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Hsiung K, Skikic M. Mood Disorder or Psychotic Disorder? Yes: A Case Report on Cycloid Psychosis. J Psychiatr Pract 2023; 29:333-339. [PMID: 37449832 DOI: 10.1097/pra.0000000000000717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Cycloid psychosis is a disorder defined by episodic, acute psychoses involving thought, affect, and motor disturbances with polymorphous symptomatology followed by periods of full remission. Antipsychotics, benzodiazepines, and electroconvulsive therapy have been used empirically in acute treatment. This disorder has faced nosologic challenges and is not yet identified as a diagnostic entity by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Questions remain as to whether cycloid psychosis is a primary psychotic or primary affective disorder, given that its course and episodicity are like that of affective disorders, while its clinical manifestations include prominent psychotic symptoms. This report describes the case of a 38-year-old male with classic features of cycloid psychosis and highlights the unique characteristics that distinguish cycloid psychosis from other similar diagnoses.
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Affiliation(s)
- Kimberly Hsiung
- HSIUNG and SKIKIC: Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN
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Bernal S, Ovejero S, Barrigón ML, Baca-García E. A cycloid psychosis relapse and SARS-CoV-2 concomitant infection. PSYCHIATRY RESEARCH CASE REPORTS 2022; 1:100006. [PMID: 36970315 PMCID: PMC10026843 DOI: 10.1016/j.psycr.2022.100006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Sara Bernal
- Department of Psychiatry, Jimenez Diaz Foundation Hospital, Madrid, Spain
| | - Santiago Ovejero
- Department of Psychiatry, Jimenez Diaz Foundation Hospital, Madrid, Spain
- Department of Psychiatry, Madrid Autonomous University, Madrid, Spain
| | - Maria Luisa Barrigón
- Department of Psychiatry, Jimenez Diaz Foundation Hospital, Madrid, Spain
- Department of Psychiatry, Madrid Autonomous University, Madrid, Spain
| | - Enrique Baca-García
- Department of Psychiatry, Jimenez Diaz Foundation Hospital, Madrid, Spain
- Department of Psychiatry, Madrid Autonomous University, Madrid, Spain
- Department of Psychiatry, Rey Juan Carlos University Hospital, Móstoles, Spain
- Department of Psychiatry, General Hospital of Villalba, Madrid, Spain
- Department of Psychiatry, Infanta Elena University Hospital, Valdemoro, Spain
- Universidad Catolica del Maule, Talca, Chile
- Department of Psychiatry, Centre Hospitalier Universitaire de Nîmes, France
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Braun B. Karl Leonhard (1904-88) and his academic influence through the 'Erlangen School'. HISTORY OF PSYCHIATRY 2021; 32:195-209. [PMID: 33345625 DOI: 10.1177/0957154x20978836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The Erlangen University Psychiatric and Mental Clinic was an annexe to the Erlangen Mental Asylum, so when Leonhard worked there he became acquainted with acute and chronic stages of schizophrenia. This can be viewed as a decisive impulse for his later differentiated classification of types of schizophrenia. The suspicion that Leonhard suffered from attention deficit hyperactivity disorder cannot be supported. His reticence concerning social-psychiatric aspects is analysed in the context of his early professional contact with the 'Erlangen system' of open care and its Nazi perversion. Leonhard's role in National Socialism is still uncertain. His unsuccessful attempts to retain the Erlangen Chair of Psychiatry and Mental Illness in 1951 can be viewed as his first difficulty in the tensions between West Germany and East Germany.
