Abstract: A growing body of evidence supports the association between Stressful Life Events (SLEs) and increased risk for relapse in Multiple Sclerosis (MS). In this open-label, randomized, controlled, one-year prospective study we investigated the effects of escitalopram on stress-related relapses in 48 women with relapsing-remitting MS. Patients were randomly assigned either to receive escitalopram 10mg/day (e-group, N=24) or to continue with treatment as usual, as a control group (c-group, N=24). SLEs were documented weekly in self-report diaries and were classified afterwards as short- or long-term depending on their psychological impact as this was subjectively felt by the patient. The cumulative risk for relapse was 2.9 times higher for controls than for escitalopram-treated patients (95% CI=1.7-5.1, p<0.001) and it was influenced only by long-term SLEs. In the e-group only 3 or more long-term SLEs were associated with a significant increase of the risk of a relapse during the following 4 weeks, and this risk was 4 times lower compared to the c-group. Our study shows preliminary evidence that escitalopram may constitute an effective and well-tolerated treatment option for the prevention of stress-related relapses in women with MS.
Abstract: BACKGROUND: Postpartum mood disturbances are very common with postpartum blues being as high as 44.5% among Greek women. This study aimed to investigate whether thyroid function within the normal range affects the incidence of postpartum mood disturbances. METHODS: In a cross-sectional study in the maternity ward of Aretaieion Hospital, 57 Greek women were evaluated for postpartum mood swings by the Maternity Blues Questionnaire and the Edinburgh Postnatal Depression Scale on the first and sixth week postpartum. Serum Free T4, Free T3 and TSH concentrations as well as thyroglobulin and thyroid peroxidase antibodies were measured on admission for delivery and daily until the fourth postpartum day. We examined the association between hormone and antibody levels, and scores in the two scales evaluating postpartum mood disturbances. RESULTS: Prepartum serum FT3 and FT4 correlated negatively with blues scores in the first week postpartum (blues on day 4: with FT3, rho=-0.44, p < or = 0.01; with FT4 rho=-0.36, p < or = 0.01). Women with lower FT3 and FT4 levels belonged to the high scoring group (high scoring group: FT3=1.22 pg/ml, FT4=0.66 ng/dl; low scoring group: FT3=1.64 pg/ml, FT4=0.73 ng/dl). Serum FT3 showed a negative independent correlation with postpartum blues scores in the first postpartum days. No association was found between thyroid antibody levels and mood scores. CONCLUSION: Our findings indicate an association between the occurrence of postpartum mood disorders and antenatal thyroid function. Within normal limits, lower levels of serum FT3 and FT4 are associated with increased incidence of mood disturbances in the first postpartum week.
Abstract: BACKGROUND: Immune activation has been shown to be involved in the pathophysiology of anxiety states and major depression and pregnancy is associated with a characteristic immune activation to sustain the fetus. Despite the possibility of a relation between immune parameters and postpartum mood disturbance, few studies have explored this association. Further, no study to-date has examined CSF. METHODS: Fifty-six Greek parturients were recruited and a detailed medical and obstetric history was recorded. All of them completed the Postpartum Blues Questionnaire (on admission and on days 1-4 postpartum) and the Edinburgh Postnatal Depression Scale (at first and sixth week postpartum). At delivery, a blood sample and a CSF sample while puncturing for epidural analgesia were taken from 33 participants; blood samples only were obtained from the rest of the 23 parturients. TNF-a and IL-6 were quantified with an ELISA assay. RESULTS: A multiple regression analysis of psychometric scores depending on cytokine levels revealed that cytokine levels were positively associated with depressive mood during the first four days postpartum (p=0.035 for CSF IL-6, p=0.025 for CSF TnF-a, p=0.023 for serum TnF-a) and also at sixth week postpartum (p=0.012 for CSF IL-6, p=0.072 for CSF TnF-a). Pregnancy duration had an adverse association to psychometric scores. CONCLUSIONS: It is suggested that immune mechanisms may play a role in the etiopathology of postpartum depressive mood shifts. The role of a "rebound" reaction of the maternal immune system postnatal should be further investigated.
Abstract: The EPDS has been validated as a screening instrument for postnatal depression in numerous communities over the last 20 years. Absence of a validation study for the Greek population has limited significantly its use in Greece. A community sample of 109 women was recruited on the second day postpartum in the two largest maternity hospitals in Athens. Ninety-five women consented to participate and to complete the EPDS, the Beck Depression Inventory (BDI), the 28-item General Health Questionnaire (GHQ), and the 26-item WHO-Quality of Life (WHO-QOL). Of them, 81 consented to be reassessed 2 months later. At that time, in addition to the baseline questionnaires, the Structured Clinical Interview for DSM-III-R (SCID), non-patient version, was conducted in order to establish psychiatric diagnosis of major and minor depression. The clinical diagnosis was used to test the criterion validity of the EPDS, and the GHQ, BDI and WHO-QOL scores were used to assess the concurrent validity of the EPDS. Cronbach's alpha coefficient was used to measure the internal consistency of the scales. A cut-off point of 11/12 on the EPDS showed optimum Receiver Operating Characteristics. The SCID showed that 12.4% of the subjects met criteria for depression at two months postpartum.
