Levent Atik

The comorbidity of adult attention-deficit/hyperactivity disorder in bipolar disorder patients.

OBJECTIVE High comorbidity ratio of bipolar mood disorder (BMD) with Axis I and Axis II diagnoses is reported in the literature. The possible relationship between BMD and attention-deficit/hyperactivity disorder (ADHD) in all age groups has been attracting more attention of researchers due to highly overlapping symptoms such as excessive talking, attention deficit, and increased motor activity. In this study, we aimed to investigate the prevalence of ADHD comorbidity in BMD patients and the clinical features of these patients. METHODS Of 142 patients, who presented to the Bipolar Disorder Unit of Zonguldak Karaelmas University Research and Application Hospital between the dates of August 1, 2008 and June 31, 2009 and diagnosed with BMD according to DSM-IV criteria consecutively, 118 patients signed informed consent and 90 of them completed the study. They all were in euthymic phase during the study evaluations. A sociodemographical data form, Wender-Utah Rating Scale (WURS), ADD/ADHD Diagnostic and Evaluation Inventory for Adults, and Structural Clinical Interview for DSM-IV Axis I Disorders, Clinical Version (SCID-I) were applied to all participating patients. RESULTS A total of 23.3% of all patients met the criteria for A-ADHD diagnosis along BMD. No difference was detected regarding sociodemographical features between the BMD+A-ADHD and the BMD without A-ADHD groups. The BMD+A-ADHD group had at least one extra educational year repetition than the other group and the difference was statistically significant. The BMD starting age in the BMD+A-ADHD group was significantly earlier (p=0.044) and the number of manic episodes was more frequent in the BMD+A-ADHD group (p=0.026) than the BMD without ADHD group. Panic disorder in the BMD+A-ADHD group (p=0.019) and obsessive-compulsive disorder in the BMD+C-ADHD group (p=0.001) were most frequent comorbidities. CONCLUSIONS A-ADHD is a frequent comorbidity in BMD. It is associated with early starting age of BMD, higher number of manic episodes during the course of BMD, and more comorbid Axis I diagnoses.

Pain perception in patients with bipolar disorder and schizophrenia

Objective: Pain perception is reported to be altered in patients with depression and schizophrenia. However, few studies have investigated the pain perception in patients with bipolar disorders. We therefore aimed to compare pain sensitivity between patients with bipolar disorder, schizophrenia and controls. Methods: Study groups consisted of 30 patients with bipolar disorder, and control groups consisted of 27 patients with schizophrenia and 59 healthy subjects. Pain perception was assessed with cold pressor test (CPT) by exposure to ice-water. Results: Patients with schizophrenia had significantly higher pain thresholds (PTh) than patients with bipolar disorder. There were no differences between the PTh of patients with schizophrenia and healthy control subjects. However, patients with bipolar disorder had significantly lower pain tolerance (PT) in the CPT than patients with schizophrenia and corresponding healthy control subjects. Conclusions: The higher PTh in the schizophrenia group compared with the bipolar group found in this study supports further investigation of a potential difference in the pain perception between patients with schizophrenia and bipolar disorder. Theoretical implications of these findings and possible relevant behavioural and neurochemical mechanisms are discussed.

Sleep disorders in Behçet's disease, and their relationship with fatigue and quality of life.

Behçet’s disease, a systemic vasculitis, can cause varying degrees of activity limitation, fatigue and quality of life impairment. To date, there have been no studies regarding sleep disturbance and its relationship with fatigue and life quality in Behçet’s disease. We aimed to evaluate sleep disorders and polysomnographic parameters, and to determine their relationship with fatigue and quality of life in Behçet’s disease. Fifty‐one patients with Behçet’s disease without any neurological involvement were interviewed regarding sleep disorders. Twenty‐one subjects with no sleep complaints were included as the control group. Sleep‐related complaints were evaluated in a face‐to‐face interview. Sleep quality, excessive daytime sleepiness, fatigue, depression, anxiety, disease activity/severity, and quality of life questionnaires and an overnight polysomnography were performed. Prevalences of restless legs syndrome (35.3%) and obstructive sleep apnea syndrome with/without other sleep disorders (32.5%) were higher than in the control group and the general population. Fatigue was higher in patients with restless legs syndrome and obstructive sleep apnea syndrome, and in those with lower minimum oxygen saturation; hence, only patients with restless legs syndrome had quality of life impairment. Sleep efficiency index and sleep continuity index were lower, and wake after sleep onset, respiratory disturbance index and apnea–hypopnea index were higher than in controls (P < 0.01). Neither sleep disorders nor polysomnographic parameters were related to disease activity and severity. In conclusion, it is important to question sleep disorder followed by a polysomnography, if necessary, in order to improve quality of life and fatigue in Behçet’s disease.

