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Clinical Abstracts
---Clinical Abstracts--Treatment of recurrent unipolar depression Frank E. Kupfer DJ: Psychotherapeutic approaches to treatment of recurrent unipolar depression: Work in progress. Psychopharmacol Bull 22:558-563. 1986.
• This is believed to be the first study examining the effectiveness of combined drug treatment and psychotherapy in adults who have experienced at least three episodes of recurrent unipolar depression. Results are presented for the initial 119 patients (27 males and 92 females, with a median age of 39.3). The patients had certain minimum qualifying scores on two standardized depression questionnaires (Hamilton Rating Scale for Depres-
EEG abnormalities in psychiatric patients Bridgers SL: Epileptiform abnormalities discovered on electroencephalographic screening of psychiatric inpatients. Arch NeuroI44:312-316. 1987.
• The author concludes from his study to define the occurrence of EEG epileptiform activity in a psychiatric population that the diagnosis of epilepsy on the basis of EEG epileptiform abnormalities and a psychiatric presentation must be made with great caution. EEG requisitions and interpretations were reviewed for 3,225 psychiatric inpatients (aged II to 85 years) since the EEG is a commonly used screening test for this category of patients. The most commonly en-
OCTOBER 1987'YOL28'NO 10
sion and the Raskin Severity of Depression and Mania Scale). After a two-week drug-free period, symptomatic individuals received a thorough evaluation, including psychosocial measures, neuroendocrine studies, and an all-night sleep EEG. All patients then received the same acute treatment: imipramine, 150-300 mgld, and interpersonal psychotherapy weekly for 12 weeks, biweekly for 8 weeks, and then monthly thereafter. After a lengthy period of improvement and stability, as measured by both questionnaire scores and imipramine levels, the patients were assigned to one of five maintenance treatment groups (psychotherapy
alone, psychotherapy plus active medication, psychotherapy plus placebo, medication clinic plus active medication, or medication clinic plus placebo). This maintenance treatment lasted three years or until a recurrence of illness. About one third of the patients attained complete remission of symptoms within eight weeks, another third required "several months," and the final third was only "partially responsive." The results in this report were not broken down according to kind of maintenance treatment. The relapse rates ranged from 8% to 15%.
countered diagnostic impressions were depression, schizophrenia, mania, and anorexia nervosa. Eighty-two patients had a history of epilepsy, and 30 of them manifested epileptiform activity on the EEG. Of the remaining 3,143 patients with no history of epilepsy, 81 had EEG epileptiform activity. Treatment with neuroleptics, antidepressants, or lithium was associated with a significantly increased incidence of epileptiform abnormalities in patients over 25 years of age. Youth, recent barbiturate abuse, and a diagnosis of anorexia nervosa or explosive behavior all associated significantly with the occurrence of epileptiform activity on the EEG. The most common EEG abnormality was a photo-
convulsive response. Only about 1% of patients without known epilepsy exhibited epileptiform abnormalities likely to be associated with epilepsy, similar to the normal population. Only four of these 3.143 patients had temporal epileptiform foci. The possible role of confounding influences on the EEG must be considered when attempting to utilize it for diagnosis in epileptic patients. Some attempt must be made to correlate suspect behavior with ictal EEG abnormalities. Epileptiform abnormalities in psychiatric patients do not necessarily indicate epilepsy.
Ronald K. McCraw, Ph.D. Fort Worth, Tex.
