Publications by authors named "Pilar Sierra"

28 Publications

  • Page 1 of 1

Presence of diclofenac, estradiol, and ethinylestradiol in Manzanares River (Spain) and their toxicity to zebrafish embryo development.

Environ Sci Pollut Res Int 2021 May 4. Epub 2021 May 4.

Unity of Antibacterial Resistance, Spanish Food Safety and Nutrition Agency, Madrid, Spain.

Diclofenac (DCF), 17-β-estradiol (E2), and 17-α-ethinylestradiol (EE2) are emerging pollutants included in the first watch list agreed by European countries and set in the EU Water Directive. The objective of the present study was the analytical monitoring of DCF, E2, and EE2 in surface water and sediment of the Manzanares River in a stretch that crosses the city of Madrid, Spain, and to assess whether such environmental levels could affect the development of aquatic vertebrates through a zebrafish embryo-larval assay. Samples taken during two campaigns in the spring of 2015 were analyzed for DCF, E2, and EE2 by LC-MS or GC-MS. The levels of E2 and EE2 measured in surface water and sediments of the Manzanares were within the ranges reported in other Spanish and European studies; however, DCF levels were higher in the present study. The zebrafish embryos exposed to the Manzanares River water (0-144h) showed lethal effects and sublethal effects (developmental delay, bradycardia, and reduced locomotion). Nevertheless, these effects were not primarily associated with the levels of DCF, E2, and EE2 present in the Manzanares River, because representative mixtures of the field study prepared in the laboratory did not exhibit such toxicity to the zebrafish embryos.
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http://dx.doi.org/10.1007/s11356-021-14167-zDOI Listing
May 2021

Attentional biases to emotional scenes in schizophrenia: An eye-tracking study.

Biol Psychol 2021 03 10;160:108045. Epub 2021 Feb 10.

Neonatal Research Group, La Fe Health Research Institute, Valencia, Spain; Department of Psychology, University of Valencia, Valencia, Spain. Electronic address:

Attentional biases to emotional information may play a key role in the onset and course of schizophrenia. The aim of this experiment was to examine the attentional processing of four emotional scenes in competition (happy, neutral, sad, threatening) in 53 patients with schizophrenia and 51 controls. The eye movements were recorded in a 20-seconds free-viewing task. The results were: (i) patients showed increased attention on threatening scenes, compared to controls, in terms of attentional engagement and maintenance; (ii) patients payed less attention to happy scenes than controls, in terms of attentional maintenance; (iii) whereas positive symptoms were associated with a late avoidance of sad scenes, negative symptoms were associated with heightened attention to threat. The findings suggest that a threat-related bias and a lack of sensitivity to positive information may represent an underlying psychological mechanism of schizophrenia. Importantly, schizophrenia symptoms modulated the attentional biases, which has aetiological and therapeutic implications.
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http://dx.doi.org/10.1016/j.biopsycho.2021.108045DOI Listing
March 2021

The effect of concomitant benzodiazepine use on neurocognition in stable, long-term patients with bipolar disorder.

Aust N Z J Psychiatry 2020 Nov 6:4867420969819. Epub 2020 Nov 6.

Department of Psychiatry and Psychology, La Fe University and Polytechnic Hospital, Valencia, Spain.

Objective: Neurocognitive dysfunction is a common feature of bipolar disorder even in euthymia, and psychopharmacological treatment could have an effect on cognition. Long-term prescription of benzodiazepines in bipolar disorder is a common practice, and their effect on neurocognition has not been well studied in this population. The aim of this study was to evaluate the impact of concomitant benzodiazepine long-term use on neurocognitive function in stable euthymic bipolar disorder patients.

Methods: Seventy-three euthymic bipolar disorder outpatients and 40 healthy individuals were assessed using a neurocognitive battery. Patients were classified in two groups according to the presence of benzodiazepines in their treatment: the benzodiazepine group ( = 34) and the non- benzodiazepine group ( = 39). Neurocognitive performance was compared between the groups using a multivariate analysis of covariance, considering age, number of depressive episodes, adjuvant antipsychotic drugs, Young Mania Rating Scale score and Hamilton Depression Rating Scale score as covariates.

Results: Both bipolar disorder groups (benzodiazepine and non-benzodiazepine) showed an impairment in memory domains (Immediate Visual Memory [ = 0.013], Working Memory [ < 0.001], and Letter-Number Sequence [ < 0.001] from the Wechsler Memory Scale-Revised-III) and slower processing speed functions (Stroop Colour [ < 0.001]) relative to the control group. Nevertheless, the benzodiazepine group showed a greater impairment in executive functions (Conceptual Level Responses [ = 0.024] from the Wisconsin Card Sorting Test and Frontal Assessment Battery [ = 0.042]).

Conclusion: Although memory and processing speed impairments were found in bipolar disorder, regardless of their benzodiazepine treatment, benzodiazepine users presented additional neurocognitive impairments in terms of executive functioning. These findings support restricted prescription of benzodiazepines in individuals with bipolar disorder.
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http://dx.doi.org/10.1177/0004867420969819DOI Listing
November 2020

Periprocedural Direct Oral Anticoagulant Management: The RA-ACOD Prospective, Multicenter Real-World Registry.

