Vulnerability to psychosis in patients attending primary and psychiatric care. Results of the RADEP study

We studied occurrence of psychotic symptoms and their associations with occurrence of depressive and manic symptoms; 563 patients attending primary care (PrC) and 163 patients attending psychiatric outpatient care (PsC) completed a questionnaire including lists of psychotic, manic and depressive symptoms, and patients with depressive symptoms were interviewed using the same questionnaire 6 months after baseline examination. Of PrC patients, 8.5% and of PsC patients, 36.2% reported at least seven lifetime psychotic symptoms. During the 6-month follow-up, the corresponding figures were 0.22% for PrC and 2.84% for PsC patients. Among PrC patients, men, young, never-married, students and unemployed reported more psychotic symptoms than others. In multivariate analyses, occurrence of psychotic symptoms was associated with young age, never being married, poor functioning and former psychiatric treatment, as well as with occurrence of manic and depressive symptoms. Psychotic symptoms are rather prevalent in primary care and very common in psychiatric care. In primary care, vulnerability to psychosis is associated with the patient's background more strongly than in psychiatric care. Concurrent occurrence of psychotic symptoms with manic and depressive symptoms is common.     

Vulnerability to psychosis increases the risk of depression. Results of the RADEP study

We studied prevalence of depressive symptoms in primary care (PrC) and in psychiatric outpatient care (PsC), and how psychotic and manic symptoms are associated with current depressive symptoms. Altogether 563 patients attending PrC and 163 patients attending PsC filled in a questionnaire including the Depression Scale (DEPS), the Mood Disorder Questionnaire (MDQ) and questions on psychotic symptoms from the Composite International Diagnostic Interview (CIDI). Patients with depressive symptoms (DEPS score > 8) were interviewed by phone using the same checklist 6 months after baseline examination. From the PrC sample, 19.5% and from the PsC sample 73.0% were DEPS positive. In the PrC but not in the PsC sample, patients' background associated strongly with occurrence of depressive symptoms. Both at baseline and at follow-up, depressive symptoms correlated significantly with psychotic and manic symptoms. In multivariate analyses, when the effects of background, health and functioning were taken into account, baseline depressive symptoms associated significantly with lifetime psychotic symptoms. Depressive symptoms at follow-up associated significantly with psychotic symptoms during the follow-up period. In the PrC sample, this association was significant even when the effect of baseline depressive symptoms was controlled. About one-fifth of patients attending primary care and about three-quarters of patients attending psychiatric outpatient patient care suffer from depressive symptoms. Vulnerability to psychosis, indicated by occurrence of psychotic symptoms, increases the risk of and slower recovery from depressive symptoms in the patients attending primary care. Therefore, vulnerability to psychosis should be evaluated when treatment intervention for patients with depressive symptoms is planned.     

Psychotism and its dimensions in primary care. Associations with patient's background and manic and depressive symptoms. Results of the RADEP study

Dimensions of psychotism have mainly been studied in clinical samples. We studied psychotism, its dimensions and their associations, in a primary care sample. In all, 1199 primary care patients over 18 years of age filled in a questionnaire including lists of psychotic (the Composite International Diagnostic Interview, CIDI), depressive (the Depression Scale, DEPS) and manic (the Mood Disorder Questionnaire, MDQ) symptoms. Psychotic symptoms were factored, and variance in factor scores was explained by patients' background and by depressive and manic symptoms. In the principal component solution, the first factor explained 22% of the total variance in psychotic (CIDI) symptoms and was named global psychotism. Varimax rotation produced seven interpretable dimensions: Schneiderian (9.7% of variance), passivity (8.9%), hallucinatory (8.5%), paranoid (7.7%), infidelity (7.6%), somatic (7.6%) and reference experiences (5.9%). Together they explained 52% of the total variance of CIDI symptoms. Global psychotism (P=0.000), as well as hallucinatory (P=0.003), paranoid (P=0.000) and infidelity (P=0.000) experiences associated inversely with age. Otherwise, patients' background associated differently with global psychotism and with factor dimensions in CIDI symptoms. Manic symptoms associated with global psychotism and with all CIDI dimensions, whereas depressive symptoms associated with global psychotism, passivity, paranoid and infidelity experiences. Psychotism is composed of a global factor and of independent dimensions, and is more prevalent in young people. Independently of patients' background, manic widely and depressive symptoms less widely associate with occurrence of psychotism.     

