Repetition of overdose: a retrospective 5-year study

This study investigated the number, timing and disposal (admission or discharge) of patients repeating an overdose who attended the accident and emergency department of a district general hospital during a 5-year period. There was a total of 1958 overdoses by 1597 individuals over the 5-year period. Overdoses were repeated by 12% (n = 191) of patients and accounted for 552 of the total overdoses (representing 361 repeats). First repeats were found to occur more frequently in the 3 months following the original overdose for 43% of patients, 70% of repetitions occurring within a year. The distribution of first repeats showed a similar pattern for males and females. During the 5-year period 49% of all repetitions occurred within 3 months. Almost one-fifth of repeaters were discharged, irrespective of whether it was the patient's 'index' (first overdose within the study period) or a repeat overdose. Within the repeater population, 31% of overdoses occurred on a Friday, Saturday and on, or immediately prior to, a Bank Holiday. Since there was no on-site psychiatric service available at such times, those patients had to wait until the next working day for assessment. The study recommends that all overdose patients should receive psychiatric assessment, and therefore on-site psychiatric services should be available for accident and emergency patients.     

Clinical study of the relation of borderline personality disorder to Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders

OBJECTIVE: The criteria for borderline personality disorder seem to select patients with very high rates of Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders. This study was undertaken to determine whether systematic assessment of patients with borderline personality disorder would reveal characteristic features of that condition which would distinguish it from these other disorders. METHOD: Eighty-seven white female patients (75 in St. Louis and 12 in Milan, Italy) who had borderline personality disorder according to both the DSM-III-R criteria and the Revised Diagnostic Interview for Borderlines were further examined with the DSM-III-R Checklist and the Perley-Guze Hysteria Checklist to determine their patterns of psychiatric comorbidity. RESULTS: Every patient had at least one additional DSM diagnosis. Patients in St. Louis and Milan averaged five and four additional diagnoses, respectively. Eighty-four percent of the patients in St. Louis met criteria for either somatization disorder, Briquet's syndrome, antisocial personality disorder, or substance abuse disorders. Patterns of comorbidity for panic (51%), generalized anxiety disorder (55%), and major depression (87%) in St. Louis were consistent with those in other studies. CONCLUSIONS: The data indicate that the boundaries for the borderline condition are not specific and identify a high percentage of patients with these other disorders. Furthermore, the comorbidity profiles closely resemble the psychiatric profiles of patients with these disorders. If the borderline syndrome is meant to include all of these disorders, its usefulness as a diagnosis is limited. Until the fundamental features of borderline personality disorder that distinguish it from the others are identified, it is recommended that clinicians carefully assess patients for these other diagnoses. Efforts should be made to change the borderline personality disorder criteria by shifting away from overlap with the criteria for the other disorders.     

Antidepressant overdoses and resultant emergency department services: the impact of SSRIs

Suicide is a major source of morbidity and mortality in patients with mental illness. The selective serotonin reuptake inhibitors (SSRIs) and other newer nontricyclic antidepressants appear to have less clinically significant toxicity in overdose, resulting in lower costs of treatment when compared with tricyclic antidepressant (TCA) overdoses. The resource utilization and cost of treatment for SSRI overdoses may not be less if (1) these agents are commonly ingested with other potentially toxic substances, or (2) health care practices have not changed in response to the apparent greater safety of SSRIs. This study evaluates demographic variables of antidepressant overdoses to determine whether differences exist in treatments and monitoring. Additionally, this study evaluates costs associated with care and the impact of co-ingestants on those same factors.     

Dysthymia in the offspring of parents with primary unipolar affective disorder.

