John D. Matthews

Mania associated with St. John's wort.

BACKGROUND St. Johns wort, the popular herbal remedy touted as an antidepressant, is generally thought to be benign, with few reported side effects. Given its possible efficacy as an antidepressant, evaluation of its propensity to cause affective switching should be evaluated. METHODS This report presents two cases of mania temporally associated with the use of St. Johns wort (hypericum). RESULTS As with other antidepressant agents, St. Johns wort may precipitate hypomania, mania, or an increased cycling of mood states, particularly in patients with occult bipolar disorder. CONCLUSIONS Because the majority of people who take this popular over-the-counter preparation do so without formal psychiatric evaluations, risk of hypericum-induced mania may be significant. Physicians should screen patients for a history of hypomania or mania before recommending use of St. Johns wort for depression.

Effects of adding cognitive therapy to fluoxetine dose increase on risk of relapse and residual depressive symptoms in continuation treatment of major depressive disorder

Patients with major depressive disorder remain at risk for relapse following remission and often continue to experience subthreshold symptoms. This study compared the rate of relapse of major depressive disorder and the prevalence of residual depressive symptoms during the continuation phase for patients treated with fluoxetine dose increase alone or in combination with cognitive therapy. A total of 132 outpatients with major depressive disorder who achieved remission with 8 weeks of treatment with fluoxetine 20 mg had the dose increased to 40 mg. They were randomized to receive cognitive therapy or medication management alone and were followed for up to 28 weeks for depressive relapse and change in depressive symptoms. A total of 47 (35.6%) out of 132 patients did not complete the 28-week continuation phase. Rates of discontinuation or relapse did not differ significantly between the groups. Change in residual symptoms or wellbeing as measured by Hamilton Depression Scale score or Symptom Questionnaire self-report also did not differ between groups. In this sample of outpatients in continuation phase treatment for major depressive disorder, the combination of cognitive therapy and fluoxetine 40 mg failed to yield any significant benefit in symptoms or relapse rates over fluoxetine 40 mg alone during 28 weeks of follow-up.

Cognitive–Behavioral Therapy for Patients With Parkinson’s Disease and Comorbid Major Depressive Disorder

Background Depression has been recognized as a common feature of Parkinson’s disease (PD), and is the most prevalent psychiatric disorder in PD patients. Objective The authors sought to determine whether cognitive– behavioral therapy (CBT) is effective in the treatment of depression within the context of PD (dPD). Method The authors enrolled 8 depressed PD patients into an open treatment study of 12 weeks of individual CBT treatment. Results There was a significant linear decrease in mean Hamilton Rating Scale for Depression (17-item) scores over Weeks 0 to 12, and 57% of patients (4/7) met criteria for remission at endpoint. Conclusion This uncontrolled study suggests that CBT may be effective in treating dPD and may be an alternative or adjunct to pharmacological treatment.

Eating disorder symptomatology in major depression

This study evaluated the relationship between eating disorder symptomatology and severity of depression in depressed outpatients before and after antidepressant treatment and assessed the effect of treatment on eating disorder symptomatology. One hundred thirty-nine outpatients (82 women and 57 men) with major depressive disorder (MDD) filled out the eating disorder inventory (EDI) before and after 8 weeks of treatment with fluoxetine 20 mg/day. Diagnoses of MDD and possible comorbid eating disorders were made with the Structured Clinical Interview for DSM-III-R-Patient Edition. Several EDI subscales correlated significantly with severity of depression both at baseline and endpoint. Additionally, all EDI subscales showed a statistically significant decrease following fluoxetine treatment, and changes in depression severity following treatment were significantly related to changes in EDI bulimia, ineffectiveness, perfectionism, and interpersonal distress subscale scores. These results suggest that several symptoms characteristic of eating disordered patients are linked to the severity of depressive symptoms. Decreases in eating disorder symptomatology following antidepressant treatment may be related to changes in depressive symptoms.

Quantitative assessment of psychomotor activity in patients with neuroleptic-induced akathisia

1. An ambulatory activity monitor with solid-state memory was employed to obtain 24-hour activity data in 29 neuroleptic-treated hospitalized patients and 9 normal controls. 2. The activity monitor is a piezoelectric device which was strapped to the non-dominant ankle. Activity was recorded in 5-minute epochs throughout the 24-hour period. 3. In contrast to patients with mania (N = 15) and schizophrenia (N = 4), depressed patients (N = 9) had higher clinical ratings of akathisia and lower levels of daytime activity. 4. Manic and depressed patients showed a delay of peak activity (= acrophase). 5. Quantifiable alterations in rest-activity rhythms may occur in neuroleptic-induced akathisia but measurement of activity may be complicated by the patients psychiatric disorder.

A double-blind, placebo-controlled study of the impact of galantamine on anterograde memory impairment during electroconvulsive therapy.