Notes: Comment on BMC Public Health
Validation of the Edinburgh Postnatal Depression Scale- Previous findings in another sample of Greek women and review of the differences with the newer results.
Angeliki Leonardou (11 January 2010) University of Athens, 1st Department of Psychiatry, Eginition Hospital
Dear Sirs,
In the interesting paper The Edinburgh Postnatal Depression Scale: translation and validation for a Greek sample, the authors mention that “the purpose of this study was to validate the Greek version of the EPDS…â€. We would like to inform you that our group has already published a validation of the EPDS based on a different translation and with a different methodology, which has been published in the Journal of Reproductive and Infant Psychology [1]. The fact that our study was not mentioned in the paper by Vivilaki et al. (whereas a study using our translation was referenced therein) [2], might not be significant if the two studies did not produce such different results. We believe that it is important to review here the methodological differences between our study and the study by Vivilaki et al., so that the clinicians and researchers interested in utilising the Greek EPDS can decide on which cut-off they should use in evaluating scores.
Our study was conducted in a sample of new mothers who have given birth in both private and public large obstetric hospitals in Athens. We approached 109 women, of which 95 (87%) agreed to participate in the study. Our initial recruitment of the study subjects took place on the second postpartum day, where initial questionnaires, as well as demographic data were collected. The reassessment of the study subjects took place in the 8th postpartum week. At that time the researcher, blind to the results of the initial questionnaires, conducted a semi-structured interview (SCID), to ascertain the presence of major depression. The diagnosis of minor depression, based on DSM-IV research criteria, was added to the assessment, as it has also been done elsewhere, as 50% of the cases, if unnoticed and untreated, will later suffer from major depression [3]. In the validation study by Vivilaki et al. the recruitment of the study subjects took place between 4 days till 16 weeks postpartum. This poses a major issue regarding the diagnosis of postpartum depression. Newly delivered mothers at 4 days postpartum could be suffering from maternity blues, whereas the women assessed in the 16th week postpartum, could indeed be suffering from postpartum depression. “Postpartum bluesâ€, also known as “5th day blues†is a condition affecting 30-80% of women during the first 3-15 postpartum days, it is significantly influenced by the hormonal fluctuation and it is usually self-limited [4]. Postpartum depression usually manifests itself at 6-8 weeks postpartum. This to our opinion poses an issue on the homogeneity of the group assessed for depressive symptoms in the Vivilaki et al study. Our results showed 5% major and 7.4% minor depression, which is consistent with the percentage found by other authors [5]. The high 31.7% diagnosis of mild depression in the BMC study could be accounted by the inclusion of maternity blues cases.
In our opinion this difference accounts for the rather unexpected difference in the cut-off points in the two Greek validation studies: our validation study shows a cut-off point of 11/12, whereas the newer validation study showed a cut-off point of 8/9, which in our opinion is too low and would include a lot of false positive cases.
Unpublished data of our study have shown that the EPDS on the second postpartum day has poor psychometric properties, regarding the ‘prediction’ of postpartum depression in the 6-8th week postpartum. ROC analysis showed that at a cut-off point of 8/9 had a sensitivity of 90.00% and a specificity of 53.52%, which means that one of the two women identified by the questionnaire as possibly depressed would be falsly alarmed. So we have found that the use of the EPDS on the first postpartum days is not encouraged, as it has already been shown elsewhere [6].
In contrast to our procedure, the validation study by Vivilaki et al. has validated the questionnaire against another, already validated questionnaire, a procedure as well already adopted by others. However it is well known that using questionnaires to diagnose depression shows a higher prevalence of the disorder [7]. This fact along with the timing of the assessment could account according to our opinion for the cut-off point of the scale being found in this newer validation study a lot lower than in the initial one.
Finally, there is another point to be made, regarding the use of the scale solely as a screening instrument. In the current paper that we comment on it is mentioned that the Greek EPDS could be used by Greek health professional for diagnostic purposes. However as the National Screening Committee [8] has already clearly stated, as well as the constructors of this questionnaire [9], we would like to suggest that it is our responsibility to teach health professional willing to use this screening questionnaire that it is NOT a diagnostic tool, and thus it can only identify possibly depressed subjects, but can not and should not be used for making the diagnosis of depression.
We do not believe that the different translation of the EPDS used by Vivilaki et al. played a significant part in the results reported. The EPDS is a fairly easy scale to translate. However, it might be confusing to users to have many different versions of the same scale, however small differences might be. Our translation came from a previous version used in Greece for over a decade, and was in a study that was published in the same journal our validation study was published [10]. It is also the only one referenced by the originator of the EPDS scale, Prof. J. Cox [11]. Our translation has already been utilized by three other Greek studies [12, 13, 14]. All the above mentioned publications can be found through the Internet when the key words in Google search engine are ‘EPDS, Greek’.
