Manic and depressive symptoms and insight in first episode psychosis

Clinical and psychological correlates of insight dimensions in patients with early psychosis

AIM

To investigate correlates of insight dimensions in Chinese adult patients with early psychosis.

METHODS

Insight dimensions including awareness of mental disorder (AMD), illness consequences (AIC) and medication effect (AME) were measured. A wide array of variables encompassing demographics, premorbid adjustment, onset profiles, symptomatology, treatment characteristics and psychological factors were comprehensively assessed.

RESULTS

Of 130 participants, 53.1%, 47.7% and 56.2% were categorized with good AMD, AIC and AME, respectively. Good AMD was associated with female gender, fewer positive and disorganization symptoms, more severe depression and greater self-stigma. Good AIC was related to female gender, more severe depression and greater self-stigma. Younger age of onset, fewer positive symptoms and greater service satisfaction associated with good AME.

CONCLUSIONS

Poor insight is prevalent in early psychosis. Differential relationships of insight dimensions with other illness variables underscore the importance of multidimensional approach in insight evaluation, and suggest potential treatment target for insight enhancement.

Towards better care for women with schizophrenia-spectrum disorders

Women with a schizophrenia-spectrum disorder (SSD) have a better clinical profile than do men at the start of their illness but progress to the same state within the first few years of living with SSD. There are benefits to be gained across different areas in the care currently offered to women with psychosis. An important point for improvement is the early detection of female-specific signs of a first episode of psychosis, to shorten the duration of untreated psychosis, with prompt access to early intervention services. Special attention should be paid to sexual health, and to any history of childhood trauma. Antipsychotics require dosing and prescription tailored to the female physiology that consider hormonal life phases such as menopause. Switching to prolactin-sparing medications can benefit both mental and somatic health. Finally, hormone replacement therapy should be considered for postmenopausal women. By providing female-specific care, women with schizophrenia-spectrum disorders will have optimal chances to fare well.

Application of the Delphi Method in the Study of Depressive Disorder

Depressive disorder is a common mental disorder that has a high prevalence and low visiting rate, which caused patients years lived with disability. Due to the complexity of the depressive disorder, the Delphi method is a better choice compared with other commonly used methods, which provides a new perspective for the prevention and treatment of depression. This article will summarize the clinical studies of depressive disorders using the Delphi method from four perspectives, and summarize the advantages and disadvantages of the Delphi method in depressive disorders research, arguing that the Delphi method can cross the gap between clinical research and clinical practice, and is a highly practical part of the research process.

The associations between illness perceptions and social rhythm stability on mood symptoms among patients with bipolar disorder

BACKGROUND

The association between illness perceptions and the effectiveness of patients' illness-management strategies has been supported across a range of medical and psychiatric disorders. Few studies have examined these variables or their association in bipolar disorder (BD). This study examined the main and interactive associations between illness perceptions and one important illness management strategy - social rhythms stability on mood symptom severity in adults with BD.

METHODS

A cross-sectional study with 131 patients with BD in Taiwan was conducted using clinician- and patient-rated mood symptoms, self-reported illness perceptions, and a measure of daily and nightly social rhythms.

RESULTS

Illness perceptions were associated with mood symptom severity, but social rhythms were not. Unfavorable illness perceptions (e.g., beliefs of experiencing more BD symptoms, having stronger emotional responses to the illness) were associated with more severe mood symptoms. Favorable illness perceptions (e.g., beliefs of being able to understand and control the illness) were associated with less severe mood symptoms, with personal control as the strongest correlate of mood symptom severity. Finally, social rhythm stability moderated the relationship between unfavorable illness perceptions and clinician-rated manic symptoms.

LIMITATIONS

The cross-sectional design limits our ability to make causal conclusions. Also, the effects pertain to patients in remission and may not generalize to more severely ill or hospitalized bipolar patients.

CONCLUSIONS

This study indicates that in patients with BD, illness perceptions are associated with symptom severity. Interventions to enhance favorable IPs and reduce unfavorable IPs may improve mood outcomes, particularly when patients have adopted regular social rhythms.

