Kemuel L. Philbrick

Decisional capacity of severely depressed patients requiring electroconvulsive therapy.

Objective The decisional capacity of severely depressed people frequently comes into question. The ability to improve this decisional capacity through educational efforts alone is not known. Our study aimed to determine the decisional capacity of severely depressed people requiring electroconvulsive therapy (ECT), and whether educational interventions improve their ability to provide informed consent for ECT. Materials and Methods Forty subjects with severe depression were recruited. Using the MacArthur Competence Assessment Tool for Treatment instrument, decisional capacity was assessed at baseline and reassessed after education. All of the subjects received standard education. Additionally, half were blindly randomized to receive an experimental educational intervention. Results At baseline, there was no statistical difference in the decisional capacity between the standard and experimental intervention groups. After educational interventions, all four areas of decisional capacity improved for both groups (understanding p < 0.001, reasoning p < 0.001, appreciation p = 0.031, choice p = 0.006). However, there was no measurable additional improvement in scores for those randomized to receive additional education. Conclusion Our findings indicate that this group of severely depressed people had good decisional capacities to give informed consent. Education improved their decisional capacity. There is an endpoint beyond which additional educational intervention does not result in measurable improvement in decisional capacity.

Major depression in medically ill patients

Major depression is one of the most common psychiatric problems complicating the treatment and prognosis of patients with active medical illness. Recognizing and treating major depressive conditions in this population can often be challenging, even for the most seasoned clinicians. This article reviews the medical and neurologic conditions that have been associated with the high prevalence rates of major depression. Highlights of the evaluation process that help confirm this suspected diagnosis are addressed, and management issues are discussed. Brief reviews of supportive psychotherapeutic tools that the clinician may find helpful are included, as well as current advances in pharmacologic interventions.

Delirium: An evidence-based medicine (EBM) monograph for psychosomatic medicine practice, comissioned by the Academy of Psychosomatic Medicine (APM) and the European Association of Consultation Liaison Psychiatry and Psychosomatics (EACLPP)

a Department of Psychiatry, Maastricht University Medical Centre, P.O. Box 5800, 6212 AZ Maastricht, The Netherlands b Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, USA c Department of Psychiatry, University of California, San Francisco, CA, USA d Medical Education Programme Psychiatry, San Francisco School of Medicine, University of California (Fresno Campus) and Fresno County Department of Behavioral Health, Fresno, CA, USA e Ingham Regional Medical Center, Lansing, MI, USA f Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA g Department of Psychosomatic Medicine and Psychotherapy, General Hospital Nuremberg, Nuremberg, Germany h Oncology Supportive Care Services, Samuel Oschin Comprehensive Cancer Institute, Samuel Oschin Cancer Center, Los Angeles, CA, USA i Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

Depressive Symptoms Associated with Poor Health-Related Quality of Life in Adults with Strabismus

