Premorbid Psychiatric History Research Articles

Influence of Sociodemographic, Premorbid, and Injury-Related Factors on Post-Traumatic Stress, Anxiety, and Depression after Traumatic Brain Injury.

Psychopathological symptoms are common sequelae after traumatic brain injury (TBI), leading to increased personal and societal burden. Previous studies on factors influencing Post-traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD), and Major Depressive Disorder (MDD) after TBI have produced inconclusive results, partly due to methodological limitations. The current study investigated the influence of commonly proposed factors on the clinical impairment, occurrence, frequency, and intensity of symptoms of PTSD, GAD, and MDD after TBI. The study sample comprised 2069 individuals (65% males). Associations between psychopathological outcomes and sociodemographic, premorbid, and injury-related factors were analyzed using logistic regression, standard, and zero-inflated negative binomial models. Overall, individuals experienced moderate levels of PTSD, GAD, and MDD. Outcomes correlated with early psychiatric assessments across domains. The clinical impairment, occurrence, frequency, and intensity of all outcomes were associated with the educational level, premorbid psychiatric history, injury cause, and functional recovery. Distinct associations were found for injury severity, LOC, and clinical care pathways with PTSD; age and LOC:sex with GAD; and living situation with MDD, respectively. The use of suitable statistical models supported the identification of factors associated with the multifactorial etiology of psychopathology after TBI. Future research may apply these models to reduce personal and societal burden.

Early psychological symptoms predict concussion recovery time in middle and high school athletes

ABSTRACT Introduction Lingering concussion symptoms can negatively impact a child’s well-being, yet variability in recovery is poorly understood. To aid detection of those at risk for prolonged symptom duration, we explored postconcussion mood and sleep symptoms as predictors of recovery time in adolescent athletes. Method We utilized analyses designed to control for potentially confounding variables, such as concussion severity indicators and premorbid psychiatric history. Participants included 393 adolescent athletes (aged 12–18 years) evaluated in outpatient concussion clinics within 2 weeks after injury. Provider-documented date of symptom resolution was obtained via medical record review. Survival analysis for recovery time was conducted in the total sample, and separately for males and females using prior medical history (psychiatric disorder, prior concussion), injury-related factors (loss of consciousness, post-traumatic amnesia [PTA], concussion symptom severity), and psychological symptoms (General Anxiety Disorder-7 Item Scale, Patient Health Questionnaire-8 Item Depression Scale, Pittsburgh Sleep Quality Index) collected at initial clinic visit. Results PTA, concussion symptoms, and sleep quality were associated with recovery in the total sample (HRs = 0.64–0.99, ps < .05). When analyzed by sex, only concussion symptoms were associated with recovery for females (with females reporting greater symptom severity than males), while for males PTA and greater depression symptoms were significant predictors of recovery (HRs = 0.54–0.98, ps < .05). Conclusions These findings identified differences in symptom presentation between sexes, particularly for mood symptoms, and suggest that assessment of postconcussive symptoms is useful in helping to identify individuals at risk for longer recovery. Continued exploration of post-injury psychological difficulties in athletes is warranted for better concussion management.

