Catatonia in an inpatient gerontopsychiatric population

There are limited data on the prevalence of catatonia in the elderly. The aim of this study was to determine the prevalence of catatonia in elderly patients (=/> 65 years) acutely admitted to the psychiatric unit of a general hospital. All patients aged 65 years and above admitted to a general hospital psychiatric unit over a 4-month period were screened for catatonia with the 14-item Bush-Francis Catatonia Screening Instrument (BFCSI). Patients with a minimum of 2 symptoms on the BFCSI were rated with the 23-item Bush-Francis Catatonia Rating Scale (BFCRS). Catatonia was simultaneously evaluated according to DSM-5 criteria. Clinical diagnoses were established using the validated Hungarian versions of the Structured Clinical Interview for DSM-IV Disorders, the Mini Mental State Examination and the Clock Drawing Test. Ninety-eight (28.1%) of the 342 patients admitted to the psychiatric unit during the study period were above 65 years of age; 11 (11.22%) and 6 (6.12%) patients were classified as having catatonia according to the BFCRS and DSM-5 criteria, respectively. The majority of the patients had catatonia due to a medical condition. A significant minority of gerontopsychiatric inpatients present with catatonia. Dementia was not a risk factor for catatonia.

Use of Electroconvulsive Therapy in Central-Eastern European Countries: an Overview

Though a number of reports on the use of electroconvulsive therapy (ECT) has been published from the Central-Eastern European region over the past two decades, a systematic review of this literature has not been published. Thus the aim of this paper was to review recent trends in ECT practice in Central-Eastern Europe. Systematic literature search was undertaken using the Medline, PSYCHINFO and EMBASE databases covering the period between January 2000 and December 2013. Relevant publications were found from the following countries: Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Serbia, Slovakia, Ukraine, but none from Albania and Moldova. ECT practice in the region shows a heterogeneous picture in terms of utilization rate, main indications, and the technical parameters of application. On one end of the spectrum is Slovakia where the majority of psychiatric facilities offer ECT, on the other end is Slovenia, where ECT is banned. In about half of the countries schizophrenia is the main indication for ECT. In Ukraine, unmodified ECT is still in use. Clinical training is generally lacking in the region and only 3 countries have a national ECT protocol. Possible ways of improving ECT practice in the region are briefly discussed.

Observing Electroconvulsive Therapy Changes Students' Attitudes: A Survey of Croatian Medical Students

AIM

To assess the impact of education and direct observation of electroconvulsive therapy (ECT) on medical students' attitudes toward ECT in particular and psychiatric treatment in general in Croatia.

METHOD

Two self-administered questionnaires were completed by year 4 medical students twice, at the beginning and the end of the psychiatry clerkship. Students were divided into 2 groups: those who observed an ECT session (47.9%) and those who did not (52.1%).

RESULTS

The survey was completed by 190 students yielding a response rate of 79.8%. Students' attitudes toward ECT and other methods of psychiatric treatment and psychiatry in general changed in positive direction after the clerkship in both groups. However, the attitudes toward ECT of students who observed a live ECT session became more positive than those who did not. Likewise, students who observed ECT were more likely to agree to receive ECT and had better knowledge about ECT compared with the other group.

CONCLUSIONS

Having watched a live ECT session had a positive effect on students' attitudes toward ECT and other types of psychiatric treatment. Watching live ECT sessions should be mandatory during the psychiatric clerkship.

Predictive value of psychosocial assessment for the mortality of patients waiting for liver transplantation

