Risk of suicide in mood disorders

Suicide is commonly associated with mood disorders. Risk factors for suicide in mood disorders can be organized according to whether their effect is on the threshold or diathesis for suicidal acts or whether they serve mainly as triggers or precipitants of suicidal acts. Predisposition to suicidal behavior or diathesis is a key element that helps to differentiate patients who are at high risk versus those at lower risk. The objective severity of mood disorders does not identify depressed patients at high risk for suicide attempt. There is a lack of agreement over the suicide risk associated with characteristics of depression such as psychotic features, agitation, or anxiety, or mixed mood states as part of bipolar disorder. Risk factors affecting the diathesis for suicidal behavior include family history of suicide, low cerebrospinal fluid 5-hydroxyindolacetic acid, alcohol and/or substance abuse, cluster B personality disorder, high past impulsivity and aggression, chronic physical illness particularly involving the brain, marital isolation, parental loss before age 11, childhood history of physical and sexual abuse, hopelessness, and not living with a child under age 18. Most common precipitants of suicidal acts in mood disorders include interpersonal losses or conflicts, financial trouble, and job problems. Identification of high risk patients and effective treatment are required for suicide prevention to reduce morbidity and mortality in affective disorders.     

Anti-tumor necrosis factor-α therapy is associated with less frequent mood and anxiety disorders in patients with rheumatoid arthritis

Aims:  The purpose of the present study was to examine the current prevalence of mood and anxiety disorders, and factors related to mood and anxiety disorders in patients with rheumatoid arthritis (RA).
Method:  The study sample included 83 consecutive patients with RA who were admitted to a rheumatology outpatient clinic. Diagnoses of psychiatric disorders were determined using the Structured Clinical Interview for DSM-IV (SCID-I). To assess physical disability and disease activity, the Health Assessment Questionnaire and the Disease Activity Score, respectively, were used.
Results:  The prevalence of any mood or any anxiety disorder was 43.4%. The two most common psychiatric diagnoses were major depression (21.7%) and generalized anxiety disorder (16.9%). Mood and anxiety disorders were unrelated to sociodemographic features, disease-related factors, and medications for RA except anti-tumor necrosis factor-α (TNF-α). These disorders, however, were identified less frequently in patients with RA receiving anti-TNF-α drugs compared to patients who did not receive such medications.
Conclusion:  Patients with RA frequently have mood and anxiety disorders, and anti-TNF-α drugs may be useful for the mental status of these patients.     

Relationship between mood and motor fluctuations in Parkinson's disease

Mood fluctuations have been reported in up to two-thirds of patients with Parkinson's disease who experience motor fluctuations. Most researchers indicate that mood fluctuations tend to be associated with motor fluctuations in that patients experience decreased mood when "off" (immobile) and elevated mood when "on" (mobile). Sixteen patients with Parkinson's disease and motor fluctuations completed hourly diaries for 7 consecutive days documenting their mood, anxiety, and motor states using visual analogue scales. Mood and anxiety fluctuations were frequently documented. Motor and emotional states were not, however, consistently correlated. When they were correlated, the most frequent pattern was the common occurrence of decreased mood, increased anxiety, and reduced motor function.     

Anxiety disorders among African-American and white primary medical care patients

The prevalence of current anxiety disorders and associated clinical patterns was examined in a sample of 125 African American and 120 white primary medical care patients between ages 18 and 64. Patients who indicated they had at least one mood or anxiety symptom in response to a screening questionnaire were interviewed to determine the presence of a DSM-IV anxiety, mood, or possible alcohol abuse disorder. Demographic data and data on mental- and physical-health-related functioning and health service utilization were also collected. The authors found no racial differences in the proportions of patients who met DSM-IV criteria for the disorders, nor in their symptom patterns, level of functional disability, or rates of health and mental health service utilization.     

