Irritable psychomotor elation in depressed inpatients: a factor validation of mixed depression

BACKGROUND: Early authors described hypomanic symptoms as mixed features in depressive episode, but this syndrome has not been sufficiently explored in previous studies. METHODS: 958 consecutive depressed patients were assessed by using a standardized method in terms of 43 psychiatric symptoms at hospitalization. RESULTS: A principal component analysis, followed by varimax rotation, extracted six interpretable factors: typical vegetative symptoms, depressive retardation/loss of feeling, hypomanic syndrome, anxiety, psychosis, and depressive mood/hopelessness. The extracted factor structure was relatively stable among several patient groups. There was no evidence that the hypomanic factor was exaggerated by antidepressant pretreatments before hospitalization. Bipolar diagnoses were associated with higher scores on depressive retardation and hypomanic symptoms, and a lower score on anxiety. LIMITATIONS: Psychiatric syndromes and their interrelationships, found in the present study, may be strongly influenced by the rating instrument used. The sample of this study was depressed inpatients. The results should not be generalized for depressed outpatients or epidemiological depressed populations. CONCLUSIONS: Hypomanic symptoms, as characterized by the flight of ideas, racing thought, increased drive, excessive social contact, irritability, and aggression are a salient syndrome in acutely ill depressed patients, lending support to the factor validity of mixed depression. The symptoms may not be related to pretreatments with antidepressants, or comorbidity of substance abuse, suggesting that they reflect various natural phenomenological manifestations of depressive episodes. Anxiety is unlikely to play a major role in the core phenomenological features of mixed depression. Hypomanic symptoms during a depressive episode were more represented in bipolar disorders, which may serve for further clarifications of latent bipolarity in unipolar depression, and prediction of switch into maniform states under biological depression treatments.     

Letter: Myocardial infarction and estrogen therapy in premenopausal women.

This letter was written in response to the paper by Mann et al. (British Medical Journal 2: 241-245, 1975) which reported an association between oral contraceptive (OC) use and acute myocardial infarction. Rosenberg et al. found that among 34 patients with myocardial infarction, 4 were current users of OCs and 2 used other estrogen-containing drugs. Among 1213 reference women the use was 79 and 26, respectively. The "relative risk" for OC users was 1.9 (95% confidence interval) and for other estrogen users it was 2.8 as compared with nonusers. When standardized for age these estimates became 2.2 and 2.1 and when standardized for the effects of cigarette smoking, history of hypertension, angina, and/ or diabetes the summary rate-ratio estimate for OC users decreased to 1.3 and left essentially unchanged the estimate for other estrogen users. These results are compatible with a modest increase, if any, in risk of myocardial infarction in premenopausal women associated with estrogen use, such as that reported by Mann et al.     

Hysterectomy and oophorectomy are unrelated to bone loss in older women

OBJECTIVE: The relation of hysterectomy and oophorectomy to change in bone mineral density (BMD) was examined in older women using and not using estrogen replacement therapy (ERT). METHODS: Women aged 60-80 years from the Rancho Bernardo Study attended clinic visits in 1988-1991 and 1992-1995 when hysterectomy and oophorectomy were ascertained, ERT use was validated and spine and hip BMD was assessed at both visits with DEXA. Women were either current ERT users or nonusers at both visits. RESULTS: Among these 447 women, average age was 71 (S.D.=9.0); average years postmenopause was 24.7 (S.D.=10.9). Overall, 122 had a hysterectomy with ovarian conservation and 91 had a hysterectomy with bilateral oophorectomy; 41% reported current ERT use for an average duration of 19.1 years (S.D.=10.8). Hysterectomized women were 2.3 times more likely to report ERT use than intact women (P<0.001). Comparisons adjusted for age, obesity, and age at menopause but not for ERT use showed hysterectomized women had less bone loss per year at the hip than intact women (P<0.05). However, this difference was explained by ERT; after adjustment for ERT, mean hip bone loss per year was -0.57% for intact women, -0.42% for hysterectomized women with ovarian conservation and -0.32% for bilaterally oophorectomized women (P's>0.10). There were no differences by hysterectomy or oophorectomy in bone loss at the spine or femoral neck. For all sites, women using ERT had higher BMD at both visits than nonusers (P's<0.001). Stratification by ERT showed that within users and nonusers, there were no differences in BMD or bone loss at any site by hysterectomy or oophorectomy. CONCLUSIONS: There are no long term effects of hysterectomy and bilateral oophorectomy on bone loss. Women who use ERT have better BMD than nonusers.     