Psychiatric symptoms related to interferon therapy for chronic hepatitis C: clinical features and prognosis

Psychiatric symptoms during interferon (IFN) therapy for viral hepatitis have been a crucial problem in consultation-liaison psychiatry. However, there have been few studies on psychiatric management for these symptoms and their prognosis. Among 943 patients who were treated with IFN for chronic hepatitis C between 1991 and 1995, 43 patients (4.6%) developed psychiatric symptoms during IFN treatment. Three patients (0.3%), with pre-existing psychiatric disorders showed aggravated symptoms and were excluded from the study. All three patients were able to finish the IFN therapy with psychiatric management. Forty patients (4.2%) manifested psychiatric symptoms induced by IFN. Thirteen patients (1.4%) were diagnosed as anxiety disorder and 21 patients (2.2%) revealed mood disorder with depressive features. There were other psychiatric disorders in six patients (0.6%), including psychotic disorder with delusions/hallucinations in four patients (0.4%), mood disorder with manic features in one patient (0.1%) and delirium in one patient (0.1%). Women developed psychiatric symptoms significantly more than men. Ten of 40 patients (25%) stopped IFN treatment because of manifesting psychiatric symptoms induced by IFN. Twelve patients (30%) required psychiatric treatment for more than 24weeks after ceasing IFN, and seven patients still had anxiety, insomnia and mild hypothymia at the end of the present study. Statistical analysis revealed that IFN-beta therapy and psychiatric manifestations including psychotic symptoms, delirium and manic symptoms were significantly related to long-term psychiatric problems. There are considerable numbers of patients who have required long-term psychiatric management even after cessation of IFN treatment.     

Cannabis use and non‐clinical dimensions of psychosis in university students presenting to primary care

Skinner R, Conlon L, Gibbons D, McDonald C. Cannabis use and non‐clinical dimensions of psychosis in university students presenting to primary care. Objective: To explore the relationship between cannabis use and self‐reported dimensions of psychosis in a population of university students presenting for any reason to primary care. Method: One thousand and forty‐nine students attending the Student Health Unit, National University of Ireland, Galway, completed self‐report questionnaires on alcohol and substance misuse, non‐clinical dimensions of psychosis [Community Assessment of Psychic Experiences (CAPE)], anxiety and depression [Hospital Anxiety and Depression Scale (HADS)]. Association of cannabis use with psychiatric symptoms was explored whilst controlling for confounds. Results: More frequent cannabis use was independently associated with greater intensity of positive, negative and depressive psychotic symptoms. The earlier the age of onset of cannabis use, the more positive psychotic symptoms were reported. Conclusion: These findings support the hypotheses that cannabis use increases the risk of developing psychotic symptoms and that this risk is further increased in those individuals who use cannabis more heavily and commence it at a younger age.     

Prevalence and description of psychotic features in bipolar mania

Psychotic symptoms are common in both the manic and depressive phases of bipolar disorder. More than half of patients with bipolar disorder will experience psychotic symptoms in their lifetime. Grandiose delusions are the most common type of psychotic symptom, but any kind of psychotic symptom, including thought disorder, hallucinations, mood-incongruent psychotic symptoms, and catatonia can present as part of a manic episode. Psychotic symptoms suggest poor prognosis when they occur in the absence of affective symptoms. However, psychotic symptoms can mask affective symptoms and make the distinction between manic-depressive illness and other psychiatric disorders difficult, especially in minorities. Careful assessment of prior psychiatric history, family history, and treatment response can aid in the differentiation of affective disorders with psychotic features from psychotic disorders.     

Psychiatric Symptoms Endorsed by Somatization Disorder Patients in a Psychiatric Clinic