Best Regards
Angeliki A. Leonardou, Ioannis M. Zervas
References
1. Leonardou AA, Zervas YM, Papageorgiou CC, Marks MN, Tsartsara EC, Antsaklis A, Christodoulou GN, Soldatos CR: Validation of the Edinburgh Postnatal Depression Scale and prevalence of postnatal depression at two months postpartum in a sample of Greek mothers. Journal of Reproductive and Infant Psychology, 2009, 27 (1): 28-39.
2. Gonidakis F, Rabavilas AD, Varsou E, Kreatsas G, Christodoulou GN: A 6-month study of postpartum depression and related factors in Athens Greece. Comprehensive Psychiatry 2008, 49: 275-282.
3. Horwath E, Johnson J, Klerman GL: Depressive symptoms as relative and attributable risk factors for first-onset major depression. Archives of General Psychiatry, 1992, 49: 817-823.
4. Kennerley H., Gath D: Maternity blues. I. Detection and measurement by questionnaire. British Journal of Psychiatry, 1989, 155: 356-362.
5. Gavin N, Gaynes B, Lohr K, Meltzer-Brody S, Gartlehner G, Swinson T: Perinatal Depression. A Systematic Review of Prevalence and Incidence. Obstetrics and Gynecology, 2005, 106 (5): 1071-1083.
6. Lee DTS., Yip ASK., Chan SSM, Tsui MHY, Wong WS, Chung TKH: Postdelivery screening for postpartum depression. Psychosomatic Medicine 2003, 65: 357-361.
7. Garcia-Esteve L, Ascaso C, Ojuel J, Navarro P: Validation of the Edinburgh Postnatal Depression Scale (EPDS) in Spanish mothers. Journal of Affective Disorders, 2003, 75: 71-76.
8. National Screening Committee: www.nelh.nhs.uk/screening. 2001
9. Cox JL, Holden JM, Sagovsky R: Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry1987, 150: 782-786.
10. Thorpe K, Dragonas T, Golding J: The effects of psychosocial factors on the mother’s emotional well-being during early parenthood: A cross-cultural study of Britain and Greece. Journal of Reproductive and Infant Psychology, 1992, 10: 205-217.
11. Cox J, Holden J: Perinatal mental health: a guide to the Edinburgh Postnatal Depression Scale. 2003, Royal College of Psychiatrists.
12. Gonidakis F, Leonardou AA: Maternity blues and Post-partum depression. Findings from Greece. European Psychiatric Review, 2009, 1 (2): 21-23.
13. Boufidou F, Lambrinoudaki I, Argeitis J, Zervas IM, Pliatsika P, Leonardou A, Petropoulos G, Hasiakos D, Papadias K, Nikolaou C: CSF and plasma cytokines at delivery and postpartum mood disturbances. Journal of Affective Disorders, 2009, 115 (1): 287-292.
14. Lambrinoudaki I, Rizos D, Armeni E, Pliatsika P, Leonardou A, Sygelou A, Argeitis J, Spentzou G, Hasiakos D, Zervas I, Papadias C: Thyroid function and postpartum mood disturbances in Greek women. Journal of Affective Disorders, 2009, doi: 10.1016/j.jad.2009.07.001.
Competing interests
The authors declare that they have no competing interests.
Abstract: OBJECTIVE: The aim of this study was to investigate the role of vasomotor and mood symptoms on insomnia in postmenopausal women. METHODS: One hundred sixty-three postmenopausal women, not receiving hormone therapy, attending a menopause clinic at the University of Athens, Greece, were included in this cross-sectional study. Climacteric symptoms were assessed by Greene's scale, whereas psychological morbidity was measured by Zung Self-Assessment Depression Scale, Symptom Checklist-90-R, and Athens Insomnia Scale. RESULTS: Vasomotor symptoms were significantly associated with insomnia (P = 0.001). When depressive symptomatology was added to the logistic regression analysis, the predictive ability of the model was significantly improved as defined by the increase in the log likelihood (P < 0.001) and the increase in the area under the receiver operating characteristic curve. CONCLUSIONS: Insomnia in postmenopausal women attending a menopause clinic is related both to the effects of vasomotor symptoms and depressive symptomatology. Mood symptoms seem to affect sleep independently of vasomotor symptoms, suggesting that depression should be carefully assessed and treated in postmenopausal women with insomnia.
