Effectiveness of a Mobile Outreach and Crisis Services unit in reducing psychiatric symptoms in a population of homeless persons with severe mental illness.

The purpose of this study was to use a time-lag design to evaluate the effectiveness of a Mobile Outreach and Crisis Services unit in remitting psychiatric symptomatology, improving global functioning, and decreasing homelessness in a population of homeless, severely mentally ill residing in a mid-sized urban center. Using a time-lag study design, two groups of subjects--25 individuals before receiving services (control group) and 25 individuals after receiving services (experimental group)--were contrasted across outcome measures. The results indicate that a MOCS unit utilizing a Program for Assertive Community Treatment mode was effective in significantly decreasing psychiatric symptomatology, reducing homelessness, and increasing global functioning. If carefully implemented and interpreted, a time-lag design may be a means of providing valuable feedback and information in a timely manner.

Psychocutaneous disorders.

Dermatologic conditions are commonly associated with psychiatric sequella, eg, urticaria, alopecia, psoriasis, or acne. Moreover, the onset and course of dermatologic disorders may be significantly influenced by stress, emotional disturbances, or psychiatric disorder. Compulsions involving the skin, excoriations, or hair pulling (trichotillomania) are the more frequently encountered problems. In some cases, skin conditions are self-induced or reflect signs or symptoms of an underlying psychiatric disorder, including psychosis or obsessive-compulsive disorder. Additionally, skin lesions have been frequently described in case reports of factitious dermatitis. Finally, adverse effects of psychotropic drugs may cause dermatologic side effects, mostly idiosyncratic skin eruptions. These problems are discussed with emphasis on clinical features, comorbidity, and psychiatric management.

Depressive mood symptoms associated with ovarian suppression.

OBJECTIVE: To determine if sertraline is helpful in the management of depressive symptoms associated with ovarian suppression during GnRH agonist therapy as compared with a placebo-controlled group. DESIGN: Double-blind placebo-controlled prospective study design. SETTING: An obstetrics/gynecological office specializing in infertility in an academic environment. PATIENT(S): Premenstrual women with laparoscopically diagnosed endometriosis who required GnRH agonist therapy for treatment and did not have significant depressive or premenstrual mood symptoms at baseline. INTERVENTION(S): Participants were randomly assigned to either the sertraline treatment group or to the placebo group for the 3-month duration of the GnRH agonist therapy. MAIN OUTCOME MEASURE(S): The 21-item Hamilton Rating Scale for Depression (HRSD), which is an instrument designed to assess depressive symptomatology. RESULT(S): A Hotellings T(2) test for repeated measure analysis indicated a statistically significant (P<.05) between-group difference across time for the HRSD (T(2) = 13.3; F[3, 28] = 4.1; P=.02) with the sertraline treatment group manifesting significantly fewer depressive symptoms than the control group. CONCLUSION(S): The results indicate that sertraline is an effective option in the management of depressive mood symptoms associated with ovarian suppression during GnRH agonist therapy.

Assessment of sexual functioning during the menstrual cycle.

In a study of 115 women who presented with complaints of premenstrual symptoms, we investigated the relationship between the menstrual cycle and different aspects of sexual functioning, using the Changes in Sexual Functioning Questionnaire. Women who were assessed at the screening visit during the late luteal phase of their menstrual cycle reported less desire to engage in sexual activity and less frequent sexual activity than women who were assessed during other phases of the menstrual cycle. The 24 women who returned for the second and third visits reported less frequent orgasms and less satisfaction from their orgasms premenstrually than during midcycle.

Female hypoactive sexual disorder: case studies of physiologic androgen replacement.

Menopause, surgical or naturally occurring, with reduced or deficient ovarian functioning has a major impact on morbidity and mortality in mid- to late life. A growing body of literature notes the role of androgens in maintaining women's health and emotional well-being. The administration of physiologic levels of testosterone replacement therapy as an adjunct to estrogen replacement requires further investigation. The Sexual Energy Scale was used to measure the patient's subjective experience of vitality or sexual energy with androgen replacement therapy. Three cases of women who had undergone a total abdominal hysterectomy with bilateral oophorectomy with complaints consistent with female hypoactive sexual desire disorder and free testosterone levels of < 2.0 pg/ml are presented. Physiologic androgen replacement is helpful in increasing sexual desire for some women.

Self-injurious behavior in elderly patients with dementia: four case reports.

Self-injurious behavior (SIB) is a polymorphous and poorly understood phenomenon, probably representing the final common pathway arising from a variety of etiologies. SIB is a clinical problem that affects elderly patients, but has received little attention. Although the specific prevalence rates of SIB in elderly patients with dementia is unknown, the lack of data is striking, considering the frequency with which geriatric psychiatrists may be consulted for these and related behavioral problems. The authors present four cases of elderly patients with SIB and dementia who responded favorably to psychopharmacologic treatment.

Training psychiatric residents for Part II of the American Board of Psychiatry and Neurology Examination.

