Symptoms of the suicide crisis syndrome and therapist emotional responses: associations to self-harm and death by suicide within 18-months post-discharge among patients at an acute psychiatric department.

BACKGROUND AND AIMS: This study explored the associations between symptoms of the Suicide Crisis Syndrome (SCS) at admission and self-harm and death by suicide post-discharge. The association between clinicians' emotional responses toward inpatients at admission and post-discharge self-harm and suicide death was also explored. METHODS: Within the first 24-h of admission, patients completed a self-report measure of symptoms of SCS, and clinicians reported their emotional responses toward the patients. Follow-up data were obtained from the Norwegian Patient Registry and the Norwegian Cause of Death Registry. RESULTS: Within 18 months post-discharge, 44 (12.7%) out of 347 patients had self-harmed, and five patients (1.4%) had died by suicide. At admission, patients who later self-harmed reported higher symptoms of SCS compared to the other patients. Clinicians reported more negative emotional responses toward the self-harm group. In a regression analysis, previous suicidal behavior and a diagnosis of "emotionally unstable personality disorder" (EUPD; F60.3) were associated with increased risk of self-harm post-discharge. CONCLUSION: The results indicated that patients with post-discharge episodes of self-harm are significantly different from patients who do not self-harm in terms of more intense symptoms of SCS during admission. Clinicians' negative emotional responses may be relevant in the assessment of the risk of post-discharge self-harm.

Exploring associations between the Modular Assessment of Risk for Imminent Suicide (MARIS) questionnaire and recent suicidal ideation and behavior among patients admitted at an acute psychiatric inpatient department.

PURPOSE: The aim of the present study was to investigate the psychometric validity of the Modular Assessment of Risk for Imminent Suicide (MARIS) questionnaire in relation to recent suicidal ideation and behavior among a sample of patients admitted to an acute psychiatric inpatient department in Norway. METHODS: The MARIS was completed within the first 24 h after admission by 338 patients and their clinicians. Information on recent suicidal ideation and behavior was extracted from patients' medical charts. Two out of four MARIS modules, the Suicide Trigger Scale Short-Form (STS-SF; modified version), and the Therapist Response Questionnaire Short-Form (TRQ-SF) demonstrated good internal consistency. The relationships between the STS-SF, addressing symptoms of the suicide crisis syndrome, and the TRQ-SF, exploring therapist emotional responses, and recent suicidal ideation was investigated by logistic regression analysis. RESULTS: In the logistic regression analysis including pre-selected diagnoses, age, and gender as covariates, both STS-SF and TRQ-SF showed significant associations with recent suicidal ideation (inclusive of suicidal behavior in 27% of the patients with suicidal ideation). CONCLUSION: Both the STS-SF and the TRQ-SF showed concurrent and incremental validity with regard to suicidal ideation. This is the first study showing the cross-cultural validity of the MARIS and supports its clinical utility as a suicide risk assessment tool in inpatient settings. Additionally, this study adds to the literature supporting the value of assessing clinicians' emotional responses to high risk patients.

Identification of unhealthy alcohol use by self-report and phosphatidylethanol (PEth) blood concentrations in an acute psychiatric department.

BACKGROUND: The use of standard screening methods could improve the detection rate of unhealthy alcohol use in patients admitted to psychiatric acute and emergency departments. The aim of the present study was to investigate the ability of the alcohol biomarker phosphatidylethanol (PEth) to identify patients with high levels of alcohol consumption prior to admission. METHODS: The data were prospectively collected at admittance to an acute psychiatric department in the period January 2016 to June 2017. A blood sample for the analysis of PEth was available from 177 patients. We compared the PEth concentrations with the Alcohol Use Disorders Identification Test (AUDIT) scores during the hospital stay, and psychiatric diagnoses at discharge. RESULTS: A total of 45.8% of the patients had a PEth concentration ≥ 0.03 µmol/L, indicating significant alcohol consumption. AUDIT scores consistent with unhealthy alcohol use were present in 51.7%. There was a significant positive correlation between PEth concentrations and AUDIT scores (r = 0.631, p < 0.001). PEth was above the detection limit of 0.03 µmol/L in 19% of those reporting an average daily intake of zero alcohol units per day during the last week before admission. PEth concentrations were significantly higher among those with an alcohol diagnosis than among those without such a diagnosis (0.82 µmol/L vs. 0.09 µmol/L, p = 0.001). CONCLUSION: PEth provides supplementary information on recent alcohol consumption in a psychiatric population and would be particularly helpful in patients unable or unwilling to give such information at admission.

Research based on existing clinical data and biospecimens: a systematic study of patients' opinions.

