Manic-depressive psychosis in children younger than 15 years: a register-based investigation of 39 cases in Denmark.

Using a nationwide psychiatric case register covering a background population of 5.1 million inhabitants, 39 children (23 boys, 16 girls) were identified who got the diagnosis of manic-depressive psychosis between 1970 and 1986 before the age of 15. The frequency of manic-depressive psychosis in this child psychiatric population was 1.2%. The mean age for first-time admission with this diagnosis was 12.7 years. There was no sex difference. Twenty-six of the children got the diagnosis of manic-depressive psychosis during their first admission. Survival analysis was used to describe the prognosis and the diagnostic development of the group. As a whole, the group had a poor prognosis with many readmissions. The most common differential diagnoses were other types of psychosis in boys and oppositional and emotional disorders in girls.     

Prediction of in-patient use in first-admitted patients with psychosis.

PURPOSE: The aim of this study is to examine the utilization of psychiatric services for inpatients with psychosis over a period of five years after first admission, and to identify factors that contribute to intensive service use in terms of cumulative length of in-patient treatment and readmission rate. METHODS: A cohort of 424 patients with psychotic disorders (out of a sample of 2565 first-admitted patients from a catchment area in Switzerland) was examined by means of register data. RESULTS: Patients admitted for psychosis spent the longest time in hospital compared to other diagnoses, but there was considerable within-sample variation, and most patients (60.4%) had only one in-patient episode. Of the total time accumulated in this sample, 50.5% was 'consumed' by 10.7% of patients. Regarding the overlap between 'heavy use' and 'frequent use' (those 10% of the sample with the longest/ most frequent hospitalizations), only 39.5% of the 'frequent users' were also 'heavy users' (vice versa: 38.6%). 'Clinical' measures were the main predictors of the overall time spent as an in-patient (schizophrenia diagnosis, therapeutic measures, clinical improvement). Concerning 'heavy use', homelessness was yet another important risk factor. Sociodemographic variables (age, level of education, living alone) particularly influenced the number of hospitalizations. A younger age at first admission was predictive of 'heavy' and 'frequent' use. DISCUSSION: Clinical and sociodemographic factors explain differences in in-patient service consumption among patients with psychosis. Efforts to devise effective interventions have to take both into account, but different measures are needed to address 'heavy' and 'frequent' use.     

Manic-depressive patients with delusions. Clinical and diagnostic course

A study was made of the hospital records of 114 first admission patients under 60 years with a diagnosis of manic-depressive psychosis and coexisting paranoid symptoms. The male/female ratio was 1/1.4, and the females were significantly older. Symptomatology and treatment are presented. Seventy per cent disclosed delusions of reference and misinterpretation and 50% had synthymic delusions. During 11-15 years of admission 75% of the patients were re-admitted. The diagnostic concept was changed in 33%. Significantly more females were diagnosed unipolar manic-depressive. According to the general practitioners and hospital records psychotic traits were still present in 50% of the patients at follow-up. Significantly more patients diagnosed as unipolar manic-depressive had no relapse and no remaining psychotic traits. And significantly more patients with changed diagnosis had remaining psychotic traits. The need for prospective studies of patients with coexisting affective and paranoid symptomatology is stressed.     

Validity of diagnoses and other clinical register data in patients with affective disorder

Studies validating the clinical diagnoses of affective disorder recorded in case registers against research diagnostic criteria do not exist. In the present study, a random sample of 100 patients was selected among 21,734 patients who were recorded in the Danish Psychiatric Central Register with a diagnosis of manic-depressive psychosis at their first admission to psychiatric ward in a period from January 1, 1971 to December 31, 1993. Case notes from alt over Denmark were reviewed for all 100 patients and diagnoses were made with the use of OPCRIT. Patients who were still alive were contacted and interviewed face to face or by telephone. In total, 95 out of the 100 patients received an ICD-10 diagnosis of affective disorder computed with OPCRIT and confirmed at the interviews. Other clinical characteristics such as the age at onset and the number of affective episodes estimated from the register corresponded well with information from the case notes and the interviews.     

