Eugene M Cassidy

Unawareness of illness and its relationship with depression and self-deception in schizophrenia

Both poor insight and depressive symptomatology are common features of schizophrenia that may be independent of positive and negative symptoms. Forty-six patients with DSM-III-R schizophrenia were evaluated for level of insight (schedule for unawareness of mental disorder), depression (Calgary depression scale for schizophrenia, Beck depression inventory), and self-deception or denial (balanced inventory of desirable responding). Patients with a greater unawareness of their illness had relatively less depressive symptomatology and relatively greater self-deception. This relationship was particularly strong for unawareness of the social consequences of having a mental disorder. These results suggest that the presence of depressive symptomatology in schizophrenia is related to the level of insight, and contingent at least in part on the absence of self-deception as a denial defense.

Clinical characteristics and outcome of patients diagnosed with psychogenic nonepileptic seizures: a 5-year review.

OBJECTIVE The goal of this article was to describe the clinical characteristics and outcomes of patients diagnosed with psychogenic nonepileptic seizures (PNES). METHODS We conducted a retrospective review of patients diagnosed with PNES in a 5-year period. RESULTS Fifty patients with PNES were identified, giving an estimated incidence of 0.91/100,000 per annum. Thirty-eight were included for review, 15 of whom were male (39%). Eighteen patients had been diagnosed with epilepsy as well as PNES (47%). We demonstrated a gender difference in our patients, with males having higher seizure frequencies, more antiepileptic drug use, and a longer interval before diagnosis of PNES. Females were diagnosed with other conversion disorders more often than males. Impaired social function was observed in PNES, as was resistance to psychological interventions with a subsequent poor response to treatments. CONCLUSIONS PNES remains a difficult condition to treat, and may affect males in proportions higher than those described in previous studies.

Prevalence of post-stroke depression in an Irish sample and its relationship with disability and outcome following inpatient rehabilitation.

Purpose: (1) To examine the prevalence of depressive symptoms and operationally defined depressive disorder (major depression) in an Irish sample of subjects undergoing inpatient rehabilitation following their first stroke. (2) To investigate factors predictive of depression following stroke. (3) To examine the relationship between post-stroke depression and outcome following inpatient rehabilitation. Methods: Fifty consecutive patients meeting inclusion criteria who were admitted for inpatient rehabilitation to a specialised unit following their first stroke were prospectively studied. Inclusion criteria: first stroke 3 – 12 months previously, lesion identified on CT or MRI, age 18 – 65 years, at least some sensory/motor impairment, no pre-existing disabling condition and Barthel Index score > 14 prior to stroke. Mood (Center for Epidemiologic Studies Depression scale, Hamilton Depression Rating Scale, DSM-IV diagnostic criteria for Major Depressive Disorder), Cognition (Mini-Mental State Examination) and Disability (Barthel Index, Rankin Disability Scale) were assessed one week after admission (baseline) and again after 2 months of rehabilitation. Outcome was measured as effectiveness of rehabilitation (Shah et al., 1990) and length of inpatient stay (LOS). Results: 10/50 (20%) of the sample met criteria for major depressive disorder on admission. The best predictor of depression was gender, with females having a two-fold higher rate of both subjectively reported and objectively rated depressive symptoms. Depression was unrelated to baseline Barthel Disability, side of lesion or previous psychiatric history. The best predictor of effectiveness of rehabilitation was baseline Barthel Disability score. Depression did not predict either effectiveness or LOS. Conclusion: (1) Major depression is common in subjects undergoing rehabilitation following their first stroke. (2) Females appear to be especially at risk, possibly reflecting an increased general risk of depression. (3) Depression in our sample was not related to functional disability following stroke or early functional outcome following rehabilitation.

Sensitivity and specificity of the Distress Thermometer and a two-item depression screen (Patient Health Questionnaire-2) with a 'help' question for psychological distress and psychiatric morbidity in patients with advanced cancer.

Brief screening tools may help clinicians in busy settings detect patients who are experiencing severe psychological distress. This study examined the performance of the Distress Thermometer (DT) and a two‐item depression screen [the Patient Health Questionnaire‐2 (PHQ‐2)] with a ‘help’ question in screening for distress and psychiatric morbidity among patients with advanced cancer.

