An observer-rated strategy for differentiating schizophrenic and manic states in inpatient settings.

OBJECTIVES: Differentiating schizophrenia from mania in acutely psychotic patients can be difficult, but is important in determining immediate and subsequent management. Such differentiation is generally addressed by clinical interviews, but an observational approach may assist. This paper therefore describes the development of a relevant observational measure. METHODS: We developed a provisional list of 49 items (weighting features with suggested specificity to schizophrenia and mania) for independent completion by two nurses and judged its ability to predict diagnosis provided by consultant psychiatrists. RESULTS: Eighty-seven psychotic patients were recruited, and 173 completed data sets were analysed. We refined the item set to two sets of 10 items that best-differentiated schizophrenia from mania and vice versa. Optimal differentiation was achieved with a score of at least 7 on both the schizophrenia and mania item sets. Difference scores (i.e. schizophrenia items affirmed minus mania items affirmed) were also generated, with a difference score of +1 (i.e. one or more schizophrenia items being affirmed than mania items) showing optimal differentiation (sensitivity 0.67, specificity 0.82) between the two conditions. Evaluating all potential difference scores, we demonstrated that, as difference scores increased, diagnostic accuracy in identifying each condition was very high. CONCLUSION: Analyses allow the properties of an observational measure (the 20-item Sydney Psychosis Observation Tool) to be described. While a single cut-off difference score was derived with acceptable discriminatory ability, we also established the capacity of varying difference scores to assign both schizophrenia and mania diagnoses with high accuracy.

Hypnosis and suggestion as interventions for functional neurological disorder: A systematic review.

OBJECTIVE: Functional neurological disorder (FND) involves the presence of neurological symptoms that cannot be explained by neurological disease. FND has long been linked to hypnosis and suggestion, both of which have been used as treatments. Given ongoing interest, this review examined evidence for the efficacy of hypnosis and suggestion as treatment interventions for FND. METHOD: A systematic search of bibliographic databases was conducted to identify group studies published over the last hundred years. No restrictions were placed on study design, language, or clinical setting. Two reviewers independently assessed papers for inclusion, extracted data, and rated study quality. RESULTS: The search identified 35 studies, including 5 randomised controlled trials, 2 non-randomised trials, and 28 pre-post studies. Of 1584 patients receiving either intervention, 1379 (87%) showed significant improvements, including many who demonstrated resolution of their symptoms in the short-term. Given the heterogeneity of interventions and limitations in study quality overall, more formal quantitative synthesis was not possible. CONCLUSIONS: The findings highlight longstanding and ongoing interest in using hypnosis and suggestion as interventions for FND. While the findings appear promising, limitations in the evidence base, reflecting limitations in FND research more broadly, prevent definitive recommendations. Further research seems warranted given these supportive findings.

Calibrating violence risk assessments for uncertainty.

Psychiatrists and other mental health clinicians are often tasked with assessing patients' risk of violence. Approaches to this vary and include both unstructured (based on individual clinicians' judgement) and structured methods (based on formalised scoring and algorithms with varying scope for clinicians' judgement). The end result is usually a categorisation of risk, which may, in turn, reference a probability estimate of violence over a certain time period. Research over recent decades has made considerable improvements in refining structured approaches and categorising patients' risk classifications at a group level. The ability, however, to apply these findings clinically to predict the outcomes of individual patients remains contested. In this article, we review methods of assessing violence risk and empirical findings on their predictive validity. We note, in particular, limitations in calibration (accuracy at predicting absolute risk) as distinct from discrimination (accuracy at separating patients by outcome). We also consider clinical applications of these findings, including challenges applying statistics to individual patients, and broader conceptual issues in distinguishing risk and uncertainty. Based on this, we argue that there remain significant limits to assessing violence risk for individuals and that this requires careful consideration in clinical and legal contexts.

Apathy and depression in mild cognitive impairment: distinct longitudinal trajectories and clinical outcomes.

OBJECTIVES: Apathy is a common symptom in mild cognitive impairment (MCI) and may predict progression to dementia. Little research, however, has investigated the longitudinal trajectory of apathy in patients with MCI or controlled for depression, which can mimic apathy, when examining its clinical correlates. The current study sought to address these issues. DESIGN: A prospective longitudinal study was conducted over 3 years. SETTING: Nine memory clinics around Australia. PARTICIPANTS: One hundred and eighty-five patients with MCI at baseline. MEASUREMENTS: Measures of cognition, function, neuropsychiatric symptoms, caregiver burden, and medication use were completed annually with additional assessments at 3 and 6 months. Patients were also assessed for dementia by expert clinicians at these time points. RESULTS: Of 164 patients who completed measures of neuropsychiatric symptoms, 59 (36.0%) had apathy and 61 (37.2%) had depression. The proportion affected by apathy and overall apathy scores increased over time, in contrast to measures of depression, which remained relatively stable. Apathy was associated with incident dementia and worse cognition, function, neuropsychiatric symptoms, and caregiver burden independent of both depression and incident dementia. Depression was associated with worse function, albeit to lesser degree than apathy, and neuropsychiatric symptoms. CONCLUSIONS: Apathy increases in MCI and is associated with worse clinical outcomes. These findings provide further evidence for apathy as a marker of clinical decline in older people and poorer outcomes across neurocognitive disorders.

