To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Frequently associated with early psychosis, depressive and manic dimensions may play an important role in its course and outcome. While manic and depressive symptoms can alternate and co-occur, most of the studies in early intervention investigated these symptoms independently. The aim of this study was therefore to explore the co-occurrence of manic and depressive dimensions, their evolution and impact on outcomes.
We prospectively studied first-episode psychosis patients (N = 313) within an early intervention program over 3 years. Based on latent transition analysis, we identified sub-groups of patients with different mood profiles considering both manic and depressive dimensions, and studied their outcomes.
Our results revealed six different mood profiles at program entry and after 1.5 years follow-up (absence of mood disturbance, co-occurrence, mild depressive, severe depressive, manic and hypomanic), and four after 3 years (absence of mood disturbance, co-occurrence, mild depressive and hypomanic). Patients with absence of mood disturbance at discharge had better outcomes. All patients with co-occurring symptoms at program entry remained symptomatic at discharge. Patients with mild depressive symptoms were less likely to return to premorbid functional level at discharge than the other subgroups. Patients displaying a depressive component had poorer quality of physical and psychological health at discharge.
Our results confirm the major role played by mood dimensions in early psychosis, and show that profiles with co-occurring manic and depressive dimensions are at risk of poorer outcome. An accurate assessment and treatment of these dimensions in people with early psychosis is crucial.
While specialized early intervention programs represent the gold standard in terms of optimal management of first-episode psychosis (FEP), poor medication adherence remains a predominant unmet need in the treatment of psychosis. In this regard, an interaction between insight and adherence in FEP patients has been hypothesized but has been challenged by multiple pitfalls.
Latent profile analysis and trajectory modeling techniques were used to evaluate insight and adherence of 331 FEP patients engaged at the beginning, middle, and end of a 3-year specialized early psychosis program. A Bayesian model comparison approach was used to compare scores of clinical, functional, and socioeconomic outcomes at the end point of the study.
Nearly one-third of the patients maintain a high level of insight and adherence during the entire program. At the end of the 3-year follow-up, more than three-quarters of patients are considered adherent to their medication. Patients with low levels of insight and adherence at the beginning of the program improve first in terms of adherence and then of insight. Furthermore, patients with high levels of insight and adherence are most likely to reach functional recovery and to experience an increase in environmental quality of life.
Latent FEP subpopulations can be identified based on insight and adherence. Medication adherence was the first variable to improve, but a gain in insight possibly plays a role in the reinforcement of adherence.
Prevention of violent behaviors (VB) in the early phase of psychosis (EPP) is a real challenge. Impulsivity was shown to be strongly related to VB, and different evolutions of impulsivity were noticed along treatments. One possible variable involved in the relationship between VB and the evolution of impulsivity is cannabis use (CU). The high prevalence of CU in EPP and its relationship with VB led us to investigate: 1/the impact of CU and 2/the impact of early CU on the evolution of impulsivity levels during a 3-year program, in violent and non-violent EPP patients.
178 non-violent and 62 violent patients (VPs) were followed-up over a 3 year period. Age of onset of CU was assessed at program entry and impulsivity was assessed seven times during the program. The evolution of impulsivity level during the program, as a function of the violent and non-violent groups of patients and CU precocity were analyzed with linear mixed-effects models.
Over the treatment period, impulsivity level did not evolve as a function of the interaction between group and CU (coef. = 0.02, p = 0.425). However, when including precocity of CU, impulsivity was shown to increase significantly only in VPs who start consuming before 15 years of age (coef. = 0.06, p = 0.008).
The precocity of CU in VPs seems to be a key variable of the negative evolution of impulsivity during follow-up and should be closely monitored in EPP patients entering care since they have a higher risk of showing VB.
Although evidence from psychosis patients demonstrates the adverse effects of cannabis use (CU) at a young age and that the rate of CU is high in subgroups of young violent patients with psychotic disorders, little is known about the possible effect of the age of onset of CU on later violent behaviors (VB). So, we aimed to explore the impact of age at onset of CU on the risk of displaying VB in a cohort of early psychosis patients.
Data were collected prospectively over a 36-month period in the context of an early psychosis cohort study. A total of 265 patients, aged 18–35 years, were included in the study. Logistic regression was performed to assess the link between age of onset of substance use and VB.
