Toward the validation of RDC schizoaffective 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.

DSM-III criteria for affective disorders and schizophrenia : A preliminary appraisal using family interview findings

We performed a blind family interview study of 226 first-degree relatives of 63 probands meeting DSM-III criteria for schizophrenia, schizoaffective disorder, and bipolar disorder, as diagnosed by the National Institute ot Mental Health Diagnostic Interview Schedule (DIS). A small test-retest reliability study demonstrated good agreement between the proband interviewer and the principal family interviewer for the major diagnostic categories of psychotic disorders. Excellent compliance was obtained, with 85% of living relatives interviewed personally.

Three principal findings emerged front the study. First, as expected, bipolar disorder, as defined by DSM-III, displayed a strong familial comportent, comparable to that found by many studies using criteria other than those of DSM-III. Second, patients meeting DSM-III criteria for schizophrenia and schizoaffective disorder displayed a low familial prevalence of schizophrenia. Although initially suprising, this finding is in agreement with the results of several other recent lantily studies of schizophrenia. Upon comparing our results with those of other recent family studies of schizophrenia, it appears that the familial component in schizophrenia tnay be less than was estimated by earlier studies using older and “broader” definitions of schizophrenia.

Third, we found that patients meeting DSM-III criteria for schizophrenia appeared genetically heterogeneous. Those who had displayed a superimposed full affective syndrome at some tinte in the course of their illness, together with those probands meeting DSM-III criteria for schizoaffective disorder, displayed a high familial prevalence of major affective disorder, similar to that found in the families of the bipolar probands. On the other hand, “pure” DSM-III schizophrenie probands, who had never experienced a superimposed full affective syndrome, displayed a low familial prevalence of major affective disorder, similar to that found in the general population. These findings favor the possibility that probands meeting DSM-III criteria for schizophrenia, but displaying a superimposed full affective syndrome, may in sonie cases have a disorder genetically relatcd to major affective disorder.

Further prospective family interview studies, using DSM-III criteria and larger samples, will be necessary to test these preliminary impressions.

Génétique épidémiologique des troubles de l’humeur: une nouvelle voie de recherches?

Les récents progrès de la biologie moléculaire offrent l’espoir d’une meilleure compréhension de la composante génétique des maladies mentales, la dépression en particulier. L’accès à un nombre quasiment illimité de marqueurs génétiques polymorphes et couvrant le génome, accroît l’efficacité des techniques de liaison génétique (linkage) qui permettent l’étude de la cotransmission des marqueurs génétiques et du trait clinique dans des familles dont plusieurs membres sont malades. D’ores et déjà, en ce qui concerne les troubles de l’humeur, 2 pistes ont été mises en évidence: celle d’une liaison à l’extrémité distale du bras long du chromosome X (Mendlewicz et al., 1987) et celle d’une liaison à l’extrémité du bras court du chromosome 11 (Egeland et al., 1987). Toutefois, ces résultats n’ont pas été constamment répliqués, ce qui soulève le problème de l’hétérogénéité étiologique des troubles dépressifs.

Mood disorders with delusionsversusschizophrenic disorders with delusions. Second phase of a longitudinal study of a cohort of adolescent psychiatric inpatients with delusions

The prognostic significance of an index episode of affective disorder with delusions was assessed in a longitudinal study of a cohort of adolescent psychiatric inpatients (n= 43). Part I of a study has been reported in a previous article. Initial assessmentdata (anamnestic variables, clinical assessment) did not discriminate between onset of affective disorder and schizophrenia. Part II of the study provides a longitudinal perspective of the cohort's diagnostic and life adjustment: diagnoses of schizophrenia increased, schizophreniform disorders disappeared, affective disorders were stable and a schizo-affective category emerged. Patients in the schizophrenic category had severely impaired life adjustment, while the level of functioning in unipolar and bipolar patients was consistently satisfactory. Compared to the initial diagnosis, the cohort showed a tendency to develop into schizophrenia. It is too early to affirm that every adolescent with delusional symptoms at onset will later develop schizophrenia, however, this risk appears real.

Clinical correlates of acute bipolar depressive episode with psychosis

BACKGROUND

Psychotic bipolar depressive episodes remain remarkably understudied despite being common and having a significant impact on bipolar disorder. The aim of this study is to identify the characteristics of depressed bipolar patients with current psychosis compared to those without psychosis.

METHODS

We used baseline data of a comparative effectiveness study of lithium and quetiapine for bipolar disorder (the Bipolar CHOICE study) to compare demographic, clinical, and functioning variables between those with and without psychotic symptoms. Of the 482 participants, 303 (62.9%) were eligible for the present study by meeting DSM-IV criteria for an acute bipolar depressive episode. Univariate analyses were conducted first, and then included in a model controlling for symptom severity.

RESULTS

The sample was composed mostly of women (60.7%) and the mean age was 39.5±12.1 years. Psychosis was present in 10.6% (n=32) of the depressed patients. Psychotic patients had less education, lower income, and were more frequently single and unemployed. Psychosis was also associated with a more severe depressive episode, higher suicidality, more comorbid conditions and worse functioning. Most group differences disappeared when controlling for depression severity.

LIMITATIONS

Only outpatients were included and the presence of psychosis in previous episodes was not assessed.

CONCLUSION

Psychosis during bipolar depressive episodes is present even in an outpatient sample. Psychotic, depressed patients have worse illness outcomes, but future research is necessary to confirm if these outcomes are only associated with the severity of the disorder or if some of them are independent of it.

Treatment response in nonpsychotic vs psychotic manias - A follow up study from India

BACKGROUND

Studies on treatment outcome in mania had been many. A few studies from the west address the issue of outcome in mood congruent and mood incongruent manias. None could be found from India.

