Treatment Of Psychiatric Comorbidity Research Articles

Psychiatric comorbidities and concurrent substance use among people who inject drugs: a single-centre hospital-based study

The management of people who inject drugs (PWID) is compounded by the presence of psychiatric comorbidities leading to frequent relapses and poor treatment outcomes. Early identification and treatment of psychiatric comorbidities should be included in the management to enhance treatment outcomes. The objective of this study was to estimate the prevalence of psychiatric comorbidities and concurrent substance use among opioid injectors. This hospital-based, cross-sectional study was conducted from March 2021 to August 2022. This study included opioid injectors of all ages and both sexes. The Mini International Neuropsychiatric Interview-7 (MINI-7) and WHO-ASSIST were used to determine psychiatric comorbidities and concurrent substance use, respectively. Both crude and adjusted odds ratios were calculated to assess associations among demographic variables, concurrent substance use and psychiatric comorbidities. Among the 328 opioid injectors, the overall prevalence of psychiatric comorbidities was 88.1%, with the majority (68.6%) having more than one comorbidity. The most common psychiatric comorbidities were panic disorder (41.2%), social anxiety disorder (40.5%), and antisocial personality disorder (39.3%). Concurrent use of alcoholic beverages doubled the risk of ASPD (odds ratio 2.14 (1.24–3.72)). Cocaine (odds ratio 2.36 (1.10–5.03)) and amphetamines (odds ratio 7.68 (2.21–26.65)) increased the risk of OCD. Daily heroin injections were negatively associated (odds ratio 0.18 (0.03–0.94)) with psychotic disorders. Younger age (adjusted odds ratio 0.20 (0.79–0.53)) and never married status (adjusted odds ratio 2.62 (1.06–6.47)) were the only significant variables in the regression analysis. In conclusion, opioid injectors had a higher prevalence of numerous psychiatric comorbidities. The most common comorbidity was anxiety disorders. Concurrent use of tobacco, cannabis, cocaine, inhalants, etc., greatly increased the risk of psychiatric comorbidities.

Anorexia Nervosa and Psychiatric Comorbidities – It’s not all about food

Introduction Anorexia nervosa (AN) is a severe psychiatric disorder that usually begins during adolescence and is associated with a high risk of mortality and morbidity, its treatment is complex and often ineffective. Psychiatric comorbidity is common in patients with eating disorders (with the prevalence of 20–95%), namely 39% in AN.ObjectivesThe purpose of the authors is to review the most common areas of psychiatric comorbidity in AN, how it affects the course of both diseases and the potential treatment approaches.MethodsA brief non-systematized review is presented, using the literature available on PubMed and Google Scholar.ResultsThe most common psychiatric comorbidities in AN are: Affective disorders in 24-38% (mainly unipolar depression which can appear in up to 75% of patients, compared to 11% in bipolar disorder); Anxiety disorders in 25.5% (11% with panic disorder, 20% social phobia/social anxiety disorder, 15% specific phobias, 10% generalized anxiety disorder, 13% post-traumatic stress disorder); Obsessive compulsive disorder in 12%; Substance use disorders at 17%; Personality disorders around 30%. Other pathologies occur less commonly but can have a significant impact on the patient, namely Autism spectrum disorder (predictive factor for unfavourable outcome) or Schizophrenia (there are reports of reciprocal relationships between the two pathologies). Some of these comorbidities may increase mortality in AN, namely unipolar depression, personality disorders, alcohol and illicit drug use. The profound impact that starvation has on mood and cognition is well known. It can condition symptoms that are confused with other psychiatric diseases and change their clinical presentation. As such, the specific clinical characteristics and the therapeutic approach will be presented for each of the psychiatric comorbidities.Conclusions Early diagnosis and treatment of psychiatric comorbidities in AN are essential to improve the prognosis of this eating disorder. The additional treatment of these pathologies will increase complexity of the already challenging treatment of AN, with the additional symptomatology often being perpetuated by an uncontrolled eating disorder and a poor compliance to treatment.The limited evidence available for approaching these cases is based on the few studies available, most with insufficient samples.Disclosure of InterestNone Declared

