Psychosis in bipolar and unipolar affective illness with special reference to schizo-affective disorder

Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review

BACKGROUND

Lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment. However, despite a considerable amount of research, the impact of psychotic symptoms on BD remains unclear, and there are very few systematic reviews on the subject.

AIM

To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. An electronic literature search of six English-language databases and a manual search was undertaken to identify published articles on psychotic symptoms in BD from January 1940 to December 2021. Combinations of the relevant Medical Subject Headings terms were used to search for these studies. Articles were selected after a screening phase, followed by a review of the full texts of the articles. Assessment of the methodological quality of the studies and the risk of bias was conducted using standard tools.

RESULTS

This systematic review included 339 studies of patients with BD. Lifetime psychosis was found in more than a half to two-thirds of the patients, while current psychosis was found in a little less than half of them. Delusions were more common than hallucinations in all phases of BD. About a third of the patients reported first-rank symptoms or mood-incongruent psychotic symptoms, particularly during manic episodes. Psychotic symptoms were more frequent in bipolar type I compared to bipolar type II disorder and in mania or mixed episodes compared to bipolar depression. Although psychotic symptoms were not more severe in BD, the severity of the illness in psychotic BD was consistently greater. Psychosis was usually associated with poor insight and a higher frequency of agitation, anxiety, and hostility but not with psychiatric comorbidity. Psychosis was consistently linked with increased rates and the duration of hospitalizations, switching among patients with depression, and poorer outcomes with mood-incongruent symptoms. In contrast, psychosis was less likely to be accompanied by a rapid-cycling course, longer illness duration, and heightened suicidal risk. There was no significant impact of psychosis on the other parameters of course and outcome.

CONCLUSION

Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.

Psychotic Depression: Diagnosis, Differential Diagnosis, and Treatment

Psychotic depression was initially considered to be at one end of a continuum of severity of major depression. Subsequent experience demonstrated that psychosis is an independent trait that may accompany mood disorders of varying severity. While much has been learned about the impact of severe mood congruent delusions and hallucinations on the course and treatment response of depression, less is known about fleeting or mild psychosis, mood incongruent features, or psychotic symptoms that reflect traumatic experiences. Acute treatment of psychotic unipolar depression generally involves the combination of an antidepressant and an antipsychotic drug or electroconvulsive therapy. There is inadequate information about maintenance treatment of unipolar psychotic depression and acute and chronic treatment of psychotic bipolar disorder. Decision-making therefore still must rely in part on clinical experience.

The International College of Neuropsychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 1: Background and Methods of the Development of Guidelines

BACKGROUND

This paper includes a short description of the important clinical aspects of Bipolar Disorder with emphasis on issues that are important for the therapeutic considerations, including mixed and psychotic features, predominant polarity, and rapid cycling as well as comorbidity.

METHODS

The workgroup performed a review and critical analysis of the literature concerning grading methods and methods for the development of guidelines.

RESULTS

The workgroup arrived at a consensus to base the development of the guideline on randomized controlled trials and related meta-analyses alone in order to follow a strict evidence-based approach. A critical analysis of the existing methods for the grading of treatment options was followed by the development of a new grading method to arrive at efficacy and recommendation levels after the analysis of 32 distinct scenarios of available data for a given treatment option.

CONCLUSION

The current paper reports details on the design, method, and process for the development of CINP guidelines for the treatment of Bipolar Disorder. The rationale and the method with which all data and opinions are combined in order to produce an evidence-based operationalized but also user-friendly guideline and a specific algorithm are described in detail in this paper.

Self-reported work ability of Norwegian women in relation to physical and mental health, and to the work environment

OBJECTIVES

To examine the self-reported level of work ability among female employees and the relationship between work ability and demographic characteristics, physical health, mental health, and various psychosocial and organizational work environment factors.

METHODS

Participants were 597 female employees with an average age of 43 years from urban and rural areas in Norway. Trained personnel performed a structured interview to measure demographic variables, physical health, and characteristics of the working environment. Mental health was assessed using the 25-item version of the Hopkins Symptoms Checklist (HSCL-25). Work ability was assessed using a question from the Graded Reduced Work Ability Scale.

