Kenneth Krajewski

Suicidality, panic disorder and psychosis in bipolar depression, depressive-mania and pure-mania

This study was undertaken to assess links between suicidality, panic disorder, psychosis, bipolar depression, depressive-mania and pure-mania. The subjects are a consecutive series of 129 persons with bipolar disorder who were admitted to a university teaching hospital; 53 had bipolar depression, 32 had depressive-mania and 44 had pure-mania. They met the Research Diagnostic Criteria (RDC) for major depressive disorder (bipolar depression), primary mania (pure-mania) or both disorders (depressive-mania) at entry into the study. Suicidality, intra-episode panic disorder (IEPD) and psychotic features were ascertained using structured interviews. Sources of data included a routine clinical interview, serial clinical assessments, the Schedule for Affective Disorders and Schizophrenia (SADS), the Structured Clinical Interview for DSM-III-R and reviews of charts. Multivariate logistic regression analysis was used to determine the strength of the relationships between suicidality, IEPD, psychotic features and the phase of illness. The rates of suicidality (79.3%, 56.3% and 2.3%), IEPD (62.3%, 62.5% and 2.3%) and psychotic features (52.8%, 96.9% and 88.6%) differed significantly between the groups with bipolar depression, depressive-mania and pure-mania. Subjects with bipolar depression and depressive-mania resembled one another with respect to the severity, but not rate of suicidality. They had identical rates of IEPD. Subjects with bipolar depression had a higher probability of being suicidal and a lower probability of being psychotic than persons with either subtype of mania. Pure-mania was distinguished by low rates of suicidality and IEPD. The authors describe directions for prospective studies of the relationships between phase of illness and phenomena in groups of bipolar persons.

Treatment of bipolar depression with carbamazepine: Results of an open study

Bipolar disorder (BPD) is a serious, potentially lethal disease afflicting 1.2% of the adults in the United States (Weissman et al 1988). The rate of illness increases greatly if variants such as cyclothymia and pseudounipolar disorder are included in estimates. Morbidity and early mortality stem from multiple sources; 18.9% of the deaths of 9389 bipolar patients were due to suicide (Goodwin and Jamison 1990 pp 228-230). Substance abuse is an important factor (Regier et al 1990). The lifetime rate of the abuse of or dependence upon alcohol and/or other drugs is 61% (Goodwin and Jamison 1990 pp 210-226). Antidepressants may have pernicious effects on persons with BPD. They may induce rapid cycling (Wehr and Goodwin 1989), mania (Wehr and Goodwin 1989; Angst 1985), or mixed states (Dilsaver and Swarm 1995). Despite deficiencies of existing regimens for BPD and its epidemiological significance, minimal effort is devoted to the development of new strategies for its treatment. Goodwin and Jamison (1990) provide a detailed history of the treatment of BPD. Only recent contributions will be reviewed here. Lithium (Goodwin et al 1969; Wehr and Goodwin 1989), bupropion (Haykel and Akiskal 1989), and tranylcypromine (Himmeloch et al 1991) are alternative treatments. Bupropion may be useful in the treatment of rapidly cycling patients (Haykel and Akiska 1989) and persons with depressive mania

Is Schizoaffective Disorder a Stable Diagnostic Category: A Retrospective Examination

Debate continues about whether clear nosologic boundaries can be drawn between schizoaffective disorder (SA), schizophrenia (SP), and bipolar disorder (BPD). This study attempted to clarify these boundaries. A retrospective review of the records of adult psychiatric inpatients with DSM-IV diagnoses of SA (n=96), SP (n=245), and BPD (n=203) was conducted. Patients were assessed at admission and discharge using standardized rating scales (completed by physicians and nurses) and self-report inventories. Differential improvement over time also was examined. Significant differences were found for gender, legal status at admission, age, LOS, episode number, and ethnicity. Overall, SA was rated by clinicians as intermediate between SP and BPD, although SA rated themselves as the most severe. SA was similar to SP on positive symptoms, intermediate on negative symptoms, and similar to BPD on mood- and distress-related symptoms. Independent of diagnosis, differences in change scores from admission to discharge were related to severity level at admission. Although several differences were found in symptom severity across domains, no syndrome was identifiable associated with the diagnosis of SA and the diagnosis was unstable over time, thereby bringing into question the validity of SA as a diagnostic entity.

Prior history of physical and sexual abuse among the psychiatric inpatient population: A comparison of males and females

Despite increasing attention given to the high prevalence and effects of abuse in the severely mentally ill, few studies have looked at its effects among males. While both male and female psychiatric patients report greater abuse history than the general population, studies have focused on females alone. The current study compared the effects of abuse history between 271 severely mentally ill males (n = 160) and females (n = 111). The mean age of participants was 33.7 years (SD = 9.73), and included 129 Caucasians, 120 African Americans, 15 Hispanic-Americans, and 7 “Other” (i.e., Asian and native American descent). Primary Axis I diagnoses included Bipolar disorder (23.2%) major depressive disorder (27.7%) schizophrenic disorder (26.6%), substance-related disorders (10.3%), and miscellaneous disorders (12.1%). Each patient completed a comprehensive assessment, including clinician ratings, self-report measures, clinical and structured interviews. Comparisons between genders revealed that females were more likely to report both physical and sexual abuse, and males were more likely to report no history of abuse. In addition, Caucasians were more likely to report abuse than were African Americans, and voluntary patients were more likely to endorse abuse history than those admitted involuntarily. Few gender differences were found in psychological symptoms among males and females. Satisfaction with the home environment was significantly lower for abused than nonabused females. This was not true for males. However, abused psychiatric patients were perceived by the physicians, nurses, and themselves as having greater emotional disturbance than were nonabused patients, regardless of gender. Clinical implications are discussed.

