A case of postpsychotic depression improved by switching antipsychotic monotherapy.

AIM: Postpsychotic depression is challenging to differentiate, yet it is clinically frequent, puts patients at risk for suicide, and affects their mental capacity. Treatment with antipsychotics for postpsychotic depression is desirable; however, there is no consensus on which antipsychotics are optimal. CASE PRESENTATION: We report the case of a young male patient with schizophrenia in his 20s who developed postpsychotic depression, including despair, overwhelming loss, humiliation, and suicidal ideation during treatment with paliperidone. As a result, we switched his medication to lurasidone, which relieved his depressive symptoms without any symptom relapse and his social functioning improved. CONCLUSION: Postpsychotic depression has more psychic characteristics than behavioral. According to various international guidelines for the pharmacological treatment of schizophrenia, antipsychotics should be administered for depressive symptoms of schizophrenia. As evidenced in this case report, lurasidone may be a practical alternative for improving postpsychotic depression.

Revisiting the concept of late catatonia.

AIM: The objective of this paper is to introduce the concept of late catatonia to foreign readers for the first time in English. METHODS: The original study was conducted about 20 years ago. The subjects were 16 persons who first visited our institutions between 1990 and 1996. They fulfilled the following criteria: 1) late-onset psychosis, with the initial mental changes occurring after 40 years of age; 2) more than one catatonic symptom observed during the clinical course; 3) a total clinical course lasting more than 2 years; and 4) no evidence of apparent organic brain disease. The medical records of individual patients were retrospectively reviewed to summarize the clinical features of this diagnosis. RESULTS: The crucial feature was the evolution or longitudinal change in the clinical picture over time, with the clinical course being divided into five stages: stage I (prodromal depression), stage II (anxiety and agitation), stage III (hallucination and delusion), stage IV (catatonia syndrome), and residual state. As for treatment, the effect of psychotropic agents was very limited. The electroconvulsive treatment was the most effective treatment option. CONCLUSION: Apart from the current diagnostic dichotomy of schizophrenia and mood disorder, the concept of late catatonia is useful in clinical settings and may provide clinically important knowledge.

[The use of operational criteria for evaluations of mental competency].

Today, either the DSM-IV or the ICD-10 is generally used for forensic purposes, especially for evaluations of mental competency. The use of operational criteria, such as the DSM-IV, in forensic settings has some risks. Here, these risks, as well as the advantages of operational criteria and precautions for their use, are discussed. Compared with the DSM-IV, the ICD-10 is preferred because this tool is less likely to complicate evaluations of the mental status of a criminal at the time of the crime when sufficient information is not available to make a diagnosis. The evaluation consists of two steps. The first step, which is based on empirical science, is to provide a psychiatric diagnosis. The second step, which is based on normative science, is to allocate the diagnosis to one of four categories of a forensic frame of reference and to provide useful information for judicial members to make a judgment about the mental competency of the criminal. To standardize evaluations, the use of not only global standard criteria, but also a general rule for the judgment of mental competency within each allocated category is needed.

Melancholic and reactive depression: a reappraisal of old categories.

BACKGROUND: The dominant diagnostic model of the classification of depression today is unitarian; however, since Kurt Schneider (1920) introduced the concept of endogenous depression and reactive depression, the binary model has still often been used on a clinical basis. Notwithstanding this, to our knowledge, there have been no collective data on how psychiatrists differentiate these two conditions. We therefore conducted a survey to examine how psychiatrists in Japan differentiate patients with major depressive disorder who present mainly with melancholic features and those with reactive features. METHODS: Three case scenarios of melancholic and reactive depression, and one-in-between were prepared. These cases were designed to present with at least 5 symptoms listed in the DSM-IV-TR with severity being mild. We have sent the questionnaires regarding treatment options and diagnosis for those three cases on a 7-point Likert scale (1 = "not appropriate", 4 = "cannot tell", and 7 = "appropriate"). Five hundred and two psychiatrists from over one hundred hospitals and community clinics throughout Japan have participated in this survey. RESULTS: The melancholic case resulted significantly higher than the reactive case on either antidepressants (mean ± SD: 5.9 ± 1.2 vs. 3.6 ± 1.7, p < 0.001), hypnotics (mean ± SD: 5.5 ± 1.1 vs. 5.0 ± 1.3, p < 0.001), and electroconvulsive therapy (mean ± SD: 1.5 ± 0.9 vs. 1.2 ± 0.6, p < 0.001). On the other hand, the reactive case resulted in significantly higher scores compared to the melancholic case and the one- in-between cases in regards to psychotherapy (mean ± SD: 4.9 ± 1.4 vs. 4.3 ± 1.4 vs. 4.7 ± 1.5, p < 0.001, respectively). Scores for informing patients that they suffered from "depression" were significantly higher in the melancholic case, compared to the reactive case (mean ± SD: 4.7 ± 1.7 vs. 2.2 ± 1.4, p < 0.001). CONCLUSIONS: Japanese psychiatrists distinguish between major depressive disorder with melancholic and reactive features, and thus choose different treatment strategies regarding pharmacological treatment and psychotherapy.