Clinical Correlates of False Positive Assignment in Bipolar Screening Measures Across Psychiatric Diagnoses among Patients without Bipolar Disorder

ObjectiveIn this study, we aimed to determine clinical correlates of false positive assignment (FPA) on commonly used bipolar screening questionnaires. MethodsA retrospective chart review was conducted to a total of 3885 psychiatric outpatients. After excluding patients who have bipolar spectrum illnesses, patients who were assigned as having hypomania on the mood disorder questionnaire (MDQ) or the hypomania checklist-32 (HCL-32) were identified as patients who had FPA. Psychiatric diagnoses and severity of emotional symptoms were compared between patients with and without FPA. ResultsPatients with FPA on the MDQ showed significant associations with presence of major depressive disorder, generalized anxiety disorder, and alcohol-use disorder, while patients with FPA on the HCL-32 showed associations with presence of panic disorder and agoraphobia. FPA on the MDQ was also associated with greater emotional symptoms and lifetime history of suicide attempts. Logistic regression analysis showed that male sex, younger age, presence of alcohol-use disorder, and severity of depression and obsessive-compulsive symptoms were significantly associated with FPA on the MDQ. ConclusionThe FPA for the MDQ was associated with clinical factors linked to trait impulsivity, and the FPA for both the MDQ and the HCL-32 could be related to increased anxiety.     

Quality of life in patients with stable disease after surgery, radiotherapy, and chemotherapy for malignant brain tumour

OBJECTIVES: to evaluate quality of life in patients with malignant brain tumour with stable disease after combined treatments in comparison to patients with other chronic neurological conditions, and to explore the relation of quality of life to clinical, pathological, affective and cognitive factors. METHODS: fifty seven patients who were stable after surgery, radiotherapy and chemotherapy and 24 controls with spastic paraparesis, peripheral neuropathies, myasthenia, ataxia, Parkinson's disease, or multiple sclerosis, were studied. Patients were evaluated by functional living index-cancer, Karnofsky performance status, activity of daily living, self-rating depression scale, state-trait anxiety inventory, and tests for cognitive abilities. RESULTS: separate Mann-Whitney test comparisons did not show any difference in measures of health related quality of life (functional living index-cancer), autonomy in daily life (activity of daily living), or mood between tumour and control patients, although the first had slower mental speed and worse attention. Seventy three per cent of patients with brain tumour and 58% of the control patients continued or resumed previous work activity. Quality of life was significantly associated with depression, state anxiety, and performance status in the patients with brain tumour, whereas in control patients, state anxiety was the only factor related to quality of life. CONCLUSIONS: after intensive multimodality treatments, selected patients with brain tumour with stable disease may have satisfactory quality of life that may be not worse than in patients with other chronic neurological illnesses. During the period of stable disease, depressed mood, possibly a reaction to impaired physical and cognitive performance, seems to play a major role in determining quality of life.     

Anticonvulsants in agitation and behavior disorders in demented subjects. Report of 8 cases]

Aggressive agitation, agitation and insomnia with generalized anxiety are commonly observed in Alzheimer's disease. These symptoms remain a principal problem in the clinical management of elderly patients. Neuroleptics are commonly the selected medication for controlling severe aggression, especially the violent out bursts often seen in demented patients. Their use is frequently complicated by side effects, particularly somnolence and confusion. Valpromide and Carbamazepine have been efficacy alternatives and very well tolerated. We report eight cases of demented patients who presented an agitation and aggressive behaviors and had been treated with Valpromide or Carbamazepine. The patients agitation was well controlled at that point and had no apparent side effects. A combination Valpromide or Carbamazepine with neuroleptics permitted a reduction doses of neuroleptics and their side effects. We think that these behaviors disorders belong to the mood disorders. The symptomatology is modified because an alteration of cognitive faculty.     

Mood disorder with mixed features due to vitamin B(12) and folate deficiency

Vitamin B(12) and folate deficiency is often associated with affective disorders mainly of the depressive type. We report a case of a 42-year-old woman with a mood disorder with mixed depressed/manic features that was due to vitamin B(12) and folate deficiency. The psychopathology developed over a five-year period without hematologic or other overt clinical characteristics of pernicious anemia. Replacement treatment with vitamin B(12) and folate was rapidly followed by full clinical remission, electroencephalographic normalization and neuropsychological improvement. At a one-year follow-up this condition was stable. Consequently, patients who respond poorly to psychopharmacologic treatment and/or present with atypical mood symptoms would warrant determination of vitamin B(12) and folate serum levels.     

