Presence Of Manic Symptoms Research Articles

T109. TRAVERSING THE TRANSDIAGNOSTIC GAP BETWEEN DEPRESSION, MANIA AND PSYCHOSIS WITH NATURAL LANGUAGE PROCESSING

BackgroundThe biological, clinical and social factors which underpin the aetiology of psychotic disorders are known to overlap between different ICD-10/DSM-5 diagnostic categories. A transdiagnostic approach to investigate clinical phenotype may enable a better understanding of pathophysiology at individual patient level. We applied natural language processing (NLP) tools to electronic health record (EHR) data from patients presenting with an ICD-10 diagnosis of unipolar depression to determine if symptoms at diagnosis could predict subsequent onset of a bipolar or psychotic disorder.MethodsData were obtained from 20,582 adults presenting with unipolar depression (ICD-10 F32 or F33, excluding F32.3 and F33.3) to the South London and Maudsley (SLaM) NHS Foundation Trust between April 2006 and March 2018.Natural language processing (NLP) techniques were used to extract data on 21 mood and affective symptoms from free text clinical assessments documented in the period -3/+3 months from the date of the diagnosis of unipolar depression. We obtained descriptive analyses of demographics and symptom prevalence.Symptoms were categorised into four groups: 1. Depressive (low mood, anhedonia, feelings of guilt, hopelessness, helplessness, psychomotor retardation, worthlessness, tearfulness, low energy), 2. Manic (elation, grandiosity, pressured speech, flight of ideas), 3. Biological symptoms (insomnia, disturbed sleep, low appetite, weight loss, poor concentration) and 4. Emotional/behavioural symptoms (mood instability, agitation, irritability). The symptom network structure was estimated using the Enhanced Least Absolute Shrinkage and Selection Operation procedure. We assessed network stability via a case-dropping bootstrapping procedure.We investigated associations between each of the four symptom groups and clinical outcomes using multivariable Cox regression to predict five-year risk of bipolar disorder (ICD-10 F30/F31) or a psychotic disorder (ICD-10 F2*).ResultsOf all patients presenting with unipolar depression, 19,569 (95.1%) had at least one documented depressive symptom, 16,199 (78.7%) had at least one biological symptom, 10,006 (48.6%) had at least one emotional/behavioural symptom, and 1,372 (6.67%) had at least one manic symptom. Patients with at least one manic symptom were significantly more likely to be male (OR: 1.25 (95% CI 1.12 - 1.40), p < 0.001) and less likely to be of Black (OR: 0.80 (0.68 - 0.93), p = 0.004) or Other ethnicity (OR: 0.78 (0.66 - 0.91), p = 0.003). Elation was the most commonly reported manic symptom (3.17%). Network analysis revealed that the presence of manic symptoms was associated with co-occurrence of agitation, irritability and mood instability. Agitation was the most central symptom in terms of strength, betweenness and expected influence. The resulting network remained stable after dropping up to 33% of cases from the sample.1,861 (9.04%) patients who initially presented with unipolar depression subsequently developed a mania/bipolar disorder or psychotic disorder within 5 years. The presence of at least one manic (HR: 1.71, 1.50 – 1.97), biological (HR: 1.33, 1.16 – 1.53) or emotional (HR: 1.91, 1.73 – 2.13) symptom was associated with significantly increased risk of onset of a bipolar or psychotic disorder.DiscussionWe found that patients with unipolar depression have a heterogenous clinical phenotype with a significant proportion going on to develop a bipolar or psychotic disorder within 5 years. Symptoms extracted from the EHR using NLP were predictive of subsequent onset of a bipolar or psychotic disorder. A transdiagnostic approach to defining clinical phenotype may help to better predict subsequent clinical outcomes.

Diagnostic dilemma and management difficulties in a case of chronic mania

Chronic mania has been defined as the presence of manic symptoms more than 2 years without remission. These patients have poor outcomes, severe impairment in functioning, and diagnostic and management difficulties. There are few cases with chronic mania reported in the Indian literature. We aim to present a case of chronic mania with challenges in diagnosis and management.

