treatment of psychiatric illness, suicidal behavior rates have been on the rise. The greatest challenge to confronting this crisis is the effective identification and treatment of those at risk for suicide. This challenge has been difficult to address due, in part, to the lack of a clear biological basis for suicidal behavior. Toward addressing this knowledge gap, evidence has been identified of a significant heritable component to suicidal behavior. Subsequent genetic research efforts have focused on the examination of common sites of genetic variation within candidate genes and throughout the genome. These efforts have identified many potentially important risk loci, but the majority of the risk expected to arise from genetic variation remains unexplained by current data. The primary objective of this dissertation was to examine the contribution of largely unexplored rare and potentially damaging genetic variation within suicidal behavior. To do this, targeted next-generation sequencing approaches were employed within a cohort of individuals diagnosed with bipolar disorder, a group particularly enriched for suicidal behavior. Sequence data was generated that examined essentially all protein-coding regions of the human genome (“exome”), with expanded sequencing around and within candidate genes hypothesized to play a role in suicidal behavior risk. The secondary objective of this dissertation focused on the assessment of rare variation within bipolar disorder through sequenced pedigrees and followup in a large collaborative bipolar disorder versus normal control sequencing dataset. These objectives were addressed through the thoughtful application of diverse and complimentary methods. These methods were selected to investigate individual variants, genes, and biological pathways. This approach offered examinations of the potential impact of rare genetic variation within focused regions and across complex biological process pathways that could be disrupted through damaging variation in many different genes. The presented efforts represent the largest examinations of rare functional variation with suicidal behavior and bipolar disorder performed, to date. No individual variant or gene survived correction for multiple testing for either phenotype. These results are consistent with other initial sequencing efforts in complex psychiatric phenotypes, offering conclusions that larger samples will likely be required to identify significant associations for single variants and genes. Within pathway analyses, however, we identified a significant enrichment of rare damaging variation that segregated within bipolar disorder pedigrees in genes that have been implicated in de novo studies of autism. This finding was further replicated within three large case/control sequencing samples, providing support to emerging evidence of a potential overlap of risk loci for autism and bipolar disorder. Many additional results approached significance that bear further consideration. These results offer potential candidate genes and pathways that could be utilized in future sequencing efforts for suicidal behavior and bipolar disorder. In addition, highly valuable resources in the form of datasets strongly enriched for novel rare loci were produced that can significantly contribute to ongoing efforts to investigate bipolar disorder and suicidal behavior. These data can be used in combination with other emerging datasets to generate more powerful meta- and mega-analyses to confidently identify risk loci for both phenotypes.

Aim To determine the neural correlates of Bipolar Disorder (BD) using functional Magnetic Resonance Imaging (fMRI) in different phases of the illness. Methods Five fMRI studies were conducted in adult female BD patients and healthy matched comparison subjects. The first two studies examined patients with bipolar depression and hypomania using captioned-pictures to characterize mood-state related patterns of activation. The subsequent three studies investigated BD euthymia using emotional words and faces to identify a potential trait-marker. Results During depression, bipolar patients demonstrated additional subcortical activation in the thalamus, amygdala, hypothalamus and medial globus pallidus. In hypomania, patients again had additional subcortical activation involving the caudate and the thalamus. In both studies patients had prefrontal cortex activation, but the pattern differed from that in healthy subjects. These studies suggested a pattern of mood-state related subcortical recruitment for emotional processing in BD. The next set of studies examined euthymic BD patients to partition trait and state-markers. The first study used implicit positive and negative word-associated affect and found diminished responses to positive and negative affective words as compared to healthy subjects in both cortical and subcortical brain regions, in particular the cingulate, thalamus and caudate. The second study used the emotional Stroop task to elicit implicit affective processing and euthymic patients had less cortical and subcortical activation in response to affect, in particular decreased left ventral prefrontal cortex (BA47) activation. The final study used explicit emotional processing of fear and disgust to examine affective responses, and showed that patients were generally less responsive to disgust, but had comparatively greater activations to fear. Conclusions BD patients have a likely deficit in the ventral prefrontal cortex that is evident in euthymia. Prefrontal cognitive appraisal of emotions is constrained in euthymic, depressed and hypomanic phases, reflected in subcortical changes that suggest additional processing. The likely cause for this is a functional prefrontal cortex deficit that results in compensatory changes in emotional processing systems. Treatment probably stabilizes these systems without normalizing them. Our studies demonstrate the benefits of examining BD in its different phases, and future studies should attempt to emulate this in medication-free patients.

