General Hospital Psychiatry - Articles in Press

Psychological comorbidities in Chinese patients with acute-on-chronic liver failure - Corrected Proof

Zhongping Duan, Yuanyuan Kong, Jie Zhang, Huimin Guo — 2012-02-03

Abstract: Objectives: Patients with acute-on-chronic liver failure (ACLF) experience long-term chronic liver diseases plus an acute liver function decompensation. This study aimed to determine whether psychological symptoms in patients with hepatitis B virus (HBV)-related ACLF differ from those with other chronic liver diseases and to identify which factors could predict psychological impairment in liver patients.Methods: This was a paired case–control study. A total of 120 inpatients, including 40 cases for HBV-related ACLF, 40 paired controls for HBV-related cirrhosis and 40 paired controls for chronic hepatitis B (CHB), as well as 40 paired healthy controls were studied.Results: A high proportion of patients with HBV-related ACLF were classified as Child's stage C. The prevalence of depression in patients with HBV-related ACLF was significantly higher than in CHB patients and healthy controls, but was equivalent to patients with HBV-related cirrhosis. Patients with HBV-related ACLF had significantly higher level of self-esteem than those with HBV-related cirrhosis. However, there was no significant difference among the three liver patient groups and healthy controls in anxiety and suicide intent. Lower education level, anxiety, poor sleep quality and greater severity of disease were associated with elevated depression.Conclusions: Patients with HBV-related ACLF and cirrhosis are at higher risk of depression. It appears that severity of liver disease measured by Child–Pugh class, rather than additional acute liver function decompensation, significantly predicted depression among liver patients.

Valproate-induced hyperammonemic encephalopathy: an update on risk factors, clinical correlates and management - Corrected Proof

2012-02-03

Abstract: Introduction: Valproate (VPA)-induced hyperammonemic encephalopathy (VHE) is a serious drug-related adverse effect characterized by lethargy, vomiting, cognitive slowing, focal neurological deficits and decreased levels of consciousness ranging from drowsiness to coma.Methods: We present a case series (n=5) and also review previous cases of VHE (n=30) in psychiatric patients to provide an update on risk factors, clinical correlates and management of VHE.Results: To our knowledge, there are 30 (16 female, 14 male) previously reported VHE cases in psychiatric patients. Risk factors for VHE include VPA–drug interactions, mental retardation, carnitine deficiency and presence of urea cycle disorders. Length of VPA treatment, VPA dosage, serum VPA levels and serum ammonia levels do not appear to correlate with onset or severity of VHE.VPA discontinuation is the primary treatment of VHE, although, l-carnitine, lactulose and neomycin have been used adjunctively in some patients.Conclusion: Clinicians should consider VHE in patients taking VPA who present with lethargy, gastrointestinal symptoms, confusion and decreased levels of drowsiness. VPA discontinuation is currently the mainstay of treatment for VHE, although more research is warranted to delineate the underlying risk factors for VHE and consolidate treatment modalities for this potentially life-threatening drug adverse effect.

Cardiovascular risk factors in patients with first-episode psychosis in São Paulo, Brazil - Corrected Proof

2012-02-03

Abstract: Objective: The objective was to evaluate the cardiovascular profile of first-episode psychosis patients in São Paulo, Brazil, an issue that has not been sufficiently explored in low-/middle-income countries.Method: A cross-sectional study was performed 1 to 3 years after an initial, larger survey that assessed first-episode psychosis in São Paulo. We evaluated cardiovascular risk factors and lifestyle habits using standard clinical examination and laboratory evaluation.Results: Of 151 contacted patients, 82 agreed to participate (mean age=35 years; 54% female). The following diagnoses were found: 20.7% were obese, 29.3% had hypertension, 39.0% had dyslipidemia, 19.5% had metabolic syndrome, and 1.2% had a >20% 10-year risk of coronary heart disease based on Framingham score. Also, 72% were sedentary, 25.6% were current smokers, and 7.3% reported a heavy alcohol intake.Conclusion: Compared to other samples, ours presented a distinct profile of higher rates of hypertension and diabetes (possibly due to dietary habits) and lower rates of smoking and alcohol intake (possibly due to higher dependence on social support). Indirect comparison vs. healthy, age-matched Brazilians revealed that our sample had higher frequencies of hypertension, diabetes and metabolic syndrome. Therefore, we confirmed a high cardiovascular risk in first-episode psychosis in Brazil. Transcultural studies are needed to investigate to which extent lifestyle contributes to such increased risk.

A case of ‘cybersuicide’ attempt using chloroform - Corrected Proof

Manon J. Gosselink, Andrea M. Siegel, Eefje Suk, Erik J. Giltay — 2012-02-03

Abstract: Background: The effects of the internet on suicide attempts are not well known. On the internet, there is a wide spectrum of suicide prevention sites. However, prosuicide information can also be obtained via the internet.Objective: The objective was to obtain awareness to medical professionals of the observed growing influence of internet on suicidal patients.Method: We present a 20-year-old man who tried to attempt suicide by means of chloroform inhalation, after easily obtaining both option and the resources via the internet. When found, he had an oxygen saturation below 60%, dilated pupils, a Glasgow Coma Scale of 3 and supraventricular tachycardia. In our hospital, he developed severe rhabdomyolysis, toxic hepatitis and massive hemolysis caused by the delayed production of toxic metabolites of chloroform. Diuresis was forced by intravenous fluids. He fully recovered.Conclusion: The internet has to be considered as a double-edged tool, having both positive and negative effects on suicidal thoughts. Awareness of and effective preventive strategies against ‘cybersuicide’ are amended.

The New York PTSD risk score predicts having, not developing, PTSD - Corrected Proof

Jeffrey Sonis — 2012-02-03

Boscarino and colleagues describe the development and validation of a clinical prediction rule, the New York PTSD risk score. The results show that the Primary Care PTSD screening test was, by far, the strongest predictor of having (i.e., prevalent not incident) PTSD. Although the increase in discrimination of the model by adding psychosocial risk factors to the results of the PTSD screening was statistically significant, the size of the increase was small. For example, in the development sample, the positive predictive value increased from 29.3%, using only the Primary Care PTSD Screen, to 33.9% after adding the psychosocial risk factor variables. The negative predictive value was unchanged. In the trauma validation sample, the positive predictive value increased (from 40.3% to 48.6%) after adding the psychosocial variables to the model, while in the pain study validation sample, the positive predictive value actually decreased after adding psychosocial variables to the model (from 70.1% to 69.8%). These findings suggest that, for simplicity, a clinician who wants to screen for current PTSD would do just about as well by simply using the Primary Care PTSD screen without spending the additional time required to ask the psychosocial questions or use the nomogram developed by Boscarino and colleagues to estimate the probability that someone has PTSD.