Pre-onset risk characteristics for mania among young people at clinical high risk for psychosis

IntroductionPsychosis and mania share conceptual, genetic and clinical features, which suggest the possibility that they have common antecedents. Participants identified to be at-risk for psychosis might also be at-risk for mania. We aimed to identify the rate and predictors of transition to mania in a cohort of youth with clinical or familial risk for psychosis. MethodsAmong a cohort of 416 young people with an at-risk mental state for psychosis defined using the Ultra-High-Risk (UHR) criteria, 74.7% were followed up between 5 and 13years from their baseline assessment. We undertook a matched case-control examination of those who developed mania over the follow-up period compared to those who did not develop mania or psychosis. Transition to mania was determined using either a structured clinical interview, or diagnoses from a state-wide public mental health contact registry. Clinical characteristics and risk factors were examined at baseline using information from structured interviews, clinical file notes, rating scales and unstructured assessments. ResultsEighteen participants developed mania (UHR-Manic transition or UHR-M, 4.3%). In comparison with participants matched on age, gender and baseline-study who developed neither mania nor psychosis, more UHR-M participants had subthreshold manic symptoms or were prescribed antidepressants at baseline. They also had lower global functioning. DiscussionIn addition to the UHR criteria, features such as subthreshold manic symptoms and antidepressant use may help identify at-risk groups that predict the onset of mania in addition to transition to psychosis. Presence of manic symptoms may also indicate syndrome specificity early in the prodromal phase.

The association between immune activation and manic symptoms in patients with a depressive disorder

Although recent studies have shown that immunological processes play an important role in the pathophysiology of mood disorders, immune activation may only be present in specific subgroups of patients. Our study aimed to examine whether immune activation was associated with (a) the presence of manic symptoms and (b) the onset of manic symptoms during 2 years of follow-up in depressed patients. Patients with a depressive disorder at baseline (N=957) and healthy controls (N=430) were selected from the Netherlands Study of Depression and Anxiety. Assessments included lifetime manic symptoms at baseline and two-year follow up, as well as C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) at baseline. Within depressed patients, immune activation was not related to the presence or absence of lifetime manic symptoms at baseline. However, CRP levels were strongly elevated in depressed men who developed manic symptoms compared with those who did not develop manic symptoms over 2 years (P<0.001, Cohen's d=0.89). IL-6 and TNF-α were also higher in depressed men with an onset of manic symptoms, but this association was not significant. However, we found that the onset of manic symptoms was particularly high in men with multiple elevated levels of inflammatory markers. Depressed men who developed manic symptoms during follow-up had increased immunological activity (especially CRP) compared with depressed men who did not develop manic symptoms. Further research should explore whether a treatment approach focusing on inflammatory processes may be more effective in this specific subgroup of depressed patients.

Two Opinions About One Child—What's the Clinician To Do?

Two Opinions About One Child—What's the Clinician To Do?

Episode length and mixed features as predictors of ECT nonresponse in patients with medication-resistant major depression

This study aimed to ascertain predictors of nonresponse to electroconvulsive therapy (ECT) in a large sample of major depressive patients resistant to pharmacologic treatment. A total of 208 depressive patients (31 with major depression [UP], 101 with bipolar disorder II [BP II], and 76 with bipolar disorder I [BP I] according to DSM-IV criteria) were included in the study and treated with bilateral ECT on a twice-a-week schedule. The patients were assessed before (baseline) and a week after the ECT course (final score) using the Hamilton Rating Scale for Depression-17 items (HAM-D-17), the Young Mania Rating Scale (YMRS), the Brief Psychiatric Rating Scale (BPRS), and the Clinical Global Improvement (CGI). Responders were defined as those patients with a reduction of at least 50% in HAM-D-17 score and a rating of 2 ("much improved") or 1 ("very much improved") in the CGI-Improvement subscale. At the end of the ECT course, 152 patients (64%) were classified as responders and 56 patients (36%) were classified as nonresponders. On backward stepwise logistic regression, bipolar subtype (odds ratio [OR]=17.85; 95% confidence level [CL]=1.786-178.407), higher mean baseline YMRS scores (OR=1.094; 95% CL=1.025-1.166), lower mean baseline HAM-D-17 scores (OR=0.928; 95% CL=0.860-1.002), and length of current episode (OR=1.047; 95% CL=1.009-1.086) were identified as statistically significant predictors of nonresponse. ECT was an effective treatment for approximately two-thirds of the patients with medication-resistant depression who were included in this study. ECT nonresponse was associated with bipolar subtype, presence of manic symptoms during depression, slightly less severe depressive symptomatology, and protracted duration of the episode.

