Welcome to the first issue of IJPCP for 2008. We trust the contents are stimulating to academic and clinical psychiatrists, but this issue may be particularly valued by those with an interest in mood disorders in community and general hospital settings, and in the pharmacological treatment of patients in the early stages of psychosis.
Screening for depressive symptoms after childbirth is common practice, but many of the employed instruments have uncertain psychometric properties. Da Silva Magalhães and colleagues (Pelotas, Brazil) assessed the characteristics of the Beck Depression Inventory (BDI) in a large (n = 772) community sample of post-partum women and their spouses, and found that it comprised two factors – depressive symptoms and somatic symptoms – and that women had significantly higher scores on items for both factors.
Depressive symptoms and disorders in the community and in hospital
Depressive symptoms and disorders are also common in general hospital patients. Uguz and colleagues (Konya, Turkey) used the Structured Clinical Interview for DSM-IV in 74 patients with multiple sclerosis, and found that 61% met criteria for at least one current mood or anxiety disorder. One-third of patients fulfilled criteria for major depression, this being more common in patients experiencing an exacerbation of neurological symptoms. Badura-Brzoza and colleagues (Katowice, Poland) undertook a case-control study of anxiety and depressive symptoms and ‘sense of coherence’ in patients (n = 51) after limb amputation, and found the proportion with depressive symptoms was similar in a control group of patients undergoing surgery for chronic back pain. Lower sense of coherence was seen in patients with high BDI scores, older patients, those who were unemployed, with fewer years of education, and who had not improved following an operation.
Liaison psychiatrists are often referred patients admitted after episodes of non-fatal self-harm, or recognised to be dependent upon alcohol. In a retrospective study, Peritogiannis and colleagues (Ioannina, Greece) examined the notes of 48 patients with DSM-IV defined borderline personality disorder, admitted to the psychiatric unit of a general hospital, and found they were admitted significantly more frequently than patients with Axis 1 disorders, much of this being due to suicide attempts or threats of self-harm, and the lack of suitable outpatient facilities for continuing care. Pombo and colleagues (Lisbon, Portugal) interviewed 133 alcohol dependent patients using two proposed typologies, and found that they characterised patients similarly – with a group with dependence arising from anxiety and use of alcohol to reduce conflict (an ‘anxiopathic’ sub-type), and a second group using alcohol to lift mood (the ‘thymopathic’ sub-type), these groups being distinguishable on the basis of demographic, clinical and consumption-related variables.
Of course depression is often hard to treat, and many patients express a preference for use of idiosyncratic approaches. Berner and colleagues (Freiburg, Germany) report the findings from a large (n = 2224) sample completing a questionnaire survey, showing that approximately 30% reported depressive symptoms, and that one-quarter of respondents had a lifetime history of treatment for depression. There was strong reported preference for self-help with ‘phytotherapeutic’ (i.e. herbal) remedies, rather than for conventional pharmacological or psychological treatments delivered by a health professional, although individuals with more severe symptoms expressed greater preparedness to seek professional advice.
Antidepressants form the mainstay of treatment for many patients with moderate or severe depressive symptoms in most countries. Yoram Barak (Tel-Aviv, Israel) examined a database of over 2 million antidepressant prescriptions, and found significant variations in the proportion of prescriptions for antidepressant drugs given as a monotherapy, rather than in combination with other psychotropics. SSRIs were the antidepressant drugs most likely to be prescribed as a single intervention, but there were marked differences within this class. Many clinicians rely upon evidence-based guidelines and algorithms when making treatment decisions for patients with mood disorders, and Nobutaka Motohashi (Yamanshi, Japan) and colleagues have refined existing algorithms for treatment of unipolar and bipolar mood disorders, combining an appraisal of evidence with questionnaire responses and emergent group consensus. Guidelines often advocate withdrawal of so-called ‘depressogenic’ medications (for example, certain antihypertensive drugs): benzodiazepines are often thought to have this property, but Scott Patten (Calgary, Canada) reminds us of the lack of credible evidence that benzodiazepines can cause depression.
Pharmalogical treatment of psychosis
Antipsychotic drugs are often used in patients with diagnoses other than schizophrenia. Catts and colleagues (Queensland, Australia) report findings from a small sample (n = 15) of patients undergoing quetiapine treatment for first episode psychosis. They describe an early reduction in severity of positive symptoms, but negative symptoms reduced only after 12 weeks of treatment. Quetiapine treatment was associated with a reduction in the proportion of patients with comorbid substance abuse problems, but also with significant weight gain. The relationship between insight and symptom severity during antipsychotic drug treatment is investigated by Češková and colleagues (Brno, Czech Republic: many showed an improvement in insight from admission to follow-up after discharge from hospital, there being a strong association between increased insight and symptomatic recovery. Bräunig and colleagues (Berlin, Germany) describe the use of risperidone long-acting injectable for maintenance treatment in a small sample (n = 16) of patients with bipolar disorder, with evidence of continuing benefit and high degrees of patient satisfaction: however these findings can only be preliminary and a controlled study is warranted. Finally, Rowe and Clark (Birmingham, UK) describe the findings of a questionnaire survey of attitudes of over 800 UK consultant psychiatrists to the diagnosis and treatment of schizoaffective disorder. Most respondents considered it to be a useful term, but there was little consensus on its distinguishing features, aetiology and management.