Virginia Tuckwell

Violence in schizophrenia : role of hallucinations and delusions

The study examines the relationship between hallucinations/delusions and violent behaviour in a sample of long-stay inpatients with chronic schizophrenia. Thirty-one subjects defined as violent and meeting DSM-111-R criteria for schizophrenia were compared with 31 matched non-violent schizophrenia patients with respect to detailed phenomenologies of auditory hallucinations using the Mental Health Research Institute Unusual Perceptions Schedule (Carter and Copolov, 1993; Carter et al., 1995) and delusions using the Maudsley Assessment of Delusions Schedule (Taylor et al., 1994). Patients in the violent groups were significantly more likely to experience negative emotions, tone and content related to their voices than those in the non-violent group, whilst patients in the non-violent group were more likely to experience positive emotions, tone and content related to their voices. Patients in the non-violent group were significantly more likely to report success in coping with their voices. There was no association between command hallucinations and violent behaviour. Patients in the violent group were more likely to hold persecutory delusional beliefs than those in the non-violent group, while patients in the non-violent group were likely to hold grandiose delusions than those in the violent group. Patients in the violent group were also more likely to report that the delusion made them feel angry, while those in the non-violent group were more likely to report that the delusion made them feel elated. The results suggest specific aspects of the phenomenologies of hallucinations and delusions that should be clinically assessed to determine the likelihood of violence as a result of such psychotic symptoms.

A Prospective Study of Aggression among Psychiatric Patients in Rehabilitation Wards

Objective: The aim of the study was to determine, among patients in rehabilitation wards, the prevalence and nature of aggressive behaviour and the relationship between aggressive behaviour and patient characteristics and ward factors. Method: The aggressive behaviour of all 220 inpatients within the rehabilitation program of a large psychiatric hospital in Victoria was assessed using the Staff Observation Aggression Scale. Results: Physical assaults occurred at a rate of 97.6 per 100 patients per year. About 40% of all incidents appeared to be unprovoked. Most physical incidents involved use of body parts and use of a weapon was uncommon. Aggression was most often directed at a staff member. Serious injury was rare. Aggressive behaviour was correlated with gender and duration of admission for the whole sample; however, there were different correlates of aggressive behaviour for different ward populations and different types of aggression. As for ward variables, time of day but not patient/staffing level was associated with aggressive behaviour. Conclusions: There was a high rate of aggressive behaviour among patients in rehabilitation wards; this should be taken into consideration in the planning of their community placement. The findings also caution against aggregating different ward populations and types of aggressive behaviour for research.

Efficacy and cognitive effects of right unilateral electroconvulsive therapy

The efficacy, memory, and cognitive effects of right unilateral (RUL) electroconvulsive therapy (ECT) at 2.5 times threshold in 32 inpatients with moderate to severe major depressive disorder were evaluated at baseline, during the course of treatment, and 1 month after treatment. Neuropsychological assessment included the Randt Memory Test, Personal Memory Test, short-version Wechsler Adult Intelligence Scale–Revised, and Self-Rating Scale of Memory Functions. At the treatment end point, although the Hamilton Depression Rating Scale mean score was decreased by 54.2%, the response rate of 2.5 times threshold RUL ECT using stringent criteria was only 31.2%. Treatment was associated with significant anterograde memory impairment in the short term. Mean total scores of the Randt Memory Test and Personal Memory Test were decreased from baseline by 14.8% and 32.5%, respectively, after six sessions of ECT. These memory deficits were significantly improved by the 1 month follow-up examination. Subjective memory scores increased consistently during treatment, correlating with improvements in mood. No adverse effects on nonmemory cognition were found. Although RUL ECT at 2.5 times threshold is not associated with marked or persistent cognitive disturbances, its efficacy may be insufficient in clinical practice.

The differentiation of depression from dementia by temporal lobe magnetic resonance imaging

Temporal lobe Magnetic Resonance Imaging (MRI) was performed in 43 patients with NINCDS/ADRDA Alzheimers disease (AD) (33 probable, 7 possible, 3 definite) and 32 subjects with DSM-III-R Major Depression (DEP) matched for age, sex and level of education. Hippocampus (anterior and posterior, right and left), amygdala, entorhinal cortex, parahippocampal gyrus and cerebral cortex were rated for atrophy on a 4-point scale. Good discrimination between groups could be achieved using a cut-off of 2 or more on anterior hippocampal atrophy rating (sensitivity 93%; specificity 84%; 89% cases correctly grouped overall). Even among a subgroup of 9 mild AD subjects and 10 cognitively impaired DEP subjects (matched on mini-mental state score), the same cut-off correctly grouped 84% (16/19) cases. Hippocampal atrophy increased with age in both AD and DEP subjects leading to a reduction in specificity (but not sensitivity) for those aged over 75. Within the AD group a significant correlation was observed between length of history and atrophy of the entorhinal cortex (r = 0.39, P = 0.009). We conclude that temporal lobe atrophy on MRI can provide good discrimination between AD and DEP subjects, including those DEP patients with cognitive impairment apparent on screening tests of cognitive function.

Aggressive Behaviour in Schizophrenia: The Role of Psychopathology:

Objective:The aim of this study was to determine the psychopathological correlates of aggressive behaviour in schizophrenia. Method:Thirty-one aggressive patients in rehabilitation wards meeting DSM-III-R criteria for schizophrenia were compared with 31 matched non-aggressive patients in relation to their psychopathology using the Clinical Global Index (CGI), Positive and Negative Symptoms scale (PANSS) and the Montgomery-Asberg Depression Rating Scale. Results:The aggressive group had significantly higher CGI, positive symptom, negative symptom, general psychopathology and total PANSS scores than the non-aggressive group. The two groups could be distinguished by three sets of symptoms: symptoms with verbal or/and physical aggression as part of their definition; symptoms suggesting frontal lobe impairment; and excitement. The two groups did not differ in their level of depressive symptomatology. Conclusions:The aggressive group were overall more ill than the non-aggressive group, and the former could be distinguished from the latter by certain aspects of their psychopathology.

