Experiences of nurses providing care to hospitalized patients with acute mania in Türkiye: A phenomenological study

The main purpose of this study was to determine the experiences of nurses who care for hospitalized patients experiencing an acute manic episode. This qualitative study was carried out with 15 nurses working in a psychiatric ward in Türkiye. Data were collected through semi-structured in-depth individual interviews and focus-group interviews in which the face-to-face interview technique was used. Two main themes emerged from the analysis of the qualitative data: (1) the difficulties experienced and (2) the most effective elements of care. Under the first main theme, the following sub-themes emerged: difficulties in setting boundaries, safety concerns, difficulties in managing the patient's demands, inability to choose the appropriate word(s), and the "emotional whirlwind" experienced. The second main theme, on the other hand, included the following sub-themes: meeting basic needs, ensuring treatment compliance, encouragement to engage in physical activity, and having a sufficient number of qualified personnel. The study revealed that the nurses had difficulties in caring for their manic patients. On the basis of these results, it is recommended that nurses be given counseling and training on setting boundaries, ensuring safety, managing the patient's demands, coping with their own emotions, and communicating better. In addition, the study identified the importance of nursing interventions to meet patients' basic needs, encourage them to engage in physical activity, and ensure treatment compliance, and the importance of there being an adequate number of qualified personnel. These results may help students and other nurses in terms of assessing and setting priorities in cases needing acute psychiatric care.

A retrospective study of pituitary-thyroid interaction in patients with first-episode of bipolar disorder type I in Mania State

ABSTRACT

Bipolar disorder (BD)-mania is related to the dysfunction of anterior pituitary gland, but the pituitary-thyroid interaction on the acute stage of BD has been controversial. In order to rule out the effects of drugs, we aimed to determine the upstream interaction of first-episode of BD type I in mania state, and tried to find the relationship between thyroid-stimulating-hormone (TSH) and Prolactin (PRL)This study included 70 real-world patients diagnosed with first-episode BD-mania recuited and 70 healthy controls (HC) matched for age and sex from 2016 to 2017 in the same district of Shanghai. We compared the levels of thyroid hormones and prolactin between the two groups, and linear regression and curve estimation were used for the correlation analysis of TSH and PRLThere were differences in triiodothyronine (TT3), total thyroxin (TT4), and free thyroxine (FT4) concentrations between the groups (P's < .05). After being grouped by sex, higher PRL in the male and female BD-mania subgroup were observed compared to each isosexual HC [(P's < .01, Cohen's d = 0.82/1.08, 95%CI (0.33, 1.31)/(0.58, 1.58)]. Higher FT4 in the male BD-mania group was observed compared to the HC males [(P's  < .01, Cohen's d = 0.90, 95%CI (0.41, 1.39)] while the female BD-mania group showed lower TT3 and TT4 compared to the HC females [(P's  < .01, Cohen's d = 0.93/0.88, 95%CI (0.43, 1.42)/(0.39, 1.37)]. In the female BD-mania group, correlation analysis established an inverse relationship between PRL and TSH (r2 = 0.25, F = 11.11, P < .01).The findings demonstrate that sex impacts the concentration of hormones secreted by the anterior pituitary of patients with first-episode BD-mania. The increased PRL may be a putative mechanism that underlies the onset in female patients with a moderate inverse relationship between TSH and PRL. Thyroid hormones and prolactin levels may be developed as potential markers for identifying BD-manic.

Impact of duration of untreated illness in bipolar I disorder (manic episodes) on clinical outcome, socioecnomic burden in Egyptian population

INTRODUCTION

Bipolar disorder (BD) is a serious and chronic mental illness that may result in disability. We evaluated effect of the duration of untreated of bipolar (DUB) (manic episodes) on clinical outcomes, including episode severity, residual symptoms, duration of hospitalization, and suicide attempts, and on socioeconomic status of patients.

METHODS

A total of 216 participants who had bipolar I disorder (manic state) recruited from November 2017-December 2019 from an inpatient psychiatric unit. Patients divided into 2 groups based on DUB: Group A, with DUB < 4 months; and Group B, with DUB ≥4 months. All participants had evaluation for demographic and clinical features, Socioeconomic scale, Young mania rating scale (YMRS) at admission and discharge.