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Hausmann A, Dehning J, Heil M, Mauracher L, Kemmler G, Grunze H. Does a Lack of Awareness of Cycloid Psychosis Hamper Adequate Treatment for Patients Suffering From This Disorder? A Case Report. Front Psychiatry 2020; 11:561746. [PMID: 33281638 PMCID: PMC7689091 DOI: 10.3389/fpsyt.2020.561746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/19/2020] [Indexed: 02/05/2023] Open
Abstract
Categorial systems of nosology are based on a cross-sectional enumeration of symptoms with a predefined cut-off, but hardly capture rapid fluctuations of manifestation nor longitudinal characteristics, e.g., cyclicity. Especially with disorders presenting with an admixture or frequent change of psychotic and affective symptoms, diagnostic specifity of the DSM and ICD diminishes. In those instances, alternative concepts as cycloid psychosis might display more accurately the very characteristics and course of a mental disorder and help to tailor individualized treatments. Karl Leonhard described three major subtypes of cycloid psychosis: anxiety-happiness psychosis, confusion psychosis, and motility psychosis, all showing a pleiomorphic symptom profile resembling intraphasic switching of poles. Here we present the case of a 59-year-old woman suffering from cycloid psychosis as defined by the criteria of Perris. Between 2013 and June 2019, the patient was admitted 35 times for compulsory treatment. A frequent change of diagnoses, ranging from adjustment disorder to complex PTSD, and from unipolar depression to "pseudoneurotic schizophrenia," resembles the puzzling manifestations. Most of the time the patient was labeled as schizoaffective disorder despite never displaying clear psychotic core symptoms. Despite treatment with different antipsychotics including LAI the cumulative length of hospitalization increased steadily from 74 days in 2014 to 292 days in 2017. When reviewing the case in 2017 the longitudinal pattern of her disorder and the diverse acute manifestations were finally conceptualized as a cyclic on-off of an atypical psychosis. After starting lithium to pre-existing LAI antipsychotics and valproic acid, the number of days per year spent in inpatient care sharply dropped to 136 in 2018. We propose to reconsider cycloid psychosis as a useful clinical concept whose descriptive value, validity and utility for treatment decisions should be further evaluated. Lithium alone or in addition to valproic acid may act on cyclicity as a core symptom of cycloid psychosis as well as of bipolar disorder, even in the absence of major affective symptoms.
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Affiliation(s)
- Armand Hausmann
- Department Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Julia Dehning
- Department Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Michel Heil
- Department Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Laurin Mauracher
- Department Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Georg Kemmler
- Department Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Heinz Grunze
- Psychiatrie Schwäbisch Hall & Paracelsus Medical University Nuremberg, Nuremberg, Germany
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Freudenreich O, Kontos N, Querques J. Classification of Schizoaffective Disorder: The History of a Vexing Concept. Psychiatr Ann 2020. [DOI: 10.3928/00485713-20200410-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Teixeira R, Duarte J. Psicoses Cicloides. Passado e futuro. REVISTA LATINOAMERICANA DE PSICOPATOLOGIA FUNDAMENTAL 2019. [DOI: 10.1590/1415-4714.2018v22n1p117.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Abstract
Este artigo pretende rever a origem do conceito de Psicoses Cicloides, a sua psicopatologia e a sua evolução. Através de uma análise da literatura, os autores procuram perceber a validade nosológica deste conceito, assim como o seu enquadramento atual e a sua utilidade futura na psiquiatria.
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Hirjak D, Meyer-Lindenberg A, Fritze S, Sambataro F, Kubera KM, Wolf RC. Motor dysfunction as research domain across bipolar, obsessive-compulsive and neurodevelopmental disorders. Neurosci Biobehav Rev 2018; 95:315-335. [PMID: 30236781 DOI: 10.1016/j.neubiorev.2018.09.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 08/08/2018] [Accepted: 09/12/2018] [Indexed: 02/07/2023]
Abstract
Although genuine motor abnormalities (GMA) are frequently found in schizophrenia, they are also considered as an intrinsic feature of bipolar, obsessive-compulsive, and neurodevelopmental disorders with early onset such as autism, ADHD, and Tourette syndrome. Such transnosological observations strongly suggest a common neural pathophysiology. This systematic review highlights the evidence on GMA and their neuroanatomical substrates in bipolar, obsessive-compulsive, and neurodevelopmental disorders. The data lends support for a common pattern contributing to GMA expression in these diseases that seems to be related to cerebello-thalamo-cortical, fronto-parietal, and cortico-subcortical motor circuit dysfunction. The identified studies provide first evidence for a motor network dysfunction as a correlate of early neurodevelopmental deviance prior to clinical symptom expression. There are also first hints for a developmental risk factor model of these mental disorders. An in-depth analysis of motor networks and related patho-(physiological) mechanisms will not only help promoting Research Domain Criteria (RDoC) Motor System construct, but also facilitate the development of novel psychopharmacological models, as well as the identification of neurobiologically plausible target sites for non-invasive brain stimulation.
