A multicenter clinical study provides a clear profile of the background and headache characteristics of l,420 patients with confirmed tension headache. The results verify characteristics that astute clinicians have noted in these patients for years. A guideline for differentiation of tension headache from migraine and other conditions is provided, and the essentials of management are discussed.
Data from 101 consecutively admitted intensive care unit (ICU) patients were examined to determine whether oxidative metabolic stress existed within the 48 hours before delirium onset. The occurrence of pneumonia and sepsis at any time during hospitalization was also recorded. Delirium was defined retrospectively with the Confusion Assessment Method (CAM). Older patients were found to develop delirium more frequently than younger patients. There were no differences in illness severity (APACHE II) between those who developed delirium and those who did not. Three measures of oxygenation (hemoglobin, hematocrit, pulse oximetry) were worse in the patients who later developed delirium. Two measures of oxidative stress (sepsis, pneumonia) occurred more frequently among those diagnosed with delirium. Hence, patients with indicators of oxidative dysfunction developed delirium more frequently, and this was not linked to illness severity.
The consultation-liaison (C-L) psychiatrist often sees chronic mentally ill patients when they are admitted to the medical-surgical services of the general hospital. Little research has been directed to the special needs and concerns of these patients in the general hospital. This area has become more relevant now that many of these patients are no longer cared for in the safety of the state hospital setting, often making baseline medical histories inaccessible. They have an overall higher mortality rate than the general population, cannot give adequate histories, and their psychotic illness can mask an underlying medical illness. In this preliminary investigation of the problems of this special population, the authors examined the issues concerning nursing needs, length of hospital stay, medical diagnosis, and possible complicating problems encountered during these patients' hospital stays in the setting of an urban university hospital. The authors discuss the implications of the role of the C-L psychiatrist in addressing their patients' acute problems.
The authors report on the psychometric characteristics and clinical efficacy of two versions of a recently developed screening measure of depression (the DMI-18 and DMI-10) in the cardiac population. Patients with acute coronary syndrome or heart failure (N = 322) completed the DMI measures, psychosocial questionnaires, and a semistructured clinical interview during the hospital stay. The DMI-18 and DMI-10 measures have adequate psychometric properties, demonstrating high sensitivity and specificity when evaluated against clinical judgment based on a semistructured interview. The DMI-18 and DMI-10 are appropriate for use as screening instruments in cardiac patients.
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FREEZE - FLIGHT ----- FIGHT - FRIGHT (&FAINT.) 2004
Great improvement is observed in many depressed patients upon treatment with a combination of MAO inhibitors, serotonin precursor, and antihypotensive drugs. The authors have found Marplan to be the most effective antidepressant when used in conjunction with the antihypotensive Florinef to prevent syncope. A combination of serotonin precursor (5-HTP) and Ritalin (to compensate for metabolic inability to decarboxylate 5-HTP into serotonin) enhances the effect of MAO inhibitors, but also increases the danger of hypotension. Sitting and upright blood pressure recordings must be taken regularly and drug dosages modified accordingly. Intermittent blood potassium and SGO-transaminase tests are also necessary. Serotonin deficiency is usually chronic in melancholia and will return after MAOI effects wear off unless maintenance precursor therapy is continued. The interval between office visits can be increased if patients are willing to record their own blood pressures at home and take Florinef as required.
In the 1980s, patients suffering from unexplained fatigue and what seemed like a prolonged attack of acute mononucleosis were given the diagnosis of chronic mononucleosis or chronic infection with the Epstein-Barr virus. Although the diagnosis has great appeal, the Epstein-Barr virus does not cause the syndrome (CFS) of chronic fatigue, which has been renamed and redefined chronic fatigue syndrome to remove the inference that the virus is its cause. From a historical perspective, both syndromes represent the 1980s equivalent of neurasthenia, a disease of fatigue that influenced the development of psychiatric nosology. Because patients with depression and anxiety also have chronic fatigue and because most patients with CFS have an affective disorder, the assessment of organic causes of this syndrome requires careful psychiatric diagnosis and treatment. Defining chronic fatigue syndrome as a medical disorder may deprive patients of competent treatment of their affective disorder.
There is controversy about the role and function of a consultation-liaison (C-L) psychiatrist, as reflected in the ongoing debate about what to call ourselves. To clarify the essential elements of our function, the authors analyzed the process and content of the entire consultation experience from the time of initial consultation to the time of discharge in 50 patients across 5 urban teaching hospitals. The common components of the C-L process, in this pilot study, were identified to be facilitative, consensus-seeking, and interpretative. Implications of these findings for the C-L psychiatrist's role in the general hospital are discussed.
The contributions of consultation-liaison psychiatrists have significantly influenced the practice of medicine. The author reviews the pertinent literature that substantiates this observation as well as suggests areas that hold promise for such contributions in the future.