Anxiety,depression and swallowing disorders in patients with Parkinson's disease

Swallowing disturbances (SDs), anxiety and depression are commonly present in Parkinson's disease (PD) patients. We hypothesized that there is an association between the presence of SDs and the PD affective state. Sixty-nine PD patients were assessed for the presence of SDs by undergoing cognitive screening with the Mini Mental State Examination (MMSE), completing three inventories: a swallowing disturbance questionnaire (SDQ), the Spielberger manual for the trait anxiety and Beck depression inventories. All patients underwent clinical swallowing evaluations by a speech and language pathologist (SLP). Patients diagnosed with SDs were also assessed by fiberoptic endoscopic evaluation of swallowing (FEES) performed by an ENT and SLP. Thirty-eight patients experienced SDs, the other 31 did not. The clinical characteristics of the two groups were matched. Patients with SDs experienced increased anxiety and depression compared to patients without SDs. Comparisons between patients who scored in the two opposite ends of the anxiety and depression ranges demonstrated that the most anxious and depressed patients reported more swallowing difficulties (SDQ scores) compared with the least anxious and depressed ones. In addition, the most anxious patients had significantly increased disease severity and decreased MMSE scores compared with the least anxious patients. Disease severity was also increased in the most depressed patients compared with the least depressed ones. Advanced disease emerged as being associated with high anxiety levels and greater numbers of SDs. The contribution of anxiety or depression to the development or worsening of SDs and their role in treatment strategy warrant further investigation.     

The acute treatment of anxiety and depression

Anxiety and depression are commonly occurring symptoms. Anxiety disorders and mood disorders usually share common symptoms and they frequently co-exist. There is a considerable body of research that has demonstrated that anxiety and depression can be distinguished from each other at the syndrome level. There is also evidence that such a distinction is arbitrary and not well substantiated. Clinically, the practitioner is often faced with the problem of treating a patient who presents with anxiety and depressive symptoms at the same time. It is well-established that the first line of treatment in major mood disorder is the used of tricyclic antidepressant in adequate dosage. The first line of treatment for the anxiety disorders is usually the administration of benzodiazepine anxiolytics. The anti-depressants have to be given for some months to the majority of patients whereas the anxiolytics are given for short periods. The tricyclics have a relatively slow onset of action compared to the benzodiazepines. Recent evidence is available about the effectiveness of the triazolo-benzodiazepines in panic disorder with or without secondary major mood disorder. There are also reports of the effects of the triazolo-benzodiazepines in primary mood disorder. In these mood disorders, the benzodiazepines caused rapid relief of both anxious and depressive symptomatology. The effects of the benzodiazepines occur even in the presence of melancholic depression. Where anxiety and depression coexist, the clinician may wish to consider beginning anti-depressant therapy with combined tricyclic antidepressant and benzodiazepine to produce rapid symptom relief. After four weeks the benzodiazepine should be faded out and therapy continued with the tricyclic medication alone.     

The homocysteine hypothesis of depression

High levels of homocysteine are associated with cerebrovascular disease, monoamine neurotransmitters, and depression of mood. A plausible hypothesis for these associations is that high homocysteine levels cause cerebral vascular disease and neurotransmitter deficiency, which cause depression of mood. The homocysteine depression hypothesis, if true, would mandate inclusions of imaging studies for cerebrovascular disease and measures of homocysteine, folate, and B12 and B6 vitamins in the clinical evaluation of older depressed patients. Longitudinal studies and clinical trials should be designed to challenge the hypothesis.     

Problem type and referral to HMO mental health treatment

The present study examined the cases of 353 patients seen in the outpatient department of psychiatry at a large west coast HMO. Comparisons were made between self-referred and physician-referred patients in the types of problems presented for treatment. Patients with relationship problems were self-referred more than those with adjustment, anxiety, and mood disorders who were more likely to be physician-referred. HMO patients with a self-referral option appear to enter mental health treatment because of relationship problems at a higher rate than their physician-referred counterparts.     

Relationships among pain, anxiety, and depression in primary care

Pain, anxiety, and depression are commonly seen in primary care patients and there is considerable evidence that these experiences are related. This study examined associations between symptoms of pain and symptoms and diagnoses of anxiety and depression in primary care patients. Results indicate that primary care patients who endorse symptoms of muscle pain, headache, or stomach pain are approximately 2.5-10 times more likely to screen positively for panic disorder, generalized anxiety disorder, or major depressive disorder. Endorsement of pain symptoms was also significantly associated with confirmed diagnoses of several of the anxiety disorders and/or major depression, with odds ratios ranging from approximately 3 to 9 for the diagnoses. Patients with an anxiety or depressive disorder also reported greater interference from pain. Similarly, patients endorsing pain symptoms reported lower mental health functioning and higher scores on severity measures of depression, social anxiety, and posttraumatic stress disorder. Mediation analyses indicated that depression mediated some, but not all of the relationships between anxiety and pain. Overall, these results reveal an association between reports of pain symptoms and not only depression, but also anxiety. An awareness of these relationships may be particularly important in primary care settings where a patient who presents with reports of pain may have an undiagnosed anxiety or depressive disorder.     

