Thyroid dysfunction has been linked to psychiatric disorders, particularly to affective disorders. Moreover, aging of the population receiving mental health care leads to an increased epidemiological risk of thyroid disease.

Assess the prevalence of abnormal thyroid function, and its correlations to clinical factors, in an acute psychiatric inpatients ward dedicated to affective disorders.

Reflect on the clinical relevance of thyroid function screening on admission in mental health care.

Retrospective, descriptive study, concerning inpatient episodes from a 12 month period (January to December 2015) in a ward dedicated to affective disorders, in a tertiary psychiatric hospital.

The prevalence of thyroid dysfunction across all psychiatric diagnostic groups was 11%. Preliminary data has shown higher prevalence in non-elderly women with personality disorder as a main diagnosis (30%, P = 0.017). Only women were under thyroid replacement therapy, which was significantly more prevalent in those diagnosed with bipolar disorder.

The relatively high prevalence of thyroid dysfunction underlines the relevance of its screening in mental health inpatients. Our results were consistent with the known epidemiology of thyroid disease. Correlations with bipolar and personality disorder were noted, which can contribute to improve the understanding of clinical-epidemiological relationships between thyroid disease and specific psychiatric disorders.

The authors have not supplied their declaration of competing interest.

Mixed features refers to the presence of high and low symptoms occurring at the same time, or as part of a single episode, in people experiencing an episode of mania or depression. In most forms of bipolar disorder, moods alternate between elevated and depressed over time. A person with mixed features experiences symptoms of both mood “poles” – mania and depression – simultaneously or in rapid sequence.

To review the nosological status of bipolar mixed states and its treatment.

Online search/review of the literature has been carried out, using Medline/Pubmed, concerning “mixed states”, “affective disorder”, “bipolar disorder”.

The presence of depressive symptomatology during acute mania has been termed mixed mania, dysphoric mania, depressive mania or mixed bipolar disorder. Highly prevalent, mixed mania occurs in at least 30% of bipolar patients. Correct diagnosis is a major challenge. The presence of mixed features is associated with a worse clinical course and higher rates of comorbidities. There is ongoing debate about the role of antidepressants in the evolution of such states.

Clinical vigilance and careful evaluation are required to ensure mixed states are not missed in the clinical context. Atypical antipsychotics are emerging as the medications of choice in the pharmacological management of mixed states.

The authors have not supplied their declaration of competing interest.

The Wernicke-Korsakoff syndrome comprises a complex of symptoms including Wernicke's encephalopathy and the Korsakoff's syndrome. While the former is characterized by a classic clinical triad of ataxia, ophtalmoplegia and a global confusional state; the Korsakoff's syndrome is characterized by memory impairment and confabulation. These two entities are now considered as a clinical spectrum of a same disease caused by deficiency of thiamine (vitamin B1).

To describe a case of Wernicke-Korsakoff Syndrome with psychotic symptoms in a 13-year-old female patient with anorexia nervosa.

The patient and family were interviewed. Literature relevant to the case was reviewed.

A 13-year-old Caucasian female was admitted to the emergency department with bradycardia (38 bpm) and a two-month history of weight loss totaling 6 kg. This loss of weight was a result of dietary restriction and over-exercise because she “felt too fat”. On admission she has a body mass index of 12.17. She was diagnosed with anorexia nervosa and was hospitalized. On day 11 after hospitalization, patient initiated alteration in behavior, fluctuating mental state with periods of lucidity and periods of confusion, memory impairment and psychotic symptoms, with paranoid delusions and auditory hallucinations. The classic triad of Wernicke's encephalopathy was not present. The treatment with thiamine was initiated and the symptoms including psychotic symptoms improved.

Wernicke-Korsakoff syndrome should be considered in cases of anorexia nervosa with a confusional state and memory impairment even if the classic symptoms are not present.

