The McLean-Harvard First-Episode Mania Study: prediction of recovery and first recurrence

OBJECTIVE: Since improved prediction of illness course early in bipolar disorder is required to guide treatment planning, the authors evaluated recovery, first recurrence, and new illness onset following first hospitalization for mania. METHOD: Bipolar disorder patients (N=166) were followed 2-4 years after their first hospitalization for a manic or mixed episode to assess timing and predictors of outcomes. Three aspects of recovery were measured: syndromal (DSM-IV criteria for disorder no longer met), symptomatic (Young Mania Rating Scale score /=8 weeks), switching (onset of new dissimilar illness before recovery), relapse (new episode of mania within 8 weeks of syndromal recovery), and recurrence (new episode postremission) were also assessed. RESULTS: By 2 years, most subjects achieved syndromal recovery (98%, with 50% achieving recovery by 5.4 weeks); 72% achieved symptomatic recovery. Factors associated with a shorter time to syndromal recovery for 50% of the subjects were female sex, shorter index hospitalization, and lower initial depression ratings. Only 43% achieved functional recovery; these subjects were more often older and had shorter index hospitalizations. Within 2 years of syndromal recovery, 40% experienced a new episode of mania (20%) or depression (20%), and 19% switched phases without recovery. Predictors of mania recurrence were initial mood-congruent psychosis, lower premorbid occupational status, and initial manic presentation. Predictors of depression onset were higher occupational status, initial mixed presentation, and any comorbidity. Antidepressant treatment was marginally related to longer time to recovery and earlier relapse. CONCLUSIONS: Within 2-4 years of first lifetime hospitalization for mania, all but 2% of patients experienced syndromal recovery, but 28% remained symptomatic, only 43% achieved functional recovery, and 57% switched or had new illness episodes. Risks of new manic and depressive episodes were similar but were predicted by contrasting factors.     

Phenomenology and outcome of subjects with early- and adult-onset psychotic mania

OBJECTIVE: This study examined clinical differences between subjects with early-onset and adult-onset psychotic mania. METHOD: Subjects were from an epidemiologically derived, hospitalized sample who met criteria for definite bipolar disorder after 24 months of follow-up and whose index episode had been manic. Information collected regarding demographic characteristics, psychotic and depressive symptoms, childhood behavior problems and school functioning, substance/alcohol use disorders, and episode recurrence for two subgroups were compared: those whose illness first emerged before age 21 (early onset) (N=23) and those whose first episode occurred after age 30 (adult onset) (N=30). RESULTS: A larger proportion of the early-onset subjects were male, had childhood behavior disorders, had substance abuse comorbidity, exhibited paranoia, and experienced complete episode remission less frequently during 24-month follow-up than the adult-onset subjects. CONCLUSIONS: These data add to the body of evidence that has suggested that many subjects with early-onset psychotic mania have a more severe and developmentally complicated subtype of bipolar disorder.     

Antidepressant-associated switches from depression to mania in severe bipolar disorder

OBJECTIVES: To determine whether switching from depression to mania is part of the natural history of bipolar illness or results from antidepressant (AD) treatment by examining bipolar patients with psychosis early in their illness course. METHODS: A multi-facility cohort of 123 first-admission inpatients, aged 15-60 years, with DSM-IV bipolar disorder (BD) with psychotic features, was followed for four years, and 76 individuals experienced at least one episode of depression. Frequency of and risk factors for switches from depression to mania, time to switch, and duration of the subsequent manic episode were examined in relation to AD use (with anti-manic and/or antipsychotic medications). RESULTS: The 76 respondents experienced 113 depressive episodes. Those prescribed ADs had more depressive episodes and spent more time depressed than non-users. A total of 23 depressive episodes in 17 respondents ended in a manic/hypomanic/mixed episode (20%). The time to switch and duration of the subsequent manic episode were not significantly different for the seven respondents and nine episodes involving AD treatment versus the 10 respondents and 14 episodes without ADs. None of the risk factors (age of onset 相似文献   

Prediction of outcome in mania by mood-congruent or mood-incongruent psychotic features.

