Systematic Literature Review of Psychiatric Comorbidities in Adults with Epilepsy

Background and PurposeMental illness is disproportionately common in people with epilepsy (PWE). This systematic literature review identified original research articles that reported the prevalence of psychiatric comorbidities based upon clinical assessments in a sample of PWE and assessed the clinical features of the populations found in studies included in our review of mental health comorbidity.MethodsThe included articles were written in English and published from 2008 to 2018, and focused on adults aged ≥18 years who had psychiatric diagnoses determined in clinical assessments, such as those found in medical records, clinician psychiatric evaluations, structured diagnostic interviews, and mental health screening questionnaires specific for a psychiatric disorder. The primary outcome was the prevalence of psychiatric comorbidities as a percentage of the total sample of PWE. Additional data included the overall sample size, mean age, epilepsy type, study design, and method of diagnosis. A modified Newcastle Ottawa Scale was used to assess the quality of the studies. All 23 articles that were consistent with the inclusion criteria were related to observational studies.ResultsMood disorders and anxiety disorders were the most common psychiatric comorbidities, with prevalence rates of 35.0% and 25.6%, respectively. Major depressive disorder was the most common mood disorder, with a prevalence of 24.2%. Post-traumatic stress disorder (PTSD) had the highest reported prevalence among anxiety disorders, at 14.2%, followed by general anxiety disorder at 11.1%. Other comorbidities included psychosis (5.7%), obsessivecompulsive disorder (3.8%), schizophrenia (1.7%), bipolar disorder (6.2%), and substance abuse (7.9%). The pooled prevalence of suicidality, as reported for two studies, was 9.3%. Temporal lobe epilepsy (TLE) was associated with higher levels of psychiatric comorbidity. Two (8.7%) of the 23 studies compared psychiatric comorbidities in TLE with that of extratemporal lobe epilepsy (ETLE), and one of these two studies found that depression was more common in TLE (53.8%) than in ETLE (25%). Regarding seizure types, partial seizures were associated with a higher prevalence of depression vs generalized seizures.ConclusionsThis systematic literature review of recent original research found a relatively high prevalence of mental health comorbidities in PWE. Mood and anxiety disorders are the most common comorbidities, while psychotic spectrum conditions such as schizophrenia and bipolar disorder are much rarer. The prevalence of comorbidity may vary with the epilepsy type and treatment responsiveness. These findings suggest that screening tools for depression and anxiety should be included as part of the training for epilepsy care, while resources for other relatively common conditions such as PTSD and substance abuse disorders should be readily available to neurology specialists who treat PWE.     

Using Avoidable Admissions to Measure Quality of Care for Cardiometabolic and Other Physical Comorbidities of Psychiatric Disorders: A Population-Based,Record-Linkage Analysis

Objective:

Quality of care for comorbid physical disorders in psychiatric patients can be assessed by the number of avoidable admissions for ambulatory care sensitive (ACS) conditions. These are admissions for physical conditions that, with appropriate primary care, should not require inpatient treatment. Avoidable admissions for ACS conditions feature prominently in Australia’s National Health Performance Framework and have been used to assess health care provision for marginalized groups, such as Indigenous patients or those of lower socioeconomic status. They have not been applied to people with mental illness.

Methods:

A population-based, record-linkage analysis was used to measure ACS admissions for physical disorder in psychiatric patients of state-based facilities in Queensland, Australia, during 5 years.

Results:

There were 77 435 males (48.0%) and 83 783 females (52%) (total n = 161 218). Among these, 13 219 psychiatric patients (8.2%) had at least 1 ACS admission, the most common being for diabetes (n = 6086) and angina (n = 2620). Age-standardized rates were double those of the general population. Within the psychiatric group, and after adjusting for confounders, those who had ever been psychiatric inpatients experienced the highest rates of ACS admissions, especially for diabetes.

Conclusions:

In common with other marginalized groups, psychiatric patients have increased ACS admissions. Therefore, this measure could be used as an indicator of difficulties in access to appropriate primary care in Canada, given the availability of similar administrative data.     

Psychiatric Liaison Referral of Elderly Inpatient in a Medical School Hospital

Abstract: A retrospective study of elderly inpatient referral was carried out at Saga Medical School Hospital in order to assess the effectiveness of consultation-liaison service. A total of 51 patients aged 65 and over were referred to the Psychiatric Department. Their referral rate, clinical characteristic, diagnosis and psychiatric recommendation were reviewed from the records. A comparison of various aspects concerning the referral for the periods before and after the installation of an effective psychiatric consultation-liaison service showed a mild change. The striking finding was that the referral rate increased significantly for male patients under 75 years of age.     