RESULTS

Of the 597 female employees, 8.9% reported an extremely or very reduced ability to work. Twenty-four percent reported poor physical health and 21.9% reported mental distress (>/= 1.55 HSCL-25 cut-off). Women, who reported moderately and severely reduced work ability, did not differ a lot. Moderately reduced work ability increased with age and was associated with physical and mental health. Severely reduced work ability was strongly associated only with physical health and with unskilled occupation. Of eight work environment variables, only three yielded significant associations with work ability, and these associations disappeared after adjustment in the multivariate analysis.

CONCLUSION

Results indicate that ageing, in addition to poor self-reported physical health and unskilled work, were the strongest factors associated with reduced work ability among female employees. Impact of work environment in general was visible only in univariate analysis.

The impact of psychosocial and organizational working conditions on the mental health of female cleaning personnel in Norway

BACKGROUND

This study examined the association between psychosocial and organizational work conditions and mental health among women employed in the cleaning profession in Norway.

METHODS

Self-report questionnaires were mailed to 661 cleaning staff personnel from seven cleaning organizations in seven different cities across Norway. The response rate was 64%, of which 374 (88%) respondents were women. The questionnaires assessed socio-demographic information and employment history, work organization, and psychosocial working conditions. The Hopkins Symptoms Checklist (HSCL-25) was included to assess mental health.

RESULTS

On average, respondents were 43 years old and reported 10.8 years of experience working in the cleaning industry. The proportion of women scoring a HSCL-25 equal to or above 1.75 was 17.5%, which was higher than the average prevalence of mental health problems among working Norwegian women (8.4%). A factor analysis of the questions specific to the psychosocial work environment identified the following four underlying dimensions: leadership, co-workers, time pressure/control, and information/knowledge. Two of these, poor satisfaction with leadership (OR = 3.6) and poor satisfaction with co-workers (OR = 2.3), were significantly related to mental health. In addition, having contact with colleagues less than once a day (OR = 2.4) and not being ethnically Norwegian (OR = 3.0) increased the risk for mental health problems.

CONCLUSION

Mental health problems are frequent among female cleaning professionals in Norway. Our results indicate that quality of leadership, collaboration with co-workers, and ethnicity were significantly associated with mental health.

The impact of psychosocial and organizational working conditions on the mental health of female cleaning personnel in Norway

Background

This study examined the association between psychosocial and organizational work conditions and mental health among women employed in the cleaning profession in Norway.

Methods

Self-report questionnaires were mailed to 661 cleaning staff personnel from seven cleaning organizations in seven different cities across Norway. The response rate was 64%, of which 374 (88%) respondents were women. The questionnaires assessed socio-demographic information and employment history, work organization, and psychosocial working conditions. The Hopkins Symptoms Checklist (HSCL-25) was included to assess mental health.

Results

On average, respondents were 43 years old and reported 10.8 years of experience working in the cleaning industry. The proportion of women scoring a HSCL-25 equal to or above 1.75 was 17.5%, which was higher than the average prevalence of mental health problems among working Norwegian women (8.4%). A factor analysis of the questions specific to the psychosocial work environment identified the following four underlying dimensions: leadership, co-workers, time pressure/control, and information/knowledge. Two of these, poor satisfaction with leadership (OR = 3.6) and poor satisfaction with co-workers (OR = 2.3), were significantly related to mental health. In addition, having contact with colleagues less than once a day (OR = 2.4) and not being ethnically Norwegian (OR = 3.0) increased the risk for mental health problems.

Conclusion

Mental health problems are frequent among female cleaning professionals in Norway. Our results indicate that quality of leadership, collaboration with co-workers, and ethnicity were significantly associated with mental health.