Comorbidity of attention-deficit/hyperactivity disorder, Tourette's syndrome and bipolar I disorder in an adolescent patient with schizencephaly - Corrected Proof

Chou-Yu Yeh, Liang-Jen Wang, Yu-Chieh Huang — 2012-01-30

Abstract: There is compelling evidence for an association between structural brain deformities and psychiatric disorders. We report the case of an adolescent boy who was diagnosed with both attention-deficit/hyperactivity disorder and Tourette's syndrome. A full-blown manic episode occurred when he was 13 years old. During his admission to a psychiatric ward, closed-lip schizencephaly in the left frontal lobe and the right parietal lobe was identified through brain imaging. Effective control of his manic symptoms was achieved with quetiapine monotherapy within 3 weeks. This case report implies that the pathophysiology of psychiatric disorders, especially in young patients with multiple comorbid conditions, may be associated with abnormalities in the anatomical and functional development of the brain.

Suicidality and panic in emergency department patients with unexplained chest pain - Corrected Proof

2012-01-30

Abstract: Objectives: The present study aims to document the problem of suicidality in emergency department (ED) patients with unexplained chest pain and to assess the strength and independence of the relationship between panic and suicidal ideation (SI) in this population.Method: This cross-sectional study included 572 ED patients with unexplained chest pain. SI, history of suicide attempts, history of SI and the presence of thoughts about how to commit suicide were assessed. Logistic regression analyses were used to quantify the relationship between current SI and panic.Results: Approximately 15% [95% confidence interval (CI), 12%–18%] of patients reported current SI, and 33% (95% CI, 29%–37%) reported history of SI. Nearly 19% (95% CI, 16%–22%) of patients had thought about a method to commit suicide, and 33% (95% CI, 29%–37%) had a history of a suicide attempt. Panic attacks were diagnosed in 42% (95% CI, 38%–46%) of patients, and 45% (95% CI, 39%–51%) of those had panic disorder. Panic increased the crude likelihood of current SI [odds ratio (OR)=2.53, 1.4–4.5]. This increase in SI risk remained significant after controlling for confounding factors (OR=1.70, 95% CI, 1.0–2.9).Conclusions: Suicidality and SI were common and often severe in our sample of ED patients with unexplained chest pain.

Psychopathological dimensions of tinnitus and psychopharmacologic approaches in its treatment - Corrected Proof

Hasan Belli, Seyda Belli, Mehmet Faruk Oktay, Cenk Ural — 2012-01-30

Abstract: Background: The aim of this review to investigate presence of psychopathological states and efficacy of psychopharmacological drugs in the treatment of tinnitus.Materials and Methods: An extensive Internet search has been performed for this aim through PubMed by using related key words in English.Results: Higher anxiety and depression levels and somatoform disorder clusters are defined in patients with tinnitus. Additionally, impulsivity, hostility, demanding, physical discomfort, anxiety for health, emotionality and suicidal tendency are also defined in these people. Personality characteristics in these patients are depression, hysteria and hypochondriac features. Besides these symptom clusters, more severe psychopathologies like personality disorders may be encountered in these patients. Sertraline, paroxetine and nortriptyline can be considered as the first-line antidepressants in the psychopharmacological treatment of tinnitus. There are studies which have reported the efficacy of sulpiride. Carbamazepine, valproate and gabapentin can be effective as mood stabilizers. Short-acting benzodiazepines like alprazolam and midazolam are effective in signs of anxiety. Clonazepam and diazepam can be evaluated as other options. However, some glutamate receptor antagonists also can be used in the treatment of tinnitus.Disturbed sleep is frequently associated with tinnitus. Sleep disturbance can disrupt the quality of life in the patients with tinnitus. These patients might benefit from cognitive–behavioral therapy, which offers the promise of relief from tinnitus-related distress and insomnia.Conclusion: When pathophysiologic reasons are excluded, it should be at least considered that tinnitus is exaggerated by psychopathological symptoms. Life quality of patients can be increased by treating these symptoms.

Using root cause analysis to reduce falls with injury in the psychiatric unit - Corrected Proof

Alexandra Lee, Peter D. Mills, Bradley V. Watts — 2012-01-30

Abstract: Objective: The objective was to identify how falls on psychiatric units occur, the underlying root causes and effective action plans to reduce falls and injuries.Methods: A search of the Veterans Health Administration National Center for Patient Safety database was conducted to identify root cause analysis (RCA) reviews where a fall was sustained by a patient on a psychiatric unit. Seventy-five RCAs from January 2000 to March 2010 were included.Results: One hundred and thirty-eight actions were identified from the RCA reports. The most common activities the individual was engaged in during a fall included getting up from a bed, chair or wheelchair (21.3%); walking/running (10.7%); bathroom related (9.9%) or behavior related (9.9%). The most common root causes were environmental hazards (11.2%), poor communication of fall risk (8.9%), lack of suitable equipment (8.9%) and need for improvement of the current system for falls assessment (8.9%). Staff education (19.9%), development of tools to improve falls documentation (17.0%) and providing falls prevention equipment (14.2%) were the most frequent actions taken.Conclusions: The results describe the location, activity and root causes surrounding falls that occur in psychiatric units resulting in injury, and provide some suggestions on how to implement a successful action plan.

