Vaios Peritogiannis

Atypical antipsychotics in the treatment of delirium.

Delirium is common in all medical settings. Atypical antipsychotics are increasingly used for the management of delirium symptomatology but their effectiveness has not been systematically studied. The aim of the present study was therefore to provide an up‐to‐date review on the use of atypical antipsychotics in the treatment of delirium. A search was conducted of the databases of MEDLINE, PsycINFO and EMBASE from 1997 to 2008 for English‐language articles using the key words ‘delirium’ and the names of all the atypical antipsychotics. A total of 23 studies were used for this review. Fifteen of the studies were single‐agent trials. Four studies were comparison trials, including one double‐blind trial, and four studies were retrospective, including three comparison studies. All studies reported improvement of delirium symptomatology after the administration of atypical antipsychotics. No study included a placebo group. Other limitations included sample heterogeneity, small sample size, different rating scales for delirium, and lack of adequate controls. The improvement in delirium was observed within a few days after treatment initiation and the doses given were relatively low. Atypical antipsychotics were well tolerated, but safety was not evaluated systematically. Atypical antipsychotics appear to be effective and safe in symptomatic treatment of delirium but the evidence is limited and inconclusive. There are no double‐blind, placebo‐controlled studies assessing the efficacy and safety of these agents in delirium. Further research is needed with well‐designed studies.

Use of Coercive Physical Measures in a Psychiatric Ward of a General Hospital in Greece

Background: Coercive physical measures are commonly used in psychiatric units throughout the world for the management of severe behaviourally disturbed patients. Aim: The aim of this study was to assess the rates of coercive physical measures (seclusion and restraint) used in psychiatric inpatients in the psychiatric unit of a general hospital in Greece. Methods: A retrospective chart review of all admissions to the psychiatric unit of the University General Hospital of loannina during a six-month period was conducted. Differences between patients who were subjected to coercion and patients who did not receive any coercive treatment were statistically analyzed and compared. Results: Of the total of 282 admissions during the study period, 31 (11.0%) cases had been subjected to some form of coercive physical measures: 9.55% and 1.76% were affected by seclusion and mechanical restraint, respectively (one patient had been subjected to both). The mean duration of any one seclusion and mechanical restraint was 64.9 hours and the mean number of seclusion and restraint per affected case was 3.58. Statistical analysis between the group subjected to coercive measures and the group who was not did not reveal any association with demographic data or diagnosis. Coercive measures were found to be associated only with the type of admission at intake. Conclusions: Involuntary admissions were associated with statistically significant higher levels of restraint and seclusion in this patient sample. Strategies that will enhance patients’ follow-up are expected to prevent involuntary admissions and reduce the use of coercive measures.

Recent Insights on Prevalence and Corelations of Hypoactive Delirium

Delirium is a complex neuropsychiatric syndrome which is common in all medical settings. It often goes unrecognized due to difficulties in the detection of its hypoactive variant. This review aims to provide an up-to-date account on recent research on hypoactive delirium (HD). Thirty-eight studies, which were conducted in various clinical settings, including the Intensive Care Unit (ICU), were included in this review. Those studies involved recent research that has been published during the last 6 years. Prevalence of HD was found to vary considerably among different settings. HD seems to be more common in critically ill patients and less common in patients examined by consultation-liaison psychiatric services and in mixed patient populations. The presence of HD in ICU patients was associated with higher short- and long-term mortality and other adverse outcomes, but no such association was reported in other settings. Research on other possible associations of HD with clinical variables and on symptom presentation yielded inconclusive results, although there is some evidence for a possible association of HD with benzodiazepine use. There are several methodological issues that need to be addressed by future research. Future studies should examine HD in the primary care setting; treatment interventions should also be the objective of future research.

The contribution of a mobile mental health unit to the promotion of primary mental health in rural areas in Greece: a 2-year follow-up.

During the 2 years of the mobile mental-health units operation in Northwestern Greece, the referrals increased rapidly with 29.4% of patients never having received mental-health care before, while hospitalizations and relapses reduced significantly, indicating that community-oriented programs can contribute greatly to successfully addressing the needs of patients in remote rural areas.

Conversion pseudodementia in the elderly: A review of the literature with case presentation

Few data exist in the literature regarding conversion pseudodementia. The knowledge results from case reports and case series that describe a syndrome characterized by cognitive impairment, regression and physical dependency. In elderly patients, this condition can cause serious diagnostic problems and, occasionally, discrimination from dementia is awkward. The reported case assembles all the characteristic traits of conversion pseudodementia. The development of the symptomatology, the diagnostic approach and the difficulties of management and treatment of conversion pseudodementia are discussed. The authors also provide a review of the international literature; certain conclusions and proposals are presented.