Psychiatric comorbidity in older adults with bipolar disorder

INTRODUCTION: Comorbidity patterns and correlates among older adults with bipolar disorder (BPD) are not well understood. The aim of this analysis was to examine the prevalence of comorbid PTSD and other anxiety disorders, substance abuse and dementia in a population of 16,330 geriatric patients with BPD in a Veterans Health Administration administrative database. METHODS: Patients were identified from case registry files during Federal Fiscal Year 2001(FY01). Comorbidity groups were compared on selected clinical characteristics, inpatient and outpatient health resource use, and costs of care. RESULTS: Four thousand six hundred and sixty-eight geriatric veterans with BPD were comorbid for either substance abuse, PTSD and other anxiety disorder, or dementia (28.6% of all veterans with BPD age 60 or older). Mean age of all veterans in the four comorbidity groups was 70.0 years (+/-SD 7.2 years). Substance abuse was seen in 1,460 (8.9%) of elderly veterans with BPD, while PTSD was seen in 875 (5.4%), other anxiety disorders in 1592 (9.7%), and dementia in 741 (4.5%) of elderly veterans. Individuals with substance abuse in this elderly bipolar population are more likely to be younger, minority, unmarried and homeless compared to elderly bipolar populations with anxiety disorders or dementia. Inpatient use was greatest among geriatric veterans with BPD and dementia compared to veterans with BPD and other comorbid conditions. CONCLUSION: Clinical characteristics, health resource use and healthcare costs differ among geriatric patients with BPD and comorbid anxiety, substance abuse or dementia. Additional research is needed to better understand presentation of illness and modifiable factors that may influence outcomes.     

Psychiatric comorbidity in a population of Parkinson''s disease patients

Behavioural disturbances are frequently observed in Parkinson's disease (PD), including mood and anxiety disorders. The existence of a comorbidity between such psychiatric disorders in PD patients has been suggested only in a few studies. To assess the prevalence of mood and anxiety disturbances, and the rate of comorbidity of such disorders in PD. Secondary aim was to correlate the prevalence of psychiatric disorders in PD with age, sex, laterality of motor symptomatology, clinical features, severity of disease, age of onset and PD duration, and anti-parkinsonian therapy. Ninety consecutive PD outpatients, and 90 age- and sex-matched controls were included. All PD patients enrolled were non-fluctuating (21 de novo, 69 treated with levodopa or dopamine agonists). PD patients and controls with Mini Mental State Examination score <23 were excluded. Psychiatric diagnosis was performed by semistructured interview according with DSM-IV criteria and the severity of depressive and anxious symptoms was rated with clinical rating scales. Major depression was found in 21.1% PD patients vs. 3.3% controls (P < 0.01, chi-square analysis), dystimia in 18.8% PD patients vs. 4.4% controls (P < 0.05), panic disorders in 30% PD patients vs. 5.5% controls (P < 0.01). No difference in the prevalence of other anxiety disorders was observed between the two groups. The comorbidity of mood and anxiety disorders was found in 19.3% PD patients vs. 8.6% controls (P < 0.01). No correlation was reported between the prevalence of behavioural disturbances and any of the demographic, clinical or pharmacological data taken into account. Our findings might suggest the existence of a wide spectrum of psychiatric disorders in PD ranging from pure depressive disorders, comorbid depressive and anxiety disorders, and pure anxiety disorders, presumably linked to the same neurobiological substrate.     

Suicide Risk Among Holocaust Survivors Following Psychiatric Hospitalizations: A Historic Cohort Study

The association between Holocaust experience, suicide, and psychiatric hospitalization has not been unequivocally established. The aim of this study was to determine the risk of suicide among 3 Jewish groups with past or current psychiatric hospitalizations: Holocaust survivors (HS), survivors of pre-Holocaust persecution (early HS), and a comparison group of similar European background who did not experience Holocaust persecution. In a retrospective cohort study based on the Israel National Psychiatric Case Register (NPCR) and the database of causes of death, all suicides in the years 1981–2009 were found for HS (n?=?16,406), early HS (n?=?1,212) and a comparison group (n?=?4,286). Age adjusted suicide rates were calculated for the 3 groups and a logistic regression model was built to assess the suicide risk, controlling for demographic and clinical variables. The number of completed suicides in the study period was: HS—233 (1.4%), early HS—34 (2.8%), and the comparison group—64 (1.5%). Age adjusted rates were 106.7 (95% CI 93.0–120.5) per 100,000 person-years for HS, 231.0 (95% CI 157.0–327.9) for early HS and 150.7 (95% CI 113.2–196.6) for comparisons. The regression models showed significantly higher risk for the early HS versus comparisons (multivariate model adjusted OR?=?1.68, 95% CI 1.09–2.60), but not for the HS versus comparisons. These results may indicate higher resilience among the survivors of maximal adversity compared to others who experienced lesser persecution.     