Selecting suitable candidates for liver transplantation is the most challenging task of pre-transplant evaluation. In addition to somatic assessment, psychosocial evaluation has been proven important in identifying patients at high risk of potential failure. The Transplant Evaluation Rating Scale (TERS) is a widely used rating instrument for the assessment of psychosocial risk factors before liver transplantation. The aim of this study was to explore the predictive value of TERS for mortality in liver transplant patients before and after transplantation. The medical records of patients referred for psychiatric evaluation before liver transplantation between 2003 -2013 were analysed. Administering TERS was part of the pre-transplant evaluation. The TERS scores of patients who died before and after transplantation were compared with those who survived following transplantation. One hundred and sixteen patients were referred for pre-transplant psychiatric evaluation. Patients with successful liver transplants scored significantly lower on TERS than those who died before transplantation (30.65 ± 6.06 vs. 34.75 ± 8.25, p = .031). Patients who died after transplantation scored significantly better on TERS than those who died before transplantation (28.79 ± 2.81 vs. 34.75 ± 8.25, p = .003). There was no significant difference between the deceased and surviving transplanted patients' TERS scores (28.79 ± 2.81 vs. 31.19 ± 6.66, p = .365). TERS appears to be a suitable rating instrument to help select candidates who have higher chance to survive prior to transplantation but it could not predict post-transplant mortality.

Catatonia in disulfiram intoxication - a case report and a brief overview of the literature

Catatonic syndromes could accompany a variety of psychiatric and medical conditions. The most common conditions underlying catatonia are affective disorders followed by schizophrenia, but several medical conditions including intoxications affecting the central nervous system can also present with catatonic signs and symptoms. Therapeutic doses of disulfiram could induce catatonia with or without accompanying psychosis or mood disorder. A case of disulfiram intoxication manifesting with catatonia is reported here together with a brief overview of the literature. A patient was admitted to the toxicology ward after a suicide attempt with approximately 20 g of disulfiram. On transfer to the psychiatric ward, she was sitting still, in a semi-stuporous state and displayed motiveless resistance to instructions or attempts to move (active negativism). She was unresponsive to most of the questions (mutism), occasionally verbigerated 1-2 words and stared for more than 20 seconds between shifting attention. After developing a comatosus state her treatment continued at the toxicology ward, where a contrast-enhanced computer tomography scan revealed bilateral emollition of 1.5 cm diameter in both nucleus lentiformis at the level of the third ventricle. Following treatment her condition improved and she benefited of rehabilitation facility and a second psychiatric treatment. She was discharged free of neurological and psychiatric symptoms. In conclusion, we underscore the importance of accurate diagnosis of the underlying psychiatric or medical condition when encountering a fast emerging catatonic syndrome and focus first on treating the causative condition while simultaneously attempting symptomatic treatment of catatonia.

Predictors of suicide attempts after violent offences in schizophrenia spectrum disorders

The aim of this survey was to identify predictors of suicide attempts that immediately followed a violent crime in patients with schizophrenia. Documentations of patients diagnosed with schizophrenia and released in a 10 years period from the National Institute of Forensic Psychiatry were reviewed. Twenty-six out of 223 patients attempted suicide after the violent crime. The young age of the victim, and living in partnership were those factors differentiating suicidal violent offenders from their non-suicidal counterparts.

Reasons for acute psychiatric admission of patients with dementia

INTRODUCTION

The estimated number of patients living with dementia in Hungary is between 150,000 and 300,000. Hungary's prevalence of vascular dementia is much higher than that of other countries. Patients with dementia can be admitted to psychiatric hospitals for several reasons, the least common of which is cognitive decline. Comorbid psychiatric disorders or dementia-related behavioral disturbances are much more common reasons.

AIM

To examine the reasons for the acute psychiatric admission of patients suffering from dementia in a psychiatric center in Budapest.

MATERIALS AND METHODS

In this retrospective survey the data of dementia patients who were referred to the Centre for Psychiatry and Addiction Medicine (CPAM) at Szent István and Szent László Hospitals between August 1 and October 31, 2014 were analyzed with special attention paid to the reasons for hospitalization.

RESULTS

Altogether 302 patients were admitted to the CPAM over the study period and 26.15% of them suffered from dementia. The distribution of dementia subtypes was as follows: 43% mixed type (vascular and neurodegenerative), 40.5% vascular type, 11.4% Alzheimer's disease, and 5.1% other types. A small percentage (12.7%) of patients had mild dementia, while 34.2% and 53.2% suffered from moderate and severe dementia, respectively. The major causes of hospitalization were aggressive behavior (34.2%), delirium (19%), and divagation and confusion 15.2% each. They were mainly associated with moderate and severe dementia. Suicide attempt was the reason for admission in 10.1% of cases, and delusions in 6.3%. With regard to admission outcome, 44.3% of patients were transferred to a medical ward, 12% within 3 days of psychiatric admission. Nearly 9% of patients required extended hospitalization, 21.5% were discharged home, 20.3% were transferred to a nursing home and 5.1% died while in hospital. More than half of the patients were rated on the CGI-C scale; 59% of them scored 2 points (much improved), 25% scored 1 point (very much improved) and 16% scored 3 points (moderate improvement).

