Severe Somatic Illness Research Articles

Case Report: Experience with Cariprazine in Organic Delusional Disorder in an Elderly with Concomitant Somatic Pathology, Brief Report

Background: Organic disorder remains one of the most pressing issues in practical psychiatry, especially a disorder dominated by persistent or recurrent delusions. The difficulty for practitioners is often due to the older age of patients and the burden of concomitant therapeutic diseases. Modern and potentially promising pharmacological drugs developed in recent years include partial agonists of D2 and D3 receptors. Currently, there are insufficient publications of studies on Cariprazine use in various disorders that are not associated with endogenous pathology. Case Presentation: The author presented the results of the patient’s clinical examination with a complex of psychodiagnostic techniques, instrumental research methods, observation data in the department, and an analysis of the patient’s medical history. The paper describes the experience of treating a patient with the latest generation antipsychotic drug Cariprazine. Results: The author presents a case report on Cariprazine therapy in a 71-year-old female patient with a persistent organic delusional disorder with concomitant severe somatic illness. Conclusion: Cariprazine showed good efficacy in this case. Delusional symptoms were significantly reduced, and the author noted a reduction in negative symptoms. Mild side effects of the drug quickly resolved in the course of treatment. The key point is that the description of this case may be relevant to justify the need for further clinical studies on Cariprazine. Further clinical studies of the drug in the treatment of various mental pathologies may be in demand by specialists around the world.

Structural Parameters of the Brain and Bone Structures of the Head and Neck in Patients with Various Types of Mucopolysaccharidoses According to Magnetic Resonance Imaging of the Brain

Background. Mucopolysaccharidoses are diseases from the group of lysosomal storage diseases that have a progressive course. CNS damage is one of the main factors in the development of severe, life-threatening complications. Aims — аssessment of structural changes in the brain and bones of the head and neck in patients with various types of mucopolysaccharidoses. Methods. The research included 136 children aged from 11 months to 17 years, 81 patients of which showed various types of mucopolysaccharidoses: MPS I — 15 people, MPS II — 37, MPS III A — 10, MPS IIIB — 4, MPS IIIC — 2, MPS IVA — 6, VI — 7 people. The control group included 56 children without neurological, psychiatric and severe somatic illnesses. Results. For mucopolysaccharidoses types I, II, III and VI, the most characteristic structural changes on the brain MRI were white matter lesions, mainly periventricular: expansion of the perivascular spaces (70%), atrophy of the cerebral hemispheres (42%), hippocampus, (31%), ventriculomegaly (6.2%), stenosis of the cervical spine (64%), hydrocephalus, expansion of the cerebrospinal fluid spaces of the posterior cranial fossa, arachnoid cysts. Conclusions. The results of the obtained data analysis made it possible to identify the macrostructural specifics of the brain disorders and cervical spine in various types of MPS, as well as their prognostic significance.

Antipsychotic Medications and Mortality in Children and Young Adults

Dose-related effects of antipsychotic medications may increase mortality in children and young adults. To compare mortality for patients aged 5 to 24 years beginning treatment with antipsychotic vs control psychiatric medications. This was a US national retrospective cohort study of Medicaid patients with no severe somatic illness or schizophrenia or related psychoses who initiated study medication treatment. Study data were analyzed from November 2022 to September 2023. Current use of second-generation antipsychotic agents in daily doses of less than or equal to 100-mg chlorpromazine equivalents or greater than 100-mg chlorpromazine equivalents vs that for control medications (α agonists, atomoxetine, antidepressants, and mood stabilizers). Total mortality, classified by underlying cause of death. Rate differences (RDs) and hazard ratios (HRs) adjusted for potential confounders with propensity score-based overlap weights. The 2 067 507 patients (mean [SD] age, 13.1 [5.3] years; 1 060 194 male [51.3%]) beginning study medication treatment filled 21 749 825 prescriptions during follow-up with 5 415 054 for antipsychotic doses of 100 mg or less, 2 813 796 for doses greater than 100 mg, and 13 520 975 for control medications. Mortality was not associated with antipsychotic doses of 100 mg or less (RD, 3.3; 95% CI, -5.1 to 11.7 per 100 000 person-years; HR, 1.08; 95% CI, 0.89-1.32) but was associated with doses greater than 100 mg (RD, 22.4; 95% CI, 6.6-38.2; HR, 1.37; 95% CI, 1.11-1.70). For higher doses, antipsychotic treatment was significantly associated with overdose deaths (RD, 8.3; 95% CI, 0-16.6; HR, 1.57; 95% CI, 1.02-2.42) and other unintentional injury deaths (RD, 12.3; 95% CI, 2.4-22.2; HR, 1.57; 95% CI, 1.12-2.22) but was not associated with nonoverdose suicide deaths or cardiovascular/metabolic deaths. Mortality for children aged 5 to 17 years was not significantly associated with either antipsychotic dose, whereas young adults aged 18 to 24 years had increased risk for doses greater than 100 mg (RD, 127.5; 95% CI, 44.8-210.2; HR, 1.68; 95% CI, 1.23-2.29). In this cohort study of more than 2 million children and young adults without severe somatic disease or diagnosed psychosis, antipsychotic treatment in doses of 100 mg or less of chlorpromazine equivalents or in children aged 5 to 17 years was not associated with increased risk of death. For doses greater than 100 mg, young adults aged 18 to 24 years had significantly increased risk of death, with 127.5 additional deaths per 100 000 person-years.