Paediatric bipolar disorder and its controversy.

OBJECTIVES: Paediatric bipolar disorder - bipolar disorder occurring in prepubertal children - is a diagnosis subject to considerable controversy. Whilst historically considered to be very rare, proponents since the 1990s have argued that mania can present differently in children and, as such, is much more common than previously thought. Such proposals raise questions about the validity of proposed phenotypes and potential risks of iatrogenic harm. METHODS: I critically examine the construct of paediatric bipolar disorder using Robins and Guze's (1970, American Journal of Psychiatry126, 983-987) influential criteria for the validity of a psychiatric diagnosis. I review, in turn, evidence relating to its clinical description, delimitation from other conditions, follow-up studies, family studies, laboratory studies, and treatment response. RESULTS: Across domains, existing research highlights significant challenges establishing the diagnosis. This includes significant heterogeneity in operationalising criteria for children; variable or poor inter-rater reliability; difficulty distinguishing paediatric bipolar disorder from other conditions; large differences in rates of diagnosis between the United States of America and other countries; limited evidence of continuity with adult forms; and a lack of evidence for proposed paediatric phenotypes in children at genetic high-risk of the condition. Laboratory and treatment studies are limited, but also do not provide support for the construct. CONCLUSIONS: Evidence for the more widespread existence of paediatric bipolar disorder and its various proposed phenotypes remains weak. The ongoing popularity of the diagnosis, most evident in America, may reflect social pressures and broader limitations in psychiatric nosology. The uncertainty around the diagnosis highlights the need for careful longitudinal assessment of children potentially affected.

Distinguishing apathy and depression in dementia: A longitudinal study.

OBJECTIVES: Apathy is a common symptom in dementia, though can be difficult to distinguish from depression due to shared features and frequent co-occurrence. As such, a significant limitation of much previous research on apathy is the failure to control for depression. The current study sought to address this by examining the trajectory and clinical correlates of apathy after controlling for depression. METHODS: Seven hundred and seventy-nine patients with dementia were recruited from nine memory clinics around Australia. Measures of dementia severity, cognition, functional ability, neuropsychiatric symptoms, caregiver burden and medication use were completed at baseline and at regular intervals over a 3-year period. Driving and institutionalisation data were obtained throughout the study. Mortality data were obtained from state registries 8 years after baseline. RESULTS: Of the 662 patients with completed measures of neuropsychiatric symptoms, 342 (51.7%) had apathy and 332 (50.2%) had depression at baseline, while 212 (32.0%) had both. Whereas apathy increased over time, depression remained relatively stable. Apathy, but not depression, was associated with greater dementia severity, poorer cognition and function, driving cessation and mortality. Both apathy and depression were associated with greater neuropsychiatric symptoms, psychosis, caregiver burden and institutionalisation. CONCLUSIONS: Apathy increases over the course of dementia and is associated with worse clinical outcomes independent of depression. Distinguishing apathy and depression appears important given their different implications for prognosis and management.

Apathy and Depression in Huntington's Disease: Distinct Longitudinal Trajectories and Clinical Correlates.

OBJECTIVE: Huntington's disease (HD) is an autosomal-dominant neurodegenerative disease resulting in motor disturbances, dementia, and psychiatric symptoms. Apathy is a common manifestation and rated as one of the most impactful by patients and caregivers. It can often be difficult to distinguish from depression because of shared features and frequent overlap. This study examined the longitudinal trajectories and clinical correlates of apathy and depression. METHODS: Data were drawn from the Cooperative Huntington Observational Research Trial, a prospective, multicenter observational study that recruited 1,082 patients with HD. Measures of cognition, function, neuropsychiatric symptoms, motor function, and medication use were completed annually over 5 years. RESULTS: Overall, 423 patients (39%) showed evidence of apathy at study baseline, and both the prevalence and overall severity of apathy increased over time. Depression, by contrast, affected a similar proportion at baseline, although levels remained relatively stable over the study. Apathy was associated with worse cognition, function, neuropsychiatric symptoms, and motor symptoms. Depression was associated with worse neuropsychiatric symptoms, suicidal ideation, and independence but not other outcomes after control for other variables. CONCLUSIONS: Apathy in HD increased over time and was associated with worse clinical outcomes. These associations were independent of depression and other clinical variables. The findings highlight the need to distinguish between apathy and depression given their distinct implications for prognosis and management.