Psychosis risk syndrome comorbid with panic attack disorder in a cannabis-abusing patient affected by Arnold–Chiari malformation type I - Corrected Proof

2012-01-30

Abstract: Objective: An 18-year-old man with Arnold–Chiari malformation (ACM) type I developed sudden panic attacks. He also manifested sleep disorder, cannabis abuse, and psychosis-risk syndrome (PRS). Although with average–superior intelligence, he had executive dysfunction. This prompted us to explore the relation between ACM, cannabis abuse, PRS and panic disorder.Method: We report the case and briefly review the literature focusing on ACM and psychiatric disorders.Results: Behavior therapy led to gradual abstinence from cannabis with disappearance of anxiety symptoms. The patient is currently well and maintained on omega-3 polyunsaturated fatty acids.Conclusions: Locus coeruleus compression and cannabis abuse may have triggered the symptoms, and the latter might also be PRS-related. PRS and anxiety symptoms should be explored in ACM patients to allow better prevention of psychosis and anxiety disorders.

Psychiatric morbidity predicts perceived burn-specific health 1 year after a burn - Corrected Proof

Aili J.F. Low, Johan Dyster-Aas, Mimmie Willebrand, Lisa Ekselius, Bengt Gerdin — 2012-01-24

Abstract: Objective: Individual factors such as gender, age, coping and personality traits and injury-related factors such as injury severity have been implicated as risk factors for poor perceived health after burns. As psychiatric morbidity is common in individuals who sustain burns, the aim of this study was to examine the effect of preinjury psychiatric problems on perceived health after injury.Method: A total of 85 consecutive patients treated at a national burn center were prospectively assessed: the patients were interviewed during acute care with the Structured Clinical Interview for DSM-IV Axis I Disorders. One year after injury, perceived health was assessed with the Burn-Specific Health Scale-Brief (BSHS-B). Multiple regression analyses were used to evaluate the predictive effect of preinjury psychiatric history on perceived postinjury health.Results: Psychiatric morbidity, especially mood disorders, affected outcome for six of the nine BSHS-B subscales, with the covariates mainly being the length of hospital stay and total burn size.Conclusion: The results show that a history of preinjury psychiatric disorders, especially during the year before the burn, affects perceived outcome regarding both physical and psychological aspects of health 1 year after injury and that it is a risk factor for worse perceived outcome.

Reversible ptosis probably related to duloxetine use - Corrected Proof

Mustafa Mehmet Ozkose, Sinan Guloksuz, Bahri Ince, Kursat Altinbas — 2012-01-24

Duloxetine (Cymbalta) is a dual serotonin–noradrenaline reuptake inhibitor and is used to treat depressive disorders, stress urinary incontinence and fibromyalgia . Here we report a case of reversible ptosis of eye lid that we judged to be related to duloxetine use.

Effect of communicating depression severity on physician prescribing patterns: findings from the Clinical Outcomes in MEasurement-based Treatment (COMET) trial - Corrected Proof

2012-01-24

Abstract: Objective: In this secondary analysis from the Clinical Outcomes in MEasurement-based Treatment trial (COMET), we evaluated whether providing primary care physicians with patient-reported feedback regarding depression severity affected pharmacological treatment patterns.Method: Intervention-arm physicians received their patients' 9-item Patient Health Questionnaire scores monthly. Odds of having no change in antidepressant treatment during the 6-month study period were calculated. Relationships between depression symptom status (partial or nonresponse) at month 3 and treatment changes in months 3 through 6 were assessed.Results: Among 503 intervention and 412 usual care (UC) patients with major depressive disorder, most received antidepressant monotherapy at baseline (79.4% UC vs. 88.4% intervention; P=.047). Few switched their baseline antidepressant (17.4%), increased their dose (12.4%) or augmented with a second medication (2%). Odds of having no change in antidepressant therapy did not differ significantly between study arms (odds ratio 1.21; 95% confidence interval 0.78–1.88; P=.392). Few month 3 partial or nonresponders had a regimen change over the following 3 months; the study arms did not differ significantly (partial responders: 4.1% UC vs. 7.7% intervention; P=.429; nonresponders: 14.6% UC vs. 15.9% intervention; P=.888).Conclusions: Among depressed patients treated in primary care, little active management was observed. The lack of treatment modification for the majority of partial and nonresponders was notable.

Quetiapine-induced frequent premature ventricular contraction - Corrected Proof

Akiko Deguchi, Masayuki Nakamura, Takehiro Hayashi, Akira Sano — 2012-01-16

Abstract: A 17-year-old female diagnosed with bipolar II disorder was treated for emotional lability with quetiapine. Two-lead electrocardiography revealed frequent monomorphic premature ventricular contraction (PVC) during an electroencephalography examination. Twenty-four-hour Holter electrocardiography revealed 0.6% uniform frequent PVCs and indicated that the readministration and second-time withdrawal of quetiapine markedly increased (7.1%) and decreased the frequency of PVC (1.1%), respectively. This case indicates that quetiapine can cause PVC as a serious side effect.

Auditory hallucination and agitation due to memantine in a patient with Alzheimer's disease: a case report - Corrected Proof

Seishi Terada, Yosuke Uchitomi — 2012-01-16

Abstract: Memantine is a noncompetitive N-methyl-d-aspartate receptor antagonist that is well tolerated. However, dementia patients presenting with confusion or worsening of visual hallucinations with memantine treatment have been reported. In this report, we describe an Alzheimer's disease patient presenting with severe auditory hallucination with memantine treatment.

Onset and risk factors for anxiety and depression during the first 2 years after lung transplantation - Corrected Proof

2012-01-16

Abstract: Objective: Anxiety disorders are prominent in chronic lung disease; lung transplant recipients may therefore also be at high risk for these disorders. We sought to provide the first prospective data on rates and risk factors for anxiety disorders as well as depressive disorders during the first 2 years after transplantation.Method: A total of 178 lung recipients and a comparison group (126 heart recipients) received psychosocial and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition assessments at 2, 7, 12, 18 and 24 months posttransplant. Survival analysis determined onset rates and risk factors.Results: The panic disorder rate was higher (P<.05) in lung than heart recipients (18% vs. 8%). Lung and heart recipients did not differ on rates of transplant-related posttraumatic stress disorder (15% vs. 14%), generalized anxiety disorder (4% vs. 3%) or major depression (30% vs. 26%). Risk factors for disorders included pretransplant psychiatric history, female gender, longer wait for transplant, and early posttransplant health problems and psychosocial characteristics (e.g., poorer caregiver support and use of avoidant coping).Conclusions: Heightened vigilance for panic disorder in lung recipients and major depression in all cardiothoracic recipients is warranted. Strategies to prevent psychiatric disorder should target recipients based not only on pretransplant characteristics but on early posttransplant characteristics as well.