Mental health in myasthenia gravis patients and its impact on caregiver burden

Psychiatric comorbidities are relevant in patients with Myasthenia gravis (MG). Also, MG patients experience a reduced health-related quality of life (HRQoL). We aimed to quantify the impact of depression as well as self-perceived MG severity on HRQoL and caregivers' burden. In this cross-sectional study, we used a survey encompassing demographic, disease-related information, and standardized questionnaires to assess symptoms of depression, anxiety, HRQoL (MG Quality of Life scale; MG-QoL15), and caregiver burden (Burden Scale for Family Caregivers; BSFC). Data from 1399 participating patients (96%) and 1042 caregivers (65%) were eligible for further analysis. Symptoms of depression and anxiety disorder were indicated by 31% and 36% of patients. Self-reported MG severity (MG severity) and MG-QoL15 scores were strongly associated (estimated marginal means for severe versus mild MG severity = 18 95% CI [16; 21]; p ≤ 0.001). Adjusting for symptoms of depression decreased the estimated strength of this association (estimated marginal means for severe versus mild MG severity = 15 [13; 17]; p ≤ 0.001). Caregiver burden was associated to MG disease severity (estimated marginal means for severe vs. mild MG severity = 0.16 [0.13; 0,19); p ≤ 0.001) and also negatively influenced by symptoms of depression (estimated marginal means = 0.12 [0.09; 0.15]). Symptoms of depression and anxiety disorder in MG are frequent. Beyond MG severity, symptoms of depression have negative effects on HRQoL as well as on caregivers’ burden. Diagnosis and treatment of psychiatric comorbidities should be considered an important element in MG care. Screening tools for mental health conditions should be implemented at least in specialized MG centers.

Cardiovascular disease and subsequent risk of psychiatric disorders: a nationwide sibling-controlled study.

The association between cardiovascular disease (CVD) and selected psychiatric disorders has frequently been suggested while the potential role of familial factors and comorbidities in such association has rarely been investigated. We identified 869,056 patients newly diagnosed with CVD from 1987 to 2016 in Sweden with no history of psychiatric disorders, and 910,178 full siblings of these patients as well as 10 individually age- and sex-matched unrelated population controls (N = 8,690,560). Adjusting for multiple comorbid conditions, we used flexible parametric models and Cox models to estimate the association of CVD with risk of all subsequent psychiatric disorders, comparing rates of first incident psychiatric disorder among CVD patients with rates among unaffected full siblings and population controls. The median age at diagnosis was 60 years for patients with CVD and 59.2% were male. During up to 30 years of follow-up, the crude incidence rates of psychiatric disorder were 7.1, 4.6, and 4.0 per 1000 person-years for patients with CVD, their siblings and population controls. In the sibling comparison, we observed an increased risk of psychiatric disorder during the first year after CVD diagnosis (hazard ratio [HR], 2.74; 95% confidence interval [CI], 2.62-2.87) and thereafter (1.45; 95% CI, 1.42-1.48). Increased risks were observed for all types of psychiatric disorders and among all diagnoses of CVD. We observed similar associations in the population comparison. CVD patients who developed a comorbid psychiatric disorder during the first year after diagnosis were at elevated risk of subsequent CVD death compared to patients without such comorbidity (HR, 1.55; 95% CI, 1.44-1.67). Patients diagnosed with CVD are at an elevated risk for subsequent psychiatric disorders independent of shared familial factors and comorbid conditions. Comorbid psychiatric disorders in patients with CVD are associated with higher risk of cardiovascular mortality suggesting that surveillance and treatment of psychiatric comorbidities should be considered as an integral part of clinical management of newly diagnosed CVD patients. This work was supported by the EU Horizon 2020 Research and Innovation Action Grant (CoMorMent, grant no. 847776 to UV, PFS, and FF), Grant of Excellence, Icelandic Research Fund (grant no. 163362-051 to UV), ERC Consolidator Grant (StressGene, grant no. 726413 to UV), Swedish Research Council (grant no. D0886501 to PFS), and US NIMH R01 MH123724 (to PFS).

The Interaction of HIV With Mental Health in the Modern Antiretroviral Therapy Era.