Patients with somatization disorder (SD) endorse high rates of psychiatric symptoms. However, prior studies have not addressed whether these endorsed symptoms reflect underlying psychiatric illness or whether they represent symptom overendorsement mirroring somatic complaints in patients with SD. Thirty-two female outpatients with SD and 101 with other psychiatric disorders completed a checklist of current and lifetime psychiatric symptoms. These findings were analyzed with respect to the diagnoses given by their treating psychiatrists. Patients with SD displayed significantly more current and lifetime psychiatric symptoms than did patients without either SD or cluster B personality disorder. Patients with SD endorsed a large number of psychotic, manic, depressive, and anxiety symptoms; however, they endorsed few alcohol use disorder symptoms. Psychotic and manic symptoms endorsed by patients with SD did not reflect their clinical diagnoses: only two patients with SD carried an additional clinician diagnosis of either schizophrenia or bipolar disorder, despite high rates of endorsed symptoms by the group. Patients with cluster B personality disorders but without SD showed a symptom profile similar to that of patients with SD. Psychiatric outpatients with SD endorse many more psychiatric symptoms than do other psychiatric patients. Patients with SD in the psychiatric treatment setting may mimic other psychiatric illnesses; therefore, SD should be considered in the differential diagnosis for a wide variety of psychiatric illness, including psychotic and mood disorders     

Diagnostic subtypes of bipolar disorder in older versus younger adults

OBJECTIVE: To investigate differences in diagnostic subtypes of bipolar disorder as according to ICD-10 between patients whose first contact with psychiatric health care occurs late in life (over 50 years of age) and patients who have first contact earlier in life (50 years of age or below). METHODS: From 1994 to 2002 all patients who received a diagnosis of a manic episode or bipolar disorder at initial contact with the mental healthcare system, whether outpatient or inpatient, were identified in Denmark's nationwide register. RESULTS: A total of 852 (49.6%) patients, who were over age 50, and 867 patients, who were 50 or below, received a diagnosis of a manic episode or bipolar disorder at the first contact ever. Older inpatients presented with psychotic symptoms (35.4%) significantly less than younger inpatients (42.6%) due specifically to a lower prevalence of manic episodes with psychotic symptoms. Conversely, older inpatients more often presented with severe depressive episodes with psychotic symptoms than younger inpatients (32.0% versus 17.0%). Among outpatients, no significant differences were found between patients older than 50 years and patients 50 years of age or younger. However, a bimodal distribution of age at first outpatient contact was found with an intermode of 65 years and outpatients older than 65 years more often presented with severe depressive episodes with psychosis. CONCLUSIONS: Bipolar patients who are older at first psychiatric hospitalization (>50 years) present less with psychotic manic episodes and more with severe depressive episodes with psychosis than younger patients. The distribution of age at first outpatient contact is bimodal with an intermode of 65 years and outpatients older than 65 years more often present with severe depressive episodes with psychosis.     

Childhood trauma and distress experiences associate with psychotic symptoms in patients attending primary and psychiatric outpatient care. Results of the RADEP study

GoalWe studied the prevalence of and association between psychotic symptoms and childhood trauma experiences in primary care patients compared with psychiatric care patients.Patients and methodsWe note 911 primary care and psychiatric care patients over 16 years of age filled in a questionnaire including a list of lifetime psychotic symptoms of the Composite International Diagnostic Interview (CIDI) and the childhood Trauma and Distress Scale (TADS). Prevalence of and correlations between psychotic symptoms and childhood trauma and stressful experiences were calculated. Association between the sum of CIDI symptoms and the TADS sum score was analysed by Anova.ResultsIn primary care, more than half of the patients had had at least one psychotic symptom during their lifetime, and nearly 70% of patients had experienced a childhood trauma at some time or more often. In psychiatric care patients, CIDI symptoms were more prevalent and TADS scores were higher than in primary care patients. In the whole sample, CIDI symptoms correlated with TADS scores. The association remained even when the effects of age, service, and patient's functioning were taken into account. There was a dose-response between TADS scores and CIDI symptoms.ConclusionChildhood trauma experiences associate with psychotic symptoms. In clinical work, it is important to acknowledge that psychotic symptoms and childhood trauma experiences are common not only in psychiatric care but also in primary care patients, and thus require adequate attention.     