Psychosis in bipolar disorder: phenomenology and impact on morbidity and course of illness

Although psychosis is common in bipolar disorder, few studies have examined the prognostic significance of psychotic features. In addition, some studies suggest that the presence of mood-incongruent psychosis, in particular, is associated with poorer outcome compared with mood-congruent psychosis. We assesses the phenomenology and prevalence of mood-congruent and mood-incongruent psychotic symptoms in 352 patients with bipolar I disorder participating in the Stanley Foundation Bipolar Treatment Network. We compared the demographic and clinical features, and measures of psychosocial and vocational functioning in patients with and without a history of psychosis. The phenomenology of psychosis in this cohort of patients with bipolar disorder was similar to that reported in earlier studies and supported the lack of diagnostic specificity of any one type of psychotic symptom. There were no significant differences between patients with and without a history of psychosis on any demographic, psychosocial, vocational, or course of illness variables. Only family history of bipolar disorder was significantly more common in patients with nonpsychotic bipolar disorder compared to patients with a history of psychosis. Among bipolar patients with a history of psychosis, only the proportion of women and lifetime prevalence rates of anxiety disorders occurred significantly more in patients with mood-incongruent delusions. In this large cohort of outpatients with bipolar I disorder, neither a history of psychosis nor of mood-incongruent psychosis had prognostic significance at entry into the Network. The lack of observable prognostic impact may have been, in part, due to the relatively high morbidity and poor functional outcome of a substantial portion of the total cohort.

Age-at-first-registration and heterogeneity in affective psychoses

BACKGROUND

Previous research into age of onset in affective disorders has produced conflicting results. This paper examines the influence of heterogeneity on the age-at-first-registration distribution for the ICD-9 diagnostic group 'affective psychosis'.

METHOD

For 1979-1991, data for age-at-first-registration for 4985 individuals diagnosed with affective psychosis (ICD-9 296.x) were extracted from a name-linked mental health register. These data were divided into (i) '296.1 only', a category used to code unipolar depression (males = 700; females = 1321); and (ii) '296 other', all 296 cases other than 296.1 (males = 1280; females = 1684). Inception rates for each 5-year age division were adjusted for the background population age-structure as a rate per 100,000 population.

RESULTS

The age-at-first-registration distribution for affective psychosis has a wide age range, with women outnumbering men. There is a near-linear increase in inception rates for both men and women with 296.1 only, while the bulk of those with affective psychoses (296 other) have an inverted U-shaped age distribution. Males have an earlier modal age-at-first-registration for 296 other compared to females.

CONCLUSION

The heterogeneity in terms of subtypes and sex in affective psychosis clouds the interpretation of age-at-first-registration. Separating those with unipolar psychotic depression from other subclassifications and differentiating by sex may provide clues to factors that precipitate the onset of affective psychosis.

A polymorphism in the dopamine beta-hydroxylase gene is associated with "paranoid ideation" in patients with major depression

BACKGROUND

Increased dopaminergic activity may play a primary role in psychotic depression. Dopamine beta-hydroxylase (DbetaH) catalyses the key step in biosynthesis of the neurotransmitter noradrenaline from dopamine, and low DbetaH activity is a possible risk factor for developing psychotic depression. An exon 2 polymorphism (DBH*444 g/a) of the DbetaH gene (DBH) is significantly associated with both serum and cerebrospinal fluid levels of DbetaH.

METHODS

We determined the genotype of the DBH*444g/a polymorphism in a cohort of 164 patients with major depression and examined the association of this polymorphism with paranoid ideation, interpersonal sensitivity, and psychoticism on the Hopkins Symptom Checklist.

RESULTS

Patients who possessed the A allele were significantly more likely to have higher scores for interpersonal sensitivity and paranoia than patients without the A allele (p =.004 and p =.048, respectively), suggesting that this allele may predispose patients to paranoia in major depression. In addition, we found an association between prolactin levels in men and DBH*444 g/a genotype such that homozygous G individuals displayed significantly higher levels than homozygous A or heterozygote individuals.

CONCLUSIONS

Depressed patients with the GG genotype of DbetaH have lower scores for interpersonal sensitivity and paranoid ideation. The GG genotype may be protective against the development of psychosis in the presence of a major depressive episode.