Psychiatric Outcomes after Mild Traumatic Brain Injury in Adults

<h3>Research Objectives</h3> To enhance the knowledge regarding psychiatric outcomes after mild traumatic brain injury (mTBI) in adults, specifically considering premorbid psychiatric history. <h3>Design</h3> A retrospective observational study using a clinical dataset from the initial evaluation in clinic. Self-reported premorbid psychiatric history was determined by clinician interviews. <h3>Setting</h3> An ambulatory mTBI clinic. <h3>Participants</h3> Participants were 85 adults with mTBI confirmed by clinicians. Participants were 14 to 365 days post injury with valid psychiatric history and outcomes data. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> The Psychiatric Diagnostic Screening Questionnaire (PDSQ) was part of the clinical assessment process. The PDSQ is a brief screening measure for common psychiatric diagnoses based upon the diagnostic and statistical manual of mental disorders, 4th edition. Major depressive disorder (MDD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD) scales represented psychiatric outcomes. Raw scores were used as well as binary categories with scores above and below cut-off scores indicating caseness. <h3>Results</h3> There were no significant differences (p > .05) in demographic and injury characteristics (age, gender, race, loss of consciousness, and days since injury) by psychiatric history status (yes/no) with exception of year of education (p= .025). On average, participants were 36.6 years old with 13.8 years of education. Men (47.6%) and women (52.4%) were fairly even in representation. Most participants were Caucasian (89.4%). Individuals with premorbid psychiatric histories had greater symptoms of GAD (F(1, 76)= 11.90, p=.001, partial eta squared=0.14), MDD (F(1, 76)= 4.62, p=.035, partial eta squared=0.06), and PTSD (F(1, 76)= 6.54, p=.013, partial eta squared=0.08). When considering scores above respective cut-offs for each outcome, similar findings were revealed. Of note, the Odds Ratio for positive screens on depression was 7.08 (p < .001), and it was 5.45 (p= .002) for anxiety, among those with a premorbid psychiatric history. There was no association with PTSD screening and premorbid psychiatric history (p= .083). <h3>Conclusions</h3> Premorbid psychiatric history is demonstrably associated with worse psychiatric outcomes after mTBI in adults, particularly for anxiety and depression outcomes. <h3>Author(s) Disclosures</h3> None.

Clinical utility of the GAD-7 in identifying anxiety disorders after traumatic brain injury

ABSTRACT To determine if the GAD-7 provides incremental value, predicting a final diagnosis of an anxiety disorder after traumatic brain injury (TBI). Retrospective analysis of archival data of 100 patients with TBI, who underwent neuropsychological evaluation 1–12 months after injury. Receiver Operating Characteristic analysis determined the optimal cutoff point for clinically significant symptoms on the GAD−7. Hierarchical logistic regression analyses determined the relative contributions of premorbid psychiatric history, injury severity, and GAD−7 results in predicting a final diagnosis of anxiety disorder. GAD−7 cutoff point of ≥7 yielded the best combination of sensitivity and specificity regarding a final diagnosis of anxiety disorder. Within hierarchical logistic regression models, injury severity did not statistically significantly add to prior psychiatric history in predicting a final diagnosis of anxiety disorder. When GAD-7 was added, it made a statistically significant contribution in accounting for such a diagnosis and increased sensitivity from 71% to 91%. The GAD−7 holds diagnostic utility as a screening measure for anxiety disorders in patients with TBI. It should not be used in isolation but as part of a more comprehensive interview and history. The GAD−7 can benefit clinicians in assisting with timelier identification and treatment of symptoms of anxiety.

Clinical Utility of the Patient Health Questionnaire-Adolescent in Adolescents With Traumatic Brain Injury.

To determine the clinical utility of the Patient Health Questionnaire-Adolescent (PHQ-A) in screening for depressive disorders in adolescents following traumatic brain injury (TBI). Retrospective analysis of data collected as a part of routine clinical care over a period of 4 years. Regional rehabilitation facility. Adolescents (n = 101) with mild to moderate-severe TBI who were referred for an outpatient neuropsychological evaluation within 1 to 12 months postinjury. PHQ-A, PHQ-A_2 (2-item version), and Processing Speed Index (PSI) from the Wechsler scales of intelligence. Both premorbid depressive disorder and PHQ-A scores predicted a postinjury diagnosis of depressive disorder, with a combined sensitivity of 0.91 and specificity of 0.59. PHQ-A_2 did not reach acceptable levels of sensitivity in predicting suicidal thoughts. PHQ-A scores did not add significantly to the prediction of PSI results after accounting for TBI severity. PHQ-A has clinical utility as a screening instrument for depressive disorders in outpatient adolescents with TBI when the cutoff for clinically significant concern is set at more than 4 and premorbid psychiatric history is also taken into account.