Phenomenology associated with age at onset in patients with bipolar disorder at their first psychiatric hospitalization

OBJECTIVE: To compare the clinical presentation of patients with early-onset (age <18 years) and typical-onset (age 20-30 years) bipolar disorder at the time of first hospitalization. METHODS: Patients, aged 12-45 years at their first psychiatric hospitalization, with a DSM-IV diagnosis of bipolar disorder, manic or mixed, were evaluated on measures of manic, depressive, and positive psychotic symptoms. Differences in symptom profiles between early- and typical-onset groups were examined. RESULTS: One hundred three early-onset and 58 typical-onset patients were compared. Mixed episodes were more common in the early-onset group, while psychotic features and current substance use were more common in the typical-onset group. There was no significant difference in manic symptom severity ratings between early- and typical-onset groups (F = 1.8, df = 11, 144, p = 0.06). However, these groups differed in depressive (F = 4.2, df = 16, 139, p < 0.001) and positive psychotic (F = 2.8, df = 16, 139, p = 0.001) symptom profiles. Typical-onset bipolar patients reported more severe weight loss and formal thought disorder compared with early-onset patients. CONCLUSIONS: Depressive and positive psychotic symptoms may differ in association with age at onset among patients with bipolar disorder. Additional studies are necessary to determine whether homogeneous phenotypes of bipolar disorder can be delineated based upon age at onset.     

Affective Dysregulation and Reality Distortion: A 10-Year Prospective Study of Their Association and Clinical Relevance

Evidence from clinical patient populations indicates that affective dysregulation is strongly associated with reality distortion, suggesting that a process of misassignment of emotional salience may underlie this connection. To examine this in more detail without clinical confounds, affective regulation-reality distortion relationships, and their clinical relevance, were examined in a German prospective cohort community study. A cohort of 2524 adolescents and young adults aged 14–24 years at baseline was examined by experienced psychologists. Presence of psychotic experiences and (hypo)manic and depressive symptoms was assessed at 2 time points (3.5 and up to 10 years after baseline) using the Munich-Composite International Diagnostic Interview. Associations were tested between level of affective dysregulation on the one hand and incidence of psychotic experiences, persistence of these experiences, and psychotic Impairment on the other. Most psychotic experiences occurred in a context of affective dysregulation, and bidirectional dose-response was apparent with greater level of both affective dysregulation and psychotic experiences. Persistence of psychotic experiences was progressively more likely with greater level of (hypo)manic symptoms (odds ratio [OR] trend = 1.51, P < .001) and depressive symptoms (OR trend = 1.15, P = .012). Similarly, psychotic experiences of clinical relevance were progressively more likely to occur with greater level of affective dysregulation (depressive symptoms: OR trend = 1.28, P = .002; (hypo)manic symptoms: OR trend = 1.37, P = .036). Correlated genetic liabilities underlying affective and nonaffective psychotic syndromes may be expressed as correlated dimensions in the general population. Also, affective dysregulation may contribute causally to the persistence and clinical relevance of reality distortion, possibly by facilitating a mechanism of aberrant salience attribution.     

Depressive symptoms amongst adolescent primary care attenders

Abstract. Background: Background High rates of depressive disorder have been documented amongst adolescents attending general practitioners (GPs) in urban areas. However, little is known about the associations of adolescent depression in primary care. Method: We completed a cross-sectional questionnaire survey of adolescents, their parents and general practitioners, following adolescent attendance at the surgery. Results: We found high levels of depressive symptoms to be present in adolescent attenders of a broad range of social backgrounds. Depressive symptoms were associated with the following demographic and contextual factors: older age, female gender and parental psychiatric symptoms. They were also associated with the presence of physical symptoms causing psychosocial impairment, with health risks (use of cannabis and exposure to drugs) and with use of services (both primary care and mental health services). Levels of depressive symptoms were similar in urban and suburban groups. However, associations of depressive symptoms with smoking, exposure to drugs, cannabis use and primary care attendance were demonstrated in the suburban group and not the urban group. Conclusion: Adolescent GP attenders have high levels of depressive symptomatology. GP recognition and intervention should have the potential to impact on adolescent depression and on associated risks.     