Does sleep EEG data distinguish between UP, BPI or BPII major depressions? An age and gender controlled study

Clinical characteristics and sleep EEG data of 14 unipolar (UPR), 14 bipolar I (BPI) and 14 bipolar II (BPII) patients, matched for age and gender, were investigated during a major depressive episode. We observed a remarkable similarity in the clinical characteristics of the three samples and, concerning sleep EEG data, a trend to a higher percentage of awakening among BPI patients. Pairwise comparisons of the three subgroups showed that only the Newcastle rating scale score reached significant difference between BPI and UPR groups. We observed trends regarding the difference of awakening both between BPI and BPII groups and between BPI and UPR groups, difference of percentage of REM sleep between BPI and BPII groups and difference of Sleep Period Time between BPII and UPR groups. We also observed that the distribution of REM latencies in the BPI subgroup was different from the two others.

Sleep-onset rapid eye movement periods in neuropsychiatric disorders: implications for the pathophysiology of psychosis

This paper reviews the literature describing the occurrence of sleep-onset rapid eye movement periods in narcolepsy, schizophrenia, psychotic depression, and delirium tremens; the association of narcolepsy with psychotic disorders; the neuropathology of the brainstem in narcolepsy and schizophrenia; and other behavioral disorders resulting from probable brainstem pathology. These findings suggest that some forms of psychosis are a manifestation of pathophysiological changes in the brainstem. Some implications of this hypothesis for the treatment of psychoses are discussed. Future research should investigate psychoses and the psychobiological correlates of such biological markers as sleep-onset rapid eye movement periods across diagnostic categories.

Pharmacologic treatment of schizoaffective disorder

In contrast to the considerable systematic study of the pharmacologic treatment of schizophrenia and mood disorders, the pharmacologic treatment of schizoaffective disorder has been relatively ignored. The authors reviewed the available literature regarding the pharmacologic treatment of schizoaffective disorder. The total number of controlled studies of the acute and prophylactic treatment of schizoaffective disorder was small and few used modern criteria to define the disorder. In studies of schizoaffective disorder, bipolar type (manic), lithium and antipsychotics produced comparable albeit incomplete responses, except in highly agitated patients when antipsychotics exerted superior efficacy. The combination of lithium and antipsychotics appeared to be superior to antipsychotics alone for schizoaffective, bipolar type patients. In the only controlled study of schizoaffective disorder, depressed type, the presumed superiority of combined antidepressant and antipsychotic treatment to antipsychotic alone was not found. Although combined antipsychotic and thymoleptic treatment represents common prophylactic management of schizoaffective disorder in clinical practice, the efficacy of this strategy has not been studied in controlled trials. Advances in the nosology of schizoaffective disorder, emerging epidemiologic data demonstrating large numbers of patients with this disorder in clinical populations, and preliminary evidence that clozapine may have combined antipsychotic and thymoleptic properties as well as efficacy in both the psychotic and affective components of schizoaffective disorder, suggest that renewed interest in the diagnosis and treatment of this disorder may lead to improved delivery of care for this understudied but seriously ill group of patients.

Psychotic depression: a review and clinical experience

We review research literature on psychotic (delusional) depression, including demographic, illness pattern, clinical, biological marker and treatment issues. Secondly, we report a study of a consecutive sample of 137 patients meeting criteria for DSM-III melancholia, RDC definite endogenous depression and our "clinical" criteria for endogenous depression, of whom there were 35 "psychotic depressives" (PDs). The PDs were contrasted with the remaining 76 depressives (EDs) and with an age and sex-matched subset (MEDs). The PDs were distinctly older than the EDs at assessment and at initial onset of any affective disorder. Compared to the MEDs, they tended to have longer illnesses, were more likely to be hospitalised (and to have longer stays), to receive (in the past and for the current episode) combination antipsychotic/antidepressant medication and/or ECT, and to have a poorer course over the following year. They were no more likely to have a bipolar pattern, a family history of depressive disorder, schizophrenia or alcoholism, or vegetative depressive features. Developmental psychosocial stressors and antecedent life event stressors were not over-represented. Most of the PDs had delusions, one-fifth reported hallucinations and psychomotor disturbance was marked. Other differential clinical findings were sustained mood disturbance, constipation, and the absence of a diurnal variation in mood and energy.

