Evaluating the clinical effectiveness of a specialized perinatal psychiatry inpatient unit

Women experiencing severe perinatal mental illness during pregnancy or postpartum have unique needs when psychiatric hospitalization is indicated. Although many countries have established mother–baby psychiatric units, similar facilities have not been available in the US. In 2011, the University of North Carolina at Chapel Hill inaugurated the first Perinatal Psychiatry Inpatient Unit in the US. We describe the unique characteristics of the patient population and report clinical outcomes guiding development and refinement of treatment protocols. Ninety-two perinatal patients were admitted between September 2011 and September 2012, and 91 completed self-report measures at admission and discharge. Perinatal unipolar mood disorder was the most frequent primary diagnosis (60.43 %), and 11 patients (12 %) were admitted with psychosis. The data document clinically and statistically significant improvements in symptoms of depression, anxiety, and active suicidal ideation between admission and discharge (p?<?0.0001), as assessed by the Edinburgh Postnatal Depression Scale, Patient Health Questionnaire, and Generalized Anxiety Disorder Scale. Overall functioning was also improved, demonstrated by a significant mean difference of ?10.96 in total scores of the Work and Social Adjustment Scale (p?<?0.0001). Data suggest that delivering specialized and targeted interventions for severe maternal mental illness in a safe and supportive setting produces positive patient outcomes.     

Consistency of remission and outcome in bipolar and unipolar mood disorders: a 10-year prospective follow-up

BACKGROUND: Previous studies of the natural course of bipolar disorder have suggested that relapse and psychosocial impairment are more common than many would expect during treatment under routine conditions. The present research sought to identify patterns of consistency in longitudinal recovery after an index manic or depressive episode in patients formerly hospitalized for major affective disorders. The data extend prior findings from the Chicago Follow-up Study involving four successive assessments of course and outcome for bipolar and unipolar patients over a 10-year follow-up interval. METHODS: Thirty-four RDC bipolar I manic, 17 psychotic unipolar depressed, and 72 nonpsychotic unipolar depressed patients were assessed at index hospitalization and prospectively followed-up at 2, 4.5, 7.5 and 10 years. Psychosocial functioning, rehospitalization, and overall outcome were rated by standardized instruments. Patterns of consistent remission or impairment in functioning were compared across follow-up periods. RESULTS: Consistently good functioning was observed more often among patients with unipolar nonpsychotic depression than bipolar disorder or unipolar psychotic depression. Psychosis at index hospitalization was not associated with poorer outcomes for either the bipolar or unipolar groups, although it significantly predicted psychosis at follow-up more robustly for unipolar than bipolar patients. Less than half of the bipolar cohort had good work performance at each follow-up, while unipolar nonpsychotic depressed patients had consistently better work functioning. Rehospitalization was more common for the bipolar than unipolar patients at the 4.5- and 7.5-year assessments. Sustained remission across follow-ups was associated with remission at subsequent follow-ups regardless of diagnostic polarity at index hospitalization. LIMITATIONS: The observational design, small sample size, and naturalistic treatment of subjects in this protocol prompts caution when interpreting treatment outcome findings. The availability of a bipolar cohort with relatively low attrition over a 10-year period may limit the generalizability of the current findings to patients who remain engaged in sustained contact with a long-term research program. CONCLUSIONS: Over a 10-year follow-up period, about half of bipolar patients show sustained remissions or patterns of improvement, while 30-40% experience some functional decline. The degree of consistency in remission patterns over time may hold greater prognostic significance than the polarity of an index affective episode in anticipating subsequent levels of psychosocial adjustment in severe mood disorders.     

