Long-term lithium treatment in bipolar disorder: effects on glomerular filtration rate and other metabolic parameters.

BACKGROUND: Concerns about potential adverse effects of long-term exposure to lithium as a mood-stabilizing treatment notably include altered renal function. However, the incidence of severe renal dysfunction; rate of decline over time; effects of lithium dose, serum concentration, and duration of treatment; relative effects of lithium exposure vs. aging; and contributions of sex and other factors all remain unclear. METHODS: Accordingly, we acquired data from 12 collaborating international sites and 312 bipolar disorder patients (6142 person-years, 2669 assays) treated with lithium carbonate for 8-48 (mean 18) years and aged 20-89 (mean 56) years. We evaluated changes of estimated glomerular filtration rate (eGFR) as well as serum creatinine, urea-nitrogen, and glucose concentrations, white blood cell count, and body-mass index, and tested associations of eGFR with selected factors, using standard bivariate contrasts and regression modeling. RESULTS: Overall, 29.5% of subjects experienced at least one low value of eGFR (<60 mL/min/1.73 m2), most after ≥15 years of treatment and age > 55; risk of ≥2 low values was 18.1%; none experienced end-stage renal failure. eGFR declined by 0.71%/year of age and 0.92%/year of treatment, both by 19% more among women than men. Mean serum creatinine increased from 0.87 to 1.17 mg/dL, BUN from 23.7 to 33.1 mg/dL, glucose from 88 to 122 mg/dL, and BMI from 25.9 to 26.6 kg/m2. By multivariate regression, risk factors for declining eGFR ranked: longer lithium treatment, lower lithium dose, higher serum lithium concentration, older age, and medical comorbidity. Later low eGFR was also predicted by lower initial eGFR, and starting lithium at age ≥ 40 years. LIMITATIONS: Control data for age-matched subjects not exposed to lithium were lacking. CONCLUSIONS: Long-term lithium treatment was associated with gradual decline of renal functioning (eGFR) by about 30% more than that was associated with aging alone. Risk of subnormal eGFR was from 18.1% (≥2 low values) to 29.5% (≥1 low value), requiring about 30 years of exposure. Additional risk factors for low eGFR were higher serum lithium level, longer lithium treatment, lower initial eGFR, and medical comorbidity, as well as older age.

Factor structure and reliability of the Italian adaptation of the Hypomania Check List-32, second revision (HCL-32-R2).

OBJECTIVE: To assess the psychometric properties of the Italian adaptation of the Hypomania-Check-List 32-item, second revision (HCL-32-R2) for the detection of bipolarity in major depressive disorder (MDD) treatment-seeking outpatients. METHODS: A back-to-back Italian adaption of the "Bipolar Disorders: Improving Diagnosis, Guidance, and Education" English module of the HCL-32-R2 was administered between March 2013 and October 2014 across twelve collaborating sites in Italy. Diagnostic and Statistical Manual Fourth edition (DSM-IV) diagnoses were made adopting the mini-international neuropsychiatric interview, using bipolar disorder (BD) patients as controls. RESULTS: In our sample (n=441, of whom, BD-I=68; BD-II=117; MDD=256), using a cut-off of 14 allowed the HCL-32-R2 to discriminate DSM-IV-defined MDD patients between "true unipolar" (HCL-32-R2(-)) and "sub-threshold bipolar depression" (HCL-32-R2(+)) with sensitivity=89% and specificity=79%. Area under the curve was .888; positive and negative predictive values were 75.34% and 90.99% respectively. Owing to clinical interpretability considerations and consistency with previous adaptations of the HCL-32, a two-factor solution (F1="hyperactive/elated" vs. F2="irritable/distractible/impulsive") was preferred using exploratory and confirmatory factor analyses, whereas items n.33 ("I gamble more") and n.34 ("I eat more") introduced in the R2 version of the scale slightly loaded onto F2 and F1 respectively. Cronbach׳s α=.88 for F1 and .71 for F2. LIMITATIONS: No cross-validation with any additional validated screening tool; treatment-seeking outpatient sample; recall bias; no systematic evaluation of eventual medical/psychiatric comorbidities, current/lifetime pharmacological history, neither record of severity of current MDE. CONCLUSIONS: Our results seem to indicate fair accuracy of HCL-32 as a screening instrument for BD, though replication studies are warranted.

Depressive symptoms and major depressive disorder in patients affected by subclinical hypothyroidism: a cross-sectional study.