The authors have not supplied their declaration of competing interest.

showed a greater interference of facial stimuli at high load than low load, confirming the effectiveness of perceptual load manipulation. More importantly, patients tarried significantly longer at high load. This is consistent with deficits in control of attention, showing that bipolar patients are more prone to distraction by task-irrelevant stimulus only when the task is more demanding. Moreover, for bipolar patients neutral and angry faces resulted in a higher interference with the task (longer response time), compared to controls, suggesting an attentional bias for neutral and threating social cues. Nevertheless, a more detailed investigation regarding the attentional impairments in social context in BD is needed.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Catatonia is a complication of bipolar disorder, which is a constellation of symptoms such as catalepsy, mutism, and stupor. Standard therapy for catatonia contains benzodiazepines and electroconvulsive therapy. An uncomplicated catatonia is usually a benign condition. On the other hand, malignant catatonia is a life-threatening condition that is complicated with fever, autonomic instability, delirium, and rigidity. The syndrome is typically fulminant and progresses rapidly within a few days without appropriate intervention. Several previous reports suggested that some catatonia are associated with the overstimulation of N-methyl-D-aspartate (NMDA) receptor, and that amantadine may have an effectiveness for catatonia, as a NMDA receptor antagonist. We report a case of successful treatment for malignant catatonia refractory to benzodiazepines, by using amantadine.

A 64-year-old Japanese woman with bipolar disorder was referred to our hospital because of 8-week prolonged fever. On admission, she was in febrile and stuporous states. Severe rigidity was observed in her extremities. Blood tests, lumbar puncture, and blood cultures were all negative. Brain MRI was normal. Consequently, we reached a diagnosis of malignant catatonia, and thus we gave additional benzodiazepines for her catatonic symptoms. However, there was no improvement, and we finally add a 50 mg/day amantadine for her malignant catatonic state.

Her fever resolved in a few days. Gradual dose-titration of amantadine led her clinical manifestation to completely disappeared.

Amantadine can be a potential option as one of the pharmacological therapies for refractory malignant catatonia.

The authors have not supplied their declaration of competing interest.

The research interest in social cognition in bipolar disorder has increased in a significant way in the last decade showing major impairments, especially in mental state reasoning, even during euthymia (Samamé et al., 2012; Samamé et al., 2015). Social cognitive processes in humans describe the ways individuals draw inferences about other people's beliefs and the ways they weigh social situational factors in making these inferences (Green et al., 2008). A causal relationship between social cognition deficits and global functioning has been already established in schizophrenic populations (Green et al., 2015). But there is still little information regarding the relation between social cognition and social functioning in bipolar disorder.

To review the relationship between general/social functioning and social cognitive impairments in bipolar patients.

A systematic review of literature was conducted. Relevant articles were identified through literature searches in PubMed/Medline, EBSCOHost and Google Scholar databases dating from 2000 to 2015 using the keywords “bipolar”, “social cognition”, “theory of mind”, “mentalizing”, “emotion recognition”, “emotion processing”, “functioning” and “quality of life”.

The findings of the review will be discussed, regarding the specificity of the thymic state of the patients and the social cognition instruments used.

To the best of our knowledge, the present review is the first to explore specifically the relation between the social cognition deficits and the general/social functioning of bipolar patients. This exploration is of interest for a better comprehension of this disorder to improve the outcome of the patients.

The authors have not supplied their declaration of competing interest.

Weight loss positively influences mental health but findings are mixed in patients undergoing bariatric surgery. The permanent changes in body image, diet-related stress, and unmet expectations could increase mental health problems such as major depression and self-harm behaviors. Mixed symptoms during major depressive episode were often misdiagnosed as agitated depression, and should be regarded as a risk factor for suicide and rapid cycling course of illness.

Single case report.

A 45-year-old woman, initially diagnosed as a unipolar depressive episode after bariatric surgery, did not show improvement after SSRI treatment. She had no history of previous episode but her temperament was described as hyperthymic. Antidepressant worsened irritability, racing/crowded thoughts, heightened anxiety and aggressive impulses, mood instability, impaired concentration, insomnia and she had a suicide attempt (antidepressant overdose). After mood stabilizer and atypical antipsychotic, symptoms fully remitted and she is stable in the last year.

Self-harm emergencies after bariatric surgery are higher than before surgery. Intentional overdose is considered the most common self-harm mechanism. Psychiatric follow-up after bariatric surgery and early recognition of bipolar depression with mixed features as a distinct condition among the variety of depressive syndromes is essential to reduce the risk of self-harm behaviors and improve treatment outcomes. Premorbid temperamental features, especially hyperthymic and cyclothymic temperaments, are often responsible for such mixed depressive presentations.

The authors have not supplied their declaration of competing interest.

