Noel Kennedy

Meta-analysis of magnetic resonance imaging brain morphometry studies in bipolar disorder

BACKGROUND Several studies assessing volumetric measurements of regional brain structure in bipolar disorder have been published in recent years, but their results have been inconsistent. Our aim was to complete a meta-analysis of regional morphometry in bipolar disorder as assessed using magnetic resonance imaging (MRI). METHODS We conducted a systematic literature search of MRI studies of bipolar disorder and identified studies which reported volume measurements in a selected number of regions. Twenty-six studies comprising volumetric measurements on up to 404 independent patients with bipolar disorder were included. A meta-analysis was carried out comparing the volumes of regions in bipolar disorder to comparison subjects using a random effects model. RESULTS Patients with bipolar disorder had enlargement of the right lateral ventricle, but no other regional volumetric deviations which reached significance. Strong heterogeneity existed for several regions, including the third ventricle, left subgenual prefrontal cortex, bilateral amygdala and thalamus. CONCLUSIONS Regional volume of most structures we studied is preserved in bipolar disorder as a whole, which was significantly associated only with right-sided ventricular enlargement. However the extensive heterogeneity detected indicates the need for further studies to establish if consistent regional brain volume deviation exists in bipolar disorder or in specific clinical subsets of the illness.

Suicide and other causes of mortality in bipolar disorder: a longitudinal study

BACKGROUND The high risk of suicide in bipolar disorder is well recognized, but may have been overestimated. There is conflicting evidence about deaths from other causes and little known about risk factors for suicide. We aimed to estimate suicide and mortality rates in a cohort of bipolar patients and to identify risk factors for suicide. METHOD All patients who presented for the first time with a DSM-IV diagnosis of bipolar I disorder in a defined area of southeast London over a 35-year period (1965-1999) were identified. Mortality rates were compared with those of the 1991 England and Wales population, indirectly standardized for age and gender. Univariate and multivariate analyses were used to test potential risk factors for suicide. RESULTS Of the 239 patients in the cohort, 235 (98.3%) were traced. Forty-two died during the 4422 person-years of follow-up, eight from suicide. The standardized mortality ratio (SMR) for suicide was 9.77 [95% confidence interval (CI) 4.22-19.24], which, although significantly elevated compared to the general population, represented a lower case fatality than expected from previous literature. Deaths from all other causes were not excessive for the age groups studied in this cohort. Alcohol abuse [hazard ratio (HR) 6.81, 95% CI 1.69-27.36, p=0.007] and deterioration from pre-morbid level of functioning up to a year after onset (HR 5.20, 95% CI 1.24-21.89, p=0.024) were associated with increased risk of suicide. CONCLUSIONS Suicide is significantly increased in unselected bipolar patients but actual case fatality is not as high as previously claimed. A history of alcohol abuse and deterioration in function predict suicide in bipolar disorder.

Incidence and distribution of first-episode mania by age: results from a 35-year study

BACKGROUND Few epidemiological studies have investigated incidence by age or age at onset distributions for mania or bipolar disorder. The current study aimed to determine these in a defined area in south-east London, over a 35-year period. METHOD All cases of first-episode mania presenting to psychiatric services in Camberwell, south-east London, between 1965 and 1999 were identified. Incidence rates by age, using 5-year age-at-onset bands, were estimated and the structure of the age-at-onset distribution for first-episode mania was investigated using finite mixture distributions (admixture analysis). RESULTS The incidence of DSM-IV bipolar I disorder (BP I), first manic episode peaked in early adult life (16.38/100,000 population per year in the 21-25 years band) with a much smaller peak in mid-life. A two-component normal mixture distribution fitted age at onset better than either a single normal distribution or a three-component mixture, implying the existence of early and later onset subgroups. The early onset group had a stronger family history of bipolar disorder, and showed more acute, severe and atypical symptoms during their first manic episode. CONCLUSIONS The incidence of mania peaks in early adult life but there is clear evidence of early and later onset subgroups which may represent different forms of disorder.

Trends in cannabis use prior to first presentation with schizophrenia, in South-East London between 1965 and 1999.