ABSTRACTPeople with HIV (PWH) receiving effective antiretroviral therapy (ART) continue to display residual immune dysregulation that amplifies the risk for neuropsychiatric comorbidities. At the same time, PWH commonly experience intersectional stigma and other psychosocial stressors that are linked to neuroendocrine stress responses, potentiate residual immune dysregulation, and alter other biobehavioral processes relevant to health outcomes. This special issue of Psychosomatic Medicine seeks to advance our understanding of the intersection of HIV with mental health in the modern ART era. Several articles cover topics related to the prevalence and treatment of psychiatric comorbidities among PWH such as depression, suicidality, and substance use disorders. Other articles delineate biobehavioral mechanisms relevant to mental health in PWH such as inflammation, immune activation, neuroendocrine signaling, cellular aging, the microbiome-gut-brain axis, and neurobehavioral processes. Collectively, the articles in this special issue highlight the continued importance of biobehavioral and neurobehavioral mental health research in the modern ART era.

The recent surge of functional movement disorders: social distress or greater awareness?

To analyze the interrelated factors that have led to the striking increase in functional movement disorders in recent years, with a focus on functional tic-like behaviours (FTLB). The sudden onset of FTLB has been widely observed in several countries since the beginning of the SARS-CoV-2 pandemic, whereas it was previously very rarely reported. Pandemic-related FTLB typically occur in young females, share complex, disabling and tic-lookalike patterns, and are usually triggered by the exposure to videos portraying tic-like behaviours on social media. Both pandemic-related FTLB and prepandemic FTLB are associated with high levels of depression and anxiety. FTLB related to the pandemic highlight the role of social media in the psychopathological behaviours of our time. We suggest FTLB are due to a combination of predisposing factors (high genetic and epigenetic risk for anxiety and depression, negative past experiences) and precipitating factors (pandemic and its impact on mental health, exposure to certain social media content). These factors of vulnerability may increase the risk of developing behavioural and emotional problems in youth, such as FTLB. Early diagnosis and appropriate treatment of psychiatric comorbidities seem to be predictors of positive prognosis.

BDNF and Cortisol in the Diagnosis of Cocaine-Induced Depression.

BackgroundMajor depressive disorder (MDD) and cocaine use disorder (CUD) are related with disability and high mortality rates. The assessment and treatment of psychiatric comorbidity is challenging due to its high prevalence and its clinical severity, mostly due to suicide rates and the presence of medical comorbidities. The aim of this study is to investigate differences in brain derived neurotrophic factor (BDNF) and cortisol plasmatic levels in patients diagnosed with CUD-primary-MDD and CUD-induced-MDD and also to compare them to a sample of MDD patients (without cocaine use), a sample of CUD (without MDD), and a group of healthy controls (HC) after a stress challenge.MethodsA total of 46 subjects were included: MDD (n = 6), CUD (n = 15), CUD-primary-MDD (n = 16), CUD-induced-MDD (n = 9), and 21 HC. Psychiatric comorbidity was assessed with the Spanish version of the Psychiatric Research Interview for Substance and Mental Disorders IV (PRISM-IV), and depression severity was measured with the Hamilton Depression Rating Scale (HDRS). Patients were administered the Trier Social Stress Test (TSST) before and after the biological measures, including BDNF, and cortisol levels were obtained.ResultsAfter the TSST, Cohen's d values between CUD-primary-MDD and CUD-induced-MDD increased in each assessment from 0.19 post-TSST to 2.04 post-90-TSST. Pairwise differences among CUD-induced-MDD and both MDD and HC groups had also a large effect size value in post-30-TSST and post-90-TSST. In the case of the BDNF concentrations, CUD-primary-MDD and CUD-induced-MDD in post-90-TSST (12,627.27 ± 5488.09 vs.17,144.84 ± 6581.06, respectively) had a large effect size (0.77).ConclusionResults suggest a different pathogenesis for CUD-induced-MDD with higher levels of cortisol and BDNF compared with CUD-primary-MDD. Such variations should imply different approaches in treatment.

