Diagnosis Of Primary Affective Disorder Research Articles

Suicide in a National Student Mental Health Patient Population, 1997-2012.

Entering higher education is a time of transition that coincides with the typical age of onset of serious mental illness. Awareness of the distinguishing characteristics of students with mental illness who die by suicide may inform clinical management. We aimed to compare the characteristics of mental health patients who died by suicide as students with other young people who died by suicide. UK data were analyzed for individuals aged 18-35 years in contact with mental health services who died by suicide from 1997 to 2012. Univariate analyses examined the sociodemographic, behavioral, and clinical features of those who died as students. Backward stepwise regression analysis identified factors independently associated with student deaths. In all, 214 university students died by suicide within 12 months of mental health service contact. Factors associated with student deaths were: being younger, female, from an ethnic minority group, and a primary diagnosis of affective disorder. Medication nonadherence was less likely to be associated with student deaths. Deaths by suicide are split almost equally between male and female students, unlike the predominance of male suicide in the general population. There are clear differences in the characteristics of the student and nonstudent groups, although causation could not be established.

Suicide in recently discharged psychiatric patients: a case-control study

Few controlled studies have specifically investigated aspects of mental health care in relation to suicide risk among recently discharged psychiatric patients. We aimed to identify risk factors, including variation in healthcare received, for suicide within 3 months of discharge. We conducted a national population-based case-control study of 238 psychiatric patients dying by suicide within 3 months of hospital discharge, matched on date of discharge to 238 living controls. Forty-three per cent of suicides occurred within a month of discharge, 47% of whom died before their first follow-up appointment. The first week and the first day after discharge were particular high-risk periods. Risk factors for suicide included a history of self-harm, a primary diagnosis of affective disorder, recent last contact with services and expressing clinical symptoms at last contact with staff. Suicide cases were more likely to have initiated their own discharge and to have missed their last appointment with services. Patients who were detained for compulsory treatment at last admission, or who were subject to enhanced levels of aftercare, were less likely to die by suicide. The weeks after discharge from psychiatric care represent a critical period for suicide risk. Measures that could reduce risk include intensive and early community follow-up. Assessment of risk should include established risk factors as well as current mental state and there should be clear follow-up procedures for those who have self-discharged. Recent detention under the Mental Health Act and current use of enhanced levels of aftercare may be protective.

The Application of Cognitive-Behavioral Therapy for Psychosis in Clinical and Research Settings

This study compared the practice of cognitive-behavioral therapy (CBT) for psychosis across research and routine clinical settings. An observer-rated adherence measure was used to compare the content of 40 therapy sessions of clients with positive psychotic symptoms. Twenty therapist-client dyads came from a research setting in the United Kingdom and 20 from three clinical settings, two in the United Kingdom and one in the United States. In the research setting CBT was provided by research clinical psychologists and trained local therapists. In the clinical settings CBT was part of a case management service by trained therapists. Therapist adherence to CBT for psychosis did not differ between the research and clinical settings. However, clinicians in the research settings scored significantly higher on items for schema work (z=-1.98, p<.05), relapse prevention interventions (z=-2.08, p<.05), and formulating a model of relapse (z=-2.61, p<.01). CBT for psychosis conducted in clinical settings was more strongly characterized by assessment of symptoms and work on coping strategies and less so by relapse prevention and schema-level work. Relapse prevention interventions and schema work could be considered more challenging for therapists to undertake. The findings suggest that therapists working in routine clinical settings are able to establish good therapeutic relationships with people with psychosis and to work on assessing and coping with their psychotic symptoms. However, some therapeutic approaches may be more challenging in this context.