A-147 Post-Concussive Symptoms in Adolescent Athletes with Premorbid Psychiatric History: A Matched Case–Control Study

Abstract Objective To examine sport-related concussion (SRC) symptoms in adolescent athletes with premorbid psychiatric history (PPH+) compared to a matched control sample without such history (PPH-). It was hypothesized that adolescents with PPH+ would report higher symptom severity both initially and at 3-month follow-up. Method Participants aged 13–18 (M age = 14.9) who reported a psychiatric history (N = 29) presented to clinic within 7 days of sustaining a SRC. Subjects were matched to those without premorbid psychiatric history (N = 29) by age, sex, race, sport, and time to clinic ( 1 day). All participants (N = 58) completed the Post-Concussion Symptom Scale (PCSS) at initial visit and 3-month follow-up as part of the North Texas Concussion Registry (ConTex). Independent sample T tests compared PCSS total and cognitive/fatigue, vestibular, ocular, posttraumatic migraine, and anxiety/mood domain scores between groups across time points. Results Consistent with our hypothesis, the PPH+ group reported significantly higher PCSS total (M = 41.0/132 vs. M = 27.7/132; p = .02), posttraumatic migraine domain (M = 3.5/6 vs. M = 2.5/6; p = .03), and anxiety domain (M = 1.1/6 vs. M = 0.4/6; p = .002) severity at the initial evaluation. However, there were no significant differences in PCSS total (PPH+ M = 4.1/132 vs. PPH- M = 3.3/132) or domain scores at 3-month follow-up. Conclusion(s) After matching by age, sex, race, sport, and time to clinic, adolescents with self-endorsed PPH+ reported higher total symptom, posttraumatic migraine, and anxiety domain symptom severity immediately following SRC but not at 3-month follow-up. Findings suggest that adolescents with PPH+ may experience higher subjective levels of distress following SRC, although further research is needed to understand the role of recovery in this population.

Dimensions of burn survivor distress and its impact on hospital length of stay: A national institute on disability, independent living, and rehabilitation research burn model system study

ObjectiveGuided by the Transactional Model of Stress and Coping, this study seeks to (1) examine the independent relationships between the level of distress among burn survivors, pre-morbid psychiatric history, and burn severity on length of hospital stay, and (2) to examine the relationship between having a premorbid psychiatric history and level of distress following a burn injury. MethodsData collected by the National Institute on Disability, Independent Living, Rehabilitation Research funded Burn Model System (N = 846) was used to theoretically link psychological distress with the length of hospital stay for survivors of burn injuries. Structural Equation Modeling was used to evaluate the aims of this study. ResultsAlthough counterintuitive, and while significant, burn severity was found to have a rather modest association with a burn survivor’s level of distress, indicating that one’s ability to cope may be a better predictor of distress rather than burn severity alone. Premorbid psychiatric history was significantly associated with increased levels of distress. While burn severity was associated with length of stay, level of distress did not act as a partial mediator. Length of stay was, however, significantly related to having a premorbid-psychiatric history. Of notable interest, a significant racial, ethnic, and gender difference exists in level of distress. Women and people of color experience higher levels of distress holding constant burn severity and psychiatric history. ConclusionA need exists to assess for and address premorbid and current mental health challenges of burn survivors, specifically the ability to cope, especially among people of color and women, regardless of the burn size or severity.

The Role of Premorbid Psychiatric History and Current Mood Ratings on Self-Reported Concussion Symptom Severity