Abstract: There is growing body of evidence that support an association between stressful life events and an increased risk for Multiple Sclerosis (MS) exacerbations. However, the nature of this relationship remains unclear, because of the lack of agreement about the definition of stress and/or because of research design problems. This article summarizes the psychological and biological mechanisms by which stress may impact MS progression. Findings indicate a number of factors, including stressor chronicity, frequency, severity and type, depression, anxiety, health locus of control, optimism, perceived social support, and coping strategies. Applied implications are discussed, concentrating on the need for multidisciplinary care interventions that target patients' disease symptoms.
Abstract: BACKGROUND: Executive function deficits in depression implicate involvement of frontal-striatal circuits. However, studies of hypothalamic-pituitary-axis (HPA) function suggest that stress-related brain changes of hippocampus may also implicate prefrontal-hippocampal circuits, which may explain the profile of both executive dysfunction and memory deficits. In this study we examined the performance of patients with major depressive disorder (MDD) on tasks of memory and executive function in relation to melancholic features and to cortisol levels. Our hypothesis was that raised cortisol levels in melancholic patients would correlate with these deficits. METHOD: Forty female MDD patients, 20 having melancholic features (MEL vs. Non-MEL), and 20 sex-age- and education-matched normal controls were investigated using the Cambridge neuropsychological test automated battery (CANTAB), to assess memory (paired associative learning, PAL; short-term recognition memory, SRM) and executive (intradimensional/extradimensional set-shifting, ID/ED; Stockings of Cambridge, SOC) functions. Plasma and salivary cortisol levels were measured. RESULTS: The MDD patients performed worse than controls on PAL and both executive tasks. The MEL group differed from controls on all tests, and differed from the non-MEL only at the ED stage of the ID/ED task. Patient cortisol levels were within the normal range and did not correlate with neuropsychological performance for any group. CONCLUSIONS: MDD patients showed neuropsychological deficits on tasks of executive function and memory, supporting the model of frontal-temporal dysfunction. MEL vs. non-MEL performed worse overall and demonstrated a qualitative difference in set shifting, perhaps implicating more extensive prefrontal involvement. Cortisol levels did not correlate with depression severity or the observed deficits.
Abstract: PURPOSE: The aims of this study were first, to examine the general relation between stressful life events (SLEs) and clinical relapses in women with multiple sclerosis (MS) and second, to investigate the relations of the specific stressor attributes of duration, type, and severity on MS exacerbations. METHODS: Twenty six ambulating women with relapsing-remitting MS were followed-up for a mean of 56.3 weeks. Patients documented SLEs weekly in self report diaries which were then collected at regular pre-scheduled clinic visits every 4 weeks. SLEs were classified as short-term if they had subjectively no lasting effect and long-term if they had a subjectively felt psychological impact that lasted at least 10-14 days after the event. The severity of SLEs was determined using the Recent Life Change Questionnaire. RESULTS: Experiencing three or more SLEs, during a 4-week period, was associated with a 5-fold increase of MS relapse rate (95% CI 1.7-16.4, p=0.003). The presence of at least one long-term SLE was associated with three times (95% CI 1.01-9.13, p<0.05) the rate of MS exacerbation during the following 4 weeks. There was no significant association between the severity (95% CI 0.99-1.01, p>0.05) or the type (chi2=7.29, df=5, p>0.05) of stressor and the risk for relapse. CONCLUSION: Ambulatory women with relapsing-remitting MS who experience cumulative SLEs may be at a greater risk for relapse. Duration is the only stress attribute that seems to increase the risk for relapsing in contrast to stress type and stress severity that were not found to interact with MS exacerbation.
Abstract: In clinical practice, a proportion of patients with psychotic or mood disorders are treated with electroconvulsive therapy (ECT) while receiving concomitantly antipsychotic and/or other psychotropic agents. Aripiprazole is a second-generation antipsychotic that seems to have a favorable side-effect profile. However, to the best of our knowledge, there are, as yet, no available reports on the safety of ECT-aripiprazole combination. We report the cases of 4 female inpatients--3 suffering from major depression and 1 from schizophrenia--who underwent ECT--1 of them twice--while receiving aripiprazole (10-15 mg/d), as part of their regimen. In all cases, the combination was well tolerated and only minimal side effects were reported.
Abstract: OBJECTIVE: This study examines the role of an introductory course in cognitive therapy and the relative importance of trainees' characteristics in the selection process for an advanced course in cognitive therapy. METHOD: The authors assessed the files of all trainees who completed one academic year introductory course in cognitive therapy over the last seven consecutive years (N = 203). The authors examined variables such as previous training, overall involvement during the course, performance, and ability to relate to others, as well as the trainer's evaluations of their performance. RESULTS: Interaction skills in group situations and performance in written assignments were better predictors for admission into the advanced course. CONCLUSIONS: Trainees' abilities to learn and to successfully relate to others in group situations are critical for entering an advanced cognitive therapy training course. These findings question the policy of full-scale training in cognitive therapy based merely on the candidates' professional background, stressing instead the merits of an introductory course as an appropriate screening procedure.