This study examined whether there is a familial relation between primary early-onset dysthymia and major affective disorder. In addition, it explored the prevalence of other forms of psychopathology and social impairment in the adolescent and young adult offspring of patients with primary unipolar affective disorder. Subjects included 47 offspring of patients with primary unipolar depression, 33 offspring of patients with chronic orthopedic and rheumatological conditions, and 38 offspring of randomly selected community controls with no personal or family history of psychiatric disorder. All offspring received structured diagnostic interviews. Diagnoses were derived blind to parental group by using multiple sets of diagnostic criteria. The offspring of unipolar patients exhibited significantly higher rates of affective disorder, major depression, and dysthymia than did the offspring of medical and normal controls. The groups did not differ on rates of nonaffective disorders. Parental characteristics associated with dysthymia in offspring included chronic depression, age of onset of major depression, number of hospitalizations, and multiple family members with major affective illness. These results support the view that at least some forms of early-onset dysthymia are variants of major affective illness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship of current psychiatric disorder to functional disability and distress in patients with inflammatory bowel disease

Although prior theories about psychiatric disorders causing inflammatory bowel disease (IBD) have largely been discredited, these same disorders have at times been associated with functional gastrointestinal symptoms such as those found in irritable bowel syndrome. Since functional gastrointestinal symptoms can also occur in patients with organic pathology, we hypothesized that a current psychiatric disorder might amplify or produce additional gastrointestinal symptoms in patients with organic gastrointestinal diseases such as IBD, leading to additive functional disability and decreased quality of life. This pilot study evaluated a sequential sample of 40 IBD patients using the NIMH Diagnostic Interview Schedule, structured interviews for functional gastrointestinal symptoms, and prior episodes of emotional, physical, and sexual abuse as well as self-report measures of personality and disability. We compared IBD patients with and without a current psychiatric disorder while controlling for disease severity. Eight patients with major depression were treated with antidepressants. Patients with a current psychiatric disorder had significantly higher 1) mean number of lifetime psychiatric diagnoses, 2) prevalence rates of prior sexual and physical victimization, and, 3) mean numbers of both gastrointestinal and other medically unexplained symptoms despite no differences in severity of IBD. Significant and trend level differences were apparent on several measures of functional disability. A regression analysis showed that number of psychiatric diagnoses, number of functional gastrointestinal symptoms, and dissociation scale scores significantly discriminated the groups. Treatment of current major depression decreased functional disability despite no objective changes in gastrointestinal disease severity. It was concluded that the presence of a current psychiatric disorder appears to alter the perception of disease severity in patients with IBD. Nonrecognition of the psychiatric disorder may lead to unnecessary and aggressive interventions for IBD patients such as medication changes, invasive testing, or surgery. The presence of a current psychiatric illness also appears to be associated with increased functional disability. Psychiatric evaluation and treatment, therefore, have an important role in the ongoing management of IBD patients with distressing gastrointestinal symptoms not directly attributable to their IBD.     

Tumor enucleation as the conservative treatment of choice for renal carcinoma

BACKGROUND: The coexistence of other psychiatric disorders in patients with bulimia nervosa is of major clinical and theoretical interest. We therefore studied a group of consecutively evaluated bulimic patients. METHOD: The Structured Clinical Interview for DSM-III-R (SCID) was administered to a sample of 59 female patients with DSM-III-R-defined bulimia nervosa. RESULTS: The following frequencies of lifetime Axis I comorbid diagnoses were found (in decreasing frequency): any affective disorder (75%), major depressive disorder (63%), any anxiety disorder (36%), any substance abuse disorder (20%), social phobia (17%), generalized anxiety disorder (12%), and panic disorder (10%). In the 44 cases with an affective disorder, 27 (61%) had the onset of affective disorder, 27 (61%) had the onset of their affective disorder prior to the onset of their bulimia, 15 (34%) afterward, and 2 (5%) concurrently. In the 21 cases with any anxiety disorder, 15 (71%) had the onset of their anxiety disorder prior to the onset of their bulimia, 4 (19%) afterward, and 2 (10%) concurrently. CONCLUSION: These data confirm previous reports of a strong association between bulimia nervosa and affective illness, which in most cases precedes the eating disorder. In addition, a high frequency of anxiety disorders, particularly social phobia, is seen in bulimic patients.     

