Bruno Trancas

Depression and anxiety symptoms following cancer diagnosis: a cross-sectional study

Abstract Introduction: The aims of the present study were to assess demographic and clinical characteristics of patients after receiving a cancer diagnosis, and to determine possible risk factors for anxiety and depression. Methods: All consecutive patients aged 18 or above, were assessed before starting intravenous chemotherapy for the first time with the Hospital Anxiety and Depression Scale (HADS), the Distress Thermometer, and a Visual Analog Scale for pain. Demographic and clinical data were also collected. Results: The patients assessed (n = 270) had a mean age of 59.4 (SD = 11.8) years, and 50.7% were women. Tumours were more frequently colorectal (27.2%), lung (18.8%) and breast (17.6%), and 68.9% were stages 3 or 4. A HADS Anxiety score ≥8 was present in 30% of the patients, a Depression score ≥8 in 24.1%, and a Distress score ≥4 in 44.4%. Independent risk factors for HADS Depression score ≥8 were being a woman (OR = 2.45; p = 0.004), being older (OR = 1.04; p = 0.005), and cancer stage 3–4 (OR = 2.24; p = 0.023) in the multivariable analysis; for Anxiety ≥8 they were being a woman (OR = 2.47; p = 0.002), having a past psychiatric consultation (OR = 2.83; p = 0.029), and cancer stage 3–4 (OR = 1.90; p = 0.047). Conclusion: These results suggest the need for greater awareness and a differentiated approach to patients at increased risk of anxiety and depression in the early stages of treatment and before starting chemotherapy.

Characteristics of frequent users of an acute psychiatric inpatient unit: a five-year study in Portugal.

OBJECTIVE This study examined demographic and clinical characteristics of frequent users of a psychiatric inpatient unit in Portugal. METHODS Data (2004-2008) for 1,348 consecutive psychiatric inpatients were reviewed. Frequent users (N=137), who had at least three admissions in the study period, were compared with nonfrequent users (N=1,211) on age, gender, race-ethnicity, diagnosis, and compulsory admissions. Data were analyzed with chi square and Students t tests. RESULTS Frequent users accounted for 29% of admissions. They were significantly younger than nonfrequent users (39±14 versus 44±17, p<.001), and a larger proportion had compulsory admissions (28% versus 14%, p<.001). The frequent user group also had significantly higher rates of bipolar disorder (61% versus 46%, p<.001) and schizophrenia (29% versus 18%, p<.003). CONCLUSIONS Understanding characteristics of frequent users can inform development of appropriate services. Research should address other variables related to frequent admissions, including socioeconomic factors, general medical and psychiatric comorbidities, and treatment compliance.

Efficacy of Electroconvulsive Therapy in Bipolar Disorder with Mixed Features

Introduction. Mixed states represent a frequent presentation of bipolar disorder, associated with higher resistance to psychopharmacology. Limited evidence supports the use of ECT in these patients. We aim to report our experience on treating bipolar mixed states with ECT. Methods. Retrospective data were collected from all bipolar patients submitted to acute ECT treatment, between June 2006 and June 2011. Three groups were created in terms of affective polarity of the episode. CGI rating was used to establish clinical remission and demographic and clinical variables were compared among groups. Long-term outcome was assessed through readmission measures, considering the use of continuation or maintenance ECT. Results. During the study time frame, a total of 50 ECT course treatments were performed on 41 bipolar patients. All affective episodes, except one mixed state, showed a positive clinical response. Patients with mixed state presentation tended to be younger and have an earlier first hospitalization than depressed patients. No differences were found in terms of ECT sessions performed, length of hospital admission, referral to continuation ECT treatment, number of readmissions, and time until next readmission. Conclusions. Our results support the effectiveness of ECT in patients experiencing a mixed affective state.

