Being female, disabled, having a psychiatric history and ‘doctor-hopping’ are some of the predominant characteristics of patients with delusional infestations, a new study finds.

The largest case series of delusional infestation from one institution found a female to male ratio of 2.89:1, with nurses and teachers over-represented.

Of 147 patients who presented with animate (worms and insects) and inanimate delusional infestations, 81 per cent of patients had prior psychiatric conditions, with depression being the most prevalent (74 per cent).

Some 33 per cent of delusional infestation patients who presented at the Mayo Clinic between 2001 and 2007 were self-described as disabled, with 16 patients owing their disability to their delusions.

Journal of the American Academy of Dermatology 2012; doi:10.1016/j.jaad.2011.12.012

Despite older tricyclic antidepressants demonstrating a significantly greater efficacy over newer drugs, a major 30-year meta-analysis concludes the differences are largely a result of changes in trial designs, leading to greater placebo response and lower drug response.

Antidepressant efficacy steadily declined over the past 30 years, while placebo response increased, possibly a result of increasing trial size and “declining quality control”, the analysis of 142 drug-placebo comparisons involving almost 30,000 patients suggested.

“Placebo-associated respon-ses have increased from former levels of 20 to 30 per cent to current levels of 30 per cent to 50 per cent, and to as high as 59.2 per cent in a 1997 trial involving paroxetine,” the US researchers wrote in Neuropsychopharmacology.

Over the same time, trials have shifted from older tricyclics to newer SSRIs and atypicals. Although the older trials of tricyclics demonstrated greater benefit over placebo than more recent trials of newer drugs, the researchers found that if more recent placebo response rates were substituted into the older trials, “both types of agents yielded identical meta-analytically pooled [rate ratios]”.

The study authors blamed the decreasing drug-placebo difference on “declining quality-control and greater heterogeneity of diagnostic and clinical assessments”, as well as a number of other possible factors including the recruitment of less severely-ill patients into trials.

They argued that if their suggested explanations were correct, several “practical considerations for the design and conduct of therapeutic trials” were needed.

Looking at the factors that correlated with larger drug-placebo differences, they suggested limiting collaborating sites in trials to between two and 10, and limiting the number of subjects per trial to between 30 and 75.

“Such conservative considerations for the design of trials may improve outcomes,” they said, as well as lowering costs, time, complexity and exposure of acutely-depressed patients to placebo.

Neuropsychopharmacology 2011; doi:10.1038/npp.2011.306

The idea that patients who present with medication-resistant depression could be harbouring a hidden bipolar disorder has been bolstered by the largest study of the topic so far.

Patients who required two or more changes of antidepressant over an eight-year period were considerably more likely to receive a revised diagnosis of bipolar disorder than patients with ‘easy to treat’ depression, the Taiwanese researchers reported in the British Journal of Psychiatry.

Using a nationwide database of one million health service users containing over 4,000 people diagnosed with depression, researchers found that 26 per cent of ‘difficult to treat’ depression patients received a bipolar disorder diagnosis, compared with below 10 per cent of those with ‘easy to treat’ depression.

The results added weight to concerns that bipolar disorder was under-diagnosed and often mistaken for depression due to patients not mentioning, or clinicians not screening for mania.

The researchers said the findings offered a “useful sign” for psychiatrists when predicting bipolar disorder in patients before manic symptoms emerged.

A likely next step would be to investigate the casual effect of antidepressant medication and bipolar disorder. It was difficult to determine whether the subsequent appearance of manic symptoms could be attributed to the use of antidepressants or simply the result of a pre-existing bipolar disorder, they said.

British Journal of Psychiatry 2012; 10.1192/bjp.bp.110.086983

The adverse side effects of most neuromodulators and muscle relaxants overshadow any pain relief potential in rheumatoid arthritis (RA), a new Cochrane Review finds.

About one in three RA patients who took a cannabis mouth-spray suffered an adverse event such as dizziness, light-headedness, dry mouth, nausea and falls, in exchange for an average pain reduction of 2.6 on a scale of 0 to 5, 0.7 points lower than placebo after five weeks, the review found.

“The potential harms outweigh the modest benefits,” the authors said. “Our review does not support the use of cannabinoids in patients with RA.”

In one small study, 50 per cent of patients who applied capsaicin experienced a burning or stinging skin irritation, but only 2 per cent stopped treatment, deeming the reaction a small price to pay for an average pain level of 14 out of 100 – 34 points lower than placebo.