W. Steven Metzer, M.D. University ofArkansas College ofMedicine
{continued} 559
f---------Clinical Abstracts------Psychiatric aspects of AIDS Faulstich ME: Psychiatric aspects of AIDS. Am J Psychiatry 144:551-556,1987
• Patients already diagnosed as having AIDS or AIDS-related complex frequently develop psychiatric symptoms similar to those reported in patients with terminal cancer. Diagnoses such as adjustment disorder with depressed mood, major depressive disorder, dementia, delirium, and panic disorder are not uncommon. Individuals in high-risk groups are frequently affected by anxiety and hypochondriasis. CNS complications of AIDS represent a major area of concern for the consulting psychiatrist. Subacute en-
Liaison psychiatry in Britain Mayou R: A British view of liaison psychiatry Gen Hosp Psychiatry 9:18-24, 1987
• The British author of this article notes that liaison psychiatry is very much a North American creation. Nowhere else is it an established subspecialty. The boundaries and role of liaison psychiatry are seemingly very different in Britain from those in North America. The author hopes that description ofthe differences will diminish parochialism. In Britain the National Health Service aims to provide integrated care for the local populations. There is little private care and no tradition of public demand for counseling and therapy for the' 'worried well." Only recently has consultation-liaison been in any way recognized as a .. special interest." There probably are fewer than ten full-time liaison psychiatrists in the United Kingdom and the Republic of Ireland. The most common reason for psychiatric referral within the general hospi-
S60
cephalitis and subcortical dementia appear to be the most frequent CNS complications and are characterized pathologically by neuronal loss, cerebral atrophy, glial nodules, and microfocal demyelination. The etiology of these changes is unclear but may relate to the HTLV-III virus itself or to opportunistic infections by other agents. Patients suffering from this complication have deficits that may be discernible on neuropsychological testing. Clinically, patients with AIDS dementia initially appear depressed but eventually become severely delusional and disoriented and demonstrate marked global cognitive deficits. Gradually, the disease results
tal is attempted suicide. The proportion of admissions referred is low, perhaps 2% of medical admissions and less than I % of all referrals. Medical social work is well established in all general hospitals. In one survey of453 consecutive nonoverdose medical admissions, 113 patients were seen by social workers, as compared with 12 psychiatric referrals. The author concludes that the British system differs from the American one in two ways: The total resources are considerably less, and the role of liaison psychiatry within the whole range of general hospital psychiatry appears narrower. While British psychiatrists can learn clinical liaison skills from American psychiatrists, American liaison psychiatrists can learn most from Britain by looking at clinical practice research both inside and outside what we in the United States have become accustomed to regarding as liaison psychiatry.
in seizures, mutism, and coma. The psychosocial implications of AIDS are particularly difficult. Negative societal reactions such as the belief that AIDS patients are responsible for their disease and the associated ostracism tend to weaken their social support systems. They should be provided with stress-management and problemsolving skills, as well as antianxiety and antidepressant therapy when indicated. Finally, patient management should also include dissemination of recent updates on AIDS and information on etiology and modes of transmission of the disease. John L. Black. M.D. MavoClinic
OCT08ER I 7
Allan Burstein, M.D. Freehold, N.J.
PSYCHOSOMATICS
• This is believed to be the first study examining the effectiveness of combined drug treatment and psychotherapy in adults who have experienced at least three episodes of recurrent unipolar depression. Results are presented for the initial 119 patients (27 males and 92 females, with a median age of 39.3). The patients had certain minimum qualifying scores on two standardized depression questionnaires (Hamilton Rating Scale for Depres-
EEG abnormalities in psychiatric patients Bridgers SL: Epileptiform abnormalities discovered on electroencephalographic screening of psychiatric inpatients. Arch NeuroI44:312-316. 1987.
• The author concludes from his study to define the occurrence of EEG epileptiform activity in a psychiatric population that the diagnosis of epilepsy on the basis of EEG epileptiform abnormalities and a psychiatric presentation must be made with great caution. EEG requisitions and interpretations were reviewed for 3,225 psychiatric inpatients (aged II to 85 years) since the EEG is a commonly used screening test for this category of patients. The most commonly en-
OCTOBER 1987'YOL28'NO 10
sion and the Raskin Severity of Depression and Mania Scale). After a two-week drug-free period, symptomatic individuals received a thorough evaluation, including psychosocial measures, neuroendocrine studies, and an all-night sleep EEG. All patients then received the same acute treatment: imipramine, 150-300 mgld, and interpersonal psychotherapy weekly for 12 weeks, biweekly for 8 weeks, and then monthly thereafter. After a lengthy period of improvement and stability, as measured by both questionnaire scores and imipramine levels, the patients were assigned to one of five maintenance treatment groups (psychotherapy
alone, psychotherapy plus active medication, psychotherapy plus placebo, medication clinic plus active medication, or medication clinic plus placebo). This maintenance treatment lasted three years or until a recurrence of illness. About one third of the patients attained complete remission of symptoms within eight weeks, another third required "several months," and the final third was only "partially responsive." The results in this report were not broken down according to kind of maintenance treatment. The relapse rates ranged from 8% to 15%.