Background Electroconvulsive therapy (ECT) continues to be an effective treatment option for patients who fail to respond to pharmacological interventions, are unable to tolerate medications, and show a suboptimal response to behavioral and psychotherapeutic treatments. However, risks for cognitive impairment may contribute to some patients’ refusal of ECT. Methods The present study examined galantamine as a pharmacological intervention to reduce cognitive adverse effects from ECT. Thirty-nine inpatients diagnosed with major depressive disorder; bipolar disorder, depressed type; or schizoaffective disorder, depressed type and admitted for ECT were randomized to galantamine or placebo. Study drugs were initiated 24 to 48 hours before starting ECT and continued throughout the course of ECT. A neuropsychological test battery was administered at baseline and 24 to 48 hours after completing a course of ECT treatments. Depression severity was monitored using the 17-item Hamilton Rating Scale for Depression and Clinical Global Impression Scale at baseline, weekly, and end point. Self-rated adverse effects were monitored weekly. Results Thirty participants (12 patients in the galantamine group, 18 patients in the placebo group) had both pretreatment and posttreatment neuropsychological ratings. Those in the galantamine group scored significantly higher at discharge for delayed memory (t28 = 2.44, P < 0.05). Hierarchical regressions examined if treatment condition predicted changes in delayed memory scores from baseline to discharge. Inclusion of the treatment condition in the final model made a significant incremental improvement in prediction (&Dgr;R2 = 0.12, F1,27 change = 4.65, P < 0.05; &bgr; = 0.37, t = 2.16, P < 0.05). Galantamine was well tolerated with no clinically significant bradycardia or prolonged paralysis when administered with ECT. Conclusions Galantamine may be protective against impairment in retention of new learning. Galantamine exhibited minimal adverse effects and was safe when administered during ECT. The present findings require replication by future researchers using larger samples before broad conclusions can be drawn.

Predictors of stable personality disorder diagnoses in outpatients with remitted depression.

This study examined the stability of comorbid personality disorder diagnoses once an outpatient’s depression remitted. The sample consisted of 75 outpatients who responded to treatment in an 8-week acute treatment phase for depression, who met criteria for remission throughout a 26-week continuation phase, and who completed a personality assessment (Structured Clinical Interview for DSM-III-R-axis II Disorders) at the beginning and at the end of each treatment phase. The authors found that after a major depressive disorder is successfully treated, personality disorder diagnoses remain stable across time during continuation treatment. Gender was the only potential predictor variable that was significant: the proportion of men who had a stable personality disorder diagnosis in cluster A or cluster B was significantly greater than the proportion of women who had a stable personality disorder diagnosis in these two clusters. Among women, those with any stable personality disorder had a significantly longer duration of the current major depressive disorder compared with those who never met criteria for any personality disorder; this was also true for women with a cluster C personality disorder diagnosis.

Risk of suicidality in depression with serotonergic antidepressants.

Since depression is a risk factor for suicidal thoughts and behaviors, and since suicidal behaviors are associated with low serotonin activity, are selective serotonin reuptake inhibitors (SSRIs) more effective than other antidepressants in treating suicidality in depressed patients? There is inconclusive evidence for and against this hypothesis. However, all studies suggest that antidepressants are effective treatments of suicidal ideations and behaviors, and SSRIs have been shown to have prophylactic effects in preventing suicidal behaviors. Although some reports suggest that SSRIs might increase suicidal ideations and behaviors, the results of large, double-blind studies do not suggest a causal relationship between pharmacotherapy and the emergence of suicidality. Undertreatment of depression and therapeutic failure are more significant problems with the use of antidepressants in suicidal patients than the risk of using antidepressants in overdose. Prescribing inadequate doses of antidepressants is therefore a source of overlooked risk.

Development and Application of a Brief Multi-faceted Tool for Evaluating Inpatient Psychiatric Care

Increasingly, hospitals are expected to monitor and document service delivery variables, such as treatment outcome and patient satisfaction with care, which are thought to be associated with the quality of care received by patients. Documenting the patients collaboration in the treatment-planning process also has become more important. However, for many clinically oriented units, translating these expectations into a useable instrument and an efficient measurement procedure is a complex and difficult task. This paper outlines the development of a brief multi-faceted program evaluation instrument and assessment process for completing these tasks. The authors describe the rationale behind their approach to these measurement issues, and they introduce an instrument capable of effectively measuring both outcome and satisfaction. They also provide an overview of how they apply the instrument in their inpatient psychiatry service. The strengths and weakness of this assessment strategy are reviewed.

An open study of aripiprazole and escitalopram for psychotic major depressive disorder.

Objective: This 7-week trial assessed the efficacy and tolerability of aripiprazole combined with escitalopram in the acute treatment of major depressive disorder, with psychotic features (MD-Psy). Methods: Sixteen male and female patients with a Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of MD-Psy were recruited for this study from September 13, 2004 to August 9, 2006. Escitalopram and aripiprazole were flexibly dosed for 7 weeks, with maximum dosages of 20 and 30 mg/d, respectively. The 17-item Hamilton Rating Scale for Depression (HAM-D-17) and Structured Clinical Interview for DSM-IV psychosis module were used to measure depression and psychosis responses. The Barnes Akathisia Scale and the Simpson Angus Scale were used to assess for akathisia and extrapyramidal symptoms. Results: Thirteen of the 16 subjects completed the study. The MD-Psy response rate (50% or greater drop in HAM-D-17 and no psychosis) (intent-to-treat, last observation carried forward) was 62.5%, and the MD-Psy remission rate (HAM-D-17, <8, and no psychosis) (intent-to-treat, last observation carried forward) was 50.0%. Ten of the 16 subjects developed akathisia; however, 9 of the 10 subjects had resolution or partial resolution of akathisia with dose adjustment or treatment with propranolol. Conclusions: The combination of escitalopram and aripiprazole seems to be an effective and safe treatment for MD-Psy.