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The findings were recently presented at the 28th European College of Neuropsychopharmacology (ECNP) Congress in Amsterdam, the Netherlands.

The study researchers analyzed 2,811 individuals with depressionwho were a part of the Bridge-II-MIX study – an international study of depression and suicide. All participants were assessed by a psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders (DSM) – the standard classification of mental disorders used by mental health professionals in the US.

Many parameters were studied, including previous suicide attempts, family history, current and previous treatments and the patient’s clinical presentations. Psychiatric symptoms, sociodemographic and clinical risk factors for bipolar disorder were also collected. Of the participants, 628 had already attempted suicide.

“The strength of this study is that it’s not a clinical trial, with ideal patients – it’s a big study, from the real world,” says study author Dr. Dina Popovic, a psychiatrist at Barcelona Hospital Clinic and the Clinical Research Institute of Biomedical Research in Spain.

Suicide is the 10th leading cause of death for Americans, according to the American Foundation for Suicide Prevention.

Among American men, the suicide rate is about four times higher than among women. The suicide rate for Americans is also higher in white men (14.2 deaths per 100,000) than Native Americans (11.7 deaths per 100,000).

Dr. Popovic says they found that “depressive mixed states” often preceded suicide attempts and that mixed depressive features were associated with hallmarks of bipolarity. She explains:

“A ‘depressive mixed state’ is where a patient is depressed, but also has symptoms of ‘excitation,’ or mania. We found this significantly more in patients who had previously attempted suicide, than those who had not. In fact, 40% of all the depressed patients who attempted suicide had a ‘mixed episode’ rather than just depression.”

Patients who suffer from ‘mixed depression’ are at a much higher risk of suicide

A comparison was made between those who had and those who had not attempted suicide but who were depressed.

Risk of attempting suicide is at least 50% higher, the scientists found, if a depressed patient presents any of the following symptoms:

• Risky behavior (for example, reckless driving, promiscuous behavior)
• Psychomotor agitation (pacing around a room, wringing one’s hands, pulling off clothing and putting it back on and other similar actions)
• Impulsivity (acting on a whim, displaying behavior characterized by little or no forethought, reflection or consideration of the consequences).

There is an important message here, the study says, for all health care professionals who see patients suffering from depression and who may not pay enough attention to these symptoms. Early identification of symptoms and timely treatment of mixed depressive states could represent a major step in suicide prevention.

Dr. Popovic adds:

“In our opinion, assessing these symptoms in every depressed patient we see is extremely important, and has immense therapeutical implications. Most of these symptoms will not be spontaneously referred by the patient, the clinician needs to inquire directly, and many clinicians may not be aware of the importance of looking at these symptoms before deciding to treat depressed patients.”

In a previous report from Medical News Today, a draft recommendation issued by the US Preventive Services Task Force suggested that doctors should screen all adults for depression.

Broadly speaking, psychosis means a loss of contact with reality; it is a symptom of mental illness rather than a medical condition in its own right.

Generally, there are two types of psychiatric disorder that produce psychotic symptoms: schizophrenia and mood disorders, such as bipolar disorder.

This page offers a full description of psychosis, what causes it, and how it is treated.

What is psychosis?

Psychosis is a symptom rather than a disease.

Psychosis is an umbrella term and means that an individual experiences things that no one else experiences and has beliefs with no basis in reality.

Psychosis is classically associated with schizophrenia spectrum disorders, and, while there are other symptoms, one of the defining criteria for schizophrenia is the presence of psychosis.