A prospective study of assaults on staff by psychiatric in-patients.

This study determined the prevalence and features of assaults on staff, compared them with other aggressive incidents by psychiatric in-patients, and studied their relationship with the ward atmosphere. There were 181 physical assaults among 279 staff in two months, i.e. 389 assaults per 100 staff per year. A few patients were responsible for the majority of the assaults. Most assaults were triggered off by staff-patient interaction. About one-third of the staff were significantly psychologically shaken by the incidents. Patients were more likely to be provoked and used more severe means of aggression against staff than against other targets of aggression. There were no significant differences between the characteristics of patients who assaulted staff and those who had other targets of aggression.

Structural Neuroimaging Studies in Late-Life Depression: A Review

Which patients presenting with depression in late life will progress to a dementia syndrome has been an important research question in recent times. In this paper we review selectively structural neuroimaging investigations of late-life depression (LLD) that have been performed over the past two decades. These studies indicate that there are neuroimaging changes commonly observed in LLD patients when compared to normal controls. Findings include ventricular enlargement and sulcal widening, and reduction in volume size of frontal lobes, hippocampus and caudate nucleus. White matter lesions are more common in depressed subjects and tend to be more severe. Some studies report these changes to be more pronounced in patients who present with late-onset depression (LOD) but this has been contradicted by other studies. Preliminary work suggests that these changes may be associated with a poor prognosis but there is a dearth of systematic, well-controlled longitudinal studies.

Risk of adverse events with the use of augmentation therapy for the treatment of resistant depression.

Augmentation therapy is used for those situations where a patient’s depression is either treatment-resistant, or partially and/or insufficiently responsive to treatment. It also may be used to attempt to induce a more rapid treatment response.Using drugs together may increase the risk of adverse effects, through potentiation of existing adverse effects or alterations in plasma concentrations of the drug. It is important that clinicians are aware of potential risks of augmentation therapy.Lithium augmentation of a tricyclic antidepressant is relatively well tolerated and the dangers are no greater than using these medications on their own. There are also no reports of serious adverse events when lithium is added to a monoamine oxidase inhibitor. With lithium augmentation of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitor (SSRI) therapy there have been case reports of the development of a central serotonin syndrome, and thus caution must exercised.A serious concern when using a tricyclic antidepressant to augment an SSRI is the effect of the SSRI on the cytochrome P450 system and the resulting significant increase in tricyclic antidepressant blood concentrations.Augmentation with thyroid hormones appears to be well tolerated and effective. Case reports and open studies indicate that augmentation with buspirone and the psychostimulants, carbamazepine and valproic acid (valproate sodium) is effective and results in minimal adverse effects. However, there is no empirical evidence supporting these results. Recent work supports the tolerability and efficacy of pindolol augmentation.Considerable caution should be exercised when combining psychotropic drugs. The practitioner should only do so with a full knowledge of the compounds involved and their pharmacological properties.

A review of the use of augmentation therapy for the treatment of resistant depression: implications for the clinician

Objective: To critically review the literature on augmentation therapy in resistant depression in order to assist the clinician to make a reasoned choice. Augmentation therapy is defined as the addition of a second agent to an existing antidepressant regimen with the aim of achieving improved clinical response. Method: The available literature which related specifically to currently popular augmentation strategies in treatment resistant depression for the past 20 years was examined. The scientific evidence supporting the efficacy of these regimens and their safety was reviewed. Results: Considerable research on lithium augmentation has been undertaken, and on triiodothyronine augmentation to a lesser degree. A number of other drugs have been trialled as augmentation agents with claims of success; however, most of the evidence supporting these agents is anecdotal and in the form of case reports. There are very few well-performed double-blind placebo-controlled studies of augmentation therapy. Conclusions: Because of possible complex pharmacodynamic and pharmacokinetic interactions, augmentation therapy is not without its potential complications. Lithium augmentation of tricyclic antidepressants can be recommended as a safe and effective strategy and there is a body of scientific evidence supporting the addition of T3 as an effective augmentation agent. Recent research with pindolol augmentation of selective serotonin re-uptake inhibitors (SSRIs) is encouraging, but these findings require replication. There is no empirical evidence supporting buspirone, carbamazepine, sodium valproate, methylphenidate or amphetamine as effective augmentation agents, or that adding a tricyclic to a SSRI has usefulness in relieving depressive symptoms. There is a need for considerable research in this area, with more prospective well-controlled placebo studies.

Antiglaucoma Medication and Clinical Depression

Objective: The aim of this paper is to alert the medical community to the potential risk of clinical depression following the use of antiglaucoma medication. Method: The available literature concerning systemic side-effects of topical antiglaucoma medication and the association of these agents with clinical depression were reviewed. In addition, two cases are reported of the occurrence of clinical depression following use of topical betaxolol which only resolved completely after switching glaucoma medication. Results/Conclusions: The case reports presented here add to the increasing body of literature linking topical ophthalmic β-adrenoceptor antagonists with depression. While these cases are uncommon, this phenomenon continues to be poorly recognized by the medical profession, psychiatrists, ophthalmologists and general practitioners alike.