Michael K. Popkin

Presentation of the Steroid Psychoses

This study suggests that patients receiving daily doses of 40 mg of prednisone or its equivalent, are at greater risk for developing steroid psychosis. Psychotic reactions were twice as likely to occur during the first 5 days of treatment as subsequently. Premorbid personality, history of previous psychiatric disorder, and a history of previous steroid psychosis did not clearly increase the patients risk of developing psychotic reaction during any given course of therapy. Steroid psychoses present as spectrum psychoses with symptoms ranging from affective through schizophreniform to those of an organic brain syndrome. No characteristic stable presentation was observed in these 14 cases reported here. The most prominent symptom constellation to appear some time during the course of the illness consisted of emotional lability, anxiety, distractibility, pressured speech, sensory flooding, insomnia, depression, perplexity, agitation, auditory and visual hallucinations, intermittent memory impairment, mutism, disturbances of body image, delusions, apathy, and hypomania. Phenothiazines administered in average daily doses of 212 mg produced excellent response in all patients studied. Of particular note was the fact that tricyclic antidepressants produced an exacerbation or worsening of the clinical state in all patients to whom they were administered.

Depressed Mood and Other Variables Related to Bone Marrow Transplantation Survival in Acute Leukemia

Routine psychiatric evaluations of 100 adult patients undergoing allogeneic bone marrow transplantation for acute leukemia were reviewed to examine the possible relationship of psychiatric and psychosocial factors to duration of survival following the procedure. Three variables were found to independently affect outcome: illness status (first remission vs. other status), presence of depressed mood, and the extent of perceived social support. Patients transplanted while in their first remission had significantly improved survival; patients with depressed mood, regardless of specific psychiatric diagnosis, had poorer outcomes; and patients with a high level of perceived social support had improved survival. The possible mechanisms by which these variables affect outcome are discussed.

Suicide in the Medical Patient

According to the statistical abstract of the United States for 1982–1983, there were 1,913,800 deaths in the United States in 1979 [1]. Twenty-seven thousand, or 1.4 percent of those deaths were by suicide, yielding a suicide rate of 11.9/100,000/year. The rate was highest (39.2/100,000) for white males sixty-five years and over and lowest (0.1/100,000) for black females between five and fourteen years. It is generally accepted that physical illness is a risk factor for suicide. If this is true, then in caring for persons with significant physical illness, physicians are dealing with a population at increased risk of suicide. In its opening section, this article will review the evidence that points to a positive correlation between suicide and physical illness. Next the association between specific illnesses, such as peptic ulcer and cancer, and suicide will be examined. Third, risk factors associated with the occurrence of suicide in medical-surgical hospitals will be reviewed. Fourth, the occurrence of suicide in relationship to medical procedures will be discussed. Fifth, the evaluation and management of suicidal patients in medical settings will be briefly considered. This review will not consider the relationship between physical illness and attempted suicide.

Lifetime prevalence of psychiatric disorders in patients with alopecia areata

Thirty-one patients with alopecia areata were administered a structured psychiatric interview (the Diagnostic Interview Schedule; DIS). Overall, 74% had one or more lifetime psychiatric diagnoses. Particularly noteworthy were the high lifetime prevalence rates of major depression (39%) and generalized anxiety disorder (39%). In addition, patients reported increased rates of psychiatric disorders in first-degree relatives: anxiety disorders (58%), affective disorders (35%), and substance use disorders (35%). Patients with patchy alopecia areata were more likely to have a diagnosis of generalized anxiety disorder. No relationships were found between major depression and any variable characterizing alopecia areata history. Possible interrelationships between psychiatric disorders and alopecia areata are discussed. The study suggests that patients with alopecia areata are at increased risk for psychiatric disorders, and calls attention to the need for psychiatric assessment in this population.