Other disorders also have psychotic symptoms, including:

• Schizophrenia
• Schizoaffective disorder and other subtypes of schizophrenia
• Acute and transient psychotic disorders
• Bipolar disorder (previously known as manic depression)
• Major depressive disorder with psychotic features
• Postpartum (also called postnatal) psychosis – a severe form of postnatal depression
• Substance-induced psychosis (including alcohol, certain illegal drugs, and some prescription drugs, including steroids and stimulants)

These are the primary causes of psychotic symptoms, but psychosis can also be secondary to other disorders and diseases, including:

• Brain tumor or cyst
• Dementia (Alzheimer’s disease, for example)
• Neurological illness, such as Parkinson’s disease and Huntington’s disease
• HIV and other infections that may affect the brain
• Some types of epilepsy
• Stroke

Causes of psychosis

The exact causes of psychosis are not well understood but might involve:

• Genetics – research shows that schizophrenia and bipolar disorder may share a common genetic cause.
• Brain changes – alterations in brain structure and changes in certain chemicals are found in people who have psychosis. Brain scans have revealed reduced gray matter in the brains of some individuals who have had a history of psychosis, which may explain effects on thought processing.
• Hormones/Sleep – postpartum psychosis occurs very soon after giving birth (normally within 2 weeks). The exact causes are not known, but some researchers believe it might be due to changes in hormone levels and disrupted sleep patterns.

Symptoms of psychosis

Psychotic symptoms can be separated out and given specific descriptions. The classic signs of psychosis are:

• Hallucinations – hearing, seeing, or feeling things that do not exist
• Delusions – false beliefs, especially based on fear or suspicion of things that are not real

Psychotic symptoms in disorders such as schizophrenia may also include:

• Disorganized thought, speech, or behavior
• Disordered thinking – jumping between unrelated topics, making strange connections between thoughts
• Catatonia – unresponsiveness

Depending on the cause, psychosis can come on quickly or slowly. The same is the case in schizophrenia, although symptoms are more likely to have a slow onset and begin with milder psychosis, which in some cases does not convert to the full disorder.

The slow onset of schizophrenia (also called the prodromal phase) is often not recognized by the patient or their family and friends. The milder, initial symptoms of psychosis might include:

• Feelings of suspicion
• Distorted perceptions
• Depression and suicidal feelings
• Obsessive thinking
• Sleep problems

Hallucinations can affect any of the senses (sight, sound, smell, taste, and touch) in the person with psychosis, but in about two-thirds of patients with schizophrenia, hallucinations are auditory – hearing things and believing them to be real when they do not exist.

The following auditory hallucinations are common in schizophrenia:

• Hearing several voices talking, often negatively, about the patient
• A voice giving a commentary on what the patient is doing, or
• Repeating what the patient is thinking

Bizarre delusions are experienced during psychosis

Paranoia is a common part of psychotic delusions.

Examples of psychotic delusions include the paranoid type – more likely to be associated with schizophrenia – and delusions of grandeur.

Paranoid delusions: these may cause the person with psychosis to be unduly suspicious of individuals or organizations, believing them to be plotting to cause them harm.

Delusions of grandeur: clearly false but strongly held belief in having a special power or authority – for instance, they may believe that they are a world leader.

Diagnosis of psychosis

In this section, we will discuss the available tests and methods for diagnosing psychosis.

Early diagnosis

Early diagnosis of psychosis improves long-term outcomes. This is not always achieved, however. The milder forms of psychosis that can lead to schizophrenia are left untreated for an average of 2 years, and even full psychosis can take a number of years before it receives the attention of medical professionals.

To increase the chances of early detection, guidance for healthcare systems drawn up by psychiatrists recommend that the “possibility of a psychotic disorder should be carefully considered” in a young person who is:

• Becoming more socially withdrawn
• Performing worse for a sustained period at school or work, or
• Becoming more distressed or agitated yet unable to explain why

There is no biological test for psychosis itself, and if laboratory tests are done, it is to rule out other medical problems that might provide an alternative explanation.

Questions for patient and family

Psychosis is primarily diagnosed by clinical examination and history – the doctor examines the patient and asks about their symptoms, experiences, thoughts, and daily activities, and they will also ask if there is a family history of psychiatric illness.

Other medical conditions are ruled out first of all, especially delirium (sudden onset of a confused state), but epilepsy and a number of other medical explanations are possible.

Doctors will also check for any history of intoxication with drugs, both legal and illegal, and toxins, usually asking for a urine sample to check this.