countered diagnostic impressions were depression, schizophrenia, mania, and anorexia nervosa. Eighty-two patients had a history of epilepsy, and 30 of them manifested epileptiform activity on the EEG. Of the remaining 3,143 patients with no history of epilepsy, 81 had EEG epileptiform activity. Treatment with neuroleptics, antidepressants, or lithium was associated with a significantly increased incidence of epileptiform abnormalities in patients over 25 years of age. Youth, recent barbiturate abuse, and a diagnosis of anorexia nervosa or explosive behavior all associated significantly with the occurrence of epileptiform activity on the EEG. The most common EEG abnormality was a photo-
convulsive response. Only about 1% of patients without known epilepsy exhibited epileptiform abnormalities likely to be associated with epilepsy, similar to the normal population. Only four of these 3.143 patients had temporal epileptiform foci. The possible role of confounding influences on the EEG must be considered when attempting to utilize it for diagnosis in epileptic patients. Some attempt must be made to correlate suspect behavior with ictal EEG abnormalities. Epileptiform abnormalities in psychiatric patients do not necessarily indicate epilepsy.
Ronald K. McCraw, Ph.D. Fort Worth, Tex.
W. Steven Metzer, M.D. University ofArkansas College ofMedicine
{continued} 559
f---------Clinical Abstracts------Psychiatric aspects of AIDS Faulstich ME: Psychiatric aspects of AIDS. Am J Psychiatry 144:551-556,1987
• Patients already diagnosed as having AIDS or AIDS-related complex frequently develop psychiatric symptoms similar to those reported in patients with terminal cancer. Diagnoses such as adjustment disorder with depressed mood, major depressive disorder, dementia, delirium, and panic disorder are not uncommon. Individuals in high-risk groups are frequently affected by anxiety and hypochondriasis. CNS complications of AIDS represent a major area of concern for the consulting psychiatrist. Subacute en-
Liaison psychiatry in Britain Mayou R: A British view of liaison psychiatry Gen Hosp Psychiatry 9:18-24, 1987
• The British author of this article notes that liaison psychiatry is very much a North American creation. Nowhere else is it an established subspecialty. The boundaries and role of liaison psychiatry are seemingly very different in Britain from those in North America. The author hopes that description ofthe differences will diminish parochialism. In Britain the National Health Service aims to provide integrated care for the local populations. There is little private care and no tradition of public demand for counseling and therapy for the' 'worried well." Only recently has consultation-liaison been in any way recognized as a .. special interest." There probably are fewer than ten full-time liaison psychiatrists in the United Kingdom and the Republic of Ireland. The most common reason for psychiatric referral within the general hospi-
S60
cephalitis and subcortical dementia appear to be the most frequent CNS complications and are characterized pathologically by neuronal loss, cerebral atrophy, glial nodules, and microfocal demyelination. The etiology of these changes is unclear but may relate to the HTLV-III virus itself or to opportunistic infections by other agents. Patients suffering from this complication have deficits that may be discernible on neuropsychological testing. Clinically, patients with AIDS dementia initially appear depressed but eventually become severely delusional and disoriented and demonstrate marked global cognitive deficits. Gradually, the disease results
tal is attempted suicide. The proportion of admissions referred is low, perhaps 2% of medical admissions and less than I % of all referrals. Medical social work is well established in all general hospitals. In one survey of453 consecutive nonoverdose medical admissions, 113 patients were seen by social workers, as compared with 12 psychiatric referrals. The author concludes that the British system differs from the American one in two ways: The total resources are considerably less, and the role of liaison psychiatry within the whole range of general hospital psychiatry appears narrower. While British psychiatrists can learn clinical liaison skills from American psychiatrists, American liaison psychiatrists can learn most from Britain by looking at clinical practice research both inside and outside what we in the United States have become accustomed to regarding as liaison psychiatry.
in seizures, mutism, and coma. The psychosocial implications of AIDS are particularly difficult. Negative societal reactions such as the belief that AIDS patients are responsible for their disease and the associated ostracism tend to weaken their social support systems. They should be provided with stress-management and problemsolving skills, as well as antianxiety and antidepressant therapy when indicated. Finally, patient management should also include dissemination of recent updates on AIDS and information on etiology and modes of transmission of the disease. John L. Black. M.D. MavoClinic
OCT08ER I 7
Allan Burstein, M.D. Freehold, N.J.
PSYCHOSOMATICS