Prediction of treatment response in bipolar, manic disorder

We examined the records of 53 patients with a diagnosis of bipolar affective disorder, manic. Thirteen patients were refractory to lithium carbonate treatment. Clinical variables hypothesized to have value in predicting response including the presence of elation, grandiosity, paranoia, irritability, delusions and hallucinations did not predict treatment response.

Voluntary motor performance in psychotic disorders: a replication study

Voluntary motor performance was used to investigate the hypothesis of a continuum of psychosis from depression through schizophrenia. 43 schizophrenic, 36 schizoaffective, 50 major depressive, 20 manic, and 25 nonpsychotic patient controls were tested for tapping speed, finger dexterity, hand grip strength, and neuropsychological motor performance. Sex was included as an independent variable, and the effects of psychotropic drugs were evaluated. A continuum of motor dysfunction from depression through schizophrenia was not obtained. A measure of current psychotic symptoms was not associated with motor or neuropsychological performance. Motor performance was significantly worse in schizophrenic, schizoaffective, and psychotic affective disorders, when compared to nonpsychotic affective disorders. In this final analysis, psychoticism was defined by history. The results are discussed in terms of the hypothesis that psychoticism is a trait that is independent of diagnosis.

Familial rates of affective illness in Sardinia with special reference to schizoaffective disorder

Familial rates of psychiatric disorders were studied in southern Sardinia and showed an increase in relatives of probands with the following research diagnostic criteria (RDC) diagnoses: normal, unipolar depression, schizoaffective depressive, schizoaffective bipolar, bipolar with mania and bipolar with hypomania. A significantly higher risk for bipolar schizoaffective disorder was observed in relatives of bipolar schizoaffectives compared with relatives of normal probands.

Family history study of major psychiatric disorders and syndromes

The family history of major psychiatric disorders was examined among relatives of 193 in-patients fulfilling the Research Diagnostic Criteria (RDC) for Schizophrenia, Unspecified Functional Psychoses, Schizoaffective Disorder, Manic Disorder or Major Depressive Disorder. The morbid risk (MR) for schizophrenia was greater among the relatives of probands with non-affective psychoses whereas the MR for mania was greater among the relatives of probands with affective bipolar disorder. When major psychiatric syndromes were examined, only manic syndrome showed familial aggregation.

Schizoaffective disorder: a dimensional approach

The current categorical approach has not proved successful in resolving the problem of classifying patients with both affective and schizophrenic features. A dimensional approach is suggested; postulating two interacting factors; "dissociotaxia", a neurointegrative abnormality; and "hyperactivation", an abnormality in activation regulation. The latter factor can convert dissociotaxia to associative dyscontrol and produce mixed schizoaffective features. Clinical-phenomenological, prognostic, genetic-familial, treatment response and biological evidence is reconsidered from this standpoint; and the preferability of the dimensional approach is suggested, both for understanding the underlying psychopathology, and for constructing a different classification system, extensible to other areas of psychiatry.

Psychiatric genetics and psychiatric nosology

At the present time, family and twin data are used in psychiatry to test clinical concepts at issue, and, in particular, to validate or reject diagnostic classifications. The dichotomy between the schizophrenias and the effective disorders, as suggested by Kraepelin, has been supported by contemporary family and twin studies and also is corroborated by modern family and adoption studies. In the atypical psychoses it is demonstrated impressively how family data vary with different sampling procedures and diagnostic practices. In the affective disorders, the family findings at first favored the separation of unipolar and bipolar disorders but, subsequently, this concept was questioned and revised. Currently, psychiatric genetics attempts to contribute to the understanding of the affective disorders, in particular the depressions, by delineating subgroups and by looking for possible genetic relations between depression and frequently associated disorders, such as anxiety or anorexia.