Childhood adversity and cardiovascular disease in early adulthood: a Danish cohort study.

To examine the effect of childhood adversity on the development of cardiovascular disease (CVD) between ages 16 and 38, specifically focusing on ischaemic heart disease and cerebrovascular disease. Register data on all children born in Denmark between 1 January 1980 and 31 December 2001, who were alive and resident in Denmark without a diagnosis of CVD or congenital heart disease until age 16 were used, totalling 1 263 013 individuals. Cox proportional hazards and Aalen additive hazards models were used to estimate adjusted hazard ratios (HRs) and adjusted hazard differences of CVD from ages 16 to 38 in five trajectory groups of adversity experienced between ages 0 and 15. In total, 4118 individuals developed CVD between their 16th birthday and 31 December 2018. Compared with those who experienced low levels of adversity, those who experienced severe somatic illness and death in the family (men: adjusted HR: 1.6, 95% confidence interval: 1.4-1.8, women: 1.4, 1.2-1.6) and those who experienced very high rates of adversity across childhood and adolescence (men: 1.6, 1.3-2.0, women: 1.6, 1.3-2.0) had a higher risk of developing CVD, corresponding to 10-18 extra cases of CVD per 100 000 person-years in these groups. Individuals who have been exposed to childhood adversity are at higher risk of developing CVD in young adulthood compared to individuals with low adversity exposure. These findings suggest that interventions targeting the social origins of adversity and providing support for affected families may have long-term cardio-protective effects.

Attitudes Towards Assisted Suicide Among Hospital Workers: Results of a Large Multiprofessional Survey in French-Speaking Switzerland

"Background: Worldwide, assisted dying is currently on the rise. For health care professionals (HCP), this raises questions regarding roles and responsibilities. Switzerland is a social laboratory for a non-medicalized form of suicide assistance (SA). Aims: To describe experiences and attitudes of Swiss HCP toward SA in the hospital setting and to identify associated factors. Methods: An online questionnaire survey targeted all HCP involved in patient care at two tertiary hospitals in French-speaking Switzerland. The primary outcome was a favorable attitude toward SA. Associated factors were assessed using logistic regression. Results: A total of 5127 professionals responded (37.1%). The sample was representative of the hospitals, with 74% being female, 52% nurses, 23% physicians and 25% other professions. 69% supported the view that each HCP should have the choice to participate or not in SA. The majority favored access to SA in case of severe somatic illnesses, irrespective of prognosis, but less for patients with mental disorders or healthy seniors. 60% of all HCP were generally ready to be involved in SA, but only 30% of physicians would prescribe a lethal substance. 58% of HCP would consider assisted suicide for themselves in certain circumstances. Independent factors associated with a favorable attitude toward SA were: younger age, graduation in Switzerland, non-physician profession. Working in palliative care or being protestant was associated with a less favorable attitude. Conclusion: The diverse attitudes of HCP suggest that the Swiss model of SA may have to be reconsidered, including the question about the participation of hospital workers. "

Mental health as perceived by Norwegian adolescents living with parental somatic illness: Living in an earthquake zone