Presentations to the emergency department with self-harm or suicidal behaviours: A role for digital mental health services?

Emergency Department (ED) is an important site for assessing people presenting with self-harm or suicidal behaviors. Digital mental health services (DMHS) offer evidence-based interventions for mental health issues, but are often under-utilised, and information about them is rarely provided in ED. This feasibility study explored whether offering information about a DMHS to individuals presenting to ED with self-harm/suicidal behaviors resulted in self-enrolment in DMHS interventions for anxiety, depression and/or chronic pain. METHODS: all individuals aged 18+ presenting with self-harm/suicidal behaviors to a metropolitan ED were screened for symptoms of anxiety, depression and/or chronic pain. Those with these symptoms were invited to participate in a study investigating enrolment with a DMHS. Study participants were provided with information about DMHS and followed up at one month. RESULTS: 260 individuals presented with self-harm/suicidal behaviors over the 6-month study period. Many reported low mood (73.5%, n = 191) anxiety (67.2%, n = 174) and/or chronic pain (18.5%, n = 48). Half of those eligible for DMHS agreed at point of ED discharge to be contacted about participation in the DMHS study (51.4%, n = 108). One-third of these participated in the study (35.2%, n = 38). Rates of past-month high-risk SB (65.8%, n = 25), depression (92.1%, n = 35), anxiety (78.9%, n = 30) and chronic pain (57.9%, n = 22) were very high. Of these, 39.5% (n = 15) self-enrolled with the DMHS; almost all (80.0%, n = 13) engaged with an online intervention. CONCLUSIONS: A subset of people presenting to emergency department with suicidal behaviors will engage with DMHS. Better understanding is needed of factors contributing to uptake of DMHS in this group.

Pseudodementia, pseudo-pseudodementia, and pseudodepression.

Dementia has a wide range of reversible causes. Well known among these is depression, though other psychiatric disorders can also impair cognition and give the appearance of neurodegenerative disease. This phenomenon has been known historically as "pseudodementia." Although this topic attracted significant interest in the 1980s and 1990s, research on the topic has waned. In this paper, we consider reasons for this decline, including objections to the term itself and controversy about its distinctness from organic dementia. We discuss limitations in the arguments put forward and existing research, which, crucially, does not support inevitable progression. We also discuss other neglected masquerades, such as of pseudodementia itself ("pseudo-pseudodementia") and depression ("pseudodepression"). Based on this reappraisal, we argue that these terms, while not replacing modern diagnostic criteria, remain relevant as they highlight unique groups of patients, potential misdiagnosis, and important, but neglected, areas of research.

Delusions and theories of belief.

Cognitive neuropsychiatry is a branch of cognitive psychology that seeks to explain neuropsychiatric symptoms in terms of disruptions or damage to normal cognitive processes. A key objective of this approach is to use insights derived from the study of pathological symptoms to inform accounts of premorbid cognitive systems. Delusions, in particular, can be considered to represent dysfunction of the cognitive processes underlying belief formation, so studying delusions may provide unique insights into nonpathological belief. While this approach has provided compelling accounts for a range of delusions in terms of putative cognitive dysfunctions, it is less clear that it has achieved progress in its reciprocal goal of informing understanding of belief more generally. In this review, we trace the origins of the cognitive neuropsychiatric approach and consider the reasons for the lack of progress. We propose a tentative framework to overcome these challenges and suggest directions for future research.

Psychosis and longitudinal outcomes in Huntington disease: the COHORT Study.

OBJECTIVE: Huntington disease (HD) is an autosomal dominant neurodegenerative disease involving motor disturbances, cognitive decline and psychiatric symptoms. Psychotic symptoms occur in a significant proportion of patients. We sought to characterise the clinical outcomes of this group of patients. METHODS: Data were drawn from the Cooperative Huntington Observational Research Trial, a prospective, multi-centre observational study. 1082 patients with HD were recruited. Measures of cognition, function, behavioural disturbance and motor function were completed annually over 5 years. RESULTS: Overall, 190 patients (17.6%) displayed psychotic symptoms. These patients demonstrated worse cognition, function and behavioural disturbances than patients without psychosis over time. Patients with psychosis also demonstrated lower levels of chorea than patients without psychosis, despite adjusting for concurrent antipsychotic and tetrabenazine use. CONCLUSIONS: Psychosis in HD is associated with poorer outcomes in cognition, function and behavioural symptoms. Patients with psychotic symptoms may also have less chorea. Altogether, the findings suggest patients with psychosis have a distinct clinical course.