OBJECTIVE: The aim of this study was to determine the significance of mood congruence of psychotic features in mania as a predictor of outcome. METHOD: Fifty-four patients with bipolar disorder were followed prospectively for 4 years after recovery from an episode of mania with psychotic features. Assessments of residential and occupational status, interepisode symptoms, and episode recurrences were made at 6 and 48 months after recovery. Categorical outcomes were evaluated by logistic regression and recurrence risk with survival analysis. RESULTS: Mood-incongruent psychotic features during the index manic episode predicted a shorter time in remission at 4 years (hazard ratio = 2.6), and Schneiderian first-rank symptoms predicted poor residential status at 4 years (odds ratio = 20.1). CONCLUSIONS: Differentiation of mood congruence of psychotic features in mania evidently has prognostic validity and, therefore, has utility as a nosological characteristic.     

Sibutramine-induced mania as the first manifestation of bipolar disorder

Background

Sibutramine, used in obesity treatment, has been associated with many neuropsychiatric side effects including hypomanic and manic episodes. Hypomanic/manic episodes related to sibutramine treatment were earlier reported in patients who had previous history of bipolar disorder, after sibutramine overdose, after over-the-counter product illegally containing very high dose of sibutramine, together with psychotic symptoms, in organic patient, or after interaction of sibutramine with other drugs.

Case presentation

We report the first case of a patient with clear manic episode, after treatment with recommended dose of sibutramine, without previous history of mood disorders, organic changes or drug interactions, that was followed by episode of depression.

Conclusion

Minimal recommended dose of sibutramine induced manic episode that was the first manifestation of bipolar disorder. The manic episode, associated with sibutramine treatment, was induced in a person without previous history of mood disorders. Potential risks associated with the treatment of obesity using sibutramine warn physicians to be alert not only to common and cardiovascular but also to psychiatric adverse effects. A careful assessment of patient’s mental state and detailed psychiatric family history should be done before sibutramine treatment. In patients with a family history for bipolar disorder the use of even minimal dose of sibutramine should be contraindicated.     

Predictors of recurrence in bipolar disorder: primary outcomes from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

OBJECTIVE: Little is known about clinical features associated with the risk of recurrence in patients with bipolar disorder receiving treatment according to contemporary practice guidelines. The authors looked for the features associated with risk of recurrence. METHOD: The authors examined prospective data from a cohort of patients with bipolar disorder participating in the multicenter Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study for up to 24 months. For those who were symptomatic at study entry but subsequently achieved recovery, time to recurrence of mania, hypomania, mixed state, or a depressive episode was examined with Cox regression. RESULTS: Of 1,469 participants symptomatic at study entry, 858 (58.4%) subsequently achieved recovery. During up to 2 years of follow-up, 416 (48.5%) of these individuals experienced recurrences, with more than twice as many developing depressive episodes (298, 34.7%) as those who developed manic, hypomanic, or mixed episodes (118, 13.8%). The time until 25% of the individuals experienced a depressive episode was 21.4 weeks and until 25% experienced a manic/hypomanic/mixed episode was 85.0 weeks. Residual depressive or manic symptoms at recovery and proportion of days depressed or anxious in the preceding year were significantly associated with shorter time to depressive recurrence. Residual manic symptoms at recovery and proportion of days of elevated mood in the preceding year were significantly associated with shorter time to manic, hypomanic, or mixed episode recurrence. CONCLUSIONS: Recurrence was frequent and associated with the presence of residual mood symptoms at initial recovery. Targeting residual symptoms in maintenance treatment may represent an opportunity to reduce risk of recurrence.     

Adjunctive antidepressant use and symptomatic recovery among bipolar depressed patients with concomitant manic symptoms: findings from the STEP-BD

OBJECTIVE: Practice guidelines have advised against treating patients with antidepressants during bipolar mixed states or dysphoric manias. However, few studies have examined the outcomes of patients with co-occurring manic and depressive symptoms who are treated with antidepressants plus mood stabilizing drugs. METHOD: The authors compared outcomes in patients with bipolar disorder who received a mood stabilizing agent with versus without an antidepressant for a bipolar depressive episode accompanied by > or = 2 concurrent manic symptoms. The 335 participants were drawn from the first 2,000 enrollees in the National Institute of Mental Health (NIMH) Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Kaplan-Meier survival curves and Cox regression models were used to compare time to recovery. General linear models examined the relationship between antidepressant use or mania symptom load at the study entry and mania or depression symptom severity at the 3-month follow-up. RESULTS: Adjunctive antidepressant use was associated with significantly higher mania symptom severity at the 3-month follow-up. The probability of recovery at 3 months was lower among patients with higher baseline depression severity. Antidepressant use neither hastened nor prolonged time to recovery once potential confounding factors were covaried in a Cox regression model. CONCLUSIONS: In bipolar depression accompanied by manic symptoms, antidepressants do not hasten time to recovery relative to treatment with mood stabilizers alone, and treatment with antidepressants may lead to greater manic symptom severity. These findings are consistent with those from the STEP-BD randomized trial for pure bipolar depression, in which adjunctive antidepressants did not yield higher recovery rates than did mood stabilizer monotherapy.     