ABSTRACT Purpose Severe parental somatic illnesses can influence the entire family, including adolescents’ everyday life, psychosocial functioning and health. Within salutogenesis, it is highlighted that stressor life events, such as parental somatic illness, might lead to a chain of events that can produce tension. There is a lack of in-depth understanding regarding how adolescents living in a situation with a severely somatically ill parent (SIP) perceive their own mental health. The aim of this study was therefore to explore the lived experience of Norwegian adolescents living with an SIP, and their perception of the parental illness’ influence on their mental health. Methods Interpretative phenomenological analysis was used. In-depth interviews were conducted with 11 adolescents (aged 13–18 years) who had an SIP. Two adolescents with an SIP participated in study preparation and data analysis. Results Adolescents perceived parental somatic illness as a multifaceted influence on their mental health as it represented both personal and relational strain and growth. Their perceptions can be conceptualized by the super-ordinate theme “living in an earthquake zone”, and by two themes, “inner shakes—but not falling apart” and “relational aftershocks—gains and losses”. Conclusion For adolescents, parental somatic illness means personal and relational strain and growth.

Association of Antipsychotic Treatment With Risk of Unexpected Death Among Children and Youths

Children and youths who are prescribed antipsychotic medications have multiple, potentially fatal, dose-related cardiovascular, metabolic, and other adverse events, but whether or not these medications are associated with an increased risk of death is unknown. To compare the risk of unexpected death among children and youths who are beginning treatment with antipsychotic or control medications. This retrospective cohort study was conducted from 1999 through 2014 and included Medicaid enrollees aged 5 to 24 years in Tennessee who had no diagnosis of severe somatic illness, schizophrenia or related psychoses, or Tourette syndrome or chronic tic disorder. Data analysis was performed from January 1, 2017, to August 15, 2018. Current, new antipsychotic medication use at doses higher than 50 mg (higher-dose group) or 50 mg or lower chlorpromazine equivalents (lower-dose group) as well as control medications (ie, attention-deficit/hyperactivity disorder medications, antidepressants, or mood stabilizers) (control group). Deaths during study follow-up while out of hospital or within 7 days after hospital admission, classified as either deaths due to injury or suicide or unexpected deaths. Secondary outcomes were unexpected deaths not due to overdose and death due to cardiovascular or metabolic causes. This study included 189 361 children and youths in the control group (mean [SD] age, 12.0 [5.1] years; 43.4% female), 28 377 in the lower-dose group (mean [SD] age, 11.7 [4.4] years; 32.3% female), and 30 120 in the higher-dose group (mean [SD] age, 14.5 [4.8] years; 39.2% female). The unadjusted incidence of death in the higher-dose group was 146.2 per 100 000 person-years (40 deaths per 27 354 person-years), which was significantly greater than that in the control group (54.5 per 100 000 population; 67 deaths per 123 005 person-years) (P < .001). The difference was primarily attributable to the increased incidence of unexpected deaths in the higher-dose group (21 deaths; 76.8 per 100 000 population) compared with the control group (22 deaths; 17.9 per 100 000 population). The propensity score-adjusted hazard ratios were as follows: all deaths (1.80; 95% CI, 1.06-3.07), deaths due to unintentional injury or suicide (1.03; 95% CI, 0.53-2.01), and unexpected deaths (3.51; 95% CI, 1.54-7.96). The hazard ratio was 3.50 (95% CI, 1.35-9.11) for unexpected deaths not due to overdose and 4.29 (95% CI, 1.33-13.89) for deaths due to cardiovascular or metabolic causes. Neither the unadjusted nor adjusted incidence of death in the lower-dose group differed significantly from that in the control group. The findings suggest that antipsychotic use is associated with increased risk of unexpected death and appear to reinforce recommendations for careful prescribing and monitoring of antipsychotic treatment for children and youths and to underscore the need for larger antipsychotic treatment safety studies in this population.

Depression, Anxiety, and Cognitive Impairment : Comorbid Mental Health Disorders in Heart Failure.

