Murali Rao

Quantitative Electroencephalography in Frontotemporal Dementia with Methylphenidate Response: A Case Study

Frontotemporal dementia is an underdiagnosed illness with predominant behavioral and executive manifestations. Historically, diagnosis has been based on a combination of clinical history, neuropsychological testing, and brain imaging. No effective treatment currently exists for this disorder. A case is presented using quantitative EEG with methylphenidate challenge correlated with SPECT. The patient underwent neuropsychological testing, a SPECT brain study, and a quantitative EEG, which was repeated after methylphenidate administration. SPECT was significant for hypoperfusion to the bilateral frontotemporal regions, with left-sided hypoperfusion greater than homologous right as demonstrated by LORETA analysis. QEEG correlated with SPECT, and demonstrated profound left greater than right bi-frontotemporal slowing, which normalized partially after methylphenidate administration. The patient has remained on methylphenidate as an outpatient, and has had significant behavioral improvement. Quantitative EEG may provide both diagnostic and therapeutic data with regard to frontotemporal dementia. Further studies of methylphenidate in this population are needed to confirm these data.

Poststroke Depression: A Review Emphasizing the Role of Prophylactic Treatment and Synergy with Treatment for Motor Recovery

Abstract Neuropsychiatric manifestations are common post stroke. Depression has a prevalence rate of 9% to 34% in the initial 3 to 6 months following stroke and is the most common neuropsychiatric sequel of stroke. Poststroke depression (PSD) has a significant adverse impact on the course of rehabilitation following stroke, resulting in overall impaired functional outcome. An increased risk of suicide and increased mortality have been reported. The association of depression and stroke is wellestablished, highly complex, and multifactorial in origin, and the etiology of PSD involves size, location and number of lesions, stroke subtype, stroke severity, social handicap, and family support. Additionally, depression itself is an independent risk factor for stroke. In this article, we review the complex pathogenesis of PSD and summarize pharmacological treatment options. Because of recent important results that may relate to underlying cellular restorative processes, we focus on early prophylactic treatment, particularly as it involves selective serotonin uptake inhibitors (SSRIs). There is a recently recognized synergy between functional recovery and depression prophylaxis. New evidence that antidepressants, and SSRIs in particular, can make a substantial contribution to stroke recovery is explored.

Pseudopseudoseizures: Conditions That May Mimic Psychogenic Non-Epileptic Seizures

BACKGROUND Video electroencephalography (vEEG) has proven to be a valuable tool in the differentiation of pseudoseizures or psychogenic non-epileptic seizures (PNES) from epileptic seizures. Clinicians should, however, be aware of a number of conditions that may be misdiagnosed as pseudoseizures. OBJECTIVE To review a number of somatic conditions that can present with disturbances of consciousness and unusual motor activity without epileptiform findings on vEEG. METHOD We report a case of a young woman who presented with a number of neuropsychiatric symptoms, including episodic posturing and rhythmic movements. The absence of epileptiform findings on vEEG resulted in a diagnosis of conversion disorder with pseudoseizures. She was ultimately diagnosed with N-methyl-D-aspartate (NMDA) receptor autoimmune encephalitis (AIE) secondary to an ovarian tumor. AIE and other potential mimics of pseudoseizures are discussed. RESULTS A number of somatic conditions can present with symptoms that may be misinterpreted as pseudoseizure.

Central poststroke pain: current diagnosis and treatment.

Abstract Central post-stroke pain syndrome (CPSP) is a debilitating sequel that can follow thalamic sensory stroke. Less well recognized, CPSP follows lateral medullary stroke and parietal cortical stroke and may develop anywhere along the spinothalamic or trigemino-thalamic pathways. Patients describe sharp, stabbing, or burning pain and experience hyperpathia and especially allodynia. Although CPSP was first described over 100 years ago, CPSP is too frequently under-recognized. It is treatable disorder. Pharmacological therapy, magnetic stimulation, and invasive electrical stimulation are reviewed and recommendations made.