P01-82 - Heterogeneity of DSM-IV major depressive disorder as a consequence of subthreshold bipolarity

ContextThere is growing evidence that major depressive disorder (MDD) might be overdiagnosed at the expense of bipolar disorders (BPD).AimTo identify a subgroup of subthreshold BPD among DSM-IV MDD, which is distinct from pure MDD regarding validators of bipolarity.MethodData come from the ten-year prospective-longitudinal EDSP-Study, a community survey from Munich, and were assessed with the DSM-IV/M-CIDI. Subthreshold BPD was defined as fulfilling criteria for MDD plus presence of manic symptoms, but never having met criteria for hypomania.ResultsAmong 488 respondents with MDD, about 60% had pure MDD and 40% subthreshold BPD. Compared to pure MDD, the subthreshold BPD group was found to have(a)an increased family history of mania,(b)considerably higher rates of nicotine dependence and alcohol use disorders,(c)twice as high rates of panic disorder, and(d)a tendency towards higher rates of criminal acts.(e)In prospective analyses, subthreshold BPD converted more often into BPD during follow-up with the criterion D (symptoms are observable by others) being of critical predictive relevance.ConclusionData suggest that MDD is a heterogeneous concept including a large group of subthreshold BPD, which is clinically significant and shares similarities with BPD. Findings might support the need for a broader concept and a more comprehensive screening of bipolarity.

Dysfunctional Attitudes and Cognitive Schemas in Bipolar Manic and Unipolar Depressed Outpatients

Dysfunctional thought patterns are presumed to underlie cognitive biases in mood disorder patients. However, few studies have compared dysfunctional thought patterns in bipolar manic and unipolar depressed patients. Cognitive schemas and dysfunctional attitudes were evaluated using the cognitive checklist for mania and Dysfunctional Attitudes Scale (DAS) in 34 bipolar manic, 35 unipolar depressed, and 29 nonpsychiatric control subjects. Unipolar depressed subjects had significantly higher total DAS scores and subfactor scores as compared with nonpsychiatric controls, whereas bipolar patients had intermediate scores between both groups. Significant correlations emerged between cognitive checklist for mania total and subcomponent scores and the DAS (total, performance subfactor, and approval subfactor scales) for the bipolar, but not the unipolar or nonpsychiatric control groups. Core beliefs among bipolar patients appear negativistic during manic phases, potentially reflecting an overcompensation for depression. The findings support clinical approaches targeting depressive cognitions regardless of the presence of manic symptoms.

Insight, quality of life and cognitive functioning in euthymic patients with bipolar disorder

Introduction The relationship between insight, quality of life and cognition in bipolar disorder has not been clearly established. Method A neuropsychological battery assessing attention, mental control, perceptual-motor skills, executive functions, verbal fluency, abstraction and visuo-spatial attention was administered to 70 remitted bipolar patients and 50 healthy controls. Insight was assessed using the Scale to Assess Unawareness of Mental Disorder; Quality of Life was assessed using the Portuguese version of the WHO Quality of Life Assessment – Abbreviated version (WHOQOL–BREF–PT). Results No differences in QoL and cognitive performance were observed between bipolar patients with ‘impaired’ and ‘preserved’ insight. Insight was found to be correlated with poorer psychological and environmental QoL. A multiple regression model showed that depressive symptoms were significant predictors of physical, psychological and environmental QoL. Conclusion The present study adds to the notion that depressive symptoms, even of low intensity, are strong predictors of QoL. The present study suggests that the impact of insight on self-reported QoL may be subtle during remission and may be more substantially affected in the presence of manic symptoms.

Mania in the medically ill

Manic symptoms frequently occur in patients with comorbid medical disorders and present a diagnostic and treatment challenge. Manic symptoms may be due to an independent psychiatric illness, may be induced or precipitated by a medical condition, or may result from medication or substance use. The presence of manic symptoms in medically ill patients can lead to misdiagnosis or complicate the management of comorbid medical illness. It is of paramount importance to identify the etiology of the mania and, in particular, differentiate primary from secondary mania. Management of mania in the medically ill should focus on treating the underlying medical condition, medication management (antipsychotic agents, mood stabilizers, and/or benzodiazepines), and psychotherapy (if needed). Selecting appropriate medication for treatment requires basic knowledge of the pharmacokinetics of the medications, their side effect profile, and drug-drug interaction. The majority of deficits accompanying secondary mania resolve with treatment of the underlying cause, and supportive psychopharmacology may be all that is needed, but if symptoms persist, patients may need medications for a longer duration.