Depression, anxiety, and cognitive impairment constitute established risk markers for incident cardiovascular disease (CVD) and are associated with impaired life expectancy and quality of life and high hospitalization rates and healthcare expenditure. This review summarizes current knowledge about mental health disorders in patients with CVD and heart failure (HF). Emerging evidence suggests various shared pathophysiological mechanisms between psychological comorbidities and CVD (e.g., systemic inflammation and autonomic dysfunction). Bi-directional interactions involving the central nervous and cardiovascular systems may help explain the rising prevalence of comorbid mood disorders with increasing CVD severity and support the concept of alternative pathophysiological mechanisms in the presence of severe somatic illness, making symptoms less responsive or unresponsive to psychotropic pharmacotherapy. Considering high prevalence and negative impact of psychological comorbidities in CVD and HF, routine care should integrate screening for these conditions. Multidisciplinary treatment approaches with active patient participation in disease management were shown to improve outcomes. However, better understanding of factors mediating the adverse prognostic effects of mood disorders is needed. This might enable more targeted treatment and possibly also facilitate better understanding of the pathophysiological mechanisms driving CVD.

Frequent users of the emergency department services in the largest academic hospital in the Netherlands: a 5-year report.

To investigate the demographic and service characteristics, motive for consultation, and disposition of adult frequent users (FUs) of the largest academic hospital in the Netherlands over a 5-year period. This retrospective study included all patients aged 18 years and older visiting the emergency department (ED) during a 5-year period (2009-2013). Frequent ED use was defined as having four or more visits to the ED during a year. Patient and service characteristics, motive for consultation, and disposition were explored. Frequent ED users represented 2% of all patients who visited the ED during 2009-2013 (8% of all ED consultations). On average, each FU visited the ED five times per year. Compared with nonfrequent users (NFUs), FUs were significantly less often self-referred, less frequently transported to the hospital by ambulance, received a lower urgency code upon arrival to the ED, and more often admitted to hospital than NFUs. Complaints related to the digestive system (19%), general complaints such as fever (18%), respiratory (10%), or cardiovascular problems (10%) were the main motive for consultations of the frequent ED users. Two percent of the FUs were serial FUs (FUs during 3 or more consecutive years). Frequent use of the ED has been depicted as inappropriate use of these services. However, our study shows that FUs consist of a relatively small number of patients and that FUs suffer from chronic, and often, severe somatic illnesses that require specialized medical care.

Nightmare frequency in last trimester of pregnancy.

BackgroundPregnancy-related dreams are often found in pregnant women but also the number of negatively toned dreams seems to be increased in this challenging phase of a woman’s life.MethodsNightmare frequency and subjectively experienced stress was elicited via questionnaires. The mothers-to-be were approached during their application visit about 4–8 weeks prior to delivery in three obstetric hospitals. The present analysis included 406 women aged 16–40 years in the last trimester of their pregnancy. Women with severe somatic illnesses and/or psychiatric disorders were excluded. The representative sample included 496 women (age range: 14–93 years.).ResultsThe findings clearly indicate that pregnant women report nightmares more often compared to a representative sample and that nightmare frequency is closely related to subjectively experienced stress during daytime. Moreover, baby-related dreams were correlated with nightmare frequency but not with day-time stress.ConclusionsFuture studies should investigate the prevalence of nightmare disorders in pregnancy and study whether brief interventions like Imagery Rehearsal Therapy are beneficial for pregnant women suffering from nightmares.

Ill and substance-abusing parents: how can the general practitioner help their children? A qualitative study.

BackgroundSevere illness among parents may interfere with their parenting. Children having ill or substance-abusing parents are at risk of own health problems and psychosocial difficulties. The health care system should identify families in need of help and provide the help needed. For ill parents, it can be difficult to seek help and advices for their parenting. The aim of this study was to identify important factors for the general practitioner (GP) to bear in mind during encounters with ill and substance-abusing parents, to enable the GP to provide appropriate support for the children.MethodA qualitative approach was chosen and the data material was semi-structured individual interviews with 12 parents with mental illness, substance abuse or severe somatic illness. The participants were recruited through GPs in Norway, and the interviews were performed in 2014. We used systematic text condensation for analysis.ResultsIt was important for the participants that the GP was oriented about their family and children’s situation. They wanted to be regarded as competent parents in ordinary families; however, they were aware that their illness affected their parenting. They expressed a need for advice about how to inform the children of their illness and talk to them about their challenges, and, if necessary, utilize helpers who could inform the children and talk to them directly. There were often many agencies involved, and it was important that the helpers cooperated and shared information. In addition, the parents were in need of information about support services.ConclusionIll parents in this study conveyed a double message to their helpers. They wanted to be considered as responsible and well-intended parents who wished the best for their children. At the same time they needed support in parenting. The GP should take the time to listen to the parents’ first spontaneous description about an ordinary daily life (while realising that it may not necessarily be an accurate report), then explore their worries and needs of support.