Exploring the borders of the schizoaffective spectrum: a categorical and dimensional approach

BACKGROUND: Schizoaffective disorder has long been considered as an intermediate condition between major mood disorders and schizophrenia, however, the nature of the relationship to these diagnoses remains unclear. We aimed at examining the nature of such a relationship in a mixed sample of psychotic disorders by using a dimensional and categorical approach to psychopathology. METHODS: Six-hundred and sixty psychotic inpatients were assessed for lifetime ratings of mania, depression, psychosis and incongruence, diagnosed according to Research Diagnostic Criteria, and classified as having nonaffective psychosis without mood syndromes (n=429), nonaffective psychosis with mood syndromes (n=101), schizoaffective disorder mainly schizophrenic (n=41), schizoaffective disorder mainly affective (n=42) or mood disorder with psychotic symptoms (n=47). We tested for associations of illness-related features including risk factors, premorbid, clinical and outcome variables with classes of disorders and lifetime ratings of psychopathology, and examined the relative contribution of categorical and dimensional representations of psychopathology in explaining disease characteristics. RESULTS: While categories at the extreme end of the psychotic spectrum meaningfully differed across a number of the illness-related variables, no substantial discontinuity was apparent between adjacent categories of psychotic disorders. Risk factors, premorbid adjustment, clinical features and impairment appeared to be present in a mostly monotonic continuous fashion from nonaffective psychoses to mood disorders with psychotic features. The overall association pattern of illness-related variables with mood and psychotic syndromes was largely independent of specific diagnostic categories, and the dimensional approach was neatly superior to the traditional diagnostic approach in explaining the characteristics of the illness. LIMITATIONS: This was a cross-sectional study with retrospective assessment of illness-related-variables and lifetime psychopathology. CONCLUSION: The results are compatible with the notion of the schizoaffective spectrum and with a continuum model of the psychotic illness.     

Gender and psychiatric diagnosis: a profile of admissions to mental hospitals in the Western Cape Province, South Africa

Summary Objectives: This retrospective, epidemiological study aimed to identify gender patterns of admission to public mental hospitals, with regard to psychiatric diagnosis and management. Methods: The hospital records of a random, stratified sample of all 7938 patients admitted to the three psychiatric hospitals in the Western Cape Province for a calendar year were studied for gender differences regarding demographic features, admission-related variables, DSM-IV diagnosis, as well as management during hospitalisation and on discharge. Results: Findings were that more women than men were admitted overall. For women the main DSM-IV diagnoses were mood (41%) followed by psychotic disorders (29%); while for men the main diagnoses were psychotic disorders (47%) and substance abuse (23%). Significantly more women than men were labelled with mood, anxiety and adjustment disorders, and with avoidant, dependent, histrionic and borderline personality disorders. Significantly more men were diagnosed as substance abusers, schizophrenic and with cognitive disorders, and also anti-social personality disorder. More women were medicated, both during hospitalisation and on discharge; and more women also received ECT, while more men absconded from hospital. Conclusions: While some results confirm international research, there are areas of variance, as in schizophrenic and bipolar disorders. The findings have psychiatric service implications and indicate the need for further research into the gendered development of psychopathology.     

Cycloid Psychosis Comorbid with Prader–Willi Syndrome: A Case Series

Psychosis is a relatively common psychiatric phenomenon seen in patients with Prader–Willi Syndrome (PWS). However, the presentation is atypical and difficult to classify within currently defined affective or psychotic disorders. This distinct presentation may be better understood as a phenomenon called “cycloid psychosis,” described as an episodic psychosis with rapid full recovery between episodes. This study retrospectively analyzed the cases of 12 patients with genetically confirmed PWS who presented to an ambulatory psychiatric center for a change in behavior consistent with psychosis. Each case was then assessed for symptoms of cycloid psychosis, bipolar disorder, depression with psychotic features, schizophrenia, and schizoaffective disorder. Out of the 12 patients, 11 (91.7%) met the currently described diagnostic criteria for cycloid psychosis. Of the 12 patients, 7 (58.3%) also met the diagnostic criteria for bipolar disorder, and 1 (8.3%) also met the diagnostic criteria for schizoaffective disorder. None of the patients met the criteria for schizophrenia or depression with psychotic features. The findings in this study suggest that cycloid psychosis and bipolar disorder may both be comorbid with PWS. Psychiatric comorbidities in patients with PWS are atypical and clinicians should be aware of conditions such as cycloid psychosis when managing this vulnerable population.     