DISCUSSION

A high proportion of dementia patients acutely admitted to a psychiatric ward was medically compromised and either died soon after admission (5%) or was transferred to a medical ward for further treatment. This highlights the importance of a thorough medical work-up including physical examination and laboratory investigations for dementia patients requiring acute psychiatric admission. It is of note that only a small number of patients could be discharged home or to a nursing home. These figures underscore the need for more nursing home places and a better functioning social care system in this field.

DO PREVIOUS OFFENCES PREDICT VIOLENT ACTS IN PSYCHIATRIC PATIENTS? A RETROSPECTIVE STUDY IN HUNGARY

AIM

To investigate the presence of offences in the previous past history of perpetrators of violent acts who have undergone forced medical treatment.

METHODS

The documentation of all patients released over a 10-year period from the National Institute of Forensic Psychiatry (IMEI) was reviewed. A comparison was drawn between patients who were convicted of any type of offense before the violent act (patients with previous offences-PPO) and those who were not (patients with no previous offences-PNO).

RESULTS

Eighty-six (29%) and 208 (71%) patients formed the PPO and PNO groups, respectively. Prior contact with psychiatric services was significantly higher in the PPO group (p=0.038) and this group was also more likely to offend under the influence of a psychoactive substance (p<0.001). Exceptional brutality and other qualifying factors were more frequent in the PNO group (p=0.019).

CONCLUSION

As IMEI is the only forensic institution in Hungary, the picture presented here reflects the situation in the entire country. A recidivism rate of 29% is within the internationally published range.

[Prevalence of psychiatric disorders in homeless population]

BACKGROUND

Prevalence of psychiatric disorders in homeless population is high and it can increase the risk of criminal behavior. In Hungary no systematic study was performed in this field until this time. This study aimed to survey the prevalence rate of psychiatric disorders among people living in homeless shelters and explore its correlations with demographic variables. Investigating the correlation between psychiatric disorders and criminal behavior was also among the aims of the study.

METHODS

Data concerning medical and forensic history was collected in a structured interview and then SCID-I and SCID-II diagnostic interview was performed in voluntary persons living in 3 homeless shelters.

RESULTS

Eighty-six percent of the sample had a diagnosable psychiatric disorder. Personality disorder and alcohol dependence were the most common diagnoses in males, while personality disorder and anxiety disorders were the most common diagnoses in females. Comorbid conditions were present in 72% of the cases. Only 37% of those who had a DSM diagnosis were currently in psychiatric care. The lowest rate was found in patients with major depression (31%). Only drug and psychopharmacon dependence showed significant correlation (p=0.023 and p=0.024) with violent and non-violent offending out of the diagnostic subgroups.

CONCLUSIONS

Prevalence of severe mental disorders among homeless persons is high in Hungary too. Low rate of homeless persons being in psychiatric care indicates that traditional structure of care is not suitable for them, they need a tailored complex approach. This survey confirmed that criminal behavior is not more frequent among those homeless persons who have psychiatric disorders neither in terms of violent nor in non-violent acts except those having drug or psychopharmacon dependence.

[Psychiatric aspects of infectious diseases -- a literature review]

It is essential for the psychiatrist working in the consultation-liaison field or with comorbid patients to be familiar with the psychiatric aspects of central nervous infectious diseases or infectious diseases with psychiatric symptoms. Authors have reviewed the most important psychiatric aspects of common infectious diseases. Essential knowledge for setting up a diagnosis and starting appropriate treatment has been summarized. The most important interactions of infectological and psychiatric treatments have also been discussed.