Abstract: Twenty-two patients with major depressive disorder, 11 of them with melancholic features, and 11 controls were investigated with CANTAB subtests focusing in visual memory/learning and executive functions. Melancholic patients performed worse than the other groups in all tasks and manifested a significant impairment in set shifting. The results are discussed in association with prefrontal dysfunction.
Abstract: Quality of life (QoL) in menopause is influenced by many parameters, including vasomotor symptoms, psychological status and culture. The aim of the present study was to examine the association of hormone therapy (HT) with QoL and psychological symptoms in Greek postmenopausal women. The study assessed 216 postmenopausal women (mean age 54.5 years) attending a university menopause clinic in Greece. Fifty-three were users of HT and 163 were not. QoL was evaluated by the Utian Quality of Life Scale (UQOL) and psychological symptoms were assessed by the Symptom Checklist-90-R (SCL-90-R). Women on HT were younger and more educated than women not using HT. Adjusting the analysis for the women's characteristics, HT users had better total UQOL scores than non-users (p < 0.05). Marital status and education had independent effects on QoL, with married and more educated women scoring higher (p < 0.05). Assessment of psychological symptomatology, after adjustment for sociodemographic variables across the different dimensions, revealed that HT users had better SCL-90-R scores than non-users for obsessionality, interpersonal sensitivity and for the general index (p < 0.05). Concluding, even though the impact of sociodemographic and lifestyle variables must be factored into the assessment of QoL, HT use is independently related to an improvement in the total score and in most domains of QoL, and has a significant positive effect on many aspects of psychological well-being in Greek postmenopausal women.
Abstract: This is a case report of a 33 year old woman with a history of psychosis, who presented to the women's mental health clinic for consultation at the 12(th) week of gestation, having already received olanzapine throughout the first trimester. She was followed from that point on at our clinic and remained on small doses of olanzapine for the rest of her pregnancy, which was uncomplicated. She gave birth to a healthy female, which at the age of three months was diagnosed with developmental dysplasia of the hip and subsequently received appropriate treatment with favorable outcome. The possibility of the association of this congenital dysplasia with the use of olanzapine during pregnancy is further discussed in this paper.
Abstract: Data on attitudes toward electroconvulsive therapy have been reported from various countries; no information, however, is available from Greece. In this survey, we report the results of a questionnaire reflecting the general attitude of Greek medical students toward ECT. A total of 161 sixth (final)-year medical students who had no previous exposure to a formal didactic experience on ECT, were asked to complete a questionnaire before attending a scheduled 90-minute lecture on ECT, as part of their regular curriculum. Questions in the questionnaire could be grouped to indicate a positive, a reserved, or a negative attitude toward ECT. Overall, before the lecture, 50.3% held a positive attitude toward ECT, 43.5% were reserved, and 6.2% held a negative attitude. A subgroup of these students (n = 137) were asked again to score the same questionnaire immediately following the lecture to rate the impact of the didactic seminar. The proportion of students with a positive attitude after the lecture was increased to 78.1%, (P < 0.001), while the proportion of students with reserved and negative attitudes were reduced to 20.4% (P < 0.001) and 1.5%, respectively. These encouraging findings reflect, however, only the immediate effects of the lecture and do not guarantee persistence of this change in attitudes over time.
Abstract: In this article, in an attempt to integrate recent findings with existing knowledge, we provide an overview of issues related to nightmares that could be useful as a guide to clinical work. After defining what should be considered as a nightmare, we look into the relationship of nightmares with issues such as normal development and maturation, as well as culture. Issues of stress and personality are then discussed in their relation to situational and chronic nightmares. State and trait factors are further elaborated on as we explore the relationship of nightmares and psychopathology. A brief review of organic and pharmacological causes of nightmares follows before we embark on a discussion of issues that relate nightmares to psychological trauma. Some final remarks on treatment conclude our review.
Abstract: BACKGROUND: Patients with psychosis have activation of the hypothalamic-pituitary-adrenal (HPA) axis during the acute phase of the psychosis. Whether this has any morphological consequences for the pituitary gland is currently unknown. AIMS: To examine pituitary volume variation in people at different stages of psychotic disorder. METHOD: Pituitary volume was measured using 1.5 mm, coronal magnetic resonance images in 24 people with first-episode psychosis, 51 with established schizophrenia and 59 healthy controls. RESULTS: Compared with the control group, the people with first-episode psychosis had pituitary volumes that were 10% larger, whereas those with established schizophrenia had pituitary volumes that were 17% smaller. In both of the groups with psychosis, there was no difference in pituitary volume between those receiving typical antipsychotic drugs and those receiving atypical antipsychotics. CONCLUSIONS: The first episode of a psychosis is associated with a larger pituitary volume, which we suggest is due to activation of the HPA axis. The smaller pituitary volume in the group with established schizophrenia could be the consequence of repeated episodes of HPA axis hyperactivity.