Can a targeted psychological intervention be effective for young people following a first manic episode? Results from an 18‐month pilot study

Aim: There is a scarce literature describing psychological interventions for a young, first‐episode cohort who have experienced psychotic mania. This study aimed to assess whether a manualized psychological intervention could be effective in reducing symptomatology and relapse, and improve functional outcome in this population. Methods: The study was an open‐label design, drawn from a larger pharmacotherapy trial. All participants in the pharmacotherapy trial were offered a manualized psychological intervention in addition to case management. Inclusion in the psychotherapy group was based on participant's choice, and on completion of four or more of the eight modules offered. All clinical files were audited to ensure accuracy of group allocation. Forty young people aged 15 to 25 years old who had experienced a manic episode with psychotic features were recruited into the study, with 20 people in the combined treatment as usual plus psychotherapy group (P+TAU), and an equal number of matched control participants who received treatment as usual (TAU) within the same service. All participants were prescribed antipsychotic and mood‐stabilizing medication. Symptomatic, functional and relapse measures were taken both at baseline and at 18‐month follow‐up. Results: Manic symptoms improved significantly for both groups, with no differences between groups. Depression scores and overall symptom severity were significantly lower in the P + TAU group. No differences were evident between groups with regard to numbers or type of relapse. The P + TAU group had significantly better social and occupational functioning after 18 months. Conclusion: This study suggests that a manualized psychological intervention targeted to a first‐episode population can be effective in reducing depression and overall symptom severity, and can improve functional outcome following a first episode of psychotic mania.     

Mood state at study entry as predictor of the polarity of relapse in bipolar disorder.

Of the placebo-controlled maintenance studies conducted in bipolar disorder, few have enrolled patients who present depressed. In fact, only lithium and lamotrigine have been studied over the long term with placebo-controlled designs in recently manic and recently depressed bipolar patients. Given the magnitude of the unmet medical need and the data suggesting that symptomatic patients with bipolar disorder spend the majority of their time depressed, this is unfortunate. Our review of the pre-lithium literature and more recent publications suggests that mood state at study entry predicts the polarity of relapse and the response to treatment. Accordingly, a need exists to enroll recently depressed patients in maintenance studies to elucidate the complete spectrum of efficacy of putative mood stabilizers and improve the long-term treatment of bipolar depression. Patients presenting depressed for a maintenance study tend to relapse into depression; those presenting manic, into hypomania/mania/mixed states. This is particularly true during the first several months of the randomized treatment. The polarity of the index episode tends to predict the polarity of relapse into a subsequent episode in a ratio of about 2:1 to 3:1. We conclude that putative mood stabilizers must be tested in recently manic and recently depressed patients to determine their spectrum of prophylactic efficacy.     

Longitudinal outcome and medication noncompliance among manic patients with and without mood-incongruent psychotic features.

The prognostic utility of mood-incongruent psychotic features was examined in a sample of 23 hospitalized manic patients. Patients were initially subdivided according to whether they met Research Diagnostic Criteria (RDC) for schizoaffective, mainly affective (mood-incongruent) manic disorder (SAM; N = 11) or RDC primary manic (mood-congruent or nonpsychotic) manic disorder (PM; N = 12). Patients were then followed over a 9-month posthospitalization period and rated every 3 months for relapse status, symptom severity, social adjustment, and medication noncompliance. Patients with SAM and PM did not differ at follow-up on rates or timing of manic or depressive relapses or on cycling of symptoms of mood disorder. However, at follow-up, SAM patients had more severe positive and negative psychotic symptoms and poorer social adjustment, and were less medically compliant than PM patients. Results are consistent with the view that mania with mood-incongruent psychotic features is a poor-prognosis subtype of bipolar disorder.     