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Affiliation(s)
- Dusan Hirjak
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Andreas Meyer-Lindenberg
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stefan Fritze
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Katharina M Kubera
- Center for Psychosocial Medicine, Department of General Psychiatry, Heidelberg University, Heidelberg, Germany
| | - Robert C Wolf
- Center for Psychosocial Medicine, Department of General Psychiatry, Heidelberg University, Heidelberg, Germany
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Grunze H, Vieta E, Goodwin GM, Bowden C, Licht RW, Azorin JM, Yatham L, Mosolov S, Möller HJ, Kasper S. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Acute and long-term treatment of mixed states in bipolar disorder. World J Biol Psychiatry 2018; 19:2-58. [PMID: 29098925 DOI: 10.1080/15622975.2017.1384850] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Although clinically highly relevant, the recognition and treatment of bipolar mixed states has played only an underpart in recent guidelines. This WFSBP guideline has been developed to supply a systematic overview of all scientific evidence pertaining to the acute and long-term treatment of bipolar mixed states in adults. METHODS Material used for these guidelines is based on a systematic literature search using various data bases. Their scientific rigour was categorised into six levels of evidence (A-F), and different grades of recommendation to ensure practicability were assigned. We examined data pertaining to the acute treatment of manic and depressive symptoms in bipolar mixed patients, as well as data pertaining to the prevention of mixed recurrences after an index episode of any type, or recurrence of any type after a mixed index episode. RESULTS Manic symptoms in bipolar mixed states appeared responsive to treatment with several atypical antipsychotics, the best evidence resting with olanzapine. For depressive symptoms, addition of ziprasidone to treatment as usual may be beneficial; however, the evidence base is much more limited than for the treatment of manic symptoms. Besides olanzapine and quetiapine, valproate and lithium should also be considered for recurrence prevention. LIMITATIONS The concept of mixed states changed over time, and recently became much more comprehensive with the release of DSM-5. As a consequence, studies in bipolar mixed patients targeted slightly different bipolar subpopulations. In addition, trial designs in acute and maintenance treatment also advanced in recent years in response to regulatory demands. CONCLUSIONS Current treatment recommendations are still based on limited evidence, and there is a clear demand for confirmative studies adopting the DSM-5 specifier with mixed features concept.
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Affiliation(s)
- Heinz Grunze
- a Institute of Neuroscience , Newcastle University , Newcastle upon Tyne , UK
- b Paracelsus Medical University , Nuremberg , Germany
- c Zentrum für Psychiatrie Weinsberg , Klinikum am Weissenhof , Weinsberg , Germany
| | - Eduard Vieta
- d Bipolar Disorders Programme, Institute of Neuroscience , Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM , Barcelona , Catalonia , Spain
| | - Guy M Goodwin
- e Department of Psychiatry , University of Oxford, Warneford Hospital , Oxford , UK
| | - Charles Bowden
- f Dept. of Psychiatry , University of Texas Health Science Center , San Antonio , TX , USA
| | - Rasmus W Licht
- g Psychiatric Research Unit, Psychiatry , Aalborg University Hospital , Aalborg , Denmark
- h Clinical Department of Medicine , Aalborg University , Aalborg , Denmark
| | - Jean-Michel Azorin
- i Department of Psychiatry , Hospital Ste. Marguerite , Marseille , France
| | - Lakshmi Yatham
- j Department of Psychiatry , University of British Columbia , Vancouver , BC , Canada
| | - Sergey Mosolov
- k Department for Therapy of Mental Disorders , Moscow Research Institute of Psychiatry , Moscow , Russia
| | - Hans-Jürgen Möller
- l Department of Psychiatry and Psychotherapy , Ludwigs-Maximilian University , Munich , Germany
| | - Siegfried Kasper
- m Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
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Abstract
The motility psychoses are a group of acute psychiatric conditions characterized by salient disorders of movement (increased, decreased and disorganized), psychotic experiences, confusion and good prognosis. The debate on whether they are just atypical forms of schizophrenia or manic-depressive insanity or constitute an independent group of psychoses has not yet been settled. Erik Strömgren's classical chapter deals with the history and clinical aspects of the motility psychoses. Based on a historical analysis and an empirical study of a patient cohort, the author draws conclusions on the nature of this clinical group that has stood the test of time well.