Cobalamin deficiency presenting as obsessive compulsive disorder: case report - Corrected Proof

Vivek Sharma, Devdutta Biswas — 2012-01-09

Abstract: Cobalamin deficiency commonly presents with a wide range of neuropsychiatric manifestations ranging from myelopathy, neuropathy, optic neuritis and dementia to mood disorders, chronic fatigue and psychosis even without classical hematological abnormalities like anemia and macrocytosis. However, obsessive compulsive disorder (OCD) in relation to vitamin B12 deficiency has not been described so far. We report a case of middle-aged man presenting with OCD, low serum cobalamin and a positive family history of vitamin B12 deficiency who responded well to methylcobalamin replacement.

School refusal by patients with gender identity disorder - Corrected Proof

2012-01-09

Abstract: Objective: The accumulating evidence suggests that school refusal behavior is associated with severe negative outcomes. However, previous research has not addressed school refusal by patients with gender identity disorder (GID). In this study, we tried to clarify the prevalence of school refusal among GID patients and the relationship of school refusal to demographic characteristics.Methods: A total of 579 consecutive Japanese GID patients at the outpatient GID Clinic of Okayama University Hospital between April 1997 and October 2005 were evaluated.Results: The prevalence of school refusal was 29.2% of the total sample. School refusal was more frequent among GID patients with divorced parents than those with intact families. Multiple logistic regression analysis showed that younger age at consultation and divorce of parents were significantly associated with school refusal among the male-to-female GID patients.Conclusion: The rate of school refusal among GID patients is high, and school refusal is closely related with a low level of education and current unemployment. We should pay more attention to GID patients of school age to prevent their school refusal, which results in low educational achievement.

Postpartum catatonia treated with electroconvulsive therapy: a case report - Corrected Proof

2012-01-09

Abstract: Catatonia is a rare syndrome that occurs in mood and psychotic disorders, and general medical conditions. Postpartum depression affects 10%–15% of women within 6 months after delivery. Postpartum psychosis affects 0.1%–0.5% of women within weeks after delivery, though it can occur within hours; it carries risk for suicide and infanticide. There is limited evidence available to guide treatment. We review a case of postpartum psychosis that presented with catatonia and was resistant to medications, but responded to electroconvulsive therapy.

Validation of the Risk Model for Delirium in hip fracture patients - Corrected Proof

2012-01-09

Abstract: Objective: The Risk Model for Delirium (RD) score is a 10-item questionnaire that allocates hip fracture patients after admission to hospital to be either at high or at low risk for delirium. This allows targeted preventive actions. Clinical reliability, validity and feasibility of the RD score are discussed.Methods: Demographic data, RD score and delirium incidence of all consecutive admissions for hip fractures in patients 65 years and older were collected. In 102 patients, the RD score was repeated. Interobserver reliability and validity were determined. The correlation between delirium and items both included and not included in the RD score was calculated.Results: A total of 378 patients were included; 102 (27%) were diagnosed with a delirium. The intraclass correlation coefficient of the RD score was 0.77 [confidence interval (CI) 0.68–0.84]. Sensitivity was 80.4% (71.4–87.6), and specificity was 56.2% (50.1-62.1). Area under the receiver operating characteristic curve was 0.73 (CI 0.68–0.77). A multivariable logistic regression analysis showed that besides the RD score, a trochanteric fracture and male gender were independent risk factors for delirium.Conclusions: The RD score is a reliable, feasible and valid instrument for predicting delirium in hip fracture patients.

Alterations in P wave duration and dispersion in depressive patients following electroconvulsive therapy - Corrected Proof

2011-12-16

Abstract: Objective: Electroconvulsive therapy (ECT) consists of controlled convulsive seizure by electric stimulation of the brain. Although various electrocardiographic (ECG) changes have been reported during ECT, atrial conduction has not been studied extensively. The aim of the present study was to assess the effects of ECT on systemic arterial blood pressure and ECG parameters (P wave duration, P wave dispersion and heart rate).Methods: Thirty depressive patients undergoing ECT were included. Echocardiographic examination was performed on all patients before ECT sessions to exclude systolic heart failure and diastolic dysfunction which may affect P wave duration and dispersion. Twelve-lead ECG records were obtained before the first ECT and after the third session of ECT. Blood pressure was measured before and after convulsive therapy session.Results: Compared to baseline values, maximum P wave duration (99.3±14.6 to 111.3±8.2 ms, P=.001), P wave dispersion (50±14.8 to 63.3±10.3 ms, P=.001), and systolic (110.7±12 to 116±12.2 mmHg, P=.043) and diastolic blood pressures (70.7±9.4 to 75.3±8.2 mmHg, P=.028) were significantly increased after convulsive therapy session.Conclusions: We proposed that ECT alone or in combination with atypical antipsychotics or antidepressants may influence atrial conduction as evidenced by the significantly prolonged maximum P wave duration and P wave dispersion. Longer-term follow-up of patients undergoing ECT may be appropriate to evaluate the possible long-term outcomes of our short-term results.

Delirium secondary to pregabalin - Corrected Proof

Catherine Hickey, Barbara Thomas — 2011-12-16

Abstract: Fibromyalgia is a common and disabling disease, and treatment can be challenging. More recently, pregabalin has been approved to treat pain associated with fibromyalgia. However, it can have serious neuropsychiatric sequelae. Several case reports have documented delirium secondary to pregabalin, usually in older patients with multiple medical comorbidities and concurrent medications. We describe a case of delirium in a young patient without significant medical problems and in the absence of other potentially causal medications. In this case, pregabalin appears to be the single causal etiology for delirium. We recommend clinicians to consider the causal role it may play in any patient who presents with delirium.

