Treatment effect modifiers for the patient education programme for Parkinson's disease.

AIM: A recent randomised controlled trial showed significant benefits for Parkinson's disease (PD) caregivers' psychosocial problems and need for help and a trend towards significant improvement of patients' quality of life after participation in the Patient Education Programme for Parkinson's disease (PEPP). Large variations in change scores were found, indicating variation in benefit. The aim of this study was to search for treatment effect modifiers. METHODS: Outcome measures were patients' quality of life [Parkinson's Disease Questionnaire (PDQ)-39] and caregivers' psychosocial burden [Belastungsfragebogen Parkinson Angehörigen kurzversion (BELA-A-k)]. Candidate treatment effect modifiers were participants' characteristics and baseline scores on psychological questionnaires (BELA-P/A-k, PDQ-39, EQ-5D, Self-rating Depression Scale) and patients' neuropsychological test scores (Mini Mental State Examination, National Adult Reading Test, Dutch version, Word Test, Behavioural Assessment of the Dysexecutive Syndrome rule shift, Trail Making Test, Stroop). Secondary analyses of data from a randomised controlled trial with 64 patients and 46 caregivers were performed using regression analyses with treatment group interaction terms. RESULTS: No significant modifiers were found for the patients. In the caregiver group, a higher MMSE score of the patient at baseline was found to be a significant predictor of a lower BELA-A-k Bothered by score post-intervention of the caregiver. CONCLUSIONS: A potential predictor of treatment benefit was found for caregivers of PD patients with better cognitive functioning. This study did not find treatment effect modifiers for PD patients: demographics, disease stage and time of diagnosis, cognitive functioning, level of baseline psychosocial burden, participating with or without a caregiver, and caregiver changes did not influence treatment outcome. The PEPP seems suitable for the majority of patients.

The benefits of a standardized patient education program for patients with Parkinson's disease and their caregivers.

The Patient Education Program Parkinson (PEPP) is a standardized psychosocial intervention aiming at improving the health-related quality of life (Hr-Qol) of patients with Parkinson's disease (PD) and caregivers. A randomized controlled trial was performed to assess its effectiveness. Sixty-four PD patients and 46 caregivers were allocated to either the intervention group (PEPP) or the control group (usual care). The intervention consisted of eight weekly sessions of 90-minute duration. Assessments were performed on psychosocial problems (BELA-P/A-k), Hr-Qol (PDQ-39/EQ-5D) and depression (SDS) at baseline and one week after the end of the PEPP. Participants rated their mood on a visual analogue scale before and after each session. A significant effect for the caregivers on psychosocial problems and need for help was found and a trend for significance for patients' quality of life. Patients' and caregivers' mood improved significantly after each session. This study provides indications that PD patients and caregivers benefit from the PEPP.

Cognitive functioning in patients with suspected chronic toxic encephalopathy: evidence for neuropsychological disturbances after controlling for insufficient effort.

OBJECTIVES: Chronic toxic encephalopathy (CTE) caused by long term occupational exposure to organic solvents is still a controversial disorder. Neuropsychological testing is the cornerstone for diagnosing the syndrome, but can be negatively influenced by motivational problems. In this nationwide study, we investigated the neuropsychological functioning and psychological symptoms of a large group of patients with suspected CTE, and ruled out alternative explanations for their complaints, including suboptimal performance due to insufficient effort. METHODS: We studied participants with suspected CTE (n = 386) who were referred for further diagnosis to the Netherlands Centre of Occupational Diseases in the period 1998-2003 and who had completed the entire diagnostic protocol. Patients were excluded if there was the slightest suspicion that test performance had been negatively influenced by insufficient effort (n = 221), or if comprehensive assessment identified an alternative diagnosis (n = 80). Insufficient effort was defined by a combination of three indices. The neuropsychological test scores of the patient group (n = 85) were compared with those of a control group of building trade workers matched for sex, age, and educational level (n = 35). RESULTS: The patient group had significantly more psychological complaints and performed significantly worse than the control group on tests of speed of information processing and memory and learning. However, only a small percentage of the patients had clearly abnormal scores for cognitive speed (9%) or memory (8%). Attention, verbal abilities, and constructional functions were not disturbed. Exposure duration and cognitive complaints were significantly correlated, whereas the correlation between exposure duration and neuropsychological domain scores was not significant. CONCLUSIONS: Insufficient effort was present in a substantial part of the patient group. After minimising the likelihood that insufficient effort negatively influenced neuropsychological scores, we still found neuropsychological deficits in speed of cognitive processing and memory; however, these scores were clearly abnormal only in a minority of patients with suspected CTE. Screening instruments should focus on these domains.

Does the MMPI-168 exaggerate psychotic pathology?

Three scoring versions of the MMPI, scored on the same protocol, were compared in a multivariate design with 198 psychiatric patients. The MMPI-168 schizophrenia scale had a statistically higher elevation than the Dutch and American scoring versions. This makes MMPI-168 profiles more often "schizophrenic" than other scoring versions. The MMPI-168 systematically overscores the presence of "psychotic" code types, 45% of all protocols. Implications of the findings are discussed.

Screening psychiatric admissions for anticardiolipin antibody.

Anticardiolipin antibody (aCL) may provide an instrument for screening in neuropsychiatric syndromes due to cerebral ischemia. Thirty-five psychiatric patients, aCL-positive on admission, were matched against aCL-negative patients. Their clinical records on admission and after 2-years of follow-up were analyzed without knowledge of aCL results. An inventory was made of cerebrovascular and systemic vascular symptoms. In 13 out of 35 aCL-positive cases, vascular morbidity, suggesting ischemic causes of central nervous system pathology, could be demonstrated during follow-up and none in the comparison group. No correlation was found, however, between Hachinski ischemic scores on admission and aCL-positivity. Yet, if only on the basis of increased incidence of subsequent ischemia, the aCL-IgG/M isotype appears to be a valuable predictor of vascular neuropsychiatric symptoms.