Once psychosis is narrowed down to a psychiatric cause, there are clearly defined criteria that must be met before a diagnosis is confirmed. Psychiatrists generally rely on the American Psychiatric Association (APA)’s publication known as the DSM (Diagnostic and Statistical Manual of Mental Disorders) to make psychiatric diagnoses.

Brain scans

Brain scans may be done in the early stages of medical attention so that other conditions – often treatable and reversible – can be ruled out.

EEG (electroencephalography) testing records the brain’s electrical activity and may help to rule out delirium, head injury, or epilepsy as possible causes of psychotic symptoms.

Treatments for psychosis

In this section, we discuss the treatments for psychosis and some methods of prevention.

Antipsychotic drugs

Treatment with a class of drugs known as antipsychotics is the most common therapy for people with a psychotic illness.

Antipsychotics are effective at reducing psychosis symptoms in psychiatric disorders such as schizophrenia, but they do not themselves treat or cure underlying psychotic illnesses.

So-called second-generation antipsychotics are most commonly used by doctors to treat psychosis. While their use is widespread in the United States, this is controversial. The World Health Organization (WHO) does not recommend them, except clozapine (branded Clozaril and FazaClo in the U.S.), which may be used, under special supervision, if there has been no response to other antipsychotic medicines.

Cannabis appears to have a significant impact on the recognition and processing of human emotions like happiness, sadness and anger, according to research published in the journal PLOS One.

Scientists are only just starting to understand how cannabis affects the brain.

Cannabis consumption is known to cause immediate, residual and long-term changes in brain activity that can affect appetite and food intake, sleep patterns, executive function and emotional behavior.

Conflicting evidence has suggested that it can intensify both positive and negative mood states.

Lucy Troup, assistant professor of psychology at Colorado State University, and her graduate students wanted to look at how, if at all, cannabis use impacts a person’s ability to process emotions.

For nearly 2 years, the team has been conducting experiments using an electroencephalogram (EEG) to measure the brain activities of about 70 volunteers.

All the participants identified themselves as chronic, moderate or non-users of cannabis. They were all confirmed to be legal users of marijuana under Colorado Amendment 64, either medical marijuana users aged 18 years and above, or as recreational users aged 21 years or older.

An EEG can record a wide variety of generalized brain activity. In this study, the researchers used it to measure the “P3 event-related potential” of the participants.

P3 refers to the electrical activity in the brain that is triggered by noticing something visually. P3 activity is known to be related to attention in emotional processing.

Marijuana use may reduce ability to empathize

While connected to an EEG, participants responded to faces wearing four separate expressions: neutral, happy, fearful and angry. The team collected P3 data that captured the reactions in certain parts of the brain when subjects focused on the face.

Cannabis users responded more intensely to faces showing negative expression, particularly angry ones, compared with controls. Conversely, their response to positive expressions, represented by happy faces, was smaller than that of the controls.

Little difference was observed between the reactions of cannabis users and non-users when asked to pay attention to and “explicitly” identify the emotion.

However, cannabis users scored lower in a task that asked them to focus on the sex of the face and then to identify the emotion. This suggests a reduced ability to “implicitly” identify emotions and to empathize on a deeper emotional level.

The researchers conclude that cannabis affects the brain’s ability to process emotion, but that the brain may be able to counter the effects, depending on whether the emotions are explicitly or implicitly detected.

Troup comments:

“We’re not taking a pro or anti stance, but we just want to know, what does it do? It’s really about making sense of it.”

She explains that the aim of the emotion-processing paradigm was to see if the reactions in people who use cannabis would be different from those who do not.

In further studies, Troup is looking into the effects of cannabis on mood disorders like depression and anxiety, and one of her team members is investigating the effect of cannabis on learning.

Medical News Today recently reported that cannabis use could put young people more at risk of schizophrenia.

A current or previous infection with Candida albicans appears to be more common in some people with mental illness than people without the condition. This is according to a study that found this to be the case in a group of men with schizophrenia or bipolar disorder and a group of women with these disorders who had memory problems.

The study, led by Johns Hopkins University School of Medicine in Baltimore, MD, is published in the journal npj Schizophrenia.