AIM

To compare the treatment response in three groups of patients with mania- Nonpsychotic, psychotic with mood congruent and psychotic with mood incongruent features.

MATERIALS AND METHODS

All consecutive manic patients admitted during 2013 to 2014, meeting inclusion and exclusion criteria were taken up. 28 patients with nonpsychotic Mania, 10 with mood congruent psychotic symptoms (MIC-) & 12 with mood incongruent psychotic features (MIC+). Diagnosis was confirmed using SCID. Mood stabilizers and Olanzapine or equivalent doses of antipsychotics were administered. Semi structured proforma was used for Socio Demographic & clinical details. YMRS, HDRS, Semi structured proforma to assess response (ISBD recommendations), CGI -BP & SAPS were used. Last 5 tools to assess the response to treatment at every 2 weeks, for 8 weeks.

STATISTICAL ANALYSIS

Statistical Package for Social Sciences, version 17.0 was used.

RESULTS

These three groups did not show statistically significant difference in the socio-demographic variables. Severity of Mania was higher in Psychotic Mania. Psychotic Manias (group 2 and 3 combined) showed longer response time. However, mood incongruent psychotic manias when compared against the other 2 groups clubbed together did not differ significantly.

LIMITATIONS

All patients were from a tertiary referral centre and were hospitalized. Majority of them had a past history. The sample sizes were small. Treatment could not be fully matched.

CONCLUSION

Our findings support the view that psychotic manias on the whole take significantly longer time than mania without psychotic symptoms to respond, and also scored higher on indices of severity. Mood Incongruent Psychotic Manias and Mood Congruent Psychotic Manias did not differ in severity & response time.

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.

Lithium for schizophrenia

BACKGROUND

Many people with schizophrenia do not achieve a satisfactory treatment response with ordinary anti-psychotic drug treatment. In these cases, various add-on medications are used, among them lithium.

OBJECTIVES

To assess whether:1. Lithium alone is an effective treatment for schizophrenia, schizophrenia-like psychoses and schizoaffective psychoses; and2. Lithium augmentation of antipsychotic medication is an effective treatment for the same illnesses.

SEARCH METHODS

In July 2012, we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. This search was updated on January 20, 2015. For the first version of the review, we also contacted pharmaceutical companies and authors of relevant studies to identify further trials and obtain original participant data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of lithium compared with antipsychotics or placebo (or no intervention), whether as sole treatment or as an adjunct to antipsychotic medication, in the treatment of schizophrenia or schizophrenia-like psychoses or both.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data, we calculated random-effects meta-analyses, risk ratios (RRs), and 95% confidence intervals (CI) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD) and 95% confidence intervals. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) to create 'Summary of findings' tables and assessed risk of bias for included studies.

MAIN RESULTS

The update search in 2012 detected two further studies that met our inclusion criteria. We did not find any further studies that met our inclusion criteria in the 2015 search. This review now includes 22 studies, with a total of 763 participants (median mean age: 35 years, range: 26 to 72 years). Most studies were small, of short duration, and incompletely reported. As we detected a high risk of bias in many studies, the overall methodological quality of the included sample was rather low.Three small studies comparing lithium with placebo as the sole treatment showed no difference in any of the outcomes we analysed.In eight studies comparing lithium with antipsychotic drugs as the sole treatment, more participants in the lithium group left the studies early (eight RCTs; n = 270, RR 1.77, 95% CI 1.01 to 3.11, low quality evidence).Thirteen studies examined whether the augmentation of antipsychotic drugs with lithium salts is more effective than antipsychotic drugs alone. More participants who received lithium augmentation had a clinically significant response (10 RCTs; n = 396, RR 1.81, 95% CI 1.10 to 2.97, low quality evidence). However, this effect became non-significant when we excluded participants with schizoaffective disorders in a sensitivity analysis (seven RCTs; n = 272, RR 1.64, 95% CI 0.95 to 2.81), when we excluded non-double-blind studies (seven RCTs; n = 224, RR 1.82, 95% CI 0.84 to 3.96), or when we excluded studies with high attrition (nine RCTs; n = 355, RR 1.67, CI 0.93 to 3.00). The overall acceptability of treatment (measured by the number of participants leaving the studies early) was not significantly different between groups (11 RCTs; n = 320, RR 1.89, CI 0.93 to 3.84, very low quality evidence). Few studies reported on side effects. There were no significant differences, but the database is too limited to make any judgement in this regard. For example, there were no data on thyroid dysfunction and kidney problems - two major and well-known side effects of lithium.

AUTHORS' CONCLUSIONS

The evidence base for the use of lithium in schizophrenia is limited to 22 studies of overall low methodological quality. There is no randomised trial-based evidence that lithium on its own is an effective treatment for people with schizophrenia. There is some GRADE low quality evidence that augmentation of antipsychotics with lithium is effective, but the effects are not significant when more prone-to-bias open RCTs are excluded. Nevertheless, further large and well-designed trials are justified. These should concentrate on two target groups: (1) people with no affective symptoms, so that trialists can determine whether lithium has an effect on the core symptoms of schizophrenia, and (2) people with schizoaffective disorders for whom lithium is widely used in clinical practice, although there is no evidence to support this use.