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INTRODUCTION :Chronic obstructive pulmonary disease (COPD) is a progressive, partially reversible, preventable, and treatable lung disease which is characterized by long-term breathing problems which typically worsens over time. Acute exacerbations and frequent comorbidities contribute to the overall severity in individual patients and eventually everyday activities, such as walking or getting dressed, become difficult. Psychiatric illnesses are increasingly common in patients with chronic illnesses like COPD. Despite this, psychiatric co-morbidities among patients with COPD are less studied in comparison with general medical conditions.AIM :To study the psychiatric morbidity in individuals with COPD.METHODOLOGY :60 patients including inpatients and outpatients in the Department of Pulmonology, NRI Academy OF Medical Sciences, Guntur, diagnosed with COPD consenting for the study were included. Diagnosis of COPD was made using HRCT chest and pulmonary function tests(PFT).A descriptive study was done and psychiatric disorders were diagnosed using the Mini International Neuropsychiatric Interview Questionnaire (MINI).RESULTS :Among the 60 patients two-third patients had psychiatric comorbidity.Anxiety and Depression were the most frequently diagnosed psychiatric disorders in the study and more than 50 % of the patients had history of smoking.There was a significant correlation between severity of COPD and psychiatric disorders.CONCLUSION :This study showed increased psychiatric morbidity in patients suffering from COPD. The presence of psychiatric disorders in COPD leads to increased morbidity. However, these have not been screened for routinely. Early detection and treatment of psychiatric comorbidity in COPD will help in reducing the morbidity and increase in the level of functioning.

Obesity and Eating Disorders in Children and Adolescents: The Bidirectional Link.

Obesity, eating disorders and unhealthy dieting practices among children and adolescents are alarming health concerns due to their high prevalence and adverse effects on physical and psychosocial health. We present the evidence that eating disorders and obesity can be managed or prevented using the same interventions in the pediatric age. In the presence of obesity in the pediatric age, disordered eating behaviors are highly prevalent, increasing the risk of developing eating disorders. The most frequently observed in subjects with obesity are bulimia nervosa and binge-eating disorders, both of which are characterized by abnormal eating or weight-control behaviors. Various are the mechanisms overlying the interaction including environmental and individual ones, and different are the approaches to reduce the consequences. Evidence-based treatments for obesity and eating disorders in childhood include as first line approaches weight loss with nutritional management and lifestyle modification via behavioral psychotherapy, as well as treatment of psychiatric comorbidities if those are not a consequence of the eating disorder. Drugs and bariatric surgery need to be used in extreme cases. Future research is necessary for early detection of risk factors for prevention, more precise elucidation of the mechanisms that underpin these problems and, finally, in the cases requiring therapeutic intervention, to provide tailored and timely treatment. Collective efforts between the fields are crucial for reducing the factors of health disparity and improving public health.

S3263 Co-morbidity of Anxiety and Depression in Readmitted Adult Patients With Eosinophilic Esophagitis? A Cross-Sectional Study of the National Readmission Database

Introduction: Eosinophilic esophagitis is a chronic medical condition that negatively impacts patients' health-related quality of life (HRQOL). In addition to the inadequate treatment, the disturbing symptoms and patient compliance to a life-long treatment formula could lead to mental health distress in this population. Studies have shown that poor recognition and treatment of psychiatric co-morbidities in chronic medical conditions are associated with increased risks of disease severity, non-adherence to treatment, and increased healthcare costs. This study, therefore, examines the prevalence of co-morbid depression and anxiety in readmitted adult patients with EoE. Methods: Our study population comprised adults ages 19 years or above readmitted within 180 days of index EoE hospitalization. The eligible subjects were identified from the U.S. National Readmission Data between 2012 and 2018, using the ICD9 /10 diagnostic codes recorded during admission. We defined EoE (530.13 or K20.0), depression (311.xx or F32.x), and anxiety (300.xx or F41.x) as having primary or secondary diagnostics codes documented for these conditions during hospitalization. We extracted patient demographic data and hospital factors. We performed descriptive statistics and multivariable analysis to examine the relationship between EoE, depression, and anxiety. Results: A weighted total of 4472 EoE adult patients were readmitted within 180 days of the index EoE hospitalization over seven years. There was no difference in the proportion of readmission by gender. About 81% of the cases readmitted were moderate or high severity, and 74% of the patients reside in small metropolitan/ rural areas. Approximately 18% of the patients readmitted for EoE had co-morbid anxiety symptoms while 11% had co-morbid depressive disorders. Generalized linear models adjusting for demographics and hospital factors showed a significant association between EoE and risk of anxiety (OR, 1.07; 95% CI, 1.02-1.12). There was no evidence of elevated risk of depression in patients readmitted for EoE (OR, 1.03; 95% CI, 0.99-1.07). Medicare or private insurance, and non-teaching hospital admissions, were significantly associated with a lower risk of anxiety in EoE readmissions. Conclusion: Our study supports the evidence of the risk of mental health distress in patients with EoE. We found a significant association between EoE readmission and anxiety. These findings have implications for the assessment and treatment of mental health in patients readmitted for EoE.