Body composition and dietary intake in relation to drug abuse in a cohort of HIV-positive persons

We examined the relationships between drug abuse, weight, body composition, and dietary intake in persons infected with HIV in a cross-sectional analysis of baseline data from a longitudinal study of nutritional status and HIV. Body composition was measured by bioelectrical impedance analysis. Dietary data were collected by 3-day food records or 24-hour recalls. We analyzed data from 39 current intravenous drug users (IVDU), 103 past intravenous drug users (past-IVDU), 239 users of nonintravenous drugs (users-NIVD), and 61 nonusers (reference category). In the men, there were no differences in weight, body mass index (BMI), or body composition among the drug-use groups. In the women, there was a trend to lower weight and BMI across the drug use categories: IVDU women had lower average weight (-13.7 kg; p = .006), BMI (-5.6 units; p = .003) and less fat mass than non-users (-9.8 kg; p = .0001). In women, drug users had higher weight-adjusted energy intakes than nonusers, whereas in the men both drug using groups, NIVD and IVDU, had higher energy intakes than nonusers. These data suggest that intravenous drug-abuse is associated with lower weight and fat mass in women with HIV infection despite adequate self-reported energy intake.     

Cytohormonal and morphological alterations in cervicovaginal smears of postmenopausal women on hormone replacement therapy

The objective of the study was to study the cytohormonal and morphological alterations in cervicovaginal smears associated with the use of hormone replacement therapy (HRT) and to assess the utility of vaginal cytology in determining the response to HRT. Ninety postmenopausal women (30 on estrogen-progesterone combination (HRT) for 1 to 24 mo (user 1), 30 on estrogen therapy (ERT) for 1 to 44 mo (user 2), and 30 not on any hormones (nonusers)) were included in the cross-sectional study. Their lateral vaginal wall smears and cervical smears were examined for hormonal and morphological assessments, respectively. The smear pattern showed predominance of parabasal cells in 46.6% of nonusers, while none of the users had >70% parabasal cells. A high percentage (>70%) of intermediate cells was found in 46.6% of users and only in 16.6% of nonusers. A high maturation value (MV) was found in more than 75% of users but in only 16.6% of nonusers. The women with high MV (>50) were significantly less symptomatic than did nonusers. Atrophic changes were present in cervical smears of 14/20 (46.6%) nonusers when compared with 1/60 (1.66%) users. Atypical squamous cells of undetermined significance (ASC-US) were diagnosed in seven users and three nonusers. It persisted on follow-up in four users and one nonuser. Histology revealed one mild dysplasia among users. Lactobacilli were more frequently observed in users. The cytohormonal pattern on vaginal smears correlates well with the response to hormonal therapy and clinical symptoms. Awareness of the morphological alterations associated with the use of replacement hormones would enable the cytologists to reduce the false-positive diagnoses while evaluating postmenopausal smears.     

Hormone replacement therapy in Germany: determinants and possible health-related outcomes. Results of National Health Surveys from 1984 to 1999

OBJECTIVES: To explore the determinants of hormone replacement therapy (HRT) use and possible health-related outcomes in Germany. METHODS: 827 current HRT users (age range 31-78 years, who had taken HRT products in the last 7 days before the medical interview) and 2371 age-matched nonusers were identified from five population-representative National Health Surveys performed from 1984 to 1999 in Germany. Cross-sectional comparisons between HRT users and nonusers were performed for socioeconomic factors and possible health-related outcomes. Regression models were used to obtain odds ratios of HRT use. RESULTS: HRT use increased dramatically from 3% in 1984/1985 to 21% in 1998/1999 among German women aged 40-69. Regression analysis and comparison between HRT users and nonusers suggested that HRT use was closely associated with socioeconomic factors and personal lifestyle that may favor better health. In HRT users, however, we did not observe any health-related benefits in satisfaction with life or health. While HRT users appeared superior to nonusers with respect to the glycemic status, histories of cardiovascular diseases, despite a favorable lipid profile, occurred not less than in the group of nonusers. CONCLUSIONS: In the settings of our cross-sectional studies in Germany HRT did not improve users' health benefits and did not show cardioprotective effects. The better glycemic status should be balanced against the higher risks of cardiovascular diseases and breast cancer.     

Possible involvement of endorphin withdrawal or imbalance in specific premenstrual syndromes and postpartum depression

Premenstrual and postpartum dysphoric changes are very prevalent. However, their etiology is still obscure. The authors hypothesize that changes in levels of endorphins may be involved in the pathophysiology of these changes. Studies of various endorphins indicate a possible relationship between levels of endorphins and depressive symptoms. In addition, some studies of naloxone and naltrexone suggest a relationship between a blockage in the action of endorphins and the development of a syndrome of dysphoric symptoms similar to the depressive features manifested premenstrually and postpartum by many women and frequently seen in some depressed outpatients. There is also some evidence that there may be a relationship between elevated levels of endorphins and other subtypes of depressive syndromes. Endorphins and estrogen levels have been shown to covary. During the postpartum and the premenstrual period, levels of both change rapidly and substantially. Therefore the link between changes in levels of endorphins and the dysphoric changes during the periods in focus is supported from three complementary directions: (1) the characteristic psychiatric symptomatology, (2) the reported hormonal changes, and (3) the possible involvement of endorphins in neuroendocrine regulation.     