The effect of gender and age at onset of depression on mortality

BACKGROUND: Depression has a marked negative impact on geriatric patient mortality and morbidity. The risk factors and exact reasons for these effects are not well understood. METHOD: Seeking to better define the factors, we retrospectively analyzed the effects of gender and age at onset of affective disorder in a naturalistic study of 192 geriatric patients consecutively admitted to a large midwestern tertiary care center between 1980 and 1987 for the treatment of unipolar depression. RESULTS: After controlling for age at index admission, patients with an onset of depression before age 40 suffered significantly (p < .05) less mortality in follow-up than those with onset after age 40. When effects of gender are examined, the effects of age at onset are most profound in women, with a threefold increase in the rate of death in the cohort with age at onset of depression after 70 years when compared to those with onset before age 40. CONCLUSION: These results and those of others suggest that depressed elderly women with no previous history of affective disorder are at a markedly increased risk compared with elderly women with a history of affective illness for morbidity and mortality and that a significant proportion of elderly depressed patients are admitted to a psychiatric hospital for a depression that is secondary to serious medical illness.     

Reversal of cognitive and affective deficits associated with depression and learned helplessness by mood elevation in patients

Therapeutic implications of the learned helplessness model of depression were tested in a clinical population (48 male medical and psychiatric patients of a VA hospital). In pretreatment, 2 groups of nondepressed medical patients waited, 2 groups of nondepressed medical patients received helplessness training, and 2 groups of psychiatric patients (diagnosed as primary affective disorder) waited. In treatment, Ss received either E. Velten's (1968) mood-elation procedure as "therapy" or Velten's (1968) mood-neutral procedure as placebo. Performance on cognitive and mood tasks was assessed. Three separate administrations of the Depression Adjective Check List indicated that helplessness training induced depressive affect, and the mood elation procedure decreased depressive affect for both helpless and depressed Ss. The mood neutral procedure and the waiting periods were associated with no affective changes. On the cognitive (anagrams) task, performance deficits were associated with helplessness and depression but were reversed by mood elation. Results are interpreted as consistent with the learned helplessness model of depression. (23 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Suicidal ideation and behavior and noncompliance with the medical regimen among diabetic adolescents

OBJECTIVE: To examine (1) the 1-year and lifetime prevalence of suicidal thoughts and behavior among adolescents with insulin-dependent diabetes mellitus (IDDM), (2) the relationship between suicidal thoughts and serious noncompliance with the medical regimen, and (3) factors including psychiatric disorder, self-efficacy expectations, and hopelessness that might mediate the relationship between suicidal thoughts and noncompliance. METHOD: Semistructured and structured interview instruments and self-report questionnaires were used to determine history of suicidal thoughts and behavior, serious noncompliance with the medical regimen, current psychiatric disorder, hopelessness, and self-efficacy expectations among 91 adolescents attending outpatient clinic appointments. RESULTS: The rate of suicidal ideation among the diabetic adolescents was higher than expected, but the rate of suicide attempts was comparable with that reported for the general population. Suicidal thoughts were strongly associated with serious noncompliance with the medical regimen. Duration of IDDM and psychiatric diagnosis were related to both suicidal ideation within the previous year and lifetime suicidal ideation. Diagnosable psychiatric disorder and not living in a two-parent home were related to noncompliance with medical treatment. CONCLUSIONS: Suicidal thoughts and serious noncompliance with the medical regimen are strongly associated among diabetic teenagers, and psychiatric disorder is a common correlate of both.     

Differences in psychosocial and health correlates of major and minor depression in medically ill older adults

