George E. Tesar

USE OF STIMULANTS IN THE MEDICALLY ILL

This article discusses the use of psychostimulants, such as dextroamphetamine, methylphenidate, and pemoline, in a variety of illnesses, including depression in the medically ill, cancer, HIV, and AIDS. The chemistry and pharmacology, side effects, drug interactions, dosing, and abuse potential also are reviewed.

Depression and heart disease: what do we know, and where are we headed?

Depression and heart disease have an intricate association and perhaps a causal relationship. We review the current status of depression and heart disease and provide an algorithm for diagnosing and treating depression in cardiac patients that internists and cardiologists can use in their daily patient encounters. Depression is a risk factor for new cardiac disease and has a detrimental effect in established cardiac disease. Clinicians should routinely screen for it in cardiac patients and should not hesitate to treat it.

QT Interval Prolongation Associated With Quetiapine (Seroquel) Overdose

Received June 3, 1999; accepted June 14, 1999. From the Department of Psychology and Psychiatry, Cleveland Clinic Foundation (CCF), 9500 Euclid Avenue, Cleveland, OH 44195. Address correspondence and reprint requests to Dr. Tesar, Department of Psychiatry and Psychology, CCF, 9500 Euclid Avenue, Cleveland, OH 44195. Copyright 2000 The Academy of Psychosomatic Medicine. Haloperidol and other typical antipsychotics are known to cause cardiac conduction abnormalities, including QTc interval prolongation on an electrocardiogram (ECG). Newer antipsychotics, such as olanzapine, risperidol, and quetiapine, have a reputation for cardiovascular safety. We report a case of quetiapine overdose that was associated with clinically significant QT interval prolongation.

Valproate-induced hyperammonemic encephalopathy: a brief review

Abstract Background: This brief review presents a comprehensive evaluation of valproate-induced encephalopathy (VHE) and also discusses potential mechanisms of the condition. Scope: Sodium valproate (VPA) is an effective antiepileptic drug used in neurology as well as in psychiatry, in adults and children. VHE requires early diagnosis and management. Focused research efforts in understanding the condition will help decrease its incidence. Delay in recognition of VHE can result in the development of potentially life-threatening complications. Findings: Management options are described. Since VPA frequently causes a modest rise in plasma ammonia levels which is asymptomatic, it is important to recognize the symptoms of VHE promptly and to correlate them with the plasma ammonia levels. Conclusions: Although there are several case reports on VHE, this review is a comprehensive evaluation of its causes and potential mechanisms. Rapid diagnosis and management will help in reducing VHE-related morbidity.

Quality of life in 1931 adult patients with epilepsy: Seizures do not tell the whole story

OBJECTIVE The aim of the work described here was to characterize quality of life (QOL) and its determinants in a large cohort of adult patients with epilepsy. METHODS Validated measures reflecting disease severity and psychosocial functioning were electronically collected on all outpatients seen during 2009. Multivariate regression adjusting for repeated measures identified determinants of QOL, as defined by the Quality of Life in Epilepsy Questionnaire-10 (QOLIE-10). RESULTS Seven thousand seven hundred eighty-four visits from patients with epilepsy were identified. The questionnaire completion rate was 77%, yielding 5960 records corresponding to 1931 individual patients for analysis. Following multivariate modeling, the two most clinically significant QOL predictors were seizure severity (mean QOLIE-10 score=28.8 if LSSS>40 vs 19.2 otherwise) and depression (mean QOLIE-10 score=31.7 if PHQ-9≥10 vs 19.3 otherwise). CONCLUSIONS Optimizing quality of life in patients with epilepsy requires an approach that extends beyond controlling seizures. Collection of validated health status measures improving patient management is possible within the setting of routine clinical care.

