John H. Lloyd

Depression in People Living with HIV/AIDS Attending Primary Care and Outpatient Clinics

Objective: Our aim was to gain an estimate of the rate of depressive disorder in patients with HIV/AIDS attending general practice and to investigate factors associated with depression. A further objective was to determine the ability of non-mental health medical practitioners to detect depressive symptoms in their patients with HIV/AIDS. Method: Participants comprised 322 persons living with HIV/AIDS ((PLWHA); 13 females, 309 males; mean age 41.4, SD = 8.9) who were recruited from four general practice clinics specializing in HIV medicine and from an infectious diseases clinic. Medical, psychiatric and sociodemographic data were obtained. In addition, participants completed the Inventory to Diagnose Depression (IDD), a self-report measure to detect depression. Results: Twenty-two per cent of the sample met criteria for a current Major Depressive Episode (DSM-IV defined) on the IDD. Overall, there was moderate agreement between treating doctors’ diagnosis of depression and patients’ self-report of depressive symptoms. A multivariate model indicated that being in a current relationship was associated with lowered odds of depression (OR = 0.43; CI = 0.23–0.81). The factors strongly associated with increased odds of depression were a past history of illicit drug use (OR = 2.98; CI = 1.60–5.54) and a diagnosis of ‘stress’ by treating doctors (OR = 5.65; CI = 2.50–12.77). HIV-related medical variables such as immune function, use of antiretroviral medication and duration of HIV infection were not associated with depression. Conclusions: There was a high rate of self-reported depression in this group of PLWHA which was also recognized by treating clinicians. Being in a relationship appeared to afford protection against depression while having a history of illicit drug use and current ‘stress’ were highly associated with depression. Interestingly, HIV-related medical variables including laboratory markers of HIV disease, duration of illness and antiretroviral medication regimen were not related to depression.

Neuropsychiatric morbidity in focal epilepsy

BACKGROUND Previous work has identified elevated prevalence rates for psychiatric disorders in individuals with medically refractory focal epilepsy, particularly temporal lobe epilepsy. Many studies were undertaken before the advent of video electroencephalogram monitoring (VEM) and magnetic resonance imaging (MRI). AIMS To investigate which characteristics of the focal epilepsy syndromes are associated with the presence of depression or psychosis. METHOD Three hundred and nineteen individuals with focal epilepsy admitted for VEM were seen over an 11-year period. The lifetime history of depression and psychosis, epileptic site, laterality and type of lesion were determined by clinical assessment, VEM and MRI scan. RESULTS There was a significant association between the prevalence of depressive symptoms and non-lesional focal epilepsy. There were no significant differences in prevalence of neuropsychiatric disorders between the groups with temporal lobe epilepsy and those with extratemporal lobe epilepsy. CONCLUSIONS These findings contrast with previous findings in smaller cohorts. The association between non-lesional focal epilepsy and depression may be due to the effects of a more diffuse epileptogenic area.

Clinical characteristics and outcome in patients with psychogenic nonepileptic seizures.

Objectives: To examine baseline clinical features of psychogenic nonepileptic seizures (PNES) in a large cohort and to investigate outcome over a period of up to 10 years. Studies investigating PNES have been limited by differences in diagnostic criteria, short follow-up periods, and the use of limited outcome measures. Method: Patients with PNES were identified, using strict diagnostic criteria. Baseline neurological, neuropsychiatric, and neuroimaging data were obtained from medical records. Long-term outcome was assessed with ratings of seizures, psychopathology, and quality of life in a subset of the patients. Results: Patients with PNES (n = 221) experienced long delays in diagnosis (&mgr;, 5.6 years; standard deviation, 7.7 years) and high rates (>60%) of prolonged treatment with antiepileptic drugs. Compared with previous studies, a relatively low proportion (8.1% to 17.9%, depending on diagnostic criteria) had comorbid epilepsy. An unexpected finding was that 22.6% of PNES patients had magnetic resonance imaging abnormalities. Patients assessed at follow-up (n = 61) exhibited poor long-term outcomes with ongoing PNES, high rates of psychopathology, low rates of specialist follow-up, poor quality of life, and poor overall levels of functioning. Conclusions: These results demonstrate the need for earlier diagnosis of PNES and comorbidities and highlight the need for diagnostic and therapeutic approaches that combine neurological and psychiatric perspectives. PNES = psychogenic nonepileptic seizures; VEM = video-electroencephalographic monitoring; EEG = electroencephalogram; AEDs = antiepileptic drugs; MRI = magnetic resonance imaging; ES = epileptic seizures; QOL = quality of life.

Suicidal Behaviour in People with HIV/AIDS: A Review

Objective: To review the existing literature on suicidal behaviour in people with HIV/AIDS infection. Method: A search on the Index Medicus/MEDLINE database was performed, for articles that investigated and/or reviewed suicidal behaviour in people with HIV at any stage of the illness. Only articles written in English were used in this review. Results: Most studies have been done on homosexual/bisexual groups, with little data available for heterosexual populations or women. Studies show an increased rate of suicidal ideation, suicide attempts and completed suicide in individuals with HIV/AIDS. Of note, there is a high prevalence of psychiatric illness and substance abuse in those with suicidal behaviour. Conclusions: The increased rate of suicidal behaviour in HIV-infected persons is consistent with findings in other medically ill groups with chronic, life-threatening disorders. However, assessment of any possible direct effect of HIV/AIDS on suicidal behaviour is confounded by methodological limitations of many of the studies. More longitudinal studies encompassing other affected groups including heterosexual populations and women are needed to elucidate the relationship between suicidal behaviour and HIV/AIDS.