Mokken scaling analysis of the Hospital Anxiety and Depression Scale in individuals with cardiovascular disease - Corrected Proof

Theodore D. Cosco, Frank Doyle, Roger Watson, Mark Ward, Hannah McGee — 2011-12-16

Abstract: Objective: The Hospital Anxiety and Depression Scale (HADS) is a prolifically used scale of anxiety and depression. The original bidimensional anxiety-depression latent structure of the HADS has come under significant scrutiny, with previous studies revealing one-, two-, three- and four-dimensional structures. The current study examines the latent structure of the HADS using a non-parametric item response theory method.Method: Using data conglomerated from four independent studies of cardiovascular disease employing the HADS (n=893), Mokken scaling procedure was conducted to assess the latent structure of the HADS.Results: A single scale consisting of 12 of 14 HADS items was revealed, indicating a unidimensional latent HADS structure.Discussion: The HADS was initially intended to measure mutually exclusive levels of anxiety and depression; however, the current study indicates that a single dimension of general psychological distress is captured.

When patients do not hurt: silent acute abdomen in a patient with schizophrenia - Corrected Proof

Carolina Retamero, Camille Paglia — 2011-12-12

Abstract: The phenomenon of pain insensitivity in schizophrenia and other psychotic disorders has been described since the early 20th century. Medical conditions often present atypically in the seriously mentally ill patient. Emergency physicians, primary care practitioners, surgeons and psychiatrists must maintain a high index of suspicion for acute abdomen in seriously mentally ill patients who may exhibit a diminished or absent perception of pain. The authors present a case of an atypical presentation of acute abdomen in a patient with schizophrenia.

Contacts with mental health services before suicide: a comparison of Indigenous with non-Indigenous Australians - Corrected Proof

Jerneja Sveticic, Allison Milner, Diego De Leo — 2011-12-12

Abstract: Objective: Most people who die by suicide never seek help, particularly members of ethnic minorities. This study compared the prevalence of contacts with mental health services, types of services accessed and factors related to help-seeking behaviors by Indigenous and non-Indigenous Australians.Method: All suicides by Indigenous and non-Indigenous persons from Queensland, Australia, during the period 1994–2007 were analyzed using descriptive statistics and logistic regression models.Results: Non-Indigenous suicide cases were almost two times more likely than Indigenous counterparts to have ever received help for mental health problems (43.3% vs. 23.8%). The most common source of help for Indigenous persons was inpatient care, while for non-Indigenous persons, it was general practitioners. Factors increasing the likelihood of service utilization by Indigenous persons were suicide attempt in last year, living in metropolitan area and not being married. Among non-Indigenous persons, these factors were recent communication of suicidal intent or suicide attempt, recent treatment for physical illness and problematic consumption of alcohol.Conclusions: Indigenous Australians die by suicide at a rate twice higher than the non-Indigenous population, yet they are significantly less likely to seek professional help for mental health concerns. Help-seeking behavior among Indigenous Australians at risk of suicide should be promoted thorough provision of culturally appropriate services.

Oral-paliperidone-induced tardive dyskinesia: a case report - Corrected Proof

Han-Ting Wei, Ya-Wen Lai, Mu-Hong Chen, Ying-Sheue Chen — 2011-12-12

Abstract: Objectives: Tardive dyskinesia (TD) is generally considered the most severe extrapyramidal sequelae of antipsychotic treatments.Method: Case report.Results: We present a 20-year-old woman with previous treatment of risperidone 6–7 mg daily for approximately 4 years. She developed TD 2 years later after switching to paliperidone 9 mg daily. To the best of our knowledge, she is the first case report of having direct paliperidone-induced TD. Immediate treatments including paliperidone dose reduction to 6 mg daily, clonazepam 1.5 mg daily and trihexyphenidyl 2 mg daily were performed for 1 month, and her symptoms were relieved eventually after switching to clozapine 75 mg daily.Conclusion: Although second-generation antipsychotics such as paliperidone are considered to have a lowered risk of developing TD, this case could bring awareness to clinicians of the possibility of TD with the use of any antipsychotics.

Psychosis associated with bromvalerylurea abuse in a patient with traumatic brain injury - Corrected Proof

Chun-Ya Kuo, Chih-Min Liu, Li-Ren Chang — 2011-12-12

Bromvalerylurea is a common ingredient of over-the-counter analgetic syrup in Asian countries. It has been widely used as analgesics, sedatives or hypnotics . The abuse of analgetic syrup may cause chronic bromvalerylurea intoxication . Neuropsychiatric manifestations of bromvalerylurea intoxication include psychosis, delirium, reversible dementia, ataxia, dysphagia, dysarthria and dystonia . Here we report a patient with traumatic brain injury (TBI) showing psychosis which warned us of the possible risk of analgetic syrup abuse in vulnerable patients.

A case of severe oral self-injurious Tourette's syndrome alleviated by pregabalin - Corrected Proof

2011-12-02

Abstract: Self-injurious behavior (SIB) associated with Tourette's syndrome (TS) is a severe neuropsychiatric condition that causes significant distress and can impair social functioning. The current treatment options for the condition include pharmacological, physical and psychosocial interventions. However, given the need for more effective interventions, especially for those patients who are unresponsive and/or intolerant to standard medications, further exploration of novel treatments is imperative. In this report, we present a case of SIB-TS that was successfully treated with pregabalin. The patient received 1-year of follow-up and was noted to have considerable improvement in symptoms. Although rigorous controlled studies are required, based on our case study, pregabalin may be a potential treatment option in some cases of SIB with TS.

Low-dose escitalopram for 2 days associated with corrected QT interval prolongation in a middle-aged woman: a case report and literature review - Corrected Proof

Ping-Tao Tseng, Yu Lee, Ya-En Lin, Pao-Yen Lin — 2011-12-02

Abstract: Prolongation of the corrected QT interval (QTc) on the electrocardiography is an important clinical condition because it increases the risk of torsade de pointes, a medical emergency that can cause sudden cardiac death. QTc prolongation can be induced by many drugs, including antipsychotics and tricyclic antidepressants (TCAs). Compared with TCAs, use of selective serotonin reuptake inhibitors (SSRIs) was less likely to cause severe cardiac adverse effects. Escitalopram, one of the SSRIs, has shown significant antidepressant efficacy and well tolerability. Here, we present one female patient showing QTc prolongation induced by low-dose (5 mg/day) treatment of escitalopram for 2 days. The QTc returned to normal soon after discontinuation of escitalopram. Clinicians should be cautious about cardiac effects when using a SSRI, even in a low dose.