The relationship between subclinical hypothyroidism and depression is still controversial. Our objective was to compare the prevalence of depressive symptoms and major depressive disorder in a population of patients affected by subclinical hypothyroidism and a control group without thyroid disease. The authors enrolled 123 consecutive outpatients affected by subclinical hypothyroidism undergoing follow-up at the endocrinology department of San Paolo Hospital in Milan and 123 controls without thyroid disease under the charge of general physicians.All patients and controls underwent an evaluation by means of a psychiatric interview; Hamilton Rating Scale for Depression (HAM-D); Montgomery-Asberg Depression Rating Scale (MADRS); and serum thyroid stimulating hormone, free T4, and free T3 levels. Patients were also screened for thyroid peroxidase antibodies and thyroglobulin antibodies. Patients affected by subclinical hypothyroidism had a prevalence of depressive symptoms of 63.4% at HAM-D and 64.2% at MADRS; 22 patients (17.9%) had a diagnosis of depressive episode (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria). The control group had a prevalence of depressive symptoms of 27.6% at HAM-D and 29.3% at MADRS, and only seven controls had a diagnosis of depressive episode. The prevalence of depressive symptoms between these two groups was statistically different. This study underlines a strong association between subclinical hypothyroidism and depressive symptoms, which could have some important diagnostic and therapeutic implications in the clinical practice.

[Enduring pain I. Nosology and epidemiology]. / Dolor perdurable I. Nosología y epidemiología.

Pain disorders are extraordinarily prevalent throughout clinical medicine, and are highly co-morbid with various psychiatric disorders, particularly those including depression or anxiety. Assessment of such patients tends to be based on diagnostic criteria that may not reflect the complexity of the clinical problem and can result in prioritizing somatic aspects of painful syndromes at the expense of psychiatric aspects or, conversely, over-emphasize psychiatric aspects. In the first part of this overview we consider current nosological perspectives and their potential clinical consequences, epidemiological data that underscore the association of comorbid painful and affective or anxious syndromes, and consider the importance of psychiatric assessment and treatment of such patients. The major overlap between pain disorders and psychiatric disorders, as well as the unsatisfactory state of treatments available for chronic pain syndromes, encourage a comprehensive approach to assessing and clinically managing patients with chronic pain. Many programs for pain disorder patients offer narrowly specialized treatment options. To be preferred are multi-disciplinary teams with expertise in internal medicine, neurology, pain management, and rehabilitation, as well as psychology and psychiatry. In the second part of this overview, we propose that psychiatrists can serve a key role in leading comprehensive assessment and management of complex and challenging pain-psychiatric patients who are typically only partially responsive to available treatments.

[Enduring pain II. Treatment]. / Dolor perdurable II. Tratamiento.

Pain disorders present highly challenging therapeutic problems, owing in part to complex co-morbidities associated with pain disorders, notably including psychiatric disorders characterized by depressed mood or anxiety. Many treatments are employed to treat pain-disorder patients, and most are unsatisfactory. Virtually all analgesic medicines in long-term use provide only partial efficacy and present substantial risks of adverse effects, loss of benefit over time, or dependency and risk of abuse. Commonly employed drugs with analgesic properties include non-opioids (mainly nonsteroidal anti-inflammatory agents [NSAIDs] or acetaminophen), many natural or synthetic opioids (including opiates and phenylpiperidines), some antidepressants (especially those with noradrenergic activity), a few anticonvulsants, skeletal muscle relaxants or topical remedies, and a growing variety of experimental treatments. The major overlap between pain and psychiatric disorders, as well as the currently unsatisfactory state of treatments available for chronic pain syndromes, encourage a comprehensive approach to assessment and clinical management of patients with chronic pain. Many current treatment programs for pain disorder patients offer narrowly specialized and incomplete treatment options. Ideally however, such care should be provided by multi-disciplinary teams with expertise in neurology, general medicine, pain management, physical medicine and rehabilitation, as well as psychiatry. Psychiatrists as well as pain specialists can serve an essential role in leading comprehensive assessment and general management of such complex and challenging patients who are typically only partially responsive to available treatments.

Dolor perdurable II. Tratamiento / [Enduring pain II. Treatment].

Pain disorders present highly challenging therapeutic problems, owing in part to complex co-morbidities associated with pain disorders, notably including psychiatric disorders characterized by depressed mood or anxiety. Many treatments are employed to treat pain-disorder patients, and most are unsatisfactory. Virtually all analgesic medicines in long-term use provide only partial efficacy and present substantial risks of adverse effects, loss of benefit over time, or dependency and risk of abuse. Commonly employed drugs with analgesic properties include non-opioids (mainly nonsteroidal anti-inflammatory agents [NSAIDs] or acetaminophen), many natural or synthetic opioids (including opiates and phenylpiperidines), some antidepressants (especially those with noradrenergic activity), a few anticonvulsants, skeletal muscle relaxants or topical remedies, and a growing variety of experimental treatments. The major overlap between pain and psychiatric disorders, as well as the currently unsatisfactory state of treatments available for chronic pain syndromes, encourage a comprehensive approach to assessment and clinical management of patients with chronic pain. Many current treatment programs for pain disorder patients offer narrowly specialized and incomplete treatment options. Ideally however, such care should be provided by multi-disciplinary teams with expertise in neurology, general medicine, pain management, physical medicine and rehabilitation, as well as psychiatry. Psychiatrists as well as pain specialists can serve an essential role in leading comprehensive assessment and general management of such complex and challenging patients who are typically only partially responsive to available treatments.