TH Open 2020 Apr 26;4(2):e127-e137. Epub 2020 Jun 26.

Anaesthesiology and Critical Care, Fundació Puigvert, Barcelona, Spain.

 There is scarce real-world experience regarding direct oral anticoagulants (DOACs) perioperative management. No study before has linked bridging therapy or DOAC-free time (pre-plus postoperative time without DOAC) with outcome. The aim of this study was to investigate real-world management and outcomes.  RA-ACOD is a prospective, observational, multicenter registry of adult patients on DOAC treatment requiring surgery. Primary outcomes were thrombotic and hemorrhagic complications. Follow-up was immediate postoperative (24-48 hours) and 30 days. Statistics were performed using a univariate and multivariate analysis. Data are presented as odds ratios (ORs [95% confidence interval]).  From 26 Spanish hospitals, 901 patients were analyzed (53.5% major surgeries): 322 on apixaban, 304 on rivaroxaban, 267 on dabigatran, 8 on edoxaban. Fourteen (1.6%) patients suffered a thrombotic event, related to preoperative DOAC withdrawal (OR: 1.57 [1.03-2.4]) and DOAC-free time longer than 6 days (OR: 5.42 [1.18-26]). Minor bleeding events were described in 76 (8.4%) patients, with higher incidence for dabigatran (12.7%) versus other DOACs (6.6%). Major bleeding events occurred in 17 (1.9%) patients. Bridging therapy was used in 315 (35%) patients. It was associated with minor (OR: 2.57 [1.3-5.07]) and major (OR: 4.2 [1.4-12.3]) bleeding events, without decreasing thrombotic events.  This study offers real-world data on perioperative DOAC management and outcomes in a large prospective sample size to date with a high percentage of major surgery. Short-term preprocedural DOAC interruption depending on the drug, hemorrhagic risk, and renal function, without bridging therapy and a reduced DOAC-free time, seems the safest practice.
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http://dx.doi.org/10.1055/s-0040-1712476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319799PMC
April 2020

COVID-19: opening a new paradigm in thromboprophylaxis for critically ill patients?

Crit Care 2020 06 11;24(1):332. Epub 2020 Jun 11.

Anaesthesiology and Critical Care Service, University Hospital Virgen de la Victoria, Málaga, Spain.

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http://dx.doi.org/10.1186/s13054-020-03052-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7289223PMC
June 2020

Sexual Dysfunction and Mood Stabilizers in Long-Term Stable Patients With Bipolar Disorder.

J Sex Med 2020 05 2;17(5):930-940. Epub 2020 Mar 2.

La Fe University and Polytechnic Hospital, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain. Electronic address:

Background: In addition to factors intrinsic to bipolar disorder (BD), sexual functioning (SF) can be affected by extrinsic causes, such as psychotropic drugs. However, the effect of mood stabilizers on SF and quality of life (QoL) is an underexplored research area.

Aim: To analyze SF in BD outpatients in euthymia for at least 6 months treated only with mood stabilizers and the association between SF and QoL.

Methods: A multicenter cross-sectional study was conducted in 114 BD outpatients treated with (i) lithium alone (L group); (ii) anticonvulsants alone (valproate or lamotrigine; A group); (iii) lithium plus anticonvulsants (L+A group); or (iv) lithium plus benzodiazepines (L+B group). The Changes in Sexual Functioning Questionnaire Short Form (CSFQ-14) was used. Statistical analyses were performed to compare CSFQ-14 scores among the pharmacological groups. An adaptive lasso was used to identify potential confounding variables, and linear regression models were used to study the association of the CSFQ-14 with QoL.

Main Outcome Measures: Self-reports on phases of the sexual response cycle (ie, desire, arousal, and orgasm) and QoL were assessed.

Results: The A group had better total SF scores than the L group and the L+B group. Relative to the A group, the L and L+B groups had worse sexual desire; the L group had worse sexual arousal; and the L+A group and the L+B group had worse sexual orgasm. Regarding sociodemographic factors, being female and older age were associated with worse total SF and all subscale scores. Among all subscales scores, higher sexual arousal scores were associated with better QoL.

Clinical Implications: Potential modified extrinsic factors such as psychotropic medication that can affect SF can be addressed and adjusted to lessen side effects on SF.

Strengths & Limitations: Sample of patients with euthymic BD in treatment with mood stabilizers and no antipsychotics or antidepressants, substance use as an exclusion criterion, and use of a validated, gender-specific scale to evaluate SF. Major limitations were cross-sectional design, sample size, and lack of information about stability of relationship with partner.