Antidepressant drug therapy and sexual dysfunction in men: A review

Medical literature concerning sexual dysfunction associated with antidepressant drug therapy in men is reviewed. Available information consists mainly of individual case reports or small series of cases. A complicating factor in understanding this area is the lack of sufficient information concerning sexual dysfunction associated with depression. Both erectile dysfunction and ejaculatory problems have been reported with the use of the clinically available antidepressants. No single agent seems to be implicated more frequently than the other drugs. Changes in libido have also been reported. The authors found no reported cases of priapism, which has been reported as a side effect of antipsychotic therapy.

BRIEF COMMUNICATION: Tricyclic Exacerbation Of Steroid Psychosis

Four patients in a series of 14 cases of steroid psychosis where steroids were used to treat disease not effecting the central nervous system, are reported. All demonstrated a predominantly affective mood change prior to initiation of treatment with tricyclic antidepressants by the primary physician. In each case, the patients mental state deteriorated rapidly following initiation of tricyclics in mid-dose range (i.e., 100 to 150 mg q.d.). These agents produced a qualitative change in the nature of the patients psychosis rather than simply aggravating pre-existent features. All patients experienced visual hallucinations within 4 days of tricyclic administration. Persistent auditory hallucinations (two cases) became threatening, accusatory, and constant. The exacerbated psychosis cleared rapidly with the discontinuation of the antidepressant and the addition of a phenothiazine. Phenothiazines, in doses of 400 to 800 mg q.d., were necessary to reverse the symptoms of these patients. Phenothiazines were also required to produce a salutary effect in the 10 patients who did not receive tricyclics, but at an average dose of only 200 mg. Steroids raise the effective blood level of tricyclics and alter central catecholamine movement across membranes. These changes may represent the mechanism for exacerbation of steroid psychoses.

Exacerbation of Recurrent Depression as a Result of Treatment With Varenicline

TO THE EDITOR: Varenicline, a partial alpha4beta2-nicotinic receptor agonist, was approved by the Food and Drug Administration in 2006 for smoking cessation. Recently, Robert Freedman, M.D., (1) reported the exacerbation of schizophrenia in a patient after 1 week of varenicline use (2 mg daily), and Kohen and Kremen (2) described the induction of a manic episode in a bipolar patient who was challenged with 1 week of treatment with varenicline at 2 mg daily. The case reported below is of a patient who demonstrated exacerbation of recurrent major depressive disorder following 6 weeks of treatment with varenicline.

Neuropsychiatric effects of chemotherapeutic agents for cancer

Abstract A review of the literature finds a reported incidence of CNS complications from cancer chemotherapy ranging from 5% to 86% for different classes of drugs. Patients receiving cancer chemotherapy are rarely given a systematic psychiatric evaluation, however. Psychiatric sequelae are rarely noted in the absence of neurologic disturbances. Organic mental disorders and affective disturbances are most often noted; acute psychotic reactions are rarely seen. As detailed in this review, most changes appear reversible with the exception of a significant incidence of chronic CNS effects following high-dose intravenous or intrathecal methotrexate therapy.

Psychiatric manifestations of Hashimoto's thyroiditis

Abstract The mental symptoms associated with Hashimotos thyroiditis may precede the full-blown, classic picture of hypothyroidism. The psychiatric symptoms include various mental aberrations, depression, irritability, and confusion. Indeed, patients may be mislabeled as having psychotic depression, paranoid schizophrenia, or the manic phase of a manic depressive disorder. The workup must include a thorough evaluation of thyroid function, including tests for autoantibodies. Patients usually respond favorably to thyroid replacement hormone therapy.

A framework for the study of medical depression

Abstract The authors present a framework that classifies “medical depressive syndromes” according to three critical variables: nature of the medical illness, integrity of brain structure, and status of cognition/memory. They propose that this construct initially be applied to study organic affective syndrome, regarded by them as the most straightforward of the medical depressive syndromes. Assignment of groups of patients to the appropriate cells of the model may help to clarify differences in the natural course and treatment responsiveness of these disorders.