What do general practice patients want when they present medically unexplained symptoms, and why do their doctors feel pressurized?

OBJECTIVE: We tested predictions that patients with medically unexplained symptoms (MUS) want more emotional support and explanation from their general practitioners (GPs) than do other patients, and that doctors find them more controlling because of this. DESIGN: Thirty-five doctors participated in a cross-sectional comparison of case-matched groups. Three hundred fifty-seven patients attending consecutively with MUS were matched for doctor and time of attendance with 357 attending with explained symptoms. Patients self-reported the extent to which they wanted somatic intervention, emotional support, explanation and reassurance. Doctors rated their perception of patients' influence on the consultation. Predictions were tested by multilevel analyses. RESULTS: Patients with MUS sought more emotional support than did others, but no more explanation and reassurance or somatic intervention. A minority of doctors experienced them as exerting more influence than others. The experience of patient influence was related to the patients' desire for support. CONCLUSIONS: Future research should examine why GPs provide disproportionate levels of somatic intervention to patients who seek, instead, greater levels of emotional support.     

A link between lunar phase and medically unexplained stroke symptoms: an unearthly influence?

OBJECTIVE: Lunar effects on human behaviour and health have been postulated for centuries; associations between phase of the moon and both vascular and psychiatric disease have been reported. We hypothesised that admission with medically unexplained stroke symptoms would be influenced by lunar cycle. METHODS: All admissions to the Western Infirmary Acute Stroke Unit are recorded in a comprehensive database. We analysed admissions between January 1, 1993, and September 30, 2006 (inclusive). Association between admission rate, phase of the moon, and a series of other culturally significant dates was calculated using chi-square testing. RESULTS: There were 7219 admissions during the study period, comprising 167 complete lunar cycles. Stroke admissions were evenly spread throughout lunar phases (P=.72). Admission with medically unexplained stroke symptoms was significantly increased during full moon phases (P=.023). There was no variation in admission rates during other significant dates. CONCLUSION: There was a statistically significant association between admission to the acute stroke unit with a diagnosis of medically unexplained stroke symptoms and lunar phase. The reasons for this observed variation remain elusive; our data do not support a convincing biological or psychosocial aetiology.     

Predictors and course of medically intractable epilepsy in young children presenting before 36 months of age: A retrospective, population-based study

Purpose: To determine the prevalence and identify predictors of medical intractability in children presenting with epilepsy before 36 months of age, and to assess the effect of medical intractability on long‐term mortality and intellectual function. Methods: Children with newly diagnosed epilepsy before 36 months between 1980 and 2009 while resident in Olmsted County, MN, were identified. Medical records were reviewed to collect epilepsy‐specific variables and long‐term outcome data. Medically intractable epilepsy was defined as either (1) seizure frequency greater than every 6 months at final follow‐up and failure of two or more antiepileptic drugs for lack of efficacy, or (2) having undergone epilepsy surgery after failure to respond to two or more antiepileptic drugs. Key Findings: One hundred twenty‐seven children with new‐onset epilepsy were identified and followed for a median of 78 months. Medically intractable seizures occurred in 35%, and significant predictors on multivariate analysis were age ≤12 months at diagnosis (odds ratio [OR] 6.76, 95% confidence interval [CI] 2.00, 22.84, p = 0.002), developmental delay at initial diagnosis of epilepsy (OR 20.03, 95% CI 3.49, 114.83, p = 0.0008), neuroimaging abnormality (OR 6.48, 95% CI 1.96, 21.40, p = 0.002), and focal slowing on initial EEG (OR 5.33, 95% CI 1.14, 24.88, p = 0.03). Medical intractability occurred early in the course in most children, being seen in 61% by 1 year, and 93% by 5 years after initial diagnosis. Mortality was higher (20% vs. 0%, p < 0.001) and intellectual outcome poorer (p < 0.001) if epilepsy was medically intractable. Significance: One third of children presenting with epilepsy before 36 months will be medically intractable, and significant predictors are identified. Medically intractable epilepsy is associated with increased mortality risk and significant intellectual disability.     

Which factors predict the persistence of DSM-IV depression, anxiety, and somatoform disorders in the medically ill three months post hospital discharge?

Objective

This study sought to assess the persistence of DSM-IV depression, anxiety, and somatoform disorders in a sample of 206 medical patients 3 months after hospital discharge and to examine which baseline factors predicted the persistence of disorder.