Conclusions: Lithium in monotherapy or in combination with benzodiazepines is related to worse total SF and worse sexual desire than anticonvulsants in monotherapy. While the addition of benzodiazepines or anticonvulsants to lithium negatively affects sexual orgasm, sexual arousal (which plays a significant role in QoL) improves when benzodiazepines are added to lithium. Anticonvulsants in monotherapy have the least negative effects on SF in patients with BD. García-Blanco A, García-Portilla MP, Fuente-Tomás L de la, et al. Sexual Dysfunction and Mood Stabilizers in Long-Term Stable Patients With Bipolar Disorder. J Sex Med 2020;17:930-940.
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http://dx.doi.org/10.1016/j.jsxm.2020.01.032DOI Listing
May 2020

A clinical staging model for bipolar disorder: longitudinal approach.

Transl Psychiatry 2020 01 29;10(1):45. Epub 2020 Jan 29.

Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.

Bipolar disorder (BD) has been identified as a life-course illness with different clinical manifestations from an at-risk to a late stage, supporting the assumption that it would benefit from a staging model. In a previous study, we used a clustering approach to stratify 224 patients with a diagnosis of BD into five clusters based on clinical characteristics, functioning, cognition, general health, and health-related quality of life. This study was design to test the construct validity of our previously developed k-means clustering model and to confirm its longitudinal validity over a span of 3 years. Of the 224 patients included at baseline who were used to develop our model, 129 (57.6%) reached the 3-year follow-up. All life domains except mental health-related quality of life (QoL) showed significant worsening in stages (p < 0.001), suggesting construct validity. Furthermore, as patients progressed through stages, functional decline (p < 0.001) and more complex treatment patterns (p = 0.002) were observed. As expected, at 3 years, the majority of patients remained at the same stage (49.6%), or progressed (20.9%) or regressed (23.3%) one stage. Furthermore, 85% of patients who stayed euthymic during that period remained at the same stage or regressed to previous stages, supporting its longitudinal validity. For that reason, this study provides evidence of the construct and longitudinal validity of an empirically developed, comprehensive staging model for patients with BD. Thus, it may help clinicians and researchers to better understand the disorder and, at the same time, to design more accurate and personalized treatment plans.
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http://dx.doi.org/10.1038/s41398-020-0718-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7026435PMC
January 2020

Sex differences in bipolar disorder: Impact of lifetime cannabis use on clinical course, functioning, and quality of life in bipolar disorder.

J Affect Disord 2020 04 14;266:258-262. Epub 2020 Jan 14.

Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) Spain; Department of Psychiatry, University of Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain; Instituto de Neurociencias del Principado de Asturias (INEUROPA), Spain; Mental Health Services of Principado de Asturias (SESPA), Oviedo, Spain.

Background: Cannabis use is markedly prevalent among patients with bipolar disorder (BD). However, to date, there have been no studies on this issue with a sex-based approach. This study examines if lifetime cannabis use (LCU) is differently associated with clinical course, functioning, and quality of life (QoL) in patients with BD by sex.

Methods: Secondary analysis of a cross-sectional, naturalistic, multicentre study. LCU was defined as having had at least one day of use per month for at least 12 consecutive months in a patient's life.

Results: A total of 224 patients with BD were included (65.2% women). Patients with LCU were younger (p = 0.001) and had their first hospitalization earlier (p<0.005) than those without LCU, regardless of sex. Among women, LCU was associated with being single (p = 0.006), worse sexual functioning (p = 0.006), financial functioning (p = 0.009), QoL [bodily pain (p = 0.009), vitality (p = 0.027), social functioning (p = 0.037), emotional role (p = 0.038), mental health (p = 0.001), and mental summary component (p = 0.012)]. After controlling for confounders, among women, LCU was associated with worse QoL, specifically on bodily pain (p = 0.049) and mental health (p = 0.016) subscales. Among males, no statistically significant differences were found between LCU and no LCU (NLCU) in any of the variables of the study.

Limitations: This study was a secondary analysis not powered specifically to analyze cannabis use.

Conclusions: LCU was associated with a younger age at first hospitalization in both women and men, while only women reported worse QoL on bodily pain and mental health subscales. Clinicians and public health providers should be aware of this and inform their patients and the general population of these detrimental effects.
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http://dx.doi.org/10.1016/j.jad.2020.01.043DOI Listing
April 2020

A case of antibiotic-associated mania in a 67-year-old woman.

Bipolar Disord 2019 11 7;21(7):670-672. Epub 2019 Sep 7.

IMPACT Strategic Research Centre Barwon Health, Geelong, Victoria, Australia.

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http://dx.doi.org/10.1111/bdi.12823DOI Listing
November 2019

Classification of patients with bipolar disorder using k-means clustering.

PLoS One 2019 23;14(1):e0210314. Epub 2019 Jan 23.

Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Fondos FEDER, Madrid, Spain.

Introduction: Bipolar disorder (BD) is a heterogeneous disorder needing personalized and shared decisions. We aimed to empirically develop a cluster-based classification that allocates patients according to their severity for helping clinicians in these processes.

Methods: Naturalistic, cross-sectional, multicenter study. We included 224 subjects with BD (DSM-IV-TR) under outpatient treatment from 4 sites in Spain. We obtained information on socio-demography, clinical course, psychopathology, cognition, functioning, vital signs, anthropometry and lab analysis. Statistical analysis: k-means clustering, comparisons of between-group variables, and expert criteria.