The ups and downs of Parkinson disease: a prospective study of mood and anxiety fluctuations.

BACKGROUND: Parkinson disease (PD) patients with motor fluctuations experience mood fluctuations, but studies have been limited in number and methodology. OBJECTIVES: To better understand the phenomenology of mood, anxiety, and motor fluctuations in PD. METHOD: Eighty-seven PD patients and 19 spouse controls completed questionnaires, rating scales, and diaries using visual analogue scales (VAS) to rate mood, anxiety, and motor states. Average daily variance in VAS scores was determined, and PD patients whose average daily variance was larger than that for all of the control subjects were considered to have fluctuations. RESULTS: Twenty-nine percent of patients had fluctuations in anxiety, 24% motor, and 21% mood; 65% had no fluctuations. Seventy-five percent of patients with motor fluctuations had mood and/or anxiety fluctuations, but 5 subjects reported emotional fluctuations without motor fluctuations. The combination of mood and anxiety fluctuations was frequent, but anxiety and mood did not always appear to fluctuate together. Visual inspection of diaries revealed that not all patients exhibited a temporal relationship between emotional and motor fluctuations. Compared with nonfluctuators, those with mood or anxiety fluctuations were more likely to have higher scores on psychiatric rating scales, report histories of depression or anxiety, and use psychotropic medications. CONCLUSIONS: PD patients are heterogeneous with regard to the presence, range, and pattern of fluctuations. In general, patients with mood fluctuations also have anxiety fluctuations.     

A comparative study of anxiety and depression in patients with bronchial asthma,chronic obstructive pulmonary disease and tuberculosis in a general hospital of chest diseases

Background  

Depression necessitating assistance from health professionals has a lifetime prevalence of 10%. Chronic disease increases comorbidity with mood and/or anxiety disorders. Patients with chronic pulmonary disease present with severely impaired functionality, chronic somatic and psychogenic pain, require frequent hospitalizations and have a dependency upon medical and nursing personnel. In the present study we assessed anxiety and depression in patients hospitalized for pulmonary disease in a pulmonary disease hospital.     

Pediatric mood and anxiety syndromes in primary care: who gets identified?

OBJECTIVE: To seek clues to the enhancement of primary care management by (i) Determining how often and in whom primary care clinicians in the United States, Puerto Rico, and Canada identify pediatric mood or anxiety syndromes; (ii) Determining which clinical and demographic features predict higher rates of identification; (iii) Describing assessment methods used. METHODS: This report uses the database of the multi-site Child Behavior Study. This cross-sectional study involved 206 primary care practices in the United States, Puerto Rico, and Canada; 395 clinicians and 20,861 primary care attenders aged 4-15 years. Clinicians completed a visit questionnaire addressing presence and type of psychosocial problems and how assessed. Parents completed a questionnaire addressing family demographics, child symptoms (Pediatric Symptom Checklist) and functioning, and child service use. RESULTS: Clinicians identified psychosocial problems on 17.9% of visits, but mood or anxiety syndromes on only 3.3%, most commonly in children judged to have co-morbid behavioral syndromes, of whom the majority (66.7%) already had contact with specialized mental health. Neither parental concerns about mood and anxiety symptoms nor clinician familiarity with the patient were major predictors of identification. When making a diagnosis of a pure internalizing syndrome (i.e., without a co-morbid behavioral syndrome) clinicians rarely used standardized tools or school reports. CONCLUSIONS: Neither screening for nor diagnosis of mood and anxiety syndromes is a routine part of primary care of children and adolescents. Efforts to improve care must include practical, validated screening procedures to enhance assessment for mood and anxiety syndromes, particularly among children in whom primary care clinicians identify psychosocial problems.     