BACKGROUND: The aim of the present survey was to investigate newly discharged hospital patients' opinions on secondary use of their hospital data and biospecimens within the context of health research in general and, more specifically, on genetic research, data sharing across borders and cooperation with the health industry. METHODS: A paper questionnaire was sent to 1049 consecutive newly discharged hospital patients. RESULTS: The vast majority of the respondents preferred to be informed (passive consent) or to receive no notification at all for secondary research on their health data and biospecimens (88% and 91% for data and biospecimens respectively). The rest wanted to be asked for active consent. The same trend applied for the other aspects also. 81% of respondents were positive towards genetic research without active consent. 95% were positive towards cooperating with the health industry, and 90% were positive towards data sharing. CONCLUSIONS: These results suggest that hospital patients generally are very positive to secondary research and support the concept of opting out rather than opting in.

Non-disclosure of suicidal ideation in psychiatric inpatients: Rates and correlates.

The study explored how common non-disclosure of suicidal ideation is in a sample of adult psychiatric inpatients (N = 171) plus associated patient characteristics. A large percentage (51.5%) withheld some information on suicidal ideation during admission. In multivariable analyses, correlates of non-disclosure included a diagnosis of emotionally unstable personality disorder, low satisfaction with stay, and symptoms of the suicide crisis syndrome. In univariate analyses, therapists' emotional response to the patient was also a correlate. Findings indicate that among acute psychiatric inpatients, non-disclosure of suicidal ideation is quite common, requiring awareness from clinicians relying on this parameter in suicide risk assessments.

Challenges in detecting and diagnosing substance use in women in the acute psychiatric department: a naturalistic cohort study.

BACKGROUND: This study examines sex differences in substance use and substance use disorder in the acute psychiatric department, and possible interactions between sex and clinical and social factors associated with this phenomenon. METHODS: Data concerning substance use were collected in a naturalistic cohort study (n = 384, 51.6% male, 48.4% female) in an acute psychiatric department. Recent intake of substances at admission, diagnosis of substance use disorder and demographic and socioeconomic information were recorded. At admission, serum and urine samples were analysed for substance use and breath analysis was performed for alcohol levels. RESULTS: Twice as many men as women were diagnosed with substance use disorder, whereas there were no gender differences in the number of positive toxicology screenings. Toxicology screening revealed the use of non-prescribed medication with addiction potential in 40% of both female and male patients many of whom did not report this in the admission interview. A low level of education in men and absence of parental responsibility in women showed a statistically significant interaction with a current diagnosis of substance use disorder. CONCLUSIONS: Despite no sex differences in positive toxicology screenings in the acute psychiatric department, twice as many men as women are diagnosed with substance use disorders. The use of prescription drugs with addiction potential was widely under-reported by both sexes, in patients with no prescriptions for the medications. Women with no parental responsibility are overrepresented among those diagnosed with substance use disorder, as are men with a low level of education. TRIAL REGISTRATION: The study is registered with the ClinicalTrials.gov identifier NCT01415323.

Is EEG a useful test in adult psychiatry?

BACKGROUND: We present a brief overview of the use of EEG in psychiatry, with particular emphasis on differential diagnosis examination in case of acute psychiatric conditions. METHOD: The article is based on a literature search in PubMed and the authors' own collections of articles and personal experience. RESULTS: Onset of epilepsy, encephalitis or other cerebral diseases may be accompanied by psychiatric or cognitive symptoms. Slow EEG activity may be an unspecific sign of cerebral disease. Psychiatric patients are also at an increased risk of epilepsy. In case of seizure symptoms such as convulsions or conditions with rapid changes in affective states, epileptiform activity during EEG is a specific sign of epileptic aetiology or comorbidity. Quantitative frequency analysis (QEEG) is useful for research purposes and in exceptional cases also in a clinical context. No QEEG method has as yet become accepted as providing reliable, independent markers for psychiatric disease or treatment response. INTERPRETATION: EEG should be undertaken in case of newly occurring psychoses and for conditions with a fluctuating or progradiating loss of cognitive function. Adult psychiatric patients with seizure symptoms or rapid changes in affective states should also be referred to EEG.

Giant Cell Arteritis Presenting with Mania, Psychosis, and Cognitive Dysfunction: A Case Report.