Abstract: SUMMARY: Despite the fact that a role for thyrotropin-releasing hormone (TRH) in seizure modulation has been consistently hypothesized, the exact nature of this role remains unclear. In this study, we investigated the effects of TRH administration on seizure threshold and seizure duration in 13 depressed inpatients undergoing electroconvulsive therapy (ECT). In a balanced order crossover design, an intravenous bolus of 0.4 mg TRH or placebo was administered immediately before anesthesia, during the first two sessions, in a series of bilateral ECT. In both of these sessions, a threshold titration procedure was applied by using gradual increments of the electrical charge delivered until seizure elicitation, a procedure that has been safely used in the past. Seizure threshold was defined as the lowest energy level required for induction of a grand mal seizure, by use of this titration procedure. Seizure duration was estimated both by simultaneous EEG recording and by the cuff method. Results showed that neither seizure threshold, nor seizure duration (either by cuff or by EEG) differed between the TRH and the placebo conditions, regardless of the order in which TRH or placebo were administered in the two ECT sessions. This was the case regardless of whether the patients had at baseline a blunted TSH response to TRH or not. Our findings do not support a role for TRH on seizure modulation, at least when TRH is administered exogenously. Such an effect, if it exists, could be obscured, however, by several factors, including pharmacokinetics.
Abstract: Risperidone is a novel and atypical agent with a dual antagonistic effect on 5-HT and D receptors. Open-label reports and one controlled study suggest that risperidone addition is effective in patients with obsessive-compulsive disorder refractory to treatment with serotonin reuptake inhibitors. However, risperidone has also been implicated in the production or exacerbation of obsessive-compulsive symptoms. We report six cases (schizophrenia, five cases; psychotic depression, one case) in which risperidone was effective in the treatment of the psychotic symptoms but produced obsessive-compulsive symptoms (four cases) or caused exacerbation of previous obsessive-compulsive symptoms (two cases). In all but one case, obsessive-compulsive symptoms emerged shortly after initiation of risperidone treatment with a dose above 3 mg/day. The mechanisms and risk factors for risperidone and other atypical antipsychotics to induce or exacerbate obsessive-compulsive symptoms are as yet not clear. Risperidone-induced obsessive-compulsive symptoms appear to be dose-dependent and are probably produced by serotoninergic-dopaminergic imbalance. Close monitoring of the patients receiving risperidone, especially those vulnerable to the development of obsessive-compulsive symptoms, may be of value. Gradual escalation and low final dose may be helpful.(2) (2)
Abstract: From theoretical and clinical perspectives, it is important to know if selected serotonin-reuptake inhibitors (SSRIs), often administered concurrently with electroconvulsive therapy (ECT), modify seizure duration. In a study with a double-blind, cross-over design, the authors evaluated the effect of citalopram, the most selective SSRI available, on the length of electrically induced seizures and on hormone secretion during ECT. Ten depressed women were given either 20 mg citalopram or placebo orally 2 hours before the third and fourth ECT sessions. Seizure duration was assessed by the cuff technique and from electroencephalographic recordings, whereas blood for prolactin, thyrotropin, and cortisol assessment was sampled before ECT and 5, 10, 20, 30, 40, and 60 minutes after ECT. No adverse effects after the administration of citalopram were recorded. The length of seizures was not statistically different in the citalopram (29.3+/-8.4 seconds) and placebo sessions (28.2+/-9.4 seconds). Neither pre-ECT plasma hormone levels measured 2 hours after citalopram or placebo administration nor the patterns of ECT-induced hormone secretions differed between the two drug and placebo conditions. The lack of effect of citalopram on hormones in this study may be a result of possible deficiencies of the monoaminergic (i.e., serotoninergic) systems in depression. Although safety and efficacy issues were not fully addressed by coadministering citalopram for the long term and throughout the course of ECT, these findings support the view that challenges the typical clinical practice of discontinuing SSRIs before ECT.
Abstract: Clozapine and risperidone have been implicated in the development of obsessive-compulsive symptoms. We present three cases in which olanzapine caused a significant exacerbation of obsessive-compulsive symptoms in schizophrenia (two cases) and obsessive-compulsive disorder (one case).
Abstract: The relationship between the thyrotropin (TSH) response to thyrotropin-releasing hormone (TRH) and the duration of seizures induced by electroconvulsive therapy (ECT) in depressed patients was investigated. In a balanced-order cross-over design, 16 depressed women were given 0.4 mg TRH or placebo intravenously, 20 min before ECT in the first two sessions. In the third ECT session TRH was given just prior to ECT. Thyrotropin (TSH) levels at various sampling times, as well as the duration of seizures, were measured. There was a significant inverse correlation between plasma TSH concentrations 20 min after TRH administration (deltaTSH) and seizure duration. Furthermore, when patients were categorized according to their TSH response to TRH, the group with blunted responses (deltaTSH <6 microIU/ mL, n = 7) had a longer seizure time during ECT than the group with non-blunted responses (deltaTSH > 6 microIU/mL, n = 9). Finally, the seizure duration in the group with blunted TSH responses was reduced significantly when TRH was co-administered, while it remained unchanged in the group with non-blunted TSH responses. It is concluded that a blunted TSH response to TRH might indicate a seizure susceptibility as measured by the duration of seizures induced by ECT. The fact that TRH pre-administration had a reducing effect suggests that this substance might be involved in the pathophysiology of ECT-induced seizures.