Acute dystonia during pegylated interferon alpha therapy in a case with chronic hepatitis B infection

Interferon (IFN) is the most widely prescribed drug of choice for chronic hepatitis B infection, which is a common health problem in our country. Therapy with IFN-alpha may be associated with a number of neuropsychiatric symptoms, such as Parkinsonism, akathisia, seizure, and depressive disorders. In this case report, we present clinical and laboratory findings of a case with chronic hepatitis B that developed acute dystonia soon after the first dose of pegylated interferon alpha. As far as we know, this is the first report in English literature indicating such an adverse effect of pegylated interferon alpha.

The Relationship between Quality of Life and Cognitive Functions, Anxiety and Depression among Hospitalized Elderly Patients.

Objective Older people seek not only a longer life, but also a better quality of life (QOL). Our aim was to find out the relationship between QOL and socio-demographic factors, social activities, cognitive status, depression and anxiety symptoms among medically ill and hospitalized elderly people in Turkey. Methods Two hundred forty three patients age 65 years or older were examined. The Socio-demographic Data Survey, the Mini Mental State Examination (MMSE), the Geriatric Depression Scale-short form (GDS-15), the Beck Anxiety Inventory (BAI) and the World Health Organization Quality of Life Instrument-Older Adults Module (WHOQOL-OLD) were applied to participants. The independent samples t-test and analysis of variance (ANOVA) were used to analyze quantitative data. Pearson’s correlation and linear regression analysis were performed. Results The total score for QOL was significantly higher for those who saw their family members and relatives frequently rather than rarely (p=0.002), who were always busy with social activities rather than rarely or never (p<0.001), who had more years of education (p=0.003), and who were frequently exercising (p=0.023). According to linear regression analysis, the WHOQOL-OLD total score increased by 0.295 and −0.936 units, while MMSE and GDS-15 scale scores increased one unit respectively (β=0.295, t=1.979, p=0.04; β=−0.936, t=−4.881, p<0.001). Conclusion Cognitive disabilities, depression, and other psychiatric problems along with medical disease negatively affect the QOL of elderly patients. While performing medical assessment regarding elders, detecting and treating cognitive disabilities and depression is very valuable in improving the QOL of elderly patients.

The prevalence and clinical features of the night eating syndrome in psychiatric out-patient population

OBJECTIVE In this study we aimed to investigate the prevalance and clinical correlations of night eating syndrome (NES) in a sample of psychiatric outpatients. METHOD Four hundred thirthy three consecutive psychiatric out-patients older than 18years were evaluated in the outpatient clinics using clinical interview according to the DSM-IV with regard to psychiatric diagnosis. Participants were also screened for presence of NES utilizing both clinical interview and self report based on Night Eating Questionnaire (NEQ) instruments. Sociodemographic and clinical features such as age, gender, education level, socioeconomic level and body mass index (BMI) were also recorded. The Body Shape Questionnaire (BSQ) and the Symptom Checklist-90 Revised (SCL-90R) were administered. RESULTS Based on the proposed diagnostic criteria of the NES via utilizing clinical interview method, 97 (32 male, 65 female) of the sample met diagnostic criteria for NES. The point prevalence of NES was 22.4%. No statistically significant differences were found between the two groups in terms of age, gender, marital status, education and BMI. The patients with NES had higher NEQ, BSQ and SCL-90R subscale scores than patients without NES. Prevalance of depressive disorder, impulse control disorder, and nicotine dependency was higher among patients with NES. No differences were found with regard to the medication (antipsychotics, antidepressants and mood stabilizers). CONCLUSION Night eating syndrome is prevalent among psychiatric outpatients and associated with depression, impulse control disorder, and nicotine dependency. Body dissatisfaction and higher symptom severity are also other risk factors for the development of NES.