Revisitar Processos, Redefinir Direitos: processos de levantamento de interdição-inabilitação (2010-2015)

Background: In Portugal, the restriction of Civil Rights on account of incompetence due to mental illness is achieved through two institutes, “Inabilitacao” (similar to a limited guardianship or conservatorship) and “Interdicao” (similar to general guardianship). These processes collide with individual freedom and fundamental Rights. The aim, instead of punishment, is the protection of the incompetent adults, seeking the maximum preservation of competence and proportionality between the implemented measures and the degree of competence. In psychiatric evaluations of conservatorship and guardianship procedures, which have increased in Portugal during recent years, expert responsibility has increased, because - since 2013 - the Judge only intervenes directly (through judicial interrogation) when the action is contested, which doesn’t happen frequently.Aims: To review the concepts of “Inabilitacao” and “Interdicao” (concepts similar to limited and general guardianship) and the mechanisms to modify or terminate them. To explore the Portuguese reality regarding the requests for modification of the conservatorship/guardianship sentences made in the last 6 years, identifying the personal motivations of the applicants for such requests and extracting the clinical and technical reasons that led to the modification of the civil restrictions.Methods: Retrospective descriptive study. The official judicial statistics were consulted and the collaboration of the Portuguese Superior Council of Magistrates (CSM) was obtained, allowing identification and consultation of the “Inabilitacao” and “Interdicao” cases that were the subject of pleads for termination.Results and Conclusions: The official statistics of the period under review indicated the existence of 43 concluded pleads for termination. However, of the 23 National “Comarcas” (judicial counties) contacted by the CSM by our request, only 5 answered, regarding 8 actions, of which only 6 were concluded and were able to be analysed. The original actions resulted in 4 “Interdicao” sentences and 2 “Inabilitacao” sentences. After the termination procedures, only 1 case maintained a general guardian with the remaining cases having now a limited guardian (3) or being free of restriction (2). From the technical methodology point of view, it was verified that the interview of family member / significant person was not mentioned or carried out in 7 of the 12 examinations, that in 4 of the 12 expert psychiatric reports there was no reference to clinical documents attached to the process and that in 5 occasions no additional diagnostic exams were ordered. Competence should be viewed as a potentially dynamic variable. The analysis of the expert evaluations highlights the paucity of collateral information (on severity, irreversibility or actual degree of incapacity), the role of dysfunctional family relationships (which, as altered, have resulted in a substantial improvement in competence) and the beneficial effects of support (with positive impact on function and competence).

Causes of Death in an Acute Psychiatric Inpatient Unit of a Portuguese General Hospital

INTRODUCTION Psychiatric patients are at increased risk of death from a number of natural and unnatural causes. This study examines the mortality causes of all psychiatric inpatients of an acute psychiatric unit at a general hospital in Portugal for sixteen years (1998 to 2013). MATERIAL AND METHODS Twenty-one inpatients died at the inpatient unit between 1998 and 2013 (average 1.3 per year). A retrospective study through case-file review was carried to collect demographic characteristics, medical and psychiatry diagnosis. Patients transferred to other wards during their admission were not included. RESULTS Circulatory system diseases were the most prevalent causes of death, occurring in 2/3 of patients and include pulmonary embolism (n = 6), acute stroke (n = 3), cardiac arrhythmia (n = 2), acute myocardial infarction (n = 1), abdominal aortic aneurysm rupture (n = 1) and heart failure (n = 1). Two patients died with pneumonia and in four cases the cause of death was undetermined. Only one case of suicide was registered. DISCUSSION Circulatory conditions were the most frequent causes of death in our inpatient unit. Albeit a relatively rare event, inpatient suicide does occur and, in addition to its complex consequences on staff, family and patients should remain a focus for continued prevention. CONCLUSION Mortality studies are important for determining quality of health care and to create recommendations for preventive measures.