OBJECTIVES: To compare the differences in correlates of different levels of depression in medically ill hospitalized older adults. DESIGN, SETTING, AND PARTICIPANTS: A consecutive series of 542 patients aged 60 or older admitted to the medical inpatient services of Duke Hospital underwent a structured psychiatric evaluation administered by a psychiatrist. MEASUREMENT: A wide range of demographic, social, psychiatric, and physical health data were collected, and associations with major and minor depression were assessed. RESULTS: Compared with patients without depression, those with major depression were more likely to have a history of prior episodes of depression, higher dysfunctional attitude scores, greater overall severity of medical illness, cognitive impairment, and symptoms of pain or other somatic complaints. Specific medical diagnosis was less important a predictor of major depression than overall severity of medical illness. Compared with patients without depression, those with minor depression were more likely to report non-health-related stressors during the year before hospital admission, have a diagnosis of immune system disorder, and have greater severity of medical illness. When major and minor depression were compared directly, on the other hand, no significant differences were observed except for history of depression, and that relationship was weak and present only when the etiologic approach to diagnosis was used. CONCLUSION: During hospital admission, certain psychosocial, psychiatric, and physical health characteristics of older medical patients place them at high risk for different levels of depression. Patients with major and minor depression resemble each other more than they do patients without depression. These findings may help clinicians better understand the causes of different types of depression in this setting and lead to improved diagnosis and treatment.     

Prediction of posttraumatic stress disorder by immediate reactions to trauma: a prospective study in road traffic accident victims

Road traffic accidents often cause serious physical and psychological sequelae. Specialists of various medical faculties are involved in the treatment of accident victims. Little is known about the factors which might predict psychiatric disorders, e.g. Posttraumatic Stress Disorder (PTSD) after accidents and how psychological problems influence physical treatment. In a prospective study 179 unselected, consecutively admitted road traffic accident victims were assessed a few days after the accident for psychiatric diagnoses, severity of injury and psychopathology. All were inpatients and had to be treated for bone fractures. At 6-months follow-up assessment 152 (85%) of the patients were interviewed again. Of the patients, 18.4% fulfilled the criteria for Posttraumatic Stress Disorder (DSM-III-R) within 6 months after the accident. Patients who developed PTSD were injured more severely and showed more symptoms of anxiety, depression and PTSD a few days after the accident than patients with no psychiatric diagnosis. Patients with PTSD stayed significantly longer in the hospital than the other patients. Multiple regression analysis revealed that the length of hospitalization was due mainly to a diversity of factors such as severity of injury, severity of accident, premorbid personality and psychopathology. Posttraumatic stress disorder is common after road traffic accidents. Patients with PTSD at follow-up can be identified by findings from early assessment. Untreated psychological sequelae such as PTSD cause longer hospitalization and therefore more costs than in non-PTSD patients.     

The effect of exercise training on the severity and duration of a viral upper respiratory illness

OBJECTIVE: The purpose of this study was to assess whether joint hypermobility syndrome is more frequent in patients with panic disorder, agoraphobia, or both than in control subjects and, if so, to determine whether mitral valve prolapse modifies or accounts in part for the association. METHOD: A case-control study was conducted in a general teaching hospital outpatient clinic. Subjects were 99 patients, newly diagnosed and untreated, with panic disorder, agoraphobia, or both and two groups of age- and sex-matched control subjects: 99 psychiatric patients and 64 medical patients who had never suffered from any anxiety disorder. Measures consisted of the Structured Clinical Interview for DSM-III-R, Beighton's criteria for joint hypermobility syndrome, and two-dimensional and M-mode echocardiogram. The presence of mitral valve prolapse and joint hypermobility syndrome was explored by raters who were blind to subjects' psychiatric status. RESULTS: Joint hypermobility syndrome was found in 67.7% of patients with anxiety disorder but in only 10.1% of psychiatric and 12.5% of medical control subjects. On the basis of statistical analysis, patients with anxiety disorder were over 16 times more likely than control subjects to have joint laxity. These findings were not altered after the presence of mitral valve prolapse was taken into account. Of the patients with anxiety disorder, those who had joint hypermobility syndrome were younger and more often women and had an earlier onset of the disorder than those without joint hypermobility syndrome. CONCLUSIONS: Joint laxity is highly prevalent in patients with panic disorder, agoraphobia, or both and may reflect a constitutional disposition to suffer from anxiety. Mitral valve prolapse plays a secondary role in the association between joint hypermobility and anxiety.     