Marked elevations in pro-inflammatory polyunsaturated fatty acid metabolites in females with irritable bowel syndrome

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder referred to gastroenterologists. Although the pathophysiology remains unclear, accumulating evidence points to the presence of low-level immune activation both in the gut and systemically. Circulating polyunsaturated fatty acids (PUFA) have recently attracted attention as being altered in a variety of disease states. Arachidonic acid (AA), in particular, has been implicated in the development of a pro-inflammatory profile in a number of immune-related disorders. AA is the precursor of a number of important immunomodulatory eicosanoids, including prostaglandin E2 (PGE2) and leukotriene B4 (LTB4). We investigated the hypothesis that elevated plasma AA concentrations in plasma contribute to the proposed pro-inflammatory profile in IBS. Plasma AA and related PUFA were quantified by gas chromatography analysis in IBS patients and controls. Both PGE2 and LTB4 were measured in serum using commercially available ELISA assays. AA concentrations were elevated in our patient cohort compared with healthy controls. Moreover, we demonstrated that this disturbance in plasma AA concentrations leads to downstream elevations in eicosanoids. Together, our data identifies a novel proinflammatory mechanism in irritable bowel syndrome and also suggests that elevated arachidonic acid levels in plasma may serve as putative biological markers in this condition.

Lethal catatonia responding to high-dose olanzapine therapy

We present the case of a 31-year-old woman with recent refractory bipolar disorder who developed a malignant syndrome preceded by catatonic motor features. This resistant case of lethal catatonia responded selectively to high-dose olanzapine treatment. The case illustrates the need to consider lethal catatonia in apparent cases of neuroleptic malignant syndrome that do not respond to conventional treatment with dantrolene and bromocriptine.

Central 5-HT receptor hypersensitivity in migraine without aura

Serotonin has long been implicated as a key neurotransmitter in migraine. There is a dearth of research specifically examining 5-HT1A receptor sensitivity in migraine despite the importance of this receptor in regulating central serotonergic tone. In this study we examined the hypothesis that migraine without aura is associated with hypersensitivity of central 5-HT1A receptors, using a 5-HT1A neuroendocrine challenge drug and comparing serum prolactin responses between a test group with migraine and a matched group of healthy controls. Twelve female subjects fulfilling International Headache Society (IHS) criteria for migraine without aura were evaluated. Following an overnight fast, subjects presented for testing at 9am. An intravenous canula was inserted and serum prolactin was assessed at baseline and every 30 min for 3 h following a single dose of 30 mg oral buspirone, a 5-HT1A-receptor agonist. Subjects were assessed during the first 5 days of the menstrual cycle. No subjects were taking psychotropic medication or migraine prophylactic treatment. Patients with current or previous psychiatric disorder, daily headache or analgesic overuse were excluded. 16 healthy female volunteers matched for age and menstrual status were also evaluated and served as controls. There was no difference in baseline prolactin between groups. There was a significant rise in prolactin following buspirone in both groups. Subjects with migraine had a significantly increased prolactin response to buspirone (delta max) compared to controls (P < 0.001). This study supports the hypothesis that migraine without aura is associated with a relative hypersensitivity of central 5-HT1A receptors. This is of relevance given the role of the 5-HT1A receptor in controlling raphe 5-HT tone and in the possible association between migraine and anxiety and depression.

Acute effects of low-dose interferon-α on serum cortisol and plasma interleukin-6

Major depression is associated with both hypothalamic-pituitary-adrenal (HPA) axis overactivity and immune system activation. Depression is a common occurrence following interferon (IFN)-α treatment. While IFN-α is known to stimulate the HPA axis, little is known about the effects of exogenous IFN-α in humans on the proinflammatory cytokine interleukin (IL)-6, a marker of immune system activation. This study examined the acute effects of IFN-α on cortisol and IL-6 release, and the time course of any changes in these variables. Serum cortisol and plasma IL-6 were assessed in healthy volunteers over an 8-h period following 3 million units subcutaneous IFN-α or placebo using a double-blind, placebo-controlled crossover design. IFN-α resulted in a significant increase in both cortisol and IL-6. Regular sampling over 8 h did not delineate any sequential effect of the rise in these variables over time. We conclude that IFN-α acutely stimulates both the HPA axis and proinflammatory cytokine release. The hypothesis that the effect of IFN-α on the HPA axis is indirect and mediated by IL-6 was not supported by this study. Our findings are nonetheless of relevance to the aetiology of depression following IFN-α.

Insulin as a substance of misuse in a patient with insulin dependent diabetes mellitus

Doctors should be alert to the possibility of insulin misuse, and should consider psychological evaluation, in an insulin dependent diabetic patient with poor control

Symptom-triggered benzodiazepine therapy for alcohol withdrawal syndrome in the emergency department: a comparison with the standard fixed dose benzodiazepine regimen

The aim of the study was to compare symptom-triggered and standard benzodiazepine regimens for the treatment of alcohol withdrawal syndrome in an emergency department clinical decision unit. The authors found that the symptom-triggered approach reduced cumulative benzodiazepine dose and length of stay.