The prevalence and correlates of self-harm in pregnant women with psychotic disorder and bipolar disorder

Women with severe mental illness are at increased risk of suicide in the perinatal period, and these suicides are often preceded by self-harm, but little is known about self-harm and its correlates in this population. This study aimed to investigate the prevalence of suicidal ideation and self-harm, and its correlates, in women with psychotic disorders and bipolar disorder during pregnancy. Historical cohort study using de-identified secondary mental healthcare records linked with national maternity data. Women pregnant from 2007 to 2011, with ICD-10 diagnoses of schizophrenia and related disorders, bipolar disorder or other affective psychoses were identified. Data were extracted from structured fields, natural language processing applications and free text. Logistic regression was used to examine the correlates of self-harm in pregnancy. Of 420 women, 103 (24.5 %) had a record of suicidal ideation during the first index pregnancy, with self-harm recorded in 33 (7.9 %). Self-harm was independently associated with younger age (adjusted odds ratio (aOR) 0.91, 95 % CI 0.85–0.98), self-harm in the previous 2 years (aOR 2.55; 1.05–6.50) and smoking (aOR 3.64; 1.30–10.19). A higher prevalence of self-harm was observed in women with non-affective psychosis, those who discontinued or switched medication and in women on no medication at the start of pregnancy, but these findings were not statistically significant in multivariable analyses. Suicidal thoughts and self-harm occur in a significant proportion of pregnant women with severe mental illness, particularly younger women and those with a history of self-harm; these women need particularly close monitoring for suicidality.     

Cycloid psychosis: a clinical and nosological study

BACKGROUND: Despite its clinical relevance, the diagnosis of cycloid psychosis has been relatively neglected in the psychiatric literature and in the current nosological systems. This study examined the clinical validity and nosological status of the cycloid psychosis concept. METHOD: Six-hundred and sixty psychotic in-patients were assessed for psychosis-related variables and diagnosed according to DSM-III-R, DSM-IV, ICD-10 and the Perris & Brockington criteria forcycloid psychosis. The cycloid psychosis diagnosis (N = 68, 10.3%) was examined in regard to its discriminant validity, concordance with other psychotic disorders, and predictive validity in relation to schizophrenia and psychotic mood disorders. To address putative heterogeneity within cycloid psychosis, affective (N = 38) and non-affective (N = 30) subgroups were examined. RESULTS: Cycloid psychosis had good discriminant validity regarding other psychoses (95% of correctly classified cases) and poor concordance with individual diagnoses from the formal diagnostic systems (K < 0.22). Cycloid patients had levels of psychotic, disorganization and first-rank symptoms comparable to schizophrenia, and levels of affective symptoms in-between schizophrenia and mood disorders. Regarding most clinical variables and morbidity risk of mood disorders, cycloid psychosis was closer to mood disorders. Cycloid psychosis had higher psychosocial stressors than schizophrenia and mood disorders. Affective and non-affective groups of cycloid psychosis differed in a number of variables indicating an overall better outcome for the non-affective group. CONCLUSIONS: Cycloid psychosis does not correspond closely to any DSM-III-R, DSM-IV or ICD-10 category of psychosis, and more specifically this nosological concept is not well represented by the different formal definitions of remitting psychotic disorders. Cycloid psychosis seems to be an heterogeneous condition in that affective and non-affective subgroups can be differentiated.     

Bipolar mood disorders among Polish psychiatric outpatients treated for major depression

BACKGROUND: Significant proportion of patients treated for depression may have various types of bipolar mood disorders. The aim of the study was to assess the frequency of bipolar disorders among outpatients having at least one major depressive episode, treated by 96 psychiatrists, representing all regions of Poland. METHODS: The study included 880 patients (237 male, 643 female), identified to following diagnostic categories: bipolar I, bipolar II, bipolar spectrum disorder and major depressive disorder. RESULTS: Bipolar mood disorders were found in 61.2% of patients studied, bipolar I more frequent in men and bipolar II in women, and bipolar spectrum in 12% of patients. Patients with age ranges 19-49 and 50-65 years did not differ as to the percentage of diagnostic categories. Patients with bipolar mood disorders compared to major depressive disorder had significantly more frequent family history of bipolar disorder, premorbid hyper- or cyclothymic personality, early onset of depression, symptoms of hypersomnia and hyperphagia, psychotic depression, post-partum depression, and treatment-resistant depression. Bipolar spectrum patients had most clinical features similar to classic types of bipolar disorders. LIMITATIONS: Neither structured interview for family history, nor formal criteria for a number of clinical manifestations were used. The population treated by psychiatrists may not be representative and present a subgroup with more severe mood disorders. CONCLUSIONS: Bipolar mood disorders may be very prevalent among depressive outpatients treated by psychiatrists in Poland, which is confirmed by the results of recent studies. Bipolar patients (including bipolar spectrum) significantly differ from major depressive disorder as to numerous clinical features related mostly to depressive episode.     