Results And Discussion: We obtained 12 profilers from 5 life domains that classified patients in five clusters. The profilers were: Number of hospitalizations and of suicide attempts, comorbid personality disorder, body mass index, metabolic syndrome, the number of comorbid physical illnesses, cognitive functioning, being permanently disabled due to BD, global and leisure time functioning, and patients' perception of their functioning and mental health. We obtained preliminary evidence on the construct validity of the classification: (1) all the profilers behaved correctly, significantly increasing in severity as the severity of the clusters increased, and (2) more severe clusters needed more complex pharmacological treatment.

Conclusions: We propose a new, easy-to-use, cluster-based severity classification for BD that may help clinicians in the processes of personalized medicine and shared decision-making.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0210314PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6343877PMC
October 2019

Do affective episodes modulate moral judgment in individuals with bipolar disorder?

J Affect Disord 2019 02 5;245:289-296. Epub 2018 Nov 5.

University of Valencia, Valencia, Spain; "La Fe" Health Research Institute, Valencia, Spain. Electronic address:

Background: Bipolar disorder (BD) patients experience altered emotional states and deficits in social adaptation that may also be involved in deontological moral judgments in which participants have to choose whether to sacrifice one person in order to save the lives of a greater number.

Methods: In the present study we compared the utilitarian responses of BD patients in their different states (euthymia, mania, depression) and healthy controls to moral dilemmas with low (impersonal dilemma) and high (personal dilemma) emotional saliency.

Results: Our findings revealed an increased tendency to utilitarian judgments in the three groups of BD patients in impersonal dilemmas relative to healthy individuals. In addition, utilitarian responses were increased during manic and depressive episodes in personal moral dilemmas relative to control group. Furthermore, we found no differences in social adaptation between utilitarian and deontological BD responders, though the depressive BD had a lower adaptation than the euthymic individuals.

Limitations: The recording of response times, the exhaustive control of medication effect, or the inclusion of a non-moral condition in the battery of moral dilemmas would provide a better characterization of moral judgment in BD.

Conclusions: For impersonal dilemmas, BD patients exhibited more utilitarian reasoning, which is also affected by emotional engagement for personal dilemmas during acute episodes of mania and depression. Social adaptation is not associated to utilitarian reasoning, but is rather influenced by mood state.
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http://dx.doi.org/10.1016/j.jad.2018.11.067DOI Listing
February 2019

Sleep disturbances, functioning, and quality of life in euthymic patients with bipolar disorder.

Psychiatry Res 2018 11 1;269:501-507. Epub 2018 Sep 1.

Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Department of Psychiatry, University of Oviedo, Julian Claveria 6, Oviedo 33006, Spain; Mental Health Services of Principado de Asturias (SESPA), Oviedo, Spain; Department of Psychiatry, University of Barcelona, Spain. Electronic address:

There is scarce knowledge about the impact of sleep disturbances on functioning and quality of life (QoL). This study aims to investigate the links between sleep satisfaction and duration, and functioning and QoL in euthymic BD patients. We made a secondary analysis of a cross-sectional, naturalistic, multicenter study. Inclusion criteria: DSM-IV BD diagnosis; age > 17 years; written informed consent. Sample: 119 Spanish euthymic BD outpatients. Hierarchical multiple regressions were performed controlling for confounding factors. We found that almost half of the patients reported at least one sleep complaint, nighttime awakenings (60.5%) and difficulty falling asleep (31.9%) were the most frequent. Long sleep duration was associated with worse global functioning, and also with worse occupational functioning along with caffeine consumption. Sleep satisfaction was negatively associated with worse QoL in the mental health subscale and the summary mental. In both cases, the use of benzodiazepines negatively affects these QoL domains. In conclusion, euthymic bipolar patients frequently present sleep disturbances that seem to contribute to the impairment of their functioning and QoL. Also, the use of benzodiazepines negatively affects the QoL of these patients. Thus, a detailed sleep evaluation should be performed, and the use of benzodiazepines should be reduced to the minimum.
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http://dx.doi.org/10.1016/j.psychres.2018.08.104DOI Listing
November 2018

Are affective temperaments determinants of quality of life in euthymic patients with bipolar disorder?

J Affect Disord 2018 04 31;230:101-107. Epub 2018 Jan 31.

Department of Psychiatry, La Fe University and Polytechnic Hospital, Valencia, Spain; University of Valencia, Valencia, Spain.

Background: Bipolar disorder (BD) is a disabling illness that is associated with low quality of life (QoL). This low QoL goes further than mood episodes, which suggests that stable traits, such as affective temperaments, can cause functional impairment.

Objective: Our study analyses the impact of affective temperaments on the Physical Component Summary (PCS) and Mental Component Summary (MCS) of QoL in euthymic BD patients.