Bipolar disorder and comorbid alcoholism: prevalence rate and treatment considerations

Classic Kraepelian observations and contemporary epidemiological studies have noted a high prevalence rate between bipolar disorder and alcoholism. The extent to which these two illnesses are comorbid (i.e., two distinct disease processes each with an independent course of illness), genetically linked, or different phenotypic expressions of bipolar illness itself continues to be investigated. It is increasingly clear that co-occurring alcohol abuse or dependence in bipolar disorder phenomenologically changes the illness presentation with higher rates of mixed or dysphoric mania, rapid cycling, increased symptom severity, and higher levels of novelty seeking, suicidality, aggressivity, and impulsivity. It is very encouraging that interest and efforts at evaluating pharmacotherapeutic compounds has substantially increased over the past few years in this difficult-to-treat patient population. This article will review the clinical studies that have evaluated the effectiveness of conventional mood stabilizers (lithium, carbamazepine, divalproex, and atypical antipsychotics) in the treatment of alcohol withdrawal and relapse prevention in patients with alcoholism and in the treatment of bipolar disorder with comorbid alcoholism. A number of add-on, adjunctive medications, such as naltrexone, acamprosate, topiramate, and the atypical antipsychotics quetiapine and clozapine, may be candidates for further testing.     

Psychiatric symptoms/syndromes in elderly persons with mild cognitive impairment. Data from a cross-sectional study

Objective – This study examined the prevalence of psychiatric syndromes and symptoms in elderly persons with mild cognitive impairment (MCI).
Methods – Data from a population-based study (the Kungsholmen Project) were used. All subjects with a Mini-Mental State Examination (MMSE) score ≤23 and a comparable random of those ≥24 were selected for further examination. Physicians carefully examined the included persons and those affected with dementia were excluded. The rest were stratified into 14 groups according to age and level of education. The mean MMSE score was calculated for each group and those subjects with scores 1SD below the age- and education-specific mean were classified as MCI. A structured psychiatric interview was performed and diagnoses of depression, anxiety and psychosis were made according to DSM-III-R.
Results – Being suspicious was the only symptom and being affected by an anxiety syndrome was the only diagnosis found to be associated with MCI. The association with suspiciousness might reflect the feeling of losing control that probably accompanies the loss of cognitive function experienced by the person. The association with anxiety syndromes might be a result of the fact that physical disorders have been reported to be more common in persons with cognitive impairment, as well as in persons with anxiety syndromes.
Conclusion – The results of this study suggest that the psychiatric syndromes present in MCI might be related to MCI per se . Additionally, it might reflect a developing dementia or a concomitant physical disorder.     

Service delivery in older patients with bipolar disorder: a review and development of a medical care model

Objectives:  Medical comorbidities, especially cardiovascular disease (CVD), occur disproportionately in older patients with bipolar disorder. We describe the development, implementation, and feasibility/tolerability results of a manual-based medical care model (BCM) designed to improve medical outcomes in older patients with bipolar disorder.
Methods:  The BCM consisted of (i) self-management sessions focused on bipolar disorder symptom control, healthy habits, and provider engagement, (ii) telephone care management to coordinate care and reinforce self-management goals, and (iii) guideline dissemination focused on medical issues in bipolar disorder. Older patients with bipolar disorder and a CVD-related risk factor (n = 58) were consented, enrolled, and randomized to receive BCM or usual care.
Results:  Baseline assessment (mean age = 55, 9% female, 9% African American) revealed a vulnerable population: 21% were substance users, 31% relied on public transportation, and 22% reported problems accessing medical care. Evaluation of BCM feasibility revealed high overall patient satisfaction with the intervention, high fidelity (e.g., majority of self-management sessions and follow-up contacts completed), and good tolerability (dropout rate <5%). Use of telephone contacts may have mitigated barriers to medical care (e.g., transportation).
Conclusions:  The BCM is a feasible model for older, medically ill patients with bipolar disorder, and could be an alternative to more costly treatment models that involve co-location and/or additional hiring of medical providers in mental health clinics. Future research directions pertinent to the development of the BCM and other medical care models for older patients with bipolar disorder include assessment of their long-term effects on physical health and their cost-effectiveness across different treatment settings.     