Tricyclic antidepressants. Prolonged plasma levels after overdose

Twenty-four patients hospitalized for overdose of a tricyclic antidepressant were monitored clinically, and serial plasma-drug measurements were taken for up to 144 hours. Six of 24 patients had maximum antidepressant plasma levels greater than or equal to 1,000 ng/ml, and their plasma levels at 96 hours ranged from 170 to 1,280 ng/ml. Patients ingesting substantial tricyclic overdoses may remain medically unstable for days. When high tricyclic levels persist, accurate psychiatric assessment is often impossible.     

Effect of chemoradiotherapy on the pituitary-thyroid system in children with Hodgkin''s disease

INTRODUCTION: Tacrolimus (FK 506), a potent anti-T cell agent, has been shown to be effective in preventing the rejection of transplanted organs. Published research on tacrolimus has focused on effects associated with therapeutic use. Virtually no literature addresses the acute toxicity or the management of tacrolimus overdose. We report five cases of acute overdose with tacrolimus. CASE REPORTS: A 2-year-old female with no prior medical history ingested 10 mg of tacrolimus. She remained asymptomatic. A 2-year-old female with a history of multiple visceral organ transplants ingested 11 mg of her tacrolimus. She was admitted to the hospital and activated charcoal was administered. Her renal function was monitored and no changes were noted in a 24 h period. She was discharged. A 29-year-old male renal transplant patient took 150 mg of tacrolimus. He recovered with only a minimal creatinine elevation. A 23-year-old heart and lung transplant patient ingested 375 mg of tacrolimus. She had no effects from the overdose. A 34-year-old female experienced an acute/chronic overdose of 7-9 mg and remained asymptomatic. DISCUSSION: Tacrolimus is a neutral macrolide antibiotic that is extracted from the fermentation broth of the soil fungus Streptomyces tsukubaensis. Chronic oral dosing has been associated with numerous side effects. Although these patients ingested significant doses of tacrolimus, they suffered few toxic manifestations associated with tacrolimus. CONCLUSION: Little information is available regarding acute tacrolimus overdosage. In this small series of patients, tacrolimus did not produce acute physiologic incapacitation.     

DSM-IV intermittent explosive disorder: a report of 27 cases

BACKGROUND: The authors' objective was to provide data regarding the demographic, phenomenological, course of illness, associated psychiatric and medical comorbidity, family history, and psychiatric treatment response characteristics of rigorously diagnosed subjects who met DSM-IV criteria for intermittent explosive disorder. METHOD: Twenty-seven subjects meeting DSM-IV criteria for a current or past history of intermittent explosive disorder were given structured diagnostic interviews. The subjects' medical histories, family histories of psychiatric disorders, and responses to psychiatric treatments were also assessed. RESULTS: Most subjects described their intermittent explosive disorder symptoms as very distressing and/or highly problematic. All 27 subjects described aggressive impulses prior to their aggressive acts. Of 24 subjects who were systematically queried, 21 (88%) experienced tension with the impulses; 18 (75%), relief with the aggressive acts; and 11 (48%), pleasure with the acts. Most subjects stated that their aggressive impulses and acts were also associated with affective symptoms, particularly changes in mood and energy level. Twenty-five (93%) subjects had lifetime DSM-IV diagnoses of mood disorders; 13 (48%), substance use disorders; 13 (48%), anxiety disorders; 6 (22%), eating disorders; and 12 (44%), an impulse-control disorder other than intermittent explosive disorder. Subjects also displayed high rates of comorbid migraine headaches. First-degree relatives displayed high rates of mood, substance use, and impulse-control disorders. Twelve (60%) of 20 subjects receiving monotherapy with an antidepressant or a mood stabilizer reported moderate or marked reduction of their aggressive impulses and/or episodes. CONCLUSION: Intermittent explosive disorder appears to be a bona fide impulse-control disorder that may be related to mood disorder and may represent another form of affective spectrum disorder.     