Insight into illness in patients with mania,mixed mania,bipolar depression and major depression with psychotic features

Dell'Osso L, Pini S, Cassano GB, Mastrocinque C, Seckinger RA, Saettoni M, Papasogli A, Yale SA, Amador XF. Insight into illness in patients with mania, mixed mania, bipolar depression and major depression with psychotic features. Bipolar Disord 2002: 4: 315–322. © Blackwell Munksgaard 2002 Background: Poor insight into illness is a common feature of bipolar disorder and one that is associated with poor clinical outcome. Empirical studies of illness awareness in this population are relatively scarce with the majority of studies being published over the previous decade. The study reported here sought to replicate previous report findings that bipolar patients frequently show high levels of poor insight into having an illness. We also wanted to examine whether group differences in insight exist among bipolar manic, mixed and unipolar depressed patients with psychotic features. Methods: A cohort of 147 inpatients with DSM‐III‐R bipolar disorder and 30 with unipolar depression with psychotic features, were evaluated in the week prior to discharge using the Structured Clinical Interview for DSM‐III‐R‐Patient Edition (SCID‐P), the Brief Psychiatric Rating Scale (BPRS) and the Scale to assess Unawareness of Mental Disorder (SUMD). Results: Insight into specific aspects of the illness was related to the polarity of mood episode: patients with mania showed significantly poorer insight compared with those with mixed mania, bipolar depression and unipolar depression. A linear regression analysis using SUMD score as the dependent variable and symptoms of mania as the independent variable found that specific manic symptoms did not account for level of insight. Similar results were obtained when the mean insight scores of patients with and without grandiosity were contrasted. Conclusions: We hypothesize that the lack of association between level of insight and total number of manic symptoms or with specific manic symptoms may be related to the persistence of subsyndromal symptoms in patients remitting from a manic episode.     

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.     

Affective syndromes, psychotic features, and prognosis. II. Mania

Fifty-six patients with mania and psychotic features and 14 with schizoaffective disorder, manic type, were followed up with biannual assessments during a 5-year period. Results were treated as they were in an analogous follow-up of patients with psychotic major depression or schizoaffective disorder, depressed type. Patients with schizoaffective mania experienced more morbidity during follow-up than did patients with psychotic mania. Among patients with schizoaffective mania, those with a chronic subtype did far worse than did the others, while the mainly schizophrenic--mainly affective distinction was not predictive. When depressed and manic groups were combined (n = 173), the following baseline variables were significant independent predictors of a sustained delusional outcome: longer duration of the index episode, temporal dissociation between psychotic features and affective symptoms, and impaired adolescent friendship pattern.     

A 20-month, double-blind, maintenance trial of lithium versus divalproex in rapid-cycling bipolar disorder

OBJECTIVE: The authors tested the hypothesis that divalproex would be more effective than lithium in the long-term management of patients with recently stabilized rapid-cycling bipolar disorder. METHOD: A 20-month, double-blind, parallel-group comparison was carried out in recently hypomanic/manic patients who had experienced a persistent bimodal response to combined treatment with lithium and divalproex. Sixty patients were randomly assigned to lithium or divalproex monotherapy in a balanced design after stratification for illness type (bipolar I versus bipolar II disorder). RESULTS: Of the 254 patients enrolled in the open-label acute stabilization phase, 76% discontinued the study prematurely (poor adherence: 28%; nonresponse: 26% [of whom 74% remained depressed and 26% remained in a hypomanic/manic/mixed episode], intolerable side effects: 19%). Of the 60 patients (24%) randomly assigned to double-blind maintenance monotherapy, 53% relapsed (59% into depression and 41% into a hypomanic/manic/mixed episode), 22% completed the study, 10% had intolerable side effects, and 10% were poorly adherent. The rates of relapse into any mood episode for those given lithium versus divalproex were 56% and 50%, respectively; the rates were 34% and 29% for a depressive relapse and 19% and 22% for a hypomania/mania relapse. There were no significant differences in time to relapse. The proportion discontinuing prematurely because of side effects was 16% for lithium and 4% for divalproex. CONCLUSIONS: The hypothesis that divalproex is more effective than lithium in the long-term management of rapid-cycling bipolar disorder is not supported by these data. Preliminary data suggest highly recurrent refractory depression may be the hallmark of rapid-cycling bipolar disorder.     