Abstract Purpose Psychiatric history is known to be relevant to concussion outcomes, although less is known about the role of such factors or current mood ratings in adolescents. The aim of this study was to assess the role of premorbid psychiatric history (PPH) and current mood ratings (CMR) on overall sports-related concussion (SRC) symptomology and cognitive outcomes in adolescent and young adult athletes. Methods Participants age 12–25 years (M=14.8) diagnosed with SRC (n=560) were evaluated within 14 days of injury as part of the North Texas Concussion Registry (ConTex) using the Patient Health Questionnaire-8 Items (PHQ-8), General Anxiety Disorder-7 Item Scale (GAD-7), and ImPACT. Subjects were dichotomized into those with (PPH+) and without (PPH-) pre-existing reported psychiatric diagnoses, and CMR groups were determined by normal vs. elevated scores on the GAD-7 and PHQ-8. T-tests were used to compare groups. Results Significant differences in total symptom severity scores were found between both PPH (p=.01) and CMR (p&lt;.001) groupings. PPH+ (n=27) reported significantly higher symptom scores (M=31.6) than PPH- subjects (n=316, M=20.9). Additionally, those reporting elevated CMR endorsed 2.3x higher symptom severity scores (n=48, M=42.1 vs. n=276, M=18.2). Among ImPACT cognitive scores, only Visual Memory differed between CMR groups (p=.047). Conclusion Findings suggest that PPH and elevated CMR are associated with greater self-reported symptom severity in adolescent SRC, but have little relationship to cognitive outcomes as assessed by ImPACT. Further research is needed to understand the interaction between PPH, CMR, and SRC recovery across the age spectrum.

In the media: Burns as a method of assault

AimThe aims of this study were to determine whether a change occurred in the pattern of assault burn injury cases hospitalised to the adult state burns unit, Western Australia, from 2004 to mid-year of 2012, and to compare patient and burn characteristics of adult assault burns with those admitted for unintentional burns. MethodsStudy data were obtained from the Royal Perth Hospital (RPH) Burns Minimum Dataset (BMDS). Aggregated data of unintentional burn admissions during the same period were provided by the BMDS data manager to enable comparisons with assault burn patients. ResultsAssault burn admissions during 2004–2012 accounted for approximately 1% of all adult burn hospitalisations. All assault victims were burned by either thermal or scald agents. A high rate of intubation (24%) and ICU admission (1 in 3 cases) was observed in the fire assault group. The six assault cases undergoing intubation were severe burns, median TBSA 50%, most commonly affecting the face, head and torso, half of these cases had inhalational injuries and also required escharotomies.Comparison of admissions by calendar period showed no statistically significant differences in demographic, burn cause or TBSA%. However, statistically significant differences were found for pre-morbid psychiatric history (15% vs. 58%, p=0.025) and concomitant fractures or dislocations (46% vs. 2%), p=0.011). ConclusionsWhile the proportion of assault burn admissions per total burn admissions steadily increased from 0.4% in 2009 to 1.5% in mid-2012, this proportion did not exceed that peak level observed of 2.1% for 2004.

Predictors of postconcussive symptoms 3 months after mild traumatic brain injury.

There is continuing controversy regarding predictors of poor outcome following mild traumatic brain injury (mTBI). This study aimed to prospectively examine the influence of preinjury factors, injury-related factors, and postinjury factors on outcome following mTBI. Participants were 123 patients with mTBI and 100 trauma patient controls recruited and assessed in the emergency department and followed up 1 week and 3 months postinjury. Outcome was measured in terms of reported postconcussional symptoms. Measures included the ImPACT Post-Concussional Symptom Scale and cognitive concussion battery, including Attention, Verbal and Visual memory, Processing Speed and Reaction Time modules, pre- and postinjury SF-36 and MINI Psychiatric status ratings, VAS Pain Inventory, Hospital Anxiety and Depression Scale, PTSD Checklist-Specific, and Revised Social Readjustment Scale. Presence of mTBI predicted postconcussional symptoms 1 week postinjury, along with being female and premorbid psychiatric history, with elevated HADS anxiety a concurrent indicator. However, at 3 months, preinjury physical or psychiatric problems but not mTBI most strongly predicted continuing symptoms, with concurrent indicators including HADS anxiety, PTSD symptoms, other life stressors and pain. HADS anxiety and age predicted 3-month PCS in the mTBI group, whereas PTSD symptoms and other life stressors were most significant for the controls. Cognitive measures were not predictive of PCS at 1 week or 3 months. Given the evident influence of both premorbid and concurrent psychiatric problems, especially anxiety, on postinjury symptoms, managing the anxiety response in vulnerable individuals with mTBI may be important to minimize ongoing sequelae.

