Risk factors for completed suicide in schizophrenia and other chronic psychotic disorders: a case-control study.

OBJECTIVE: Despite an increased risk for suicide among individuals diagnosed with psychotic disorders, risk factors for completed suicide remain largely unexamined in this population. Using a case-control design, this study aimed to investigate clinical and behavioural risk factors for suicide completion in schizophrenia and other chronic psychotic disorders. METHOD: A total of 81 psychotic subjects were examined; of these, 45 died by suicide. Proxy-based interviews with, on average, 2 informants were conducted using the SCID I and II interviews and a series of personality trait assessments. RESULTS: Psychotic individuals at risk for suicide are most readily identified by the presence of depressive disorders NOS, moderate to severe psychotic symptoms and a family history of suicidal behaviour. They also exhibited fewer negative symptoms, had more comorbid diagnoses and, contrary to findings in other populations, we found that cluster A and C personality trait symptoms seem to have protective effects against suicide in schizophrenics and other chronic psychotic suicides. CONCLUSIONS: Our study suggests that behavioural mediators of suicide risk, such as impulsive-aggressive behaviours, do not play a role in schizophrenic and chronic psychotic suicide. This is contrary to findings in other diagnostic groups, thus implying heterogeneity in predisposing mechanisms involved in suicide.

Dysphoric mania induced by high-dose mirtazapine: a case for 'norepinephrine syndrome'?

The antidepressant mirtazapine antagonizes central presynaptic alpha2-adrenergic auto- and heteroreceptors resulting in increased central norepinephrine and serotonin activity. Histamine H2 receptors are also antagonized, as are postsynaptic serotonin 5-HT2 and 5-HT3 receptors, leading to serotonergic activity primarily via 5-HT1A receptors. Based on the case report of a patient who developed mania with higher than recommended dosage of mirtazapine, we review the literature on the atypical nature of manic symptoms with mirtazapine. Eight subjects, including those in our study, were identified as having developed mirtazapine-induced mania with atypical features, consisting of dysphoria, irritability, insomnia, psychomotor agitation and abnormal gait. Predisposing features may have included the presence of underlying brain dysfunction and certain selective serotonin reuptake inhibitor-mirtazapine combinations. Dysphoric mania with atypical features may be induced by mirtazapine, providing support for a common hypothesis such as 'central norepinephrine hyperactivity' as the basis for development of mania with mirtazapine.

The male menopause and mood: testosterone decline and depression in the aging male--is there a link?

The objective of this study was to review the literature on the hormonal changes that occur in aging males in order to determine if testosterone declines in relation to depressed mood and if testosterone might prove useful in treatment of depression. Pertinent articles were identified through a MEDLINE search from 1966 to 1999 and by careful review of the bibliographies of articles most relevant to the topic. There is a moderate decline of total testosterone and more significant decline of bioavailable testosterone in aging males. Elderly males who are depressed appear to have the lowest testosterone levels. In eugonadal males, testosterone replacement does not have a significant effect on mood; in hypogonadal males, some studies show an effect whereas others do not. In several small studies of depressed hypogonadal males, testosterone was effective in alleviating depression. Major side effects of testosterone include increased hematocrit and potential effects on the prostate and lipid metabolism. Testosterone replacement as primary or adjuvant treatment of depression may prove useful in elderly, hypogonadal males who fail to respond to conventional antidepressants. Further studies are needed to confirm these initial impressions.

Engaging in psychotherapy with the Orthodox Jew: a critical review.

A critical overview of the current knowledge of engaging in psychotherapy with a cultural minority, Orthodox Jews, is provided. The various forms of psychotherapy that have been utilized to engage Orthodox Jews in meaningful psychotherapeutic encounters are discussed. Psychodynamic, cognitive, behavioral, couple, family, and group therapies have all been employed with success. The first key in working with cultural minorities, including Orthodox Jews, is patience. Patience is required to allow a therapeutic alliance to develop in which the therapist, the outsider, can be trusted. When patients are reluctant to accept the treatment proposed, patience is necessary to give them the time required to verify the treatment with someone they trust, often their rabbi in the case of the Orthodox Jew. Patience is also valuable when patients request a change in the frame of therapy, such as the use of a chaperon or leaving the door slightly ajar if being treated by a member of the opposite sex. The second key in working with this or any other cultural minority is flexibility. Flexibility is required, to chose treatment modalities that best fit with the patient's beliefs, to respect the patient's beliefs no matter the extent they deviate from the therapist's own, and finally, to be critical of oneself when examining transference and countertransference reactions.

Sexual side effects of antidepressants: a review.

Antidepressant-induced adverse sexual effects are becoming more frequently reported by patients who require pharmacotherapy. A MED-LINE search was conducted to generate articles reporting such events. We report here on the sexual side effects associated with tricyclics, monoamine oxidase inhibitors including moclobemide, selective serotonin reuptake inhibitors, bupropion, and on the newer antidepressants venlafaxine and nefazadone. We conclude that adverse sexual effects are an increasingly important side effect of antidepressant medications, and patients must be routinely asked about their occurrence.

Treatment of antidepressant-induced sexual side effects.