Friedrich Schiller and Psychosomatics

Friedrich Schiller (1759-1805) was not only a famous German poet but also physician and one of the leading historians of his time at the university of Jena (Germany). To show that Schiller was very early inclined for psychosomatic interactions. Analysis of the secondary literature since the death of Schiller for the subjects ‘Friedrich Schiller” and ‘psychosomatics” Already during his medical studies at the ‘Hohe Karlsschule’ in Stuttgart (Germany) Schiller studied very intensively psychosomatic issues on behalf of the disease of another student, Joseph Frédéric Grammont. After the tremendous success of his play ‘Die Räuber” he fled from his unhappy life as a military physician and lived as a poet, always threatened by diseases and poverty. Medical and psychological knowledge play an important role in the thought of Friedrich Schiller. His creativity seems to be of greatest importance for him to survive psychically and physically. The actuality of his plays is due to the description of the drama of life in every age group, beginning from early childhood. Critical turning points in his life very often caused psychosomatic reactions, especially pain. Towards the upcoming mesmerism he remained very sceptic and refused to be mesmerized by the physician Eberhard Gmelin. Despite his own severe somatic illness he could cope with pain and emphasized in his writings the importance of the freedom of anxiety in difficult conditions. His descriptions of feelings, emotions and mental states are unique in their phenomenological precision and richness.

Friedrich Schiller und die Psychosomatik aus der Perspektive der rezenten Forschung

The aim of this study is to show that Friedrich Schiller (1759 - 1805) was very early in life inclined towards psychosomatic interactions. An analysis of the secondary literature since the death of Friedrich Schiller for the subjects "Friedrich Schiller" and "psychosomatics" was undertaken. Already during his medical studies at the "Hohe Karlsschule" in Stuttgart (Germany) Schiller studied very intensively psychosomatic issues on account of the disease of another student, Joseph Frédéric Grammont, and included the topic in his three theses. Not inclined to practical work as a physician, there are many psychosomatic thoughts and medical concepts in his writings, especially in the play "Die Räuber" (1781) and in "Don Carlos, Infant von Spanien" (1787). Towards the then upcoming topic mesmerism he remained very sceptic. In coping with his own illness there are many psychosomatic aspects, too. Despite his own severe somatic illness he could cope with pain and emphasised in his writings the importance of the freedom of anxiety before death.

Abstracts and Commentaries on Key Articles in the Literature

Abstracts and Commentaries on Key Articles in the Literature

Protracted delirium with Sheehan's syndrome.

Delirium is a common problem, but often misdiagnosed and unidentified. Apart from the manifold clinical picture variable durations can also be an obstacle for its diagnosis. We present a case of protracted delirium that has developed after severe somatic illness in association with previously undiagnosed Sheehan's syndrome. The variety of psychiatric symptoms with initial psychotic disorder and the long run of the disease delayed the diagnosis of delirium and meantime gave reason to assume personality change. This case report calls attention to the possibility of protracted delirium in patients with neuropsychiatric deficit symptoms that persist subsequent to somatic illness.

Posttraumatic stress disorder in survivors of severe somatic illness and ICU treatment