Successful strabismus surgery improves health-related quality of life (HRQOL) in the majority of patients,1 but for some, HRQOL does not improve despite successful treatment, suggesting other non-strabismus factors may cause reduced HRQOL. We evaluated associations between psychological, clinical or demographic factors, and HRQOL in adults with strabismus. Consecutive adult strabismus patients were prospectively enrolled and completed four questionnaires: 1) Adult Strabismus-20 (AS-20) HRQOL questionnaire2 with four, separately scored domains (Self-Perception, Interactions, Reading Function and General Function: scored 0 [worst] to 100 [best] HRQOL); 2) DS-14 distressed personality questionnaire3 (classified: Yes/No); 3) Center for Epidemiologic Studies Depression Scale – Revised (CESD-R) depression screening questionnaire,4 (scored 0–80; ≥ 16 subnormal); 4) Diplopia Questionnaire5 rating diplopia severity (scored 0 [no diplopia] to 100 [constant diplopia]). Clinical data collected were: direction of deviation, magnitude of deviation, diplopia questionnaire score, best-eye visual acuity (LogMAR), and presence/absence of visually obtrusive co-morbidity. Demographic data collected were: age at onset of strabismus, age at assessment, and sex. Each of these psychological, clinical or demographic data points were included as a factor that may be associated with reduced HRQOL. Univariate regression analyses were performed for each AS-20 domain. Factors with a univariate significance of P<0.1 were included in multiple linear regression analyses. In multiple linear regression analyses factors were considered associated with reduced HRQOL if P=<0.05. Spearman rank correlations were calculated. If a strong correlation (r≥0.5) between factors was identified separate analyses were performed retaining only the second of any pair of correlated factors, to confirm the associations. One hundred and seventy-seven patients were recruited, median age 52 years (range 18 to 88 years). Ninety-six (54%) of 177 were female and 171 (97%) were white. 72 (41%) had childhood onset strabismus, 46 (26%) neurogenic, 30 (17%) idiopathic, 15 (8%) mechanical, and 14 (8%) sensory. One hundred and eleven (63%) of 177 had diplopia and 126 (71%) had undergone previous eye muscle surgery at least 5 weeks prior to assessment (only 28 (16%) of 177 patients had undergone surgery within 6 months of assessment). Mean best-eye visual acuity was 20/22 (range 20/15 to 20/63). Visually obtrusive co-morbidity was present in 30 (17%) of 177; Type D personality was present in 32 (18%) and CESD-R scores were elevated (subnormal) in 23 (13%). For 22 of 23 with subnormal CESD-R scores, responses were consistent with subthreshold depressive symptoms. One patient met the definition for a probable depressive episode (known diagnosis of depression and receiving psychiatric care). In univariate analysis nine factors were associated with reduced HRQOL on at least one AS-20 domain (P<0.1, eTable). The only factors highly correlated with each other were age at assessment and age at onset (r=0.57, P<0.0001). eTable Univariate Analysis of Psychological, Clinical and Demographic Factors for Associations with Reduced Health-related Quality of Life in Adults with Strabismus. In multiple linear regression analysis, for the Self-Perception domain, two of the four initially identified factors (eTable) were independently associated with reduced HRQOL: younger age at assessment (P<0.0001) and larger magnitude of deviation (P<0.0001, Table 1). Table 1 Multiple Linear Regression Analyses Showing Factors Independently Associated With Reduced Health-related Quality of Life (HRQOL) on Each of the Four Adult Strabismus-20 Questionnaire Domains. For the Interactions domain, three of the five initially identified factors (eTable) were independently associated with reduced HRQOL: greater magnitude of deviation (P=0.0002), younger age at assessment (P=0.0007) and higher (worse) CESD-R score (P=0.02, Table 1). For the Reading Function domain, two of the three initially identified factors (eTable) were independently associated with reduced HRQOL: higher (worse) diplopia questionnaire score (P<0.0001) and higher (worse) CESD-R score (P=0.0001, Table 1). For the AS-20 General Function domain, five of the six initially identified factors (eTable) were independently associated with reduced HRQOL: higher (worse) diplopia questionnaire score (P<0.0001), higher (worse) CESD-R score (P=0.0008), younger age at assessment (P=0.001), poorer best-eye visual acuity (P=0.007) and greater magnitude of deviation (P=0.01, Table 1). Finding higher depression scores associated with reduced HRQOL supports the hypothesis that other factors, unrelated to strabismus (in this case depression), may cause reduced HRQOL. Nevertheless, our data cannot address whether depression develops as a result of the poor HRQOL associated with strabismus or whether depression is an independent cause of reduced HRQOL in strabismus patients. For each of the four AS-20 domains, clinical and/or demographic factors were also associated with reduced HRQOL (Table 1), for example worse diplopia with poorer General Function. If such clinical factors were a cause of higher depression scores, we would expect clinical factors and depression scores to be correlated, which they were not. The uncertainty as to whether reduced HRQOL causes depression or vice versa has been the topic of previous studies, although conclusions differ. For strabismus patients, longitudinal studies evaluating depression status over time, for example preoperatively and postoperatively, need to be conducted to evaluate the temporal relationship between depression and reduced HRQOL. The association of depressive symptoms with poorer performance on patient-reported outcome measures (PROMs) such as HRQOL has important implications. Increasing emphasis is being placed on PROMs for the assessment of treatment effectiveness, and therefore a comprehensive understanding of the influence of additional factors such as depression is imperative. Without such insight, there may be a mismatch between the perspective of the healthcare provider (judging outcomes using objective, clinical measures), and the perspective of the patient. Any health care provider encountering elevated depression scores at the level of a possible depressive episode or worse, is responsible for ensuring the patient receives appropriate psychiatric care. Several clinical or demographic factors were associated with poorer HRQOL. The association of younger age at assessment may suggest somewhat greater insecurity and vulnerability in younger adults. Larger magnitude of deviation was also associated, consistent with previous studies showing increased awareness of misalignment with larger deviations. Reduced Reading Function and General Function HRQOL were associated with worse diplopia, as might be expected. The association of subthreshold depressive symptoms with reduced HRQOL should be considered when evaluating adults with strabismus and when interpreting patient reported outcomes. Further study is needed to elucidate whether depression develops as a result of poor HRQOL associated with strabismus, or whether depression is an independent cause of reduced HRQOL in strabismus patients.