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van de Kerkhof NW, Fekkes D, van der Heijden FM, Hoogendijk WJ, Stöber G, Egger JI, Verhoeven WM. Cycloid psychoses in the psychosis spectrum: evidence for biochemical differences with schizophrenia. Neuropsychiatr Dis Treat 2016; 12:1927-33. [PMID: 27536115 PMCID: PMC4977096 DOI: 10.2147/ndt.s101317] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Cycloid psychoses (CP) differ from schizophrenia regarding symptom profile, course, and prognosis and over many decades they were thought to be a separate entity within the psychosis spectrum. As to schizophrenia, research into the pathophysiology has focused on dopamine, brain-derived neurotrophic factor, and glutamate signaling in which, concerning the latter, the N-methyl-d-aspartate receptor plays a crucial role. The present study aims to determine whether CP can biochemically be delineated from schizophrenia. Eighty patients referred for psychotic disorders were assessed with the Comprehensive Assessment of Symptoms and History, and (both at inclusion and after 6 weeks of antipsychotic treatment) with the Positive and Negative Syndrome Scale and Clinical Global Impression. From 58 completers, 33 patients were diagnosed with schizophrenia and ten with CP according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Leonhard criteria, respectively. Fifteen patients were diagnosed with other disorders within the psychosis spectrum. At both time points, blood levels of the dopamine metabolite homovanillic acid, brain-derived neurotrophic factor, and amino acids related to glutamate neurotransmission were measured and compared with a matched control sample. Patients with CP showed a significantly better response to antipsychotic treatment as compared to patients with schizophrenia. In CP, glycine levels were elevated and tryptophan levels were lowered as compared to schizophrenia. Glutamate levels were increased in both patient groups as compared to controls. These results, showing marked differences in both treatment outcome and glutamate-related variable parameters, may point at better neuroplasticity in CP, necessitating demarcation of this subgroup within the psychosis spectrum.
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Affiliation(s)
- Nora Wa van de Kerkhof
- Vincent van Gogh Institute for Psychiatry, Centre of Excellence for Neuropsychiatry, Venray; Department of Psychiatry
| | - Durk Fekkes
- Department of Psychiatry; Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Gerald Stöber
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Würzburg, Würzburg, Germany
| | - Jos Im Egger
- Vincent van Gogh Institute for Psychiatry, Centre of Excellence for Neuropsychiatry, Venray; Behavioural Science Institute; Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Willem Ma Verhoeven
- Vincent van Gogh Institute for Psychiatry, Centre of Excellence for Neuropsychiatry, Venray; Department of Psychiatry
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Abstract
Patients with an Islamic background who suffer from hallucinations or other psychotic symptoms may attribute these experiences to jinn (i.e., invisible spirits). In this paper, we review the medical literature on jinn as an explanatory model in the context of psychotic disorders. We conducted a systematic search for papers on jinn and psychosis in Pubmed, EMBASE, Ovid Medline, PsycINFO, and Google Scholar databases. Our search yielded 105 scientific texts on jinn and their relationship with mental disorders, including 47 case reports. Among the case reports a definite biomedical diagnosis was provided in 66% of the cases, of which 45.2% involved a schizophrenia spectrum disorder. Fully 10 of 16 hallucinating patients experienced multimodal hallucinations. Although infrequently documented in the biomedical literature, the attribution of psychiatric symptoms to jinn appears to be quite common among Islamic patients, and to have significant impact on the diagnosis, treatment, and course of mental disorders, particularly psychotic disorders.