The authors concluded: “Given the relatively mild nature of the adverse events, capsaicin could be considered as an add-on therapy for patients with persistent local pain.”

A pain level 12 points lower than placebo for nefopam was cold comfort for many patients who stopped taking the drug because they were unable to cope with the side effects, including nausea and sweating.

Considering nefopam had the potential to cause more serious adverse effects such as confusion and tachycardia, and no evidence suggested it was more effective than safer analgesics available, the review did not support its use in RA.

Cochrane Database of Systematic Reviews 2012; DOI: 10.1002/14651858.CD008922.pub2

Most people with borderline personality disorder (BPD) are not violent, contrary to the overwhelming body of research, which has unduly focused on those already in the justice system, a systematic review has found.

“Although this may be the case in some patients, they are likely the minority of individuals with BPD,” the researchers from the University of Toronto wrote in Current Psychiatry Reports. “The diagnosis of BPD may be less useful in predicting violence than one might suspect, and violence in BPD may not be as strongly determined by impulsivity as is commonly held.”

Most research had been conducted in unrepresentative samples including prisoners, people undergoing mandated psychiatric treatment, psychiatric patients, substance abusers and delinquent youths, the report noted.

“Clinical lore holds that patients are at risk of committing violence, especially in the context of perceived or feared loss or abandonment in interpersonal relationships,” the researchers said. However, this and other contextual factors needed to be examined more closely.

It was important to look beyond the diagnosis of BPD and individually assess the issue in light of interpersonal relationships and other risk factors for violence, the researchers said.

The diagnostic criteria for the condition included unstable and intense interpersonal relationships, impulsivity, affective instability, and difficulties with controlling intense or inappropriate anger.

These features suggested that aggression might be a common result, but it was important to avoid over-generalising and adding to the heavy burden of stigma that BPD patients already faced, the authors wrote.
Current Psychiatry Reports 2011 doi 10.1007/s11920-011-0244-9

Depression or a history of suicide attempts in young adults substantially increases their risk of dying from heart disease, an American study has found, and the risks are particularly marked for women.

After adjusting for health and lifestyle factors such as smoking or poor diet, the risk of fatal CVD was more than double for people with depression than those without, and more than triple for those with past suicide attempts, the population based study of over 7,600 people aged 17-39 found.

Death from ischaemic heart disease (IHD) was nearly four times greater for those with depression, and more than seven times greater for people who had attempted suicide.

Women had triple the risk of fatal IHD, and a fourteen-fold greater risk for CVD. The figures for men were lower, with a 2.4 times greater risk for IHD and 3.5 times greater risk for CVD.

The authors suggested that depression may increase heart disease risk through physiological mechanisms such as lower heart rate variability and an increase in cortisol levels. However, they cautioned that their findings were limited by the relatively small number of events that occurred during the study period.

The authors noted that their study was the first population-based study to examine clinical diagnosis of depression and mortality due to CVD and IHD in young adults.

Previous studies had shown a link, but because they included middle-aged and elderly people, ”the dramatic impact of depression and suicidality on IHD mortality in younger individuals has gone unrecognised,” they wrote in the Archives of General Psychiatry.

“Our data suggest that more research should take a life-course approach to identify risk factors for IHD early in life,” they concluded.

Arch Gen Psychiatry, 2011; doi: 10.1001/archgenpsychiatry.2011.125

New research shows people with bipolar disorder — and siblings of people with schizophrenia and bipolar disorder — are more likely to work in creative professions. The study lends further support to the commonly-held view that creativity is associated with mental disorder.

Researchers from the Karolinska Institutet in Sweden studied the occupations of over 300,000 patients who had received inpatient treatment for schizophrenia, bipolar disorder or depression between 1973 and 2003, and their relatives who did not have a diagnosis of mental disorder. The patients and their non-diagnosed relatives were compared to a control group.

People’s professions were categorised using the Nordic Classification of Occupations. Creative professions included both scientific jobs (such as university teachers) and artistic jobs (designers, performing artists, musicians and authors). The team found that people with bipolar disorder were over-represented in creative professions. However, this was not true for people with schizophrenia or depression.

The researchers also found that the healthy siblings of people with bipolar disorder and schizophrenia were more likely to hold creative occupations than the control group.