Methods: A multicentre study was conducted in 180 euthymic BD patients and 95 healthy controls. Firstly, statistical analyses were performed to compare QoL and affective temperaments between the two groups. Secondly, Adaptive Lasso Analysis was carried out to identify the potential confounding variables and select the affective temperaments as potential predictors on the PCS and MCS of QoL in BD patients, as well as the control group.

Results: QoL scores in terms of PCS and MCS in BD patients were significantly lower than in healthy individuals. Whereas anxious temperament, anxiety disorder comorbidity, and age were the best predictors of PCS impairment in BD patients, anxious temperament, subclinical depressive symptoms, and age were the best predictors of MCS impairment.

Limitations: Further longitudinal studies with unaffected high-risk relatives are needed to examine the potential interaction between affective temperament and psychopathology.

Conclusions: Anxious temperament has an impact on QoL in BD in terms of both the physical component and the mental component. Systematic screening of temperament in BD would give clinicians better knowledge of QoL predictors. Further research should allow more individualized treatment of BD patients based on temperamental factors.
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http://dx.doi.org/10.1016/j.jad.2018.01.007DOI Listing
April 2018

Hypoesthesia in generalised anxiety disorder and major depression disorder.

Int J Psychiatry Clin Pract 2018 Nov 10;22(4):310-313. Epub 2018 Jan 10.

a Health Research Institute La Fe , Valencia , Spain.

The determination of soft signs can be a conducive practice to understand the differential etiology between depression and anxiety. This study aims at examining malleolar hypoesthesia role in distinguishing between patients with generalised anxiety disorder (GAD) and major depression disorder (MDD). This study examines the presence of malleolar hypoesthesia in patients with GAD ( = 47) compared to patients with MDD ( = 48) and healthy individuals (controls;  = 99). The Wartenberg wheel, a medical device for neurological use, was employed to determine the presence of hypoesthesia on both sides of the ankles. The data revealed: i) MDD patients showed higher hypoesthesia than GAD patients ( = .008), ii) participants with hypoesthesia had higher anxiety and depression scores than participants without hypoesthesia (all  < .001) and iii) logistic regression model indicated that hypoesthesia can be a predictor of MDD relative to GAD diagnosis (Odds Ratio: 17.43 (1.40-217.09;  = .026)). Malleolar hypoesthesia was higher in MDD than GAD. The detection of hypoesthesia may help to investigate the differential etiology between MDD and GAD diagnosis.
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http://dx.doi.org/10.1080/13651501.2017.1417441DOI Listing
November 2018

Comparative neurocognitive effects of lithium and anticonvulsants in long-term stable bipolar patients.

J Affect Disord 2016 Jan 14;190:34-40. Epub 2015 Oct 14.

Department of Psychiatry and Clinical Psychology, La Fe University and Polytechnic Hospital, Valencia, Spain; University of Valencia, Spain; CIBERESP, Spain.

Background: The aim of choosing a mood-stabilizing drug (lithium or anticonvulsants) or a combination of them with minimal neurocognitive effects is to stimulate the development of criteria for a therapeutic adequacy, particularly in Bipolar Disorder (BD) patients who are clinically stabilized.

Method: Three groups of BD patients were established according to their treatment: (i) lithium monotherapy (n=29); (ii) lithium together with one or more anticonvulsants (n=28); and (iii) one or more anticonvulsants (n=16). A group of healthy controls served as the control (n=25). The following tests were applied: Wechsler Adult Intelligence Scale, Trail Making Test, Wechsler Memory Scale, Rey Complex Figure Test, Stroop color-word test, Wisconsin Card Sorting Test, Tower of Hanoi, Frontal Assessment Battery, and Reading the Mind in the Eyes Test.

Results: Relative to healthy controls, BD patients showed the following: (i) those on lithium monotherapy, but not other BD groups, had preserved short-term auditory memory, long-term memory, and attention; (ii) those who took only anticonvulsants showed worse findings in short-term visual memory, working memory, and several executive functions; and (iii) all BD patients showed worse performance in processing speed, resistance to interference, and emotion recognition.

Limitations: Medication alone cannot explain why all BD patients showed common cognitive deficits despite different pharmacological treatment.

Conclusion: The impairment on some executive functions and emotion recognition is an inherent trait in BD patients, regardless of their pharmacological treatment. However, while memory, attention, and most of the executive functions are preserved in long-term stable BD patients, these cognitive functions are impaired in those who take anticonvulsants.
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http://dx.doi.org/10.1016/j.jad.2015.10.008DOI Listing
January 2016

What is the real significance and management of major thyroid disorders in bipolar patients?

Rev Psiquiatr Salud Ment 2014 Apr-Jun;7(2):88-95. Epub 2014 Jan 24.

Servicio de Psiquiatría, Hospital Universitario La Fe, Facultad de Medicina, Valencia, España.