Psychiatric manifestations of vitamin B12 deficiency: a case report

Psychiatric manifestations are frequently associated with pernicious anemia including depression, mania, psychosis, dementia. We report a case of a patient with vitamin B12 deficiency, who has presented severe depression with delusion and Capgras' syndrome, delusion with lability of mood and hypomania successively, during a period of two Months. Case report - Mme V., a 64-Year-old woman, was admitted to the hospital because of confusion. She had no history of psychiatric problems. She had history of diabetes, hypertension and femoral prosthesis. The red blood count revealed a normocytosis with anemia (hemoglobin=11,4 g/dl). At admission she was uncooperative, disoriented in time and presented memory and attention impairment and sleep disorders. She seemed sad and older than her real age. Facial expression and spontaneous movements were reduced, her speech and movements were very slow. She had depressed mood, guilt complex, incurability and devaluation impressions. She had a Capgras' syndrome and delusion of persecution. Her neurologic examination, cerebral scanner and EEG were postponed because of uncooperation. Further investigations confirmed anemia (hemoglobin=11,4 g/dl) and revealed vitamin B12 deficiency (52 pmol/l) and normal folate level. Antibodies to parietal cells were positive in the serum and antibodies to intrinsic factor were negative. An iron deficiency was associated (serum iron=7 micromol/l; serum ferritin concentration=24 mg/l; serum transferrin concentration=3,16 g/l). This association explained normocytocis anemia. Thyroid function, hepatic and renal tests, glycemia, TP, TCA, VS, VDRL-TPHA were normal. Vitamin B12 replacement therapy was started with hydroxycobalamin 1 000 ng/day im for 10 days and iron replacement therapy. Her mental state improved dramatically within a few days. After one week of treatment the only remaining symptoms were lability of mood, delusion of persecution, Capgras' syndrome but disappeared totally 9 days after the beginning of the treatment. A neurologic examination was possible because of cooperation. All the tendon reflexes of inferior members were absent. The plantars were in flexion and there was a left inferior member hypoesthesia. The cerebral scan and EEG were normal. Fundic biopsy, realized by fibroscopy, revealed fundic atrophia and intestinal metaplasia compatible with Biermers' disease. The iron deficiency exploration concluded diet deficiency. Mme V. appeared euphoric, her speech was very rapid with play on words and overactivity. This hypomania state totally disappeared 3 days after. Six Months after her hospitalisation, she presented an hypothyroidism (TSH=3,780; T3=1,35; T4=1,08). A thyroid hormones replacement was started and she continued to receive Monthly B12 replacement. Discussion - This case report illustrates psychiatric manifestations of Biermers' disease. The clinical arguments in favour are: white woman, more than 60 Years old, no history of psychiatric problems, atypical symptoms (confusional state with psychiatric symptoms), fluctuation of symptoms (severe depression with confusional state, delusion of persecution and Capgras' syndrome; delusion with lability of mood and hypomania), dramatic improvement after 9 days of vitamin B12 replacement therapy. The biological arguments are: anemia, vitamin B12 deficiency, normal folate level, atrophia and fundic metaplasia, positive antibodies to parietal cells in the serum, association between Biermers' disease and autoimmune disease (Haschimoto thyroidite). Psychiatric manifestations can occur in the presence of low serum B12 levels but in the absence of the other well recognized neurological and haematological abnormalities of pernicious anemia. Mental or psychological changes may precede haematological signs by Months or Years. They can be the initial symptoms or the only ones. Verbank et al. described the case of a patient with vitamin B12 deficiency in whom hypomania, paranoia and depression had been successively presented during a period of 5 Years before anemia have been developed. The case of Mme V. is similar in the succession of severe depression with delusion of persecution and Capgras' syndrome, delusion with lability of mood and hypomania, during a period of two Months. This report seems to be the first one of a sequence of several psychiatric states with pernicious anemia during a period of two Months with normocytosis anemia. To illustrate this illness we reviewed the literature regarding psychopathology associated with B12 deficiency. The most common psychiatric symptoms were depression, mania, psychotic symptoms, cognitive impairment and obsessive compulsive disorder. The neuropsychiatric severity by vitamin B12 deficiency and the therapeutic efficacy depends on the duration of signs and symptoms. Conclusion - We recommend consideration of B12 deficiency and serum B12 determinations in all the patients with organic mental disorders, atypical psychiatric symptoms and fluctuation of symptomatology. B12 levels should be evaluated with treatment resistant depressive disorders, dementia, psychosis or risk factors for malnutrition such as alcoholism or advancing age associated with neurological symptoms, anemia, malabsorption, gastrointestinal surgery, parasite infestation or strict vegetarian diet. In first intention, B12 deficiency should be researched by serum B12 determination (normal 200-950 pg/ml). Studies of methylmalonic acid and homocysteine showed that they are very sensitive functional indicators of cobalamin status especially when other evidence of cobalamin (B12) deficiency was equivocal. Measurement of methylmalonic acid (normal 73-271 nmol/l) and homocysteine (normal 5,4-13,9 micromol/l) should not replace the measurement of serum cobalamin.