[Neurocognitive impairments of HIV infected individuals -- preliminary results of a national prevalence study in Hungary]

BACKGROUND and

PURPOSE

The outcome of HIV infection has dramatically improved due to the widespread use of combined antiretroviral therapy (cART). Opportunistic infections faded and internal and hemato-oncological diseases along with neurological conditions came to the forth. Present study is to evaluate neurocognitive performance of the Hungarian HIV infected individuals, at first in this setting. PATIENTS and

METHODS

We performed this cross-sectional pilot study within the frames of a national, single-center; prospective study on group of HIV infected patients, analyzing medical data and neurocognitive performance. Based on international recommendations visual memory, visuomotor coordination, non-verbal learning ability, executive functions and reaction time were tested by six domains of a computerized neuropsychological test battery (Vienna Test System).

RESULTS

Data of 59 enrolled HIV individuals were analysed; nine of whom were women (15%), median age 42.6 (IQR: 32.4-48.1) years. In 32.2% (n=19) of patients neurocognitive impairment was detected. Duration of infection and cART treatment time tended to be longer in impaired group (not significant). Lower CD4 cell count at the time of examination (p=0.047), psychiatric diseases other than depression (p=0.005) were found significantly associated with impairment; tertiary education qualification were more common (p=0.033) among non-affected patients. By correlation analysis age, infected time and duration of cART were significantly associated with motor deficit.

CONCLUSION

HAND was detected in almost one third part of examined patients, which largely corresponds that in developed countries were observed. Duration of infection and of cART therapy associated motor deficit was found to be the most common impairment. This finding might be interpreted by direct effect of HIV, neurotoxicity of antiretro virals and also by accelerated ageing of this population.

Electroconvulsive therapy practice in Ukraine

BACKGROUND

Patterns of electroconvulsive therapy (ECT) use have recently been extensively surveyed in Central-Eastern Europe. However, data from post-USSR countries are limited.

OBJECTIVE

This study aimed to survey ECT practice in Ukraine.

METHODS

All psychiatric services in Ukraine were identified and contacted to obtain information on the use of ECT in 2011 using a 22-item questionnaire.

RESULTS

Of the 146 psychiatric inpatient facilities, only 5 confirmed that they performed ECT in 2011. Three other services also performed ECT but refused to provide further information. In the only private psychiatric institute where ECT was offered, 14.28% of inpatients received this treatment in 2011, whereas the corresponding figure in the 6 public psychiatric facilities was a mere 0.4%. Three centers used unmodified ECT, and only 2 centers had equipment that monitored electroencephalogram. In 7 services, in line with international recommendations, affective disorders were the first indications for ECT in Ukraine, whereas uncommon indications such as anorexia or Parkinsonism were also reported.

CONCLUSIONS

This was the first survey of ECT practice conducted in Ukraine. The provision of ECT in only 8 centers is clearly insufficient for a large country such as Ukraine, which is reflected in the low rate of inpatients treated with ECT. The very limited availability of this effective treatment modality should be addressed by the Ukrainian health authorities.

Hepatitis C virus infection epidemiology among people who inject drugs in Europe: a systematic review of data for scaling up treatment and prevention

BACKGROUND

People who inject drugs (PWID) are a key population affected by hepatitis C virus (HCV). Treatment options are improving and may enhance prevention; however access for PWID may be poor. The availability in the literature of information on seven main topic areas (incidence, chronicity, genotypes, HIV co-infection, diagnosis and treatment uptake, and burden of disease) to guide HCV treatment and prevention scale-up for PWID in the 27 countries of the European Union is systematically reviewed.

METHODS AND FINDINGS

We searched MEDLINE, EMBASE and Cochrane Library for publications between 1 January 2000 and 31 December 2012, with a search strategy of general keywords regarding viral hepatitis, substance abuse and geographic scope, as well as topic-specific keywords. Additional articles were found through structured email consultations with a large European expert network. Data availability was highly variable and important limitations existed in comparability and representativeness. Nine of 27 countries had data on HCV incidence among PWID, which was often high (2.7-66/100 person-years, median 13, Interquartile range (IQR) 8.7-28). Most common HCV genotypes were G1 and G3; however, G4 may be increasing, while the proportion of traditionally 'difficult to treat' genotypes (G1+G4) showed large variation (median 53, IQR 43-62). Twelve countries reported on HCV chronicity (median 72, IQR 64-81) and 22 on HIV prevalence in HCV-infected PWID (median 3.9%, IQR 0.2-28). Undiagnosed infection, assessed in five countries, was high (median 49%, IQR 38-64), while of those diagnosed, the proportion entering treatment was low (median 9.5%, IQR 3.5-15). Burden of disease, where assessed, was high and will rise in the next decade.