The Johns Hopkins researchers are part of a group that is investigating whether pathogens – such as fungi, bacteria, or viruses – trigger or contribute to certain mental illnesses.

They caution that their findings do not show that Candida yeast infections cause mental illness or memory impairment, or vice versa, merely that they appear to be strongly related.

A more detailed investigation of lifestyle, immune system factors, and gut-brain connections could shed more light on the underlying cause-and-effect mechanisms, they note.

However, Emily Severance, first author and assistant professor of pediatrics, says, nevertheless, “clinicians should make it a point to look out for these infections in their patients with mental illness.”

She notes that most Candida infections are treatable in the early stages. They can also be avoided by reducing sugar intake and other changes to diet, improving hygiene, and avoiding unnecessary antibiotics.

C. albicans – a yeast-like fungus – is found in small amounts in the healthy gut of humans and animals, but it can get out of balance and cause infection. In infants and those with weakened immune systems, it can lead to rashes in the throat or mouth (thrush) and it can cause sexually transmittable genital yeast infections in men and women.

The infection can become severe if it enters the bloodstream. In most people, however, healthy levels of bacteria and a strong immune system can stop the fungus getting out of balance.

Different patterns of mental illness linked to Candida in men, women
For their study, the team tested blood samples from 808 people aged 18-65 for antibody evidence of a previous or current infection with Candida. The group included 261 individuals with schizophrenia, 270 people with bipolar disorder, and 277 without a history of mental disorder (the controls).

The researchers also included data from another group of 139 people with first-episode schizophrenia, 78 of whom had not yet been treated with medication.

After taking into account factors that could skew the results – such as age, race, medication, and socioeconomic status – the researchers looked for links between mental illness and yeast infection.

Overall, there was no link between presence of mental illness and current or previous yeast infection. It was when the team drilled down to look at men and women separately that the patterns emerged.

For example, in the men, they found 26 percent of those with schizophrenia had a current or previous Candida infection, compared with only 14 percent of the male controls.

However, among women, while a greater proportion had a current or previous yeast infection, the difference between those with schizophrenia and the controls was much smaller (31.3 percent versus 29.4 percent, respectively).

Men with bipolar disorder showed a similar higher rate of Candida infection, compared with controls (26.4 percent versus 14 percent).

However, when they looked more closely, the researchers found that the link between bipolar disorder and yeast infection in the men was most likely due to homelessness. No such explanation could be found in the men with schizophrenia, however.

Candida infection linked to worse memory for women with mental illness
The participants also took part in tests of mental ability, such as short-term memory, delayed memory, attention, language skills, and visual-spatial skills.

The mental skills tests showed no measurable differences in control men and women with and without a current or previous Candida infection. However, women with schizophrenia or bipolar disorder with current or previous Candida infection had lower scores on the memory tests, compared with women without infection.

The researchers note that while they could not show a direct link between Candida yeast infection and brain processes, the results show something linked to infection appears to affect memory performance in women with schizophrenia and bipolar disorder and warrants further investigation.

They point out that one drawback of their study design is the fact they could not tell which part of the body was affected by yeast infection, and whether or not participants had a current or past infection. Also, it was not possible to account for every lifestyle variable that might affect the results.

“Because Candida is a natural component of the human body microbiome, yeast overgrowth or infection in the digestive tract, for example, may disrupt the gut-brain axis. This disruption in conjunction with an abnormally functioning immune system could collectively disturb those brain processes that are important for memory.”

Prof. Emily Severance

Prof. Severance says she and her colleagues now plan to look at the gut-brain connection in mice to find out whether there is a cause-and-effect mechanism between Candida and memory deficits.

Learn how a breakthrough discovery about a gene sheds light on the biological origins of schizophrenia.

Written by Catharine Paddock PhD

When a single drug does not work, experts recommend trying other mood stabilizers. If several medications are tried with no improvement, trying a combination of mood stabilizers is the next step. This approach is called combination therapy. Two mood stabilizers together may be more effective in relieving symptoms than one alone.

