J. Michael Bostwick

Psychiatric Adverse Effects of Corticosteroids

Psychiatric adverse effects during systemic corticosteroid therapy are common. Two large meta-analyses found that severe reactions occurred in nearly 6% of patients, and mild to moderate reactions occurred in about 28%. Although disturbances of mood, cognition, sleep, and behavior as well as frank delirium or even psychosis are possible, the most common adverse effects of short-term corticosteroid therapy are euphoria and hypomania. Conversely, long-term therapy tends to induce depressive symptoms. Dosage is directly related to the incidence of adverse effects but is not related to the timing, severity, or duration of these effects. Neither the presence nor the absence of previous reactions predicts adverse responses to subsequent courses of corticosteroids. Corticosteroid-induced symptoms frequently present early in a treatment cycle and typically resolve with dosage reduction or discontinuation of corticosterolds. In severe cases or situations in which the dose cannot be reduced, antipsychotics or mood stabilizers may be required. This review offers an approach to identifying and managing corticosteroid-induced psychiatric syndromes based on the type of symptoms and anticipated duration of corticosteroid treatment.

Implantable cardioverter-defibrillators, induced anxiety, and quality of life.

Since its approval in 1985, the implantable cardioverter-defibrillator (ICD) has supplanted antiarrhythmic drugs as the standard of care for patients with potentially lethal ventricular arrhythmias. The increased popularity of ICDs stems primarily from their safety and tolerability compared with commonly used medications notorious for adverse drug reactions. As ICD indications have broadened, the number of implantations has increased substantially, and more attention has been directed to sequelae of implantation, particularly after ICD firing. Although scant, studies of quality of life and psychiatric symptoms in patients with ICDs consistently report assorted psychiatric disturbances affecting up to 87% of recipients. Depression and anxiety predominate: up to 38% of patients experience symptoms that meet diagnostic criteria for an anxiety disorder. Psychological theories such as the classic conditioning model, learned helplessness model, and cognitive appraisal model have been invoked to conceptualize these new-onset ICD-induced anxiety disorders. Small trials of psychosocial interventions, including support groups and cognitive behavioral therapy, have had mixed results. Little is known about preexisting anxiety disorders in ICD recipients, particularly which premorbid features predict a worse prognosis, other than suggestions that younger patients and those receiving multiple shocks are at greater risk. Prospective studies of the psychopathology of patients with ICDs, both before and after implantation, are warranted.

Cocaine abuse : Dermatologic manifestations and therapeutic approaches

Cocaine affects the cutaneous system and other organ systems. Cocaine use is associated with vasculitides, infectious complications, and numerous dermatologic conditions. It has been associated with formication (ie, tactile hallucinations of insects crawling underneath the skin), which leads to delusions of parasitosis and other psychosis-related dermatologic disorders. When a patient presents to a dermatology clinic with chronic skin lesions, a vague medical history, negative findings from previous evaluations, labile affect, and delusional behavior, drug screening should be performed to identify possible cocaine use.

Taking the physician out of "physician shopping": a case series of clinical problems associated with Internet purchases of medication.

In the United States, psychoactive prescription medications rank second only to marijuana as drugs of abuse (if tobacco and alcohol are discounted). Physician shopping--visiting multiple physicians simply to procure prescriptions--has been a traditional method for acquiring drugs illicitly. As community-based efforts to curtail physician shopping have expanded, drug abusers have turned increasingly to the Internet. Illegal Internet pharmacies, increasing rapidly in number during the past decade and requiring neither prescription nor physician oversight, offer minimal interference to obtaining drugs. With no physician involved, patients cease to be patients. Instead, they become consumers able to buy prescription medications, even controlled substances, from anonymous providers offering no ongoing treatment relationship and taking no responsibility for the drugs dispensed. When complications occur, these consumers become patients, turning back to the traditional medical system to manage overdoses, addictions, and drug adverse effects and interactions. We present a case series illustrating some of the medical problems that resulted from drugs bought on-line illegally.

Quality of life of caregivers of patients with advanced-stage cancer.

There has been much research documenting the impact of having a loved one diagnosed with advanced cancer, but little is known about how to reduce care-giver burden. In this randomized controlled trial, the authors examined the potential relationship of an advanced cancer patient’s participation in an 8-session, structured, multidisciplinary intervention on the care-giver’s burden and quality of life (QOL). Although the patients randomly assigned to the intervention (n = 54) demonstrated improved QOL compared to the control condition (n = 49) participants (P < .05), there was no evidence that improving the patient’s QOL made an impact on the caregiver’s level of burden or the care-giver’s QOL. Further investigation is warranted in this area, including interventions specifically designed and targeted to both reduce caregiver burden and to improve caregiver QOL.

Group and Individual Treatment Strategies for Distress in Cancer Patients

Many cancer patients experience distress during the course of their illness. Recently, the National Comprehensive Cancer Network recommended that all cancer patients receive evaluation and treatment of distress as a routine part of their care. For some patients, psychosocial interventions may be helpful, but which patients benefit from what type of psychosocial interventions is unclear. To highlight the importance of this problem, this article examines the prevalence of distress in cancer patients and reviews the evidence that supports that cancer patients benefit from group and individual treatment strategies. Several randomized studies have examined the effects of group or individual therapy on both the emotional and the physiological well-being of cancer patients. Both individual and group interventions that are structured have proved effective in reducing distress. Clearly, more investigation is warranted and future research is needed to advance the understanding of structured interventions, to examine support groups, and to tailor psychological interventions to meet individual needs of distressed cancer patients.