Admission pattern and diagnostic stability of patients with functional psychoses in Denmark during a two-year observation period

This register-based study shows that the incidence of first-admitted patients to psychiatric hospital who were diagnosed as having functional psychoses was 55 per 100,000 inhabitants in Denmark in 1984. During a two-year observation period, half of the patients were readmitted and two-fifths had their diagnosis changed. Young and schizophrenic patients were especially liable to readmission. Reactive psychosis and paranoia were the most unstable diagnostic concepts, as half of the patients were classified differently at the latest readmission compared to the first admission. Schizophrenic patients are still to a great extent treated as inpatients. Comparisons between two catchment areas are made. It is necessary to be very careful when one is using patients' first diagnosis from the present nosologic classification for prediction of clinical and diagnostic course. Studies based on phenomenology and on diagnoses made using operational criteria are badly needed.     

Unipolar and bipolar schizoaffective disorders: A comparative study

Summary Seventy-two schizoaffective patients were investigated longitudinally (mean follow-up period 25.6 years). Unipolar (n = 37) and bipolar (n = 35) schizoaffectives were compared. Relevant differences in sociodemographic variables were found between the two groups, especially in: (a) sex distribution (more females among unipolar schizoaffectives), (b) social class, (c) occupational and educational level (higher in bipolars), and (d) premorbid personality (obsessoid and low-self-confidence personality types were more frequent in unipolars). Surprisingly there was no difference in age of onset, but some factors were identified that elevated the age of onset in bipolar and reduced it in unipolar schizoaffectives, which may explain this finding. Among bipolars there were more frequent relapses, but there was more suicidal symptomatology in unipolars. No differences were found with regard to long-term outcome, i.e. disability (Disability Assessment Schedule), level of functioning (Global Assessment Scale) or psychopathology at follow up.Supported by grants Ma 915-1/1 and Ma 915-1/2 from the German Research Association (Deutsche Forschungsgemeinschaft)     

Obsessive-compulsive disorder: admission patterns and diagnostic stability

All first-time admissions from 1970 to 1986 with obsessive-compulsive neurosis (OCD) (ICD-8 diagnosis number 300.39) or obsessive-compulsive personality disorder (OCPD) (ICD-8 diagnosis number 301.49) were analyzed based on an extract from the nationwide Psychiatric Case Register in Denmark. All patients with secondary diagnoses other than neurotic disorders or personality disorders (including “neuroses characterogenes”) were excluded from the study. A total of 284 patients were first-time admitted with a main diagnosis of OCD during the period. The sex ratio was 0.67 (males/females). A total of 126 were first-time admitted with a diagnosis of OCPD, with a sex ratio of 1.18 (males/females). Seventy-seven percent of the readmitted patients with a first-time diagnosis of OCD kept a diagnosis within the “emotional spectrum” at the last admission. About half kept OCD as a main diagnosis, whereas only 15% shifted to a severe psychiatric diagnosis such as schizophrenia or manic-depressive psychosis. Of the readmitted patients with OCPD. 13% later developed a diagnosis of manic-depressive psychosis.     

Pattern of health service utilization and predictors of readmission after a first admission for psychosis: a 2-year follow-up study

OBJECTIVE: To explore the pattern of health service utilization over 2 years following a first admission for psychosis and the baseline characteristics predicting readmission. METHOD: Patients included in a cohort of first-admitted subjects with psychosis (n = 84) were assessed at the end of a 2-year follow-up using multiple sources of information. RESULTS: At the end of the follow-up, one of three subjects had no contact with any mental health professional, and 38% of subjects had no contact with a psychiatrist. Half of the patients were readmitted over the 2-year follow-up. The baseline characteristics independently predicting psychiatric readmission were a high number of helping contacts before first admission and persistence of psychotic symptoms at discharge. CONCLUSION: Decreasing the frequency of readmission in the early course of psychosis is a public health priority. Development of psychotherapeutic programs for subjects with early psychosis who have enduring psychotic symptoms at first discharge should be promoted.     

Decreased risk of acute appendicitis in patients with schizophrenia or manic-depressive psychosis

The present study tests the hypothesis of a negative association between patients with schizophrenia, manic-depressive psychosis and acute appendicitis.Using the nation-wide Danish case registers the occurrence of acute appendicitis among up to 20,402 inpatients with schizophrenia and up to 10,281 inpatients with manic-depressive psychosis and ten individually matched control persons for each psychiatric patient was investigated. A case-control and follow-up design was applied.Persons who developed schizophrenia had a significantly decreased relative risk of acute appendicitis of 0.49 before and of 0.59 after first psychiatric admission. Similarly the occurrence of manic-depressive psychosis was associated with a decreased relative risk of acute appendicitis of 0.50 before and of 0.70 after first psychiatric admission.One or more unknown factors inversely affect the risk for the subsequent development of psychoses and acute appendicitis. Further studies of this relationship may help to clarify etiological or pathophysiological aspects of schizophrenia and manic-depressive psychosis.     