Sometimes, a mood stabilizer is used in combination with medication to relieve behavioral symptoms (hyperactivity or physical expression of distress, such as restlessness, pacing and hypersensitivity to surroundings), psychosis, anxiety or insomnia. These drugs are called adjunctive medications.

Adjunctive medications include benzodiazepines, a type of sedative that is prescribed for behavioral agitation or verbal excitement. For instance, lorazepam (Ativan®) can calm a hostile or aggressive manic patient. Antidepressants may be prescribed for depressed bipolar patients to improve their mood, but careful monitoring is necessary to avoid pushing the mood into mania or hypomania (which is less severe than full-blown mania). The choice of antidepressant is influenced by patient tolerance, potential drug interactions and side effects. For example, a patient who gained weight on lithium would be prescribed an antidepressant associated with less weight gain such as bupropion (Wellbutrin®).

Sometimes, patients with extreme manic episodes can develop psychotic symptoms, such as paranoia, hallucinations and delusions. When psychotic symptoms occur during mania, supplementing the mood stabilizer with an antipsychotic drug can be helpful. Antipsychotic medications are administered during acute treatment and usually can be tapered before continuation treatment begins. However, some patients experience the best results by staying on an antipsychotic drug. A newer class of antipsychotic medications used in the management of manic patients is risperidone (Risperdal®), haloperidol (Haldol®), quetiapine (Seroquel®) and olanzapine (Zyprexa®).

If you have bipolar disorder, one of the best things you can do to help manage your illness is learn all you can about the disorder. You can do this by reading books, going to lectures and talking to your doctor. Learn how to understand the symptoms and recognize when you need to seek help.

You may also want to find support from others who have the illness. Support groups are available in most areas and are an important part of treatment. Support groups provide emotional support, education, understanding, accountability and self-awareness. Participants develop a bond with others because they share common gound.

Talking to other people who have learned successful coping strategies with the illness is extremely helpful in dealing with bipolar disorder. The Depressive and Manic-Depressive Association is a good place to look for a support group in your area.

Other helpful hints for managing bipolar disorder include:

• Communicate openly with your doctor. You may want to keep a diary of you daily moods or checklist of symptoms to share with your doctor.
• Remain open to feedback from loved ones who may recognize early symptoms of an episode before you do.
• Try to keep stress in your life manageable when possible.
• Sleep well. Establish stable patterns by going to bed around the same time each night and get up about the same time in the morning. Poor sleep can trigger mood symptoms. If you have trouble sleeping or are sleeping too much, be sure to tell your doctor.
• Maintain a regular pattern of activity. Don’t push yourself to hard or try to do too many things at once. Try to work a predictable schedule with hours that allow you to get uninterrupted sleep. If symptoms interfere with your work, ask your doctor or therapist for help. Sometimes it is important to discuss these problems openly with employers. Your company may have a confidential Employee Assistance Program to assist you in dealing with your illness at work. If so, make an appointment.
• Avoid alcohol or mood-altering drugs. They can interfere with your medications and bring on symptoms. If you have a problem with drugs and alcohol, ask for help and consider joining a self-help program such as Alcoholics Anonymous.
• Remember that even small amounts of alcohol, caffeine and some over-the-counter medications for colds, allergies or pain can interfere with your sleep, medicine and mood.

As public health experts debate the best ways to reduce suicides––a top-five leading cause of death among Americans aged 10 to 54 in 2013––new research calls attention to the importance of early intervention based on long-term risk factors.

In a study published in the February 2015 issue of JAMA Psychiatry, a team led by NARSAD Scientific Council member and 2008 Distinguished Investigator grantee J. John Mann, M.D., probed the extent to which suicidal behavior in a parent gets passed on to children. The investigators tracked 701 children of 334 people diagnosed with mood disorders for an average of six years to identify factors that predicted suicide attempts among the children.

The research team also included 2001 NARSAD Distinguished Investigator grantee David A. Brent, M.D., 2013 Young Investigator grantee Nadine M. Melhem, Ph.D., and 1996 and 1998 Young Investigator granteeJohn G. Keilp, Ph.D.