Primary Progressive Aphasia: An Uncommon Masquerader of Psychiatric Disorders

Primary progressive aphasia is a recently described, uncommon language disorder with unclear etiological and clinical boundaries. The infrequency and ambiguity of the syndrome may prompt psychiatric consultation. The authors review the pertinent features of one such referral, including a brief literature review of the salient aspects of the differential diagnosis, and note the implications for appropriate treatment.

Catatonia as a manifestation of tacrolimus-induced neurotoxicity in organ transplant patients: A case series

Tacrolimus has been associated with severe neurotoxicity in organ transplant patients. Catatonia can be a rare manifestation of tacrolimus-induced neurotoxicity as we report two cases of catatonia in solid organ transplant patients on tacrolimus. Catatonic symptoms completely resolved in these patients after reducing the tacrolimus dosage or switching it to alternative immunosuppressants. Catatonia symptoms in organ transplant patients should alert clinicians to look for tacrolimus-induced neurotoxicity despite normal serum tacrolimus levels and neuroimaging findings.

Psychosis Likely Induced by Hydroxychloroquine in a Patient With Chronic Q Fever: A Case Report and Clinically Relevant Review of Pharmacology

Received January 9, 2012; revised June 22, 2013; accepted June 24, 2013. From Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN. Send correspondence and reprint requests to Piyush Das, M.D., Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, 11203 Stokes Boulevard, Cleveland, OH 44104; e-mail: drpiyushdas@yahoo.com & 2014TheAcademy of PsychosomaticMedicine. Published by Elsevier Inc. All rights reserved. Introduction

Wernicke Encephalopathy in a Non-Alcoholic Patient With Metastatic CNS Lymphoma and New-Onset Occipital Lobe Seizures

To the Editor: A 51-year-old man with no psychiatric or alcohol use history was treated for high-grade B-cell lymphoma involving the bowel, liver, and bone marrow, achieving complete remission with systemic chemotherapy. Six months later, he developed severe headaches secondary to relapsed CNS lymphoma. He presented with confusion, bilateral ophthalmoplegia, nonreactive pupils, and ptosis. MRI showed leptomeningeal enhancement along the temporal and occipital lobes bilaterally with adjacent parenchymal infiltration and expansion of the cavernous sinuses. On admission, high-dose intravenous methotrexate was initiated, and the psychiatry department was consulted because of concern for delirium. On mental status exam, he was noted to be confused, with florid visual hallucinations (seeing animals in his room, sparkles dancing on his skin, and the blood coursing through his veins). Wernicke encephalopathy (WE) was suspected, and, after one dose of intravenous thiamine, he became fully oriented, and his symptoms of ophthalmoplegia improved, but visual hallucinations persisted. EEG showed epileptogenic activity over the left occipital region consistent with simple partial occipital lobe seizures. Visual hallucinations resolved with initiation of levetiracetam. Discussion Thiamine deficiency leads to breakdown of the blood–brain barrier, neuronal necrosis, and irreversible brain damage in susceptible areas, including the medial thalamus and periaqueductal gray matter. Despite thiamine administration, WE patients (as high as 80%) may progress to Korsakoff syndrome, a chronic condition characterized by anterograde amnesia and confabulations. Coma and death may ensue, with 17% mortality for untreated WE. The incidence of WE in the general cancer population is unknown. In one autopsy series, 8 of 24 patients with leukemia or lymphoma had pathologic findings suggestive of WE, none of which were recognized clinically. Cancer patients are at high risk of WE due to chronic malnutrition, chemotherapy-induced nausea and vomiting, and consumption of thiamine by rapidly-growing tumors such as hematological malignancies and sarcoma. BrainMRI is the imaging procedure of choice because of high specificity (93%), although it cannot exclude WE because of low sensitivity (53%). MRI findings in alcoholic patients with acute WE may reveal atrophy of the mamillary bodies, infratentorial regions, supratentorial cortex, and corpus callosum, whereas atrophic changes are generally absent in nonalcoholic patients. Diagnosis of WE is difficult in cancer patients because there are multiple reasons for confusional states, including hypoxia, infection, electrolyte imbalances, organ failure, opioid and sedative medications, chemotherapy, and brain and meningeal metastases. WE is a neurological emergency, and thiamine (500 mg 3 times daily) should be initiated immediately, either intravenously or intramuscularly, to ensure adequate absorption.

