Effect of lithium maintenance therapy on thyroid and parathyroid function.

OBJECTIVES: To assess changes induced by lithium maintenance therapy on the incidence of thyroid, parathyroid and ion alterations. These were evaluated with respect to the duration of lithium therapy, age, sex, and family history (whether or not the patient had a first-degree relative with thyroid disease). DESIGN: Prospective study. SETTING: Affective Disorders Clinic at St. Mary's Hospital, Montreal. PATIENTS: One hundred and one patients (28 men and 73 women) with bipolar disorder receiving lithium maintenance therapy ranging from 1 year's to 32 years' duration. The control group consisted of 82 patients with no psychiatric or endocrinological diagnoses from the hospital's out-patient clinics. OUTCOME MEASURES: Laboratory analyses of calcium, magnesium and thyroid-stimulating hormone levels performed before beginning lithium therapy and at biannual follow-up. RESULTS: Hypothyroidism developed in 40 patients, excluding 8 patients who were hypothyroid at baseline. All patients having first-degree relatives affected by thyroid illness had accelerated onset of hypothyroidism (3.7 years after onset of lithium therapy) compared with patients without a family history (8.6 years after onset of lithium therapy). Women over 60 years of age were more often affected by hypothyroidism than women under 60 years of age (34.6% versus 31.9%). Magnesium levels in patients on lithium treatment were unchanged from baseline levels. After lithium treatment, calcium levels were higher than either baseline levels or control levels. Thus, lithium treatment counteracted the decrease in plasma calcium levels associated with aging. CONCLUSIONS: Familial thyroid illness is a risk factor for hypothyroidism and hypercalcemia during lithium therapy.

The relationship between psychiatrists' couple and family therapy training experience and their subsequent practice profile.

A 28-item questionnaire was returned by 291 psychiatrists who had completed training between 1962 and 1992. There were positive correlations between the amount of couple and family therapy training (CFTT) they received and the following: the extent to which graduate psychiatrists practice CFT; their involvement as supervisors, teachers, teaching program directors, or researchers; the extent to which they seek continuing education in CFT; their positive attitude toward CFT; and the extent to which they feel that their attitude to and interest in CFT has had a positive effect on the milieu in which they practice and on their personal lives.

Predictors of lithium treatment responsiveness in bipolar patients. A two-year prospective study.

Twenty-nine bipolar patients were assessed before the start of lithium therapy to study the prognostic criteria of long-term response to therapy. Assessment included clinical and demographic data and laboratory tests administered before and 2-5 days after initiation of therapy. The tests included calcium and magnesium serum levels, and thyroid hormonal status. Patients were followed up for 2 years. None of the single variables predicted the response to lithium therapy, but a combination of clinical and demographic variables, used in a discriminant function analysis, correctly identified 78.9% of responders. Multiple regression analysis predicted 46.2% of the outcome. The strongest univariate predictors were mood quality, illness duration, and substance abuse.

Effects of age of entry, day-care quality, and family characteristics on preschool behavior.

Teachers evaluated 155 4-5-year-old children attending Montréal day-care centers of excellent (N = 51), average (N = 60), or low (N = 44) quality using behavioral scales. Age of entry to day-care was also considered. Center quality was assessed by two observers using the Early Childhood Environment Rating Scale. Results point to the positive effects of longer exposure to high-quality group day-care (increased interest-participation), and the negative effects of longer exposure to low-quality centers (increased anger-defiance). Positive or negative family characteristics contributed further to these effects.

Depression in older medical inpatients: one-year course and outcome.

OBJECTIVE: This 1-year follow-up survey of 214 medical inpatients aged 65 and older describes the outcome of major depressive episode (MDE), determines the incidence of new episodes and identifies factors associated with outcome and with new episodes of MDE. METHOD: Follow-up information was obtained from 160 patients, 69 men and 91 women. RESULTS: Of the 48 cases of MDE who were interviewed, 44% improved. Underlying dysthymic disorder strongly influenced outcome: of 21 cases of MDE alone, 62% were improved at follow-up; of the 27 cases in which MDE was superimposed on dysthymic disorder initially, only 30% were improved. New episodes of MDE occurred in 21% of patients, and were associated with dysthymic disorder initially and with change of meaning of life. CONCLUSIONS: Among older medical inpatients, MDE, particularly when superimposed upon dysthymic disorder, is a persistent condition. Randomized trials are necessary to identify efficacious treatments.