Factitious disorder in a psychogeriatric inpatient - Corrected Proof

Lori-Anne Williams, Ana Hategan, James A. Bourgeois — 2011-12-02

There is a dearth of literature on factitious disorder (FD) in the geriatric population. We highlight the challenges associated with diagnosing FD in the elderly and the importance of early diagnostic consideration in order to minimize iatrogenic harm. Moreover, we report that the use of validation therapy can be successful in the management of FD.

Fluoxetine-responsive depression in a Chinese cerebrotendinous xanthomatosis - Corrected Proof

Qiaozhen Chen, Weibo Liu, Biao Jiang, Risheng Yu, Xiuzhen Li, Huichun Li — 2011-12-02

Abstract: Cerebrotendinous xanthomatosis (CTX) is an autosomal recessive, lipid storage disorder which is extremely rare in the Chinese population. It is characterized by progressive neurologic dysfunction and enlargement of tendon xanthomas, and is often accompanied with neuropsychiatric symptoms. Few reports are available regarding depression and antidepressant medication in CTX patients. Here, we report a Chinese case of CTX associated with fluoxetine-responsive major depression.

Risk of adverse events in treatment-resistant depression: propensity-score-matched comparison of antidepressant augment and switch strategies - Corrected Proof

2011-11-14

Abstract: Objective: The objective was to assess differences in adverse events between major depressive patients augmented with a second medication and patients switched to an alternative monotherapy after failing first-step treatment with citalopram.Method: Adverse event profiles for second-step switch and augment medication strategies were compared using public data files from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. In the STAR*D trial, participants failing citalopram selected acceptable next-step strategies and were randomized within acceptable strategies. This design resulted in clinically important differences when comparing across strategies, so a propensity-score-matched sample was created to compare switch (n=269) and augment (n=269) strategies.Results: Incidence proportions of any adverse event and specific adverse events were similar between the augment and switch groups. The overall incidence proportion of any distressing event was 0.78 [95% confidence interval (CI) 0.72–0.84] in the augment group and 0.80 (95% CI 0.74–0.85) in the switch group. This contrasts unmatched analyses where distressing adverse events were less common in the augment group than the switch group (risk ratio 0.85, 95% CI 0.81–0.90).Conclusion: After adjusting for selection bias inherent in the STAR*D comparison of augment with switch, clinically meaningful differences in the adverse event profiles between these treatment strategies were not observed.

Cingulate cortex aplasia and callosal dysgenesia combined with schizencephaly in a patient with chronic lying - Corrected Proof

2011-11-14

Abstract: We report on a 19-year-old patient with a 4-year history of lying and cheating who presented neuropsychological abnormalities regarding attention deficits, hyperactivity and impulsivity. Cerebral magnetic resonance imaging scans revealed schizencephaly of the right central region, dysgenesia of the corpus callosum, a noneverted gyrus cinguli and hypoplasia of the left cerebellar hemisphere. Although the patient did not fulfill the diagnostic criteria for attention-deficit/hyperactivity disorder, we suggest that the patient's behavioral alteration could be related to the neuroanatomical alterations, especially the aplasia of the gyrus cinguli.

Hidden depression in otolaryngology patients with medically unexplained symptoms - Corrected Proof

Fumiyuki Goto, Tomoko Tsutsumi, Naoki Oishi, Masaru Mimura — 2011-11-07

Abstract: Objective: To investigate the prevalence of depression among otolaryngology patients with medically unexplained symptoms (MUS) and the outcome of treatment with selective serotonin reuptake inhibitors (SSRIs).Method: Ninety patients with MUS from a population of 983 consecutive otolaryngology outpatients were enrolled. The Self-Rating Depression Scale (SDS) was used to screen for depression. In addition to standard treatment, all depressed and nondepressed patients received SSRIs for 8 weeks. The Clinical Global Impression-Improvement (CGI-I) scale was used to evaluate clinical changes in patients with MUS.Results: There were 49 patients with depression among those with MUS, according to the SDS criteria. The patients with depression showed a better outcome than those without depression, demonstrating more significantly improved CGI-I scores.Conclusion: More than half of the individuals with otolaryngological MUS had depression, and their MUS were successfully treated with SSRIs.

Mental health, substance use and intimate partner problems among pregnant and postpartum suicide victims in the National Violent Death Reporting System - Corrected Proof

Katherine J. Gold, Vijay Singh, Sheila M. Marcus, Christie Lancaster Palladino — 2011-11-07

Abstract: Objectives: Suicide during pregnancy and postpartum is a tragic event for the victim and profoundly impacts the baby, the family and the community. Prior efforts to study risks for pregnancy-associated suicide have been hampered by the lack of data sources which capture pregnancy and delivery status of victims. Introduction of the United States National Violent Death Reporting System (NVDRS) offers new insights into violent deaths by linking multiple data sources and allowing better examination of psychosocial risk factors.Methods: The analysis used data from 17 states reporting to the NVDRS from 2003 to 2007 to evaluate suicide patterns among pregnant, postpartum, and nonpregnant or postpartum women. Demographic factors, mental health status, substance use, precipitating circumstances, intimate partner problems and suicide methods were compared among groups.Results: The 2083 female suicide victims of reproductive age demonstrated high prevalence of existing mental health diagnosis and current depressed mood, with depressed mood significantly higher among postpartum women. Substance use and presence of other precipitating factors were high and similar among groups. Intimate partner problems were higher among pregnant and postpartum victims. Postpartum women were more likely to die via asphyxia as cause of death compared to poisoning or firearms.Conclusions: These findings describe important mental health, substance use and intimate partner problems seen with pregnancy-associated suicide. The study highlights mental health risk factors which could potentially be targeted for intervention in this vulnerable population.

The diagnostic challenge of frontotemporal dementia in psychiatric patients: a case report - Corrected Proof

Lucio Ghio, Alice Cervetti, Francesca Pannocchia, Werner Natta — 2011-11-07

Abstract: Frontotemporal dementia (FTD) is often misdiagnosed early in the clinical course and may be confused with primary psychiatric disorders. This is especially true when patients have a psychiatric history. In this report, we describe a case that illustrates the diagnostic challenge of FTD in a patient with a history of obsessive–compulsive disorder.