RESULTS

Group A participants were more often male, urban residents, married, literate and educated, professionally employed. Group A had a younger age of onset, less duration of illness, less frequency of episode, less suicide attempts, less duration in hospital, high mean of socioeconomic, lower mean of YMRS at admission and discharge in compared to Group B.

CONCLUSION

A longer DUB (manic episodes)was associated with negative clinical outcomes (more frequent episode, more symptoms severity, longer hospital admission, more suicide severity, more residual symptoms) and low socioeconomic state of patients with BDI (manic episodes).

Bipolar disorders

Bipolar disorders are a complex group of severe and chronic disorders that includes bipolar I disorder, defined by the presence of a syndromal, manic episode, and bipolar II disorder, defined by the presence of a syndromal, hypomanic episode and a major depressive episode. Bipolar disorders substantially reduce psychosocial functioning and are associated with a loss of approximately 10-20 potential years of life. The mortality gap between populations with bipolar disorders and the general population is principally a result of excess deaths from cardiovascular disease and suicide. Bipolar disorder has a high heritability (approximately 70%). Bipolar disorders share genetic risk alleles with other mental and medical disorders. Bipolar I has a closer genetic association with schizophrenia relative to bipolar II, which has a closer genetic association with major depressive disorder. Although the pathogenesis of bipolar disorders is unknown, implicated processes include disturbances in neuronal-glial plasticity, monoaminergic signalling, inflammatory homoeostasis, cellular metabolic pathways, and mitochondrial function. The high prevalence of childhood maltreatment in people with bipolar disorders and the association between childhood maltreatment and a more complex presentation of bipolar disorder (eg, one including suicidality) highlight the role of adverse environmental exposures on the presentation of bipolar disorders. Although mania defines bipolar I disorder, depressive episodes and symptoms dominate the longitudinal course of, and disproportionately account for morbidity and mortality in, bipolar disorders. Lithium is the gold standard mood-stabilising agent for the treatment of people with bipolar disorders, and has antimanic, antidepressant, and anti-suicide effects. Although antipsychotics are effective in treating mania, few antipsychotics have proven to be effective in bipolar depression. Divalproex and carbamazepine are effective in the treatment of acute mania and lamotrigine is effective at treating and preventing bipolar depression. Antidepressants are widely prescribed for bipolar disorders despite a paucity of compelling evidence for their short-term or long-term efficacy. Moreover, antidepressant prescription in bipolar disorder is associated, in many cases, with mood destabilisation, especially during maintenance treatment. Unfortunately, effective pharmacological treatments for bipolar disorders are not universally available, particularly in low-income and middle-income countries. Targeting medical and psychiatric comorbidity, integrating adjunctive psychosocial treatments, and involving caregivers have been shown to improve health outcomes for people with bipolar disorders. The aim of this Seminar, which is intended mainly for primary care physicians, is to provide an overview of diagnostic, pathogenetic, and treatment considerations in bipolar disorders. Towards the foregoing aim, we review and synthesise evidence on the epidemiology, mechanisms, screening, and treatment of bipolar disorders.

A phase 2a randomised, double-blind, placebo-controlled, parallel-group, add-on clinical trial of ebselen (SPI-1005) as a novel treatment for mania or hypomania

RATIONALE

Lithium is an effective prophylactic and anti-manic treatment in bipolar disorder; however, its use is declining through perceived poor tolerance and toxicity. Lithium inhibits inositol monophosphatase (IMPase), a probable key therapeutic mechanism. The anti-inflammatory drug, ebselen, also inhibits IMPase and appears well-tolerated and safe.

OBJECTIVES

To assess the efficacy of adjunctive ebselen in mania using the Young Mania Rating Scale (YMRS) (primary outcome) and the Altman Self-Rating Mania (ASRM) Scale and Clinical Global Impression-Severity Scale (CGI-S) among the secondary outcomes.