Thyroid disfunction affects negatively emotional stability and worsens the clinical course of bipolar affective disorder. The main stabilizer used in this illness, lithium carbonate has numerous effects on the physiology of the thyroid, with the most significant being the inhibition of thyroid hormone release that may occur at therapeutic levels. These dysfunctions have also been reported most frequently in bipolar patients not undergoing treatment with lithium, and was not completely explained by the effects of this drug. Apart from the numerous medical complications and mood disturbances, the cognitive or perceptual system may also be affected. In fact, the presence of thyroid disease increases the rates of obsessive compulsive disorder, phobias, panic disorder, major depressive disorder, cyclothymia, or bipolar disorder. In severe cases of hypothyroidism, the clinical symptoms and signs can be similar to a melancholic depression or dementia. It is therefore important to know well all these possible complications in daily clinical practice. This review will cover the main thyroid dysfunctions present in bipolar patients, whether ot not produced by treatment with lithium carbonate, and will provide a series of recommendations for clinical management.
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http://dx.doi.org/10.1016/j.rpsm.2013.07.005DOI Listing
April 2015

Understanding bipolar disorder in late life: clinical and treatment correlates of a sample of elderly outpatients.

J Nerv Ment Dis 2013 Aug;201(8):674-9

Hospital Universitario del Sureste, Centro de Investigación Biomédica de Salud Mental, CIBERSAM, Madrid, Spain.

The aim of this study was to examine the demographic, clinical, and treatment correlates of bipolar disorder (BD) in outpatients 65 years or older and to compare patients with BD subtype I (BD-I) versus BD subtype II (BD-II) and patients with early onset (EO; <=50 years old) versus late onset (LO; >50 years old) of the illness. Sixty-nine consecutive outpatients with BD were included. Diagnosis was delayed for a mean of 14.1 years, significantly longer in patients with EO (18.6 years) than with LO (3.3 years). Mild to moderate depressive symptoms were detected in 29% of the patients. The patients were receiving a mean of 3 different psychotropic medications. Antidepressantswere more frequently prescribed to patients with BD-II than to patients with BD-I (75.80% vs. 48.60%) and to patients with EO (71.7%) than to LO (35.3%). Geriatric BD has similar clinical characteristics with those of younger ages, and these do not seem to greatly differ with subtype or age of onset.
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http://dx.doi.org/10.1097/NMD.0b013e31829c508dDOI Listing
August 2013

[Inhospital cardio-cerebral resuscitation].

Med Clin (Barc) 2012 Nov 16;139(12):556; author reply 557. Epub 2012 Sep 16.

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http://dx.doi.org/10.1016/j.medcli.2012.03.036DOI Listing
November 2012

[Variables associated with disability in elderly bipolar patients on ambulatory treatment].

Rev Psiquiatr Salud Ment 2012 Jul-Sep;5(3):183-90. Epub 2011 Jun 30.

Servicio de Psiquiatría, Hospital Universitario La Princesa, Madrid, España.

Introduction: Studies on adult bipolar patients have demonstrated a disability associated with the bipolar disorder, even in euthymic patients, but there is a lack of data in the elderly population.

Material And Method: A cross-sectional, multicentre study on a consecutive sample of ambulatory bipolar patients (DSM-IV-TR criteria), aged 65 years or over. Retrospective and cross-sectional sociodemographic and clinical data were collected, as well as the Clinical Global Impression for Bipolar Modified scale (CGI-BP-M) and the level of disability using the World Health Organisation Disability Assessment Schedule (WHO/DAS). The disability was assessed globally and by areas. The presence of a moderate to maximum disability compared to a mild to no disability was considered a dependent variable.

Results: A moderate to maximum global disability was present in 43.6% of the sample. By areas, occupational functioning was the area most frequently affected, and personal care the least affected. The only variables which were associated with disability were the presence of medical comorbidity (P = .01), increased age (P = .005) global clinical severity (P = .0001) and in the depressive pole (P = .03). There was no relationship between clinical subtype, duration of the disease, number of previous episodes, number of hospitalisations, or other clinical variables and the degree of disability.

Conclusions: These data underline the need to establish specific therapeutic strategies in the approach to depressive symptoms and medical comorbidity, with the aim of minimising the disability in elderly bipolar patients. Given the lack of current data, new studies are needed with larger samples and control groups.
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http://dx.doi.org/10.1016/j.rpsm.2011.04.004DOI Listing
October 2013

[Impulsivity, sensation seeking and aggressiveness in patients with bipolar I and II disorder].

Rev Psiquiatr Salud Ment 2011 Oct 19;4(4):195-204. Epub 2011 Sep 19.

Servicio de Psiquiatría, Hospital Universitario La Fe. Departamento de Medicina, Universitat de Valencia, Valencia, España. sierra

Objective: Although impulsivity may seem to be strongly linked to bipolar disorder, few studies have directly measured this phenomenon. To determine its implications for the prognosis of this illness, we studied the relationship between impulsivity and other aspects that are probably related, such as sensation seeking and aggressiveness, and different clinical variables of bipolar disorder.

Method: Sixty-nine (type I, n=42; type II, n=27) outpatients from a unit specifically for bipolar patients in remission completed the Barratt Impulsiveness Scale (BIS), the Sensation Seeking Scale (SSS), the Buss-Durkee Hostility Inventory (BDHI) and the Bipolar Eating Disorder Scale (BEDS). Sociodemographic and clinical data were obtained.