Aggressive behaviour at first contact with services: findings from the AESOP First Episode Psychosis Study

Aggressive behaviour is increased among those with schizophrenia but less is known about those with affective psychoses. Similarly, little is known about aggressive behaviour occurring at the onset of illness. The main reasons for presentation to services were examined among those recruited to a UK-based first episode psychosis study. The proportion of individuals presenting with aggressive behaviour was determined and these individuals were compared to those who were not aggressive on a range of variables including sociodemographic, clinical, criminal history, service contact, and symptom characteristics. Among the aggressive group, those who were physically violent were distinguished from those who were not violent but who were still perceived to present a risk of violence to others. Almost 40% (n=194) of the sample were aggressive at first contact with services; approximately half of these were physically violent (n=103). Younger age, African-Caribbean ethnicity and a history of previous violent offending were independently associated with aggression. Aggressive behaviour was associated with a diagnosis of mania and individual manic symptoms were also associated with aggression both for the whole sample and for those with schizophrenia. Factors differentiating violent from non-violent aggressive patients included male gender, lower social class and past violent offending. Aggressive behaviour is not an uncommon feature in those presenting with first episode psychosis. Sociodemographic and past offending factors are associated with aggression and further differentiate those presenting with more serious violence. A diagnosis of mania and the presence of manic symptoms are associated with aggression.

Mania and Intellectual Disability: The Course of Manic Symptoms in Persons With Intellectual Disability

Our aim was to extend the literature by examining the presence of manic symptoms in persons with intellectual deficits with and without bipolar disorder for 3 years. Three groups (bipolar, psychopathology other than bipolar disorder, and no Axis I diagnosis) were formed with 14 participants in each group. Initially, the presence of mania symptoms were examined across diagnostic groups. The bipolar group had significantly greater endorsements on the Parent Version of the Young Mania Rating Scale and the DASH-II Mania subscale item "decreased need for sleep" than did the other groups. A 3 (group) x 3 (year) ANOVA revealed that the item endorsements differed significantly over time for the bipolar group but not the other groups. Implications of these findings are discussed.

Chronic mania: An unexpectidly long episode?

Mood disorders (unipolar and bipolar disorders) are one of the most distressing and disabling disorders known to man kind. Mood disorders may present as either a depressive phase or manic phase. Chronic mania by definition means presence of manic symptoms in excess of 2 yrs without remission. Chronic mania differs in its psychopathological presentation from the acute mania. Chronic mania also poses a diagnostic and management challenge. Along with the poor response to the treatment these patients are also likely to suffer from severe impairment in the social, familial, interpersonal and occupational functioning. These disturbances may add to the chronicity of the condition. This case underlines the significance of keeping possibility of chronic mania which has been overlooked in the recent literature.

Mood Spectrum in Patients with Different Painful Temporomandibular Disorders

The purpose of this study was to investigate for difference in the prevalence of mood disorders between patients with different painful temporomandibular disorders (TMD). After a sample size necessary for the study was calculated, 60 patients with a painful TMD were selected and divided into the following groups: myofascial pain (n=20), temporomandibular joint (TMJ) pain (n=18), combined myofascial and TMJ pain (n=22). Two distinct comparison groups were selected: subjects with a non-painful TMD (n=25) and TMD-free subjects (n=29). All participants filled out a self-report validated instrument (MOODS-SR) to evaluate psychopathological symptoms related to mood disturbances. A one-way analysis of variance (ANOVA) with Bonferroni’s post hoc test for multiple comparisons was performed to investigate for significant differences among the groups. The three groups of patients with painful TMD scored significantly higher than comparison groups in all MOODS-SR domains investigating depression, but no difference was shown between subjects with myofascial pain and those with TMJ pain. No significant differences among the groups emerged for the presence of manic symptoms, indicating that depressive disorders associated with TMD are not an expression of a more complex manic depressive illness. The study concluded that the presence of depressive symptoms in TMD patients seems to be related to the presence of a painful condition and seems to be unrelated to the location of pain. Furthermore, depressive disturbances in painful TMD patients affect the whole spectrum of depressive psychopathology.