Mental health treatments and associated factors amongst mid-aged Melbourne women

Summary The aim of this study was to describe lifetime treatment rate and the treatment modalities used for psychiatric problems and to identify variables associated with the history of psychiatric treatment among mid-aged Melbourne women. A longitudinal observational study was carried out using a population-based sample of 438 mid-aged women interviewed annually for eight years. The baseline data on sociodemographic profiles and premenstrual symptoms, and history of exposure to violence obtained at year 6 were included in this analysis. All other variables including psychiatric treatment history, psychosocial and lifestyle variables, chronic medical conditions and mood score were obtained at year 8. We found 22.2% of the women in this study had ever taken psychotropic medication. Antidepressants were the most used drugs. History of hospitalization for psychiatric problems was reported by 15 women (3.9%). 27 of 387 women (7%) reported they had received other types of treatment for psychiatric problems such as counseling or psychotherapy. Of all variables taken from the questionnaire about the treatment, only the history of psychotropic medication had a high enough frequency for regression analysis. History of psychotropic drug use was associated with interpersonal stresses, poor self-rated health, and prior history of depressive change during the premenstrual period. Socio-demographic variables, exposure to violence, lifestyle factors, and chronic physical conditions were not associated with psychotropic drug use.     

Effect of hard-drug use on CD4 cell percentage, HIV RNA level, and progression to AIDS-defining class C events among HIV-infected women

In vitro and animal studies suggest that cocaine and heroin increase HIV replication and suppress immune function, whereas epidemiologic studies are inconclusive regarding their effect on HIV infection progression. The authors prospectively examined the association between illicit-drug use and 4 outcome measures (CD4 cell percentage, HIV RNA level, survival to class C diagnosis of HIV infection, and death) in a national cohort of HIV-infected women. Women enrolled between 1989 and 1995 were followed for 5 years and repeatedly interviewed about illicit ("hard")--drug use. Up to 3 periodic urine screens validated self-reported use. Outcomes were compared between hard-drug users (women using cocaine, heroin, methadone, or injecting drugs) and nonusers, adjusting for age, antiretroviral therapy, number of pregnancies, smoking, and baseline CD4 cell percentage. Of 1148 women, 40% reported baseline hard-drug use during pregnancy. In multivariate analyses, hard-drug use was not associated with change in CD4 cell percentage (P = 0.84), HIV RNA level (P = 0.48), or all-cause mortality (relative hazard = 1.10; 95% confidence interval, 0.61-1.98). Hard-drug users did, however, exhibit a higher risk of developing class C diagnoses (relative hazard = 1.65; 95% confidence interval, 1.00-2.72), especially herpes, pulmonary tuberculosis, and recurrent pneumonia. Hard-drug-using women may have a higher risk for nonfatal opportunistic infections.     

Anabolic steroid use in the adolescent athlete

Recent surveys indicate that the use of androgenic-anabolic steroids (anabolic steroids) is prevalent among adolescent athletes, particularly those in high school. The cost of clinical drug testing makes it impractical to use random testing to identify users of these ergogenic aids. The athletic trainer is often in a position to identify anabolic steroid users if he/she knows the clinical signs and symptoms. In this article, we briefly discuss the history of anabolic steroid use, how they work, their potentially dangerous side effects, evidence of increased use by adolescent athletes, and a list of clinical signs and symptoms. Finally, we suggest strategies that may help athletic trainers counsel athletes about anabolic steroid use.     

Psychosocial factors associated with the use of hormonal replacement therapy in a longitudinal follow-up of Swedish women

Objectives: To follow up a cohort of 1400 women aged 52 years who had replied to a health questionnaire 4 years previously. The follow-up covered general and gynecological health, experience of symptoms, the use of hormone replacement, the reasons for starting HRT and effectiveness of treatment as well as comparison of users and nonusers concerning psychosocial factors and life style. Methods: A questionnaire together with a letter was mailed to the women who had responded previously. The questionnaire covered four different areas: sociodemographic background, general and gynecological health, a 20-item symptom rating scale, and questions concerning work role. Results: A total of 1194 women (85%) responded to the questionnaire; 40% of the women were currently using hormone replacement. The reasons for starting treatment were: relief of somatic (55%) and psychological symptoms (20%), increased wellbeing (5%), to prevent disease (5%) and other reasons,such as keeping young (15%). Positive effects were experienced by 86% and negative effects by 26%. Women using HRT had less frequent vasomotor symptoms, sleep problems and vaginal dryness and were more harmonious than nonusers. There were no differences between HRT users and nonusers regarding negative mood and sexual desire. Women with psychologically demanding and stressful jobs requiring concentration were more likely to use hormone replacement. Conclusions: Swedish women are increasingly willing to start hormone replacement, particularly those who suffer from vasomotor symptoms and who have stressful and psychologically demanding occupations. The majority of these experience relief of symptoms. A certain proportion will suffer from side effects and are likely to discontinue treatment.     