Abstract: We investigated the effect of thyrotropin-releasing hormone (TRH) on orientation time and recall, in nine depressed female inpatients undergoing electroconvulsive therapy (ECT). In a balanced order crossover design, an intravenous bolus of 0.4 mg TRH or placebo was administered 20 min before ECT in the first two sessions. Orientation time and retrograde and anterograde components of the memory dysfunction, immediately and 24 h later, were assessed. Administration of TRH did not influence orientation time, word recall, or immediate short story recall compared with placebo. We did find, however, an improvement in the number of short story items recalled after 24 h when patients were given TRH compared with placebo. This indicates that TRH may have a protective role against the specific negative effect of ECT on delayed recall.
Abstract: STUDY OBJECTIVE: To ascertain the optimal dose of trimethaphan camsylate administered by intravenous (i.v.) bolus injection for the control of hypertension and tachycardia during electroconvulsive therapy (ECT). DESIGN: Prospective, double blind, within-subject study. SETTING: Treating room of the psychiatric unit of the University Hospital at Stony Brook, NY. SUBJECTS: Patients undergoing ECT for major psychiatric illnesses. MEASUREMENTS AND MAIN RESULTS: Fifteen ASA status I or II patients received in a random sequence placebo, or 5, 10, or 15 mg boluses of trimethaphan during their second to fifth treatments. Blood pressure (BP) and heart rate (HR) were recorded every 30 seconds by automated oscillometric recorder. Recordings taken before administration, during seizure, 5, and 20 minutes after seizure were examined. All doses ameliorated BP (systolic, diastolic, and mean), HR, and rate pressure product (RPP) increases during the seizure, compared with placebo. The group that received 15 mg exhibited smaller increases in RPP, i.e., 67.7% increase compared with 155.4%, 110.9%, and 98.7% increases for the placebo, 5, and 10 mg, respectively. The 10 mg and 15 mg doses caused a faster return to baseline than did the 5 mg dose or placebo. No rebound hypertension, prolonged hypotension, arrhythmias, or other side effects were noted. Trimethaphan did not alter seizure duration. CONCLUSIONS: Trimethaphan is safe, practical, and effective in the management of the hyperdynamic response to ECT. An i.v. bolus injection of 15 mg is more effective than 10 mg or 5 mg.
Abstract: The effects of thyrotropin-releasing hormone (TRH) administration on electroconvulsive therapy (ECT)-induced prolactin (PRL) secretion and the duration of the seizure were studied in 14 depressed women. In a balanced order crossover design the patients were given 0.4 mg TRH or placebo intravenously 20 min before ECT during the first two sessions. In the third ECT session TRH was given just prior to ECT. ECT elicited the expected PRL response when given alone and when given 20 min after TRH when PRL plasma levels were high. During the coadministration design (third ECT session) PRL levels were raised not as a sum of the two stimuli but even significantly more. TRH failed to modify the duration of the seizure induced by ECT. Therefore, if TRH is involved in seizure modulation during ECT, our findings suggest a postictal rather than ictal role for TRH.
Abstract: The literature on the effects of electroconvulsive therapy (ECT) on non-memory cognitive functions is reviewed. It is concluded that with early methods of ECT administration (sine wave, high dose), these effects are larger than those of depression. They are less pronounced, and usually do not exceed the effects of depression, when modern methods of ECT administration (brief pulse, moderate or low dose) are used. Following ECT, these functions progressively improve. At one week to seven months after ECT, performance is better than before ECT, probably because of the alleviation of both the effects of depression and of ECT. The time course to full recovery of the non-memory effects resembles that of the recovery of amnesic effects, although the latter are more pronounced. With bilateral ECT, as with right unilateral ECT, there is evidence that right hemisphere effects are more pronounced. The results of this review argue that clinicians should take the non-memory cognitive effects of ECT into account, and patients should be informed of their existence before they sign consent for ECT.
Abstract: Despite extensive study of the effects of various pharmacological agents on the thyrotropin (TSH) and prolactin (PRL) responses to TRH challenge, the effect of serotoninergic agents remains inconclusive. We studied the effect of the serotonin antagonists methysergide (non-selective 5-HT1/5-HT2 blocker with dopaminergic properties) and ritanserin (selective 5-HT2 blocker) on the TSH and PRL responses to TRH stimulation in two groups of medication-free female depressed patients in a double-blind, within-subject design. Methysergide was found to decrease significantly the PRL response to TRH, while ritanserin had no effect. Neither compound influenced the TSH response. Results suggest that 5-HT2 mechanisms do not mediate the PRL and TSH responses to TRH challenge in depression. The reduction in PRL observed after methysergide is probably due to either 5-HT1 or dopaminergic mechanisms.
