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A meta-analysis of 41 studies showed that BD is associated with a hyperactive HPA axis with increased levels of basal cortisol, post-dexamethasone cortisol, and adrenocorticotropic hormone (ACTH), which were positively associated with mania and increased risk of cognitive impairment [162]

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These considerations underscore the importance of coordinating dietary interventions with pharmacological management to optimize safety and treatment outcomes