Lead researcher Dr Simon Kyaga said: “Creativity has long been associated with mental disorder, epitomised by Aristotle’s alleged claim that ‘no great genius has ever existed without a strain of madness’. Our study, which is much larger than previous studies, shows that people with bipolar disorder, and their siblings, are more likely to work in creative professions.”
British Journal of Psychiatry 2011; 199:373-379.

Using cannabis can lead to a loss of brain volume in people who are at risk of developing schizophrenia, according to a new study.

Previous studies have found that the brains of people with schizophrenia show structural abnormalities, particularly in a part of the brain called the thalamus. We each have two thalami — the left and the right — which are responsible for processing and relaying information.

The team studied 57 people aged between 16 and 25 who were well but who had a strong family history of schizophrenia — and were therefore at high genetic risk of the disease. Each person had a full assessment including a magnetic resonance imaging (MRI) scan. Two years later, each person returned for another MRI scan. As part of this second assessment, they were asked about their use of illicit drugs (including cannabis), alcohol and tobacco in the period between scans.

Of the 57 participants, 25 had used cannabis between the two assessments. The researchers found that those people who had used cannabis experienced a reduction in their thalamic volume. This loss was significant on the left side of the thalamus and highly significant on the right. No volume loss was found in those who had remained cannabis-free during the two-year period.

Some of the participants who used cannabis had also used other drugs, such as ecstasy and amphetamines. However, the results remained significant after controlling for this.

Lead researcher Dr Killian Welch said: “Our study demonstrates that cannabis use by people with a family history of schizophrenia is associated with thalamic volume loss. This raises the possibility that when used by people already at elevated genetic risk of the condition, cannabis may increase the likelihood of brain abnormalities associated with schizophrenia developing.

“This may facilitate our understanding of how cannabis use can lead to a worsening of previously subtle symptoms — and ultimately increase the risk of transition to schizophrenia.”
British Journal of Psychiatry 2011; 199:386-390

Driving with dementia could lead to severe injury or even death to the affected person and to others

Dr Abdul Nasir Khalil and Dr Sabina Fahy look at the delicate issue of deciding when to stop driving after a diagnosis of dementia is made.

Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal ageing. The word dementia (de — without; ment — mind) is taken from Latin meaning ‘madness’. Although dementia is far more common in the geriatric population, it may occur in any stage of adulthood. The term ‘presenile dementia’ is used to describe early-onset dementia.

Dementia is a syndrome that affects memory, attention, language and problem solving. Day-to-day functional skills or personal skills may also be impaired. It is normally required to be present for at least six months for a diagnosis to be made. Cognitive dysfunction that has been seen over shorter times, in particular over weeks or days, may be termed ‘delirium’. In all types of dementia, higher mental functions are affected first in the process. It is important to consider the ‘four As’: amnesia, aphasia, apraxia and agnosia in dementia.

Less than 10 per cent of cases of dementia are due to causes that may be reversed with treatment, such as vitamin B12/folate deficiency and hypothyroidism, et cetera.

Dementia is not merely a problem of memory; it also affects the ability to learn, reason, retain or recall past experience and there is also loss of patterns of thoughts, feeling and activities. Additional mental and behavioural problems often affect people who have dementia and influence their quality of life.

As dementia worsens, individuals may start to neglect themselves.

In a study issued by European researchers, it was estimated that about 35 million people have dementia worldwide. This figure is likely to double every 20 years, to nearly 66 million in 2030 and 115 million in 2050, according to the study. The total worldwide cost of dementia is $604 billion, which is 1 per cent of world GDP. The cost of dementia is more than the cost of heart disease, stroke and diabetes together.

Risk to self and others
The Canadian Medical Association Journal has reported that driving with dementia could lead to severe injury or even death to the affected person and to others, and that doctors should advise appropriate testing on when to quit driving.

In the United States, Florida’s Baker Act allows law enforcement agencies and the judiciary to force mental evaluation for those suspected of suffering from dementia or other mental incapabilities.

The United Kingdom DVLA (Driving and Vehicle Licensing Agency) states that dementia sufferers who specifically suffer with poor short-term memory, disorientation, lack of interest or poor judgment are almost certainly not fit to drive and, in these instances, the DVLA must be informed so that the said licence can be revoked.

Case 1
Mr MD was an 80-year-old married gentleman, referred to our team by his GP. The reason for referral was forgetfulness and insomnia.

On assessment by our team, he presented with major memory problems, was quite confused and disoriented in place and time. Although he was 80 years old, he believed he was 29 and his wife 25 years old. He also believed that his parents were alive and he believed he regularly met them, although they were deceased long ago.

