Esteve Cirera

Psychiatric Morbidity and Impact on Hospital Length of Stay Among Hematologic Cancer Patients Receiving Stem-Cell Transplantation

PURPOSE To determine the prevalence of psychiatric disorders during hospitalization for hematopoietic stem-cell transplantation (SCT) and to estimate their impact on hospital length of stay (LOS). PATIENTS AND METHODS In a prospective inpatient study conducted from July 1994 to August 1997, 220 patients aged 16 to 65 years received SCT for hematologic cancer at a single institution. Patients received a psychiatric assessment at hospital admission and weekly during hospitalization until discharge or death, yielding a total of 1,062 psychiatric interviews performed. Psychiatric disorders were determined on the basis of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Univariate and multivariate linear regression analyses were used to identify variables associated with LOS. RESULTS Overall psychiatric disorder prevalence was 44.1%; an adjustment disorder was diagnosed in 22.7% of patients, a mood disorder in 14.1%, an anxiety disorder in 8.2%, and delirium in 7.3%. After adjusting for admission and in-hospital risk factors, diagnosis of any mood, anxiety, or adjustment disorder (P =.022), chronic myelogenous leukemia (P =.003), Karnofsky performance score less than 90 at hospital admission (P =.025), and higher regimen-related toxicity (P <.001) were associated with a longer LOS. Acute lymphoblastic leukemia (P =.009), non-Hodgkins lymphoma (P =.04), use of peripheral-blood stem cells (P <.001), second year of study (P <.001), and third year of study (P <.001) were associated with a shorter LOS. CONCLUSION Our data indicate high psychiatric morbidity and an association with longer LOS, underscoring the need for early recognition and effective treatment.

Role of Depression As a Predictor of Mortality Among Cancer Patients After Stem-Cell Transplantation

PURPOSE To determine the association between depression and survival among cancer patients at 1, 3, and 5 years after stem-cell transplantation (SCT). PATIENTS AND METHODS This was a prospective cohort study of 199 hematologic cancer patients who survived longer than 90 days after SCT and who were recruited in a University-based hospital between July 1994 and August 1997. Patients received a psychiatric assessment at four consecutive time points during hospitalization for SCT, yielding a total of 781 interviews. Depression diagnoses were determined on the basis of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. RESULTS Eighteen (9.0%) and 17 patients (8.5%) met criteria for major and minor depression, respectively. Multivariate Cox regression models found major depression to be predictive of higher 1-year (hazard ratio [HR], 2.59; 95% CI, 1.21 to 5.53; P = .014) and 3-year mortality (HR, 2.04; 95% CI, 1.03 to 4.02; P = .041) but not 5-year mortality (HR, 1.48; 95% CI, 0.76 to 2.87; P = .249). Minor depression had no effect on any mortality outcome. Other multivariate significant predictors of higher mortality were higher regimen toxicity in the 1-, 3-, and 5-year models; older age and acute lymphoblastic leukemia in the 3- and 5-year models; chronic myelogenous leukemia in the 3-year model; and lower functional status and intermediate/higher risk status in the 5-year model. Use of peripheral-blood stem cells predicted lower mortality in the 5-year model. CONCLUSION After adjusting for multiple factors, major depression predicted higher 1- and 3-year mortality among cancer patients after SCT, underscoring the importance of adequate diagnosis and treatment of major depression.

Patient-rated emotional and physical functioning among hematologic cancer patients during hospitalization for stem-cell transplantation

Summary:In this 3-year prospective inpatient study, 220 patients received stem-cell transplantation (SCT) for hematologic cancer at a single institution. The objective of the study is to provide data on patient-rated emotional (depression and anxiety) and physical (overall physical status, energy level, and systemic symptomatology) functioning during hospitalization for SCT and to compare whether these differ between autologous and allogeneic SCT. Patients were assessed at hospital admission (T1), day of SCT (T2), and 7 days (T3) and 14 days (T4) after SCT, yielding a total of 852 evaluations. For the overall sample, anxiety was highest at T1 and decreased afterwards; a marked worsening in physical health status variables corresponded with a sharp increase in depression from T1 to T3, and was followed by an improvement in physical health and a reduction of depression. Compared to allogeneic SCT, a better physical outcome for autologous SCT was demonstrated by the significant group effect for systemic symptomatology and by the significant group × time interaction for overall physical status and energy level; there were no significant differences in depression or anxiety between SCT groups. These findings have implications for treatment decision making, coping with the transplantation process, and improving prevention and treatment strategies.