Role of sleep loss in the causation of puerperal psychosis

Puerperal psychosis is a rare but serious psychiatric disorder following delivery. Although controversy continues to surround its nosological status, puerperal psychosis is generally considered a mood episode with psychotic features occurring in the context of bipolar disorder or schizoaffective disorder. Due to the close temporal association with childbirth, the etiological role of gonadal steroids, particularly estrogen, has been considered. Familial factors have also been implicated in the triggering of episodes of puerperal psychosis. Sleep deprivation arising from an array of diverse factors is a common occurrence surrounding parturition. The author suggests that sleep loss plays a pivotal role in the causation of puerperal psychosis. Clinical implications of this hypothesis are discussed. Studies on the aetiology and pathogenesis of puerperal psychosis are urgently needed not only for prevention and better treatment strategies of puerperal psychosis but also for understanding the biological underpinnings of bipolar disorder.     

Is bipolar disorder still underdiagnosed? Are antidepressants overutilized?

BACKGROUND: Previous studies have suggested that bipolar disorder may be underdiagnosed, and that antidepressants may be over-utilized in its treatment. METHODS: Consecutively admitted patients (n =48) diagnosed with DSM-IV bipolar disorder, type I, (n = 44) or schizoaffective disorder, bipolar type, (n = 4) were interviewed systematically and their charts were reviewed to confirm diagnosis before admission. They were then treated according to systematic structured interview diagnoses. These data reflect the changes in diagnoses and treatment. RESULTS: 40% (19/48) were identified with previously undiagnosed bipolar disorder, all previously diagnosed with unipolar major depressive disorder. A period of 7.5+/-9.8 years elapsed in this group before bipolar diagnosis was made. Antidepressant use was high on admission (38%) and was reduced with acceptable treatment response rates. The adjunctive use of risperidone appeared to be a good treatment alternative. LIMITATIONS: While diagnoses were made prospectively, treatment response was assessed retrospectively, and was based on non-randomized, naturalistic therapy. CONCLUSIONS: Systematic application of DSM-IV criteria identified previously undiagnosed bipolar disorder in 40% of a referred population of patients with mood disorders, all previously misdiagnosed as unipolar major depressive disorder. Antidepressants appeared overutilized and risperidone was an effective alternative adjunctive therapy agent.     

Recurrence rates of bipolar disorder during the postpartum period: a study on 276 medication-free Italian women

The postpartum period is considered a time of heightened vulnerability to bipolar disorder. The primary goal of this study was to examine the frequency and the polarity of postpartum episodes in a clinical sample of women with bipolar disorder who were medication-free during their pregnancies. In addition, we sought to examine whether there are differences in terms of clinical features of bipolar disorder between women with and without postpartum episodes. Lastly, we analyzed the potential relationship between polarity of the postpartum episodes and clinical features of bipolar disorder. The presence/absence of postpartum episodes and their characteristics were obtained from medical records of 276 women with bipolar disorder who were medication-free during their pregnancies. Two hundred seven women (75.0 %) had a history of one or more postpartum mood episodes: depressive (79.7 %), (hypo)manic (16.4 %), or mixed episodes (3.9 %). Psychotic symptoms during postpartum episodes were associated with depression in 37 (22.4 %) patients, with mania in 19 (67.8 %) patients, and with mixed episodes in 7 (87.5 %) patients. Postpartum manic and mixed episodes were significantly associated with type I disorder and with psychotic features. Our findings indicate high risk of clinically ascertained mood episodes during postpartum period in bipolar women who are not treated during pregnancy.     