Cognitive impairment is a key characteristic of schizophrenia and is a clear predictor of functional outcome. This thesis explores the relationship between cognitive ability relating to social and non-social processing. Schizophrenia patients demonstrate an impaired ability to recognise, label and discriminate emotional expression within the face. The underlying mechanisms behind this social cognitive impairment are not yet fully understood. This thesis explores the notion that a basic perceptual impairment in processing facial information adversely impacts on the perception of more complex information derived from faces, such as emotional expression. Face perception relies on processing the featural characteristics of a face as well as the relationship between these features. Information pertaining to the spatial distances between features is referred to as configural information. / A group of schizophrenia patients and healthy control participants completed a battery of tasks that assessed basic neurocognition, facial emotion processing and configural face processing. A model of face processing was proposed and used to systematically pinpoint specific deficits that may contribute to impaired face processing in schizophrenia. The results indicated that schizophrenia patients show impairments on three broad constructs; basic neurocognition, facial emotion processing, and most pertinently, deficits in configural processing. It was revealed that although neurocognitive and face processing both explained a significant proportion of the variance in facial emotion processing, the effect of neurocognition was indirect and mediated by face processing. / To investigate the diagnostic specificity of these findings, a group of bipolar disorder patients was also tested on the task battery. The results indicated that bipolar disorder patients also show social and non-social cognitive impairments, however, not as severe as that demonstrated by the schizophrenia patients. Furthermore, the effect of neurocognitive performance on facial emotion processing appeared more direct for bipolar disorder patients compared to schizophrenia patients. Although deficits in face processing were observable in bipolar, they were not specific to configural processing. Thus, deficits in emotion processing were more associated to neurocognitive ability in bipolar disorder patients, and more associated to configural face processing in schizophrenia patients. The configural processing deficits in schizophrenia are discussed as a lower-order perception problem. In conclusion, the results of this thesis are discussed in terms of their implication for treatment.

Several lines of evidence implicate oxidative stress in the pathophysiology of bipolar disorder (BPD). The mood stabilizers lithium and valproate have been shown to protect against oxidative stress-induced cell death. This study examined whether an increase in cellular reductive potential due to glutathione (GSH) synthesis up-regulation underlies this neuroprotective effect. Using primary rat cortical neurons as a model, this study demonstrated that unlike lithium and valproate, carbamazepine and lamotrigine do not exert neuroprotective effects against H2O2-induced cell death. Moreover, the level of GSH and the GSH:GSSG ratio in neurons and in rat brain remained unchanged following chronic treatment with either lithium or valproate. Similarly, this study did not find a significant effect of treatment on the expression of genes encoding γ-glutamylcysteine ligase sub-units, Gclc and Gclm, in both neurons and the rat brain. These findings suggest that other molecular targets of lithium and valproate likely mediate the observed neuroprotective effects.

The etiology of bipolar disorder (BD) is multidimensional and thought to involve several factors that increase neuronal oxidative stress and disrupt intracellular calcium homeostasis. As calcium-permeable canonical transient receptor potential channels (TRPC) have been linked to bipolar pathophysiology, I sought to determine whether oxidative stress affects TRPC3/TRPC5/TRPC6 expression and/or function. Chronic (4-day) but not acute (24-hour) rotenone-induced oxidative stress dose-dependently reduced TRPC5 and TRPC6 protein levels in primary rat cortical neurons. A decrease in TRPC5 mRNA levels was only found following acute but not chronic rotenone whereas TRPC6 mRNA levels did not change significantly with either treatment. Reduced TRPC3 function was seen after chronic stress when stimulated by TRPC3/6 activator, 1-oleoyl-2-acetyl-sn-glycerol. Lithium pre-treatment attenuated the rotenone-induced reduction in TRPC3 but not TRPC6 protein levels. These results suggest TRPC subtypes are differentially regulated by oxidative stress and support a potential mechanistic link between oxidative stress and calcium dyshomeostasis in BD.

Several lines of evidence implicate oxidative stress in the pathophysiology of bipolar disorder (BPD). The mood stabilizers lithium and valproate have been shown to protect against oxidative stress-induced cell death. This study examined whether an increase in cellular reductive potential due to glutathione (GSH) synthesis up-regulation underlies this neuroprotective effect. Using primary rat cortical neurons as a model, this study demonstrated that unlike lithium and valproate, carbamazepine and lamotrigine do not exert neuroprotective effects against H2O2-induced cell death. Moreover, the level of GSH and the GSH:GSSG ratio in neurons and in rat brain remained unchanged following chronic treatment with either lithium or valproate. Similarly, this study did not find a significant effect of treatment on the expression of genes encoding γ-glutamylcysteine ligase sub-units, Gclc and Gclm, in both neurons and the rat brain. These findings suggest that other molecular targets of lithium and valproate likely mediate the observed neuroprotective effects.

The etiology of bipolar disorder (BD) is multidimensional and thought to involve several factors that increase neuronal oxidative stress and disrupt intracellular calcium homeostasis. As calcium-permeable canonical transient receptor potential channels (TRPC) have been linked to bipolar pathophysiology, I sought to determine whether oxidative stress affects TRPC3/TRPC5/TRPC6 expression and/or function. Chronic (4-day) but not acute (24-hour) rotenone-induced oxidative stress dose-dependently reduced TRPC5 and TRPC6 protein levels in primary rat cortical neurons. A decrease in TRPC5 mRNA levels was only found following acute but not chronic rotenone whereas TRPC6 mRNA levels did not change significantly with either treatment. Reduced TRPC3 function was seen after chronic stress when stimulated by TRPC3/6 activator, 1-oleoyl-2-acetyl-sn-glycerol. Lithium pre-treatment attenuated the rotenone-induced reduction in TRPC3 but not TRPC6 protein levels. These results suggest TRPC subtypes are differentially regulated by oxidative stress and support a potential mechanistic link between oxidative stress and calcium dyshomeostasis in BD.