Serious suicide attempts in affective patients

A retrospective study was carried out including all patients who in the previous 6 years had required admission to our hospital for medical or surgical reasons following attempted suicide (n = 257). Those diagnosed as having affective disorder (n = 96), according to DSM-IIIR criteria, were compared with the other non-affective suicide attempters (n = 161). Affective patients were significantly different in that they were older, more often women, married or widowed, usually used non-violent methods, made more serious attempts and presented a higher incidence of concomitant physical illness. Affective patients with a history of previous attempts were more likely to be recurrent unipolar depressives or first episode unipolars with a concurrent diagnosis of personality disorder. Most of the depressed patients made the attempt within the first 12 months of the episode. Patients who attempted suicide in the first 12 months of the depression were more likely to use non-violent methods and to receive a diagnosis of bipolar or unipolar recurrent disorder.

Suicide attempts of high medical seriousness in schizophrenic patients.

A retrospective study was conducted that included all patients who in the previous 6 years had required admission to our hospital for medical reasons following attempted suicide (N = 253). Those diagnosed as schizophrenic (n = 43) in accordance with DSM-III-R criteria were compared with the other nonschizophrenic suicide attempters. Schizophrenic patients were significantly different in that they were younger and generally unmarried, usually used violent methods, made more attempts while in a psychiatric center, and presented a lower incidence of concurrent organic illness than the nonschizophrenics; almost all of them were chronic. A large majority (80%) showed delusional and hallucinatory symptoms at the time of the attempt. In contrast, depressive symptoms were noted in an appreciably lower percentage of subjects than that in other studies of suicidal behavior in schizophrenics.

Assessment of the Efficacy of a Cognitive-Behavioural Group Psychotherapy Programme for HIV-Infected Patients Referred to a Consultation-Liaison Psychiatry Department

Background: Most HIV-infected patients attending a consultation-liaison psychiatry service show symptoms of anxiety and depression. The present study sought to evaluate the immediate and long-term efficacy of a structured cognitive-behavioural group therapy reducing anxiety and depression in HIV-infected patients referred to a consultation-liaison psychiatry department, and to identify baseline variables predictive of greater improvement. Methods: Repeated-measures ANOVA was used to analyse changes in the Beck Depression Inventory (BDI) and the state subscale of the State/Trait Anxiety Inventory (STAI) administered to 39 participants at 4 time points: T1 (1 month before beginning the therapy), T2 (during the first session), T3 (during the last session) and T4 (3 months after the last session). The therapy consisted of 16 weekly 2-hour sessions following a structured time-limited cognitive-behavioural group psychotherapy programme. Results: During the intervention time (between T2 and T3) an improvement was observed in depression and anxiety, which persisted after the 3-month follow-up period (between T3 and T4). No changes were observed during baseline (between T1 and T2). Patients with higher levels of anxiety at baseline showed greater improvement in STAI state subscale scores. Transmission of HIV infection through intravenous drug use was associated with less improvement on the BDI. Conclusions: This is the first report of an ongoing study which suggests long-lasting efficacy of a structured cognitive-behavioural group psychotherapy programme in a heterogeneous sample of HIV-1-infected patients referred to a consultation-liaison psychiatry unit.

Serious Suicide Attempts in the Elderly

A retrospective study was carried out including all those patients who, over the last 6 years (n = 257), required admission to our hospital for medical or surgical reasons following attempted suicide. The authors examined a series of clinical and demographic variables. Thirty-eight patients over 65 years of age were compared with 120 patients aged between 30 and 64 years and 99 aged under 30 years. When compared with the other two groups, a significantly higher proportion of elderly patients were widowed and showed affective disorders and concurrent physical illness.

Rapidly Cycling Bipolar II Disorder Following Liver Transplantation

During the last decade the psychiatric aspects of liver transplantation have been widely described. Although affective complications are some of the most prevalent, a complete and persistent bipolar II syndrome following transplantation has never been reported before. In this paper we describe a patient who developed a rapidly cycling bipolar II disorder after liver transplantation. He presented a major depressive episode within the first 48 hours following transplantation, and subsequently started cycling from depression to hypomania with only brief periods of euthymia. One year after transplantation, only lithium carbonate has proved to be useful to ameliorate his persistent disorder. There was no premorbid or family history of affective illness. Although the course of the disorder seemed to be independent from any pharmacologic or psychosocial factor, it is suggested that transplantation, corticosteroids, and cyclosporine may have played some role in the pathogenesis of the syndrome.