Visual hallucinations in the psychosis spectrum and comparative information from neurodegenerative disorders and eye disease

Much of the research on visual hallucinations (VHs) has been conducted in the context of eye disease and neurodegenerative conditions, but little is known about these phenomena in psychiatric and nonclinical populations. The purpose of this article is to bring together current knowledge regarding VHs in the psychosis phenotype and contrast this data with the literature drawn from neurodegenerative disorders and eye disease. The evidence challenges the traditional views that VHs are atypical or uncommon in psychosis. The weighted mean for VHs is 27% in schizophrenia, 15% in affective psychosis, and 7.3% in the general community. VHs are linked to a more severe psychopathological profile and less favorable outcome in psychosis and neurodegenerative conditions. VHs typically co-occur with auditory hallucinations, suggesting a common etiological cause. VHs in psychosis are also remarkably complex, negative in content, and are interpreted to have personal relevance. The cognitive mechanisms of VHs in psychosis have rarely been investigated, but existing studies point to source-monitoring deficits and distortions in top-down mechanisms, although evidence for visual processing deficits, which feature strongly in the organic literature, is lacking. Brain imaging studies point to the activation of visual cortex during hallucinations on a background of structural and connectivity changes within wider brain networks. The relationship between VHs in psychosis, eye disease, and neurodegeneration remains unclear, although the pattern of similarities and differences described in this review suggests that comparative studies may have potentially important clinical and theoretical implications.

The pharmacotherapeutic management of rapid cycling affective disorder: an update

In the present work the author presents a literature update regarding the pharmacotherapeutic management of rapid cycling affective disorder. This phenomenon is characterized, according to Dunner and Fieve (1974), by the presence of at least four affective episodes per year. After a consideration of the clinical features of the disorder, which are in many respects similar to those of the ‘classic’ bipolar disorder, the author describes the different therapeutic strategies available to the psychiatrist. Withdrawal of antidepressant therapy and administration of lithium salts are likely to constitute the best initial approach. In case of treatment non-responsiveness, it is possible to consider the use of different drugs; for example, carbamazepine, sodium valproate, clorgyline, thyroid hormone. To date, the therapeutic management of rapid cyclers remains extremely difficult. Further studies, especially addressed to the aetiopathogenetic aspects of the disorder, are required.

Prodromes and coping types in bipolar patients with nonpsychotic or psychotic mania

BACKGROUND

Bipolar disorder is a recurrent and cyclical illness frequently accompanied by psychotic symptoms. Detecting prodromes and enhancing coping skills for prodromal symptoms in bipolar patients are very important for relapse prevention. Psychotic features in bipolar patients are related to poor prognosis. We aimed to investigate the differences in prodromal symptoms and coping styles in psychotic and nonpsychotic bipolar patients.

METHODS

Eighty-three euthymic bipolar patients with or without a history of manic psychosis were interviewed about their demographic, diagnostic, and clinical information and completed a 40-item checklist for prodromal symptoms. After the interview, they completed the Coping Inventory for Prodromes of Mania.

RESULTS

The differences between the psychotic patients and the nonpsychotic patients were found in the prodromal durations, and a few prodromal symptoms such as afraid of going crazy (P = .03), energetic-very active (P = .01), and hearing hallucination (P = .02). The psychotic patients showed a higher score of denial or blame than the nonpsychotic ones (1.92 ± 0.73 in nonpsychosis, 2.32 ± 0.84 in psychosis; P = .03). Logistic regression revealed that the duration of prodromes (P = .02) and hearing hallucination (P = .01) were related to the presence of psychotic features.

CONCLUSION

Psychotic patients had a tendency to use denial or blame coping strategy and to experience attenuated psychotic symptoms a little more during the prodromal period. Timely psychosocial approaches for detecting signs and enhancing coping strategies would improve the outcomes.

Bipolar patients in community mental health centers and specialized units. Could they be pooled?

INTRODUCTION

Bipolar patients recruited for studies are usually picked from Bipolar Disorder Units, which only contain a fraction of the total population of patients with bipolar disorder. The purpose of this study was to determine whether the course of the illness is comparable in patients from a Community Mental Health Center (CMHC) and those from a Bipolar Disorder Unit (BDU).

METHODS

This study was carried out at the La Fe Teaching Hospital BDU and two CMCH. Data were collected from the patients' clinical records and were completed by a face-toface interview. When the latter was not possible, a telephone interview was carried out. Demographic, clinical and course-of-illness variables were gathered.

RESULTS

There were no differences in demographic characteristics between the two patient groups. Differences were found in clinical data: BDU patients were younger at illness onset (p<0.005), were admitted more frequently (p<0.05), and stayed longer in the hospital (p<0.005).

CONCLUSIONS

Bipolar patients treated at a CMHC show clear differences compared with those from a BDU. Consequently, care should be exercised when generalizing the clinical course of bipolar patients using BDU samples. These patients are not representative of the total bipolar patient population, as their clinical course is more complicated.

Lithium for schizophrenia

BACKGROUND

Many people with schizophrenia do not achieve a satisfactory treatment response with ordinary antipsychotic drug treatment. In these cases, various add-on medications are used, among them lithium.

OBJECTIVES

To review the effects of lithium for the treatment of schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register (November 2006). This register is compiled by methodical searches of BIOSIS, CINAHL, Dissertation abstracts, EMBASE, LILACS, MEDLINE, PSYNDEX, PsycINFO, RUSSMED, Sociofile, supplemented with hand searching of relevant journals and numerous conference proceedings. We also contacted pharmaceutical companies and authors of relevant studies to identify further trials and to obtain original patient data.