Effects of anabolic androgenic steroids on sleep patterns of individuals practicing resistance exercise

Anabolic androgenic steroid (AAS) abuse has become a public health problem in many countries, and is associated with many psychiatric disorders. Epidemiological studies have also found increasing numbers of sleep disorders reported by individuals using AASs. The purpose of this study was to evaluate sleep patterns and disorders in anabolic androgenic users who practice resistance exercise. The sample comprised 58 males divided into three groups: (1) 20 current AAS users aged 26 ± 1.2, (2) 21 controls with no history of AAS use, aged 26 ± 1 and (3) 17 sedentary men with no sleep disorders aged 27.2 ± 0.34. The volunteers spent a night in the sleep laboratory for polysomnography. Comparing the three groups, the user group showed reduced sleep efficiency and more wakings after sleep onset than the sedentary group (P = 0.001). The sedentary group showed a higher percentage of stage 4 than the non-users group. We suggest that using of anabolic steroids reduced sleep efficiency and alters sleep architecture.     

Use of smokeless tobacco in a group of professional baseball players

This paper describes the smokeless tobacco use practices and oral health problems of members of a minor league professional baseball team. Seventeen of 25 ballplayers reported current use of smokeless tobacco. Gingival recession and lesions in the oral mucosa were more common in smokeless tobacco users than nonusers. Reported use of smokeless tobacco was greater during baseball season than in the off-season. Of the 19 current and past users, 15 reported first using smokeless tobacco after entering professional baseball. To discourage the use of smokeless tobacco by professional athletes, teams should stop accepting free samples and do a better job educating players about health consequences associated with use.     

Treatment resistance in unipolar depression: Is it an iatrogenic phenomenon caused by antidepressant treatment of patients with a bipolar diathesis?

Major depressive disorder is a common psychiatric illness that is considered generally treatable; however, there are some patients who fail to respond in spite of adequate trials of antidepressants. Clinical factors known to contribute to treatment resistance include psychiatric and physical comorbidity, undiagnosed bipolarity, and treatment non-adherence. There is also emerging evidence that the use of antidepressants in some 'unipolar' patients may lead to a pattern of progressive diminution of therapeutic response and ultimately treatment resistance. A large number of these patients may have a bipolar diathesis even though there are no symptoms of hypomanic, manic or mixed episodes. It is hypothesized that the widespread and injudicious use of antidepressants in patients with a bipolar diathesis might result in treatment-induced resistant depression. Furthermore, attempts to manage the antidepressant-led mood instability might cause increased utilisation of other psychotropic drugs including sedative/hypnotics, neuroleptics and mood stabilisers and contribute to polypharmacotherapy.     

Appropriateness of drugs prescribed by primary care physicians for depressed outpatients.

In a sample of middle class individuals seeking martial and sexual counseling, 30% had diagnosable psychiatric illness, including 14% who had depressions at the time of interview. Those with psychiatric syndromes were significantly more likely to have prescribed psychoactive than those without these syndromes. Those with depression were more likely to have received diazepam and similar drugs than antidepressants. The same was true for those with other syndromes but in many of these cases, diazepam or other antianxiety agents seemed more appropriate. Thus, affective disorder might well be the psychiatric syndrome for which these drugs are most often inappropriately prescribed. Inappropriate treatment is a matter of concern in an illness which is potentially fatal.     

A prospective study of thoughts of self-harm and suicidal ideation during the postpartum period in women with mood disorders

Individuals with mood disorders are at higher risk for self-harm and suicidal ideation than other psychiatric group. However, the risk of self-harm and suicidal ideation after pregnancy for women with mood disorders is unknown. This investigation assessed the prevalence of thoughts of self-harm and suicidal ideation during the 1-year postpartum period in women with major depressive disorder or bipolar II disorder. Data were collected between June 2005 and March 2010 from a convenience sample of women participating in a study on the course of mood disorders during pregnancy and postpartum. Participant diagnosis was confirmed using the Structured Clinical Interview for DSM-IV. Thoughts of self-harm were assessed using the Edinburgh Postnatal Depression Scale item 10 and suicidal ideation was assessed using the Hamilton Depression Rating Scale item 3. During the 1-year postpartum period, 16.97 % reported thoughts of self-harm while 6.16 % reported suicidal ideation. Further, those reporting thoughts of self-harm or suicidal ideation postpartum also reported higher levels of depression and hypomanic symptoms. We found that a number of women in our sample of women with a diagnosed mood disorder report experiencing thoughts of self-harm and suicidal ideation during the postpartum.