A lot of studies have described that up to 50% of patients with epilepsy develop psychiatric disorders: depression, anxiety and psychotic symptoms. We can classify these symptoms according to how they relate in time to seizure occurrence, i.e. pre-ictal/prodromal, ictal, post-ictal or inter-ictal. In this case, we have a 76 years old woman that develops a maniac-episode previously that she has an episode.

Make a review about the prevalence, risk factors of psychiatric problem in epilepsy (biological, psychosocial and iatrogenic) and report of clinical case.

Review the bi-directional associations between epilepsy and bipolar disorder (epidemiological links, evidence for shared etiology, and the impact of these disorders) with a integrated clinical approach.

Theoretically, epilepsy and bipolar disorder share an important number of clinical and neurobiological features. Classic neuropsychiatric literature focused on major depression with data on bipolar disorder remains limited. However, actually there are many evidences that mood instability, mixed irritability even mania is not uncommon in patients with epilepsy.

It is important develop more sensitive and specific screening instruments to identify mood disorder in epilepsy's patients. Future research becomes decisive for a better understanding of the similarities between epilepsy and BD, and the treatment of both.

The authors have not supplied their declaration of competing interest.

Varenicline is an alpha 4 beta 2 nicotinic receptor partial agonist with dopaminergic effects, approved for smoking cessation. The complex interactions and modulations of serotonin and nicotine receptors caused by varenicline may cause mania by its serotonin agonist activity and by its release of dopamine in the striatum. We report a case of a varenicline-induced mania with the history of depression.

A 38-year-old female, with the history of depression and have been using sertraline 50 mg/day for a year, admitted for grandiose delusions, decreased need for sleep, increased amount and rapid speech, and agitation. These symptoms began 1 week after she started taking varenicline as prescribed for smoking cessation. Young Mania Score (YMS) was 32. She discontinued sertraline and varenicline after 1 week of use but symptoms of mania continued. The patient smoked about 20 cigarettes a day for more than 10 years. She had a positive history of depression in her family. Her lab work up was unremarkable; including negative urine toxicology and brain CT scan. The patient met DSM-5 criteria for a manic episode and was started on olanzapine 10 mg/day and quetiapine 100 mg/day. The patient's symptoms gradually improved within 1 week with attainment of euthymic mood, improved sleep, and resolution of grandiosity. YMS was 7.

Based on this case it might be suggested that patient's and family's psychiatric history should be assessed cautiously before prescribing varenicline for smoking cessation due to development of mood symptoms.

The authors have not supplied their declaration of competing interest.

Immune alterations are believed to be an important part in etiopathogenesis of affective disorders. However, it is not clear if the altered immune mediators are related to distinct disorders or particular psychopathology.

The aim of our study was to explore the differences in C-reactive protein levels (CRP) between euthymic BD patients and healthy controls, as well as to explore the relationship between CRP and lifetime presented psychopathology within BD.

The study group consisted of 83 patients diagnosed with BD, compared to the healthy control group (n = 73) and matched according to age, gender, and body mass index (BMI). Lifetime psychopathology has been assessed according to predominant polarity as well as previous history of suicide attempts and psychotic episodes.

The CRP levels were significantly higher in BD patients when compared to healthy controls. After covarying for confounders, we observed that CRP levels, in euthymic BD patients, were related to number of previous suicide attempts, but not other indicators of lifetime psychopathology.

BD patients per se, and particularly those with more suicide attempts, are more likely to present with proinflammatory state, even when in remission. Previous history of suicide attempts could bear specifically vulnerable endophenotype within BD. Systemic, longitudinal monitoring of the course of illness, and potential inflammatory mediators that underlie its systemic nature is warranted.

The authors have not supplied their declaration of competing interest.

Oestrogen fluctuations may be an important factor in the etiology of bipolar disorder and age at menarche is associated with the clinical course of BD. Moreover, it is associated with traits related to mood.

The aim of our study was to explore the differences in age at menarche between euthymic BD patients and healthy controls, as well as to explore the relationship between age at menarche and lifetime psychopathology within BD.

The study group consisted of 83 patients diagnosed with BD, compared to the healthy control group (n = 73) and matched according to age, gender, and body mass index (BMI). Lifetime psychopathology has been assessed according to predominant polarity as well as previous history of suicide attempts and psychotic episodes.

Age at menarche in BD patients was similar to that in controls. After covarying for confounders, we observed that age at menarche is negatively related to number of previous depressive episodes in euthymic BD patients, but not other indicators of lifetime psychopathology.