Propranolol in yawning prophylaxis: a case report - Corrected Proof

Ahmad Ghanizadeh — 2011-11-07

Abstract: Objective: Yawning is a frequent behavior with circadian effects. Sometimes, its frequency is very high and it is disturbing. However, there is no evidence-based treatment for yawning.Method: This is a case report of a man with severe yawning from about 2 years ago.Results: Yawning reduced after taking propranolol.Conclusion: Current evidence suggests that propranolol may decrease yawning through its thermoregulation effect. It is worthwhile conducting controlled clinical trials to study whether propranolol is an effective treatment for yawning.

Detoxification of high-dose zolpidem using cross-titration with an adequate equivalent dose of diazepam - Corrected Proof

2011-10-31

Abstract: Background: There have been numerous case reports of zolpidem abuse and dependence in the recent decade, giving rise to a focus on adverse withdrawal events such as seizure. No standard detoxification regimen has been proposed to date, despite the similarity of effects of zolpidem and benzodiazepines at high doses.Case Descriptions: We describe the results, in a 53-year-old female patient, of undergoing three different zolpidem detoxification programs.Conclusions: Because of her experiences, we recommend using the cross-titration strategy with an adequate equivalent dose of diazepam.

Anxiety and depression in patients with myocardial infarction: findings from a centre in India - Corrected Proof

Siddharth Sarkar, Rakesh K. Chadda, Nand Kumar, Rajiv Narang — 2011-10-31

Abstract: Objectives: The study was conducted to assess the occurrence of anxiety and depression in patients with recent myocardial infarction (MI) and also to assess the relationship of these symptoms with other relevant factors and clinical outcome.Methods: A total of 103 patients with recent MI attending the cardiology outpatient department (OPD) of a tertiary care centre in India were included. The patients were evaluated using Hamilton Anxiety Rating Scale (HAM-A), Hamilton Depression Rating Scale (HAM-D) and Mini International Neuropsychiatric Interview (MINI), and pertinent demographic and clinical parameters were recorded. The patients were followed up at 12 weeks telephonically to ascertain outcome.Results: Significant anxiety and depressive symptoms were present in 48.5% and 25.2% of the sample. Anxiety or depressive disorder diagnosis was present in 25.2% of the sample. Aspirin use predicted lower anxiety and depressive symptom scores. A multivariate linear regression showed that female sex, history of angina and use of aspirin independently predicted scores on HAM-A. Diagnosis of psychiatric disorder, use of aspirin and increased body mass index also independently predicted scores on HAM-D.Conclusions: There is a need to screen for anxiety and depressive symptoms in patients with MI, so that appropriate intervention can be incorporated in the management plan.

Prevalence of psychiatric morbidity at Mobile Health Clinic in an urban community in North India - Corrected Proof

Harshal Salve, Kiran Goswami, Baridalyne Nongkynrih, Rajesh Sagar, V. Sreenivas — 2011-10-24

Abstract: Objective: The objective was to estimate the prevalence of psychiatric morbidity amongst patients attending Mobile Health Clinic (MHC) in an urban community in South Delhi.Methods: Adult subjects were recruited by systematic random sampling at outpatient MHC. Primary Care Evaluation of Mental Disorder Patient Health Questionnaire (PHQ) was used for screening, and Mini International Neuropsychiatric Interview (M.I.N.I.) was used for the confirmation of diagnosis of psychiatric disorder of all PHQ-positive and 20% of PHQ-negative patients. Association of selected sociodemographic factors with psychiatric morbidity was also assessed.Results: In total, 350 subjects were recruited, out of which 92 (26.3%) [95% confidence interval (CI) 21.7–31.0] were found to be PHQ positive. M.I.N.I. was administered to 141 subjects (92 PHQ positives and 52 PHQ negatives). Total estimated magnitude of psychiatric morbidity by M.I.N.I. was 25.4% (95% CI 20.9–29.9). Depression (15.7%) was observed to be the most common psychiatric disorder followed by generalized anxiety disorder (11.1%) and phobic disorders (10.1%). Suicidal ideation was reported by 37 (10.6%) patients. Literate status [odds ratio (OR)=0.43] and duration of migration >20 years to study area (OR=1.27) were found to be significantly associated with psychiatric morbidity.Conclusion: In resource-poor country like India, high psychiatric morbidity at MHC justifies the use of MHC for providing outreach mental health services in difficult areas.

Life-threatening thrombocytosis following GCSF treatment in a case of clozapine-induced agranulocytosis - Corrected Proof

Sabita Dihingia, Kamala Deka, Dhrubajyoti Bhuyan, Supriya Kumar Mondal — 2011-10-24

Abstract: Clozapine was introduced in European market in 1972 as an effective treatment for schizophrenia without extrapyramidal side effects. Within a short while, the clozapine story virtually came to a halt following detection of life-threatening neutropenia and agranulocytosis. Judicial use of granulocyte colony stimulating factor (GCSF) can be life saving with infrequent side effects in these cases. Here we are presenting a case of clozapine induced agranulocytosis managed with GCSF but had transient but life-threatening thrombocytosis, a very uncommon complication of GCSF therapy. Expression of GCSF receptors on the surface of megakaryocytic lineage is thought to be the cause of this unusual phenomenon.

Association of somatic symptoms with depression and anxiety in clinical patients of general hospitals in Guangzhou, China - Corrected Proof

2011-10-17

Abstract: Objectives: In high-income countries, depression and anxiety are reported to be common reasons for patients visiting nonpsychiatric services. This study aimed to assess the rate of depression and anxiety, and their associations with somatic symptoms, in patients presenting to clinics of general hospitals in Guangzhou, China.Methods: In a hospital-based cross-sectional study of 2408 randomly selected clinical patients from 15 general hospitals, we assessed depression and anxiety via the Hospital Anxiety and Depression Scale (HADS), somatic symptoms via the Patient Health Questionnaire 15-Item Somatic Symptom Severity Scale (PHQ-15) and patients' view of the impact of somatic symptoms on their life, job and social relationships. Multiple logistic models were used to analyze the association of somatic symptoms with depression and anxiety, the underlying physical diseases and the self-rated somatic symptoms' impact on social functions.Results: Of the participants, 454 (19.0%) reported moderate to high somatic symptoms (PHQ-15 score≥10), 367 (15.2%) had depression (HADS-D score≥7), 167 (6.9%) had anxiety (HADS-A score≥10), and 125 (5.2%) had both depression and anxiety (HADS-D≥7 and HADS-A≥10). Patients with depression and anxiety had higher somatic symptoms and rated these symptoms as having a greater negative impact on their social functions. Relevant to other systemic diseases, only digestive system disease was associated with higher somatic symptoms and self-rated negative social impact, and great negative emotions. Stepwise multiple logistic analyses demonstrated that female sex and depression and anxiety were the main factors for the high somatic symptoms of the population.Conclusions: Among patients who visit hospital clinics in Guangzhou, China, somatic complaints are highly associated with depression and anxiety, and rarely associated with their underlying medical diseases. The findings indicate the importance of recognizing and managing depression and anxiety for these patients.