PSYCHIATRIC MORBIDITY AMONG THE ELDERLY IN A PRIMARY CARE SETTING—REPORT FROM A SURVEY IN SÃO PAULO,BRAZIL

Brazil has been experiencing a steady increase in the elderly population during the past few years, and as a result old age health-related problems are increasing continuously in number. Psychiatric symptoms are among the most prevalent health problems of the elderly and are an important source of distress for patients and carers, being also associated with significant growth in the costs and demand for the provision of health care services. This study aimed to investigate the prevalence of mental health problems among the elderly attending a regional primary care unit in the city of São Paulo, Brazil. A total of 351 patients older than 60 were assessed during a 6-month period with the SRQ-20 (a scale for the detection of minor psychiatric problems), four questions on psychotic symptoms, AMTS (a scale for the assessment of cognitive functioning) and CAGE (a scale for the assessment of alcoholism); demographic variables were also recorded. Subjects' mean age was 71.22 (CI=70.51–71.92) and 83.5% were female. Thirty-two per cent of subjects were considered ‘cases’ as they scored more than 7 on the SRQ-20 (26.8% of total), or more than 1 on the CAGE (1.4% of total), or at least 1 on the questions assessing psychotic symptoms (12.2% of total). There was a significant excess of women among those found to suffer from psychiatric problems (90.1% vs 80.4%). Cases were also more likely to be illiterate (23.4% vs 12.1%) and to have a lower income (2.21 vs 4.01 minimum wages). Depressive symptoms and tension were highly prevalent (72.9% of subjects). Somatic complaints and signs of inefficient functioning were also common (50.4% and 45.9% respectively). Only five patients answered affirmatively two or more CAGE questions and 12.2% scored at least 1 on the questions assessing psychotic symptoms. Cognitive deficit, as determined by the AMTS, was observed in 13.4% of the sample and was associated with ageing, being illiterate and having higher total SRQ-20 scores. We suggest, that the organization of health care services should take into account the needs of this population, and should also emphasize professional training for the correct assessment and treatment of the most frequent mental health problems in old age. © 1997 John Wiley & Sons, Ltd.     

Seven-year outcome of depression in primary and psychiatric outpatient care: Results of the TADEP (Tampere Depression) II Study

The objective of this article was to determine a 7-year naturalistic progression of depression as well as a number of potential prognostic factors among Finnish primary care and psychiatric care patients. Depression-screened patients from primary care and psychiatric care, aged 18–64, were interviewed in 1991–92 with the Present State Examination (PSE) as the diagnostic instrument. The patients were re-contacted in 1998–99, and their depression at final assessment (FinalA) and during the follow-up period (F-up) was assessed by telephone interview using the Composite International Diagnostic Interview—Short Form (CIDI-SF). 250 primary care (58.1%) and 170 (40.2%) psychiatric care patients were successfully followed. Of the primary care patients with severe depression at baseline, 42.4% had had depression during F-up and 21.2% had depression at FinalA. For the patients with mild depression at baseline, the corresponding figures were nearly the same, but for the patients with depressive symptoms clearly lower. Of the psychiatric care patients with severe depression at baseline, 61.0% had had depression during F-up and 26.2% had depression at FinalA. As with primary care patients, the corresponding figures were nearly the same for mild depression at baseline but clearly lower for depressive symptoms. Experienced lifetime mood elevation was associated with having depression during F-up in both primary care and psychiatric care patients. High Depression Scale (DEPS) score at baseline was associated with having depression at FinalA in primary care patients, but in psychiatric care patients, it was the high Hamilton Rating Scale for depression (HAM-D) and drinking problems. Severe depression and mild depression are predictive for subsequent depression at both levels of care. The long-term prognosis for depression is better in primary care. DEPS and HAM-D are useful, prognostic instruments.     

Change in accuracy of recognizing psychiatric disorders by non-psychiatric physicians: five-year data from a psychiatric consultation-liaison service

Aim: Psychiatric disorders are easily underestimated and under‐recognized by physicians. The aim of the present study was to investigate the change in accuracy of recognizing psychiatric symptoms. Methods: Consecutive 5‐year consultation–liaison data were collected and patients with one of the five common psychiatric diagnoses, including depressive disorders, substance use disorders, delirium, anxiety disorders and psychotic disorders, were chosen for analysis. The primary care physician's initial impression of a psychiatric diagnosis was recorded based on their reason for referral on the referral sheets. Accurate recognition was defined as matching of the physician's initial impression with the psychiatrist's final diagnosis. Mentioning the core symptoms of psychiatric diagnostic criteria or common synonyms would be considered as correct recognition. Results: The overall accuracy of recognition was 41.5% and there was no significant change during this 5‐year period. Substance use disorders were the one diagnosis with the highest agreement, followed by delirium, depressive disorders, anxiety disorders, and psychotic disorders. As for the factors associated with accurate recognition, male patients or those with multiple physical illnesses were more likely to have their psychiatric symptoms recognized correctly. Conclusions: Without comprehensive postgraduate psychiatric education, the accuracy of recognizing psychiatric symptoms does not improve year by year. Education should focus on common psychiatric problems among medical inpatients, especially those easily misdiagnosed, such as depression and delirium.     