Bipolar disorder: Strategies for the lifelong illness

Bipolar disorder has a lifelong course. Our understanding of the illness is not complete enough to detect it before the first manic or hypomanic episode. Treatment of bipolar disorder has three phases. The continuation phase comprises the transition between symptomatic improvement after correct diagnosis and effective treatment of an episode and functional recovery. This phase requires continuation of effective pharmacologic treatments combined with nonpharmacologic treatments that will provide the basis for education, monitoring, and anticipation of relapse. The maintenance phase begins when pre-episode function has been regained. Placebo-controlled data for mania support lithium, olanzapine, and divalproex in patients whose most recent episode responded to one of these treatments. Carbamazepine lacks placebo-controlled studies but appears to have response predictors that are complementary to those of lithium. For prevention of depressive episodes, which are at least twice as frequent as mania, placebo-controlled data support lithium, lamotrigine, and divalproex. Treatment response may depend upon the course of illness. There are relatively little data about long-term treatment response in bipolar II disorder or rapid-cycling. Although current treatments are effective, especially when combined with appropriate nonpharmacologic treatments, more definitive strategies require a better understanding of the physiologic processes underlying the recurrent nature of bipolar disorder.     

Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype

BACKGROUND: Diagnosis of child mania has been contentious. OBJECTIVE: To investigate natural history and prospective validation of the existence and long-episode duration of mania in children. DESIGN: Four-year prospective longitudinal study of 86 subjects with intake episode mania who were all assessed at 6, 12, 18, 24, 36, and 48 months. The phenotype was defined as DSM-IV bipolar I disorder (manic or mixed) with at least 1 cardinal symptom (elation and/or grandiosity) to ensure differentiation from attention-deficit/hyperactivity disorder. Parent and child informants were separately interviewed, by highly experienced research nurses, using the Washington University in St Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS). A Children's Global Assessment Scale score of 60 or less was needed to establish definite impairment. Treatment was by subjects' community practitioners. SETTING: Research unit in a university medical school. PARTICIPANTS: Subjects were obtained from psychiatric and pediatric sites by consecutive new case ascertainment, and their baseline age was 10.8 +/- 2.7 years. Onset of the baseline episode was 7.4 +/- 3.5 years. (Data are given as mean +/- SD.) MAIN OUTCOME MEASURES: Episode duration, weeks ill, recovery/relapse rates, and outcome predictors. RESULTS: Prospective episode duration of manic diagnoses, using onset of mania as baseline date, was 79.2 +/- 66.7 consecutive weeks. Any bipolar disorder diagnosis occurred during 67.1% +/- 28.5% of total weeks, during the 209.4 +/- 3.3 weeks of follow-up. Subjects spent 56.9% +/- 28.8% of total weeks with mania or hypomania (unipolar or mixed), and 38.7% +/- 28.8% of these were with mania. Major or minor depression and dysthymia (unipolar or mixed) occurred during 47.1% +/- 30.4% of total weeks. Polarity switches occurred 1.1 +/- 0.7 times per year. Low maternal warmth predicted faster relapse after recovery from mania (chi(2) = 13.6, P =.0002), and psychosis predicted more weeks ill with mania or hypomania (F(1,80) = 12.2, P =.0008). Pubertal status and sex were not predictive. (Data are given as mean +/- SD.) CONCLUSIONS: These findings validate the existence, long-episode duration, and chronicity of child mania. Differences from the natural history of adult bipolar disorder are discussed.     

Antidepressant-associated mania in late life

BACKGROUND: Elderly patients can present with mania for the first time late in life, and some elders treated with antidepressants can present with mania. Clinical characteristics of antidepressant-associated mania (AAM) in late life have not been examined. OBJECTIVES: The aims of the study were to identify elders with AAM and to compare selected clinical characteristics to those of manic elders who had not been treated with an antidepressant. We hypothesized that AAM patients would have later age at presentation of bipolar disorder. METHODS: We retrospectively reviewed inpatients with manic disorder who were aged >or=60 years. The sample was selected from admissions prior to 1990. RESULTS: AAM patients (n = 11) were more often experiencing first manic episode, and they had later age at onset of first manic episode, compared to non-AAM patients (n = 46). Most of the AAM patients had been treated with tricyclic agents. CONCLUSIONS: These preliminary findings invite further investigation. Related studies may contribute to risk-benefit analyses for the use of particular antidepressants in the elderly. Also, first episode mania in late life may prove to be a useful model of vulnerability to AAM.     