Bipolar obsessive-compulsive disorder and personality disorders

OBJECTIVES: Relatively few systematic data exist on the clinical impact of bipolar comorbidity in obsessive-compulsive disorder (OCD) and no studies have investigated the influence of such a comorbidity on the prevalence and pattern of Axis II comorbidity. The aim of the present study was to explore the comorbidity of personality disorders in a group of patients with OCD and comorbid bipolar disorder (BD). METHODS: The sample consisted of 204 subjects with a principal diagnosis of OCD (DSM-IV) and a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score>or=16 recruited from all patients consecutively referred to the Anxiety and Mood Disorders Unit, Department of Neuroscience, University of Turin over a period of 5 years (January 1998-December 2002). Diagnostic evaluation and Axis I comorbidities were collected by means of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Personality status was assessed by using the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). Socio-demographic and clinical features (including Axis II comorbidities) were compared between OCD patients with and without a lifetime comorbidity of BD. RESULTS: A total of 21 patients with OCD (10.3%) met DSM-IV criteria for a lifetime BD diagnosis: 4 (2.0%) with BD type I and 17 (8.3%) with BD type II. Those without a BD diagnosis showed significantly higher rates of male gender, sexual and hoarding obsessions, repeating compulsions and lifetime comorbid substance use disorders, when compared with patients with BD/OCD. With regard to personality disorders, those with BD/OCD showed higher prevalence rates of Cluster A (42.9% versus 21.3%; p=0.027) and Cluster B (57.1% versus 29.0%; p=0.009) personality disorders. Narcissistic and antisocial personality disorders were more frequent in BD/OCD. CONCLUSIONS: Our results point towards clinically relevant effects of comorbid BD on the personality profiles of OCD patients, with higher rates of narcissistic and antisocial personality disorders in BD/OCD patients.     

Precipitants of Elderly Psychiatric Patient Assaults on Staff: Preliminary Empirical Inquiry

Although there have been several studies of the characteristics of psychiatric patient assailants, there have been only six comprehensive, empirical assessments of precipitants to these assaults and no precipitant study has focused solely on elderly psychiatric patient assailants. This one and one-half year, retrospective study continued the inquiry into the nature of patient assault precipitants and focused only on elderly assailants. Older, male patients with a diagnosis of schizophrenia and histories of violence toward others and substance use disorder physically assaulted primarily male, mental health workers. These staff victims experienced disruptions in the domains of mastery, attachment, and meaning as well as the symptomatology associated with psychological trauma. The most common precipitants to these assaults were denial of services and acute psychosis. The findings and implications for health care providers in long-term care settings where elderly psychiatric patients reside are discussed.     

Psychiatric Disorder and Unmet Service Needs Among Welfare Clients in a Representative Payee Program

This study assessed psychiatric problems, needs for psychiatric and social services, and service utilization among clients of a public assistance program. Sixty-five clients were assessed using a structured clinical interview to determine the presence of a psychiatric disorder (using the CIDI-A), extent of social service need, and health-related quality of life (RAND SF-36). Seventy-seven percent of the sample met criteria for at least one current or lifetime psychiatric disorder. Health-related quality of life was substantially below published norms. Most clients reported needing financial, housing, and vocational assistance. Many had contact with mental health services, but few were actually receiving psychiatric treatment. Although many clients were assessed as having serious psychiatric, physical, or social needs, very few were receiving appropriate services for these problems. Findings suggest problems or barriers to the provision of services that need to be investigated among this vulnerable community population.     

The association of a heart attack or stroke with depressive symptoms stratified by the presence of a close social contact: findings from the National Health and Aging Trends Study Cohort

Objective

The objective of the study is to examine whether the risk of having clinically significant depressive symptoms following a heart attack or stroke varies by the presence of a close social contact.

Methods

The National Health and Aging Trends Study is a nationally representative longitudinal survey of US Medicare beneficiaries aged 65 and older initiated in 2011. A total of 5643 older adults had information on social contacts at baseline and depressive symptoms at the 1‐year follow‐up interview. The two‐item Patient Health Questionnaire identified clinically significant depressive symptoms. Interview questions examined social contacts and the presence of self‐reported heart attack or stroke during the year of follow‐up.

Results

A total of 297 older adults reported experiencing a heart attack and/or stroke between their baseline and follow‐up interviews. In regression analyses accounting for sociodemographics, baseline depressive symptoms, medical comorbidity, and activities of daily living impairment, older adults with no close social contacts had increased odds of depressive symptoms at follow‐up after experiencing a heart attack or stroke, while those with close social contacts had increased odds of depressive symptoms at follow‐up after experiencing a stroke, but not a heart attack.

Conclusions

Older adults have increased odds of having depressive symptoms following a self‐reported stroke, but only those with no close social contacts had increased odds of depressive symptoms following a heart attack. Social networks may play a role in the mechanisms underlying depression among older adults experiencing certain acute health events. Future work exploring the potential causal relationships suggested here, if confirmed, could inform interventions to alleviate or prevent depression among at risk older adults. Copyright © 2017 John Wiley & Sons, Ltd.