Does Insight Affect the Efficacy of Antipsychotics in Acute Mania?: An Individual Patient Data Regression Meta-Analysis

Patients having an acute manic episode of bipolar disorder often lack insight into their condition. Because little is known about the possible effect of insight on treatment efficacy, we examined whether insight at the start of treatment affects the efficacy of antipsychotic treatment in patients with acute mania. We used individual patient data from 7 randomized, double-blind, placebo-controlled registration studies of 4 antipsychotics in patients with acute mania (N = 1904). Insight was measured with item 11 of the Young Mania Rating Scale (YMRS) at baseline and study endpoint 3 weeks later. Treatment outcome was defined by (a) mean change score, (b) response defined as 50% or more improvement on YMRS, and (c) remission defined as YMRS score less than 8 at study endpoint. We used multilevel mixed effect linear (or logistic) regression analyses of individual patient data to assess the interaction between baseline insight and treatment outcomes. At treatment initiation, 1207 (63.5%) patients had impaired or no insight into their condition. Level of insight significantly modified the efficacy of treatment by mean change score (P = 0.039), response rate (P = 0.033), and remission rate (P = 0.043), with greater improvement in patients with more impaired insight. We therefore recommend that patients experiencing acute mania should be treated immediately and not be delayed until patients regain insight.

The affective dimension of early-onset psychosis and its relationship with suicide

BACKGROUND

The affective dimension has scarcely been studied in early-onset psychosis. Our aims were to investigate the prevalence and type of affective symptoms in the prodromal and acute phases of early-onset psychosis and to examine their relationship with suicide. We also sought to establish whether the presence of premorbid antecedents or the presence of affective symptoms during the prodromal and acute phase might predict a later diagnosis of bipolar disorder (BP) or schizophrenia (SZ).

METHOD

Participants were 95 youths, aged 9-17 years, experiencing a first episode of a psychotic disorder (FEP) according to DSM-IV criteria. Prodromal affective symptoms in the year prior to the onset of full-blown psychosis were assessed by means of the K-SADS. Affective symptoms during the acute episode were evaluated using the Hamilton Depression Rating Scale and the Young Mania Rating Scale. Suicidality was assessed during the acute episode and at 6 and 12 months.

RESULTS

Half of the patients experienced affective symptoms during the prodrome, with depressive symptoms being the most frequently reported. During the acute episode, 23.2% presented depressive, 41.4% mixed and 18.9% manic symptoms. After logistic regression analysis, only the presence of depressive symptoms was significantly associated with suicidality during the 12 months following the FEP. Neither early premorbid antecedents nor the prevalence or type of affective symptoms during the FEP predicted a diagnosis of BP or SZ at 12 months. However, both depressive and manic prodromal symptoms were associated with a later diagnosis of BP.

CONCLUSIONS

The FEP of both SZ and BP is preceded by an identifiable prodromal phase. Early detection programs should target young people at clinical risk for the extended psychosis phenotype. The high prevalence of affective symptoms during the early phases of psychosis may encourage clinicians to identify and treat them in order to prevent suicide behaviour.

Testing the psychopathology of psychosis: evidence for a general psychosis dimension

BACKGROUND

Psychiatric taxonomists have sometimes argued for a unitary psychosis syndrome and sometimes for a pentagonal model, including 5 diagnostic constructs of positive symptoms, negative symptoms, cognitive disorganization, mania, and depression. This continues to be debated in preparation for impending revisions of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases. We aimed to identify general and specific dimensions underlying psychopathological features of psychosis.

METHODS

The samples comprised 309 patients admitted to psychiatric services in the acute phase of their first or second episode of psychosis and 507 patients with enduring psychosis recruited from community mental health teams. Patients' symptoms were assessed on the Positive and Negative Symptom Scale. Analyses compared unitary, pentagonal, and bifactor models of psychosis.

RESULTS

In both samples, a bifactor model including 1 general psychosis factor and, independently, 5 specific factors of positive symptoms, negative symptoms, disorganization, mania, and depression gave the best fit. Scores of general and specific symptom dimensions were differentially associated with phase of illness, diagnosis, social functioning, insight, and neurocognitive functioning.

CONCLUSIONS

The findings provide strong evidence for a general psychosis dimension in both early and enduring psychosis. Findings further allowed for independent formation of specific symptom dimensions. This may inform the current debate about revised classification systems of psychosis.