Psychogeriatric clinical, electro-encephalographic and autopsy findings.

Demographic, psychiatric, and electro-encephalographic (EEG) data were compared with brain autopsy findings for 73 elderly psychiatric patients. A late onset of depression (60+ years) was more likely than early onset to be accompanied by Alzheimer's disease. There were strong associations between clinical and histopathological indicators of Alzheimer's disease. This was particularly evident for diffuse EEG slowing. Clinical as well as histopathological indicators of Alzheimer's disease were intensely related to EEG features, mainly EEG slowness (positive), reactivity to eye opening (negative) and dominant frequency (negative). Cerebrovascular pathology showed fewer EEG correlations. The results support the usefulness of the clinical electro-encephalogram in patients suspected to have Alzheimer's disease.

Effect of lithium maintenance treatment on hypothalamic pituitary gonadal axis in bipolar men.

This was a cross-sectional study assessing short- and long-term effects of lithium (Li) treatment on hormone levels. Levels of testosterone (T), prolactin (PRL), luteinizing hormone (LH), and follicule-stimulating hormone (FSH) were compared. Sixty-one lithium-treated, euthymic, stable, bipolar men were compared with 67 hospital controls and 22 healthy volunteers. Prolactin (P < or = 0.01) and luteinizing hormone (P < or = 0.001) were higher in all patients compared with healthy volunteers. Li-treated patients were evaluated at 22 to 24 mo, 2 to 5 y, and after more than 5 y of Li therapy. At 22 to 24 mo of Li treatment, levels of PRL and LH did not differ from the values of healthy volunteers or of patients treated for longer periods. In addition, the value of T was higher (P < or = 0.003) than in the group treated longer. Levels of T after more than 5 y of treatment, however, did not differ from those of the healthy volunteers.

Patterns of violent incidents by patients in a general hospital psychiatric facility.

Reports of attempted or actual physical assaults by patients in the inpatient, outpatient, and emergency settings of a psychiatric facility within a general hospital were prospectively surveyed during a one-year period. Among 397 patients discharged during the period, 46 patients were responsible for 133 violent incidents. Most incidents occurred on the locked inpatient unit during the daytime and after the first week of admission. Schizophrenia was the only diagnosis significantly associated with violence. Hitting was the most prevalent form of violence, and nurses were the most frequent targets.

Renal reactions to changes of lithium dosage.

The renal function was assessed in 51 bipolar patients on multiple-dosage lithium maintenance therapy from 1 to 22 years, after placing them on single (HS) dosage for 12-18 months. Serum lithium levels were maintained constant at a level of 0.8 mg/l. The patients were divided into three groups according to duration of previous multiple doses (b.i.d.-q.i.d.) Li therapy; less than 5 years; 5-10 years; 10-22 years. The improvement in water handling occurred only in the previously shortest multiple-dosage-treated patients and the duration of previous multiple dosage negatively influenced water handling; however, all laboratory analyses remained within normal limits. None of the patients showed clinical worsening or had an affective episode. The separate analyses showed associated gender differences in urinary volume, serum creatinine, and creatinine clearance values. Our findings confirmed the beneficial renal reaction to single-dose posology, as well the female sensitivity to Li therapy in general, and especially with concomitant antipsychotic medication.

The psychotropic effects of inhibitors of steroid biosynthesis in depressed patients refractory to treatment.

Twenty patients, diagnosed as suffering from treatment-resistant major depression, were treated with one or more drugs that decrease corticosteroid biosynthesis. Nine were psychotic, 11 nonpsychotic. Seventeen completed the treatment (8 psychotic, 9 nonpsychotic); 13 responded (5 psychotic, 8 nonpsychotic; 11 responded completely (i.e., a drop in the Hamilton Depression Scale of at least 50%, to < or = 15), and 2 responded partially. The mean age of the responders (45.2 +/- 12.6 years) did not differ significantly from that of the nonresponders (48.7 +/- 12/3). Data were analyzed in the following categories; (1) the presence or absence of psychosis, (2) response or nonresponse to treatment, and (3) the drug(s) used (aminoglutethimide, ketoconazole, or a combination of either of these with metyrapone). The patients improved over time on the Hamilton Depression Scale independent of the medication used. Responders demonstrated improvement in mood, insomnia, anxiety, diurnal variation, paranoia and obsessive compulsiveness. Nonpsychotics responded better than psychotics.