INCIDENCE OF DEPRESSIVE SYNDROMES IN A DANISH COUNTY

On the basis of a material from a cumulative registration of the psychiatric morbidity in a geographically delimited population group - the County of Aarhus with approximately 175,000 inhabitants over the age of 15 years - the frequency of depressive syndromes in psychiatric and other medical services was investigated. The material fulfils the following criteria: During the calendar years 1960 to 1964, the patients 1) were residents in the County of Aarhus, 2) had attained the age of 15 years or more, 3) had contacted at least one of the services which systematically sent information to the psychiatric register; and 4) based on an evaluation of all available data, had a main diagnosis of manic-depressive psychosis, psychogenic depression or neurotic depression. An average yearly registration rate of 1.30 per 1,000 men and 3.28 per 1,000 women was found (males: manic-depressive psychosis 0.60, psychogenic depression 0.23 and neurotic depression 0.47; females: manic-depressive psychosis 1.00, psychogenic depression 0.88 and neurotic depression 1.40). The three diagnostic groups show differences in age distribution, geographical pattern and distribution by marital status.     

Relationship of electroconvulsive therapy to course in affective illness: A collaborative study

Bipolars treated with electroconvulsive therapy (ECT) during the index episode were matched on the variables of age, sex, previous admissions and previous hospitalizations with 23 bipolars who did not receive ECT. A similar match was made for 42 unipolars who were under the age of 40 at time of admission. All patients were followed for 5 years. Those patients treated with ECT, both bipolars and unipolars, had the same numbers of episodes in follow-up as their matched groups. However, in both bipolar and unipolar ECT-treated patients, there were more follow-up rehospitalizations. The reason for this is not known but three possibilities exist. Successful treatment with ECT may make the family and patient more prone to consider rehospitalization. Secondly, the originally treated ECT patients may have had more aggressive doctors who were more likely to rehospitalize. Finally, ECT may change the course of an individual's illness in such a way that more severe episodes occur and rehospitalizations are necessary. The findings suggest the need for long-term studies following ECT on clinical and biological variables.     

Parents with psychosis.

This study examined the prevalence of parenthood in a community-based sample of first-admission patients with DSM-IV diagnoses of Schizophrenia/Schizoaffective Disorder, Bipolar Disorder with psychotic features and Major Depressive Disorder with psychosis. A total of 130 (28.7%) of 453 patients were parents at the time of first admission. Women were twice as likely as men to be parents in all diagnostic groups. Patients with mood disorder with psychosis were twice as likely to be parents as those with Schizophrenia/Schizoaffective Disorder. Substance Use Disorder was a common comorbidity among fathers and to a somewhat lesser extent among mothers as well. At the time of admission, over three-quarters of mothers were living with their children, as were half or more of the fathers with mood disorder. Most continued to live with their children after discharge. Almost 40% of mothers with mood disorders were living as single parents both before and after admission. Almost three-quarters of the children were under 16 years of age. Over 40% of mothers in all diagnostic categories had at least one child under 5 years of age. About 20% of mothers in all 3 diagnoses experienced the onset of psychosis within 6 months of childbirth. Over half of these experienced psychotic symptoms related to the child or had neglected the child prior to admission. Our findings contrast with earlier studies from more chronic patient samples in documenting that first-admission patients with psychosis are generally intimately involved in their children's lives both before and after admission. Despite the fact that over three-quarters of these parents were still in treatment at 6-month follow-up, there was virtually no evidence that any form of educational or family-oriented treatment was offered to these parents. These results, coupled with earlier reports of highly disrupted family lives and serious adverse outcomes among the children of chronically ill parents, underscore the need for early family intervention programs. In addition, there is a need for systematic research to identify effective treatment interventions for this population.     

Principal components of the Beck Depression Inventory and regional cerebral metabolism in unipolar and bipolar depression.