SELECTION CRITERIA

We included all randomised controlled trials comparing lithium to antipsychotics or to placebo (or no intervention), whether as sole treatment or as an adjunct to antipsychotic medication for the treatment of schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For homogenous dichotomous data we calculated random effects, relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

The update search in 2006 did not detect further studies that met our inclusion criteria. The review thus still includes 20 studies with a total of 611 participants. Most studies were small, of short duration and incompletely reported, but a number of authors were willing to share their data with us. Three studies comparing lithium with placebo as the sole treatment showed no difference in any of the outcomes we analysed. In eight studies comparing lithium with antipsychotic drugs as the sole treatment, more participants in the lithium group left the studies early (n=270, RR 1.8, CI 1.2 to 2.9, NNT 9, CI 5 to 33). Several of the outcomes relating to these studies suggested that lithium is less effective than antipsychotic drugs, but it was difficult to summarise the data because a variety of rating scales were used in the studies. Eleven studies examined whether the augmentation of antipsychotic drugs with lithium salts is more effective than antipsychotic drugs alone. More participants who received lithium augmentation had a clinically significant response (n=244, RR 0.8, CI 0.7 to 0.96, NNT 8, CI 4 to 33). However, statistical significance became borderline when participants with schizoaffective disorders were excluded in a sensitivity analysis (n=120, RR 0.8, CI 0.6 to 1.0, p=0.07). Furthermore, more participants in the lithium augmentation groups left the studies early (n=320, RR 2.0 CI 1.3 to 3.1, NNT 7, CI 4 to 14), suggesting a lower acceptability of lithium augmentation compared to those on antipsychotics alone. No superior efficacy of lithium augmentation in any specific aspect of the mental state was found. While based on very little data, there were no differences between groups for adverse events.

AUTHORS' CONCLUSIONS

There is no randomised trial-based evidence that lithium on its own is an effective treatment for people with schizophrenia. The evidence available on augmentation of antipsychotics with lithium is inconclusive, but does justify further, large, simple and well-designed trials. These should concentrate on two target groups: 1) people with no affective symptoms, so that trialists can determine whether lithium has an effect on the core symptoms of schizophrenia, 2) people with schizoaffective disorders for whom lithium is widely used in clinical practice, although there is no evidence to support this use.

Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders

Schizoaffective disorder (SA D/O), introduced in 1933 by Dr. Jacob Kasanin, represented a first, modest change in our concept about the diagnoses of psychotic patients away from the beliefs of E. Bleuler, i.e., that hallucinations and delusions define schizophrenia, and toward the recognition of a significant role for mood disorders. SA D/O established a connection between schizophrenia and mood disorders, traditionally considered mutually exclusive, a connection that has strengthened progressively toward the diagnostic unity of all three disorders. A basic tenet of medicine holds that if discrepant symptoms can be explained by one disease instead of two or more, it is likely there is only one disease. The scientific justification for SA D/O and schizophrenia as disorders distinct from a psychotic mood disorder has been questioned. The "schizo" prefix in SA D/O rests upon the presumption that the diagnostic symptoms for schizophrenia are disease specific. They are not, since patients with severe mood disorders can evince any or all of the "schizophrenic" symptoms. "Schizophrenic" symptoms mean "psychotic" and not any specific disease. These data and a very low interrater reliability for SA D/O suggest that the concepts of SA D/O and schizophrenia as valid diagnoses are flawed. Clinically SA D/O remains popular because it encompasses both schizophrenia and psychotic mood disorder when there is a diagnostic question. We present a review of the literature in table form based on an assignment of each article assigned to one of five categories that describe the possible relationships between SA D/O, schizophrenia and psychotic mood disorders. We conclude that the data overall are compatible with the hypothesis that a single disease, a mood disorder, with a broad spectrum of severity, rather than three different disorders, accounts for the functional psychoses.

Hallucinations in bipolar disorder: characteristics and comparison to unipolar depression and schizophrenia

OBJECTIVE

As there is very little research on the topic, we compared the frequency and the type hallucinations among hospitalized patients diagnosed with bipolar disorder (BPD) versus other major psychiatric illnesses.

METHODS

At admission, all patients hospitalized at the Department of Psychiatry at the Freie Universität Berlin (1981-2001) underwent comprehensive assessments using the standardized Association for Methodology and Documentation in Psychiatry (AMDP) system. We used these data to compare risks and types of hallucinations and associated factors by bivariate and multivariate testing in patients diagnosed with BPD, major depression, or schizophrenia.

RESULTS

At admission, the cross-sectional prevalence of current hallucinations among 4972 hospitalized subjects ranked: schizophrenia (61.1%), bipolar mixed (22.9%), bipolar manic (11.2%), bipolar depressed (10.5%), unipolar depressed (5.9%). The most frequent hallucinations across all patients were auditory, followed by somatic and visual hallucinations. There were only minor age or sex differences in risk of hallucinations. Compared with patients diagnosed with schizophrenia, hallucinations among patients with BPD were less severe, more visual and less often auditory. Characteristics of hallucinations were similar among manic and both bipolar- and unipolar-depressed subjects. Among patients with major affective disorders, those with hallucinations were less well-educated, had higher anxiety scores, less insight into the illness, and their hospitalizations averaged 17% longer. Across all diagnoses, hallucinations, particularly olfactory, were significantly associated with delusions. Hallucinations in BPD were most often accompanied by persecutory delusions; delusions of grandeur were least associated with hallucinations.

CONCLUSIONS

This study provides detailed descriptive data regarding the frequency (cross-sectional) and characteristics of hallucinations in a large sample of patients with BPD, major depression or schizophrenia. Our results suggest a link of lower education and the presence of hallucinations in major affective disorders. The significance of this finding, as well as the role of anxiety in hallucinating patients, requires further study.

Schneiderian first rank symptoms predict poor outcome within first episode manic psychosis

BACKGROUND

The validity of a sub-classification of affective psychosis according to the mood congruence of psychotic features has been questioned in the literature. While some authors have found a correlation between such symptoms and outcome, their predictive value was rather limited in these studies.