METHODS

Randomised, double-blind, placebo-controlled, parallel-group trial conducted between October 2017 and June 2019, at Oxford Health NHS Foundation Trust. Pharmacy-controlled randomisation was computer-generated, with full allocation concealment. In/outpatients (n = 68) aged 18-70, experiencing mania or hypomania, were assigned to 3 weeks ebselen (600 mg bd) (n = 33) or placebo (n = 35). Participants received usual clinical care and psychotropic medication.

RESULTS

Ebselen was numerically, but not statistically, superior to placebo in lowering scores on the YMRS (adjusted mean difference and 95% confidence interval, - 1.71 (- 5.34 to 1.91), p = 0.35) and ASRM (- 1.36 (- 3.75 to 1.17), p = 0.29). However, scores on the CGI-S were significantly lower at week 3 in ebselen-treated participants (adjusted mean difference, - 0.58 (- 1.14 to - 0.03), p = 0.04). A post hoc analysis excluding patients taking concomitant valproate treatment magnified the difference between ebselen and placebo on the YMRS. Adverse events were comparable between groups, and mild.

CONCLUSIONS

Ebselen merits further investigation where concomitant psychotropic medication is better controlled and participants taking valproate are excluded. If effective, ebselen's superior tolerance and safety could make it a useful alternative to lithium.

TRIAL REGISTRATION

Trial Registry: www.clinicaltrials.gov , Identifier: NCT03013400.

Differential-diagnostic confusion and non-specificity of affective symptoms and anxiety: An empirical study of first-admission patients

In everyday clinical work, psychiatrists encounter patients who present with symptoms spanning several diagnostic categories, e.g., showing signs of a psychosis, depression, and anxiety. This raises the critical question of which symptoms hold precedence over other and, by extension, which diagnosis is the right diagnosis. ICD-10 and DSM-5 do not provide unambiguous answers to this question and therefore psychiatry remains exposed to diagnostic disagreement with consequences for treatment and research. We explored symptom distribution in a sample of 98 first-admission psychiatric patients. We extracted and categorized singular symptoms into symptom domains: anxiety, mania, delusions, hallucinations, first-rank symptoms, and negative symptoms. Most symptoms were seen in most disorders. We found symptoms of depression and anxiety in almost all patients. Thus, just counting symptoms do not seem to be a valid way to make diagnoses. We elaborately discuss these issues in the context of the differential-diagnosis between schizophrenia and depression. Finally, we suggest that a combination of a criteria- and Gestalt-based approach to diagnosing mental disorders may contribute to counteract some of the current differential-diagnostic confusion.

The effect of smartphone-based monitoring on illness activity in bipolar disorder: the MONARCA II randomized controlled single-blinded trial

BACKGROUND

Recently, the MONARCA I randomized controlled trial (RCT) was the first to investigate the effect of smartphone-based monitoring in bipolar disorder (BD). Findings suggested that smartphone-based monitoring sustained depressive but reduced manic symptoms. The present RCT investigated the effect of a new smartphone-based system on the severity of depressive and manic symptoms in BD.

METHODS

Randomized controlled single-blind parallel-group trial. Patients with BD, previously treated at The Copenhagen Clinic for Affective Disorder, Denmark and currently treated at community psychiatric centres, private psychiatrists or GPs were randomized to the use of a smartphone-based system or to standard treatment for 9 months. Primary outcomes: differences in depressive and manic symptoms between the groups.

RESULTS

A total of 129 patients with BD (ICD-10) were included. Intention-to-treat analyses showed no statistically significant effect of smartphone-based monitoring on depressive (B = 0.61, 95% CI -0.77 to 2.00, p = 0.38) and manic (B = -0.25, 95% CI -1.1 to 0.59, p = 0.56) symptoms. The intervention group reported higher quality of life and lower perceived stress compared with the control group. In sub-analyses, the intervention group had higher risk of depressive episodes, but lower risk of manic episodes compared with the control group.

CONCLUSIONS

There was no effect of smartphone-based monitoring. In patient-reported outcomes, patients in the intervention group reported improved quality of life and reduced perceived stress. Patients in the intervention group had higher risk of depressive episodes and reduced risk of manic episodes. Despite the widespread use and excitement of electronic monitoring, few studies have investigated possible effects. Further studies are needed.