Systematic intervention for elderly inpatients with delirium: a randomized trial.

OBJECTIVE: To assess a systematic intervention in cases of delirium in elderly inpatients. DESIGN: Randomized, controlled trial. SETTING: University-affiliated, primary acute care hospital. PATIENTS: Patients aged 75 years or over admitted to the medical department. They were screened within 24 hours after admission, and 88 patients with delirium (according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, third revised edition) were detected and enrolled in the trial. The patients were randomly allocated to the treatment group (42) or the control group (46); all were followed up until the end of the study. INTERVENTION: Patients were assessed on enrolment and 1, 2, 4 and 8 weeks later. Those in the treatment group received a consultation by a geriatric internist or psychiatrist and follow-up by a liaison nurse. Those in the control group received regular medical care. OUTCOME MEASURES: Short Portable Mental Status Questionnaire (SPMSQ), Crichton Geriatric Behavioural Rating Scale (CGBRS), use of restraints, length of hospital stay, discharge to a setting providing more care than was needed before admission and mortality rate. RESULTS: Two weeks after admission, patients in the treatment group showed an improvement in their mean SPMSQ scores, from 8.2 (standard deviation [SD] 1.9) to 7.9 (SD 2.5), whereas the control group showed a deterioration, from 8.4 (SD 1.7) to 9.1 (SD 1.1); this difference had disappeared by the end of the 8-week period (p < 0.05). Mean CGBRS scores were higher in the treatment group (32.0 [SD 8.6]) than the control group (28.5 [SD 9.4]) on enrolment and had improved more markedly by the end of the 8-week period (to 23.9 [SD 7.8] v. 25.0 [SD 7.0], p = 0.06). There was no statistically significant difference between the groups in use of restraints, length of hospital stay, discharge to a setting providing more care than was needed before admission or mortality rate. CONCLUSION: The beneficial effects of systematic detection and intervention in cases of delirium in elderly inpatients were small.

Thyroid functioning during treatment for depression.

Thirty-nine unipolar depressed patients were treated, after a washout period of seven days in a double blind study with either moclobemide, placebo or amitriptyline, for 42 days. The psychopathological assessment and HRSD were done on seven day intervals and thyroid analysis was done on 14 day intervals. At the end of therapy, the levels of T4 and fT4 decreased significantly in the responders if amitriptyline was used, and non-significantly if placebo or moclobemide were used. The T4 and fT4 values of the non-responders increased non-significantly. The weight change was minimal and non-significant.

Prevalence of psychosomatic and other medical illnesses in anorexic and bulimic patients.

The occurrence of psychosomatic disorders (PSD) in patients with anorexia nervosa and bulimia nervosa has rarely been investigated. We examined the prevalence of four psychosomatic disorders [peptic ulcer (PU), bronchial asthma (BA), neurodermatitis (ND), and rheumatoid arthritis (RA)] in patients consecutively admitted to an eating disorders (ED) program. Responses to a validated questionnaire and clinical file information were obtained from 152 patients, 60% of whom were bulimic and 40% were anorexic. The average age of the patients was 27.5 years and all but two patients were female. There was a higher life-time prevalence of the psychosomatic disorders among anorexics compared with bulimic patients, except for RA. PU and BA were reported by 10% of anorexics compared with 7.6% and 8.7%, respectively, by bulimic patients. RA was rare in both anorexic (1.6%) and bulimic patients (5.4%). The young age of the patients under study was to be considered limiting the life-time prevalence. The study contains epidemiological data on the prevalence of other medical illnesses in ED patients as well as the prevalence of PSD and eating disorders in their families.

Lithium treatment and memory assessment: methodology.

Clinical observations have suggested that lithium may exert adverse effects on memory. The difficulty in achieving empirical consensus regarding this issue has reflected several methodological problems: diversity of research designs, heterogeneous samples, lack of control groups and the possible confounding of memory test scores by variables such as depression, other acute psychopathologies, organicity, treatment duration, and age. The diversity of memory tests in terms of the complexity and modality of the stimuli as well as the types of memory assessed (immediate, short- and long-term, logical, visuo-practic) has further complicated the comparison of results across studies. Furthermore, the administration of test batteries has been limited by patients' fatigue and the severity of their illness, and by the time required to complete testing. Hence, the use of test norms may be restricted. Suggestions are made for the selection of appropriate memory tests, patients sampling and data analysis. The authors discuss the difficulties inherent in blind studies and in matched-group designs examining the effects of lithium on memory. Conclusions point to the advantages of prospective within-subject designs with repeated testing in which patients serve as their own controls.