2209 – Mutiny on the ward: case report and literature review on preventing and tackling violent behavior

Introduction Psychiatry wards are witness to violent behavior. Mental health professionals are called upon to prevent/deescalate potential violence. Objectives Understand the causal factors that led to a serious group violence event in a psychiatric ward and review strategies to minimize the risk. Aims Provide a better understating and review current evidence. Methods Description of a group violence event. Non-systematic literature review concerning violence on psychiatric wards. Results In a 29-bed acute closed-door mixed-gender general-hospital psychiatry ward staff had detected that a small group of patients increasingly defied instructions, refused treatment and intimidated users. Later, two of these patients, on cue from the psychotic content of another user with schizophrenia, intruded patients’ bedrooms and assaulted a 63 year-old female patient. These two patients, with bipolar disorder, were unemployed and had a history of previous psychiatric admissions, drug abuse, criminal offenses and treatment drop-out. De-escalation techniques failed and security was summoned. Offending patients were admitted to seclusion bedrooms and restrained. Upon a crisis meeting these two patients were transferred to two nearby psychiatric departments. There are several risk factors for violence in psychiatry wards, pertaining to the ward, staff, patients and psychopathology. Prevention measures are typically related to the timely detection of these variables and deescalation techniques. When these fail, seclusion, forced medication or mechanical restraint may be necessary. Conclusions This case report confirms that violence rarely erupts without warning. Additional staff training on violence prevention and tackling is required. Some variables (e.g. overcrowding) are current structural weaknesses of the health system.

P-202 - Delirious mania or delirious affective disorder: when depression meets delirium. a case report where cognitive deficits thicken the plot

Introduction The co-occurrence of mania and delirium, named “delirious mania”, is an under-recognized entity not listed in major diagnostic classifications. Literature about this syndrome is still scarce and lacking evidence. Usually, reports of affective syndromes with delirium tend to be subdued in the manic descriptor Objectives We report the case of a 44 year old female patient with a simultaneous affective episode and delirium. Aims To demonstrate the co-occurrence of depressive/mixed symptoms and delirium Methods Review of clinical records and complementary exams. Results The patient was admitted after a three week long depressive syndrome with psychomotor agitation, followed by a week-long fluctuating pattern of delirious and mixed affective features. Shortly after admission the patient exhibited a stuporous state, with nocturnal agitation. A fluctuating pattern of symptoms ensued, with disorientation, disorganized behavior, cognitive impairment, anxiety and depressive features. The patient was put on mood stabilizers, antipsychotics and benzodiazepines. She was discharged symptom-free two months later and re-admitted 4 weeks later due to recurrence of symptoms. Electroconvulsive treatment was applied,with quick remission of affective symptoms. Yet, it took another two months until discharge, due to persistent cognitive symptoms. Medical conditions were excluded. Conclusions This case shows the simultaneous occurrence of an affective syndrome alongside delirium. The strongest treatment response occurred with ECT. The presence of depressed mood highlights the fact that this syndrome can begin without clear-cut manic symptoms. We suggest that its name should be changed to Delirious Affective Disorder, which might help to avoid misdiagnosis. Persistent cognitive deficits raise some questions in this case.

P-760 - Neurosyphilis: four case reports of immunocompetent patients presenting initially to psychiatry

Introduction Symptomatic neurosyphilis in immunocompetent patients is nowadays a rare diagnosis. Yet, if not properly diagnosed and treated, consequences for the patients health are severe. Known as “the great imitator”, its detection involves both a high degree of suspicion and adequate diagnostic tests. Psychiatric symptoms are often the presenting symptoms of this illness. Objectives The authors report four cases of neurosyphilis with psychiatric symptoms (general paresis) in immunocompetent patients. All four patients were initially referred for observation by a psychiatrist in the emergency room. Special diagnostic features of each case and potential diagnostic pitfalls are highlighted. Aims To raise awareness to the importance of this rare but highly disabling disease. Methods Review of clinical records and complementary exams. Results All patients were male, two Caucasian and two African Black, with ages ranging from 41–56 years old. Clinical presentations were quite distinct, showing the symptomatic heterogeneity of paretic neurosyphilis. Blood VDRL test was negative in one case, CSF VDRL was negative in another case. TPHA was always positive in blood and CSF. White cell count and protein quantification in the CSF remains important to confirm diagnosis. Conclusions Current prevalence of symptomatic neurosyphilis in Western Europe is unknown. Atypical cases presenting with heterogeneous psychiatric and neurologic symptoms, with no previous history of mental illness, should undergo blood VDRL testing, and specific blood treponemal testing should be considered in specific situations. A high index of clinical suspicion is needed. Confirmation of diagnosis is only possible through further CSF analysis.