Psychotic symptoms in an urban general medicine practice

OBJECTIVE: The authors' goals were to estimate the prevalence of psychotic symptoms among adults attending an urban general medical practice that serves a low-income population and to describe the mental health, social and occupational functioning, and mental health treatment of these patients. METHOD: Data were drawn from a recent study of adult primary care patients (N=1,005) in a large, urban, university-affiliated general medicine practice. During a medical visit, patients completed the psychotic disorders section of the Mini International Neuropsychiatric Interview, the Primary Care Evaluation of Mental Disorders, a drug use disorders screen, the Sheehan Disability Scale, and a questionnaire that probed demographic characteristics, health status, and mental health treatment. RESULTS: Two hundred ten (20.9%) patients reported one or more psychotic symptoms, most commonly auditory hallucinations. There was an inverse correlation between family income and the prevalence of psychotic symptoms and a positive association between prevalence and Hispanic ethnicity. Compared with patients without psychotic symptoms, patients with psychotic symptoms were significantly more likely to have major depression (42.4% versus 12.6%), panic disorder (24.8% versus 4.0%), generalized anxiety disorder (38.6% versus 8.4%), and alcohol use disorder (12.9% versus 5.0%). They were also more likely to report current suicidal ideation (20.0% versus 3.5%), recent work loss (55.0% versus 35.6%), and marital distress (28.6% versus 13.0%). Approximately one-half of the patients with psychotic symptoms (47.6%) had taken a prescribed psychotropic medication during the last month. CONCLUSIONS: Psychotic symptoms were highly prevalent in this primary care practice. These patients were at risk for several common mental disorders and often reported impaired work and social functioning. Future research should clarify the extent to which psychotic symptom reports among Hispanic patients are affected by culturally patterned idioms of distress. Clinicians who work in primary care practices that serve low-income patient populations should routinely inquire about psychotic symptoms.     

有精神病性症状的躁狂发作患者近期疗效比较

目的比较单一经典抗精神病药物（奋乃静）或心境稳定剂（碳酸锂）合并小剂量经典抗精神病药物（奋乃静）治疗有精神病性症状的躁狂发作患者的疗效和安全性;探讨影响患者近期疗效的主要因素。方法（1）将符合入组标准的精神病性症状的躁狂发作患者70例随机分为甲组34例和乙组36例两组进行为期6周治疗。甲组为单一中至大剂量经典抗精神病药物（奋乃静）治疗;乙组为心境稳定剂（碳酸锂）合并中至小剂量经典抗精神病药物（奋乃静）治疗。以Bech—Rafaelsen躁狂量表（BRMs）和临床总体印象量表（CGI）评定患者的疗效,以不良反应症状量表（TESS）评定患者的副反应;（2）采用临床流行病学方法,探讨影响有精神病性症状的躁狂发作患者近期疗效的主要因素。结果（1）在治疗第6周末,甲组患者的临床治愈率38．2％,有效率94．1％（33／34）;乙组的临床治愈率63．9％,有效率100％（36／36）,乙组在临床疗效及药物不良反应上均显著性优于甲组（P〈0．05）;（2）有精神病性症状的躁狂发作患者的近期疗效好,影响有精神病性症状的躁狂发作患者近期疗效的主要因素为患者的起病年龄、病前社会功能、病程特点及患者的精神病性症状与心境的协调性,以急性起病、病前社会功能良好、间歇性病程及患者的精神病性症状与患者心境相协调者的近期疗效为佳。结论（1）心境稳定剂合并小剂量经典抗精神病药物在治疗有精神病性症状的躁狂发作时,临床疗效优于单一经典抗精神病药物治疗且副反应相对少;（2）有精神病性症状的躁狂发作患者的近期疗效好,患者的近期疗效受多种因素的影响。     

Psychotic symptoms and emotional distress in patients with Guillain-Barré syndrome