Open-label study of adjunct modafinil for the treatment of patients with fatigue, sleepiness, and major depression treated with selective serotonin reuptake inhibitors

Despite the efficacy of selective serotonin reuptake inhibitors (SSRIs) in the treatment of major depression, a significant number of patients show partial or no remission of symptoms. Some evidence suggests that psychostimulant augmentation may be helpful in treating patients with residual symptoms of depression. The efficacy of modafinil in augmenting SSRIs in depressed patients with residual fatigue or excessive daytime sleepiness has yet to be systematically investigated. In a series of 25 patients with major depressive disorder, according to the criteria of theDiagnostic and Statistical Manual of Mental Disorders, 4th edition, who showed significant residual symptoms after an adequate SSRI trial (12 wk) and who were evaluated according to the Fatigue Severity Scale (FSS), subjects with scores ≥4 were given open-label modafinil augmentation for a minimum of an additional 6 wk. Treatment response was assessed prospectively with the FSS, the Epworth Sleepiness Scale (ESS), and the Hamilton Rating Scale for Depression (HAM-D) during the first visit and at the second and sixth weeks. Twenty-one of 25 patients in this series who were treated with modafinil and SSRIs completed the 6-wk augmentation trial. At end-point assessment, all patients showed significant improvement in fatigue and sleepiness in FSS and ESS scores, as well as in HAM-D scores (P< .01). In the second week, 29.4% of patients had a HAM-D score < 7, which was defined as remission; this rate was 64.7% in the sixth week. The rate of patients whose HAM-D score dropped by more than 50%, defined as responders to treatment, was 41.1% and 76.4% in the second and sixth weeks, respectively. Results of this preliminary, open-label trial suggest that modafinil may be effective in augmenting ongoing SSRI treatment for a portion of patients with major depression who have residual fatigue and sleepiness. Larger, placebo-controlled trials appear warranted to investigate the clinical efficacy and tolerability of modafinil augmentation of SSRI treatment in these patients.

The mediator role of ruminative thinking style in the relationship between dysfunctional attitudes and depression

BACKGROUND The main aim of the present study was to examine whether ruminative thinking styles (brooding and reflection) mediate the effects of dysfunctional attitudes on depressive symptoms. METHODS 120 psychotropic drug-naive first episode depression patients recruited from Bulent Ecevit University School of Medicine psychiatry department and Zonguldak State Hospital psychiatry department outpatient clinics were involved in the study. Participants completed the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Beck Depression Inventory (BDI), Dysfunctional Attitude Scale (DAS) and Ruminative Responses Scale (RRS-short version). Regression analyses together with the Sobel tests were performed for testing the mediator hypothesis. RESULTS According to the path model, the level of brooding fully mediated the relationship between dysfunctional attitudes and depressive symptomatology but reflection did not play a mediator role in the relationship between dysfunctional attitudes and depressive symptoms. CONCLUSIONS Assessment of brooding with both mental status examination and specific measurements and focusing on brooding as an intervention strategy would be beneficial components for an effective treatment of depression.

Childhood trauma and suicide risk in the population living in Zonguldak Province.

No previous study has investigated the association between early trauma and suicidal behavior in Zonguldak. The aim of this study was to investigate the incidence of childhood abuse and neglect in the general population living in Zonguldak province and the relationship between childhood trauma and suicidal ideations and attempts.