Shared Neurobiological Pathways Between Type 2 Diabetes and Depressive Symptoms: a Review of Morphological and Neurocognitive Findings

Type 2 diabetes (T2D) patients are twice as likely to experience depressive symptoms than people without T2D, resulting in greater economic burden, worse clinical outcomes, and reduced quality of life. Several overlapping pathophysiological processes including hypothalamic-pituitary-adrenal axis hyperactivity, sympathetic nervous system activation, and elevated pro-inflammatory biomarkers are recognized as playing a role between T2D and depressive symptoms. However, other neurobiological mechanisms that may help to further link these comorbidities have not been extensively reviewed. Reduced neuroplasticity in brain regions sensitive to stress (e.g., hippocampus) may be associated with T2D and depressive symptoms. T2D patients demonstrate reduced neuroplasticity including morphological/volumetric abnormalities and subsequent neurocognitive deficits, similar to those reported by patients with depressive symptoms. This review aims to summarize recent studies on morphological/volumetric abnormalities in T2D and correlated neurocognitive deficits. Modifying factors that contribute to reduced neuroplasticity will also be discussed. Integrating reduced neuroplasticity with other biological correlates of T2D and depressive symptoms could enhance future therapeutic interventions and further disentangle the bidirectional associations between these comorbidities.

Depression in the US population during the time periods surrounding the great recession.

OBJECTIVE To determine whether the time periods surrounding the 2008 US economic downturn were accompanied by an increase in prevalence of depression in the US adult population. METHOD We used data from the 24,182 adults aged ≥ 18 years who participated in the National Health and Nutrition Examination Survey during 2005-2012. A cross-sectional analysis was performed at each time period to determine prevalence of major and other depression as assessed by standardized questionnaires based on 9 criteria for major depressive episodes defined by DSM-IV. RESULTS The demographic characteristics of the US population were similar across time periods except for the percentage of adults living in poverty, which increased from 26.43% during 2005-2006 to 33.46% during 2011-2012. The prevalence of major depression increased from 2.33% (95% CI, 1.64%-3.01%) during 2005-2006 to 3.49% (95% CI, 2.84%-4.03%) in 2009-2010 to 3.79% (95% CI, 3.01%-4.57%) in 2011-2012. Prevalence of other depression increased from 4.10% (95% CI, 3.37%-4.88%) in 2005-2006 to 4.79% (95% CI, 4.10%-5.44%) in the 2009-2010 period but then declined to 3.68% (95% CI, 2.84%-4.48%) in the 2011-2012 time period (P = .4). After adjustment for the distribution of age, sex, race/ethnicity, education, insurance status, and poverty status in the US adult noninstitutionalized population, each 2-year period after the 2005-2006 time period was associated with a 0.4% increase in major depression prevalence (P < .001). No significant differences in other depression prevalence were noted by time period (P = .6). CONCLUSIONS The time periods surrounding the recent economic recession were accompanied by a significant and sustained increase in major depression prevalence in the US population. It is plausible that the recession, given its strong, persistent, and negative effects on employment, job and housing security, and stock investments, contributed to the sustained increase in prevalence of major depression in the US population, but other factors associated with the recession time period could have played a role. The impact of the economic downturn on depression prevalence should be considered when formulating future policies and programs to promote and maintain the health of the US population.

Depression and pegylated interferon-based hepatitis C treatment

Haris Papafragkakis1 Murali S Rao2 Martin Moehlen3 Sonu Dhillon4 Paul Martin1 1Division of Hepatology, University of Miami Miller School of Medicine, Miami, FL, 2Department of Psychiatry and Behavioral Neurosciences, Loyola University Medical Center, Maywood, IL, 3Division of Gastroenterology and Hepatology, Tulane University, New Orleans, LA, 4Division of Gastroenterology and Hepatology, St Francis Medical Center, Peoria, IL, USA

Review of mini-clinical evaluation exercise (mini-CEX) in a psychiatry clerkship

Background Direct observation of medical students with actual patients is important for the assessment of clinical skills including interviewing and counseling skills. This article describes medical students’ experience of mini-clinical evaluation exercise (mini-CEX) during their clerkship in consultation psychiatry. Materials and methods In our center during inpatient consultation psychiatry clerkship, all rotating students are expected to complete one mini-CEX assessment as part of their clinical training. We conducted retrospective analysis of mini-CEX ratings completed from 2013 to 2016. All evaluations took place at inpatient medical setting in patients admitted with medical conditions and psychiatric comorbidities. Results A total of 113 evaluations were reviewed. The time examiner observed the interaction of a student with the patient was 14.24 minutes (mean), and the time spent in providing feedback to the student was 9.71 minutes. Complexity of problem was rated as low in 0.88% (n=1), moderate in 50.44% (n=57), and high in 48.67% (n=55). Highest ratings were for professionalism, similar to previous reports. Total score calculated by examiner showed no difference by the complexity of the patient; however, we observed a trend in higher counseling score for the high complexity group. Conclusion Mini-CEX assessment during busy clerkship is feasible with good outcomes. Direct observation of medical trainees with actual patients is important for the assessment of performance-based clinical skills. Hospital psychiatry rotation covering various medical and surgical units offers a great opportunity for exposure in patient communication.