Psychiatric symptoms before systemic lupus erythematosus is diagnosed.

Psychiatric symptoms are rarely reported as an initial feature of systemic lupus erythematosus (SLE). Nevertheless, many patients have the feeling that psychiatric symptoms occurred before they were diagnosed as having SLE. This feeling was confirmed by an enquiry among members of the Dutch Lupus Patients Society: half of them had experienced psychiatric complaints before SLE was diagnosed. Two-thirds of these patients searched for professional help for these complaints. This motivated us to study whether SLE patients were admitted into psychiatric hospitals without being diagnosed as having SLE. Sera from 2121 patients admitted to a psychiatric hospital and from 500 controls matched for sex and age were tested for the presence of antinuclear antibodies (ANA) and antibodies to DNA. ANA were found in 3% of patients, as well as controls. Anti-DNA antibodies were found in 1% of both patients and controls. Two out of 114 patients psychiatric patients with ANA and/or anti-DNA antibodies had SLE and/or Sjögren's syndrome. We concluded that SLE is not an important cause of admission to psychiatric hospitals. Routine tests for the determination of antinuclear and anti-DNA antibodies on admissions in these hospitals thus would not seem useful. To study whether patients with another chronic disease also had psychiatric complaints before being diagnosed, we performed the same enquiry among members of the Dutch Sarcoidosis Patients Society. The results were almost equal to those of the enquiry of the members of the Dutch Lupus Patients Society. Why members of both societies so often report psychiatric symptoms before their disease is diagnosed should be a subject of further studies.

Depression and assessment of intellectual functioning.

This study examined the relation between WAIS and Wilson predictor of premorbid intelligence scores of 27 depressed and 34 nondepressed psychiatric patients. No significant difference was found between the WAIS and Wilson predictor of premorbid intelligence scores nor between the Verbal and Performance IQs.

Psychiatric symptoms in systemic lupus erythematosus: an update.

Twenty-one studies on the prevalence and type of psychiatric symptoms in systemic lupus erythematosus (SLE) are reviewed and evaluated. Substantial differences in prevalence of psychiatric symptoms in SLE-patients (from 17%-71%) have been reported. Of the investigated methodological aspects, differences in assessment techniques appeared to be the main source of the variability in findings. Although various types of psychiatric symptoms have been observed, depression is most frequently reported. There was no consistent relationship between the occurrence of psychiatric symptoms and other symptoms of SLE. However, the data suggest an association with (the patient's perception of) illness severity and with the experience of psychosocial stressors. Studies applying control groups (patients with other chronic diseases (e.g., rheumatoid arthritis) showed striking similarities between both patient groups with respect to prevalence and type of psychiatric symptoms. There is some evidence, however, indicating that a small proportion of the psychiatric symptomatology, in particular psychosis, is related to neurological dysfunction in SLE.

Sustained attention and pervasive hyperactivity.

A sustained attention deficit is defined as a significant decrement in task performance with task duration (time-on-task). Time-on-task effects are reported using a self-paced paper and pencil cancellation test (PPCT) in normals and in subgroups of pervasively hyperactive children. The hyperactive subgroups were pervasively hyperactive both at home and at school. They differed in degree of pervasiveness in three laboratory conditions. Task inefficiency was most pronounced in the most pervasively hyperactive group. There was no evidence in favour of a sustained attention deficit in hyperactivity: no differences were found in decline in task efficiency between the controls and the subgroups of hyperactive children.

Daily stressors and systemic lupus erythematosus: a longitudinal analysis--first findings.

Patients with systemic lupus erythematosus (SLE) and a comparison group of patients with rheumatoid arthritis (RA) completed the Dutch Everyday Problem Checklist and the Dutch Arthritis Impact Measurement Scale measuring physical and psychosocial aspects of illness. Both scales were completed 9 times at 6-week intervals. In addition several hematological and serological parameters were assayed. Analysis over several time points resulted in only weak correlations between the variables under study. The most remarkable finding of this study was that in SLE patients number and intensity of daily stressors are more strongly related to physical and psychosocial status than in RA patients.

Psychiatric symptoms as features of systemic lupus erythematosus.

An enquiry of the Dutch Lupus Patients Society revealed that 49% of the members had experienced psychiatric symptoms before systemic lupus erythematosus (SLE) was diagnosed and 33% had sought professional psychiatric help at that stage. To determine the frequency of SLE on psychiatric admission 2,121 patients were tested for the presence of SLE-specific antinuclear and anti-DNA autoantibodies. The results suggest that SLE is a cause of admission in psychiatric hospitals at the rate of 0.1-0.2% and routine screening of antinuclear and anti-DNA antibodies on admission is not an effective diagnostic approach.

Cognitive and emotional disturbances in systemic lupus erythematosus.

Do patients with central nervous system systemic lupus erythematosus (CNS-SLE) demonstrate more cognitive and emotional disturbances than SLE patients without cerebral involvement (non-CNS-SLE) and patients with rheumatoid arthritis (RA)? Test results indicated that CNS-SLE patients performed less well on two concentration subtests in comparison with both non-CNS-SLE and RA patients and scored higher on three psychopathology scales (borderline personality symptoms, dysthymic symptoms and psychotic depression). The representativity and reliability of the present results will be discussed.