Dolor perdurable I. Nosología y epidemiología / [Enduring pain I. Nosology and epidemiology].

Pain disorders are extraordinarily prevalent throughout clinical medicine, and are highly co-morbid with various psychiatric disorders, particularly those including depression or anxiety. Assessment of such patients tends to be based on diagnostic criteria that may not reflect the complexity of the clinical problem and can result in prioritizing somatic aspects of painful syndromes at the expense of psychiatric aspects or, conversely, over-emphasize psychiatric aspects. In the first part of this overview we consider current nosological perspectives and their potential clinical consequences, epidemiological data that underscore the association of comorbid painful and affective or anxious syndromes, and consider the importance of psychiatric assessment and treatment of such patients. The major overlap between pain disorders and psychiatric disorders, as well as the unsatisfactory state of treatments available for chronic pain syndromes, encourage a comprehensive approach to assessing and clinically managing patients with chronic pain. Many programs for pain disorder patients offer narrowly specialized treatment options. To be preferred are multi-disciplinary teams with expertise in internal medicine, neurology, pain management, and rehabilitation, as well as psychology and psychiatry. In the second part of this overview, we propose that psychiatrists can serve a key role in leading comprehensive assessment and management of complex and challenging pain-psychiatric patients who are typically only partially responsive to available treatments.

Dolor perdurable I. Nosología y epidemiología. / [Enduring pain I. Nosology and epidemiology].

Pain disorders are extraordinarily prevalent throughout clinical medicine, and are highly co-morbid with various psychiatric disorders, particularly those including depression or anxiety. Assessment of such patients tends to be based on diagnostic criteria that may not reflect the complexity of the clinical problem and can result in prioritizing somatic aspects of painful syndromes at the expense of psychiatric aspects or, conversely, over-emphasize psychiatric aspects. In the first part of this overview we consider current nosological perspectives and their potential clinical consequences, epidemiological data that underscore the association of comorbid painful and affective or anxious syndromes, and consider the importance of psychiatric assessment and treatment of such patients. The major overlap between pain disorders and psychiatric disorders, as well as the unsatisfactory state of treatments available for chronic pain syndromes, encourage a comprehensive approach to assessing and clinically managing patients with chronic pain. Many programs for pain disorder patients offer narrowly specialized treatment options. To be preferred are multi-disciplinary teams with expertise in internal medicine, neurology, pain management, and rehabilitation, as well as psychology and psychiatry. In the second part of this overview, we propose that psychiatrists can serve a key role in leading comprehensive assessment and management of complex and challenging pain-psychiatric patients who are typically only partially responsive to available treatments.

Dolor perdurable II. Tratamiento. / [Enduring pain II. Treatment].

Pain disorders present highly challenging therapeutic problems, owing in part to complex co-morbidities associated with pain disorders, notably including psychiatric disorders characterized by depressed mood or anxiety. Many treatments are employed to treat pain-disorder patients, and most are unsatisfactory. Virtually all analgesic medicines in long-term use provide only partial efficacy and present substantial risks of adverse effects, loss of benefit over time, or dependency and risk of abuse. Commonly employed drugs with analgesic properties include non-opioids (mainly nonsteroidal anti-inflammatory agents [NSAIDs] or acetaminophen), many natural or synthetic opioids (including opiates and phenylpiperidines), some antidepressants (especially those with noradrenergic activity), a few anticonvulsants, skeletal muscle relaxants or topical remedies, and a growing variety of experimental treatments. The major overlap between pain and psychiatric disorders, as well as the currently unsatisfactory state of treatments available for chronic pain syndromes, encourage a comprehensive approach to assessment and clinical management of patients with chronic pain. Many current treatment programs for pain disorder patients offer narrowly specialized and incomplete treatment options. Ideally however, such care should be provided by multi-disciplinary teams with expertise in neurology, general medicine, pain management, physical medicine and rehabilitation, as well as psychiatry. Psychiatrists as well as pain specialists can serve an essential role in leading comprehensive assessment and general management of such complex and challenging patients who are typically only partially responsive to available treatments.