Methods

Patients were interviewed using the Monash Interview for Liaison Psychiatry (a structured psychiatric interview for the medically ill) during admission and again at 3 months post discharge. Scales completed during admission elicited sociodemographic data, psychiatric history, mental and physical functioning, illness behavior, coping modes, and number of close relationships. Best-subset logistic regression was employed to find the best combination of these potential predictors of the persistence of psychiatric disorder.

Results

Persistence of anxiety disorders [n=43; 50.6%; 95% CI=39.5-61.6], depression (n=55; 44.4%; 95% CI=35.4-53.5), and somatoform disorders (n=35; 42.2%; 95% CI=31.3-53.0) was moderately high, with no statistically significant difference in the rate of persistence of the three groups of disorder. Family psychiatric history, education, and poorer physical and mental functioning during hospitalization predicted persistence of depression. Poorer mental functioning, less denial, and greater number of close relationships predicted persistence of anxiety disorders. Higher levels of education, use of acceptance-resignation as a coping mechanism, and greater hypochondriasis predicted persistence of somatoform disorders.

Conclusion

The belief that psychiatric disorders in hospitalized medically ill patients spontaneously remit after discharge is false. A substantial proportion persist for at least 3 months. Early detection and treatment is possible and warranted. Features of the illness (poorer physical and mental health) and personal and social factors identifiable at hospital admission identify patients at risk for persistence.     

Recognition of medically unexplained symptoms--do doctors agree?

The aim of this study was to investigate the interrater reliability of the recognition of medically unexplained symptoms by medical investigators. The casenotes of 56 consecutive secondary care out-patient attenders were examined by three medical investigators. The investigators determined whether the presenting symptoms were medically unexplained (not, probable, or definite) and the results were tested for interrater reliability. The combined kappa for the three investigators was 0.76, indicating substantial agreement. This suggests that casenote examination is a reliable method of determining whether a symptom is medically unexplained.     

Are medically unexplained symptoms and functional disorders predictive for the illness course? A two-year follow-up on patients' health and health care utilisation

Objective

To investigate whether the general practitioners' (GP) diagnosis of medically unexplained symptoms (MUS) and/or the diagnosis functional disorders (FD) can predict the patients' 2-year outcome in relation to physical and mental health and health care utilisation. Furthermore, to identify relevant clinical factors which may help the GP predict the patient's outcome.

Method

The study included 38 GPs and 1785 consecutive patients who presented a new health problem. The GPs completed a questionnaire on diagnosis for each patient. Patients completed the Common Mental Disorder Questionnaire (CMDQ) and the SF-36 questionnaire at baseline and after 24 months. A stratified sample of 701 patients was diagnosed with a psychiatric research interview. Data on health cost was obtained from national registers.

Results

A FD diagnosis following the research interview was associated with a decline in physical health (OR 3.27(95%CI 1.84-5.81)), but this was not the case with MUS diagnosed by the GP. MUS was associated with a poor outcome on mental health (OR 2.16 (95%CI 1.07-4.31)). More than 4 symptoms were associated with a poor outcome on physical health (OR 5.35 (95%CI 2.28-12.56)) and on mental health (OR 2.17(95%CI 1.02-4.59)). Neither FD nor MUS were associated with higher total health care use. However, FD (OR 2.31(95%CI 1.24-4.31)) and MUS (OR 1.98(95%CI 1.04-3.75)) was associated with increased cost in primary care.

Conclusion

Our current diagnoses of MUS show limitations in their prediction of the patients' illness course. Although, the ICD-10 diagnoses of functional disorders was not developed for the primary care setting, our results indicate that some of its elements would be useful to bring in when rethinking the diagnosis for MUS in primary care, elements that are easily obtainable for the GP in a normal consultation. Our results may contribute to the construction of a more useful diagnostic for these patients in primary care.     

A qualitative study of adolescents with medically unexplained symptoms and their parents. Part 2: How is healthcare perceived?

Medically unexplained symptoms (MUS) are common among adolescents and an important cause of clinical visits. This study sought to understand the experiences with, and perceptions of, the healthcare of adolescents who have MUS and their parents. Using a qualitative approach, six focus groups and two individual interviews were conducted with a total of ten adolescents and sixteen parents. The participants were recruited in a university hospital in Switzerland. A thematic analysis was conducted in accordance with the Grounded Theory. Six main themes emerged: needing a label for the symptoms, seeking an etiology to explain the symptoms, negotiating the medical system, medication and treatments, interactions with doctors, and the inclusion of parents during consultations. Transcending these themes, however, was the need for good communication between the adolescents, their parents and the clinicians. When explaining the symptoms, clinicians should make sure to discuss the results, investigations and lack of organic origin.     

Mood,anxiety, and physical illness: body and mind,or mind and body?