BD patients with earlier age at menarche are more likely to present with more depressive episodes in the course of illness. Systemic, longitudinal monitoring of the course of illness, and potential hormonal fluctuations within particular groups of patients are warranted.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

In literature Leonard introduce, after Wernike (1900) and Kleist (1928), the concept of cycloid psychoses, and he gives again a weight to the mixed forms in affective disorders [1–4]. A lot of different medical conditions cause pychiatric problems, like hyperammonemia, hyponatiremia, thyroid disfunction, urinary infections and still others. The aim of our study is to evaluate the role of a medical condition in perplexity inside psychotic mixed states in bipolar disorder (BD). We propouse three different cases and literature review.

Three patients with perplexity in BD were assessed with: the SCID-P for axis I diagnosis, HRSD, YMRS, internistical examination, blood test exams and urinanalysis, and first level brain imagin (CT and/or MRI). We conducted a systematic review of the literature (PubMed, Embase, PsychInfo), using the terms “bipolar disorder”, “mixed states”, “perplexity” and “medical condition”.

All our patients present: hyperammonemia, reduction of TSH and presence of infection at the urinanalysis, and a resolution of perplexity with the normalization of the blood test and urinanalysis.

To our knowledge there are not studies that confirm the relationship between thyroid and epatic dysfunction, and urinary infection with perplexity in psychotic mixed states in BD, and the resolution with the normalization of blood and urinary exams. Further research is warranted to replicate our clinical observations and to confirm our results.

The authors have not supplied their declaration of competing interest.

The presence of mixed features in bipolar disorder (BD) has been associated with a worse clinical course and high rates of comorbidities including anxiety, personality, alcohol and substance use disorders and head trauma or other neurological problems [1]. A recent study reports the connection of neurosyphilis and mania [2]. The aim of our study is to evaluate an inpatient with a psychotic mixed state due to a medical condition (neurosyphilis).

An inpatient with psychotic mixed state in BD was assessed with: SCID-P, HRSD, YMRS, and a complete internistical examination, blood test exams, urinanalysis, electrocardiogram and ecocardiogram, as well as a first level brain imagin (CT and/or MRI). We conducted a systematic review of the literature (PubMed, Embase, PsychInfo), using the terms “bipolar disorder”, “neurosyphilis” AND “mixed state”.

A comprehensive diagnostic and laboratory screening was unremarkable except for a positive venereal disease research laboratory (VDRL). Treatment for syphilis was started and we used olanzapine to control the psychiatric symptoms.

The estimated annual incidence of non-HIV STIs (sexually transmitted infections) has increased by nearly 50% during the period 1995–2008 [3]. Our case report underly, like Barbosa et al., the need to evaluate neurosyphilis as a potential cause of behavioural and psychiatric symptoms that simulate a psychotic mixed state of bipolar disorder. Olanzapine control and improve the psychiatric symptomatology in neurosyphilis. Methodological limitations, clinical implications and suggestions for future research directions are considered.

The authors have not supplied their declaration of competing interest.

Biochemical changes in treatment of schizophrenic and bipolar disorders, in Albanian patients, with atypical antipsychotic and anti-depressive drugs. Some of the adverse effects related to their use are hyperlipidemia, hepatic enzymes, type 2 diabetes and CK level, which may result in development of metabolic syndrome. This study aimed to investigate a possible increase of biochemical parameters, in patients with schizophrenia and bipolar disorders treated with atypical antipsychotic and antidepressive drugs (Olanzapin, Risperidon, Clozapin, Antidepresiv triciclik, SSRI, SNRI).

Forty subjects with schizophrenia and bipolar disorders were evaluated, 12 women and 28 men, aged between 17 and 72 years. Blood collection of the patients was taken in our laboratory and this values were measure in long treatment patients, after years of treatment. Analyses were perform in our laboratory with autoanalysator SAT 450.

Evaluation after measurements showed significant differences when comparing the mean values obtained in each patients. The biochemical indicators of development of metabolic syndrome measured in our study, show that is an increasement of lipids panel, specially triglycerides and total cholesterol, also in glucose, CK level and hepatic enzymes, presenting statistically significant changes (P < 0.05) for prolong treatment.

We conclude that the treatment with atypical antipsychotic and antidepressive drugs, promoted a substantial increasing of biochemical blood parameters. Lipids panel, hepatic enzymes, type 2 diabetes, CK levels are observed in among subjects evaluated.