Dementia and caregiver burden: A three-year longitudinal study.

OBJECTIVES: Dementia, with its progressive cognitive and functional decline and associated neuropsychiatric symptoms, places a large burden on caregivers. While frequently studied, longitudinal findings about the overall trajectory of burden are mixed. The study sought to characterize caregiver burden over a 3-year period and identify predictors of this burden. METHODS: Seven-hundred-and-eighty-one patients with dementia were recruited from nine memory clinics around Australia. Measures of caregiver burden, cognition, function, and neuropsychiatric symptoms were completed with patients and their caregivers at regular intervals over a 3-year period. Patients' level of services and medication use were also recorded. RESULTS: Of the 720 patients with measures of caregiver burden at baseline, 47.4% of caregivers had clinically significant levels of burden. This proportion increased over time, with 56.8% affected at 3 years. Overall levels of burden increased for caregivers of patients without services, though did not change for caregivers of patients receiving services or residential care after controlling for other variables. Patient characteristics-including greater neuropsychiatric symptoms, lower functional ability, fewer medications, lack of driving ability-and female sex of caregivers were associated with greater burden. CONCLUSIONS: High levels of caregiver burden are present in a large proportion of caregivers of people with dementia and this increases over time for those without services. Clinical characteristics of patients (including neuropsychiatric symptoms, function, overall health, driving status), level of services, and caregiver sex appear to be the best predictors of this burden. These characteristics may help identify caregivers at greater risk of burden to target for intervention.

Mild Cognitive Impairment and Caregiver Burden: A 3-Year-Longitudinal Study.

OBJECTIVES: Mild cognitive impairment (MCI) is common, affecting 10%-35% of people over 65, and poses unique challenges for patients and their caregivers. Comparatively little research has examined caregiver burden in this population, with longitudinal research, in particular, lacking. We examined caregiver burden in a sample of people with MCI over 3 years. DESIGN: Three-year observational study. SETTING: Nine memory clinics in Australia. PARTICIPANTS: One-hundred-and-eighty-five people with MCI and their caregivers. MEASUREMENTS: Measures of caregiver burden, cognition, function, neuropsychiatric symptoms, driving status, and medication use were completed with patients and their caregivers at regular intervals over a 3-year period. RESULTS: Between 21.1% and 29.5% of caregivers reported a clinically significant level of burden over the study. Patients' higher levels of neuropsychiatric symptoms, lower functional ability, and lack of driving ability, and caregivers' employment were associated with greater caregiver burden over time. Caregiver burden did not increase over time when controlling for patient and caregiver characteristics. CONCLUSIONS: High levels of caregiver burden are present in a significant proportion of caregivers of people with MCI. Clinical characteristics of patients - including severity of neuropsychiatric symptoms and functional impairment - and the employment status of caregivers predict burden. Such characteristics may help identify caregivers at greater risk of burden to target for intervention.

Longitudinal outcomes of patients with pseudodementia: a systematic review.

Depression and a number of other psychiatric conditions can impair cognition and give the appearance of neurodegenerative disease. Collectively, this group of disorders is known as 'pseudodementia' and are important to identify given their potential reversibility with treatment. Despite considerable interest historically, the longitudinal outcomes of patients with pseudodementia remain unclear. We conducted a systematic review of longitudinal studies of pseudodementia. Bibliographic databases were searched using a wide range of search terms. Two reviewers independently assessed papers for inclusion, rated study quality, and extracted data. The search identified 18 studies with follow-up varying from several weeks to 18 years. Overall, 284 patients were studied, including 238 patients with depression, 18 with conversion disorder, 14 with psychosis, and 11 with bipolar disorder. Irrespective of diagnosis, 33% developed irreversible dementia at follow-up, 53% no longer met criteria for dementia, and 15% were lost to follow-up. Considerable variability was identified, with younger age at baseline, but not follow-up duration, associated with better outcomes. ECT and pharmacological interventions were also reported to be beneficial, though findings were limited by the poor quality of the studies. Overall, the findings suggest that pseudodementia may confer an increased risk of irreversible dementia in older patients. The findings also indicate, however, that a significant proportion improve, while many remain burdened with their psychiatric condition, independent of organic dementia. The findings support the clinical value of the construct and the need for its re-examination in light of developments in neuroimaging, genomics, other investigative tools, and trial methodology.