METHOD

Prospective study of 108 subjects presenting with a first DSM-III-R manic episode with psychotic features to determine the frequency of different types of psychotic symptoms and to measure the predictive utility of mood incongruent psychotic symptoms (MIPS) and first-rank Schneiderian symptoms (FRSS) during the first episode for a 12-month outcome. Outcome was measured by the level of positive, negative, depressive symptoms, and psychosocial functioning. Duration of affective and psychotic symptoms was also assessed.

RESULTS

Patients presented with a wide variety of psychotic symptoms. The presence of MIPS at baseline was significantly correlated with a longer persistence of psychotic symptoms, but not with poorer outcome at 12 months. By contrast, the presence of FRSS at baseline was significantly associated with earlier onset of psychosis as well as increased severity of negative symptoms and poorer psychosocial functioning after 12 months.

CONCLUSION

The presence of FRSS during a first manic episode with psychotic features identifies a sub-group of patients with more severe presentation and poorer short-term outcome. These results question the prognostic utility of MIPS.

LIMITATIONS

Despite the relatively large number of subjects compared with other studies, the statistical power to detect all but large effect sizes is limited by the sample size.

Psychotic bipolar disorders: dimensionally similar to or categorically different from schizophrenia?

For over a century, clinicians have struggled with how to conceptualize the primary psychoses, which include psychotic mood disorders and schizophrenia. Indeed, the nature of the relationship between mood disorders and schizophrenia is an area of ongoing controversy. Psychotic bipolar disorders have characteristics such as phenomenology, biology, therapeutic response, and brain imaging findings, suggesting both commonalities with and dissociations from schizophrenia. Taken together, these characteristics are in some instances most consistent with a dimensional view, with psychotic bipolar disorders being intermediate between non-psychotic bipolar disorders and schizophrenia spectrum disorders. However, in other instances, a categorical approach appears useful. Although more research is clearly necessary to address the dimensional versus categorical controversy, it is feasible that at least in the interim, a mixed dimensional/categorical approach could provide additional insights into pathophysiology and management options, which would not be available utilizing only one of these models.

Lithium for schizophrenia

BACKGROUND

Many people with schizophrenia do not achieve a satisfactory treatment response with ordinary antipsychotic drug treatment. In these cases, various add-on medications are used, among them lithium.

OBJECTIVES

To review the effects of lithium for the treatment of schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

The reviewers searched the Cochrane Schizophrenia Group's register (March 2002). This register is compiled by methodical searches of BIOSIS, CINAHL, Dissertation abstracts, EMBASE, LILACS, MEDLINE, PSYNDEX, PsycINFO, RUSSMED, Sociofile, supplemented with hand searching of relevant journals and numerous conference proceedings. We also contacted pharmaceutical companies and authors of relevant studies to identify further trials and to obtain original patient data.

SELECTION CRITERIA

All randomised controlled trials comparing lithium to antipsychotics or to placebo (or no intervention), whether as sole treatment or as an adjunct to antipsychotic medication for the treatment of schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were extracted independently by at least two reviewers. Dichotomous data were analysed using relative risks (RR) and the 95% confidence interval (CI) estimated. Where possible the number needed to treat (NNT) or number needed to harm statistics were calculated. Continuous data were analysed using weighted mean differences (WMD).

MAIN RESULTS

The review currently includes 20 studies with a total of 611 participants. Most studies were small, of short duration and incompletely reported, but a number of authors were willing to share their data with us. Three studies comparing lithium with placebo as the sole treatment showed no difference in any of the outcomes we analysed. In eight studies comparing lithium with antipsychotic drugs as the sole treatment more participants in the lithium group left the studies early (n=270, RR 1.8, CI 1.2 to 2.9, NNT 9, CI 5 to 33). Several of the outcomes relating to these studies suggested that lithium is less effective than antipsychotic drugs, but it was difficult to summarise the data, because a variety of rating scales were used in the studies. Eleven studies examined whether the augmentation of antipsychotic drugs with lithium salts is more effective than antipsychotic drugs alone. More participants who received lithium augmentation had a clinically significant response (n=244, RR 0.8, CI 0.7 to 0.96, NNT 8, CI 4 to 33). However, statistical significance became borderline when participants with schizoaffective disorders were excluded in a sensitivity analysis (n=120, RR 0.8, CI 0.6 to 1.0, p=0.07). Furthermore, more participants in the lithium augmentation groups left the studies early (n=320, RR 2.0 CI 1.3 to 3.1, NNT 7, CI 4 to 14), suggesting a lower acceptability of lithium augmentation compared to those on antipsychotics alone. No superior efficacy of lithium augmentation in any specific aspect of the mental state was found. While based on very little data, there were no differences between groups for adverse events.

REVIEWER'S CONCLUSIONS

There is no randomised trial based evidence that lithium on its own is an effective treatment for people with schizophrenia. The evidence available on augmentation of antipsychotics with lithium is inconclusive, but it justifies further, large, simple and well-designed trials. These should concentrate on two target groups: 1) people with no affective symptoms, so that trialists can determine whether lithium has an effect on the core symptoms of schizophrenia, 2) people with schizoaffective disorders for whom lithium is widely used in clinical practice, although there is no evidence to support this use.

Differential diagnosis of depressed mood in patients with schizophrenia: a diagnostic algorithm based on a review

OBJECTIVE

To review the available literature on depressive symptomatology in schizophrenia in order to establish a diagnostic algorithm of depressive syndromes in schizophrenia.

METHOD

A literature search was performed using PubMed and Medline. Additional information was gained by cross-referencing from papers found in the database. Data from controlled studies as well as supplementary information from review articles and psychiatric manuals pertinent to the topic were used. Depressive symptoms were classified with respect to their temporal relationship to acute psychotic symptoms before the background of nosological entities as operationalized by Diagnostic Statistical Manual IV (DSM IV).