Suicide in current psychiatric in-patients: a case-control study The National Confidential Inquiry into Suicide and Homicide

Few controlled studies have investigated factors associated with suicide in current in-patients. We aimed to identify psychosocial, behavioural and clinical risk factors, including variations in care, for in-patient suicide. We conducted a national population-based case-control study of people who died by suicide between 1 April 1999 and 31 December 2000 while in psychiatric in-patient care in England. Cases were 222 adult mental health in-patients who died by suicide matched on date of death with 222 living controls. Nearly a quarter of suicides took place within the first week of admission; most of these died on the ward or after absconding. After the first week, however, most suicides occurred away from the ward, the majority of patients having left the ward with staff agreement. Previous deliberate self-harm, recent adverse life events, symptoms of mental illness at last contact with staff and a co-morbid psychiatric disorder were associated with increased risk for suicide. Being off the ward without staff agreement was a particularly strong predictor. Those patients who were detained for compulsory treatment were less likely to die by suicide. Independent predictors of in-patient suicide were male sex, a primary diagnosis of affective disorder and a history of self-harm. Being unemployed or on long-term sick leave appeared to be independently protective. Prevention of in-patient suicide should emphasize adequate treatment of affective disorder, vigilance in the first week of admission and regular risk assessments during recovery and prior to granting leave. Use of compulsory treatment may reduce risk.

Risk of dementia in people with depressive and bipolar disorders increases with increasing number of prior affective episodes

Kessing LV, Andersen PK. Does the risk of developing dementia increase with the number of episodes in patients with depressive disorder and in patients with bipolar disorder? J Neurol Neurosurg...

Late-Onset Bipolar Disorder

Mania in old age is not as rare as it was once thought to be. It may constitute up to 5 per cent of admissions in the psychogeriatric department. The clinical picture, for the most part, seems to correspond with mania in younger patients, although some patients may have atypical presentations. Secondary mania should be excluded first, before a firm diagnosis of primary affective disorder is made. The prognosis and treatment of late onset mania do not seem to differ appreciably from those in younger patients.

Mortality in a follow-up of 500 psychiatric outpatients. II. Cause-specific mortality.

In a six- to 12-year follow-up study of 500 psychiatric outpatients, death from natural causes occurred 11/2 times the expected rate, although the excess was not significant. Death from unnatural causes occurred 31/2 times the expected rate, a significant elevation. Suicide and homicide rates were particularly excessive. Unnatural mortality was excessive among younger, but not older, patients, and among all sex-race groups except black women, none of whom died unnaturally. Initial psychiatric diagnoses highly predictive of unnatural death included alcoholism, antisocial personality, drug addiction, and homosexuality. Secondary affective disorder was predictive of excess unnatural mortality, but in all cases of such death one of the four disorders associated with excess mortality antedated the affective disturbance. No patient with an index diagnosis of primary affective disorder died of an unnatural cause. Despite a frequent history of suicide attempts, hysteria was not associated with excess unnatural mortality.

Prediction of response to stabilizing lithium treatment.

As lithium has a wide range of biological effects, it is not surprising that the benefit from lithium treatment has been observed in several types of psychiatric disorders. Mood stabilization has been seen in episodic disorders; antiaggressive effect has been reported in mental retardation and other illnesses, and some endocrine and hematological effects have been utilized in internal medicine and neurology. To date, however, only the stabilizing effect on recurrent mood disorders appears to be reliably predictable. The prediction is based primarily on the diagnosis, quality of free interval and frequency of episodes; and several associated indicators can also be helpful. Results of the presented series of studies on the response to stabilizing lithium treatment suggest that such a response is predictable for most patients. The epitome of an excellent lithium responder is a patient with a good quality of remissions, a moderate frequency of recurrences, and a diagnosis of primary affective disorder. If the MMPI profile taken at the patient's optimum is abnormal, the chances of stabilization on lithium alone are greatly reduced. In addition, the responders more frequently have a family history of primary affective disorder and a positive M antigen. It appears that in the present practice the assessment of patients for stabilizing lithium treatment may frequently not be comprehensive enough. As a result, lithium is at present probably overprescribed in North America, and possibly elsewhere as well.

Stability of the diagnosis of primary affective disorder: A four-year follow-up study

Most modern studies on depression use standardized diagnostic approaches, such as the St. Louis Criteria or the RDC. The main aim of these methods is to select reliable samples for research purposes. However, doubts have been raised as to whether the groups derived through these criteria are homogeneous. In order to investigate the stability of the diagnosis of Primary Affective Disorder (PAD), a group of 78 patients meeting the criteria for this disorder were followed up for 4 years. During this period 19.2% of patients showed important psychopathological symptoms other than affective. No particular factor, apart from bipolar illness, was found to be significantly predictive of a stable diagnosis. However, the rate of diagnoses would have been greater by taking into account family history and premorbid personality of the patients. The authors conclude that other sources of information, beyond present symptoms, ought to be taken into account in order to reach more homogeneous groupings.