From Genotype to Phenotype: Two Cases of Genetic Frontotemporal Lobar Degeneration with Premorbid Bipolar Disorder

Frontotemporal lobar degeneration (FTLD) is a common early-onset dementia, which shows highly heterogeneous phenotypic presentations. Although an autosomal dominant transmission can be found only in about 10% cases, familial aggregation is frequently observed in FTLD. Recently, the progranulin gene (GRN) was reported to be involved in the disease pathogenesis. We describe two clinically different, apparently sporadic FTLD cases, sharing the previously described GRN mutation g.11019_11022delCACT (relative to nt1, NCBI NG_007886.1), alias Thr272fs, with a premorbid psychiatric history. Both patients are males and were in their sixties when diagnosed clinically with, respectively, the behavioral variant of frontotemporal dementia (bvFTD) and progressive nonfluent aphasia (PNFA). In both cases, the medical history revealed the presence of bipolar spectrum disorders. Mutations in GRN are considered to be a major cause of FTLD. However, the phenotypes associated with these mutations are highly variable. Our description of two novel FTLD genetic cases confirms the high frequency of the g.11019_11022delCACT mutation in Northern Italy. On this basis, we recommend to consider the presence of this mutation as a possible cause of the disease, particularly in patients with premorbid psychiatric symptoms.

Electrical Injury, Part II: Consequences

Electrical Injury, Part II: Consequences

Correlates of invalid neuropsychological test performance after traumatic brain injury

Primary objective: To investigate external correlates of invalid test performance after traumatic brain injury, as assessed by the California Verbal Learning Test – Second Edition (CVLT–II) and Word Memory Test (WMT).Research design: Consecutive 2-year series of rehabilitation referrals with a diagnosis of traumatic brain injury (n = 87).Methods and procedures: Logistic regression analysis was used to determine which demographic and neurological variables best differentiated those with vs. without actuarial CVLT–II or WMT evidence for invalid responding.Main outcomes and results: Twenty-one participants (about 24%) performed in the invalid range. The combination of a premorbid psychiatric history with minimal or no coma was associated with an approximately four-fold increase in the likelihood of invalid performance.Conclusions: Premorbid psychosocial complicating factors constitute a significant threat to validity of neuropsychological test results after (especially mild) traumatic brain injury. At the same time, care should be taken to not routinely assume that all persons with mild traumatic brain injury and premorbid psychiatric histories are simply malingering. The WMT appears to be a promising instrument for the purpose of identifying those cases where neuropsychological test results are confounded by factors not directly related to acquired cerebral impairment.

Problematic versus non-problematic ecstasy/MDMA use: the influence of drug usage patterns and pre-existing psychiatric factors

Recreational ecstasy (3,4-methylenedioxymethamphetamine; MDMA) use has been increasingly associated with a number of psychiatric symptoms and psychological problems. However, previous studies assessing possible psychopathological effects have not identified whether users consider their ecstasy use "problematic" or not. In addition, research has generally failed to address the potential role of premorbid psychiatric status. This study aimed to assess whether premorbid psychiatric history and/or patterns of ecstasy use would be associated with the degree of self-reported problems attributable to ecstasy. Problematic ecstasy users (n = 53) who had reported problems attributable to their ecstasy use were compared with non-problematic ecstasy users (n = 62), polydrug controls (n = 62) and illegal drug-naive controls (n = 111) on a recreational drug use questionnaire; a questionnaire, which ascertained personal and family psychiatric histories, and the Brief Symptom Inventory (BSI). Problematic ecstasy users exhibited significantly higher scores on a number of dimensions of the BSI compared to illegal drug-naive and/or polydrug controls. Problematic ecstasy users also exhibited significantly elevated scores on somatization, depression, anxiety and negative psychobiology compared to non-problematic ecstasy users. BSI scores for the non-problematic ecstasy users did not differ from polydrug or illegal drug-naive controls. Problematic ecstasy users reported significantly higher levels of ecstasy use, including lifetime consumption, average dosage and binge consumption compared to non-problematic ecstasy users. Additionally, a greater number of problematic ecstasy users reported personal and family psychiatric histories compared to controls and non-problematic ecstasy users. This study demonstrates two distinct ecstasy using groups: non-problematic ecstasy users who are not showing signs of psychopathology and problematic ecstasy users who are showing evidence of a range of symptoms. This data therefore partially supports the link between ecstasy dosage and negative psychological sequelae, but highlights the importance of the need to consider ecstasy-related attributions, pre-existing mental health status and vulnerability.