AimPatients suffering from severe somatic illness (e.g. burns, traumatic injuries, myocardial infarction, major surgery, acute respiratory distress, septic shock) that leads to ICU treatment face a high risk of psychiatric morbidity. There is a major challenge to C-/L-psychiatry both during acute treatment and long-term. The presentation will focus on the PTSD risk in survivors of acute respiratory distress syndrome (ARDS) and septic shock.MethodA literature survey on the general topic will be given in the introductory part of the presentation (1). Some major findings derived from own empirical studies on ARDS and septic shock will be summarized (2, 3).ResultsARDS and septic shock define medical conditions of acute respiratory insufficiency or/and systemic inflammation. Both medical conditions are often associated with multiorgan dysfunctions. As a rule, intensive care is based on mechanical ventilation often requiring high doses of sedatives and narcotics. Despite major progresses in intensive care medicine the rate of mortality is still very high among these patients. Several disabling psychological sequelae, such as cognitive dysfunctions, anxiety and mood disorders, posttraumatic stress disorders (PTSD) have to be evaluated in long-term survivors regarding a persisting negative impact on health-related quality of life. Several factors influencing the risk of PTSD in ARDS survivors may be discussed: increased CO2 triggering panic affects, mismatch of norepinephric overstimulation and Cortisol insufficiency, negative effects of high doses of benzodiazepines resulting in oversedation, prolonged phases of weaning and more frequent states of delirium, number of traumatic memories during ICU. Consolidation and retrieval of traumatic memories of the ICU stay are influenced by complex factors. From a clinical point of view prophylactic stress doses of hydrocortisone may reduce the major risk of PTSD associated with ARDS and septic shock.ConclusionARDS or septic shock not only define a major challenge to C-/L-psychiatry but offer an interesting model to elucidate some basic neurobiological mechanisms underlying the pathophysiology of PTSD and to develop some new prophylactic strategies for this often chronically disabling psychiatric condition.

Dépressions sévères : comorbidités somatiques

The association of somatic disease with a depressive disorder is not uncommon and affects 25% of general hospital inpatient populations. Although not well incorporated into management it is a source of mutual worsening of the two diseases. Several questions arise with this association. Firstly, it is essential to establish whether the depressive disorder is primary or secondary as these situations occasionally involve different (and even opposite) diagnostic and treatment approaches. It is then important to establish whether or not the disorder is adaptatory in nature : although an adaptatory problem does not have the same impact as depression on somatic outcome, it can progress to endogenous depression. Finally it is essential to identify the extent of suicidal risk, which is not only due to the depression but more to the feeling of despair (which is common in patients suffering from severe somatic illness). We will then examine the severity of these interlinked depressions in terms of the diagnostic difficulties (from confusion of symptoms to considering them to be unimportant). We shall then describe all of the consequences of the somatic disease on the prognosis of the depression and vice versa. Finally we will examine the question of severity from the perspective of the most widely studied associated diseases. Whilst the presence of an incapacitating somatic disease is a risk factor for depression in these vulnerable people, depression associated with the different major somatic diseases is a poor prognostic indicator. Somatic co-morbidities are still underestimated and are a factor responsible for chronic progression, deterioration and increased risk of suicide.

The Burden of Disease in Personality Disorders: Diagnosis-Specific Quality of Life

A generic quality of life measure was used to investigate the burden of disease in a large sample of patients with personality disorders. The 1,708 subjects included in this study were recruited from six different mental health care institutes in the Netherlands. The burden of disease was measured using the EuroQol EQ-5D. Personality disorders were diagnosed using the Structured Interview for DSM-IV Personality (SIDP-IV). The mean EQ-5D index value was 0.56. Primarily the total number of personality disorder diagnoses rather than the specific type determined the quality of life. Notably borderline personality disorder was not associated with the highest burden. The findings indicate that patients with personality disorders experience a high burden of disease, comparable to that of severe somatic illnesses. The results call into question the primary focus in literature on borderline personality disorder. The current study yields a strong argument in favor of reimbursing (effective) treatments for this patient population.

Attitudes of psychiatrists toward physician-assisted suicide

Physician-assisted suicide (PAS) is an important subject of the public debate. So far, legal regulations exist in the Netherlands, Belgium and in Oregon (USA). This review reports results of nine empirical studies from Japan, the Netherlands, the United Kingdom and the U. S. which examine attitudes of psychiatrists toward PAS. The approval of PAS by psychiatrists varies between the four countries (40 - 69 %). Comparisons with the attitudes of other physicians show a greater agreement among the psychiatrists. A psychiatric examination in order to evaluate competence even in patients with severe somatic illness was advocated by the majority of psychiatrists. Psychiatrists' attitudes toward PAS vary and are compared with other medical specialties, as well as in different legal and cultural contexts. Therefore, and because of missing empirical studies, results can not be transferred into the context of German speaking countries easily. So far, no acknowledged criteria for the assessment of competence exist. Further empirical research is needed on German psychiatrists' attitudes towards PAS and on competence assessment at the end of life. It remains an open question how legal changes and future developments of palliative care will influence attitudes toward PAS.