[Management of panic disorder in the elderly]. / Prise en charge du trouble panique chez le sujet âgé.

Panic disorder in the elderly is an understudied disorder, despite being associated with substantial functional impairment, diminished quality of life and increased suicide risk in this population. This disorder is likely to be underdiagnosed and sometimes inadequately treated in the absence of national and international guidelines for this vulnerable population. Few therapeutic trials have specifically focused on the efficacy and tolerability of pharmacologic and psychotherapy treatments for panic disorder in the elderly, and current approaches to detect and manage this disorder are mainly based on experts' opinion or extrapolation from data available in younger adults. This report aims to provide a summary of current knowledge on pharmacologic and psychotherapeutic treatments for panic disorder in the elderly, and to propose a medical treatment algorithm, which should be viewed as a tool that may contribute to the choice of treatment, especially for treatment-resistant older patients with panic disorder. The main results here are the emphasis on antidepressant treatment, like selective serotonin reuptake inhibitor (SSRI), restricted benzodiazepine usage, take care of drug interactions, and importance of psychotherapy like cognitive behavioral therapy (CBT).

Psychiatric symptoms and quality of life in older adults with schizophrenia spectrum disorder: results from a multicenter study.

The severity of psychopathology has a strong negative impact on quality of life (QoL) among older adults with schizophrenia spectrum disorder. However, because these subjects generally experience multiple psychiatric symptoms, it remains unclear whether decreased QoL in this population is due to specific symptoms (e.g., hallucinations), specific dimensions of psychopathology (e.g., negative symptoms), a general psychopathology dimension representing the shared effect across all psychiatric symptoms, or a combination of these explanations. Data were derived from the Cohort of individuals with Schizophrenia Aged 55 years or more (CSA) study, a large (N = 353) multicenter sample of older adults with schizophrenia spectrum disorder recruited from French public-sector psychiatric departments. We used structural equation modeling to examine the shared and specific effects of psychiatric symptoms on QoL, while adjusting for sociodemographic characteristics, general medical conditions, global cognitive functioning and psychotropic medications. Psychiatric symptoms and QoL were assessed face-to-face by psychiatrists using the Brief Psychiatric Rating Scale (BPRS) and the Quality of Life Scale (QLS). Among older adults with schizophrenia spectrum disorder, effects of psychiatric symptoms on QoL were exerted mostly through a general psychopathology dimension (ß = - 0.43, p < 0.01). Negative symptom dimension had an additional negative effect on QoL beyond the effect of that factor (ß = - 0.28, p < 0.01). Because psychiatric symptoms affect QoL mainly through two dimensions of psychopathology, i.e., a general psychopathology dimension and a negative symptom dimension, mechanisms underlying those dimensions should be considered as promising targets for therapeutic interventions to substantially improve quality of life of this vulnerable population.

Effects of depression and cognitive impairment on quality of life in older adults with schizophrenia spectrum disorder: Results from a multicenter study.

BACKGROUND: Little is known about the respective effects of depression and cognitive impairment on quality of life among older adults with schizophrenia spectrum disorder. METHODS: We used data from the Cohort of individuals with Schizophrenia Aged 55-years or more (CSA) study, a large multicenter sample of older adults with schizophrenia or schizoaffective disorder (N = 353). Quality of life (QoL), depression and cognitive impairment were assessed using the Quality of Life Scale (QLS), the Center of Epidemiologic Studies Depression scale and the Mini-Mental State Examination, respectively. We used structural equation modeling to examine the shared and specific effects of depression and cognitive impairment on QoL, while adjusting for sociodemographic characteristics, general medical conditions, psychotropic medications and the duration of the disorder. RESULTS: Depression and cognitive impairment were positively associated (r = 0.24, p < 0.01) and both independently and negatively impacted on QoL (standardized ß = -0.41 and ß = -0.32, both p < 0.01) and on each QLS quality-of-life domains, except for depression on instrumental role and cognitive impairment on interpersonal relations in the sensitivity analyses excluding respondents with any missing data. Effects of depression and cognitive impairment on QoL were not due to specific depressive symptoms or specific cognitive domains, but rather mediated through two broad dimensions representing the shared effects across all depressive symptoms and all cognitive deficits, respectively. LIMITATIONS: Because of the cross-sectional design of this study, measures of association do not imply causal associations. CONCLUSIONS: Mechanisms underlying these two broad dimensions should be considered as important potential targets to improve quality of life of this vulnerable population.

Subsyndromal and syndromal depressive symptoms among older adults with schizophrenia spectrum disorder: Prevalence and associated factors in a multicenter study.