Return to productive activity after traumatic brain injury: Relationship with measures of disability, handicap, and community integration

Wagner AK, Hammond FM, Sasser HC, Wiercisiewski D. Return to productive activity after traumatic brain injury: relationship with measures of disability, handicap, and community integration. Arch Phys Med Rehabil 2002;83:107-14. Objectives: To identify which factors are associated with successful return to productive activity (RTPA) 1 year after hospitalization with traumatic brain injury (TBI) and to examine the relations between successful RTPA and other measures of impairment, disability, handicap, and integration into the community. Design: Prospective study with 1-year follow-up. Setting: Level I trauma center. Participants: One hundred five respondents from a cohort of 378 adults hospitalized with TBI admitted between September 1997 and May 1998. Interventions: Not applicable. Main Outcome Measures: Return to productive work 1 year after injury; Disability Rating Scale (DRS); and Community Integration Scale (CIQ). Results: Of the 105 participants, 72% achieved RTPA. Logistic regression showed an association between RPTA and the following factors: premorbid educational level, premorbid psychiatric history, violent mechanism of injury, discharge status after acute hospitalization, prior alcohol and drug use, and injury severity. Handicap and community integration at 1-year postinjury, as measured by subscales of the DRS and the CIQ, were also associated with RTPA. Conclusion: Premorbid and injury-related variables and measures of handicap and community integration were associated with RTPA at 1 year. To understand and effectively support vocational pursuits in the TBI population, future studies are needed to define further causality and origin of these relationships. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Predictions and associations of fatigue syndromes and mood disorders that occur after infectious mononucleosis

Certain infections can trigger chronic fatigue syndromes (CFS) in a minority of people infected, but the reason is unknown. We describe some factors that predict or are associated with prolonged fatigue after infectious mononucleosis and contrast these factors with those that predicted mood disorders after the same infection. We prospectively studied a cohort of 250 primary-care patients with infectious mononucleosis or ordinary upper-respiratory-tract infections until 6 months after clinical onset. We sought predictors of both acute and chronic fatigue syndromes and mood disorders from clinical, laboratory, and psychosocial measures. An empirically defined fatigue syndrome 6 months after onset, which excluded comorbid psychiatric disorders, was most reliably predicted by a positive Monospot test at onset (odds ratio 2.1 [95% CI 1.4-3.3]) and lower physical fitness (0.35 [0.15-0.8]). Cervical lymphadenopathy and initial bed rest were associated with, or predicted, a fatigue syndrome up to 2 months after onset. By contrast, mood disorders were predicted by a premorbid psychiatric history (2.3 [1.4-3.9]), an emotional personality score (1.21 [1.11-1.35]), and social adversity (1.7 [1.0-2.9]). Definitions of CFS that included comorbid mood disorders were predicted by a mixture of those factors that predicted either the empirically defined fatigue syndrome or mood disorders. The predictors of a prolonged fatigue syndrome after an infection differ with both definition and time, depending particularly on the presence or absence of comorbid mood disorders. The particular infection and its consequent immune reaction may have an early role, but physical deconditioning may also be important. By contrast, mood disorders are predicted by factors that predict mood disorders in general.

Premorbid history and traumatic brain injury

The literature is replete with studies investigating predictors of outcomes in traumatic brain injury. Few, however, have addressed the pre morbid life events and behaviors that may significantly impact the physical, behavioral, cognitive, and/or psychosocial and vocational status of individuals after a traumatic brain injury (TBI). Findings of studies on premorbid history are reviewed and data are presented on a sample of 82 cases on which premorbid psychosocial information, severity of initial injury and outcome status were obtained. Cases were dichotomized into groups at high risk and at low risk for TBI, based on premorbid history. High risk and low risk groups were comparable in the severity of initial injury. Outcomes were defined by the Functional Independence Measure and the Disability Rating Scale scores at 1 year after injury. No differences were found in FIMTM or DRS scores between those with and without premorbid learning disability, psychiatric history, incarcerations, arrests, academic difficulties, or substance abuse. Explanations for the lack of significant differences are discussed. Based on experience in completing this study, a screening tool incorporating documentation of a number of pre morbid factors that might impact status at outcome is presented.