Results: Type II bipolar patients scored significantly higher on the BIS and the BDHI physical aggression subscale. Patients with predominant depressive polarity also obtained significantly higher global scores on the BDHI. No differences were found relating to prior suicide attempts or psychiatric admissions. Smoking patients scored significantly higher on the BIS non-planning subscale and the SSS disinhibition subscale.

Limitations: As patients with substance use disorder (SUD) were excluded, the sample of this study may represents a subgroup of patients with bipolar disorder with probably low levels of impulsivity.

Conclusions: Impulsivity and aggressiveness are relevant aspects of bipolar disorders that could significantly increase comorbidity, especially in type II bipolar patients. Adequate diagnosis and treatment are, therefore, important factors in improving the clinical course of this illness.
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http://dx.doi.org/10.1016/j.rpsm.2011.07.004DOI Listing
October 2011

Prevention of the renarrowing of coronary arteries using drug-eluting stents in the perioperative period: an update.

Vasc Health Risk Manag 2010 Oct 5;6:855-67. Epub 2010 Oct 5.

Department of Anaesthesiology and Critical Care Medicine, Hospital Clínic Universitari, València, Spain.

The management of patients scheduled for surgery with a coronary stent, and receiving 1 or more antiplatelet drugs, has many controversies. The premature discontinuation of antiplatelet drugs substantially increases the risk of stent thrombosis (ST), myocardial infarction, and cardiac death, and surgery under an altered platelet function could also lead to an increased risk of bleeding in the perioperative period. Because of the conflict in the recommendations, this article reviews the current antiplatelet protocols after positioning a coronary stent, the evidence of increased risk of ST associated with the withdrawal of antiplatelet drugs and increased bleeding risk associated with its maintenance, the different perioperative antiplatelet protocols when patients are scheduled for surgery or need an urgent operation, and the therapeutic options if excessive bleeding occurs.
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http://dx.doi.org/10.2147/VHRM.S7402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2952454PMC
October 2010

Psychometric performance of the Oviedo Sleep Questionnaire in patients with severe mental disorder.

Rev Psiquiatr Salud Ment 2009 Oct 25;2(4):169-77. Epub 2010 Jan 25.

Área de Psiquiatría, Universidad de Oviedo, Asturias, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, España. Electronic address:

Introduction: The prevalence of sleep disturbances among patients with severe mental disorder ranges from 30 to 80%. Since the impact of these disturbances on patients' lives is substantial, there is a need for their evaluation and management. The aim of this study was to examine the reliability and validity of the Oviedo Sleep Questionnaire (OSQ) in patients with severe mental disorder.

Material And Methods: We performed an observational, prospective (3-month), multicenter study. A total of 259 individuals (184 patients with severe mental disorder and 75 controls) were included.

Evaluation: the OSQ, the sleep items of the Bech- Rafaelsen's Scales for Depression (MES item 3) and Mania (MAS item 5), and the Clinical Global Impression Scales for Severity of Mental Disorder (CGI-SMD) and Sleep Disorder (CGI-SSD).

Results: a) Factorial structure: two factors accounted for 57.65% of the variance; factor 1 (insomnia) accounted for 44.65% and factor 2 (hypersomnia) for 13%; b) internal consistency: total OSQ=0.90, insomnia scale=0.91, hypersomnia scale=0.88; c) testretest reliability=0.87; d) convergent validity: Pearson's correlation coefficients were 0.632 with item 3 of the MES, 0.619 with item 5 of the MAS, and 0.630 with the CGI-SS (p<0.001); e) discriminant validity: the OSQ was able to differentiate between patients and controls (p=0.018), and among distinct degrees of mental disorder severity (CGISMD) (p<0.001) and sleep disorder severity (CGI-SSD) (p<0.001); f) responsiveness: the OSQ, like the CGI-SSD (p=0.004), identified a significant decrease in the insomnia severity score after 3 months (p=0.005).

Conclusions: The OSQ is a valid and reliable method for measuring the sleep/wake cycle in patients with severe mental disorder.
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http://dx.doi.org/10.1016/S1888-9891(09)73235-5DOI Listing
October 2009

Cardiovascular risk in patients with bipolar disorder.

J Affect Disord 2009 Jun 26;115(3):302-8. Epub 2008 Oct 26.

Department of Psychiatry, University of Oviedo, Spain; Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Spain.

Background: To date, little is known about cardiovascular risk (CVR) in terms of coronary heart disease (CHD) and cardiovascular mortality risk (CMR) in patients with bipolar disorder. This study provides data on the overall risk of any fatal or non-fatal coronary heart disease (CHD) and on the cardiovascular mortality risk (CMR) within 10 years in these patients.

Methods: Naturalistic, cross-sectional, multicenter study conducted in Spain. Patients were evaluated for cardiovascular risk using the Framinghan function (CHD) and the Systematic COronary Risk Evaluation (SCORE) function (CMR).