Sex differences in factors associated with quality of life in patients with epilepsy in Northeast China

ObjectiveWe aimed to investigate sex differences in factors associated with poor quality of life (QOL) in a cohort of patients with epilepsy (PWE) in Northeast China. MethodsA consecutive cohort of 221 PWE from the First Hospital of Jilin University was recruited. The Chinese versions of the Patient Health Questionnaire-9 (PHQ-9), the Beck Anxiety Inventory (BAI), and the Quality of Life in Epilepsy Inventory (QOLIE-31) were used to measure depressive symptoms, anxiety symptoms, and the QOL. ResultsA total of 221 adult PWE participated in this study. In the multivariate regression model, three independent factors were found to be significantly associated with the total QOLIE-31 score in men: epilepsy duration (p = 0.007), the PHQ-9 score (p < 0.001), and the BAI score (p < 0.001). As for the subscale domain of QOL, marital status showed a relationship with cognitive function (p = 0.047), and residence was related with medication effects (p = 0.034). Two independent factors were found to be significantly associated with the total QOLIE-31 score in women: the PHQ-9 score (p < 0.001) and the BAI score (p < 0.001). The education level of women was positively associated with three subdomain scores of QOL, including overall QOL (p < 0.001), emotional well-being (p = 0.028), and energy/fatigue (p = 0.025). ConclusionWe found that high levels of depressive and anxiety symptoms are strong predictors of a poor QOL in both men and women. Sex differences also occur in several demographic and clinical factors influencing the overall QOL or subscale domain scores such as epilepsy duration, marital status, and educational level. Timely diagnosis and treatment of psychiatric comorbidities might be crucial for improving the QOL in both men and women.

Significant Association Between Huntingtin Gene Mutation and Prevalence of Hopelessness, Depression and Anxiety Symptoms.

Summary. Background:In Huntington’s disease psychiatric symptoms may manifest prior to motor dysfunction. Such symptoms negatively impact people’s quality of life and can worsen the course of the primary disease. The aim of the present study was to assess and compare depression, anxiety and hopelessness rates in individuals with and without an abnormal expansion of CAG repeats in the huntingtin (HTT) gene and healthy controls.Materials and methods:Study involved 31 individuals referred for genetic testing for Huntington’s disease and a control group of 41. Depressive and anxiety symptoms were assessed using Beck Hopelessness Scale (BHS) and Hospital Anxiety and Depression Scale (HADS). Results between groups were compared using the Mann–Whitney U test. Two-sided Bonferroni corrected p-value was set at ≤0.017.Results:Individuals with HTT gene mutation (“gene mutation positive”, GMP) (N=20) scored higher on the HADS depression subscale (5.90 ± 4.52 vs 1.36 ± 1.91; p ≤ 0.017) than those without HTT gene mutation (“gene mutation negative”, GMN) (N=11). GMP and control groups scored higher than the GMN group on the BHS (5.65 ± 3.91 vs 2.09 ± 1.64 and 5.27 ± 4.11 vs 2.09 ± 1.64, respectively; p ≤ 0.017). No differences in anxiety levels were found.Conclusions:Depressive symptoms and hopelessness were more prevalent in individuals with HTT gene mutation than in individuals who were tested but had no said mutation. Such results emphasise the importance of timely diagnosis and treatment of psychiatric comorbidities in individuals affected by Huntington’s disease.

Individual risk and familial liability for suicide attempt and suicide in autism: a population-based study.

