Visual hallucinations, misidentification and reduplication of time:a sense of distorted reality due to a cerebral metastasis

Wij beschrijven een patiënte van 66 jaar zonder psychiatrische voorgeschiedenis die zich meldde met een atypisch psychotisch toestandsbeeld dat grotendeels voldeed aan de kenmerken van het fregolisyndroom (misidentificatie van personen). Daarnaast had patiënte reduplicatie van tijd, scenische hallucinaties en waanwaarnemingen. De oorzaak bleek een hersenmetastase vanuit een primaire longtumor. We beschrijven (aanvullende) diagnostiek en bespreken hoe te differentiëren tussen een organische en functionele psychose, daarnaast beschrijven we de psychiatrische behandeling van patiënte. Ten slotte geven we mogelijke pathofysiologische verklaringen voor het optreden en het verminderen van de symptomen bij deze patiënte.We describe a 66-year-old female patient with no prior psychiatric history who presented with an unusual psychotic state, largely in accordance with Fregoli syndrome (misidentification of people). Further, the patient suffered from reduplication of time, scenic hallucinations and psychotic perceptions. Symptoms were the result of a brain metastasis originating from a lung carcinoma. We describe the performed (additional) diagnostics and discuss how to differentiate between organic and functional psychosis, as well as the given psychiatric treatment. Finally, potential pathophysiological explanations are discussed that might explain the (reduction of) symptoms in the patient

Individual and common patterns in the order of symptom improvement during outpatient treatment for major depression

BACKGROUND: Research so far provided few clues on the order in which depressive symptoms typically remit during treatment. This study examined which depressive symptoms improve first, and whether symptoms changed before, simultaneous with, or after the core symptoms of depression (i.e., sad mood, loss of pleasure, and loss of interest). METHODS: Participants were 176 patients with Major Depressive Disorder (MDD) receiving outpatient treatment (a combination of pharmacotherapy and psychological interventions) for depression. Participants filled out the Inventory of Depressive Symptomatology - Self Report (IDS-SR) for 16 to 20 consecutive weeks. For each symptom, the timing of onset of a persistent improvement was determined for each single-subject separately. RESULTS: Which symptoms improved first differed markedly across patients. The core depression symptoms improved 1.5 to 2 times more often before (48% - 60%) than after (19% -28%) depressive cognitions ('view of myself' and 'view of the future'), anxiety symptoms ('feeling irritable' and 'feeling anxious / tense') and vegetative symptoms ('loss of energy', 'slowed down', and 'physical energy'). Only improvements in suicidal thoughts were more likely to occur before (46% - 48%) than after (29%) improvements in the depression core symptoms. LIMITATIONS: Not all 'core depression-non-core symptom' combinations could be tested because some symptoms did not improve in a sufficient number of patients. CONCLUSIONS: Which improvements mark the start of symptom remission differed between patients. Improvements in the core depression symptoms 'sad mood', 'loss of interest', and 'loss of pleasure' were more likely to occur before than after improvements in non-core symptoms

Medication

De veelal ongezonde leefstijl van mensen met een psychiatrische aandoening is onlosmakelijk verbonden met de medicatie die wordt voorgeschreven in de psychiatrie. In dit hoofdstuk gaan we dan ook uitgebreid in op het psychofarmacagebruik en beschrijven we de lichamelijke gevolgen van deze medicijnen. Daarnaast gaan we in op de achtergrond en de werkingsmechanismen van medicatie. Per medicatie- groep wordt uitgelegd hoe bijwerkingen kunnen ontstaan vanuit receptorniveau naar klinisch beeld. Lichamelijke screening wordt ingezet om verschillende lichamelijke klachten en risicofactoren systematischin kaart te brengen. Indien deze aanwezig zijn is het van belang dit te bespreken met de patiënt en samen een beleid vast te stellen. Pas alshet duidelijk is welke lichamelijke belemmeringen er zijn, kan een goed beleid worden gemaakt. De eerste stap is om te kijken welke medicijnen afgebouwd of omgezet kunnen worden om de bijwerkingen te vermin- deren. Daarna zou in samenspraak moeten worden bepaald welke niet- medicamenteuze opties er zijn om de bijwerkingen te doen afnemen. Indien dat ontoereikend is en/of de persoon voelt niets voor leefstijl- interventies, kan medicatie nodig zijn om de afwijkende waarden te behandelen, waarbij rekening moet worden gehouden met de bijwerkingen van die medicamenten. Leefstijladviezen vormen een rode draad dooralle fasen van de behandeling, en er kunnen ook specifieke leefstijl- psychiatrische interventies worden ingezet om de psychische klachten te verminderen. Dit kan weer leiden tot minder medicatiegebruik.Tot slot is het van belang dat de zorg dusdanig wordt georganiseerd dat er voldoende oog is voor zowel psychische als lichamelijke gezondheid