Sexual side effects of antidepressant medications are becoming more frequently encountered by patients who require pharmacotherapy. A MEDLINE search was conducted to generate articles that address methods of treating these iatrogenically induced clinical situations. We report here on treatment strategies to alleviate these adverse events. We conclude that clinicians should routinely ask about sexual side effects due to antidepressants and that they should be treated promptly to ensure patient compliance with antidepressant pharmacotherapy.

Expression of major histocompatibility complex class II antigen in NOD mouse thyroid.

Non obese diabetic (NOD) mice spontaneously develop thyroiditis in addition to diabetes. Mononuclear cells begin to infiltrate the thyroid of these animals in the first month of life. The expression of major histocompatibility complex (MHC) class II (Ia) antigens by cells in the thyroid from NOD mice of various ages with and without thyroiditis was examined. We found that only 1 of the 9 infiltrated thyroids from 18 8-33 day old NOD mice surveyed expressed MHC class II antigens. Therefore Ia antigen expression appears to be secondary to infiltration and does not initiate the autoimmune process. Fourteen of 17 (82.2%) infiltrated and 7 of 11 (63.6%) uninfiltrated thyroids from NOD mice aged 51-73 days contained cells expressing Ia antigens. Sixteen of 18 (88.9%) infiltrated and all 7 of the uninfiltrated thyroids from mice aged > 89 days contained Ia positive cells. These MHC class II expressing cells included thyroid epithelial cells (TEC), as well as interstitial cells such as macrophages. Ia positive cells in the thyroid have the potential of presenting thyroid specific antigen to infiltrating T cells and thereby maintaining or potentiating thyroid autoimmune destruction. Macrophages were observed in thyroid tissue from 9 of 11 (81.8%) infiltrated and 12 of 15 (80%) uninfiltrated 8-33 day old NOD mice, thyroids from 11 of 16 (68.7%) infiltrated and 6 of 9 (66.7%) uninfiltrated 51-73 day old NOD mice, as well as 28 of 29 (96.5%) uninfiltrated and all 9 of the uninfiltrated thyroid from NOD mice aged > 89 days. Thyroids from control age matched non autoimmune BALB/c mice were consistently Ia antigen negative while macrophages were seen in some of the animals aged > 60 days.

Studies of autoantibodies reactive with thyroid membrane antigens and insulin in non obese diabetic mice.

Enzyme-linked immunosorbent assay (ELISA) was used to study the temporal relationship between the appearance of murine autoantibodies reactive to insulin and thyroid membrane antigens (TMA) and the development of diabetes and thyroiditis in the non obese diabetic (NOD) mouse. Overall, 28% of NOD mice had antibodies specific for mouse thyroid membrane antigens (MTMA), 30% had antibodies to human thyroid membrane antigens (HTMA) and 23% of NOD mice had insulin autoantibodies (IAA), in at least one of their serial monthly blood samples. Non autoimmune BALB/c mice did not develop antibodies to these antigens. Presence of IAA was associated with the development of diabetes and in 87% of cases such antibodies were detected before the diabetes was diagnosed. IAA were usually demonstrated before insulitis. No association between thyroiditis and IAA was noted. Anti-MTMA and anti-HTMA antibodies were detected more frequently in NOD mice with thyroiditis than in those without thyroid inflammation. No significant association was noted between detection of serum anti-TMA antibodies and the development of diabetes. In young mice, anti-TMA antibodies were not detected in the absence of thyroiditis. Western blot analysis of NOD sera positive for MTMA by ELISA revealed a heterogeneous pattern of reactivity. The significance of these findings with respect to the pathogenesis of diabetes and thyroiditis and their association, is discussed.

High incidence of thyroiditis and anti-thyroid autoantibodies in NOD mice.

NOD mice develop spontaneous insulin-dependent diabetes mellitus (IDDM) associated with infiltration of pancreatic islets with mononuclear cells. Islet infiltration results in autoimmune destruction of insulin-secreting beta-cells. Because in humans and BB rats diabetes is often associated with autoimmune thyroid disease (ATD), the NOD mouse model was examined for evidence of thyroiditis and serum antibodies reactive with mouse thyroid membrane antigens (MTMAs). The incidence of thyroiditis was 77% in mice greater than 180 days old, 67% in mice 61-180 days old, 72% in mice 31-60 days old, 74% in mice 21-30 days old, 78% in mice 11-20 days old, and 90% in mice less than or equal to 10 days old. NOD mice less than or equal to 30 days old had less-severe thyroiditis than animals greater than 180 days old. There was no significant different in severity of thyroiditis between any of the other age-groups tested. The incidence of thyroiditis was not increased in diabetic compared with nondiabetic animals, nor was an association found between thyroiditis and sex. The high incidence of thyroiditis in the less than or equal to 30-day-old age-group indicates that infiltration of lymphocytes into the thyroid can precede initiation of insulitis in this model. Although both thyroiditis and insulitis in NOD mice began early (by the 1st and 2nd mo of life, respectively), no significant association between infiltration of these two organs was noted in individual mice.(ABSTRACT TRUNCATED AT 250 WORDS)