This research review examines the recent articles that have investigated the relationship between mood, anxiety, and physical illness (e.g., asthma, autoimmune disorders, cancer, cardiovascular disease, obesity, and sexual dysfunction). There is growing evidence of an overall negative impact of depression and other mood states, and anxiety on numerous physical illnesses and conditions, and their outcome.     

Physical training and fatigue, fitness, and quality of life in Guillain-Barré syndrome and CIDP

Many patients with Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP) experience excessive fatigue, which may persist for years and reduce quality of life. The authors performed a 12-week study of bicycle exercise training in 20 patients with severe fatigue, 16 with relatively good recovery from GBS, and 4 with stable CIDP. Training seemed well tolerated, and self-reported fatigue scores decreased 20% (p = 0.001). Physical fitness, functional outcome, and quality of life were improved.     

Psychopathology and resident status – comparing asylum seekers,refugees, illegal migrants,labor migrants,and residents

Purpose

This study aimed to describe, compare, and predict mental health outcomes of different migrant groups and native residents in Switzerland.

Subjects and methods

Asylum seekers (n = 65); refugees holding permanent protection visas (n = 34); illegal migrants (n = 21); labor migrants (n = 26); and residents (n = 56) completed an assessment by questionnaire. Main outcome variables were symptoms of posttraumatic stress, anxiety and depression. It was tested whether resident status predicted psychopathology over and above the influence of control variables including social desirability, traumatic event types and post-migration resources.

Results

Asylum seekers (54.0%) and refugees (41.4%) fulfilled criteria of PTSD most frequently. Clinically relevant symptoms of anxiety and depression were most frequently reported by asylum seekers (84.6% and 63.1%, resp.) and illegal migrants (both 47.6%). Resident status contributed to psychopathology over and above the influence of control variables.

Conclusions

Overall, asylum seekers, refugees, and illegal migrants showed high psychiatric morbidity. Differences in resident status appear to be specifically associated with mental health outcomes. This association persists even when controlling for social desirability, post-migration resources and traumatic events. This emphasizes the importance of current socio-political living conditions for mental health, even with respect to the psychopathological sequelae of past traumatic experiences.     

Vagal nerve stimulation in children under 12 years old with medically intractable epilepsy

Objective

This study aims to assess the efficacy and safety of vagal nerve stimulation (VNS) in children less than 12 years old operated on at the University Hospital Wales.

Method

Retrospective review of patients undergoing VNS insertion, over a 3-year period, was undertaken. All children had a minimum follow-up period of 2 years. Sixteen patients were identified via the paediatric epilepsy surgery database. A case note review and telephone evaluation was conducted. Seizure frequency using the McHugh classification was the primary outcome measure, with anti-epileptic drug (AED) use as a secondary outcome measure.

Results

There were 10 males and 6 females. The mean time with epilepsy prior to surgery was 5.7 years and the mean age at the time of surgery was 7.6 years. Overall, nine (56 %) children experienced a reduction in their seizure frequency of 50 % or more. Of these, four (25 %) had a reduction of more than 80 %. Seven children (44 %) had no reduction in their seizure frequency, although two of these patients reported benefit regarding seizure control and post-ictal recovery. The VNS system was removed in two patients due to infection and no benefit, respectively. Half of the cohort (50 %) reduced the number of anti-epileptic drugs post-surgery, and there was an overall mean reduction of AED of 0.5.

Conclusion

This study suggests that VNS is a safe and effective adjuvant therapy in children under 12 years old, with over half reporting significant benefit. Further studies are needed to enable preoperative selection of patients in order to maximise the potential benefit.     

Neurostimulation—Past,Present, and Beyond

Neurostimulation as a treatment for epilepsy has been around for almost 20 years in the form of vagus nerve stimulation. Newer types of neurostimulation are being developed and stand on the brink of approval for use. The two newest therapies, not yet approved in the United States, are deep brain stimulation and the Responsive Neurostimulator System . In fact, in Europe, approval has already been given for deep brain stimulation and newer forms of vagus nerve stimulation. Efficacy is similar between these therapies, and side effects are moderate, so what will be the future? The challenge will be to learn how to use these therapies correctly and offer the right treatment for the right patient.Despite the development of new antiepileptic drugs (AEDs), of which there are now 24 in total available in the United States, there are still many patients suffering from continued seizures. Patients with refractory epilepsy should initially be evaluated for resective epilepsy surgery. Neurostimulation is not a replacement for resective surgical options. Unfortunately, not all patients can be cured of their seizures by epilepsy surgery, therefore other methodologies have to be developed as well. Of the nonpharmacologic therapies available, vagus nerve stimulation (VNS) has been the procedure that has been the most accessible and best studied. The therapy has been approved since 1997 in the United States, and in Europe since 1994. Efficacy can be compared with that of a newer AED (1). Deep brain stimulation (DBS) has been studied in different forms, but only a double-blind study of bilateral stimulation of the anterior nucleus of the thalamus (2) has been accepted by the European Medicinal Agency as showing efficacy and is now approved as a therapy for epilepsy in Europe. DBS for epilepsy has not been approved in the United States. The closed-loop system (the Responsive Neurostimulator System, RNS) is also under development, and a double-blind study has also been completed (3), but approval for use in refractory focal onset epilepsy patients is pending.     