Improvement of tardive dyskinesia following amisulpride treatment

Tardive dyskinesia (TD) is a persistent, disturbing side effect of antipsychotic drug treatment. It is established that clozapine and other second generation agents cause less TD and may also improve pre-existing TD. We report a case of significant improvement of TD after the administration of amisulpride, a potential D(2)/D(3) antagonist that has atypical properties. The possible effect of fast dissociation of D(2) receptors is being discussed.

Duloxetine-induced hypomania: case report and brief review of the literature on SNRIs-induced mood switching

Abstract Manic switching during antidepressant treatment has been reported with every class of antidepressant drugs. Serotonin-noradrenaline reuptake inhibitors (SNRIs) have been increasingly used for the treatment of unipolar and bipolar depression and are well tolerated and sufficiently effective because of their dual mechanism of action. A case of duloxetine-induced hypomania in a non-bipolar patient is presented, and a brief review of all cases of SNRIs’ induced mania and hypomania has been carried out. The available data suggest that SNRIs, especially venlafaxine, can induce mood switching in patients with bipolar depression and in certain patients with unipolar depression, but the potential of duloxetine and milnacipran to induce manic or hypomanic symptoms cannot be disregarded. Switching appears to be dose-related and treatment initiation with lower doses and upward titration when needed may be preferable in selected cases and may help minimizing the risk of mood switching.

Medical Patients’ Treatment Decision Making Capacity: A Report from a General Hospital in Greece

This study aimed to assess the decision-making capacity for treatment of patients hospitalized in an internal medicine ward of a General Hospital in Greece, and to examine the views of treating physicians regarding patients’ capacity. All consecutive admissions to an internal medicine ward within a month were evaluated. A total of 134 patients were approached and 78 patients were interviewed with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and the Mini Mental State Examination (MMSE) questionnaire. Sixty-eight out of 134 patients (50.7%) were incompetent to decide upon their treatment. The majority of them (n=56, 41.8%) were obviously incapable because they were unconscious, or had such marked impairment that they could not give their own names, and the rest (n=12, 8.9%) were rated as incompetent according to their performance in the MacCAT-T. Neurological disorders, old age and altered cognitive function according to MMSE were negatively correlated with decision making capacity. Physicians sometimes failed to recognize patients’ incapacity. Rates of decision-making incapacity for treatment in medical inpatients are high, and incapacity may go unrecognized by treating physicians. Combined patient evaluation with the use of the MacCAT-T and MMSE, could be useful for the determination of incapable patients.

The Greek version of the MacArthur competence assessment tool for treatment: reliability and validity. Evaluation of capacity for treatment decisions in Greek psychiatric patients

BackgroundPatients’ informed consent prior to treatment initiation is an essential component of contemporary clinical practice, but sometimes, patients lack decision-making capacity for treatment. Such capacity can be reliably assessed with standardized tools used, and the MacArthur competence assessment tool for treatment (MacCAT-T) is one of the most widely used instruments.MethodsThe objective of this study was to translate the MacCAT-T into Greek and evaluate the Greek version’s reliability and validity in psychiatric patients. Thirty-nine psychiatric inpatients were examined with the MacCAT-T, and results showed an excellent inter-rater reliability.ResultsIntraclass correlations ranged from 0.93 to 1 for the individual items of the tool. Severity of psychopathology was negatively correlated with reasoning, appreciation, and expressing a choice (Pearson’s r 0.36, 0.539, and 0.338, respectively), but there were no associations with demographic characteristics of the patients. Of the five factors derived from the brief psychiatric rating scale, anergia was significantly correlated with appreciation, reasoning, and expressing a choice (Pearson’s r 0.46, 0.45, and 0.37, respectively).ConclusionsThe Greek version of the MacCAT-T is a reliable and valid instrument that can provide a standardized measure for assessing treatment decision capacity in Greek psychiatric patients and can be used for evaluation in the clinical practice.

Delirium in the primary care setting

Delirium is a complex multifactorial neuropsychiatric syndrome with a broad range of cognitive and neurobehavioral symptoms. It is associated with major adverse events and poor outcome. Little is known about delirium in the primary care setting. A retrospective chart review was carried out for the identification of ICD‐10 delirium cases presented in the regional medical office of a rural area in central Greece. Nine cases of delirium, mostly the hyperactive subtype, had been recorded. The patients tended to be elderly and suffering from dementia; infections were the underlying cause in most cases. All but one patient had been successfully treated in the primary care setting.