Systematic review reveals heterogeneity in the use of the Scale to Assess Unawareness of Mental Disorder (SUMD)

The Scale to Assess Unawareness of Mental Disorder (SUMD) is one of the most widely used instruments to measure insight into mental disorders. The aim of this study was to review all studies using the SUMD in the last 20 years. We performed an electronic search of MEDLINE using PubMed to identify all relevant studies published from 1993 to 2012. The following data were extracted from each article: characteristics of the SUMD (version, rating scale, scoring, and item/dimension used), methodological aspects (country, language, subject inclusion criteria, and sample size), and statistical methods to analyse insight. Of the 133 articles screened, 100 studies were included in the review. Fifty-two studies were published over the past five years. The SUMD was rarely used in its entirety, and the use of selected items or subscales was heterogeneous across studies. The studies also varied in terms of response modalities and in the use of 3- or 5-point Likert scales. The calculation of insight scores was highly variable and included the following: treating items as categorical or continuous variables, separate analysis of individual items, items expressed in terms of the sum total or the mean scores, and a range of score values used to define insight. This paper provides a systematic review of studies using the SUMD and reveals important differences in the versions used, the methods of calculation, and the interpretation of scores across studies. The use of a modified SUMD may compromise the psychometric properties of the scale, lead to erroneous conclusions, and prevents comparison of results across studies. Our review underlines the need for the standardised use of the SUMD.

Development of the insight scale for affective disorders (ISAD): modification from the scale to assess unawareness of mental disorder

BACKGROUND

Research on insight in patients with mood disorders has grown in recent years. Several instruments to assess insight have been used, but most of them have been specifically designed for psychosis and may not appear relevant to mood disorders. The aim of the present study is to develop a short, multidimensional, reliable and valid scale to measure insight in patients with mood disorders, based on the Amador's Scale to Assess Unawareness of Mental Disorders (SUMD).

METHOD

A Delphi method was used to facilitate expert participation and ensure face and content validity. The SUMD structure and items were used as a reference in the scale development. A new scale with 17 items was obtained. Internal consistency, test-retest and inter-rater reliability and validity were studied in a sample of 76 outpatients with a DSM-IV diagnosis of major depression or bipolar disorder (type I or II).

RESULTS

Internal consistency of the general items was moderate, and high for the symptoms awareness subscale. Scores on ISAD correlated with other measures of insight and with some clinical measures, thus supporting its validity.

LIMITATIONS

The majority of the sample came from community services. Future studies should use inpatients or patients with severe symptoms to broaden the range of responses. Moreover, the rating of insight and other measures by the same clinician might introduce a methodological bias.

CONCLUSION

The ISAD, with a multidimensional approach, appears as a short, reliable and valid measure of insight in mood disorders. Expert consensus ensures its face and content validity.

One-year psychosocial functioning in patients in the early vs. late stage of bipolar disorder

OBJECTIVE

The aim of this 1-year follow-up study was to compare functional outcome as well as clinical differences between patients with first- and multiple-episode bipolar disorder.

METHOD

Bipolar disorder patients with first (n = 60) and multiple episodes (n = 59) were recruited from two hospitals in Spain. The Functioning Assessment Short Test (FAST) was used to assess functioning. The Hamilton Depression Rating Scale (HAMD) and the Young Mania Rating Scale (YMRS) were administered to assess mood symptoms.

RESULTS

As expected, patients with first episode experienced a greater functioning compared to patients with multiple episodes (11.26 ± 10.94 vs. 26.91 ± 13.96; t = 6.436, P < 0.001). There were significant demographic and clinical differences between both groups. Baseline depressive symptoms (F = 9.553, df = 4, 102; P < 0.001) and age (F = 14.145, df = 4, 103; P < 0.001) were significantly associated with poor functional recovery at 6-month and 12-month assessment, respectively, in a group of patients with multiple episodes.

CONCLUSION

Our data give support to the model of staging in bipolar disorder, showing that the enduring neurotoxicity of repeated episodes may contribute to sustained impairment in multiple areas of psychosocial functioning.

Validity of the Chinese version Mood Disorder Questionnaire (MDQ) and the optimal cutoff screening bipolar disorders

To investigate the validity of the Chinese version of Mood Disorder Questionnaire (C-MDQ) in China. Patients with bipolar disorders (BP, N=284) and patients with unipolar depressive disorder (UP, N=134) were assessed with the C-MDQ. The Eigenvalues of the first two factors were 3.15 and 2.09, respectively. The Cronbach's alpha of the C-MDQ was 0.79. The frequency of positive responses of UP patients was significantly lower than those of BP patients for 12 items except the seventh item. A C-MDQ screening score of seven or more was the best cutoff between BP and UP. The C-MDQ could distinguish between bipolar II disorder (BP-II) and UP, and the best cutoff was five. A cutoff of five had a sensitivity of 0.80 and a specificity of 0.54 between BP and UP. This study demonstrated the good validity of C-MDQ in China. The best cutoff between BP-II and UP can be regarded as the optimal cutoff between BP and UP to improve the sensitivity of screening for BP-II. Five should be the optimal cutoff between the BP and UP when only the 13 items of the questionnaire are used in China.