Association study between cannabinoid receptor gene (CNR1) and pathogenesis and psychotic symptoms of mood disorders*

Cannabis can induce mood change and sometimes psychotic symptoms in normal persons. In brain, the main active ingredient of cannabis acts via the cannabinoid CB1 receptor (CNR1) which is located on chromosome 6q14‐15. Linkage studies have suggested the presence of a bipolar disorder susceptibility locus on chromosome 6q. In this population based association study, we tested the hypothesis that a microsatellite polymorphism in the promoter region of the CNR1 gene confers susceptibility to mood disorders and psychotic features. We genotyped the CNR1 gene is 154 mood disorder patients and 165 normal controls. The results showed that the triplet repeat polymorphism in the promoter region of the CNR1 gene was not likely to be involved in the pathogenesis or in the psychotic symptoms of mood disorders. © 2001 Wiley‐Liss, Inc.     

Association study between cannabinoid receptor gene (CNR1) and pathogenesis and psychotic symptoms of mood disorders

Cannabis can induce mood change and sometimes psychotic symptoms in normal persons. In brain, the main active ingredient of cannabis acts via the cannabinoid CB1 receptor (CNR1) which is located on chromosome 6q14-15. Linkage studies have suggested the presence of a bipolar disorder susceptibility locus on chromosome 6q. In this population based association study, we tested the hypothesis that a microsatellite polymorphism in the promoter region of the CNR1 gene confers susceptibility to mood disorders and psychotic features. We genotyped the CNR1 gene is 154 mood disorder patients and 165 normal controls. The results showed that the triplet repeat polymorphism in the promoter region of the CNR1 gene was not likely to be involved in the pathogenesis or in the psychotic symptoms of mood disorders.     

Childhood antecedent disorders to bipolar disorder in adults: a controlled study

OBJECTIVE: The aim of the study was to examine antecedent childhood psychiatric disorders in adult patients with bipolar disorder. METHOD: Using structured diagnostic interviews, childhood psychiatric diagnoses of 83 referred patients with diagnosed DSM-IV bipolar disorder were compared to those of 308 adults without mood disorders. RESULTS: Patients with bipolar disorder had significantly higher rates of childhood disruptive behavior disorders (ADHD, oppositional-defiant disorder, and conduct disorder), childhood anxiety disorders (separation anxiety and overanxious disorder), and enuresis, compared to patients without mood disorders. The presence of these childhood disorders was associated with an earlier age of onset of bipolar illness. LIMITATIONS: The retrospective nature of the study may have affected both the rates of disorders recalled, as well as the ages of onset of disorders. Different referral sources for bipolar and comparison participants may have also impacted findings. CONCLUSIONS: Bipolar disorder in adults is frequently preceded by childhood disruptive behavior and anxiety disorders. These childhood disorders may be important markers of risk for adult bipolar disorder.     

Dose-response relationship between number of comorbid anxiety disorders in adolescent bipolar/unipolar disorders, and psychosis, suicidality, substance abuse and familiality

OBJECTIVES: To ascertain rates of panic, obsessive-compulsive (OCD) and social phobic disorders among adolescents with bipolar disorder (BP), unipolar major depressive disorder (MDD) and psychiatric comparison patients, to assess their relationships to suicidality, psychosis, comorbidity patterns and familiality. METHODS: The first author (SCD) interviewed 313 Latino adolescents using a structured interview based on the SCID. Family history was ascertained by live interview or interview by proxy. Patients were classified as BP, MDD, or non-affectively ill comparison controls (CC). Data regarding suicidality and psychosis were collected. Regression analysis was used to test associations and control for confounding effects. Positive likelihood ratios were used to measure the dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness. RESULTS: Of the total sample, 36.7% were BP, 44.7% MDD and 18.5% CC. In BP vs. MDD the odds of panic disorder were 4.4, of OCD 5.1, and of social phobia 3.3. MDD, in turn, were more likely to have these disorders than CC. BP (but not MDD) with panic disorder and social phobia, were more likely to have suicidal ideation; among the anxiety disorders, only social phobia was associated with having greater odds of suicide attempts. Among BP and MDD, patients with all three anxiety disorders were more likely to be psychotic. Presence of any mood disorder among first-degree relatives substantially increased the odds of having panic disorder and social phobia. The presence of one comorbid anxiety disorder increased the odds of having another. Finally, there were dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness. LIMITATIONS: Single interviewer using the SCID; cross sectional exploratory study. CONCLUSIONS: BP adolescents have a greater anxiety disorder burden than their MDD counterparts. The results are compatible with the hypothesis that heavy familial-genetic loading for affective illness in juveniles is associated with bipolarity, cumulative anxiety disorder comorbidity, suicidality and psychosis. These observations are in line with pioneering psychopathologic observation in the early 1900s by two French psychiatrists, Gilbert Ballet and Pierre Kahn, who saw common ground between what until then had been considered the distinct categories of the neuroses and cyclothymic (circular) psychoses. This perspective has much in common with current complex genetic models of anxious diatheses in bipolar disorder.     