BACKGROUND There is evidence that cannabis use might be relevant to the aetiology of schizophrenia. We aimed to measure any change in cannabis use over time in those first presenting with schizophrenia in South-East London from 1965 to 1999, and compare this with change in use in those presenting with non-psychotic psychiatric disorders. METHOD The rate of cannabis use in the year prior to first ever presentation was measured over seven time periods. Logistic regression modelling was used to determine (a) whether cannabis use changed over time, after controlling for age, sex and ethnicity, and (b) whether there was an interaction between diagnosis and time. RESULTS Cannabis use increased over time in both the schizophrenia group [odds ratio per time period (OR) 2.03, 95% confidence interval (CI) 1.74-2.38, p<0.0001] and the non-psychotic disorders group (OR 1.24, 95% CI 1.05-1.47, p=0.012), after controlling for age, sex and ethnicity. However, the effect of time was significantly greater in the schizophrenia group than in the non-schizophrenia group (chi2=17, p<0.0001). CONCLUSION Cannabis use in the year prior to presentation with schizophrenia increased markedly between 1965 and 1999, and disproportionately so compared to increase in cannabis use in other psychiatric disorders.

What's New? The Clinical Epidemiology of Bipolar I Disorder

&NA; The last few decades have seen a rapid change in our understanding of the epidemiology of bipolar disorder, which has only recently started to achieve major research attention. This article reviews recent developments. In addition to electronic searches using MEDLINE and PsycLIT, references from articles were identified, major journals hand searched, and major textbooks of psychiatry and epidemiology reviewed. Studies may have overestimated the prevalence of mania, and underestimated incidence. The incidence of mania may be increasing in recent generations, but the data remain inconclusive. Age at onset of mania is earlier than previously believed, and there are gender differences in epidemiology and clinical course. Ethnic differences in epidemiology and clinical course of bipolar disorder are highlighted. Comorbid alcohol and substance abuse are common in patients suffering from bipolar disorder and are associated with a more severe clinical course and a worse outcome. Urban living and lower socioeconomic and single marital status may be risk factors for developing bipolar disorder.

Pharmacological management of treatment resistant depression: a clinical review

OBJECTIVES Treatment resistant depression (TRD), commonly encountered in clinical practice, leads to socioeconomic disability and therapeutic pessimism. This paper reviews evidence for pharmacological approaches used in TRD. METHOD Electronic literature searches were performed using Medline and Psychlit using broad search terms relating to TRD. RESULTS Agents that potentiate both serotonin and noradrenaline may allow more patients to achieve full remission. Attention must be paid to dose titration and length of treatment courses in TRD. Augmentation with lithium and switching within antidepressant class or between classes can often improve symptoms but efficacy of other augmentation approaches remains uncertain. Antidepressant combinations and addition of atypical antipsychotics can be useful but combinations of predominantly serotonergic antidepressants should be avoided. Electroconvulsive therapy retains an important role in TRD but pharmacological treatments need to be continued concomitantly. CONCLUSIONS Good improvement is seen in TRD after vigorous antidepressant treatment but most patients continue to have lower grade symptomatology.

Cannabis and hyperemesis

The adverse effects of marijuana are well documented, as well as its positive therapeutic uses. Cannabis has traditionally been associated with an antiemetic action following acute ingestion and synthetic cannabinoids have an established use as antiemetics for chemotherapy induced nausea. However, there has been limited recognition of chronic cannabis use as a cause of cyclic vomiting syndrome. Cannabinoid hyperemesis was first identified by Allen er al in 2004. Compulsive bathing was also described as part of the clinical picture. This same syndrome has been confirmed a number of times in the medical literature in the interim. The condition has, to our knowledge, never been reported, in a psychiatric patient.

Influence of ethnicity on presentation and outcome of first episode psychosis

We describe a young African male presenting to an Irish psychiatric service with first episode psychosis with an acute onset, no prodromal features and early and complete remission. Migrant and ethnic minority groups may differ in their clinical presentation, course and outcome of psychosis compared with the Caucasian population. This has implications for assessment and treatment of ethnic minority patients in an Irish context given the recent migration into a previously homogeneous population.