Results: The mean age was 46.6 years and 49% were male. Forty-six percent were in remission. Ten-year CHD risk was 7.6% (males 10.2% versus females 4.7%, p<0.001) and 10-year CMR was 1.8% (males 2.2% versus females 1.3%, p 0.161). Fifty-one percent smoked and 34% was obese. Metabolic syndrome was present in 22.4% of the sample (35.6% according to AHA and NHLBI criteria). Cardiovascular risk significantly increases with age, body mass index and presence of metabolic syndrome.

Limitations: The cross-sectional design of the study.

Conclusions: Cardiovascular risk is high in patients with bipolar disorder. It is associated with age, body mass index and metabolic syndrome. Psychiatrists should be aware of this issue and carefully monitor these patients for cardiovascular risk factors, including cigarette smoking, as part of the standard of care when treating them.
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http://dx.doi.org/10.1016/j.jad.2008.09.008DOI Listing
June 2009

The prevalence of metabolic syndrome in patients with bipolar disorder.

J Affect Disord 2008 Feb 12;106(1-2):197-201. Epub 2007 Jul 12.

Department of Psychiatry, School of Medicine, University of Oviedo, Spain.

Background: Previous studies on the prevalence of metabolic syndrome (MetS) in patients with bipolar disorder have reported rates 11% and 79% higher than in their respective general populations. This study evaluates the prevalence of MetS in a group of 194 Spanish patients with bipolar disorder.

Methods: Naturalistic, multicentre, cross-sectional study. Patients were evaluated for presence of MetS according to modified NCEP ATP III criteria.

Results: Mean age was 46.6 (SD 13.9); 49.2% were male. Forty-six percent were in remission. Patients were receiving 2.9 (SD 1.3) drugs. Overall prevalence of MetS was 22.4%. Fifty-four percent met the criterion for abdominal obesity, 36.1% for hypertriglyceridemia, 38.2% for low HDL cholesterol, 20.9% for hypertension, and 12.2% for high fasting glucose. The multivariate analysis for MetS retained only the BMI variable in the model.

Limitations: Cross-sectional study design.

Conclusions: The prevalence of MetS in patients with bipolar disorder is 58% higher than that reported for the general Spanish population. MetS is associated with BMI. Clinicians should be aware of this issue and appropriately monitor patients with bipolar disorder for MetS as part of the standard of care for these patients.
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http://dx.doi.org/10.1016/j.jad.2007.06.002DOI Listing
February 2008

Prodromal symptoms to relapse in bipolar disorder.

Aust N Z J Psychiatry 2007 May;41(5):385-91

Psychiatric Unit, Hospital La Fe, Valencia 46009, Spain.

In a cyclical and recurring illness such as bipolar disorder, prodrome detection is of vital importance. This paper describes manic and depressive prodromal symptoms to relapse, methods used in their detection, problems inherent in their assessment, and patients' coping strategies. A review of the literature on the issue was performed using MEDLINE and EMBASE databases (1965-May 2006). 'Bipolar disorder', 'prodromes', 'early symptoms', 'coping', 'manic' and 'depression' were entered as key words. A hand search was conducted simultaneously and the references of the articles found were used to locate additional articles. The most common depressive prodromes are mood changes, psychomotor symptoms and increased anxiety; the most frequent manic prodromes are sleep disturbances, psychotic symptoms and mood changes. The manic prodromes also last longer. Certain psychological interventions, both at the individual and psychoeducational group level, have proven effective, especially in preventing manic episodes. Bipolar patients are highly capable of detecting prodromal symptoms to relapse, although they do find the depressive ones harder to identify. Learning detection, coping strategies and idiosyncratic prodromes are elements that should be incorporated into daily clinical practice with bipolar patients.
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http://dx.doi.org/10.1080/00048670701266854DOI Listing
May 2007

Quality of life for patients with bipolar disorder: relationship with clinical and demographic variables.

Bipolar Disord 2005 Apr;7(2):159-65

Psychiatric Unit, La Fe University Hospital, Valencia, Spain.

Objectives: The aim of this study was to assess the quality of life in bipolar disorder patients, and to analyze a set of clinical variables and sociodemographic data that could act as quality-of-life predictors.

Methods: The study sample included 50 euthymic outpatients attending a specific bipolar patient unit. Patients were assessed with the Clinician-Administered Rating Scale for Mania, and the Hamilton Scale for Depression. To evaluate quality of life, all patients received the Spanish version of the SF-36 Health Survey. At the same time, sociodemographic and clinical data were obtained. The scores were compared with those of a control group representative of the general population.

Results: The group of bipolar patients obtained statistically significantly lower scores on all the subscales when compared with the control population. No statistically significant differences appeared when comparing the SF-36 scores with the demographic variables.

Conclusions: Bipolar patients experience lower functioning and well-being even in the stable phase of the disorder. Due to the great impact of bipolar disorder on many areas, it would be of interest to know the clinical predictors related to patient quality of life, as this would contribute to the design of different clinical interventions.
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http://dx.doi.org/10.1111/j.1399-5618.2005.00186.xDOI Listing
April 2005