Background: Giant cell arteritis (GCA) is an autoimmune vasculitis affecting medium- and large-sized arteries. Vascular inflammation may lead to narrowing of the arterial lumen, and acute occlusion may result in vision loss and stroke. The classical symptoms include headache, fever, and jaw claudication. However, there is an increasing recognition of atypical presentations. Case Presentation. We report a case of a 70-year-old woman presenting with fluctuating manic symptoms and confusion, in addition to headache and musculoskeletal pain. After diagnosis of GCA, treatment with corticosteroids gradually improved the somatic symptoms. Conclusion: Corticosteroids led to a temporary exacerbation of manic symptoms, which improved after 3 to 4 weeks of continuous treatment, indicating that the symptoms were most likely associated with GCA. The patient manifested with clinical features and a clinical course that has, to our knowledge, not been described or published before. Therefore, GCA may be an underdiagnosed disease in psychiatric populations and should be considered in case of atypical, new-onset psychiatric disorders in the elderly.

Mortality Among Patients Discharged From an Acute Psychiatric Department: A 5-Year Prospective Study.

The primary aim of the study was to explore the post discharge standardized mortality ratio of patients from an acute psychiatric department in Norway. The secondary aims were to explore if the standardized mortality ratio is still increasing and to examine the causes of death in the defined population. We conducted a 5-year prospective study among patients admitted to an acute psychiatric department with catchment area responsibilities. A total of 380 patients were included in the study, and the number and causes of deaths were obtained from the Norwegian Cause of Death Registry. Excess mortality was found for the patient group. The standardized mortality ratio for all causes of death was 6.7 (95% CI, 4.6-8.8). The study finds an increased standardized mortality ratio relative to a previous corresponding study in Norway, and the suicide risk was especially elevated the first 2 years after discharge.

Extracellular vesicles in patients in the acute phase of psychosis and after clinical improvement: an explorative study.

Extracellular vesicles (EVs) are cell-derived structures that transport proteins, lipids and nucleic acids between cells, thereby affecting the phenotype of the recipient cell. As the content of EVs reflects the status of the originating cell, EVs can have potential as biomarkers. Identifying EVs, including their cells of origin and their cargo, may provide insights in the pathophysiology of psychosis. Here, we present an in-depth analysis and proteomics of EVs from peripheral blood in patients (n = 25) during and after the acute phase of psychosis. Concentration and protein content of EVs in psychotic patients were twofold higher than in 25 age- and sex-matched healthy controls (p < 0.001 for both concentration and protein content), and the diameter of EVs was larger in patients (p = 0.02). Properties of EVs did not differ significantly in blood sampled during and after the acute psychotic episode. Proteomic analyses on isolated EVs from individual patients revealed 1,853 proteins, whereof 45 were brain-elevated proteins. Of these, five proteins involved in regulation of plasticity of glutamatergic synapses were significantly different in psychotic patients compared to controls; neurogranin (NRGN), neuron-specific calcium-binding protein hippocalcin (HPCA), kalirin (KALRN), beta-adducin (ADD2) and ankyrin-2 (ANK2). To summarize, our results show that peripheral EVs in psychotic patients are different from those in healthy controls and point at alterations on the glutamatergic system. We suggest that EVs allow investigation of blood-borne brain-originating biological material and that their role as biomarkers in patients with psychotic disorders is worthy of further exploration.

Cytokines in Relation to Motor Activity in an Acute Psychiatric Population.

Background: Deviations in motor activity are important clinical features of several psychiatric disorders in an acute state. Immune activity is associated with several psychiatric disorders and may affect motor activity. We aimed to examine the association between immune activity measured as serum levels of cytokines and deviations in motor activity, in an acute psychiatric setting. Methods: Data on motor activity and immune markers were available on 277 patients admitted to an acute psychiatric inpatient department. The degree of increased or decreased motor activity was clinically assessed at admission. Serum concentrations of the following immune markers were measured: interleukin (IL) -1ß, IL-4, IL-6, IL-10, tumor necrosis factor (TNF) -α, interferon (IFN) -γ, and transforming growth factor (TGF) -ß. Results: Scores of increased motor activity were negatively correlated with IFN-γ (rho = -0.128, p = 0.033) in an acute psychiatric population. There was also a trend towards an association between motor activity and TGF-ß (rho = 0.118, p = 0.050). In a multiple-linear-regression model correcting for age, gender, and body-mass index (BMI, kg/m2), the association did not remain significant. No significant correlations between motor retardation and circulating cytokines were found. Conclusions: After adjustment for potential confounders our study did not reveal any significant association between cytokines and motor activity. However, there is an indication of increased Th17 and decreased Th1 responses in relation to increased motor activity in line with the few previous reports in the field. The phenomenon however needs further exploration.

Quantitative EEG findings in patients with acute, brief depression combined with other fluctuating psychiatric symptoms: a controlled study from an acute psychiatric department.