Compulsive modafinil use in a patient with a history of alcohol use disorder

To the Editor,The mechanism of action of modafinil, a nonamphetamine stimu-lant, remains unknown [1,2].Modafinil is prescribed for a variety ofmedical conditions including narcolepsy, obstructive sleep apnea, shiftwork sleep disorder and bipolar depression [3,4].Modafinil is a dopamine transporter inhibitor [5] with low abuseliability; its efficacy has been investigated for the treatment of cocaine,methylphenidate and alcohol addiction [6–8]. However, few studieshave been conducted on the addictive potential of modafinil, althoughit has been suggested that modafinil should be used with caution[2,3,8]. An association between modafinil use and pathological gam-blinghasbeenreported,possiblyduetothepotentiationofthedopami-nergic system [9]. To the best of our knowledge, the case describedherein represents the first report of compulsive modafinil use, whichoccurred following 2 years of modafinil treatment.A 34-year-old male presented with a history of recurrent depressionandalcoholaddictionfor11years.Hewasadmittedtoourclinicanddiag-nosed with major depression with psychotic features 3 years previously;psychiatric outpatient follow-up was irregular. The patient was treatedwith various psychotropic medications (e.g., Selective serotonin reuptakeinhibitors (SSRIs), Serotonin-norepinephrine reuptake inhibitors (SNRIs)and Tricyclic antidepressants (TCAs) antidepressants, benzodiazepinesand carbamazepine). Due to abuse, benzodiazepine treatment wasdiscontinued 2 years previously. The patient complained of oversleep-ing,fatigueandanhedonianotrelievedbymedication.Laboratoryanal-ysisrevealednoabnormalities,andneurologicalevaluationwasnormal.Two years previously, modafinil was added to his treatment regimen,which comprised duloxetine at 60 mg/day, bupropion at 150 mg/day,modafinil at 200 mg/day and amisulpride at 400 mg/day. This regimenwas maintained for 1.5 years; the patient reported that it increased hisenergy levels.Followinga6-monthabsence,thepatientreportedtoourclinicstatingthat he had increased the dose of modafinil to 35 tablets per day(3500 mg/day),usingtabletsprescribe datnonpsychiatricandpsychiatricoutpatientclinicsorpurchasedwithoutprescription.Weofferedhospi-talizationoroutpatientfollow-up;thepatientdeclinedtobehospitalized.No signs of modafinil addiction were detected, and we altered his treat-ment regimen as follows: modafinil dose was gradually decreased;duloxetine was increased to 90 mg/day; bupropion and amisulpridedoses were maintained at current le vels; and carbamazepine was addedat 600 mg/day,Modafinildopaminereceptoraffinityissimilartothatofmethylphe-nidate, suggesting possible abuse liability [2,10]. In the present case,modafinil was used for treatment-resistant depression, and it amelio-ratedoversleeping,fatigueandanhedonia.However,thepatientreportedthat dose escalation was necessary to maintain his improved mood. Wesuggested that the duloxetine dose be increased instead and that thedose of modafinil be decreased gradually, given its stimulant action. Toreduce impulsivity, we suggested carbamazepine as more appropriatecompared with modafinil dose escalation because modafinil sharesstructuralsimilaritieswithcocaine [11].Accordingtothemostrecentpsy-chiatric records obtained from another hospital, the patient applied toother psychiatricclinicsand decreased hismoda finildosageto vetab-lets per day (500 mg/day) in accordance with our suggested treatmentregimen. At the most recent psychiatric follow-up, also at another clinic,amisulpride was ceased following consultation with our unit.During sensitization, behavioral and neurochemical responses aftersubstance abuse are potentiated [12], a process that can underlie addic-tive behavior. D1 receptors represent one possible mediator of sensitiza-tion [13].Amisulprideexhibitsonlymarginalaf finityforthepostsynapticD1 receptor [14], but this would be exacerbated by the dopamine re-uptake inhibitory effects of bupropion [15] and modafinil. Compulsivemodafinil use may beassociated withthe increase insynaptic dopaminetransmission that preferentially st imulates postsynaptic D1 receptors.Modafinil may exertdifferenteffectsin accordance withpersonalityprofile [16]; no personality measurement instruments were applied inthe present case, which represents a limitation to the study.In conclusion, in patients with a history of addiction and low treat-ment compliance, dopamine-enhancing medication should be usedwithcaution;potentialinteractionswith other prescribeddrugs shouldbe considered to reduce the likelihood of compulsive use.Melek Cengiz Mete MDOmer Şenormanci MDOzge Saracli MDNuray Atasoy MDLevent Atik MDProfessor, Bulent Ecevit University School of Medicine, PsychiatryZonguldak, TurkeyE-mail address: senorman_7@hotmail.comAvailable online xxxxReferences