A rare storm in a psychiatric ward: thyroid storm - Corrected Proof

Ting-Shou Chen, Min-Jie Wen, Yi-Jen Hung, Chang-Hsun Hsieh, Fone-Ching Hsiao — 2011-09-23

Abstract: We present the case of a previously healthy man in whom acute psychosis masked the major symptomatology of thyroid storm. This patient highlights the importance of taking into consideration a life-threatening condition, thyroid storm, in the differential diagnosis of acute psychosis, even in the absence of a history of thyrotoxicosis.

A case of deep venous thrombosis following protracted catatonic immobility recovered with electroconvulsive therapy: the relevance for an early intervention - Corrected Proof

2011-09-21

Abstract: Catatonic patients often experience prolonged inactivity and dehydration, thus being prone to venous stasis leading to life-threatening thrombosis and pulmonary embolism (PE). When this occurs, the prescription of electroconvulsive therapy (ECT), actually irreplaceable in most life-threatening cases, remains controversial essentially due to an increased risk for PE and cerebral haemorrhage, with timing clinical decisions being as crucial as difficult to take. We report the case of a catatonic patient affected by malnutrition, deep venous thrombosis, severe pressure ulcers and septic syndrome resulting from previous untimely management, successfully treated with 16 well-tolerated ECT applications upon intensive supportive care. Although anecdotal, cases like this remind the relevance of early ECT to reduce the risk for potentially life-threatening complications due to prolonged catatonic inactivity, especially to those clinicians substantially disregarding this practice.

Catatonia as a manifestation of tacrolimus-induced neurotoxicity in organ transplant patients: a case series - Corrected Proof

2011-09-21

Abstract: Tacrolimus has been associated with severe neurotoxicity in organ transplant patients. Catatonia can be a rare manifestation of tacrolimus-induced neurotoxicity as we report two cases of catatonia in solid organ transplant patients on tacrolimus. Catatonic symptoms completely resolved in these patients after reducing the tacrolimus dosage or switching it to alternative immunosuppressants. Catatonia symptoms in organ transplant patients should alert clinicians to look for tacrolimus-induced neurotoxicity despite normal serum tacrolimus levels and neuroimaging findings.

Factors influencing QT prolongation in patients hospitalized with severe anorexia nervosa - Corrected Proof

2011-09-14

Abstract: Background: Anorexia nervosa (AN) carries the highest mortality of any psychiatric disorder largely attributable to sudden cardiac death and suicide. Controversy exists regarding the underlying mechanism of cardiac risk, whether QT prolongation is a consistent feature of the disorder and whether repolarization varies by disease severity. Some of the uncertainty may relate to a lack of standardized electrocardiography (ECG). To date, studies have not utilized centrally adjudicated digital ECG, and most have relied on the Bazett formula for rate-correction, which is suboptimal at the extremes of heart rate often observed in AN.Methods: We evaluated a hospitalized cohort of medically compromised, very-low-body mass index (BMI) AN patients. The QT interval was measured with high-precision calipers by a single, blinded electrophysiologist and rate corrected (QTc) using the Fridericia formula. Anatomically corrected left ventricular (LV) mass and resting energy expenditure (REE) were calculated as proxies for disease severity. Proportions exceeding categorical thresholds for QTc prolongation and correlations between admission QTc and disease severity were performed.Results: Among 19 patients, mean BMI was 12.3 kg/m2, and 95% were female. The majority (68%) of patients were receiving QT-prolonging drugs. Four patients (21%) had QTc prolongation. Two of these patients (10.5%) exceeded the 500 ms threshold for marked QTc-prolongation, though each had concomitant factors contributing to delayed repolarization. The QTc interval was not significantly correlated with LV mass, LV mass index, BMI or REE.Conclusions: Although delayed cardiac repolarization was observed among a medically compromised cohort of patients with anorexia nervosa, the QTc interval was not a reliable correlate of disease severity despite digital ECG adjudication and optimal rate correction.

The effect of aripiprazole and quinagolide, a dopamine agonist, in a patient with symptomatic pituitary prolactinoma and chronic psychosis - Corrected Proof

Rosalie Broekhof, Manon J. Gosselink, Hanno Pijl, Erik J. Giltay — 2011-08-29

Abstract: Background: Highly potent dopamine D2 receptor antagonistic antipsychotics may induce hyperprolactinemia. Conversely, drugs for the treatment of prolactinoma may activate dopamine D2 receptors, which can induce or aggravate psychosis. Aripiprazole, as a partial D2 receptor agonist, may be the drug of choice in patients suffering from both psychosis and prolactinoma.Objective: We evaluated the effects of aripiprazole on the size of a cystic macroadenoma by magnetic resonance imaging and on prolactin levels in a patient suffering from psychosis and prolactinoma.Method: This is a case report of a 53-year-old female patient with a chronic psychotic disorder and moderate mental retardation who had developed a prolactinoma that was resected but still had residual adenoma and hyperprolactinemia. Antipsychotic medication was switched from risperidone to aripiprazole before a dopamine agonist was initiated.Results: After change in treatment, there were reductions in serum prolactin levels, tumor size and visual field defects. We observed no psychotic decompensation.Conclusion: The combination of aripiprazole and quinagolide could be considered as an effective treatment in patients suffering from both psychosis and a prolactinoma.