Increased health care utilization and increased antiretroviral use in HIV‐infected individuals with mental health disorders

The aims of the study were to describe the prevalence and associations of mental health disorder (MHD) among a cohort of HIV‐infected patients attending the Victorian HIV/AIDS Service between 1984 and 2000, and to examine whether antiretroviral therapy use or mortality was influenced by MHD (defined as a record of service provision by psychiatric services on the Victorian Psychiatric Case Register). It was hypothesized that HIV‐positive individuals with MHD would have poorer treatment outcomes, reduced responses to highly active antiretroviral therapy (HAART) and increased mortality compared with those without MHD.

Future directions in research with presymptomatic individuals carrying the gene for Huntington's disease

Presymptomatic individuals carrying the gene for Huntingtons disease (HD) provide researchers with a unique opportunity of learning more about the neuropathophysiology, symptom onset, behavioural functioning, and mediating factors of this fatal disease. In this review, we attempt to demonstrate that research over the last 8 years, since the isolation of the gene, has remained at large controversial. Although we are aware of some of the factors that can influence age at onset and disease progression, we are still unable to determine exactly when an individual will develop HD symptoms, and how fast these symptoms will progress. In an era rapidly advancing with respect to therapeutic intervention that could forestall the onset and progression of HD, systematic research with improved inclusion criteria is paramount. A greater understanding of the time course of the disease would be beneficial not only in monitoring the effectiveness of future treatments, but also in determining the most appropriate time to administer them. Finally, we present various ethical considerations, as well as put forward various recommendations that could assist in better diagnosing preclinical deficits in presymptomatic individuals.

Reversible dementia with psychosis: Hashimoto's encephalopathy.

Abstract  A case of presumed Hashimoto’s encephalopathy (HE) is presented. The presentation included memory loss, delusions, functional decline and culminated in a generalized seizure. Anti‐thyroid antibodies were detected and symptoms resolved with prednisolone. Patients with HE may present with prominent neuropsychiatric symptoms, attract psychiatric diagnoses and present to psychiatric services. Primarily a diagnosis of exclusion, HE should be considered in cases of encephalopathy in which standard investigations are negative.

The role of SPECT scanning in a neuropsychiatry unit

OBJECTIVES Single photon emission computerised tomography (SPECT) studies allow the assessment of cerebral blood flow and have been increasingly used as a clinical tool in neurology and neuropsychiatry. This paper examines the contribution of SPECT to the clinical management of patients with neuropsychiatric disorders, in particular patients with atypical or early onset dementia. METHOD All patients admitted to an eight-bed neuropsychiatry unit in a general hospital setting who had undergone SPECT scanning over a 15-month period were reviewed. Information was collected on clinical diagnosis, neuropsychological testing, structural neuroimaging and SPECT. RESULTS SPECT abnormalities were present in 88% of patients. The pattern of SPECT abnormality was concordant with structural neuroimaging in 65% of patients and concordant with neuropsychological testing in 82% of patients. The sensitivity and specificity of SPECT was 89%/79% for Alzheimers disease and 56%/79% for frontotemporal dementias. CONCLUSIONS SPECT results must be interpreted in the context of other clinical and diagnostic assessments. In no single case was the clinical diagnosis made solely on the basis of a SPECT result. SPECT was of maximum clinical use in the diagnosis of frontotemporal dementias and in confirming the diagnosis of Alzheimers dementia. SPECT was valuable in Lewy body dementia, vascular dementia and head injury. Its clinical utility in other psychiatric disorders remains unclear.

The development of clinical indicators for a consultation-liaison service

Objective: The aim of this paper is to describe the development and implementation of clinical indicators in the consultation–liaison service at Royal Melbourne Hospital (RMH). Method: A working party lead by the University of Melbourne was established in 1998 to develop clinical indicators and a database for the RMH consultation–liaison service. Core parameters for measuring service functioning and six clinical indicators were developed. The system was implemented using a data collection form and computerised database operating within a system of regular clinical reviews. Results: The clinical indicators, database and review system were found to be a feasible, useful and efficient addition to a consultation–liaison service at a major general hospital. Conclusions: Clinical indicators may be used within specialist psychiatry services to enhance clinical care and aid in service development and teaching.

The NUCOG: Construction and Piloting of a Cognitive Screening Instrument in a Neuropsychiatric Unit

Objective: To develop a cognitive screening instrument suitable for a neuropsychiatric inpatient, outpatient and consultation—liaison population. Methods: A number of cognitive screening instruments used clinically and published in the literature were reviewed. A new tool, the Neuropsychiatry Unit Cognitive Screen (NUCOG), was developed on the basis of this review, and piloted in a diverse population of patients in the unit. Conclusions: The NUCOG demonstrated a high degree of face validity, correlation with the Mini-Mental State Examination, and significant scoring differences between demented and non-demented patients.