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Salvatore P, Bhuvaneswar C, Tohen M, Khalsa HMK, Maggini C, Baldessarini RJ. Capgras' syndrome in first-episode psychotic disorders. Psychopathology 2014; 47:261-9. [PMID: 24516070 PMCID: PMC4065173 DOI: 10.1159/000357813] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 12/08/2013] [Indexed: 01/03/2023]
Abstract
BACKGROUND Misidentification phenomena, including the delusion of 'imposters' named after Joseph Capgras, occur in various major psychiatric and neurological disorders but have rarely been studied systematically in broad samples of modern patients. This study investigated the prevalence and correlated clinical factors of Capgras' phenomenon in a broad sample of patient-subjects with first-lifetime episodes of psychotic affective and nonaffective disorders. METHODS We evaluated 517 initially hospitalized, first-episode psychotic-disorder patients for the prevalence of Capgras' phenomenon and its association with DSM-IV-TR diagnoses including schizophreniform, brief psychotic, unspecified psychotic, delusional, and schizoaffective disorders, schizophrenia, bipolar-I disorder and major depression with psychotic features, and with characteristics of interest including antecedent psychiatric and neurological morbidity, onset type and presenting psychopathological phenomena, using standard bivariate and multivariate statistical methods. RESULTS Capgras' syndrome was identified in 73/517 (14.1%) patients (8.2-50% across diagnoses). Risk was greatest with acute or brief psychotic disorders (schizophreniform psychoses 50%, brief psychoses 34.8%, or unspecified psychoses 23.9%), intermediate in major depression (15%), schizophrenia (11.4%) and delusional disorder (11.1%), and lowest in bipolar-I (10.3%) and schizoaffective disorders (8.2%). Associated were somatosensory, olfactory and tactile hallucinations, Schneiderian (especially delusional perception), and cycloid features including polymorphous psychotic phenomena, rapidly shifting psychomotor and affective symptoms, pananxiety, ecstasy, overconcern with death, and perplexity or confusion, as well as rapid onset, but not sex, age, abuse history, dissociative features, or indications of neurological disorders. CONCLUSIONS Capgras' syndrome was prevalent across a broad spectrum of first-episode psychotic disorders, most often in acute psychoses of rapid onset.
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Affiliation(s)
- Paola Salvatore
- Department of Psychiatry, Harvard Medical School, Boston, Mass., USA
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Fornaro M, Martino M, De Pasquale C, Moussaoui D. The argument of antidepressant drugs in the treatment of bipolar depression: mixed evidence or mixed states? Expert Opin Pharmacother 2012; 13:2037-51. [PMID: 22946746 DOI: 10.1517/14656566.2012.719877] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The role of antidepressant drugs in acute and maintenance treatment of bipolar depression is a matter of debate that cannot be decided from the evidence available in the current literature. AREAS COVERED This review includes two sections: in the first, important contributions from the current literature, emphasizing randomized controlled trials (RCTs) and meta-analysis, highlight current controversies and methodological issues; in the second, the impact of mixed depressive features in bipolar depression is evaluated from a psychopathological perspective. EXPERT OPINION Methodological issues may complicate evaluation of the evidence from RCTs regarding antidepressants and mixed states. Moreover, nosological constructs may also contribute to the inconclusive findings, by introducing heterogeneity in patient selection and diagnosis. Acknowledging the impact of mixed features in the course of bipolar depression, essentially by the careful reading of classical Kraepelinian contributions, could enhance clinical management. This would in turn allow a more judicious use of antidepressants, ideally helping to shed some light on the much controversial 'antidepressant-related suicidality', and help to further clarify the reasons for the current literature discordance on this topic.
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Affiliation(s)
- Michele Fornaro
- University of Catania, Department of Formative Sciences, via Teatro Greco n.78, Catania, ZIP 95124, Italy.
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Legesse B, Freudenreich O, Murray E, Price B. A case report of confusional psychosis with abrupt onset and rapid resolution of symptoms. PSYCHOSOMATICS 2011; 52:468-71. [PMID: 21907068 DOI: 10.1016/j.psym.2011.01.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 05/12/2010] [Accepted: 05/14/2010] [Indexed: 11/25/2022]
Affiliation(s)
- Benalfew Legesse
- Dept. of Neurology, McLean Hospital, Harvard Medical School, Belmont, MA 02478, USA.
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