Chronic mania is variably defined but classically recognized as the presence of manic symptoms for more than 2 years without remission. The reported incidence ranges between 6–15% among all patients with bipolar disorders. Although it has been described in psychiatry literature for a long time, it has not yet found a place in current nosological systems

We present a 32-year-old single and unemployed man who is supported by his family and living with a sudden-onset, continuous illness of 12 years’ duration characterized by a resistant and markedly euphoric and expansive mood with grandiose delusions. Other features such as distractibility, pressured speech, racing thoughts and psychomotor disturbance remain significant but vary and are more responsive to medical interventions. Psychotic symptoms are largely confined to mood-congruent delusions, grandiose and religious, and are reported to have followed the mood disturbance from early on. There is no history of substance use, past psychiatric or medical illness, or head trauma and no evidence of a neurological cause on workup. This gentleman has been treated with a range of mood stabilizers and antipsychotics and two courses of ECT over the years. In the recent years, he has been on a combination of Clozapine, Valproate, and Pregabalin with relatively favorable but inadequate response and limited functional improvement.

Chronic mania lasting for 12 years, in the absence of an organic cause, despite the use of a wide gamut of modern psychotropics, alone and in combination with ECT, and with adequate compliance is an exceptionally rare entity. It poses manifold challenges both in terms of diagnostic considerations and therapeutic approaches. The overlap of symptoms of mania, schizophrenia, and schizoaffective disorders along with chronicity adds a particular layer of complexity. The hallmark of chronic mania is euphoric and expansive mood along with grandiose delusions and the presentation is relatively less centered on sleep disturbance, hypersexuality, and psychomotor agitation as compared to an acute manic episode. It is distinguished from schizophrenia spectrum disorders as it lacks flat or inappropriate affect, incongruent delusions and disorganized thought. Course of illness, prior mood episodes and family history are important in differentiating from a schizoaffective pattern of disease.

Unremitting mania of this duration is unique in its psychiatric morbidity and devastating in its impact on the individual in terms of psychosocial functioning, quality of life, physical health and safety. It also brings unprecedented stress on the family and other support systems.

This observational study aims to describe the course of the admission and clinical characteristics of admissions to the PICUs in the Phoenix Care Centre, Dublin, Ireland. The authors hypothesised that the length of stay (LOS) would be shorter in male patients as compared to females.

This retrospective cohort study was carried out at the Phoenix Care Centre Dublin, Ireland. Informed consent was not sought as this was a retrospective chart study involving anonymised clinical data which was collected as part of routine clinical care and no items of information were reported that would enable the identification of any subject. We described primary outcomes using frequencies, percentages, mean and standard deviations, median and interquartile ranges (IQR). Between groups comparisons were made using x2 tests for categorical variables; t-tests, ANOVA tests, or Kruskal-Wallis tests, for continuous variables; All analyses were two-tailed, and a P-value ≤ 0.05 was considered statistically significant

Over the study period from Jan 2014 to Jan 2017 inclusive, there were 96 admission episodes to the PICU. The mean age of admitted cases was 37.1 (SD = 11.3) years (range 18–63 years). The mean length of stay (LOS) was 59.3 (SD = 61.0) days (median 39.5 days). All patients were admitted under the Mental Health Act legislation. We identified assault as the primary risk factor for pre-admission 62% (n = 62) to the PICU. Antipsychotic polypharmacy was used in 61% (n = 55) of the admission. The mean daily antipsychotic dosage was 139.4 % (SD = 65.1) of BNF maximum daily dose. A diagnosis of acute psychotic disorder (B= -1.027, p = 0.003, 95% CI: –1.691 to –0.363) was associated with reduced LOS in PICU. Majority of admissions 43% (n = 39) had a diagnosis of schizophrenia, followed by Bipolar affective disorder BPAD 21% (n = 21), schizoaffective disorder 18% (n = 18), and acute psychotic disorder 9% (n = 9).

Psychiatric Intensive Care Unit is an essential service for the severely ill psychiatric patients and is a progressively developing sub-speciality. An important finding from our study describes the cohort of patients admitted being predominantly male, younger-aged, single, with a diagnosis of schizophrenia, legally detained, and from an Irish background. The primary indication for a referral is the risk of assault, showing the need for the intensive and secure treatment model that a PICU can provide.

We sought to assess the effectiveness of clozapine augmentation with Electroconvulsive therapy (ECT) (C+ECT) in patients with clozapine-resistant schizophrenia.

We conducted a retrospective review of electronic health records to identify patients treated with C+ECT. We determined the response to C+ECT and the rate of rehospitalisation over the year following treatment with C+ECT.