Eye movements in cocaine abusers

Using electro-oculography, we quantitatively investigated eye movements in nine heavy cocaine abusers and three groups of controls. Plasma levels of 3-methoxy-4-hydroxyphenylglycol (MHPG), a major metabolite of brain norepinephrine, in cocaine abusers were reduced to an average of 53% of normal. Cocaine abusers had normal smooth pursuit, optokinetic nystagmus, vestibulo-ocular reflex, visual suppression of the vestibulo-ocular reflex, and caloric nystagmus. Data were suggestive of a significant reduction in the degree of immediate enhancement of visual-vestibulo-ocular reflex gain by magnified vision in the cocaine abusers. However, adaptive plasticity of the vestibulo-ocular reflex was normal in the cocaine abusers. These results suggest that, despite animal data linking vestibulo-ocular reflex plasticity to central norepinephrine, this neurotransmitter may not be important to plasticity in human beings.

Differential modification of morphine and methadone dependence by interferon alpha

Subcutaneous implantation of a pellet of methadone was presented as a novel method for the establishment of physical dependence upon this agent and it was compared to (1) the state of physical dependence induced by multiple injections of methadone, administered over several days, and (2) the dependence established by injections of morphine and the implantation of a morphine pellet. Comparable signs of drug dependence were observed in rats treated with both morphine and methadone following the administration of the opiate antagonist naloxone. The administration of interferon-alpha significantly attenuated the severity of the withdrawal syndrome in dependent rats after chronic exposure to morphine and to a lesser extent after morphine and methadone in combination. In contrast, alpha interferon did not affect 6 of the 7 abstinence signs in animals dependent upon methadone alone. The observations suggest that the states of physical dependence upon morphine and methadone may be separate phenomena that involve different physiological mechanisms. Thus, interferon may be a useful adjunct in the treatment of subjects dependent upon morphine but not in those dependent on methadone.

General and specific locus of control in cocaine abusers

Although the struggle for control has been widely recognized as a central feature of addiction, information about its role in the development and maintenance of addictive behavior is limited. This study compared general and specific locus of control in three groups of cocaine abusers: (a) hospitalized subjects with no prior treatment experience, (b) hospitalized subjects with prior treatment experience, and (c) recovering cocaine abusers. Results of initial analyses of variance revealed significant group differences on both general and specific scales. Scores of recovering cocaine abusers were more internal than those of hospitalized subjects. Differences on the general scale were not significant when age was controlled. No significant differences were noted between the two groups of hospitalized subjects, but scores of hospitalized cocaine abusers made an internal shift over the course of treatment. These findings support generalizability of models previously applied to alcoholics and suggest that internality is positively correlated with recovery.

Measurement of locus of control in cocaine abusers

Although the course of recovery for cocaine abusers is particularly problematic, there has been little investigation of perceptions of control in this population. The purposes of this study were (1) to develop an instrument that would measure specific expectancies of control in cocaine abusers, and (2) to examine the relationship between specific and generalized expectancies of control in these subjects. Rotters I-E scale and a modification of the Drinking-Related Locus of Control (DRIE) scale were administered to 40 cocaine abusers in their first week of treatment. The Modified DRIE scale demonstrated adequate internal consistency and satisfactory test-retest reliability in the sample. No significant correlation was found between the Modified DRIE scale and the I-E scale, probably because of the relatively small sample size. Further validation of the Modified DRIE scale is indicated.

A Comparison Between Patients Diagnosed With Bipolar Disorder With Versus Without Comorbid Substance Abuse

ObjectivesThe purpose of the study was to compare hospitalized individuals with bipolar disorder with and without comorbid substance abuse, on demographic, hospital-related data, symptom severity, and severity change during hospitalization. MethodsIndividuals who met diagnostic criteria (bipolar disorder or bipolar disorder with comorbid substance abuse) were compared on demographic variables (sex, race, and age), hospital-related variables (episode number, length of stay, number of days out of the hospital, and legal status at the time of admission), clinician-rated measures (Brief Psychiatric Rating Scale and Affective Disorder Rating Scale), and self-report measures (Brief Symptom Inventory, Internal State Scales, Short Michigan Alcohol Screening Test, Drug Abuse Screening Test, Barratt Impulsiveness Scale, Social Functioning Questionnaire and Multidimensional Scale of Perceived Social Support). ResultsMen were more likely than women to be in the comorbid group [bipolar disorder and comorbid substance abuse (BPDSA)]. Whites were more likely than other groups to be diagnosed with BPDSA. Those with bipolar disorder alone (BPD) had more previous episodes, longer hospital stays, and less days out of the hospital between admissions. Among the rating scales, physicians and nurses were more likely to rate the BPD group with more severe symptoms. In contrast, the participants in the BPDSA group rated their own symptoms as more severe, in comparison with the BPD group. ConclusionsThese results indicated that the BPD group were sicker overall than were those with comorbid substance abuse. This suggests that some of the symptoms seen in the BPDSA group may be attributable to substance use and therefore may have abated quickly once those individuals were unable to use substances.

Aftercare compliance: Perceptions of people with dual diagnoses

This descriptive study was designed to learn, from the perspective of dually diagnosed inpatients, what factors affect their maintenance of an aftercare program. Ten audio-recorded focus groups were conducted using a structured interview schedule; additionally, patients participated in structured brief individual interviews, and their medical records were reviewed for demographic data and chief complaints on admission. Despite the numerous obstacles encountered by this population intrapersonally, interpersonally, environmentally, and socially, participants were able to provide (a) specific information to increase the understanding of compliance from their perspective and (b) recommendations for health care professionals to facilitate adherence to aftercare treatment plans.