BACKGROUND: We determined clustering of depressive symptoms in a combined group of unipolar and patients with bipolar disorder using Principle Components Analysis of the Beck Depression Inventory. Then, comparing unipolars and bipolars, these symptom clusters were examined for interrelationships, and for relationships to regional cerebral metabolism for glucose measured by positron emission tomography. METHODS: [18F]-fluoro-deoxyglucose positron emission tomography scans and Beck Depression Inventory administered to 31 unipolars and 27 bipolars, all medication-free, mildly-to-severely depressed. BDI component and total scores were correlated with global cerebral metabolism for glucose, and voxel-by-voxel with cerebral metabolism for glucose corrected for multiple comparisons. RESULTS: In both unipolars and bipolars, the psychomotor-anhedonia symptom cluster correlated with lower absolute metabolism in right insula, claustrum, anteroventral caudate/putamen, and temporal cortex, and with higher normalized metabolism in anterior cingulate. In unipolars, the negative cognitions cluster correlated with lower absolute metabolism bilaterally in frontal poles, and in right dorsolateral frontal cortex and supracallosal cingulate. CONCLUSIONS: Psychomotor-anhedonia symptoms in unipolar and bipolar depression appear to have common, largely right-sided neural substrates, and these may be fundamental to the depressive syndrome in bipolars. In unipolars, but not bipolars, negative cognitions are associated with decreased frontal metabolism. Thus, different depressive symptom clusters may have different neural substrates in unipolars, but clusters and their substrates are convergent in bipolars.     

Six-year outcomes in first admission adolescent inpatients: clinical and cognitive characteristics at admission as predictors

Persistent functional disability is common after even a single psychiatric admission in people with schizophrenia or bipolar disorder, but less is known about other conditions and about adolescent onset patients. This study examined clinical symptoms and cognitive performance at the time of the first admission for the prediction of 6-year outcomes. First admission adolescent patients with a variety of psychiatric diagnoses were assessed with comprehensive clinical ratings of psychopathology, a neuropsychological assessment, and received clinical diagnoses while experiencing their first psychiatric admission. They were contacted 6 years after discharge and examined with a structured assessment of psychiatric symptoms and functioning. Despite the low levels of overall impairment at follow-up, at least 20% of the variance in depression, psychosis, poor peer relationships and poor school attendance 6 years after the hospital admission were predicted by information collected during the hospitalization. Attentional deficits during admission predicted the presence of psychosis at follow-up more substantially than psychotic symptoms during admission, as well as predicting risk for relapse. Attentional deficits during a first psychiatric admission predicted risk for manifesting psychosis at 6-year follow-up to a more substantial degree than either a psychosis diagnosis or psychotic symptoms at admission. In contrast to psychosis, depression at follow-up was predicted by admission symptomatology, but not by cognitive deficits.     

Stability of psychotic symptomatology (delusions,hallucinations), affective syndromes,and schizophrenic symptoms (thought disorder,incongruent affect) over episodes in remitting psychoses

Summary A study was made on 140 schizophrenics, 40 schizoaffectives, 59 unipolar depressives, and 30 bipolar affective disorder patients in order to determine the quality of psychopathology over multiple episodes. The schizoaffectives were the most likely to have multiple episodes. Among the schizophrenics, there were few episodes that lacked psychotic symptoms, but almost half of the episodes for the schizoaffectives were asscociated with an absence of psychotic symptoms. Three-quarters of the patients with unipolar depression and bipolar illness showed no psychotic symptoms either congruent or noncongruent. There was a striking finding that all diagnoses were associated with a decrease in psychotic symptoms over time. These psychotic symptoms (delusions and hallucinations) became particularly more scarce among the schizoaffectives, unipolars, and bipolars. There was a 50% to 67% decrease of episodes with psychotic symptoms as more episodes occurred. For schizophrenia and schizoaffective disorder the first ten episodes were very similar to each other for affective syndromes, formal thought disorder and/or incongruent affect, and delusions and hallucinations. It was not until much time had passed that the symptom pictures changed.     

The schizophrenia diagnosis in Denmark. A register-based investigation

Patients, Danish citizens only, admitted for the first time in 1972 to a Danish psychiatric institution were selected from the national psychiatric register. To be included, the probands had to have been diagnosed as schizophrenics at least once in the period from their first admission to 1 September 1983. The study comprised 370 males and 217 females with a total of 5,298 admissions. The probands' diagnostic pattern during the above period was investigated. More males (51.9%) than females (39.2%) (P less than 0.01) were diagnosed as schizophrenics during their first admission. The average period from a patient's first contact with an in-patient institution until schizophrenia was diagnosed for the first time was 2.2 years for females and 1.7 years for males (P less than 0.05). Personality disorders, reactive psychoses, and not classifiable psychoses were the most frequent diagnoses prior to the first schizophrenia diagnosis. The diagnostic stability of schizophrenia as main diagnosis, after its first application, was 73.6% for males among a total of 2,539 admissions and 71.2% for females among 1,141 admissions. There was greater correlation between the latest and former diagnoses than between the first and subsequent diagnoses. This is valid both when distinguishing between schizophrenia and non-schizophrenia and when focusing on schizophrenia subtypes. The results are discussed, particularly the problem concerning the selection of representative cohorts for schizophrenia research projects.     