Psychological disturbances in 49 most severely compromised Guillain-Barré syndrome patients were prospectively studied by a semistructured interview and assessed by repeat psychiatric examination during the patients' stay in the neuro-intensive care unit (ICU). Additional information was obtained from attending physicians, nurses and relatives. Anxiety (82%), acute stress disorder, depressive episodes (67%) and brief reactive psychosis (25%) were observed, with oneiroid psychosis (14%) among the latter. Psychotic episodes were strongly associated (p < 0.001) with severe tetraparesis, artificial ventilation and multiple cranial nerve dysfunction. CSF protein concentration was also correlated with the occurrence of psychotic symptoms. Patients themselves experienced loss of communication to be the most difficult condition to cope with. Fifty-five percent explicitly felt reassured by the environment of the ICU and 90% described contact with relatives to be most helpful. Our data suggest that motor deprivation and loss of communication are the conditions most closely connected with the occurrence of psychotic symptoms. Therapeutically, continuous psychosocial support and psychopharmacological measures may both be valuable tools to ameliorate distress.     

Symptômes psychotiques dans l’épisode maniaque. Un regard de psychiatre libéral

Private practice requires particular vigilance with regard to signs of mood instability in patients with bipolar disorders, in particular the manic aspect, because of the risk of disruption in care. Between the episodes, psychotic symptoms can be sequels or prodroms and, if so, often stereotyped from one episode to the next. During the manic episode, mood-congruent symptoms (grandiosity, possessing superpowers, having a special relationship with God or with celebrities) are most common, but mood-incongruent symptoms (delusions of persecution, auditory hallucinations, first-rank Schneiderian symptoms) are not uncommon. In the absence of delusions or hallucinations, the clinician must be alert to a decline in insight, or when the patient shows symptoms of formal thought disturbances. For certain classical authors, mania was, by itself, a psychotic experience. The relationship between the severity of mania and the existence of psychotic symptoms is strong, but not exclusive. Some patients that have not completely stopped their treatment can have moderate symptoms of mania, albeit with some psychotic symptoms. Congruent and non-congruent psychotic symptoms may persist beyond the manic episode, raising the question of schizoaffective (SA) disorder when elements of a diagnostic criteria for schizophrenia are met. SA is a disputed diagnostic category, whose stability over time is unsatisfactory. The management of psychotic symptoms with mania is difficult in private practice: a clinical case of a female bipolar patient with erotomania before and during manic episodes illustrates the difficulties of management when the patient's insight fluctuates. The side-effects of treatments, a hypomanic switch, induced by an antidepressant despite two mood stabilizers (lithium, valproate), followed by a period of mood instability and a lack of medical coordination had contributed to an interruption in care. Statistical multivariate analyses and the grouping of symptoms and patients together with factor and network analyses suggest a partial independence of psychotic symptoms from other manic symptoms and, in cluster analyses, the likelihood of a subgroup of manic patients with psychotic symptoms.     

Depressive symptoms and psychiatric distress in low income Asian and Latino primary care patients: prevalence and recognition

The aims of the study were to: (a) assess the degree to which primary care physicians recognize psychiatric distress among an ethnically diverse primary care sample composed primarily of Asians and Hispanics; and (b) to investigate the relationship between patient and physician sociodemographic factors and overall diagnostic recognition of psychiatric distress. The study sample is comprised of 252 consecutively-selected patients and eleven primary care general internists from general medicine clinics in a large public ambulatory medical center. The measures used were the Center for Epidemiologic Studies-Depression (CES-D) scale, a demographic questionnaire, and an acculturation scale; these measures were completed during interviews conducted by trained bilingual research assistants. Physicians completed a mental health treatment summary immediately after the patient's visit. Hierarchical logistic regression analyses were performed in order to examine: (1) the degree to which providers identified psychiatric distress and (2) overall diagnostic recognition among this sample in relation to demographic characteristics and degree of acculturation. As measured by the CES-D, almost one half (47.3%) of the Latino and 41.6% of the Asian patients had depressive symptoms indicative of psychiatric distress. In contrast, physicians identified 43.8% of Latino patients and only 23.6% of Asian patients as being psychiatrically distressed (p < .01). Physicians were more likely to classify Latinos and those with higher acculturation status as distressed (p < .01 and p < .05, respectively). Higher patient acculturation status was the only factor significantly associated with overall diagnostic recognition (p < .05), as measured by physician agreement with the CES-D. Being Asian and/or having low acculturation levels may put the patient at risk for non-detection of psychiatric distress. The high prevalence of distress lends support to initiating improved methods for screening and detection of depression among low income and racially diverse primary care patients.