Antibiotics: neuropsychiatric effects and psychotropic interactions.

Antibiotics are the second most commonly prescribed class of medication in the United States. An awareness and understanding of their potential effects on the central nervous system and their interactions with psychotropic agents is important in the evaluation of neuropsychiatric signs and symptoms in patients. Since the introduction of antibiotic agents in the 1930s, numerous (primarily anecdotal) reports have appeared describing psychiatric side effects ranging from anxiety and panic to major depression, psychosis, and delirium in patients with and without a premorbid psychiatric history. Risk factors have included prior psychopathology, coexisting medical conditions, slow acetylator status, advanced age, concomitant medications, and increased permeability of the blood-brain barrier, as well as high antibiotic dosage and intrathecal or intravenous administration. Psychiatric toxicity may result from various mechanisms of action, including antagonism of gamma-aminobutyric acid or pyridoxine, adverse interactions with alcohol, or inhibition of protein synthesis. Adverse pharmacokinetic and pharmacodynamic interactions between antibiotics and concomitant medications including lithium, benzodiazepines, carbamazepine, valproate, neuroleptics, antidepressants, methadone, and disulfiram have also been reported. Because such effects are often not recognized by clinicians, accurate epidemiologic data on their incidence are not available.

Correlates of persistent depressive symptoms in widows.

Delineation of factors that predict depressive symptom severity 6 or more months after the loss of a spouse may help identify individuals at risk for persistent depressive symptoms. In this study, sociodemographic and clinical correlates of depressive symptom severity were examined among widows 6 to 16 months after the deaths of their husbands. The 50 subjects were identified from the Allegheny County, Penn., death records and were interviewed by telephone. The authors examined the relationship of depressive symptoms to sociodemographic variables, perceptions of sex role and quality of social supports, level of support sought for bereavement, and premorbid personal and family psychiatric history. Widows with persistent depressive symptoms were less likely to have worked outside the home, had less favorable perceptions of their interpersonal support systems, were more likely to have had previous psychiatric disorders, and were likely to have sought professional help in response to their bereavement. In a multivariate model, only premorbid psychiatric history and the perception of interpersonal support system made independent contributions to the prediction of Beck Depression Inventory scores above the normal range. These results suggest several factors that may identify women at risk of protracted psychiatric morbidity after their husbands' deaths. They also suggest that the persistence of depressive symptoms an average of 1 year after the loss of a spouse may reflect a pathological condition rather than normal grieving.

Secondary mania after ventral pontine infarction

Secondary mania is increasingly recognized clinically, and consists of acute exhibition of manic symptoms without past or family history of affective disorder. It has been reported with toxic and metabolic disturbances, primary and metastatic brain tumors, epilepsy, and cerebrovascular events. A multifactorial etiology has been suggested. We report two men, 52 and 56 years old, who developed grandiosity, sleeplessness, irritable mood, hyperactivity, and paranoid and religious delusions, with attempted violence in one case. Both had no premorbid psychiatric history and were healthy except for hypertension. One patient had a normal neurologic examination, and the other had mild left hemiparesis and hyperreflexia. EEGs, brainstem auditory-evoked responses, and median nerve somatosensory-evoked potentials were normal. Magnetic resonance studies demonstrated infarction of the ventral pons (on the right in the patient with left-sided signs and on the left in the patient with normal neurologic examination). The two patients responded to lithium carbonate and neuroleptics and have not had further psychiatric symptoms in 18 months of follow-up. These cases emphasize the relationship of late-onset mania with predisposing brain disease, and they suggest that brainstem disturbances can influence mood, sleep, libido, and thought.