Forty-two patients were treated with C+ECT over a 10-year period. The mean age of the patients at initiation of ECT was 46.3 (SD = 8.2) years (range 27–62 years). The mean number of ECTs given was 10.6 (SD = 5.3) (range 3–25) with the majority receiving twice weekly ECT. Seventy-six per cent of patients (n = 32) showed a Clinical Global Impression-Improvement (CGI-I) score of ≤3 (at least minimally improved) following C+ECT. The mean number of ECT treatments was 10.6 (SD = 5.3) (range 3–25) with the majority receiving twice weekly ECT. Sixty-four per cent of patients experienced no adverse events. Response to C+ECT was not associated with gender, age, duration of illness or duration of clozapine treatment. Seventy-five per cent of responders remained out of hospital over the course of 1-year follow-up, while 70% of those with no response to C+ECT were not admitted to hospital. Three patients received maintenance ECT, one of whom was rehospitalised.

This study lends support to emerging evidence for the effectiveness of C+ECT in clozapine-resistant schizophrenia. These results are consistent with the results of a meta-analysis and the only randomised controlled trial (RCT) of this intervention. Further RCTs are required before this treatment can be confidently recommended.

The first episode of psychosis is a critical period in the emergence of cardiometabolic risk.

We set out to explore the influence of individual and lifestyle factors on cardiometabolic outcomes in early psychosis.

This was a prospective cohort study of 293 UK adults presenting with first-episode psychosis investigating the influence of sociodemographics, lifestyle (physical activity, sedentary behaviour, nutrition, smoking, alcohol, substance use) and medication on cardiometabolic outcomes over the following 12 months.

Rates of obesity and glucose dysregulation rose from 17.8% and 12%, respectively, at baseline to 23.7% and 23.7% at 1 year. Little change was seen over time in the 76.8% tobacco smoking rate or the quarter who were sedentary for over 10 h daily. We found no association between lifestyle at baseline or type of antipsychotic medication prescribed with either baseline or 1-year cardiometabolic outcomes. Median haemoglobin A1c (HbA1c) rose by 3.3 mmol/mol in participants from Black and minority ethnic (BME) groups, with little change observed in their White counterparts. At 12 months, one-third of those with BME heritage exceeded the threshold for prediabetes (HbA1c >39 mmol/mol).

Unhealthy lifestyle choices are prevalent in early psychosis and cardiometabolic risk worsens over the next year, creating an important window for prevention. We found no evidence, however, that preventative strategies should be preferentially directed based on lifestyle habits. Further work is needed to determine whether clinical strategies should allow for differential patterns of emergence of cardiometabolic risk in people of different ethnicities.

Reducing hospitalisation and length of stay (LOS) in hospital following first episode psychosis (FEP) is important, yet reliable measures of these outcomes and their moderators are lacking. We conducted a systematic review and meta-analysis to investigate the proportion of FEP cases who were hospitalised after their first contact with services and the LOS in a hospital during follow-up.

Studies were identified from a systematic search across major electronic databases from inception to October 2017. Random effects meta-analyses and meta-regression analyses were conducted.

81 longitudinal studies encompassing data for 23 280 FEP patients with an average follow-up length of 7 years were included. 55% (95% CI 50.3–60.5%) of FEP cases were hospitalised at least once during follow-up with the pooled average LOS of 116.7 days (95% CI 95.1–138.3). Older age of illness onset and being in a stable relationship were associated with a lower proportion of people who were hospitalised. While the proportion of hospitalised patients has not decreased over time, LOS has, with the sharpest reduction in the latest time period. The proportion of patients hospitalised during follow-up was highest in Australia and New Zealand (78.4%) compared to Europe (58.1%) and North America (48.0%); and lowest in Asia (32.5%). Black ethnicity and longer duration of untreated psychosis were associated with longer LOS; while less severe psychotic symptoms at baseline were associated with shorter LOS.

One in two FEP cases required hospitalisation at least once during a 7-year follow-up with an average length of hospitalisation of 4 months during this period. LOS has declined over time, particularly in those countries in which it was previously longest.

After reading this article you will be able to:

• • outline the epidemiology of vitamin D deficiency in schizophrenia

• • describe the associations of vitamin D with schizophrenia and depression

• • know how to assess, and consider treatment for, vitamin D deficiency.