The investigators found that having a parent who had attempted suicide made it nearly five times more likely that one of their children would make an attempt. It has been known that both genetic and non-genetic factors related to the predisposition for suicidal behavior or to psychiatric illnesses that trigger suicidal behavior, are transmitted in families. This study sought to identify the factors responsible for such familial transmission.

Suicide attempts were more likely among those children who, like their parents, were diagnosed with a mood disorder such asmajor depression or bipolar disorder. Such diagnoses appear to be needed for the manifestation of suicidal behavior, about a year before the first attempt. Most people diagnosed with depression do not attempt suicide because they do not have a predisposition to suicidal behavior.

Independent of family history of depression, impulsive and aggressive behavioral traits among the children also made it more likely that they will attempt suicide. This indicates a greater propensity to act on emotions. Those with pronounced aggressive and impulsive traits are also more likely to be diagnosed with a mood disorder; the combination puts them at greater risk for a suicide attempt.

These findings highlight the importance of three long-term risk factors in predicting suicide attempts: a family history of suicide attempts, a family history of mood disorders, and a personal history of impulsive aggression. It’s important that such families focus on early detection and treatment of mood disorders and aggressive-impulsive traits, the researchers say.

In recent months, public officials have taken steps to make it more difficult for people to attempt suicide. There are plans to build suicide-prevention structures around San Francisco’s Golden Gate Bridge and New Jersey’s George Washington Bridge.

Efforts on all fronts may be needed to address troubling recent developments in suicide research, including the increase found in suicide rates among African American children between 1993 and 2012, as reported in JAMA Pediatrics on May 18th. This was a period in which suicide rates went down among white children.

Measuring the activity of a panel of genes may provide enough information to diagnose bipolar disorder from a blood sample, according to a study published August 4th in the journalTranslational Psychiatry. Currently, bipolar disorder is diagnosed by experienced clincians based on a subjective evaluation of a patient’s symptoms; there is no blood test or brain scan that can diagnose the disorder.

In the study, which included 37 patients with rapid-cycling bipolar disorder and 40 healthy controls, researchers found that a composite measure of activity within a set of 19 genes offered diagnostic sensitivity and specificity corresponding to a “moderately accurate” test. Their analysis also identified specific genes whose activity is lower in people with bipolar disorder than in healthy individuals, as well as an additional gene whose activity spikes when patients with bipolar disorder are in a depressed state. Those findings call attention to biological pathways likely to be involved in the disorder.

To carry out the study, a team of scientists including first author Klaus Munkholm, M.D., at the University of Copenhagen, identified 19 genes that previous studies had indicated might behave differently in people with bipolar disorder, and for which relevant variations were likely to be detectable in blood cells. They took blood samples from the patients over a period of six to 12 months, keeping track of whether patients were in manic, depressed, or euthymic (neither manic nor depressed) states at the time each sample was collected.

The team, which included Lars Vedel Kessing, M.D., a 2012 NARSAD Distinguished Investigator and 2010 Foundation Colvin Prizewinner, then measured the activity of the 19 genes they had selected. Each sample received a gene expression score that considered the activity of all 19 genes together. These scores were sufficiently different between healthy participants and those with bipolar disorder to distinguish between the two, most of the time. For a portion of their blood samples, the scientists used the gene expression score to correctly identify 78 percent of samples from patients with bipolar disorder. Sixty percent of the samples from healthy individuals were correctly identified.

Further studies will be necessary to evaluate the gene panel as a potential biomarker of bipolar disorder. Including additional information in the score, such as levels of specific proteins, might improve its diagnostic sensitivity and specificity, the scientists say.

The study also generated some insight into the biology of bipolar disorder.  Two of the genes that were tracked in the study—POLG and OGG1—were significantly less active in people with bipolar disorder than they were in healthy controls. Another, NDUFV2, showed increased activity during depressed states among people with bipolar disorder, when gene activity was compared during individual patients’ different mood states. Together, these findings point toward problems with mitochondrial function and DNA damage repair, the team says.