Female Physicians and Primary Affective Disorderppp-Reply

<h3>In Reply.—</h3> The statements in the<i>second</i>paragraph of Dr Pitts' letter to the editor require clarification. First, since most patients with affective disorder have an episodic course of illness, a history of a cluster of depressive symptoms for a given period of time<i>is</i>the basis for a diagnosis of primary affective disorder in the absence of a preexisting psychiatric disorder. Second, the term "primary affective disorder" is preferable to "manic-depressive psychosis"¹since the presence of neither psychosis nor mania (or even depression if mania is present) is required for the establishment of the presence of an affective disorder, the cause of which is unknown.²Third, there are no laboratory tests to confirm a diagnosis of primary affective disorder as there are for tuberculosis, where clinical findings can be supported or confirmed by such tests. Fourth, we found the prevalence of primary affective disorder among the female physicians to

Psychiatric Problems in Women Admitted to an Alcoholic Detoxification Center

The authors studied 293 consecutive female admissions to a public detoxification facility. One-half had a primary diagnosis of alcoholism; the rest had primary diagnosis of affective disorder (14%), antisocial personality (14%), drug abuse (6%) or did not meet the criteria for alcoholism (13%). Each subgroup had unique social backgrounds and characteristic histories of involvement with alcohol, drugs, and antisocial problems. The primary alcoholic woman in the detoxification center resembles the primary alcoholic man in the same setting. The authors underscore the importance of socioeconomic strata and primary versus secondary diagnosis in understanding the prognosis for alcoholics.

Affective disorder: studies with amine precursors

The authors assessed the clinical antidepressant effects of L-tryptophan given alone and in combination with L-dopa in 12 patients with a diagnosis of primary affective disorder; Preliminary results did not demonstrate an antidepressant response when L-dopa was combined with L-tryptophan. Also, the results did not support the catecholamine or biogenic amine hypotheses of affective disorder.

DMT—A possible relationship to schizophrenia

anxiety attacks, multiple somatic complaints.) Only two patients of the 43 originally considered to have primary affective disorder and followed up had an illness incompatible with the index diagnosis of primary affective disorder. To our knowledge this is the first prospective follow-up study over any considerable time period of patients diagnosed by explicit criteria for primary affective disorder. At the most conservative, diagnostic validity is demonstrated to be 86 per cent. At best, it is 95 per cent. This study offers evidence that the diagnosis of primary affective disorder, when carefully made by explicit criteria is stable over time.

