Preventing Suicide among Psychiatric Inpatients with Psychotic Depression.

To investigate which factors individuals with a psychotic depression experience as preventive of suicide while beeing hospitalized. Semi-structured qualitative interviews with nine inpatients, all hospitalized for a unipolar or bipolar depressive episode with psychosis, were conducted at time of discharge. For analysis we used systematic text condensation. Main outcomes were accounts of participants' experiences of suicide prevention measures and treatment, and how these affected suicidal ideation, plans, and attempts. Participants experienced (1) suicide attempts being physically interrupted or prevented; (2) receiving medical treatment to alleviate unbearable suffering; (3) finding refuge behind locked doors; (4) receiving guidance to redefine their identity and situation. They reported being protected from suicidal impulses and imagined persecutors in a secure environment with staff present. They described their autonomy as compromised by intense suffering and chaos. They retrospectively appreciated staff interventions, if these were performed compassionately and with empathy. Participants described that suicidal thoughts and actions were triggered by terrifying psychotic experiences, anxiety and sleeplessness, and felt that medication - and in one instance electroconvulsive therapy- alleviated suffering. At time of discharge, participants reported no psychotically motivated suicidal thoughts. They described a new, insightful self-view and acknowledged having been severely mentally ill. To prevent impulsive suicidal behavior, findings highlight the need for both security measures and a treatment approach focusing on modifying psychotic experiences and intense anxiety. Gaining anxious and paranoid patients' trust is essential to build motivation for medical treatment. Patients emphasize that having time to talk is crucial to this process.

Occupational outcome in bipolar disorder is not predicted by premorbid functioning and intelligence.

OBJECTIVES: Bipolar disorder (BD), over the long term, can manifest a variety of outcomes depending on a number of different conditions. There is a need for further knowledge regarding preventive factors as well as predictors of the disabling course of the disorder. Studies regarding the impact on functional outcome of premorbid and current general intellectual function [intelligence quotient (IQ)] and premorbid functioning in BD patients are sparse. The present study addressed the role of premorbid functioning [assessed with the Premorbid Adjustment Scale (PAS)], intelligence, course of illness, and sociodemographics on occupational outcome in BD. METHODS: Bipolar disorder patients were recruited consecutively from psychiatric units (outpatient and inpatient) in four major hospitals in Oslo, Norway [(N = 226: 64.4% bipolar I disorder (BD-I); 30.1% bipolar II disorder (BD-II); 5.5% bipolar disorder not otherwise specified (BD-NOS); 38.6% males]. The associations between current IQ, premorbid IQ [assessed using the National Adult Reading Test (NART)], PAS, clinical and sociodemographic characteristics, and receipt of disability benefit were analysed using descriptive statistics and logistic regression analyses. RESULTS: The number of hospitalizations for depressive episodes and illness duration was associated with a higher risk of receipt of disability benefit. PAS, premorbid and current IQ, as well as decline in IQ, did not explain the higher risk of receipt of disability benefits. CONCLUSIONS: Severe clinical course of BD was associated with receipt of disability benefit. Occupational outcome was unrelated to PAS, premorbid and current IQ, as well as decline in IQ. This suggests that the persistence of severe clinical symptoms, rather than global cognitive functioning, determines occupational outcome in BD and emphasizes the protective potential of early and continuous clinical treatment.

Neurocognitive profiles in treatment-resistant bipolar I and bipolar II disorder depression.

BACKGROUND: The literature on the neuropsychological profiles in Bipolar disorder (BD) depression is sparse. The aims of the study were to assess the neurocognitive profiles in treatment-resistant, acutely admitted BD depression inpatients, to compare the neurocognitive functioning in patients with BD I and II, and to identify the demographic and clinical illness characteristics associated with cognitive functioning. METHODS: Acutely admitted BD I (n = 19) and BD II (n = 32) inpatients who fulfilled the DSM-IV-TR criteria for a major depressive episode were tested with the MATRICS Consensus Cognitive Battery (MCCB), the Wechsler Abbreviated Scale of Intelligence, the National Adult Reading Test, and a battery of clinical measures. RESULTS: Neurocognitive impairments were evident in the BD I and BD II depression inpatients within all MCCB domains. The numerical scores on all MCCB-measures were lower in the BD I group than in the BD II group, with a significant difference on one of the measures, category fluency. 68.4% of the BD I patients had clinically significant impairment (>1.5 SD below normal mean) in two or more domains compared to 37.5% of the BD II patients (p = 0.045). A significant reduction in IQ from the premorbid to the current level was seen in BD I but not BD II patients. Higher age was associated with greater neurocognitive deficits compared to age-adjusted published norms. CONCLUSIONS: A high proportion of patients with therapy-resistant BD I or II depression exhibited global neurocognitive impairments with clinically significant severity. The cognitive impairments were more common in BD I compared to BD II patients, particularly processing speed. These findings suggest that clinicians should be aware of the severe neurocognitive dysfunction in treatment-resistant bipolar depression, particularly in BD I. TRIAL REGISTRATION: NCT00664976.