Can depression and depressive symptoms predict mortality at 18-month follow-up in acutely medically ill inpatients over the age of 80 years?

Background. The prevalence of depression in acutely medically ill elderly inpatients is high. Depression in the elderly is associated with increased mortality. Method. The association between mortality at 18-month follow-up and depression, depressive symptoms and demographic variables at the outset in a cohort of acutely medically ill elderly inpatients was examined. Results. The mortality at 18-month follow-up was 47%. Depression, depressive symptoms and demographic variables were not associated with mortality. Conclusion. An important explanation of this absence of association between mortality and depression may be an artifact due to patient selection designed to resemble normal clinical practice. © 1998 John Wiley & Sons, Ltd.     

What predicts maintenance of weight for adolescents medically hospitalized for anorexia nervosa?

We assessed the relationship between outcomes at one year and a variety of possible predictors among a group of adolescents who were hospitalized for medical complications associated with adolescent onset AN. We reviewed the 12 month outcomes of 41 adolescent patients admitted for medical complications associated with AN to our center. Data on initial percent ideal body weight, length of initial hospitalization, and percent ideal body weight at discharge from first admission were collected. Our primary outcome measure was percent ideal body weight obtained 12 months after initial discharge. Using multiple linear regression to predict percent ideal body weight achieved at 12 months postdischarge, we found that only percent of ideal body weight at discharge predicted better outcomes. Response to initial hospitalization in terms of weight gain, rather than admission weight or length of initial hospital stay, predict better outcomes at 12 months. These results suggest the need for further study of predictors of response to intensive hospital treatment in order to improve initial response rates and ultimately to better outcomes postdischarge.     

How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors

OBJECTIVE: The authors developed a methodological basis for investigating how risk factors work together. Better methods are needed for understanding the etiology of disorders, such as psychiatric syndromes, that presumably are the result of complex causal chains. METHOD: Approaches from psychology, epidemiology, clinical trials, and basic sciences were synthesized. RESULTS: The authors define conceptually and operationally five different clinically important ways in which two risk factors may work together to influence an outcome: as proxy, overlapping, and independent risk factors and as mediators and moderators. CONCLUSIONS: Classifying putative risk factors into these qualitatively different types can help identify high-risk individuals in need of preventive interventions and can help inform the content of such interventions. These methods may also help bridge the gaps between theory, the basic and clinical sciences, and clinical and policy applications and thus aid the search for early diagnoses and for highly effective preventive and treatment interventions.     

Are child-, adolescent-, and adult-onset depression one and the same disorder?

This paper reviews prior research studies examining neurobiological correlates and treatment response of depression in children, adolescents, and adults. Although there are some similarities in research findings observed across the life cycle, both children and adolescents have been found to differ from depressed adults on measures of basal cortisol secretion, corticotropin stimulation post-corticotropin releasing hormone (CRH) infusion, response to several serotonergic probes, immunity indices, and efficacy of tricyclic medications. These differences are proposed to be due to 1) developmental factors, 2) stage of illness factors (e.g., number of episodes, total duration of illness), or 3) heterogeneity in clinical outcome (e.g., recurrent unipolar course vs. new-onset bipolar disorder). Relevant clinical and preclinical studies that provide support for these alternate explanations of the discrepant findings are reviewed, and directions for future research are discussed. To determine whether child-, adolescent-, and adult-onset depression represent the same condition, it is recommended that researchers 1) use the same neuroimaging paradigms in child, adolescent, and adult depressed cohorts; 2) carefully characterize subjects' stage of illness; and 3) conduct longitudinal clinical and repeat neurobiological assessments of patients of different ages at various stages of illness. In addition, careful attention to familial subtypes (e.g., depressive spectrum disorders vs. familial pure depressive disorders) and environmental factors (e.g., trauma history) are suggested for future investigations.