Monitoring of somatic parameters at outpatient departments for mood and anxiety disorders

INTRODUCTION: Somatic complications account for the majority of the 13-30 years shortened life expectancy in psychiatric patients compared to the general population. The study aim was to assess to which extent patients visiting outpatient departments for mood and anxiety disorders were monitored for relevant somatic comorbidities and (adverse) effects of psychotropic drugs-more specifically a) metabolic parameters, b) lithium safety and c) ECGs-during their treatment. METHODS: We performed a retrospective clinical records review and cross-sectional analysis to assess the extent of somatic monitoring at four outpatient departments for mood and anxiety disorders in The Netherlands. We consecutively recruited adult patients visiting a participating outpatient department between March and November 2014. The primary outcome was percentage of patients without monitoring measurements. Secondary outcomes were number of measurements per parameter per patient per year and time from start of treatment to first measurement. RESULTS: We included 324 outpatients, of whom 60.2% were female. Most patients were treated for depressive disorders (39.8%), anxiety disorders (16.7%) or bipolar or related disorders (11.7%) and 198 patients (61.1%) used at least one psychotropic drug. For 186 patients (57.4%), no monitoring records were recorded (median treatment period 7.3 months, range 0-55.6). The median number of measurements per parameter per year since the start of outpatient treatment for patients with monitoring measurements was 0.31 (range 0.0-12.9). The median time to first monitoring measurement per parameter for patients with monitoring measurements was 3.8 months (range 0.0-50.7). DISCUSSION: Somatic monitoring in outpatients with mood and anxiety disorders is not routine clinical practice. Monitoring practices need to be improved to prevent psychiatric outpatients from undetected somatic complications

Lithium surveillance by community pharmacists and physicians in ambulatory patients:a retrospective cohort study

Background Shared care agreements between clinical pharmacists and physicians can improve suboptimal lithium monitoring in in- and outpatient settings. However, it is unknown whether incorporating community pharmacists in such agreements can also improve lithium monitoring in an outpatient setting. Aim To assess the necessity for a shared care agreement for lithium monitoring in our region by investigating: intervention rates by community pharmacists and whether those are sufficient; lithium monitoring by physicians in ambulatory patients; the extent of laboratory parameter exchange to community pharmacists. Method Patient files of lithium users were surveyed in a retrospective cohort study among 21 community pharmacies in the Northern Netherlands. Outcome was the intervention rate by community pharmacists and whether those were deemed sufficient by an expert panel. Additionally, we investigated both the percentages of patients monitored according to current guidelines and of laboratory parameters exchanged to community pharmacists. Results 129 patients were included. Interventions were performed in 64.4% (n = 29), 20.8% (n = 5), and 25.0% (n = 1) of initiations, discontinuations, and dosage alterations of drugs interacting with lithium, respectively. The expert panel deemed 40.0% (n = 14) of these interventions as "insufficient". Physicians monitored 40.3% (n = 52) of the patients according to current guidelines for lithium serum levels and kidney functions combined. Approximately half of the requested laboratory parameters were available to the community pharmacist. Conclusion Intervention rates by community pharmacists and lithium monitoring by physicians can be improved. Therefore, a shared care agreement between community pharmacists, clinical pharmacists, and physicians is needed to improve lithium monitoring in ambulatory patients

Comparing Cognitive and Somatic Symptoms of Depression in Myocardial Infarction Patients and Depressed Patients in Primary and Mental Health Care

Depression in myocardial infarction patients is often a first episode with a late age of onset. Two studies that compared depressed myocardial infarction patients to psychiatric patients found similar levels of somatic symptoms, and one study reported lower levels of cognitive/affective symptoms in myocardial infarction patients. We hypothesized that myocardial infarction patients with first depression onset at a late age would experience fewer cognitive/affective symptoms than depressed patients without cardiovascular disease. Combined data from two large multicenter depression studies resulted in a sample of 734 depressed individuals (194 myocardial infarction, 214 primary care, and 326 mental health care patients). A structured clinical interview provided information about depression diagnosis. Summed cognitive/affective and somatic symptom levels were compared between groups using analysis of covariance, with and without adjusting for the effects of recurrence and age of onset. Depressed myocardial infarction and primary care patients reported significantly lower cognitive/affective symptom levels than mental health care patients (F (2,682) = 6.043, p = 0.003). Additional analyses showed that the difference between myocardial infarction and mental health care patients disappeared after adjusting for age of onset but not recurrence of depression. These group differences were also supported by data-driven latent class analyses. There were no significant group differences in somatic symptom levels. Depression after myocardial infarction appears to have a different phenomenology than depression observed in mental health care. Future studies should investigate the etiological factors predictive of symptom dimensions in myocardial infarction and late-onset depression patients