Antidepressant-associated mania: a controlled comparison with spontaneous mania.

OBJECTIVE: Antidepressants have been associated with the induction of mania and rapid cycling. This study examined whether antidepressant-associated manic states differ in any way from spontaneous mania. METHOD: Forty-nine consecutive inpatients with antidepressant-associated manic states were compared with 49 matched inpatients with spontaneous mania in a blind, retrospective chart review. RESULTS: Across virtually every clinical measure examined, the patients with antidepressant-associated manic states experienced milder and more time-limited manic episodes than the patients with spontaneous mania. The patients with antidepressant-associated manic states were subject to frequent checking by nurses and hall restriction for a significantly shorter period of time than the patients with spontaneous mania. The patients with antidepressant-associated manic states also had significantly less severe levels of delusions, hallucinations, psychomotor agitation, and bizarre behavior, according to a standard rating instrument, than the patients with spontaneous mania. For further study the patients with antidepressant-associated mania were divided into subgroups taking four individual classes of antidepressant drugs: tricyclics (N = 19), fluoxetine (N = 13), monoamine oxidase inhibitors (MAOIs) (N = 8), and bupropion (N = 6); three patients taking combinations of drugs were not included in these analyses. The patients with MAOI- and bupropion-associated mania had a slightly lower overall rating of severity of psychopathology at admission than the subgroups with fluoxetine- and tricyclic-associated mania. CONCLUSIONS: Antidepressant-associated mania appears to be a milder and more time-limited syndrome than spontaneous mania and may represent a distinct clinical entity. MAOIs and bupropion may be associated with milder manic states than either tricyclic drugs or fluoxetine.

Comorbidity in psychosis at first hospitalization.

OBJECTIVE: The authors sought to determine the prevalence and effects of medical and psychiatric comorbidity on initial outcome in a group of patients experiencing a first episode of psychosis. METHOD: Patients with a first episode of psychosis who were consecutively admitted to a hospital (N = 102) were examined for the presence of psychiatric and medical disorders. Patients were given psychiatric diagnoses with the use of the Structured Clinical Interview for DSM-III-R and were rated weekly on symptom rating scales. Outcome variables at discharge were final symptom rating scale scores, length of hospitalization, and recovery on the basis of operationalized criteria. RESULTS: Comorbid diagnoses were present in 52.0% (N = 53) of the patients, and 37.7% (N = 20) had multiple comorbid diagnoses. The most common comorbid diagnosis was substance abuse. Patients with affected psychoses were significantly more likely than those with nonaffective psychoses to have a comorbid substance abuse diagnosis. Patients with psychiatric comorbidity had poorer initial outcomes, while those with medical comorbidity had fewer symptoms at discharge. CONCLUSIONS: Comorbidity is common and may be a useful predictor of the outcome of a first episode of psychosis.

The effects of race and comorbidity on clinical diagnosis in patients with psychosis.

BACKGROUND: For several years, studies have indicated that schizophrenia is overdiagnosed in nonwhite patients with psychosis. Whether these reports have altered racial diagnostic patterns in clinical settings remains uncertain. We hypothesized that the clinical overdiagnosis of schizophrenia in nonwhite patients persists in the public sector. Further, we explored whether differences between races in secondary (comorbid) diagnoses contribute to discrepancies in primary diagnoses. METHOD: Data were obtained by retrospective chart reviews of 173 patients with psychotic disorders discharged during a recent 7-month period from a large state psychiatric hospital. Demographic and clinical variables were obtained from the medical records. All clinical information had been recorded by the treatment teams without knowledge of this study. Only black and white racial subgroups were represented in this sample. RESULTS: Black patients were significantly more likely to be diagnosed with schizophrenia than white patients (odds ratio = 5.1), and men were more likely to be diagnosed with schizophrenia than women (odds ratio = 1.9). This racial pattern was observed even in the subgroup of patients hospitalized for the first time (odds ratio = 7.0). Neither the type nor frequency of comorbid diagnoses significantly differed between races. Additionally, black patients received higher doses of antipsychotic medication. CONCLUSION: Black patients with psychosis are significantly more likely to be diagnosed with schizophrenia than similar white patients in the public sector. This may reflect underdiagnosis of affective illness in black patients. Additionally the higher doses of antipsychotic medication that black patients received may alter clinical presentation and contribute to this discrepancy in diagnosis.