BACKGROUND: Few studies have examined the prevalence and correlates of subsyndromal and syndromal depressive symptoms (SSSD) among older adults with schizophrenia spectrum disorder. In this report, we examined the prevalence of SSSD and their associations with sociodemographic characteristics, clinical characteristics of schizophrenia, comorbidity, psychotropic medications, quality of life, functioning and mental health care utilization in a large, multicenter sample of older adults with schizophrenia spectrum disorder. METHODS: Data from the Cohort of individuals with Schizophrenia Aged 55 years or more (CSA) were used to examine the prevalence of SSSD, defined using the Center of Epidemiologic Studies Depression (CESD) scale. Clinical characteristics associated with SSSD were explored. RESULTS: Among 343 older adults with schizophrenia spectrum disorder, 78.1% had either subsyndromal (30.6%) or syndromal (47.5%) depressive symptoms. SSSD were independently associated with positive and negative symptoms, lower quality of life, non-late-onset psychosis, benzodiazepine use and urbanicity. There were no significant associations of SSSD with other sociodemographic characteristics and psychotropic medications, or with general medical conditions. We found no significant differences in the proportion of participants who were treated with antidepressants between those with syndromal depressive symptoms and those without depression (22.1% vs. 20.0%, p = 0.89). SSSD were not associated with higher mental health care utilization. LIMITATIONS: Data were cross-sectional and depression was not evaluated with a semi-structured interview. CONCLUSION: SSSD may be highly prevalent and under-assessed and/or undertreated among older adults with schizophrenia spectrum disorder. Our findings should alert clinicians about the need to assess systematically and regularly depression in this vulnerable population.

A Case of Violent Suicide Attempt in a Context of Myxedema Psychosis following Radioiodine Treatment in a Patient with Graves' Disease.

INTRODUCTION: Hypothyroidism has been associated with mood disorders but some cases of acute psychosis have also been reported. However, less attention has been paid to suicidal behavior in these patients. CASE REPORT: We report a case of suicide attempt by self-stabbing in a 43-year-old woman without past psychiatric history, four months after radioiodine therapy for Graves' disease. On clinical examination remarkable signs of myxedema were found and blood investigations showed hypothyroidism with an extremely high thyroid stimulating hormone (TSH) level (152 mUI/L; reference range 0.20-5.10). The patient presented delirium symptoms at the time of self-stabbing, which was associated with persecutory delusions and auditory harm command hallucinations. A rapid physical and psychiatric improvement was observed after the initiation of an oral thyroid replacement therapy without relapse after early discontinuation of the antipsychotic treatment. DISCUSSION: The most distinctive feature of our case is that the violent suicide attempt could be attributed to the myxedema psychosis. Suicide may result from several factors, including psychosocial stressors, psychiatric symptoms, and hormonal disturbance. This unique presentation should remind clinicians to systematically consider ordering additional tests in patients with atypical psychiatric presentation, even when serious behavioral disorders (such as violent suicide attempts) are present and may result in premature transfer to psychiatric units.

Effects of Psychiatric Disorders on Suicide Attempt: Similarities and Differences Between Older and Younger Adults in a National Cohort Study.

OBJECTIVE: Several common psychiatric disorders are associated with increased risk of suicide attempts, and the strength of these associations may vary between younger and older adults, which may explain age differences in suicide risk. Because psychiatric disorders often co-occur, it remains unclear whether (1) the risk of suicide attempt in older and younger adults is due to specific psychiatric disorders or underlying psychopathology dimensions (ie, internalizing and externalizing dimensions) and (2) the extent to which individual psychiatric disorders make distinct contributions to suicide attempt risk varies by age. METHODS: In a large nationally representative longitudinal survey, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; Wave 1, 2001-2002; Wave 2, 2004-2005), multiple-group structural equation modeling was used to examine shared and specific effects of DSM-IV-TR Axis I and Axis II disorders on the 3-year occurrence of suicide attempts in 4 different age groups (18-30 years, 31-40 years, 41-49 years, and ≥ 50 years). RESULTS: The study population included 34,653 individuals. In each age group, effect of psychiatric disorders on risk of attempting suicide was almost exclusively mediated through a general psychopathology factor representing the shared effect across all disorders (P < .01). The magnitude of this effect was significantly lower in older than in younger adults (P < .05). No individual disorder had significant additional effects on attempt risk. CONCLUSIONS: These findings underscore the importance of assessing suicide attempt risk in patients at all ages who present with common psychiatric disorders and the need for prevention strategies focused on the general psychopathology dimension.

A comprehensive model of predictors of suicide attempt in heavy drinkers: Results from a national 3-year longitudinal study.

BACKGROUND: Heavy drinkers are at high risk for suicide attempt and suicide. Multiple factors, when examined in isolation, have been implicated in the risk of suicide attempt in this population. In this report, we present a comprehensive model of the 3-year risk of suicide attempt in heavy drinkers using a longitudinal nationally representative study, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; wave 1, 2001-2002; wave 2, 2004-2005). METHODS: We used structural equation modeling to simultaneously examine effects of four broad groups of clinical factors previously identified as potential predictors of attempted suicides: 1) alcohol use disorder severity, 2) severity of comorbidity, 3) sociodemographic characteristics and 4) help-seeking for alcohol problems. Heavy drinking was defined as drinking 5 or more drinks in a day more than once a week in the month prior to Wave 1. RESULTS: About 1.5% of the 1573 heavy drinker participants (i.e., 5.1% of the NESARC sample) attempted suicide during the 3-year follow-up period. After adjusting for all other factors, several factors independently predicted attempted suicides: the alcohol use disorder liability factor measured by DSM-IV-TR criteria for alcohol abuse and dependence and two dimensions of psychopathology, the general psychopathology factor accounting for the shared effects of all comorbid psychiatric disorders and the externalizing dimension accounting for the shared effects of comorbid substance use disorders. No other factor predicted this risk in addition. CONCLUSION: This model may help identify individuals with heavy drinking at high risk of suicide and develop more effective suicide prevention strategies.