F.G. has received support or honoraria for CME, advisory work and lectures from Bristol-Myers Squibb, Janssen, Lundbeck, Otsuka, Roche and Sunovion, and has a family member with professional links to Lilly and GSK, including shares. She is in part funded by the National Institute for Health Research's (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London and the South London Collaboration for Leadership in Applied Health Research & Care Funding scheme, and by the Maudsley Charity. The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

We aimed to examine clinical and risk outcomes at follow-up, and reoffending and readmission rates, for a sample of 50 admissions to a female medium secure unit (MSU). Demographic, clinical risk assessment (HCR-20 and HoNOS-Secure) and quality of life data were collected using validated measures for all admissions to a female MSU ward in London, UK, between April 2008 and November 2014.

All clinical and risk assessment scale scores had improved at follow-up. Quality of life compared favourably to community samples and was good for physical, social and environmental factors and acceptable for psychological health. Twenty-six per cent had at least one readmission, while 17.5% reoffended in the period studied. A longer duration of admission and use of restrictions on discharge was associated with reduced reoffending, but not readmission.

Admission is associated with improvement on clinical risk assessment at follow-up. Longer hospital admissions and use of restrictions on discharge may be necessary to prevent reoffending in this group.

None.

Remission and recovery rates for people with first-episode psychosis (FEP) remain uncertain.

To assess pooled prevalence rates of remission and recovery in FEP and to investigate potential moderators.

We conducted a systematic review and meta-analysis to assess pooled prevalence rates of remission and recovery in FEP in longitudinal studies with more than 1 year of follow-up data, and conducted meta-regression analyses to investigate potential moderators.

Seventy-nine studies were included representing 19072 patients with FEP. The pooled rate of remission among 12301 individuals with FEP was 58% (60 studies, mean follow-up 5.5 years). Higher remission rates were moderated by studies from more recent years. The pooled prevalence of recovery among 9642 individuals with FEP was 38% (35 studies, mean follow-up 7.2 years). Recovery rates were higher in North America than in other regions.

Remission and recovery rates in FEP may be more favourable than previously thought. We observed stability of recovery rates after the first 2 years, suggesting that a progressive deteriorating course of illness is not typical. Although remission rates have improved over time recovery rates have not, raising questions about the effectiveness of services in achieving improved recovery.

There has been much recent excitement about the possibility that some cases of psychosis may be wholly due to brain-reactive antibodies, with antibodies to N-methyl-D-aspartate receptor (NMDAR) and the voltage-gated potassium channel (VGKC)-complex reported in a few patients with first-episode psychosis (FEP).

Participants were recruited from psychiatric services in South London, UK, from 2009 to 2011 as part of the Genetics and Psychosis study. We conducted a case–control study to examine NMDAR and VGKC-complex antibody levels and rates of antibody positivity in 96 patients presenting with FEP and 98 controls matched for age and sex. Leucine-rich glioma inactiviated-1 (LGI1) and contactin-associated protein (CASPR) antibodies were also measured. Notably, patients with suspicion of organic disease were excluded.

VGKC-complex antibodies were found in both cases (n = 3) and controls (n = 2). NMDAR antibody positivity was seen in one case and one control. Either LGI1-Abs or CASPR2-Abs were found in three cases and three controls. Neuronal antibody staining, consistent with the above results or indicating potential novel antigens, was overall positive in four patients but also in six controls. Overall, antibody positivity was at low levels only and not higher in cases than in controls.

This case–control study of the prevalence of antibodies in FEP does not provide evidence to support the hypothesis that FEP is associated with an immune-mediated process in a subgroup of patients. Nevertheless, as other bio-clinical factors may influence the effect of such antibodies in a given individual, and patients with organic neurological disease may be misdiagnosed as FEP, the field requires more research to put these findings in context.

To measure patient satisfaction with psychiatric outpatient care in a university hospital setting. We wished to ascertain whether there was an association between increased patient satisfaction and background factors such as demographic details, diagnosis and patient preference for outpatient treatment in a hospital or a community setting.

We conducted a cross-sectional survey of individuals’ satisfaction levels with their outpatient treatment. Outpatients were invited to complete the Client Satisfaction Questionnaire-8 (CSQ-8), a well validated self-report instrument, along with some additional questions on their attitudes to the service.

One hundred and sixty-two respondents had a mean total CSQ-8 score of 26.7 (s.d. = 4.6) indicating a moderate to high level of satisfaction with outpatient care. Ninety percent of patients were satisfied with their psychiatric outpatient care. There were no significant sociodemographic or clinical associations with satisfaction levels identified. Sixty one percent of patients were in favour of retaining outpatient care in the university hospital.

This study demonstrates high satisfaction levels with psychiatric outpatient care in a university hospital setting. The majority of patients expressed a preference for maintaining outpatient care in the general hospital setting, rather than transferring to a stand-alone mental health facility in a suburban setting.