Cannabis et trouble bipolaire : recherche d’une association à partir d’une revue de la littérature

Introduction

It has been established that cannabis use is involved in the emergence and evolution of psychotic disorders. Although cannabis use is very frequent in mood disorders, there has been a considerable debate about the association observed between these two disorders. This review aims to clarify the relation between cannabis use and bipolar disorder, in order to unveil a possible causality and find the effect of cannabis on the prognosis and expression of bipolarity.

Methods

The review used MedLine database using the keywords “cannabis” or “marijuana” and “bipolar” or “mania” or “depression”. This search found 36 articles who were clinically relevant to the subject and were included and discussed in this review.

Results

The first studies discussing the link between cannabis use and psychotic disorders reveal manic features in the substance abuse group, hence suggesting a possible association between cannabis use and bipolar disorder, in favor of triggering a manic episode. According to the studies, between 25 and 64% of bipolar patients are cannabis users, and the prevalence is higher in younger and male patients. The risk of developing a mood disorder is higher among cannabis users compared to the general population. This substance abuse in bipolar disorders would increase the frequency and duration of manic episodes without changing the total duration of mood episodes. In a first episode of bipolar disorder, the use of cannabis would increase the rate of relapses of manic episodes and worsen the prognosis of the disorder.

Discussion

The frequency of substance abuse in bipolar disorders is higher than the prevalence in the general population, and cannabis is one of the most used illegal substances in the worldwide. Hence, the association between cannabis use and bipolar disorders is frequent. Cannabis users may experience euphoria, relaxation and subjective feelings of well-being; this substance may also have antiepileptic effect, which may explain some of the effects of cannabis on bipolar disorders. In fact, the use of cannabis would increase the frequency and duration of manic episodes in bipolar patients without increasing the total duration of mood episodes, suggesting a possible antidepressing and mood stabilizing effects. This impact of cannabis on mood disorders and its possible pharmacological effect is still controversial and needs further experiencing to be proved.     

Psychosis in mania: specificity of its role in severity and treatment response

BACKGROUND: Psychosis is a prominent characteristic of manic episodes. We investigated relationships between the presence of psychotic features, the severity of the manic syndrome, and syndrome severity's response to treatment. METHOD: 179 subjects meeting Research Diagnostic Criteria for a manic episode of bipolar I disorder were hospitalized for acute manic episodes and treated in a randomized trial of lithium, divalproex sodium, or placebo. Factor and cluster analyses were carried out using the clinician-rated Schedule for Affective Disorders and Schizophrenia, Change version (SADS-C) and the nurse-rated Affective Disorder Rating Scale (ADRS). RESULTS: Subjects with psychotic features had significantly (p < .005) greater overall impairment (lower Global Assessment Scale [GAS] scores) but did not differ in severity of mania scores compared with those without psychotic features. Psychosis factor scores correlated significantly (p < .000001) with GAS scores but not with mania scores. Baseline psychosis factor scores did not correlate with subsequent treatment-associated change in mania scores, but change in mania scores during treatment correlated significantly (p < .000001) with change in the psychosis factor. Changes in psychosis factor scores correlated significantly with changes in mania rating scale scores regardless of treatment. CONCLUSIONS: Psychotic features as a component of manic episodes contribute substantially to overall impairment. Treatments that successfully treat mania also reduce psychosis scores.     

Efficacy of electroconvulsive therapy in treatment-resistant bipolar disorder: a case series

The response to electroconvulsive therapy for six bipolar patients after pharmacotherapy failure is discussed. METHODS: Inclusion criteria were as follows: (1) bipolar mood disorder, manic, depressive or mixed episode (DSM-IV); (2) failure of pharmacotherapy, that is, for mania, manic episode unresponsive to at least 2 adequate antimanic trials for 6 weeks; and for bipolar depression, bipolar depressive episode unresponsive to at least 2 adequate antidepressant trials for 8 weeks. The patients underwent 12 bilateral sessions of ECT 3 times per week. Clinical response was considered a reduction of 50% or greater in the Young Mania Rating Scale (YMRS) and in the Hamilton Rating Scale for Depression-21 items (HAMD-21). Final YMRS <6 and HAMD-21 <8 defined remission. RESULTS: Six of the 9 referred patients consented to be submitted to ECT. Four were male, with ages ranging from 29 to 61 years, and their age at onset ranged from 19 to 49 years. Four showed psychotic features. All responded to ECT.