Subjective life satisfaction and objective functional outcome in bipolar and unipolar mood disorders: a longitudinal analysis

BACKGROUND: Quality of life (QOL) has gained increasing attention as an important yet underappreciated component of functional outcome in mood disorders. In particular, the relationship between subjective life satisfaction and objective measures of psychosocial adjustment has not been well-studied. The goal of the present study was to examine the longitudinal associations between subjective life satisfaction and objective functional outcome among individuals with bipolar and unipolar mood disorders. METHOD: One hundred fifty-seven mood disordered subjects were assessed at index hospitalization for bipolar mania (n=35), unipolar psychotic depression (n=27), or unipolar nonpsychotic depression (n=95). All were prospectively followed up three times, at approximately 2, 4.5 and 7-8 years. Global outcome, work performance, social adjustment, recurrent depressive episodes, and dimensions of life satisfaction were assessed by semi-structured interviews using standardized ratings. RESULTS: Subjective life satisfaction strongly paralleled global functioning, work performance and social adjustment at each follow-up for patients with unipolar nonpsychotic depression, but not bipolar disorder or unipolar psychotic depression. Depressive symptoms and objective functional impairment contributed to poor QOL in most domains, independent of illness chronicity, medication use, or affective disorder subtype. LIMITATIONS: Findings might have differed had a different QOL measure been used, although the present measure showed concurrent validity with a previously used instrument. Sample sizes for the bipolar and psychotic depression groups were sufficient to detect moderate, but not small, correlations between objective functioning and subjective QOL. CONCLUSIONS: Recurrent depression remains a substantial contributor to poor life satisfaction across affective disorder subtypes. Subjective QOL in bipolar and unipolar psychotic depression patients may not accurately reflect objective functional outcome status, potentially due to diminished insight, demoralization, or altered life expectations over time.     

Anxiety disorders comorbidity in mood disorder subgroups: data from a mood disorders clinic

BACKGROUND: Previous research has identified a high rate of anxiety disorders comorbidity in patients with a primary mood disorder diagnosis. Discrepancies between studies in the comorbidity prevalence of specific anxiety disorders in mood disorders, and of anxiety disorders comorbidity between unipolar depression and bipolar mood disorder are in part due to differences in sampling and diagnostic assessment methodology. METHOD: The authors reviewed the charts of 138 patients who received the SCID-P for DSM-III on enrollment in a Mood Disorders Clinic during the period 1982 through 1988. The comorbidity of specific DSM-III Anxiety Disorders with specific mood disorders was determined and comparatively examined using non-parametric statistics. RESULTS: There was high overall comorbidity of anxiety disorders that did not differ between bipolar and unipolar subjects. There were no differences in the comorbidity of individual anxiety disorder diagnoses in the unipolar vs. bipolar groups. However, in unipolar patients with, compared to those without an additional diagnosis of dysthymia, there was greater overall anxiety disorders comorbidity, with a particularly high prevalence of generalized anxiety disorder. LIMITATION: The subgroup of patients with bipolar I disorder was relatively small (N=8). CONCLUSION: Mood and anxiety disorders comorbidity is complex and presents a continuing challenge for both clinicians and researchers.