Individualized DTI-ALPS Identifies Phase-Specific Glymphatic Dysfunction in Early-Stage Bipolar Disorder

Background: The glymphatic system, essential for brain waste clearance and neuroimmune regulation, remains underexplored in the context of bipolar disorder (BD) among young populations. Methods: Using diffusion tensor image analysis along the perivascular space (DTI-ALPS), we compared ALPS indices derived from the conventional FSL-based (cFSL) pipeline with those from the individualized ALPS (iALPS) pipeline. A cohort of young adults comprising 77 individuals with BD and 289 healthy controls was analyzed to evaluate methodological consistency and to identify disorder-specific alterations in glymphatic function. Results: The two pipelines showed only moderate agreement (Lin’s concordance correlation coefficient = 0.52–0.60), suggesting that differences in ROI placement strategies significantly affect ALPS estimation. While the cFSL pipeline detected no group differences, the iALPS pipeline identified a trend-level reduction in ALPS index in patients with BD during depressive episodes, particularly in the right hemisphere (p = 0.036, uncorrected, FDR-adjusted p = 0.071). No significant glymphatic alterations were observed in individuals with early-stage BD. Conclusions: These findings suggest that glymphatic dysfunction in psychiatric disorders may be phase-specific on illness. The use of individualized and automated analytical strategies, such as the iALPS pipeline, appears to enhance sensitivity to subtle, state-related brain changes that conventional methods may overlook. This methodological advancement provides a more biologically informed framework for future large-scale and longitudinal studies aimed at elucidating the role of glymphatic function in the pathophysiology of psychiatric disorders.