Effectiveness of geriatric psychiatry consultation in an acute care hospital: a randomized clinical trial.

OBJECTIVE: To evaluate the effectiveness of geriatric psychiatry consultation in reducing the severity of confusion, anxiety, depression, abnormal behavior, and functional disability among a selected group of aged medical and surgical inpatients. DESIGN: Randomized clinical trial. Cases assessed on enrollment at 2, 4, and 8 weeks later. SETTING: Primary acute care hospital. PATIENTS: Eighty hospitalized patients aged 65 or older who were referred to a multi-disciplinary team and had not received a psychiatric consultation in the month prior to referral. Sixty-three patients completed the trial. INTERVENTIONS: Patients in the treatment group received a geriatric psychiatry consultation and, when appropriate, follow-up at least once per week for 8 weeks. Control patients received usual medical care. MAIN OUTCOME MEASURES: Short Portable Mental Status Questionnaire, Anxiety Status Inventory, Geriatric Depression Rating Scale, and Crichton Geriatric Behavioral Rating Scale. RESULTS: The effect of the consultation on psychiatric symptoms and functional status was positive but small. The differences in scores of all measures between treatment and control groups were not statistically significant, but there were consistent trends for more treatment than control cases to have improved on all measures, significantly so on the Anxiety Status Inventory (P less than 0.05). Cases with delirium or depression improved most often. More control than treatment cases were discharged after 4 and 8 weeks, but twice as many treatment cases were discharged home. CONCLUSIONS: Geriatric psychiatry consultation, while not highly effective overall, may be beneficial if targeted to those most likely to benefit and compliance by referring physicians can be improved.

Cultural factors and reaction to hysterectomy.

The role of cultural background in the etiology of depressive symptoms associated with hysterectomy has been rarely explored. However, the increasing interest in the transcultural aspects of psychiatry in the last decade gives a particular relevance to this subject. In the current study, 152 women underwent hysterectomy in a downtown hospital of a large city. The population under study consisted of women of various ethnic backgrounds, French Canadian (35%), English Canadian (29%), European (22%) and other (14%). The women completed the Zung self-rating depression scale (SDS) before the operation and six times after during a one year period. They also answered two questionnaires, the first before the operation and the last one a year after. These questionnaires explored the presence of fears, misconceptions, the attitudes toward the operation, the satisfaction regarding medical care and the general pre- and post-operative adjustment. English Canadian women reported the lowest scores on the SDS; they had few misconceptions and fears. They had the best post-operative adjustment of the three groups. French Canadian women showed intermediate scores on the SDS and expressed more misconceptions and feelings of mutilations pre-operatively. Women of European origin showed the highest scores on the SDS at all observations, expressed more regrets about the operation and had a more difficult post-operative adjustment than the other two groups. This study suggests that cultural factors may contribute to the reaction to hysterectomy in women of different ethnic backgrounds. Education, the type of society: patriarchal versus matriarchal, the emphasis on the women's reproductive ability in a particular culture, are among other factors that seem to play an important role.

Contribution to the validation of the SCL-90-R in French-speaking women.

This study is a contribution to the French validation of the Derogatis (1977) Symptom Check-List SCL-90-R. Norms reflecting the mental health status of a representative sample of French-speaking women from Montreal, Canada, are provided. Results indicated that the women in our sample generally obtained higher raw scores than those reported by Derogatis for the nonpatient group for the nine symptom scales and the three global scores. The reliability of the French version yielded a satisfactory Cronbach alpha of .91. High and significant positive correlations were found on the test-retest as well as on the Spearman-Brown split-half test. Validity was assessed using the principal component analysis on six factors accounting for 88% of the variance. The correlations between the symptom scales ranged from .32 to .74, indicating the relative independence of the dimensions of the French version of the SCL-90-R. The usefulness of the method will be enhanced by further cross-validation and concurrent validity studies including patient populations.