Among the 265 patients, 72 had displayed VB and 193 had not. While violent patients began using cannabis on average at age 15.29 (0.45), nonviolent patients had started on average at age 16.97 (0.35) (p = 0.004). Early-onset CU (up to age 15) was a risk factor for VB (odds ratio = 4.47, confidence interval [CI]: 1.13–20.06) when the model was adjusted for age group, other types of substance use, being a user or a nonuser and various violence risk factors and covariates. History of violence and early CU (until 15) were the two main risk factors for VB.
Our results suggest that early-onset CU may play a role in the emergence of VB in early psychosis.
Twenty-first century urbanization poses increasing challenges for mental health. Epidemiological studies have shown that mental health problems often accumulate in urban areas, compared to rural areas, and suggested possible underlying causes associated with the social and physical urban environments. Emerging work indicates complex urban effects that depend on many individual and contextual factors at the neighbourhood and country level and novel experimental work is starting to dissect potential underlying mechanisms. This review summarizes findings from epidemiology and population-based studies, neuroscience, experimental and experience-based research and illustrates how a combined approach can move the field towards an increased understanding of the urbanicity-mental health nexus.
Lithium and quetiapine are considered standard maintenance agents for bipolar disorder yet it is unclear how their efficacy compares with each other.
To investigate the differential effect of lithium and quetiapine on symptoms of depression, mania, general functioning, global illness severity and quality of life in patients with recently stabilised first-episode mania.
Maintenance trial of patients with first-episode mania stabilised on a combination of lithium and quetiapine, subsequently randomised to lithium or quetiapine monotherapy (up to 800 mg/day) and followed up for 1 year. (Trial registration: Australian and New Zealand Clinical Trials Registry – ACTRN12607000639426.)
In total, 61 individuals were randomised. Within mixed-model repeated measures analyses, significant omnibus treatment × visit interactions were observed for measures of overall psychopathology, psychotic symptoms and functioning. Planned and post hoc comparisons further demonstrated the superiority of lithium treatment over quetiapine.
In people with first-episode mania treated with a combination of lithium and quetiapine, continuation treatment with lithium rather than quetiapine is superior in terms of mean levels of symptoms during a 1-year evolution.
Moods are so essential to our navigating the world that when they go awry it is only a matter of time until distress and disaster hit. Moods allow us to gauge people and circumstance, alert us to danger and opportunity, and provide us with the means to convey our emotional and physical state to others.
Jamison (2003, p. xv)
Bipolar disorder, also known as manic depression, is a mood disorder that can involve extreme changes in affect, cognition, and behavior. In its extreme form, bipolar disorder can be associated with psychotic symptoms and can require inpatient admission due to disorganization and impulsivity in the manic phase, or due to suicidal ideation or neglect of self-care in the depressive phase. It affects males and females in equal numbers, and has similar rates across all socio-economic groups. Its onset generally occurs during late adolescence or early adulthood, with this having significant implications for the person's developmental trajectory and quality of life. This will be described later in the chapter.
While the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition – Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000) should be consulted regarding diagnosis, a brief summary is as follows:
A major depressive episode is diagnosed through the presence of depressed mood or loss of interest or pleasure for most of the day, nearly every day for two weeks or more. It must also be accompanied by five or more from nine symptoms, including feelings of worthlessness or guilt, insomnia or hypersomnia, psychomotor agitation or retardation, and fatigue.
Other things may change us, but we start and end with family.
Anthony Brandt (in Simpson, 1988, no. 3740)
In this chapter we discuss the role of family work in interventions with young people with bipolar disorder. We recognize that family work is a specialized area and highly recommend Miklowitz's (2008) Bipolar Disorder: A Family-Focused Treatment Approach (second edition) and Miklowitz and Goldstein's (1997) Bipolar Disorder: A Family-Focused Treatment Approach, which have heavily influenced our intervention. We also acknowledge that some of the family therapy literature describes highly detailed interventions, particularly for communication skills and problem-solving (e.g. Mueser & Glynn, 1999). However, as with the rest of this manual, we place a strong emphasis on “real world” work and the following describes interventions that we have found effective when working with our population.
While for simplicity we have included this as a separate chapter, we suggest that in clinical work, the components described and the philosophy outlined should be interwoven throughout the intervention rather than being provided as a discrete module.
The rationale behind family work
There are a number of reasons for including family and relationship work in a psychological intervention for young people in the early phase of bipolar disorder. Firstly, in our population of young people aged between 15 and 25 years, almost 56% were living with their families, or had returned to the care of their families after developing their first episode (Hasty et al., 2006).
Prodromal symptoms before manic depressive relapses show considerable variation in their nature and timing between individuals … Prodromal symptoms, however, are consistent within individuals giving them a predictive value for each patient.