BACKGROUND: Patients with brief depressive episodes and concurrent rapidly fluctuating psychiatric symptoms do not fit current diagnostic criteria and they can be difficult to diagnose and treat in an acute psychiatric setting. We wanted to study whether these patients had signs of more epileptic or organic brain dysfunction than patients with depression without additional symptomatology. METHODS: Sixteen acutely admitted patients diagnosed with a brief depressive episode as well as another concurrent psychiatric diagnosis were included. Sixteen patients with major depression served as controls. Three electroencephalographic studies (EEG) were visually interpreted and the background activity was also analysed with quantitative electroencephalography (QEEG). RESULTS: The group with brief depression and concurrent symptoms had multiple abnormal features in their standard EEG compared to patients with major depression, but they did not show significantly more epileptiform activity. They also had significantly higher temporal QEEG delta amplitude and interhemispheric temporal delta asymmetry. CONCLUSION: Organic brain dysfunction may be involved in the pathogenesis of patients with brief depressive episodes mixed with rapidly fluctuating psychiatric symptoms. This subgroup of depressed patients should be investigated further in order to clarify the pathophysiology and to establish the optimal evaluation scheme and treatment in an acute psychiatric setting.

Clinical characteristics of patients with bipolar disorder and premorbid traumatic brain injury: a cross-sectional study.

BACKGROUND: About one in ten diagnosed with bipolar disorder (BD) has experienced a premorbid traumatic brain injury (TBI), while not fulfilling the criteria of bipolar and related disorder due to another medical condition (BD due to TBI). We investigated whether these patients have similar clinical characteristics as previously described in BD due to TBI (i.e. more aggression and irritability and an increased hypomania/mania:depression ratio) and other distinct clinical characteristics. METHODS: Five hundred five patients diagnosed with BD type I, type II, or not otherwise specified, or cyclothymia were interviewed about family, medical, and psychiatric history, and assessed with the Young Mania Rating Scale (YMRS) and the Inventory of Depressive Symptoms Clinician Rated 30 (IDS-C30). Principal component analyses of YMRS and IDS-C30 were conducted. Bivariate analyses and logistic regression analyses were used to compare clinical characteristics between patients with (n = 37) and without (n = 468) premorbid TBI. RESULTS: Premorbid TBI was associated with a higher YMRS disruptive component score (OR 1.7, 95% CI 1.1-2.4, p = 0.0077) and more comorbid migraine (OR 4.6, 95% CI 1.9-11, p = 0.00090) independently of several possible confounders. Items on disruptive/aggressive behaviour and irritability had the highest loadings on the YMRS disruptive component. Premorbid TBI was not associated with an increased hypomania/mania:depression ratio. CONCLUSIONS: Disruptive symptoms and comorbid migraine characterize BD with premorbid TBI. Further studies should examine whether the partial phenomenological overlap with BD due to TBI could be explained by a continuum of pathophysiological effects of TBI across the diagnostic dichotomy. Trial registration ClinicalTrials.gov: NCT00201526. Registered September 2005 (retrospectively registered).

Can cycles of chills and fever resolve bipolar disorder mania?

Treatment resistance is common in populations of patients with bipolar disorder stressing the need for new therapeutic strategies. Favourable effects of fever on mental disease have been noted throughout history. Today there is increasing evidence that immunological processes are involved in the pathophysiology of mental disorders. We present a case in which a patient with treatment resistant bipolar disorder mania seemingly recovered as a result of recurrent fever. This indicates that artificial fever might become a last resort therapy for treatment resistant mania.

Association analysis between suicidal behaviour and candidate genes of bipolar disorder and schizophrenia.

BACKGROUND: The present study investigated associations between the strongest joint genetic risk variants for bipolar disorder (BD) and schizophrenia (SCZ) and a history of suicide attempt in patients with BD, SCZ and related psychiatric disorders. METHODS: A history of suicide attempt was assessed in a sample of 1009 patients with BD, SCZ and related psychosis spectrum disorders, and associations with the joint genetic risk variants for BD and SCZ (rs2239547 (ITIH3/4-region), rs10994359 (ANK3) and rs4765905 (CACNA1C)) were investigated. Previously reported susceptibility loci for suicide attempt in BD were also investigated. Associations were tested by logistic regression with Bonferroni correction for multiple testing. RESULTS: The risk allele in rs2239547 (ITIH3/4-region) was significantly associated with a history of suicide attempt (p=0.01) after multiple testing correction (p threshold<0.017). The previous suicide attempt susceptibility loci were only nominally associated, but had the same direction of risk in the replication sample (sign test, p=0.02). LIMITATIONS: Relatively small sample size and retrospective clinical assessment. CONCLUSIONS: We detected a novel association between suicide attempt and the ITIH3/4-region in a combined group of patients with BD, SCZ and related psychosis spectrum disorders. This may be useful in understanding molecular mechanisms of suicidal behaviour in severe mental disorders, although replication is warranted.