[Dementia with Lewy bodies (DLB) accompanied by symptoms of late catatonia: what to consider and how to treat].

Dementia with Lewy bodies (DLB) has recently often been reported to exhibit various psychiatric symptoms. However, some DLB patients do not present typical clinical courses or psychiatric symptoms. We report two DLB patients with characteristic psychiatric symptoms: a depressive state and anxiety in the early stage, and auditory hallucination, delusion of guilt, and catatonia in the later stage. Pharmacotherapy was ineffective, but electroconvulsive therapy proved to have a marked effect. The clinical course represents the symptomatic concept of "late catatonia," which Sommer first reported in 1910 and Kocha later reappraised. In Japan, this has been prevailing as a useful concept in the field of clinical geriatric psychiatry. We discuss what to consider and how to treat DLB patients including those with atypical courses and psychiatric symptoms. We consider and treated them as "late catatonia", with a favorable response to treatment. There is an important viewpoint which helps us understand the process. The viewpoint is to distinguish between "genera" and "types" of mental illnesses as inherited from classical psychopathology to modern psychiatry. DLB corresponds to "genera" and late catatonia to "types." In treating DLB patients with atypical symptoms and courses, it appears clinically very important to think more about late catatonia, exhibiting characteristic symptoms. This also reveals the usefulness of understanding and treating such cases based on the concept of "genera" and "types."

[A study on involutional melancholia].

In 1896 Kraepelin described (involutional) melancholia as a single clinical entity separate from manic-depressive psychosis. Because of the high incidence of depression in the involutional period, its symptomatic characteristics, and somewhat poor prognosis, this was recognized as valid at that time. Nowadays, the broadening concept of mood disorder denies involutional melancholia as a valid independent entity, and so it is included in mood disorders. A closer psychopathological inspection, however, still reveals several crucial differentiating points, which suggest that should be separated from the current mood disorder concept. Its cardinal symptoms are as follows: unveiled basic anxiety (Schneider K), specific autistic thinking (Kranz H), lack of insight, dissimulation, and severe suicidal thoughts. Patients fear that their innermost mind will be revealed, try to hide it, and even pretend to be healthy. Melancholic patients are believed to be at an extremely high risk of suicide. Difference between species and types of disease and the diagnostic hierarchial rule, which classifies all mental disorders into four different hierarchies (groups), are also referred to. The reevaluation of involutional melancholia is imperative for the present field of clinical psychiatry.

Musical hallucinations in schizophrenia. 2. Relations with verbal hallucinations.

The musical hallucinations reported by 33 schizophrenics who fulfilled ICD-10 diagnostic criteria were assessed semiologically. The subjects were 24 men and 9 women. The duration of 48 episodes of musical hallucinations varied. They occurred at all times during the course of schizophrenia, and 9 of them (18.8%) occurred before the diagnosis was made. All of the episodes could be divided into three stages: 17 (35.4%) were first stage, close to obsession, 5 (10.4%) were second stage, close to Schneiderian first-rank symptoms, and 26 (54.2%) were third stage, which is the autochthonous experience. The sounds were in a subjective space in 38 episodes and in the majority of cases, their content was familiar. The second stage was associated with xenopathic experience ("gemachtes Erlebnis") and audition of thought, and words were added to melodies that normally had no lyrics. Musical hallucinations in schizophrenia are pseudohallucinations that originate in memory representations, and they may undergo a transition to true hallucinations. The authors think that the three stages are related to the severity of the disease.