Perry et al. (1995, p. 405–6)
Research indicates that between 70% and 90% of people with bipolar disorder will have more than one episode (Keller et al.,1993; Gitlin et al., 1995; Tacchi & Scott, 2005), with naturalistic studies showing that around 49.8% of people will relapse within a year, and 68% within 2 years (Silverstone et al., 1998; Lam & Wong, 2005). Amongst those who relapse, two-thirds will have multiple relapses, with 9 being the mean number of episodes (Keller et al., 1993; Gitlin et al., 1995). Given these high rates of relapse in bipolar disorder, work on relapse prevention remains an essential aspect of psychological intervention for this population.
It is encouraging that there often appear to be signs or symptoms which occur before a person becomes symptomatic, with early identification of these providing an opportunity to intervene and prevent relapse. There is also evidence that about 75% of people with bipolar disorder are themselves able to reliably identify their prodromal symptoms for both mania and depression (Jackson et al., 2003), even following a first episode (Ward et al., 2003). In their randomized treatment trial, Perry et al. (1995) found that most of the trial participants had identifiable early signs, which began between two and four weeks prior to a manic or depressive relapse.
The core of all treatments, biological and psychosocial, lies in the clinical relationship which develops between patients and professionals.
McGlashan et al. (1990, p. 182)
Diagnostic difficulties in bipolar disorder
There is growing acknowledgement that bipolar disorder may be significantly underdiagnosed (Bowden, 2001). For example, Hirschfeld and colleagues' (2003) survey of over 600 members of the US National Depressive and Manic Depressive Association (now known as the Depression and Bipolar Support Alliance) found that 69% of people with bipolar disorder reported having been misdiagnosed at least once. Furthermore, over one-third of respondents had a latency period of at least 10 years between initially seeking help and receiving the correct diagnosis and treatment. Unfortunately there was little change in rates of misdiagnosis between this survey, in 2003, and when it was previously conducted in 1994.
Underdiagnosis and misdiagnosis in bipolar disorder result in part from its complexity and overlap of symptoms with other disorders. Unipolar depression appears to be the most common misdiagnosis, which is understandable as many individuals have 2 or 3 depressive episodes before they experience the first manic or hypomanic episode. Ghaemi et al. (2000a) reported that around 40% of people with bipolar disorder are initially misdiagnosed with unipolar depression, while Angst (2006) suggested that, using the broadest available criteria, between one-quarter and half of people diagnosed with unipolar depression may in fact meet the criteria for bipolar disorder.
As research emerges on the effectiveness of psychological therapies for bipolar disorder, this is the first manual guiding the treatment of those in adolescence and early adulthood, taking into account the developmental issues which can have significant impact on therapeutic outcomes. Core issues covered include engagement difficulties, how cognitive therapy should be adapted for adolescents, the impact of the disorder on the person's psychosocial development, managing comorbidity (particularly alcohol and substance use), medication adherence, the impact of family dynamics, and issues around control and independence in the therapeutic relationship. The manual is illustrated with case studies and text boxes describing tips and techniques for the therapist. Providing clear clinical guidance, backed by an extensive literature review and theoretical overview, this is essential reading for all mental health specialists implementing psychological interventions for young people with bipolar disorder.
Bipolar disorder, also known as manic depression, affects at least 1 or 2 in every 100 people.
Bipolar disorder is a mood disorder involving extreme changes in emotion. While anyone can experience “ups and downs,” bipolar disorder can result in a person at times feeling extremely happy, excitable, and invincible, and at other times feeling irritable, miserable, or even suicidal. Bipolar disorder can also affect the way people think and behave, can affect work, study, and relationships, and can result in hospitalization. It is also a disorder that can keep returning if not treated properly. However, it can also be managed very effectively, with evidence showing that getting help earlier can result in better outcomes.
Diagnosis should only be made by a health professional, but symptoms can include the following:
Symptoms of mania
Feeling “high,” full of energy, or easily annoyed for at least 7 days, and:
Feeling “driven” to do things, which may feel out of control at times.
Reckless or impulsive behavior and doing things you usually wouldn't, e.g. spending excessively, being more promiscuous, making decisions without thinking them through, or using drugs or alcohol excessively.
Finding it very hard to concentrate or focus on one task, and not being able to finish tasks.
Feeling physically jumpy.
Talking very fast.
Feeling like your thoughts are going very fast, or jumping from one subject to another.
Feeling like you don't need any sleep.
Increased sexual drive.
Feeling you have special abilities or talents that no-one else has.