Of the physicians who took the American Board of Psychiatry and Neurology (ABPN) Examination, Part II, in 1995, 41% failed. The Accreditation Council for Graduate Medical Education (ACGME) requires that residency psychiatry programs conduct an organized evaluation of residents' clinical skills at least twice during the 4 years of training. At the University of Oklahoma Health Science Center-Tulsa, the residents attend formal didactic instruction on conducting a psychiatric interview. Having gained this didactic foundation, they then participate in actual patient interviews. First- and 3rd-year residents are mock examiners, paired with an experienced board-certified psychiatrist. Second- and 4th-year residents examine an actual patient. A survey evaluating this curriculum was rated as very good to excellent by the participants.

Diabetes mellitus and major depression: considerations for treatment of Native Americans.

Non-insulin dependent diabetes mellitus (NIDDM) extracts a heavy toll on the Native American community in the United States. Evidence indicates that patients with NIDDM are three times more likely to have a co-existing diagnosis of depression. Untreated major depression unfavorably impacts the complication rates of NIDDM. Thus, Native Americans who are at increased risk for NIDDM are likely to be at increased risk for major depression. Physicians in Oklahoma should be aware of important treatment issues when selecting an antidepressant medication to treat major depression in Native Americans with NIDDM. Treatment options for major depression in the context of diabetes are discussed. Evidence currently indicates that the serotonin reuptake inhibitors (SSRIs) have significant advantages and a more favorable side effect profile for the treatment of depression in patients with diabetes mellitus.

Depressive symptoms associated with gonadotropin-releasing hormone agonists.

The gonadotropin-releasing hormone (GnRH) agonists are a relatively new class of drugs that are potentially effective in treating disorders that are aggravated either by estrogen or testosterone. GnRH agonists are effective in the treatment of endometriosis, as well as other disorders, such as advanced prostrate cancer, precocious puberty and uterine leiomyomata. While the GnRH agonists reduce the extent of the endometrial lesions and the occurrence of pelvic pain associated with endometriosis, these agents are associated with physical and psychiatric side effects. The adverse effects of these agents are consistent with the physiological effects of ovarian suppression, such as vasomotor instability, vaginal dryness, and headaches. Preliminary results of a prospective, double-blind placebo-controlled study and an open label trial indicates that depressive mood symptoms increase in women treated with GnRH agonist therapy for endometriosis. Additional evidence suggest that sertraline effectively manages depressive mood symptoms associated with GnRH agonist therapy. The reason for the decline in mood on GnRH agonists is postulated to be associated with the decline in estrogen levels. Effective treatment strategies for depressive mood symptoms in women on GnRH agonists therapy may offer insight into the mechanisms of action of estrogen on mood.

Sertraline in the treatment of depression associated with gonadotropin-releasing hormone agonist therapy.

BACKGROUND: Endometriosis is thought to affect 5-10% of reproductive age women in the general population and is commonly treated with gonadotropin-releasing hormone (GnRH) agonists. Recent studies suggest depressive symptoms are associated with women treated with GnRH agonist for endometriosis. METHODS: A retrospective pilot study of 42 female patients, 22 in the treatment group (sertraline) and 20 in the control group (no sertraline), was conducted. All subjects had laproscopically diagnosed endometriosis and were treated with 24 weeks of GnRH agonist therapy. Assessment instruments included the Hamilton Depression Rating Scale and the Menopausal Symptom Index. RESULTS: The results indicate that patients receiving concomitant sertraline reported significantly less depressive symptoms, but did not differ significantly in physical symptoms than the group receiving a GnRH agonist alone. CONCLUSIONS: Antidepressants, such as sertraline, appear to be significantly helpful in the treatment of mood symptoms during the course of GnRH agonist therapy.

Anxiety and mood disorders associated with gonadotropin-releasing hormone agonist therapy.

Gonadotropin-releasing hormone (GnRH) agonists are synthetic derivatives of the native decapeptide produced by the hypothalamus. These agents cause a reversible suppression of the synthesis and release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) by the anterior pituitary gland. With GnRH agonist therapy, there is a resulting loss of endogenous ovarian gonadotropin stimulation and a severe hypo-estrogen state consistent with castrate levels of estrogen. Recently, GnRH agonists such as leuprolide and goserelin have been noted to be effective in treating mild to severe endometriosis. Side effects of these agents are consistent with the physiological effects of ovarian suppression, such as vasomotor instability, vaginal dryness, and headaches. However, despite some reports of emotional lability as an adverse effect of GnRH agonists, it appears that the occasional, rather severe psychiatric consequences of these agents are underappreciated. In this article, we present the case reports of 4 women of reproductive age with no prior psychiatric history who were treated with a GnRH agonist for endometriosis. These women developed symptoms consistent with various psychiatric disorders, including panic disorder and major depression with and without psychotic features. Three of these patients were given sertraline while on GnRH agonist therapy, which improved their mood and anxiety symptoms. Women undergoing GnRH agonist therapy may provide a model with which to investigate mood disorders during the perimenopausal stage of life.