Studies on the individual gender-specific risk and familial co-aggregation of suicidal behaviour in autism spectrum disorder (ASD) are lacking. We conducted a matched case-cohort study applying conditional logistic regression models on 54 168 individuals recorded in 1987-2013 with ASD in Swedish national registers: ASD without ID n = 43 570 (out of which n = 19035, 43.69% with ADHD); ASD + ID n = 10 598 (out of which n = 2894 individuals, 27.31% with ADHD), and 270 840 controls, as well as 347 155 relatives of individuals with ASD and 1 735 775 control relatives. The risk for suicidal behaviours [reported as odds ratio OR (95% confidence interval CI)] was most increased in the ASD without ID group with comorbid ADHD [suicide attempt 7.25 (6.79-7.73); most severe attempts i.e. requiring inpatient stay 12.37 (11.33-13.52); suicide 13.09 (8.54-20.08)]. The risk was also increased in ASD + ID group [all suicide attempts 2.60 (2.31-2.92); inpatient only 3.45 (2.96-4.02); suicide 2.31 (1.16-4.57)]. Females with ASD without ID had generally higher risk for suicidal behaviours than males, while both genders had highest risk in the case of comorbid ADHD [females, suicide attempts 10.27 (9.27-11.37); inpatient only 13.42 (11.87-15.18); suicide 14.26 (6.03-33.72); males, suicide attempts 5.55 (5.10-6.05); inpatient only 11.33 (9.98-12.86); suicide 12.72 (7.77-20.82)]. Adjustment for psychiatric comorbidity attenuated the risk estimates. In comparison to controls, relatives of individuals with ASD also had an increased risk of suicidal behaviour. Clinicians treating patients with ASD should be vigilant for suicidal behaviour and consider treatment of psychiatric comorbidity.

Psychopharmacology of Autism Spectrum Disorder

People with autism spectrum disorder (ASD) are at high risk for co-occurring psychiatric and behavioral disorders. Risperidone and aripiprazole are approved by the US Food and Drug Administration for the treatment of irritable mood-associated problems (eg, aggression, self-injury, tantrums, and mood lability) in youth with ASD. Several other medications have been used as adjuncts to risperidone, with some evidence for reduction in irritability and hyperactivity. To date, there are no medications that have been consistently effective in treating the core social and communication deficits seen in people with ASD. There are, however, two investigational drugs that have shown promise in that regard, and they are, or will soon be, in phase III trials. This article presents a brief overview of current and potential psychopharmacologic agents used in the treatment of psychiatric comorbidities in people with ASD. [ Psychiatr Ann . 2019;49(3):120–124.]

Prevalence, pattern, impact, diagnosis and treatment of psychiatric comorbidity in bipolar disorder Chair: Keming Gao

Prevalence, pattern, impact, diagnosis and treatment of psychiatric comorbidity in bipolar disorder Chair: Keming Gao

Clinical aspects of differential diagnosis in adult ADHD patients

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that until recently was considered as belonging exclusively to childhood. With the introduction of diagnostic criteria applicable for adults in DSM‑5, the scientific interest in the evolution of symptoms and possible associated conditions has increased further. This disorder remains underdiagnosed in adulthood, and continuous research is needed regarding the way symptoms of childhood are also manifested in adulthood. In this paper we intent to summarize the scientific information on the transition of ADHD symptomatology from childhood to adulthood, as well as the main difficulties that the mental health specialist can face in the differential diagnosis or in the treatment of psychiatric comorbidities. We consider that is particularly important to raise awareness on the psychosocial dysfunctions experienced by an adult with ADHD in order to diagnose as early as possible this condition and initiate a more effective intervention.

Evaluation of the association between sexual dysfunction and demyelinating plaque location and number in female multiple sclerosis patients

Purpose To investigate the frequency of sexual dysfunction (SD) in female multiple sclerosis (MS) patients and to explore its association with the location and number of demyelinating lesions.Material and Methods We evaluated 42 female patients and 41 healthy subjects. All patients underwent neurological examination and 1.5 T brain and full spinal MRI. All subjects completed the female sexual function index (FSFI), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Short-Form 36 Quality of Life Scale (SF-36). All participants were also evaluated for serum thyroid stimulating hormone (TSH), T4, estradiol, and total testosterone.Results No statistically significant differences between the MS and control groups were found for age, body mass index (BMI), serum TSH, T4, E2, and total testosterone level. MS patients had a statistically significantly lower FSFI and SF-36 scores and higher BDI and BAI scores compared with healthy subjects. The location and number of demyelinating lesions were not associated with SD.Conclusion In our cohort, this difference in SD appears unrelated to the location and number of demyelinating lesions. These findings highlight the importance of the assessment and treatment of psychiatric comorbidities, such as depression and anxiety, in MS patients reporting SD.