RESULTS

Depression is a common and devastating comorbid syndrome in patients suffering from schizophrenic disorder. The paper summarizes the relevant diagnostic steps to guide the clinician towards therapeutic interventions, which differ depending on the nature of the depressive syndrome.

CONCLUSION

Differentiating depressives states in schizophrenia has consequences in terms of choosing therapeutic strategies. An algorithm which leads the practitioner to a reliable diagnosis and in consequence to a valid therapy is presented.

Prevalence and description of psychotic features in bipolar mania

Psychotic symptoms are common in both the manic and depressive phases of bipolar disorder. More than half of patients with bipolar disorder will experience psychotic symptoms in their lifetime. Grandiose delusions are the most common type of psychotic symptom, but any kind of psychotic symptom, including thought disorder, hallucinations, mood-incongruent psychotic symptoms, and catatonia can present as part of a manic episode. Psychotic symptoms suggest poor prognosis when they occur in the absence of affective symptoms. However, psychotic symptoms can mask affective symptoms and make the distinction between manic-depressive illness and other psychiatric disorders difficult, especially in minorities. Careful assessment of prior psychiatric history, family history, and treatment response can aid in the differentiation of affective disorders with psychotic features from psychotic disorders.

Treatment of schizoaffective disorder and schizophrenia with mood symptoms

OBJECTIVE

Patients with concurrent schizophrenic and mood symptoms are often treated with antipsychotics plus antidepressant or thymoleptic drugs. The authors review the literature on treatment of two overlapping groups of patients: those with schizoaffective disorder and those with schizophrenia and concurrent mood symptoms.

METHOD

MEDLINE searches (from 1976 onward) were undertaken to identify treatment studies of both groups, and references in these reports were checked. Selection of studies for review was based on the use of specified diagnostic criteria and of parallel-group, double-blind design (or, where few such studies addressed a particular issue, large open studies). A total of 18 treatment studies of schizoaffective disorder and 15 of schizophrenia with mood symptoms were selected for review.

RESULTS

For acute exacerbations of schizoaffective disorder or of schizophrenia with mood symptoms, antipsychotics appeared to be as effective as combination treatments, and there was some evidence for superior efficacy of atypical antipsychotics. There was evidence supporting adjunctive antidepressant treatment for schizophrenic and schizoaffective patients who develop a major depressive syndrome after remission of acute psychosis, but there were mixed results for treatment of subsyndromal depression. There was little evidence to support adjunctive lithium for depressive symptoms and no evidence concerning its use for manic symptoms in patients with schizophrenia.

CONCLUSIONS

Empirical data suggest that both groups of patients are best treated by optimizing antipsychotic treatment and that atypical antipsychotics may prove to be most effective. Adjunctive antidepressants may be useful for patients with major depression who are not acutely ill. Careful longitudinal assessment is required to ensure identification of primary mood disorders.

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.

A review of schizoaffective disorder: I. Current concepts

This paper reviews recent literature on schizoaffective disorder. Research studies of diagnosis, clinical course and outcome and family history are evaluated. It is concluded that schizoaffective disorder is a heterogeneous category which includes patients with bipolar disorder, schizophrenia, a genetically distinct psychosis and a genetic disposition to both schizophrenia and bipolar disorder.

Course of schizoaffective psychosis: further data from a retrospective study

This study investigated the clinical course and outcome of 72 patients, diagnosed as suffering from schizoaffective psychosis (according to ICD-9 criteria) who also satisfied Research Diagnostic Criteria for schizoaffective disorder. The current overall functioning of these patients was related to the number and frequency of episodes, regardless of the duration of the illness: the lesser the number or frequency of relapses, the better the overall functioning. In addition, there were no statistically significant differences in psychosocial impairment between bipolar and unipolar schizoaffective disorder.

Schizo-affective psychoses in childhood: a follow-up study

A follow-up study of 16 schizo-affectives (part of a group of 57 children originally diagnosed as schizophrenic) is reported. All 57 patients were under 14 years. They were reinvestigated after an average follow-up period of 16 years (range 6 to 40 years). Of the 57 psychoses 28% had a typical schizo-affective character. In contrast to purely schizophrenic psychoses, we found an overrepresentation in the schizo-affective psychoses of affective psychoses and suicides in the ancestry. Further, in the schizo-affective psychoses there were more premorbidly well adjusted, harmonious personalities. In contrast, maladjusted, dishormonious, introverted characters predominated in purely schizophrenic psychoses. The schizo-affective psychoses had mainly an acute-recurrent character and followed a favorable course. The schizo-affective and affective phases were of significantly shorter duration than the schizophrenic episodes.

A comparison of in-patient and out-patient prescribing

The prescribing of psychotropic medication to 96 attenders at a lithium clinic was compared with their prescriptions while in-patients. As out-patients, they received fewer psychotropic drugs fewer times a day. This suggests that psychiatrists do not adopt intransigent stances in favour of polypharmacy and irrational psychotropic prescribing, as previous studies have implied. Caution is advised before attributing apparently irrational prescribing to bad clinical practice, or advocating remedial action aimed at changing the habits of prescribers.

Thyrotropin response to thyrotropin-releasing hormone in RDC schizodepressed men

Biological tests may help clarify the relationships of schizoaffective disorder to both major depressive disorder and schizophrenia. Thyrotropin-releasing hormone (TRH), 500 micrograms i.v., was administered to 14 schizodepressed, 23 schizophrenics, 41 unipolar major depressives (all by RDC) and 45 healthy controls, all males 20-67 years old with no significant differences in age, body height or weight. Results showed no differences in maximal delta TSH (dTSH max) amongst schizoaffective depressed, schizophrenia and healthy control groups (10.1 +/- 1.3, 9.2 +/- 1.1, 9.7 +/- 0.8 microU/ml, means +/- SEM respectively). Mean major depressives' dTSH max was lower than in each of the other three groups (6.2 +/- 0.4 microU/ml, P less than 0.01 for all). Utilizing a less than or equal to 5.0 microU/ml cut-off criterion for blunting, the schizodepressed had 36%, schizophrenics 44%, healthy controls 22% and major depressed 59% blunters (P less than 0.05 from other three groups). Schizodepressed patients appeared significantly different from major depressed but closer to schizophrenics (and healthy controls) on the TRH test.