The authors have not supplied their declaration of competing interest.

Maca (Lepidium meyenii) is a plant grown in the Andes Mountains, formerly used for nutritional purposes. Nowadays is used as a nutritional supplement and energizing.

To describe a case of manic episode secondary to maca consumption, as an ingredient of an energizing product.

To report on antidepressant properties of maca, based on a clinical case.

X. is a 27-years-old male without any psychiatric history. He came to the emergency service because of the presence of sudden onset behavioral disorders, presenting a manic-like episode of seven hours of evolution. His symptoms consisted in psychomotor restlessness, hyperactivity, insomnia, verbose and loud speech, hyperthymia, megalomaniac verbalizations, and unsuitable future plans. The patient had self-awareness of his symptoms and was self-critical with his behavior. He reported he was consuming an energizing supplement containing maca from about two weeks ago. Treatment with olanzapine 20 mg was initiated, and the patient remained under observation for 24 hours.

Symptomatology subsided completely after 24 hours. The patient is discharged from the hospital with diagnosis of manic episode secondary to maca, without any treatment. He was advice to not take stimulants.

There are studies reporting that maca plant has antidepressant properties, associated with the activation of noradrenergic and dopaminergic systems, as well as the attenuation of oxidative stress. However, more studies are needed to identify specific compounds that produce these effects.

The authors have not supplied their declaration of competing interest.

Psychiatric symptoms are common among brain tumor patients. Meningiomas are the most common benign brain tumors accounting for 13 to 26% of all intracranial tumors and might present exclusively with psychiatric symptoms. To diagnose a manic episode according to DSM-5 criteria the episode must not be attributable to the physiological effects of a substance or to another medical condition.

Describe a case of first manic episode with a frontal meningioma along with a brief review of available literature.

The case we report is based on information collected from interviews with the patient and the family members as well as from the clinical files. The literature review was performed using the PubMed database.

We describe the case of a 58-year-old woman presenting with symptoms of a first manic episode with psychotic features. There were no previous hypomanic or major depressive episodes. In order to exclude organic causes a brain CT scan was performed that revealed a possible frontal lesion. A brain MRI confirmed the presence of a frontal meningioma with an approximate diameter of 1.4 cm.

The majority of the cases described in the literature refer to large tumors presenting with major depressive symptoms. Given the absence of similar cases in the literature, it seems unlikely that such a small benign lesion may cause a manic episode with psychotic features. Nevertheless, we cannot exclude that possibility.

The authors have not supplied their declaration of competing interest.

Endocannabinoid System (ECS) has been highlighted as one of the most relevant research topics by neurobiologists, pharmacists, basic scientists and clinicians (Skaper and Di Marzo, 2012). Recent work has associated major depressive disorder with the ECS (Ashton and Moore, 2011). Despite the close relationship between depression and bipolar disorders, as far as we know, there is no characterization of ECS and congeners in a sample of patients with bipolar disorders.

The objective of this work is to characterize the plasma levels of endocannabinoids and congeners in a sample of patients with bipolar disorders.

The clinical group was composed by 19 patients with a diagnosis of bipolar disorders using SCID-IV (First et al., 1999). The control group was formed by 18 relatives of first- or second-degree of the patients.

The following endocannabinoids and congeners were quantified: N-palmitoleoylethanolamide (POEA), N-palmitolylethanolamide (PEA), N-oleoylethanolamide (OEA), N-stearoylethanolamide (SEA), N-arachidonoylethanolamide (AEA), N-dihomo-γ-linolenoylethanolamide (DGLEA), N-docosatetraenoylethanolamide (DEA), N-linoleoylethanolamide (LEA), N-docosahexaenoylethanolamide (DHEA), 2-arachidonoylglycerol (2-AG), 2-linoleoylglycerol (2-LG), and 2-oleoylglycerol (2-OG).

The result showed statistically significant lower levels of AEA, DEA and DHEA in clinical sample. Previous research also identified lower levels of AEA in depressed women (Hill et al., 2008, 2009). Until date, it is unknown if DEA and DHEA have some effect on EC receptors, and whether they have some direct effects on endocannabinoids.

It would be necessary to carry our other research with a larger sample, which could allow the control of potential confounding variables.

The authors have not supplied their declaration of competing interest.