Ritalin effects in children with learning disability

321 Ritalin effects in children with learning disability DONALD F. KLEIN and RACHEL GITTELMAN-KLEIN Long Island Jewish-Hillside Medical Center, Glen Oaks, New York, U.S.A. Stimulants have been reported to ameliorate both the behavior of children with “emotional problems”, as well as their performance on various measures of intellectual functioning and learning. As a result there is a growing trend in the U.S.A. to view stimulants as useful for learning disability. However, so far all studies have been conducted with children selected because of behavior disorders. Therefore, it is not known whether stimulants are a relevant intervention among children who are poor achievers, but who have no significant psychopathology. This study tested the effects of methylphenidate on the intellectual functioning of children free of behavioral deviance, but with learning lags. Fifty children, 7-12, not hyperactive, with an I.Q. of at least 85,2 yr below their expected grade level in reading, and free of moderate to severe psychopathology, were randomly assianed to methvluhenidate or ulacebo for 12 weeks. A battery of achievement and cognitive tests was adni treatment, ripeated 4 and 12 weeks after treatment. The child was &en weekly by a psychiatrist, blind to the treatment. Results. On the Wide Range Achievement Test, both reading and arithmetic scores were significantly improved by methylphenidate after 4 weeks. Over the first month of methylphenidate treatment, the children gained 4 months in’ reading, 7 months in arithmetic, whereas the placebo treated group gained only 14 months in readine and showed no chance in arithmetic CD < 0.005). After 12 weekzof treatment the pi&e was considegably different. The methylphenidate and placebo groups were no longer significantlj different either on the reading or arithmet~cc‘scores of the WRAT. The Grav Oral Reading Test was not sensitive to drue effect at anv noint. Children’s uerformance on the Porteus Maze test showsd marked gain in favor of the &g-treated @up after 4 and 12tveeks of treatment. Comment. The above results indicate that methylphenidate does have a positive effect on cognitive function, independent of its clinical action in behavior disorders. However it may be unjustified to generalize about stimulant effects on learning from short-term studies. The current practice in American pediatric psychopharmacology of long-term treatment on the basis of short-term investigations should be reviewed by appropriate long-term studies. The validation of specific diagnostic criteria for primary affective disorder by means of a blind five year follow-up GEORGE E. MURPHY, ROBERT A. WOODRUFF and MARIJAN HERJANIC Department of Psychiatry, Washington University, School of Medicine, St. Louis, Missouri, U.S.A. One hundred fifteen patients admitted to Renard Hospital in 1962 and 1963 with depressive symptoms were interviewed systematically with a structured research protocol containing approximately 500 items of information. Each interview lasted l&4 hr. Clinical diagnoses were made on the basis of these interviews. Follow-up interviews were sought with these same patients 5 yr later, to test the validity (stability over time) of the original diagnoses. Each patient was interviewed blindly bv interviewers who had not narticipated in the original colikction of data and who had no knowledge of the patient’s index diagnosis.& Fifty-two patients met specific inclusion and exclusion criteria (no other psychiatric illness or atypical symptoms) for primary affective disorder at the initial interview and were so diagnosed. Of these, follow-up was obtained with 43 (83 per cent). Thirty-seven of the 43 patients (86 per cent) were diagnosed blindly at follow-up as having primary affective disorder. They had unequivocal primary affective disorder during the follow-up interval and no other psychiatric illness, or were well throughout the entire interval. Each of these circumstances satisfies the basic requirement for a legitimate diagnostic entity: that it remain the same or disappear, but that it not turn into something else. Six patients receiving an index diagnosis of primary affective disorder were given another diagnosis at follow-up. Four had developed interval conditions not ordinarily considered incompatible with primary affective disorder (alcoholism, organic brain syndrome,

Validity of the diagnosis of primary affective disorder. A prospective study with a five-year follow-up.

In a five-year prospective follow-up study of 115 psychiatrically hospitalized patients, interinterview reliability for depressive symptoms was 94%. Specific interrater diagnostic reliability was 80%, using explicit diagnostic criteria. Disagreement was solely on degree of certainty within a specific diagnosis, not between different diagnoses. Interrater reliability was 100% for presence or absence of affective disorder. Follow-up was blind. Of 52 patients initially diagnosed by explicit criteria as having primary affective disorder, 43 were followed up. Blind diagnostic agreement was 86%. An additional 9% not concordant by blind diagnosis fell within the usual clinical concept of primary affective disorder. Only two patients (5%) had a course incompatible with the natural history of primary affective disorder. To our knowledge this is the first blind, prospective validation of criteria for the diagnosis of primary affective disorder.

Variability of the clinical course of primary affective disorder.

In a five-year prospective follow-up study, 37 patients were concordant for the diagnosis of primary affective disorder at index and blind follow-up interview. This report describes their clinical course graphically. Six patients (16%) were chronically ill during the entire follow-up period. Nine (24%) had no recurrence of depression. The remaining 22 patients had one to nine further depressive episodes with durations varying from two weeks to one year. At follow-up, 13 patients were ill: six chronically plus seven others. Three fourths of the patients were well more than three fourths of the time during the follow-up interval, with few or no lingering symptoms.

Marihuana use and psychiatric illness.

One hundred regular marihuana users and 50 nonuser friends were interviewed by a psychiatrist. A high lifetime incidence of psychopathology was found in both groups. Half of each group fulfilled criteria for some psychiatric diagnosis. One third received a diagnosis of primary affective disorder. Among users, 12% received a diagnosis of sociopathy compared to none of the controls. Almost every diagnosed psychiatric illness among the users began before first marihuana use. Alcohol, tobacco, sexual experience, "acting out" behavior in limit-testing areas usually antedated marihuana experience. It is concluded that at least some regular marihuana users come from a population at high risk for psychiatric problems, and that these difficulties almost always preceed use of marihuana.