Lithium prophylaxis of schizoaffective disorders: a prospective study

A prospective study was carried out in order to provide an answer to the following questions. (1) Is lithium effective as a prophylactic agent in broadly defined schizoaffective disorders? (2) Taking for granted that schizoaffective disorders represent a heterogeneous group of conditions, in which schizoaffective patients is lithium effective? (3) Are there any clinical, historical or biological predictors of response to lithium prophylaxis in schizoaffective patients? (4) What are the minimum plasma lithium levels required for effective prophylaxis in schizoaffective disorders? The study confirmed the efficacy of lithium prophylaxis in broadly defined schizoaffective disorders, but showed that this treatment is relatively ineffective in schizoaffective patients with a prominent schizophrenic-like component in their clinical picture and in those diagnosed cross-sectionally as schizodepressive. The only successful predictor of response was a previous bipolar course of the illness (which was associated with a positive outcome of prophylaxis). Plasma lithium levels in the range of 0.45-0.60 mEq/l did not prove to be useful for prophylactic purposes in schizoaffective disorders.

Prediction of outcome by historical, clinical and biological variables in schizoaffective disorder, depressed type

The usefulness of several historical, clinical and biological variables as possible predictors of outcome was tested in a sample of patients with a cross-sectional diagnosis of schizoaffective disorder, depressed type. Four historical items were found to be successful: a family history of chronic schizophrenia, the occurrence of schizophrenic symptoms at some stage of the illness in the absence of depression and an onset of the index episode as exacerbation of previous symptoms (all associated with a relatively poor outcome), and a personal history of previous manic episodes (associated with a relatively good outcome). The various aspects of the clinical picture during the index episode, as well as the response on dexamethasone suppression test, were not found to have any predictive value. These findings confirm that, in patients with a cross-sectional diagnosis of schizodepressive disorder, the previous course of the illness is of crucial importance for prognosis, and support the usefulness of a multiaxial classification of schizoaffective states, taking into account not only cross-sectional symptomatology but also course.

Nosological status of schizoaffective disorders: Theoretical models and empirical evidence

The question of the nosological status of schizoaffective disorders remains one of the most controversial issues of clinical psychiatry. There are, in fact, at least five different hypotheses about the nature of these disorders: • that they are always variants of schizophrenia, • that they are always variants of major affective disorders, • that they represent a “third psychosis” distinct from both schizophrenia and manic-depressive illness, • that they find their place in the intermediate position of a “continuum” whose poles are represented by the typical forms of schizophrenia and manic-depressive illness, • that they result from the simultaneous occurrence of a true schizophrenia and a true manic-depressive illness in the same patient. The last of these hypotheses can hardly be accepted, since it would predict an annual frequency of schizoaffective disorders of about 2 per 108, compared to the actual frequency of 2 per 105. Of the remaining four hypotheses, the first two are consistent with the Kraepelinian “dichotomic” paradigm, whereas the third and the fourth contradict this paradigm. The results of empirical investigations (that is, of family studies, outcome studies and studies on response to drug treatments in schizoaffective patients) do not provide a full support to any of the above hypotheses. What empirical evidence seems to show, instead, is that schizoaffective disorders represent a heterogeneous group of syndromes. Part of these disorders can be interpreted, upon close scrutiny, as variants of either of the major psychoses (for instance, bipolar schizoaffective States appear to be closely allied to major affective disorders). There seems to be, however, a subpopulation of schizoaffective patients which escapes the Kraepelinian dichotomic model.

Neuropsychological functioning in schizoaffective disorder, depressed type

Neuropsychological functioning in schizoaffective disorder, depressed type, was tested by two parallel studies. In Study 1, the Luria-Nebraska Neuropsychological Battery (LNNB) was administered to samples of patients meeting Research Diagnostic Criteria (RDC) for schizodepressive disorder, major depressive disorder or schizophrenia, and to a normal control group. In Study 2, the same test battery was used in patients with a former RDC diagnosis of schizodepressive or major depressive disorder, examined from 2 to 4 years after the index episode, during a phase of remission. Study 1 showed that the performance of schizodepressives on LNNB is, on average, intermediate between those of depressives and schizophrenics, which finding is compatible with the view that RDC schizoaffective depression encompasses a heterogeneous group of syndromes, some of which are related to major depression and some to schizophrenia. Study 2 showed that the mean scores on the LNNB scales Memory and Intellectual processes are significantly higher in patients with a former diagnosis of schizodepressive disorder, which supports the idea that the outcome of these patients is worse, on average, than that of "pure" depressives.

Response to the dexamethasone suppression test in schizoaffective disorder, depressed type

Response to the dexamethasone suppression test (DST) was tested in 20 patients fulfilling the Research Diagnostic Criteria (RDC) for schizoaffective disorder, depressed type, and in 52 patients meeting RDC for major depressive disorder. Non-suppression was observed in 25% of the schizodepressives and in 40.4% of the depressives. No significant difference between suppressor and non-suppressor schizodepressives was found with respect to demographic, historical and clinical variables. These results do not support the usefulness of the DST for the identification of a homogeneous subtype of schizoaffective disorders.