Although he had retired as a bus driver, he said he still drove a bus and tractor and also was actively involved in farming, although he was not. His knowledge of current affairs was poor. He denied any biological signs of depression. He also denied any delusional beliefs or perceptual problems. There was no past or family history of psychiatric illness or dementia. He had past medical history of cerebrovascular accident (CVA) in 2006 and prostate carcinoma.

Collateral history from his daughter-in-law revealed that he had memory problems that worsened gradually in the previous year. His short-term memory was very poor and he was very repetitive. His sleep pattern had been erratic; he had gotten up in the middle of the night, left the house and was found wandering on the farm. On one occasion, when his son and daughter-in-law came home around midnight from an outing, he had lit a big fire outside his home on the farm.

As a retired bus driver, he still looked for the bus in the yard and also had an obsession with keys and had lost keys of doors. The main concern was that he was still driving and there had been several reports from neighbours in relation to dangerous driving, e.g. driving on the wrong side of the road.

On the Mini–Mental State Examination (MMSE), he scored 15/30, losing all five points on time and one on place. His short-term recall, attention and construction of pentagons were very poor, scoring nil on all these domains.

Although he had suffered a CVA four years ago, clinical assessment and the pattern of his memory difficulties and the gradual deterioration were all suggestive of Alzheimer’s disease and we made a diagnosis of Alzheimer’s dementia with vascular risk factors.

He was commenced on memantine. The Cognitive Linguistic Quick Test (CLQT) was administered by the occupational therapist, which showed impairment in all the five cognitive domains of the test. His scores on the CLQT were as follows:
1)    Attention: severe impairment;
2)    Memory: severe impairment;
3)    Executive functions: moderate impairment;
4)    Language: moderate impairment;
5)    Visuospatial skills: mild impairment.

We advised the family to disable the car immediately and also informed the GP regarding the same.

Case 2
Mr POH, an 88-year-old single gentleman, was referred to our team by his GP. The reason for referral was memory loss and to assess fitness to drive. He was assessed by our team on a domiciliary visit. On interview, the patient admitted to having memory loss and said that he has been forgetful for the previous year. He also complained of initial insomnia, low energy and some loss of interest but had good appetite, no death wish and no psychotic features.

He had no significant past medical history, no past psychiatric history and no family history of psychiatric illness or dementia. He had mobility problems and had been mobilising using a walking stick.

All patients should be advised that even mild problems with memory may be associated with impaired reaction times

On collateral history from his sister, who was living with him for the past 40 years, she said that she had noted a gradual deterioration in his memory over the past few years and he had become even more forgetful. His concentration had been very poor and he repeated things. He also forgot names and had burned things after leaving them on the stove.

On mental state examination, he was a pleasant man, having nominal aphasia. His mood was euthymic and he had no psychotic features. On the MMSE, he scored 13/30, losing seven points on orientation, all three on short-term recall and some deficits on other domains as well. He scored 2/3 on the clock-drawing test.

Based on the clinical assessment and cognitive testing, we made a provisional diagnosis of Alzheimer’s dementia. We did a CT brain scan and dementia screen bloods to rule out any treatable causes of dementia. The result of the scan showed findings consistent with atrophic changes. We commenced him on donepezil and referred him to the team social worker for help to maximise supports in the community.

The occupational therapist assessed his cognitive skills with regard to driving using the CLQT, which showed severe impairment in all the five domains of the test. We communicated the diagnosis and findings to the GP, the patient and his sister and advised that the patient stop driving immediately.

Driving issues
Although many people with dementia are capable of driving safely, dementia is an important diagnosis in relation to driving. As the disease progresses, the ability to drive safely is eventually lost and it is important that driving stops at this point. The doctor’s role is to diagnose the condition and provide as much information as possible and to ensure safe driving for as long as possible.

In addition, the doctor should make an immediate decision on safety issues if they arise and ensure that the driving stops when necessary.

Unfortunately, there are as of yet no regulations in Ireland under which the driving licensing authority can be notified so that the licence can be revoked.

In Ireland, only a district judge can remove a driving licence and while theoretically this is an option, in practice the person with dementia who persists in driving when clearly hazardous may be oblivious to the need for a driving licence.

As the incidence of dementia is on the rise, and the cost to the State is also rising, it is important to diagnose this condition as early as possible and supply information and supports to the families and carers in relation to maintaining safe driving.