Female hypoactive sexual desire disorder due to androgen deficiency: clinical and psychometric issues.

Menopause, surgical or naturally occurring, with reduced or deficient ovarian functioning has a major impact on morbidity and mortality in mid to late life. In particular, a growing body of literature is focusing on the role of androgens in maintaining women's health and emotional well-being. Further study is needed in the administration of physiologic levels of testosterone replacement therapy as an adjustment to estrogen replacement. The Sexual Energy Scale was developed to provide an objective means of measuring the change in a patient's subjective experience of vitality/sexual energy with androgen replacement therapy. The scale also provides a clinical indication for androgen replacement dosage adjustment. Advantages in using low doses of methyltestosterone in women with hypoactive sexual desire disorder are discussed.

Obsessive-compulsive disorder.

The prevalence of OCD in a dermatologic practice may be much higher than in the general population. OCDs can be debilitating in one's interpersonal, social, and occupational functioning. The obsessions and compulsions typically begin fairly early in life and may consume prolonged lengths of the patient's time to complete daily rituals of washing, checking, touching, arranging, hoarding, or ruminating. Evidence is mounting for support of a neurobiologic basis in the etiology of OCD. In terms of treatment, the psychopharmacologic agents (clomipramine, fluoxetine, fluvoxamine, sertraline, paroxetine) and behavior therapy alone or in combination with SRIs help a significant majority of patients suffering from this disorder. The OCD spectrum of disorders is varied. Patients presenting to the dermatologist will exhibit an interesting array of symptoms, including those who compulsively hand wash, pick at nails or skin, pull body hair, or display other SIB. Increased awareness of these disorders will enable the dermatologist to identify and treat patients with OCD appropriately.

Onset of menses in two adult patients with Prader-Willi syndrome treated with fluoxetine.

Prader-Willi syndrome (PWS) is characterized by hypotonia at birth, hypogonadism, early childhood obesity, and mental deficiency. Hypogonadotropic hypogonadism is a major characteristic of patients with PWS, and it is speculated to be due to hypothalamic insufficiency. Two adult female patients with PWS and no prior history of menses are presented. Both of these patients were treated with fluoxetine for psychopharmacologic management of obsessive features in the form of food preoccupation and hyperphagia or for compulsive behaviors in the form of severe self-injurious behaviors. The two female patients with PWS who had primary amenorrhea developed vaginal bleeding believed to be menses following at least 6 months of treatment with fluoxetine. Mature hypothalamic function is characterized by pulsatile release of gonadotropin-releasing hormone (GnRH) in a critical range of frequency and amplitude. Central nervous system neurotransmitters may modify GnRH secretion. Fluoxetine specifically inhibits the reuptake of serotonin which may impact the hypothalamic-pituitary-ovarian system in female patients with PWS.

Self-injurious behavior and serotonin in Prader-Willi syndrome.

Low central nervous system (CNS) serotonin levels have been associated with impulsive, aggressive and self-injurious behavior (SIB). Persons with Prader-Willi Syndrome (PWS) often engage in self-injury by severe compulsive skin picking and gouging and often manifest compulsive eating, hoarding, and explosive outbursts. Some of the compulsive behaviors seen in patients with obsessive-compulsive disorder (OCD) bear similarity to behaviors associated with PWS: Skin picking, trichotillomania, and onychophagia (nail biting). There is abundant evidence that selective serotonin reuptake inhibitors (SSRIs) are effective in treating OCD. Three cases are described in which persons with PWS responded favorably to SSRI treatment. Two persons showed a significant decrease in skin picking. The third case showed a significant decrease in hoarding and explosive outbursts. Strategies are discussed for investigating the possibility of a shared neurochemical basis for the self-injurious, aggressive, and compulsive behaviors in persons with PWS. PWS may provide a relatively homogenous model for the study of skin picking and explosive outbursts among other populations.

Pharmacologic treatment of severe skin-picking behaviors in Prader-Willi syndrome. Two case reports.

BACKGROUND: Prader-Willi syndrome (PWS) is characterized by hypotonia at birth, hypogonadism, early childhood obesity, and mental deficiency. Other behavioral symptoms that become prominent during adolescence and adulthood include temper outbursts, stealing and hoarding food, and skin picking. The self-excoriating skin picking behavior observed in individuals with PWS is quite common and can lead to persistent sores and infections, even requiring hospitalization. OBSERVATION: Two patients with PWS who displayed repetitive, self-mutilatory behavior of skin picking are described. They were both treated successfully with different doses of fluoxetine, a selective serotonin reuptake inhibitor. CONCLUSIONS: The skin-picking behavior in patients with PWS may be a variant of the spectrum of obsessive-compulsive disorders. Obsessive-compulsive disorders have been successfully treated with serotonin reuptake inhibitors such as fluoxetine. Thus, fluoxetine may be considered an option in the management of skin-picking behavior in patients with PWS.