Psychiatric Treatment and Management of Psychiatric Comorbidities of Movement Disorders

Pediatric movement disorders may present with psychiatric symptoms at many points during the course of the disease. For the relatively common pediatric movement disorder, Tourette syndrome, psychiatric comorbidities are well-described and treatment is well-studied. Managing these comorbidities may be more effective than improving the movements themselves. For more uncommon movement disorders, such as juvenile-onset Huntington disease, treatment of psychiatric comorbidities is not well-characterized, and best-practice recommendations are not available. For the least common movement disorders, such as childhood neurodegeneration with brain iron accumulation, psychiatric features may be nonspecific so that underlying diagnosis may be apparent only after recognition of other symptoms. However, psychiatric medication, psychotherapy, and psychosocial support for these disorders may prove helpful to many children and adolescents.

Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic

Background and aimsPatients suffering from chronic nonmalignant pain constitute a heterogeneous population in terms of clinical presentation and treatment results. Few data are available about what distinguishes different groups in this huge population of patients with chronic persistent pain (CPP). A subgroup that is poorly studied, consists of the most severely impaired chronic pain patients. At the Uppsala University Hospital Pain Clinic, there is a specialized department accepting the most complex patients for rehabilitation. In the endeavour to improve and evaluate treatment for this subgroup, a better understanding of the complex nature of the illness is essential. This prospective study aimed to describe the characteristics of this subgroup of patients with CPP. MethodsSeventy-two consecutive patients enrolled in the Uppsala programme were evaluated. We collected data on demographics, type of pain and experienced symptoms other than pain using a checklist of 41 possible symptoms. Psychiatric comorbidity was assessed by a psychiatrist using a structured clinical interview. Quality of life (QoL), pain rating and medication/drug/alcohol usage were measured by validated questionnaires: SF-36, NRS, DUDIT and AUDIT. Concerning physical functioning and sick leave, a comparison was made with data from the Swedish Quality Register Registry for pain rehabilitation (SQRP). ResultsThe cohort consisted of 61% women and the average age was 45 (range 20–70) years. For this cohort, 74% reported being on sick leave or disability-pension. In the SQRP 59% were on sick leave at the time they entered the rehabilitation programmes [1]. On average, the study-population reported 22 symptoms other than pain, to be at a high rate of severity. Patients treated in conventional pain-rehabilitation programmes reported a mean of 10 symptoms in average. Symptoms reported with the highest frequency (>80%), were lethargy, tiredness, headache and difficulties concentrating. Seventy-six percent were diagnosed with a psychiatric disorder. Sixty-nine fulfilled the criteria for depression or depression/anxiety disorder despite that most (65%) were treated with psychotropic medication. Alcohol/drug abuse was minimal. Seventy-one percent were on opioids but the doses were moderate (<100mg) MEq. The pain rating was ≥7 (out of a maximum of 10) for 60% of the patients. ConclusionThis study describes what makes the subgroup of pain patients most affected by their pain special according to associated factors and comorbidity We found that they were distinguished by a high degree of psychiatric comorbidity, low physical functioning and extreme levels of symptom preoccupation/hypervigilance. Many severe symptoms additional to pain (e.g. depression/anxiety, tiredness, disturbed sleep, lack of concentration, constipation) were reported. The group seems hypervigilant, overwhelmed with a multitude of different symptoms on a high severity level. ImplicationsWhen treating this complex group, the expressions of the illness can act as obstacles to achieve successful treatment outcomes. The study provides evidence based information, for a better understanding of the needs concerning these pain patients. Our result indicates that parallel assessment and treatment of psychiatric comorbidities and sleep disorders combined with traditional rehabilitation, i.e. physical activation and cognitive reorganization are imperative for improved outcomes.

Managing aggression in epilepsy

Behavioural changes associated with epilepsy can be challenging for patients and clinicians. Evidence suggests an association between aggression and epilepsy that involves various neurophysiological and neurochemical disturbances. Anti-epileptics have variable effects on behaviour and cognition that need consideration. Early detection and careful consideration of history, symptomatology and possible common comorbid psychiatric disorders is essential. Appropriate investigations should be considered to aid diagnosis, including electroencephalogram (EEG), video EEG telemetry and brain imaging. Optimising treatment of epilepsy, treatment of psychiatric comorbidities and behavioural management can have a major positive effect on patients' recovery and well-being.Learning Objectives• Understand the epidemiology of aggression in epilepsy• Comprehend the link between anti-epileptics and aggression, including the important role of pharmacodynamics• Be aware of the pharmacological treatments available for managing aggressive behaviour in epilepsy