An approach to the diagnosis and classification of schizoaffective disorders for research purposes

A classification of schizoaffective disorders for research purposes is presented. Two main categories are preliminarily singled out: 1) that characterized by the consecutive appearance of an affective and a schizophrenic syndrome (type I), 2) that marked by the concurrent appearance of a full schizophrenic and a full affective syndrome (type II). Within type I, two subtypes are distinguished: 1) that beginning as a typical schizophrenic disorder and shifting later on into a recurrent affective syndrome (affective subtype), 2) that beginning as an affective disorder and showing in its further course a progressive schizophrenic development towards deterioration (schizophrenic subtype). For type II, a multiaxial classification is proposed. Axis 1 should be used to describe the cross-sectional symptomatology, axis 2 to define the course, and axis 3 to note the presence of associated factors. On axis 1, schizoaffective disorder type II can be divided into a manic and a depressive subtype. Operational diagnostic criteria for each are provided. On axis 2, an affective (recurrent) and a schizophrenic (continuous with exacerbations) subtype can be distinguished.

The diagnosis of mania

Manic illnesses are often misdiagnosed, particularly in adolescence when they are commonly and wrongly regarded as schizophrenic. Recent American studies suggest that the presence of Schneiderian and other schizophrenic symptoms has no influence on the duration or the response to treatment of manic illnesses, or on the morbidity of first-degree relatives, and that the concept of schizoaffective disorder, manic type is therefore redundant. Other evidence suggests that, although delusions of reference or persecution have no effect on outcome, the presence of auditory hallucinations or passivity phenomena is associated with a considerably worse outcome over the next few years.

Approaches to the evaluation and treatment of rapid-cycling affective illness

The definition and clinical aspects of rapid cycling affective illness are reviewed and various factors associated with the onset and maintenance of rapid cycling enumerated. On the basis of this information and of reports of the response of rapid cycling patients to various treatment interventions, an approach is suggested to the evaluation and treatment of rapid cycling affective illness.

Effectiveness of lithium prophylaxis in schizoaffective psychoses: application of a polydiagnostic approach

The effectiveness of lithium prophylaxis has been tested in a group of patients fulfilling the relatively broad ICD-9 definition of schizophrenic psychosis, schizoaffective type, and in each of the subgroups resulting from the application to the same patients of four different sets of diagnostic criteria for schizoaffective or cycloid psychoses. Moreover, a comparison has been made, within the whole patient population, between responders and non-responders to treatment, with respect to some clinical and biological variables. The mean number of morbid episodes and the mean total morbidity have been found significantly reduced during the treatment period, as compared with a control period of the same length, in the whole patient population as well as in subjects meeting RDC and Kendell's criteria for schizoaffective disorder (with special regard to schizomanics) and Perris's criteria for cycloid psychoses. No significant difference between the two periods has been observed in patients diagnosed as schizoaffectives according to Welner et al. Clinical/historical variables (with special regard to those concerning the course of the illness and the family history of major psychoses) have been found the most reliable predictors of response, whereas biological variables did not discriminate between responders and nonresponders to prophylaxis.

On the nosology of severe psychiatric post-partum disorders. Results of a catamnestic investigation

A group of 57 women, who had been hospitalised for puerperal psychiatric disorders from 1958 to 1977, were reexamined in 1982. The aim of the study was to determine the proportion of patients who had suffered from nonpuerperal psychotic relapses or other subsequent psychopathology, to define the sample diagnostically, taking into account progress in classification, to characterize the so far relatively neglected later course of illness, and to establish criteria related to relapse and global clinical outcome. Of these patients 65% had at least one nonpuerperal relapse, only 25% remained free of later psychopathology, but the global outcome was favorable or relatively favorable in many cases. Of the patients who had had nonpuerperal relapses 43% were classified as suffering from affective psychosis, as many as 38% from schizoaffective psychosis, and only 19% from schizophrenia. Schizoaffective psychosis seems to be particularly liable to be provoked by childbirth. No major evidence was found that endogenous psychoses with puerperal onset and nonpuerperal relapses have a course of illness different from that of the corresponding diagnostic category in general. Cases with exclusively puerperal decompensations seem to be nosologically independent from the traditionally recognized endogenous psychoses. Characteristics strongly related to nonpuerperal relapses were a family history of psychosis and the occurrence of psychotic episodes before the index episode. Puerperal relapses occurred at a much higher rate in patients who also had nonpuerperal relapses than in patients without.

Psychotic features in major depression. Is mood congruence important?

We studied outcome and family history in 203 patients with psychotic depression. Patients whose psychotic features were mood-incongruent were significantly younger and had a slightly poorer outcome. Morbid risks for affective disorder and schizophrenia among relatives distinguished these mood-incongruent patients from patients with non-psychotic depression but not from patients with schizophrenia. In contrast, depressive probands with mood-congruent psychotic features resembled probands with non-psychotic depression and differed significantly from schizophrenia probands in terms of family history. While depressed patients with mood-congruent psychotic features experienced poorer short-term outcome relative to non-psychotic depressed patients, a 40-year follow-up has shown that these differences disappear over time. Moreover, these two groups are quite similar according to family history data. Both family history and short-term outcome data suggest that major depression with mood-incongruent psychotic features cannot be classified altogether with either affective disorders or schizophrenia. More definite conclusions must await the results of long-term outcome and family studies of these patients presently underway.

The phenomenology of bipolar I manic-depressive illness

There have been several advances in the knowledge of the phenomenology of Bipolar Manic-Depressive Illness in the past decade. Studies of groups of carefully diagnosed bipolar patients have characterized features of the course of illness, the presence and prognostic influence of psychotic features, the influence of stressful life events, features of social adjustment and aspects of personality and long-term functioning. Similar studies of bipolar illness in non-western cultures would be of interest.