The authors evaluated the effect of stress due to the Ji-Ji, Taiwan, earthquake, which occurred at 1:47 a.m. on September 21, 1999, on the onset of acute myocardial infarction in six counties near the earthquake epicenter. The rate of hospitalization due to acute myocardial infarction increased during the 6 weeks after the earthquake, and a significantly higher number of patients were hospitalized with acute myocardial infarction during that period, compared with the same 6-week period in the previous year (99 and 65 patients, respectively). The findings suggest that extreme emotional stress due to the natural disaster, superimposed on the stress of awakening, increased the incidence of acute myocardial infarction in this population.
Despite its implications for treatment strategies, the potential role of previous depression on the medical course after coronary heart disease (CHD) has not yet been thoroughly studied.
The aim of this study was to determine whether the presence of major and minor depression, dysthymia, and demoralization in the years preceding the first myocardial infarction (MI) or angina, was associated with poor cardiac outcome at 2.5-year follow-up.
A group of 97 consecutive patients with acute CHD, admitted to a coronary-care unit, were studied while in remission from the acute phase of CHD. Various clinical depression measures were used to assess the occurrence or recurrence of mood disorders preceding the first episode of CHD (baseline visit) and at 2.5 years after the first interview.
Among the variables examined as potential cardiac risk factors, only dysthymia attained statistical significance.
Further research is needed to identify an effective treatment for dysthymic patients.
The authors examined characteristics of body dysmorphic disorder in the largest sample for which a wide range of clinical features has been reported. The authors also compared psychiatrically treated and untreated subjects. Body dysmorphic disorder usually began during adolescence, involved numerous body areas and behaviors, and was characterized by poor insight, high comorbidity rates, and high rates of functional impairment, suicidal ideation, and suicide attempts. There were far more similarities than differences between the currently treated and untreated subjects, although the treated subjects displayed better insight and had more comorbidity.
Hypochondriasis, now often designated as health anxiety, is important in terms of prevalence, levels of suffering, and health services cost in adults. Whereas the DSM-IV-TR suggests that the condition primarily begins in adulthood, retrospective reports point to a possible origin in childhood with onset as early as preschool age. However, little research has addressed health anxiety in children. In the present study we explored parental-reported health anxiety symptoms (HAS) and their association with physical and mental health in a population-based sample of 5- to 7-year-old children.
Parents of 1323 children (49.7% boys), recruited from the birth cohort: Copenhagen Child Cohort CCC 2000, completed questionnaires regarding their child's HAS, and physical and mental health. Associations were examined using multiple logistic regression analyses adjusted for concurrent chronic physical disease.
HAS were present in 17.6% and present 'a lot' (categorized as considerable HAS) in 2.4% of the children. Children with considerable HAS demonstrated more physical health problems and internalizing disorders than children with no or non-considerable HAS, but in the majority (71.9%) no associated chronic physical disease or other mental disorder was reported. In a subsample of children with functional somatic symptoms (FSS), impairing FSS were more likely among children who reported HAS.
The findings suggest that HAS present as primary complaints early in life and are associated with impairing child health problems in the area of FSS and internalizing disorders. These aspects may be important to understand and also to prevent the development of severe health anxiety.
Psychosomatic assessment for living liver donors for adults has as yet not been described in detail. Between August 1998 and September 2003, 205 donor candidates were admitted for psychosomatic evaluation; 13.2% of whom (N=27) were excluded. Mental disturbances, especially when accompanied with social stress, were frequent reasons for exclusion. Selected donors had higher social status with regard to education and employment rate than other donor candidates. Candidates with better psychosocial resources are selected in the psychosomatic evaluation, and this contributes to the good psychosocial outcome of living donors.
This study prospectively evaluated 247 consecutive liver transplantation candidates for the presence of psychiatric disorders. While one-half did not meet DSM-III criteria for a psychiatric diagnosis, 18.6% had delirium, 19.8% had an adjustment disorder, 9% had alcohol abuse or dependence, 4.5% had major depression, and 2% had other drug abuse or dependence. Delirious subjects were significantly more likely to have a lower serum albumin, lower Mini-Mental State exam scores, higher Trailmaking Test scores (both A and B), and more dysrhythmia on electroencephalogram (EEG). In addition, while both delirious and nondelirious subjects were judged to have high levels of overall stress, those with delirium had significantly poorer adaptive functioning and lower occupational, family, and social scale ratings. Thus, while all liver transplant candidates are under substantial psychosocial stress and require psychosocial support, those identified as being delirious require particular attention because of their numerous cognitive, medical, and psychosocial problems.
The authors report on measures of distress in 26 subjects who had been diagnosed with environmental illness (EI) by a "clinical ecologist." EI subjects were more likely than control subjects to meet criteria for one or more personality disorder diagnoses assessed with the Structured Interview for DSM-III Personality Disorders and exhibited more somatic, mood, and anxiety symptoms assessed with the Symptom Checklist-90-R and the Illness Behavior Questionnaire. The authors conclude that subjects receiving this diagnosis may suffer from unrecognized psychological distress, which may account for some or all of the symptoms that had resulted in a diagnosis of EI.