Comparison of personality traits in patients with frontal and temporal lobe epilepsies

The current study sought to characterize and compare personality traits of patients with temporal lobe epilepsy (TLE) and frontal lobe epilepsy (FLE). Ninety-seven adults with medically intractable epilepsy (TLE n=58, FLE n=39) completed the Personality Assessment Inventory (PAI) as part of routine preoperative investigations. Not surprisingly, both epilepsy groups endorsed significantly more symptoms across PAI clinical scales than the normative sample, most notably on scales assessing Depression and Somatic Complaints. Direct comparison of personality profiles of people with FLE and TLE revealed that FLE was associated with relative elevations on scales assessing emotional lability and relationship difficulties (i.e., Mania, Borderline Features, Antisocial, Stress, and Nonsupport). Although effect sizes were moderate to large, the clinical significance of these differences was questionable (<1 SD). However, results of a logistic regression suggested that the Borderline Features and Anxiety scales have incremental validity in predicting seizure site (FLE vs TLE) above education and duration of recurrent seizures. These results suggest that patients with FLE may exhibit more behavioral traits associated with frontal dysfunction than patients with TLE.

Valproate-Induced Hyperammonemic Encephalopathy in General Hospital Patients With One or More Psychiatric Disorders

BACKGROUND Divalproex sodium/valproic acid (VPA) is an antiepileptic drug approved for use in epilepsy and bipolar disorder. Valproate-induced hyperammonemia occurs in up to 50% of VPA-treated patients, some of whom may become encephalopathic. Valproate-induced hyperammonemic encephalopathy (VHE) is thought to be rare, and for a variety of reasons, the diagnosis requires a high index of suspicion. OBJECTIVE The studys goals are to determine how common VHE is, and the quality of treatment provided when diagnosed. METHODS Retrospective, cross-sectional survey of general hospital patients. The hospitals laboratory and pharmacy databases were combined to identify a cohort of all VPA-treated patients who developed hyperammonemia during a 5-year period. Hospital records of the subset of patients with a psychiatric disorder were selected and reviewed for data collection. RESULTS Twenty of 793 (2.52%) VPA-treated patients had signs and symptoms consistent with VHE. The majority were White males on multiple psychotropic agents. Valproate was appropriately discontinued in 8 (40%) patients. Lactulose was the only ammonia-lowering drug used, and it was administered to 6 patients and only one among them had VPA discontinued. CONCLUSION Study results indicate that VHE may be more common in psychiatric patients than previously assumed but underrecognized and inadequately treated. The diagnosis of VHE requires a high index of suspicion. Outcome is favorable once it is recognized and treated appropriately.

Whither Hospital and Academic Psychiatry

If psychiatrists are to bring value to the health care team, training a renewable force of such psychiatrists is essential. Have psychiatrists been trained to bring maximal value to the health care team? Is such training being provided now? Given the current health care climate, will sufficient funding be available to train this renewable force optimally? This article addresses these questions from an historical-developmental perspective, identifies current challenges, and outlines opportunities for further growth and development.

Assessment of depression in epilepsy: the utility of common and disease-specific self-report depression measures

Abstract Objectives: Depression is common in epilepsy, with rates ranging from 20 to 55% in most samples and reports as high as 70% in patients with intractable epilepsy. However, some contend that depression may be over- and/or under-reported and treated in this population. This may be due to the use of common self-report depression measures that fail to take into account the overlap of disease and depressive symptoms and also the host of side effects associated with antiepileptic medication, which may also be construed as depression. Methods: The present study examined the utility of common self-report depression measures and those designed specifically for the medically ill, including a proposed new measure, to determine which may be more appropriate for use among people with epilepsy. Results: We found that common self-report depression measures are useful for screening depression in epilepsy, particularly with a raised cutoff for one, with sensitivities ranging from .91 to .96. A measure designed for the medically ill obtained the greatest specificity of .91, suggesting its use as a diagnostic tool with a slightly raised cutoff. The positive likelihood ratio of this latter measure was 8.76 with an overall classification accuracy of 88%. Conclusions: Assessment of depression in epilepsy can be improved when utilizing self-report measures that better differentiate disease symptoms from neurovegetative symptoms of depression (e.g. fatigue, sleep disturbance). This was demonstrated in the present study. Clinical implications are discussed.