Latent class analysis of lifetime depressive symptoms in the national comorbidity survey

OBJECTIVE: Although clinical trials have documented the importance of identifying individuals with major depression with atypical features, there are fewer epidemiological data. In a prior report, the authors used latent class analysis (LCA) to identify a distinctive atypical depressive subtype; they sought to replicate that finding in the current study. METHOD: Using the National Comorbidity Survey data, the authors applied LCA to 14 DSM-III-R major depressive symptoms in the participants' lifetime worst episodes (N=2,836). Validators of class membership included depressive disorder characteristics, syndrome consequences, demography, comorbidity, personality/attitudes, and parental psychiatric history. RESULTS: The best-fitting LCA solution had six classes. Four were combinations of atypicality and severity: severe atypical, mild atypical, severe typical, and mild typical. Syndrome severity (severe atypical and typical versus mild atypical and typical classes) was associated with a pronounced pattern of more and longer episodes, worse syndrome consequences, increased psychiatric comorbidity, more deviant personality and attitudes, and parental alcohol/drug use disorder. Syndrome atypicality (severe and mild atypical versus severe and mild typical classes) was associated with decreased syndrome consequences, comorbid conduct disorder and social phobia, higher interpersonal dependency and lower self-esteem, and parental alcohol/drug use disorder. CONCLUSIONS: As in prior reports, the atypical subtype of depression can be identified in epidemiological samples and, like typical depression, exists in mild and severe variants. Atypical depressive subtypes were characterized by several distinctive features. However, the correspondence between epidemiologically derived typologies of atypical depression and DSM-IV major depression with atypical features is not yet known.     

Changes in the pattern of drug overdoses

OBJECTIVE: To describe changes in the pattern of patients with drug overdoses hospitalized over the past two decades. DESIGN: Retrospective data review. SETTING: A 719-bed university-affiliated hospital. PATIENTS: All adults admitted to the hospital with drug overdoses in 1968, 1979, and 1989. PRIMARY OUTCOME MEASURES: Changes in demographics, drugs used, and discharge disposition. RESULTS: A majority of patients admitted with drug overdoses have had previous suicide attempts; and while women predominate, they make up a decreasing proportion of admissions over time (76% in 1968 to 52% in 1989 (p = 0.003). Benzodiazepines were the drugs most commonly used in 1979 and 1989, and cocaine has shown a marked increase in use over time, while barbiturate overdoses have progressively decreased. The use of two or more drugs is common and has been consistent over time, as has been the concomitant use of alcohol. The mortality rate has remained low at 1%, but mean length of stay has decreased dramatically from 6.6 days in 1979 to 3.2 days in 1989 (p < 0.001) and discharge disposition has shifted from out-patient to inpatient psychiatric care. CONCLUSIONS: The majority of patients admitted to a general acute care hospital following a drug overdose have a history of previous suicide attempts and are followed by a mental health professional. The changing pattern of drugs used over two decades reflects trends in drugs used in the community in general and by patients with mental illness in particular. Discharge disposition has changed over time and is related to patients' insurance status.     

Molecular characterization of a retrotransposon in Drosophila melanogaster, nomad, and its relationship to other retrovirus-like mobile elements

During a 18-year-period 93 patients (f = 76, m = 17) with a factitious disorder were identified in the psychiatric consultation service of a university hospital (incidence: 0.62%). 50% of women were working in medical professions whereas only 6% of men. Chronic courses of illness were prevailing, but at least one quarter of female patients showed an intermittent type. There was a classical Munchhausen syndrome in 11% of patients. Depressive and anxiety disorders (10%, 4%) were to be respected as psychiatric comorbidity. Ca 25% of the patients suffered from a somatic illness in addition to the factitious disorder, and one third of the women had symptoms of psychosomatic, especially of eating disorders. Previous somatoform disorders, deliberate self harm and attempts of suicide were to be noted in the psychiatric history of many patients. There were frequent traumatizing events (foster home, disturbing family disharmony, physical and sexual abuse, early losses, serious illnesses) in the early biography. Various psychosocial stressors could be identified in the actual eliciting situation. The results are discussed in respect of epidemiology, development and clinical phenomenology of factitious disorders, psychodynamics and psychopathology of deception and self harm, and therapeutic options in the psychiatric consultation service.