The usefulness of the 28-item General Health Questionnaire (GHQ) in detecting psychiatric comorbidity in a sample of hospitalized gastroenterology patients was tested. Validity coefficients were determined by comparing the results of the GHQ with findings from a psychiatric interview. At the best discriminating score (8/9), the GHQ yielded a sensitivity of 77%, a specificity of 75%, a positive predictive value of 67%, and a misclassification rate of 24%. The GHQ did not accurately identify alcohol dependence and abuse and did not discriminate between patients with anxiety disorders and those with depressive disorders. Despite its limitations, the GHQ, if supplemented with specific questions about alcohol abuse, can effectively screen medical inpatients for psychiatric disorders.
Patients with chronic psychiatric diagnoses have a prevalence of chronic hepatitis C (HCV) approximately 11 times higher than the general American population. Posttraumatic stress disorder (PTSD) is particularly common among HCV patients.
The authors describe the effect of treatment with pegylated-interferon-alpha(2b) (IFN) and ribavirin for patients with HCV on their posttraumatic stress disorder (PTSD) symptoms.
Sixteen patients with HCV and combat-related PTSD were followed for 24 weeks and assessed with self-report measures of PTSD, hostility, and depression.
Depression and Resentment scores significantly increased in five patients treated with IFN and ribavirin, but no significant differences were found in PTSD scores when compared with 11 control patients.
The results suggest that patients with PTSD and HCV can be safely treated with anti-viral therapies when they are given appropriate psychiatric care.
The aim of the study was to describe the use of the Brief Symptom Inventory in characterizing the type and severity of emotional distress in 26 patients with chronic hepatitis C who were receiving interferon-alpha-2B and ribavirin. The 6-month actuarial incidence of neuropsychiatric toxicity, determined by physician interview, was 58%. Significant differences in mean depression, anxiety, and somatization Brief Symptom Inventory T scores were noted in the 15 patients with clinically apparent neuropsychiatric toxicity compared to the 11 patients without neuropsychiatric toxicity. Because of its brevity and simplicity, the Brief Symptom Inventory may prove to be a useful adjunct to clinician assessment in detecting and monitoring emotional distress during interferon-alpha treatment of chronic hepatitis C.
The purpose of this study was to systematically describe the neuropsychiatric side effects of treatment with interferon-alpha-2b (INF-alpha) and ribavirin in patients with chronic hepatitis C as well as to compare different instruments used to measure these side effects. Fifty-five patients with chronic hepatitis C were prospectively followed for 24 weeks and assessed with seven neuropsychiatric symptom measures and one quality of life scale. Of 42 patients treated with INF-alpha and ribavirin, 11 (26%) were receiving psychiatric treatment at baseline. They scored higher on all rating scales at baseline and became more symptomatic during treatment. Of the 31 patients (74%) not in psychiatric care at baseline, 15 (48%) required treatment for neuropsychiatric symptoms, and seven (23%) met criteria for major depression during INF-alpha therapy. The control group of 13 untreated subjects showed little change over the 24-week period. All symptom scales were highly intercorrelated, suggesting that use of one is sufficient for monitoring symptoms.
Pharmacogenetics has arrived in clinical psychiatric practice with the FDA approval of the AmpliChip CYP450 Test that genotypes for two cytochrome P450 2D6 (CYP2D6) and 2C19 (CYP2C19) genes. Other pharmacogenetic tests, including those focused on pharmacodynamic genes, are far from ready for clinical application. CYP2D6 is important for the metabolism of many antidepressants and antipsychotics, and CY2C19 is important for some antidepressant metabolism. Poor metabolizers (PMs), lacking the enzyme, account for up to 7% of Caucasians for CYP2D6 and up to 25% of East Asians for CYP2C19. Patients having three or more active CYP2D6 alleles (up to 29% in North Africa and the Middle East), are called CYP2D6 ultra-rapid metabolizers (UMs). CYP2D6 phenotypes (particularly PMs) are probably important in patients taking tricyclic antidepressants (TCAs), venlafaxine, typical antipsychotics, and risperidone. The CYP2C19 PM phenotype is probably important in patients taking TCAs and perhaps citalopram, escitalopram, and sertraline. On the basis of the literature and the authors' clinical experience, the authors provide provisional recommendations for identifying and treating CYP2D6 PMs, CYP2C19 PMs, and CYP2D6 UMs. The next few years will determine whether CYP2D6 genotyping is beneficial for patients taking the new drugs aripiprazole, duloxetine, and atomoxetine. Practical recommendations for dealing with laboratories offering CYP2D6 and CYP2C29 genotyping are provided.
Polytherapy is common in the management of bipolar disorder, as are the side effects associated with this treatment strategy.
The authors review the literature on drug-drug interactions involving oxcarbazepine and identify specific mechanisms that may have clinical importance.
The authors provide a case report of a patient who developed phenytoin toxicity associated with an oxcarbazepine-phenytoin interaction.
Co-administration of phenytoin and oxcarbazepine resulted in toxic levels of phenytoin. Therefore, the patient's daily dosage of oxcarbazepine and phenytoin were reduced.
Although oxcarbazepine is an inducer of the 3A4 isoenzyme, it acts as an inhibitor of the 2C19 isoenzyme, and it can raise levels of other agents, for example, phenytoin, that are also metabolized by this isoenzyme.