Thiothixene in the Management of Delirium: A Case Series

BACKGROUND Pharmacologic strategies are often required to help manage agitated patients with delirium. First-and second-generation antipsychotic medications (such as haloperidol, quetiapine, and olanzapine) are commonly used. OBJECTIVE On the psychiatric consultation service in our hospital, thiothixene has been used based on its favorable potency, sedative, and cost profiles. Little has been written about the utility of this drug for management of delirium. METHODS We reviewed our experience with thiothixene in this setting using pharmacy records to identify patients who received at least 1 dose between July 2011 and March 2014. We scrutinized the relevant medical records (n = 111) and recorded the following data: age, sex, medical diagnoses, signs and symptoms of delirium, dosing of thiothixene, and response to thiothixene in terms of both apparent benefit as well as side effects. RESULTS Resolution or improvement was documented in 78% of patients and good tolerability in 82% of patients. CONCLUSIONS Although further data from a randomized, controlled trial would be ideal, our experience suggests that thiothixene could be a safe and effective pharmacologic treatment for agitation and psychosis due to delirium.

Factors associated with failure of adult strabismus-20 questionnaire scores to improve following strabismus surgery

Importance Health-related quality of life (HRQOL) typically improves following strabismus surgery. Nevertheless, for some patients, HRQOL does not improve, and reasons for this are unknown. Objective To identify factors associated with failure of adult strabismus–20 (AS-20) HRQOL scores to improve following strabismus surgery. Design, Setting, and Participants Prospective observational case series at the Mayo Clinic, Rochester, Minnesota, comprising 276 adults, between July 2012 and August 2016. Main Outcomes and Measures Participants completed the AS-20 HRQOL questionnaire, diplopia questionnaire, Center for Epidemiologic Studies Depression Scale–Revised (CESD-R) (depressive symptoms), and Type-D Scale 14 questionnaire (type-Distressed [type-D] personality) both preoperatively and 6 weeks postoperatively. To assess factors associated with failure of HRQOL to improve (no change or decrease in score), univariate and multiple logistic regression analyses were performed. Each of the 4 AS-20 domains (self-perception, interactions, reading function, and general function) were analyzed separately including only patients able to improve at least by the magnitude of previously defined 95% limits of agreement. Factors assessed were age (at onset and at surgery), sex, number of previous surgeries, presence of visually obtrusive facial anomaly, visual acuity, preoperative and postoperative diplopia questionnaire scores, alignment (as a vector), presence of esotropia, presence of a vertical deviation, CESD-R scores, and type-D personality. Stepwise multiple logistic regression analyses were performed to assess factors associated with failure of AS-20 scores to improve for each domain. Results Of the 276 participants, the median age was 57 years (range, 18-91 years), 153 were women (55%), and 266 were white (96%). Failure to improve was associated with worse diplopia postoperatively on the self-perception (adjusted risk ratio [RR], 1.01; 95% CI, 1.00-1.02), reading function (adjusted RR, 1.02; 95% CI, 1.01-1.03), and general function domains (adjusted RR, 1.02; 95% CI, 1.01-1.03). In addition, failure to improve on the self-perception domain was associated with type-D personality postoperatively (adjusted RR, 4.26; 95% CI, 1.90-9.57) and failure to improve on the interactions domain was associated with postoperative depressive symptoms (adjusted RR, 1.04; 95% CI, 1.02-1.06) and coexisting visually obtrusive anomaly (adjusted RR, 2.12; 95% CI, 1.04-4.32). Conclusions and Relevance Postoperative diplopia, depressive symptoms, type-D personality, and visually obtrusive facial anomalies were associated with failure of AS-20 scores to improve (remaining the same or worsening) following strabismus surgery. The association of nonstrabismus factors may have implications for patient treatment and is worthy of continued study.