Affective disorders in first-degree relatives of adolescent onset bipolars, unipolars, and normal controls

Two hundred and fifty-nine first-degree relatives of 23 adolescent bipolars (81 relatives); 26 unipolars (95 relatives); and 24 normal controls (83 relatives) were assessed for the presence of affective disorders, using the family history method. First-degree relatives of bipolar probands were significantly more likely to have a bipolar illness than those of unipolar probands (p = 0.03) and normal controls (p = 0.001). Rates of unipolar depression in first-degree relatives of bipolars and unipolars were not significantly different but differed significantly between bipolars and normals (p = 0.002) and unipolars and normals (p = 0.006). The implications of these findings for clinical work, diagnosis, and research in adolescents with affective disorders are discussed.     

Obsessive-compulsive disorder in adolescence. Differential diagnostic considerations in relation to schizophrenia and manic-depressive disorder: a comparison of phenomenology and sociodemographic characteristics.

Some borderline cases of obsessive-compulsive disorder (OCD), schizophrenia, and manic-depressive disorder in whom the diagnosis had been difficult to assess in adolescence are presented. The records of 27 OCD patients with admission both in adolescence and adulthood were compared to a group of manic-depressive and schizophrenic patients with an admission in adolescence where the OCD diagnosis had been given. Some differential diagnostic considerations and difficulties in the borderline area between OCD, manic-depressive psychosis and schizophrenia at the time of the first manifestation in adolescence are described. The symptomatology in the three groups of patients as it was presented in adolescence only showed a few differences, and the patients offered differential diagnostic difficulties to the clinicians.     

Time trends in first admissions for schizophrenia and paranoid psychosis in Stockholm County, Sweden

Several studies have reported decreasing time trends in first diagnosed schizophrenia patients. The aim of this study was to analyze time trends for first admissions with a diagnosis of schizophrenia or a diagnosis of either schizophrenia or paranoid psychosis during 1978-1994 in Stockholm County, Sweden, with a population of around 1.8million. Information about first psychiatric admission with the diagnosis schizophrenia or paranoid psychosis for residents of Stockholm County was obtained from the Swedish population-based psychiatric inpatient register. Age-adjusted average yearly changes in first hospitalization rates were estimated in a Poisson regression model. Time trends in first admission rates were calculated from 1978 to 1994, while admissions during 1971 to 1977 were observed only to eliminate later re-admissions. First admissions for schizophrenia declined by 1.9% annually for females and by 1.3% for males, while first admissions for schizophrenia and paranoid psychosis together were unchanged over the study period for both genders. Our results indicate that the incidence of schizophrenia and paranoid psychosis taken together was essentially the same over the studied time period in Stockholm County, and that the apparent decline in first admission rates for schizophrenia may be an effect of changes in clinical diagnosis over time.     

Hospitalization patterns in schizophrenia. A 13-year follow-up

All first admitted patients in 1972 from a catchment area of 582,000 inhabitants aged 15 years or more who were diagnosed as schizophrenic at least once from 1972 until September 1983 (n = 53) were followed-up on average 13 years after first admission. About 20% of the cohort was hospitalized on any given day throughout the length of the follow-up period. The duration of hospitalization decreased from a mean of 8.2 months for the first admission to 1.7 months for the tenth or later admission. The readmission risk increased as a function of the number of previous admissions. Patients with income from occupation or from grants for education had shorter duration of first in-patient period. If the patients were diagnosed as schizophrenics already during the first hospitalization the risk for prolonged duration of the first in-patient period was increased but the readmission risk diminished. Furthermore, readmission risk after the first discharge was diminished by own income and by out-patient treatment and increased by low social status. High proportion of follow-up time in hospital (greater than or equal to 30%) was correlated to affective flattening present at first admission. Of the cohorts' total number of admissions (n = 493) 12% were involuntary. Involuntary admissions were more frequent in the first half of the follow-up period and were correlated to a previous involuntary admission.