A Generalist's Guide to Treating Patients With Depression With an Emphasis on Using Side Effects to Tailor Antidepressant Therapy

This review provides a guide to the primary care physician for diagnosing and managing depression. To identify relevant articles, a PubMed search (ending date parameter, October 15, 2009) was conducted using the keywords depression, antidepressants, side effects, adverse effects, weight gain, sexual dysfunction, and sleep disturbance, and the reference lists of relevant articles were hand searched. This review explores the challenges in diagnosing depression that will and will not respond to antidepressants (ADs) and describes the value of 2-question screening instruments followed by in-depth questioning for positive screening results. It underscores the implications of veiled somatic presentations in which underlying depression is missed, leading to fruitless and expensive medical work-ups. Following this survey of the difficulties in diagnosing depression, the 4 options generalists have for treating a patient with depression are discussed: watchful waiting, antidepressant therapy, psychotherapy, and psychiatric referral. This review proposes that physicians, once they decide to prescribe, use AD side effects to advantage by selecting medications to minimize negative and maximize positive possibilities, thereby improving adherence. It focuses on the 3 most troubling adverse effects-sleep disturbance, sexual dysfunction, and weight gain. It provides AD-prescribing principles to assist primary care physicians in successfully managing depression and appropriately referring patients to a psychiatrist. Antidepressant therapy is not a panacea for treating patients with depression. An approach blending enlightened observation, medications, and psychotherapy often helps depressed patients recover to their former baselines.

Impulse control disorders in patients with dopamine agonist‐treated prolactinomas and nonfunctioning pituitary adenomas: a case–control study

We aimed to assess the prevalence of impulse control disorders (ICDs) in patients with prolactin‐secreting adenomas treated with dopamine agonists (DAs), to identify associated factors and to compare it with a group of patients with nonfunctioning pituitary adenoma.

An Updated Review of Implantable Cardioverter/Defibrillators, Induced Anxiety, and Quality of Life

Despite overall favorable acceptance of implantable cardioverter-defibrillators (ICDs), patients may experience discharges as frightening and painful. The authors reviewed ICD-induced psychopathology in 2005. During the past 2 years the number of studies examining psychopathology and quality of life after ICD implantation has increased dramatically, warranting this update of that review. Variables assessed have included recipient age, gender, social support network, perception of control and predictability of shocks, and personality style. Now the picture of what is known is, if anything, cloudier than it was 2 years ago, with little definitive and much contradictory data emerging in most of these categories.

Psychiatric Adverse Effects of Pediatric Corticosteroid Use

Corticosteroids, highly effective drugs for myriad disease states, have considerable neuropsychiatric adverse effects that can manifest in cognitive disorders, behavioral changes, and frank psychiatric disease. Recent reviews have summarized these effects in adults, but a comprehensive review on corticosteroid effects in children has not been published since 2005. Here, we systematically review articles published since then that, we find, naturally divide into 3 main areas: (1) chronic effects of acute prenatal and neonatal exposure associated with prematurity and congenital conditions; (2) immediate behavioral effects of acute exposure via oncological protocols; and (3) acute behavioral effects of sporadic use in children and adolescents with other conditions. PsycInfo, MEDLINE, Embase, and Scopus were queried to identify articles reporting psychiatric adverse effects of corticosteroids in pediatric patients. Search terms included corticosteroids, adrenal cortex hormones, steroid psychosis, substance-induced psychoses, glucocorticoids, dexamethasone, hydrocortisone, prednisone, adverse effects, mood disorders, mental disorders, psychosis, psychotic, psychoses, side effect, chemically induced, emotions, affective symptoms, toxicity, behavior, behavioral symptoms, infant, child, adolescent, pediatric, paediatric, neonatal, children, teen, and teenager. Following guidelines for systematic reviews from the Potsdam Consultation on Meta-Analysis, we have found it difficult to draw specific conclusions that are more than general impressions owing to the quality of the available studies. We find a mixed picture with neonates exposed to dexamethasone, with some articles reporting eventual deficits in neuropsychiatric functioning and others reporting no effect. In pediatric patients with acute lymphoblastic leukemia, corticosteroid use appears to correlate with negative psychiatric and behavioral effects. In children treated with corticosteroids for noncancer conditions, adverse effects have been observed both during treatment and after cessation, although the data from article to article are not consistent enough to establish dose relationships. By and large, inhaled corticosteroids are considered safe and free of severe neuropsychiatric effects. Although both antipsychotic medications and benzodiazepines have been used to treat corticosteroid-induced mania and psychosis, no unified management strategy has emerged. Large-scale standardized investigations are needed to clarify the psychiatric effect of corticosteroids on children in all these conditions. Meanwhile, there is general agreement that patients as well as caregivers should be warned of the potential for behavioral adverse effects when patients receive these drugs.