Abstract: Despite widespread cancer awareness programs, deleterious delays in seeking diagnosis and care for cancer are as prominent now as as they were 50 years ago. These delays may be seen as attempts to resolve or postpone the crisis brought on an individual by the suspicion of terminal illness. The use of denial-like processes in the cognitive appraisal employed to assess this crisis is influenced by a variety of personal, social, and physical factors. Case material is examined to discuss the integration of these factors by the crisis model of physical illness and to examine the implications of such an approach for earlier detection and treatment of cancer.
Abstract: Presbyophrenia is characterized by memory impairment, disorientation, confabulation, hypomanic features, and a preserved social facade. These occur in the absence of prior history of alcoholism or affective illness. We present three cases with presbyophrenia and suggest that the syndrome is a recognizable subtype of dementia, possibly related to disruption of aminergic pathways in frontal and subcortical structures.
Abstract: Blood pressure changes recorded during electroconvulsive therapy (ECT) in 23 psychiatric in-patients with major depressive disorders correlated with and predicted the degree of anterograde memory changes measured 48-72 h after ECT. The Randt memory test was the principal measure of memory change. A subgroup of older patients with cardiovascular illness received trimethaphan, a ganglionic blocker that impedes a hypertensive surge during the treatment. They did not differ in memory function from a younger subgroup that did not receive trimethaphan. Control of the hypertensive response in the older age group counterbalanced the additional memory dysfunction that was anticipated as a result of advanced age and cardiovascular pathology.
Abstract: We used the Randt Memory Test (RMT) to examine the effects of electroconvulsive therapy (ECT) on memory in 23 depressed patients. Immediate recall was unaffected by ECT, but delayed recall was reduced 48-72 h following reorientation after ECT. These changes were not correlated with the total seizure time or with the dose of electrical energy. Most patients rated their memory as improved after ECT on the Squire Subjective Memory Questionnaire. Improvement in mood, as reflected in behavior scales, was correlated with the subjective perception of memory performance, but not with the objective performance on the RMT. Improvement in depressive mood is independent of changes in performance on tests of memory. The RMT is a convenient and useful instrument to monitor the memory effects of ECT.
Abstract: We examined the relation between age and recovery of memory functions after electroconvulsive therapy (ECT). In a group of patients 20-65 years of age, older depressed patients treated with ECT experienced more severe and longer lasting memory deficits than did younger patients. Testing conducted 24-72 h after a course of ECT showed more severe deficits in older patients for verbal and visuospatial anterograde memory, and for retrograde memory. The difference between younger and older subjects was marginal at 1 month follow-up, seen only in differences in verbal anterograde memory. At 6 months follow-up, no difference in memory test scores between older and younger patients was observed. Older patients are more vulnerable to cognitive effects of ECT, and these effects last longer.
Abstract: Denial has been thought of as a primitive defense mechanism, although in the medically ill population there is some indication that it may promote adaptation. In this study the authors examined the relationship of denial and psychological adaptation in 63 end-stage renal disease (ESRD) patients. While all patients had similar levels of global dysfunction, the patients with low denial scores had significantly greater interpersonal sensitivity and greater mood and sleep dysfunction than did those with high denial scores. The inability of some ESRD patients to use denial-like processes can be understood from a cognitive-behavioral perspective. This may have treatment implications for mood dysfunction in this group.
Abstract: Catatonia is defined only as a subtype of schizophrenia in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III) and DSM-III-revised (DSM-III-R), but catatonic symptoms are prominent in patients with psychoses, affective disorders, systemic illnesses, and neurotoxic states. We reviewed the case records of a 30-bed University Hospital adult inpatient psychiatric unit between 1985 and 1990, and identified 43 cases with admission or discharge diagnoses of schizophrenia, catatonic type (295.2). Of these, the records were adequate for detailed review in 19 cases. On discharge, seven were classified as schizophrenia, seven as affective disorder, and five as organic affective disorder. Eleven patients underwent electroconvulsive therapy (ECT), with excellent results in eight; 34 psychotropic medication trials were administered, with successful results in only two patients. Catatonia should be defined as a separate class in DSM-IV, thus encouraging the proper diagnosis and management of a treatable condition.
Abstract: The brain concentration of fluphenazine was measured in two groups of rats, one treated with fluphenazine and electroconvulsive shock, and the other with fluphenazine only. No difference was found in brain fluphenazine concentration between the two groups. The experiment was replicated with a larger number of rats and the same result was obtained. Electroconvulsive shock does not increase the concentration of fluphenazine in brain tissue.