Clozapine therapy in refractory affective disorders: polarity predicts response in long-term follow-up.

BACKGROUND: To determine the efficacy and tolerance of long-term clozapine therapy in refractory affective illness. METHOD: Hospital records were reviewed for 193 treatment-resistant patients with a discharge diagnosis of bipolar disorder (N = 52), schizoaffective disorder (N = 81), unipolar depression (N = 14), schizophrenia (N = 40), or other disorders (N = 6) started on clozapine therapy as inpatients at McLean Hospital. An independent "best-estimate" diagnosis, based on DSM-III-R criteria, was established for each patient. Patients were contacted at least 6 months after clozapine initiation for structured follow-up interviews by raters blind to diagnosis. Patients were stratified by diagnosis, and a variety of patient characteristics and outcome measures were compared. RESULTS: Subjects were followed up a mean of 18.7 months after clozapine initiation. Bipolar manic and schizoaffective bipolar subjects had significantly better outcomes than unipolar, bipolar, and schizoaffective depressed patients on a variety of measures. One or more episodes of depression prior to clozapine predicted clozapine discontinuation (p = .01). Affective and schizoaffective subjects had baseline measures of social functioning similar to that of the schizophrenics but had significantly greater improvement in scores at follow-up. CONCLUSION: Clozapine is an efficacious and well-tolerated therapy for refractory affective illness. Manic symptomatology predicts a more favorable response than depression.

The McLean First-Episode Psychosis Project: six-month recovery and recurrence outcome.

The McLean First-Episode Psychosis project began in 1989. The authors describe the study design, diagnostic distribution, and recovery and relapse data on the first 102 recruited subjects. Fifty-nine percent of the subjects had a diagnosis of bipolar disorder, 15 percent psychotic depression, 10 percent schizophrenic spectrum, 9 percent delusional disorder, and 8 percent other psychotic disorders. By 6 months, 80 percent recovered syndromically but only 55 percent recovered functionally, and only 50 percent recovered both functionally and syndromically. Non-white and male patients were more likely to have a recurrence. Men were less likely and bipolar patients were more likely to recover functionally. Patients with nonaffective psychosis had longer hospitalizations and lower rates of functional recovery 6 months after discharge.

Childhood abuse in first-episode psychosis.

Of 38 adult patients admitted for first-episode psychosis, 20 reported childhood abuse, with equal prevalence in men and women. Patients with histories of childhood abuse had significantly more dissociative symptoms, but not more severe psychiatric symptoms. Childhood abuse was not related to rate of recovery and was only marginally related to longer stays in hospital. Although childhood abuse did not affect recovery during first-episode psychosis, it may contribute to a chronic course in some patients.

Neurologic factors predict a favorable valproate response in bipolar and schizoaffective disorders.

The hypothesis that neurologic factors influence the response to valproate (divalproex sodium) in bipolar and schizoaffective disorders was tested. In 115 predominantly lithium-refractory inpatients, neurologic findings were recorded, and blind raters assessed valproate response from the medical record. Patients with a seizure history were much more likely to have a robust response to valproate (70%), when compared with patients without such history (34.6%). History of head injury and abnormal electroencephalographic findings also tended to be more common in those patients with good response. Overall, the group of patients with any neurologic abnormality exhibited a significantly higher rate of good response to valproate (43.6%) than did the neurologically normal group (24.3%). Bipolar or schizoaffective patients with abnormal neurologic features may represent a distinct subtype of illness and appear to be good candidates for valproate therapy.