Old-age psychiatry services
We are a relatively new Old-Age Psychiatry Team in the East Galway Mental Health Services, as we started in June 2009. We carry out joint assessments at the patient’s residence after we get a referral from the GP/other doctor. Usually, the doctor takes a full history from the patient, takes a collateral history, performs cognitive tests like the MMSE, clock-drawing test and Montreal Objective Cognitive Assessment Test in certain instances, while the community nurse concentrates on the functional and social assessment and further collateral history.

After the initial assessment, we usually request a full dementia screen and a CT brain scan to rule out any organic cause for the cognitive impairment (if these are not already done). In cases where patients are diagnosed with dementia and there is a concern about driving, the occupational therapist carries out further driving assessment using the CLQT.

The CLQT assesses five cognitive domains and when scored, provides a severity rating (from normal to severe impairment) for each subtest, including attention, memory, executive functions, language and visuospatial skills. We do not have a psychologist on our team at present.

All patients should be advised that even mild problems with memory may be associated with impaired reaction times. Enquiries should be made about recent accidents, getting lost, near misses, slower or faster driving and minor scrapes when manoeuvring. The occurrence of such events may increase the urgency of advice to limit or stop driving. Family should be involved in the discussion since they may need to take an active role in preventing driving and providing alternative transport. Recommendations to have an on-road driving assessment if such a facility is available often helps. The patient and family should be advised that insurance may be invalid if the patient continues to drive against medical advice.

Different strategies can be worth considering if it becomes necessary to prevent someone from driving if they cannot be easily persuaded that it is no longer safe for them to do so. The Alzheimer’s Society of Ireland has made certain recommendations in this regard:
• Suggest that taxi or public transport may be more convenient;
•    Hide the car keys;
•    Immobilise the car by removing the main distributor lead and tucking it away inside the engine;
•    Suggest that you drive the car when together because you need the practice;
•    Replace the car with a new one that is a different model and colour;
•    Sell the car.

As the incidence of dementia is increasing and as estimated, is likely to double every 20 years, it is important to diagnose the condition early and provide much-needed information and support to the patients and carers.

With regard to driving, the aim should be to balance safety with as much freedom as possible and ensure safe driving for as long as possible. However, the doctor should make an immediate decision on safety issues and, if they arise, ensure that the driving stops.

• Dr Abdul Nasir Khalil, Registrar in Old Age Psychiatry and
• Dr Sabina Fahy, Clinical Tutor and Consultant in Old Age Psychiatry, East Galway Mental Health Services, Ballinasloe, Co Galway.

A new study has for the first time in humans linked levels of leptin, a hormone produced by fat cells, with symptoms of depression and anxiety, independent of weight.

The study, published in the journal Clinical Endocrinology, suggests that leptin levels may be related to depressive and anxiety symptoms in women, regardless of weight or body fat.

A team led by Dr Elizabeth Lawson from Harvard Medical School and Massachusetts General Hospital studied 64 women in four groups: 15 with anorexia nervosa, 20 normal weight and healthy, 17 overweight or obese, and 12 normal weight with hypothalamic amenorrhoea (women with this condition do not menstruate and have low leptin levels, but unlike anorexic women, their fat levels do not differ from healthy controls).

They measured fasting blood leptin levels along with weight and total body fat, and administered tests for depression and anxiety symptoms and also levels of experienced stress (HAM-D, HAM-A and Perceived Stress Scale respectively; higher scores signify increased symptoms).

Women with lower symptoms of depression and anxiety exhibited higher leptin levels and vice-versa. HAM-D and HAM-A scores across the groups were negatively correlated with leptin levels (HAM-D: r = -0.43, P = 0.0004; HAM-A: r = -0.34, P = 0.006). This remained significant after controlling for both fat mass and body weight. Perceived Stress Scale scores were also negatively correlated with leptin levels (r = -0.35, P = 0.007), although this did not remain significant after controlling for fat mass or body weight. Women in all groups who scored above eight (a standard cutoff signifying depression) on the HAM-D score exhibited lower leptin levels than those scoring below the cutoff. This also remained significant after controlling for fat mass and body weight.

The authors wrote: “Our findings place leptin on a growing list of hormones that are correlated with psychiatric symptoms. Whether leptin influences depression or vice versa… needs to be investigated.”

Clinical Endocrinology doi: 10.1111/j.1365-2265.2011.04182.x