Folie a Deux: Shared Psychotic Disorder in a Medical Unit.

INTRODUCTION: A shared psychotic disorder is a system of delusions shared by two or more individuals. Shared psychotic disorders typically develop in pairs or groups with a close relationship who are socially isolated. The function and affect of those inflicted with shared psychotic disorders usually remain intact. For these reasons, a shared psychotic disorder is seldom identified, diagnosed, and treated. This case describes a shared psychotic disorder incidentally discovered in a medical unit. CASE: The patient was a 47-year-old woman with no known past psychiatric history who had been medically admitted for gastroenteritis. On the day of discharge, a psychiatric consult was requested for "paranoia and bizarre behavior." The patient was seen making statements that she needed security and the FBI to escort her as she left the hospital. Another person in the patient's room was discovered to be the patient's mother who had been staying with her in the hospital. Evaluation of the patient along with observation of her mother revealed that the two shared a complex system of delusions revealing a diagnosis of shared psychotic disorder. Discussion. A shared psychotic disorder is a unique psychiatric diagnosis. It may be even rarer to diagnose in the inpatient medical setting because multiple individuals from a shared system are typically not seen. In this case, the patient and her mother had multiple clinical characteristics of a shared psychotic disorder, including an enmeshed relationship and social isolation. The treatment for shared psychotic disorders involves separation of the individuals and pharmacotherapy with antipsychotics. This case also presented a unique ethical dilemma as the psychiatric team was called to evaluate a patient and found a patient and another individual to have symptoms. CONCLUSION: A shared psychotic disorder is important to consider on the differential when cases of psychosis with delusional systems are seen on medical floors.

Anti-inflammatory effects of melatonin: A systematic review and meta-analysis of clinical trials.

Chronic inflammation contributes to multiple diseases including cardiovascular diseases, autoimmune disorders, metabolic disorders, and psychiatric conditions. Melatonin, a hormone responsible for circadian rhythm, plays a complex role within the immune system, including having an anti-inflammatory effect. While there are numerous animal studies demonstrating this effect, few human clinical trials have been conducted. This systematic review of clinical trials examined whether exogenous melatonin reduces levels of inflammatory markers in humans. We searched PubMed, Embase, Cochrane Library, Scopus, and PsycINFO, and the references of the identified articles for randomized and non-randomized placebo-controlled trials. Data were extracted from the articles and meta-analyses were conducted using a random effects model to calculate standardized mean differences (SMDs, i.e., Cohen's d). From an initial search result of 4548 references, 31 studies met the inclusion criteria and were included involving 1517 participants. Melatonin had significant anti-inflammatory effects on interleukin (IL)-1 (SMD -1.64; 95% confidence interval [CI] -2.86, -0.43; p = 0.008), IL-6 (-3.84; -5.23, -2.46; p < 0.001), IL-8 (-21.06; -27.27, -14.85; p < 0.001), and tumor necrosis factor (TNF) (-1.54; -2.49, -0.58; p = 0.002), but not on C-reactive protein (CRP) (-0.18; -0.91, 0.55; p = 0.62). Trimming outlier studies with large effect sizes eliminated publication bias, and summary effect sizes were significant for IL-1 (SMD -1.11; 95% CI -1.90, -0.32; p = 0.006), IL-6 (-1.91; -2.98, -0.83; p = 0.001), and IL-8 (-13.46; -18.88, -8.04; p < 0.001), but not for TNF (-0.45; -1.13, 0.23; p = 0.19). Exogenous melatonin reduced levels of inflammatory markers and may be useful for prevention and adjuvant treatment of inflammatory disorders. Melatonin is safe with few side effects, which makes it an excellent agent for prevention of inflammatory disorders. Because chronic inflammation increases with aging and inflammation plays a role in the etiology of numerous diseases that affect older populations, melatonin has the potential to be widely used particularly in older adults.

Apathy in late-life depression: common, persistent, and disabling.

OBJECTIVE: The aims of this study were to examine: (1) the relationship between apathy and disability in late-life depression, and (2) the functional significance of improvement in apathy following escitalopram treatment in terms of its relationship to disability. METHODS: Subjects were 71 non-demented elderly with non-psychotic major depression. After a 2-week single-blind placebo period, subjects who had Hamilton Depression Rating Scale (HDRS) ≥ 18 received escitalopram 10 mg daily for 12 weeks. Apathy and disability were assessed with the Apathy Evaluation Scale (AES) and the World Health Organization Disability Assessment Scale II (WHODAS), respectively. These measures and the HDRS were administered at baseline and again following 12 weeks of treatment. RESULTS: At baseline, 38% of depressed subjects had significant apathy (AES ≥ 36.5). Severity of apathy at baseline significantly correlated with severity of disability. In a multivariate regression model, baseline severity of apathy, but not the overall depressive syndrome (HDRS), significantly correlated with baseline disability. Following escitalopram treatment, improvement in apathy significantly correlated with improvement in disability measures, while change in the rest of the depressive syndrome did not. The overall change in apathy and disability in response to escitalopram treatment was significant but small. CONCLUSION: Apathy is common in late-life depression and is associated with disability above and beyond the influence of other depressive symptoms. Given the strong relationship between apathy and disability, understanding the neurobiology of apathy and developing treatments for apathy may improve the functional outcomes of late-life depression.