High Scores on the Montgomery-Åsberg Depression Rating Scale and Psychotic Symptoms Predict Suicide: A Prospective Cohort Study of Psychiatric Acute Ward Patients.

Objective: To investigate the role of depression severity in suicide risk by studying the predictive value of psychotic symptoms and depression scale scores, controlled for suicidal behavior and gender.Methods: We conducted a prospective cohort study of consecutive psychiatric acute ward admissions between 2005 and 2014 from a Norwegian catchment area. Inclusion criteria were an ICD-10 diagnosis of unipolar or bipolar depression with a current depressive episode (n = 1,846); depression severity was measured by the Montgomery-Åsberg Depression Rating Scale (MADRS). Patients were assessed for suicidal ideation/planning, self-harm, and recent suicide attempts on admission. Mean follow-up time was 5.5 years (minimum/maximum: 0/10.6 years). We used Cox regression analyses and Kaplan-Meier analyses to explore potential predictors and time to suicide.Results: During the follow-up period, 46 patients died by suicide, 30 (65%) of these within the year following admission. Psychotic depression (P = .014), admission MADRS score (P = .006), suicide attempts (P = .021), and male sex (P = .043) significantly predicted suicide. Suicidal ideation and self-harm did not predict suicide. The cumulative suicide risk in psychotic depression was 1.7% after 12 weeks and 3.0% after 52 weeks.Conclusions: Depression severity as measured with the MADRS or a diagnosis of psychotic depression independently predicted suicide. More suicides may be prevented by implementing intensive treatment and post-discharge follow-up for patients who present to psychiatric acute wards with severe depressive episodes and recent suicide attempts, regardless of self-reported suicidal ideation, suicide plans, and self-harm.

Psychotic Depression and Suicidal Behavior.

OBJECTIVE: This study investigated how severely depressed individuals experienced the relationship between psychotic symptoms and suicidal ideation and behavior. METHOD: Semi-structured qualitative interviews were conducted with a purposive sample of nine inpatients from a psychiatric university hospital between September 2012 and May 2013 fulfilling diagnostic criteria for a psychotic depressive episode as part of a unipolar or bipolar disorder. Analysis was conducted using systematic text condensation. RESULTS: Participants experienced (1) being directed to perform impulsive potentially fatal actions, (2) feeling hounded to death, (3) becoming trapped in an inescapable darkness, and (4) being left bereft of mental control. They described how impulsivity directed by delusions and hallucinations resulted in unpredictable actions with only moments from decision to conduct. Suicide was seen as an escape not only from life problems but also from psychotic experiences and intense anxiety. Participants reported being in a chaotic state, unable to think rationally or anticipate the consequences of their actions. Their ability to identify and communicate psychotic symptoms and suicidal ideation and behavior was compromised, leaving them to struggle alone with these terrifying experiences. CONCLUSIONS: Suicide risk assessments based on verbal reports from individuals with psychotic depression may not always be valid due to potential impulsivity and underreporting of suicidal ideation. It may be important for clinicians to explore the delusional content of such patients' experiences to assess the possibility of suicide as a result of shame, guilt, remorse, or altruistic intentions to save others from harm.

Treatment-resistant bipolar depression: a randomized controlled trial of electroconvulsive therapy versus algorithm-based pharmacological treatment.

OBJECTIVE: Electroconvulsive therapy (ECT) is regarded by many clinicians as the most effective treatment for treatment-resistant bipolar depression, but no randomized controlled trials have been conducted, to the authors' knowledge. They compared efficacy measures of ECT and algorithm-based pharmacological treatment in treatment-resistant bipolar depression. METHOD: This multicenter, randomized controlled trial was carried out at seven acute-care psychiatric inpatient clinics throughout Norway and included 73 bipolar disorder patients with treatment-resistant depression. The patients were randomly assigned to receive either ECT or algorithm-based pharmacological treatment. ECT included three sessions per week for up to 6 weeks, right unilateral placement of stimulus electrodes, and brief pulse stimulation. RESULTS: Linear mixed-effects modeling analysis revealed that ECT was significantly more effective than algorithm-based pharmacological treatment. The mean scores at the end of the 6-week treatment period were lower for the ECT group than for the pharmacological treatment group: by 6.6 points on the Montgomery-Åsberg Depression Rating Scale (SE=2.05, 95% CI=2.5-10.6), by 9.4 points on the 30-item version of the Inventory of Depressive Symptomatology-Clinician-Rated (SE=2.49, 95% CI=4.6-14.3), and by 0.7 points on the Clinical Global Impression for Bipolar Disorder (SE=0.31, 95% CI=0.13-1.36). The response rate was significantly higher in the ECT group than in the group that received algorithm-based pharmacological treatment (73.9% versus 35.0%), but the remission rate did not differ between the groups (34.8% versus 30.0%). CONCLUSION: Remission rates remained modest regardless of treatment choice for this challenging clinical condition.

The effect of electroconvulsive therapy on neurocognitive function in treatment-resistant bipolar disorder depression.

OBJECTIVE: To compare the effects of right unilateral (RUL) electroconvulsive therapy (ECT) and algorithm-based pharmacologic treatment (APT) on neurocognitive function in treatment-resistant bipolar disorder depression. METHOD: Inpatients with DSM-IV-TR-diagnosed, treatment-resistant bipolar depression, who were acutely admitted to 1 of the 7 clinical study centers in Norway, were recruited from May 2008 to April 2011 into a prospective, randomized controlled, 6-week acute treatment trial. General neurocognitive function was assessed with the MATRICS Consensus Cognitive Battery (MCCB), and retrograde memory for autobiographical events was assessed with the Autobiographical Memory Interview-Short Form (AMI-SF) before and shortly after (mean = 23.5 days) a trial with either RUL brief-pulse ECT (mean dose = 233.3 mC) or APT. RESULTS: Seventy-three patients entered, and 39 (nECT = 19, nAPT = 20) completed. Both groups showed improvements in all MCCB domain scores, with no significant differences between the study groups (no interaction effect: F1,37 = 1.52, P = NS). Improvements in neurocognitive performance were significantly correlated with reductions in depression ratings posttreatment. The AMI-SF score was significantly lower (based on consistent answers from pre- to posttreatment) in the ECT group (72.9%) than in the APT group (80.8%, P = .025), indicating reduced consistency in autobiographical memory after ECT. CONCLUSIONS: General neurocognitive function was unaffected by RUL brief-pulse ECT treatment and positively related to improved mood in bipolar depression. Autobiographical memory consistency was reduced in patients treated with ECT. The results suggest that ECT can be used in treatment-resistant bipolar depression without compromising general neurocognitive function. The clinical relevance of reduced autobiographical memory consistency in the ECT group requires further investigation. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00664976.

Bipolar disorder patients have similar levels of education but lower socio-economic status than the general population.

BACKGROUND: There is conflicting evidence regarding the educational level and its importance for social and occupational functioning in bipolar disorder (BD). The aim of this study was to investigate how educational achievement relates to function in BD compared with the general population, and which clinical factors are associated with level of education. METHODS: Hospitalized patients with DSM-IV BD (N=257; 69.3% BD I; 25.7% BD II; 5.1 BD NOS; 51.4% females) were consecutively recruited from mental health clinics throughout Norway and compared with a geographically matched reference sample from the general population (N=56,540) on levels of education, marital status, income, and disability benefits. Further analyses of association were carried out using logistic regression analyses. RESULTS: A significantly higher proportion of subjects in the BD group than in the reference group was single, had low income, or was disabled. No between-group difference was found in educational level. In the reference group education was inversely correlated with the risk of being disabled, but no such relationship was found in the BD group. Rapid cycling and recurring depressive episodes were the only clinical characteristics associated with low educational level. LIMITATIONS: Acutely admitted patients might not be representative for milder forms of disease. CONCLUSIONS: Despite similar levels of education, BD patients had lower social and occupational function than the general population, and no association was found between education and disability for BD patients.

Despite clinical differences, bipolar disorder patients from acute wards and outpatient clinics have similar educational and disability levels compared to the general population.

BACKGROUND: The aims of this study were to compare clinical characteristics and educational and occupational functioning in two Bipolar Disorder (BD) samples recruited respectively from acutely admitted inpatients and public outpatient clinics and to investigate if the two BD samples differed in the same way in education and work ability from the general population. METHODS: DSM-IV BD patients were consecutively recruited from acute wards throughout Norway (N=252; 69.8% BD I; 25.0% BD II; 5.2% BD NOS) and from outpatient clinics in the Oslo region (N=230; 60.4% BD I; 33.5% BD II; 6.1% BD NOS) and demographic and clinical characteristics were compared. A reference sample from the general population (N=100 869) was used to compare levels of education, marital status and disability benefits. RESULTS: The acute ward sample was older, and had more men, more BD I disorder, more hospitalisations and suicide attempts, longer illness duration, an earlier age of onset and first treatment and used a higher number of antipsychotics, anticonvulsants and lithium than the outpatient sample. Both samples were educated to the same level as their respective reference populations, but received disability benefit and were single to a higher but similar degree. CONCLUSIONS: Clinical differences between the BD samples had no consequence for educational achievement and receipt of disability benefit compared to the general population indicating that other factors than severity of illness play a role for education and work abilities in BD patients.