CONCLUSION

Key data on HCV epidemiology, care and disease burden among PWID in Europe are sparse but suggest many undiagnosed infections and poor treatment uptake. Stronger efforts are needed to improve data availability to guide an increase in HCV treatment among PWID.

Use of electroconvulsive therapy in the Baltic states

OBJECTIVES

While the use of electroconvulsive therapy (ECT) has been investigated worldwide, nothing is known about its use in the Baltic states. The purpose of this study was thus to explore ECT practice in the three Baltic countries.

METHODS

A 21-item, semi-structured questionnaire was sent out to all psychiatric inpatient settings that provided ECT in 2010.

RESULTS

In Lithuania, four services provided ECT in 2010. Only modified ECT with anaesthesia and muscle relaxation is performed in the country. In 2010, approximately 120 patients received ECT, i.e., 0.375 patients/10,000 population. Only two centres offer ECT in Latvia. The first centre treated only three patients with ECT in 2010, while the second centre six patients. In both centres outdated Soviet machines are used. The main indication for ECT was severe, malignant catatonia. ECT is practiced in five psychiatric facilities in Estonia. In 2010, it was used in the treatment of 362 patients (17% women) nationwide, i.e., 2.78 patients/10,000 population. Only a senior psychiatrist may indicate ECT in Estonia and pregnancy is no contraindication. In 2010, the main indication for ECT was schizophrenia (47.8%).

CONCLUSIONS

This 2010 survey revealed significant differences in the use and availability of ECT between the Baltic countries.

Electroconvulsive therapy practice in Serbia today

This is the first survey of the practice of electroconvulsive therapy (ECT) in the Republic of Serbia. A retrospective chart review was undertaken including all patients having received ECT in Serbia in 2012. Only one center in Serbia offered ECT in 2012 to a total of 54 patients (54% women). Thirty-six (36) patients received acute ECT treatment and eighteen (18) patients maintenance ECT, yielding a ECT utilization rate of 0.05/100.000 population. ECT was delivered with a modern square-wave (brief pulse) machine with EEG and ECG monitoring. In all cases the electrode placement was bifrontal and treatment modified (with anesthesia). The most frequent indication was recurrent depressive disorder (66.7%) for both acute and maintenance treatment. The limited availability of ECT in Serbia raises serious concerns. Provision of updated and effective treatment modalities for severe psychiatric disorders is crucial and the need for additional ECT services in Serbia is urgent.

Lamotrigine in the treatment of psychotic depression associated with hereditary coproporphyria -- case report and a brief review of the literature

OBJECTIVE

We report a successful treatment with lamotrigine of a patient with hereditary coproporphyria presenting with affective and psychotic symptoms.

CASE REPORT

M.F., a 38-year-old, single woman was admitted to an acute psychiatric ward because of suddenly emerging psychosis. Ms F's hereditary coproporphyria was diagnosed 9 years before the current admission. While on treatment with olanzapine (20mg/day) the psychotic symptoms have gradually disappeared. In view of her significant mood fluctuations predominantly with depressed phases, lamotrigine was started and titrated up to 125 mg/day. Ms F's mood gradually became euthymic, suicidal ideations and anxiety disappeared. At 5-month follow-up, while still on lamotrigine, her porphyria was asymptomatic.

CONCLUSION

To the best of our knowledge, this is the first report about the safe administration of lamotrigine in hereditary coproporphyria. Lamotrigine did not trigger an acute porphyric attack as confirmed by clinical and laboratory findings.

A clinical review of the treatment of catatonia

Catatonia is a severe motor syndrome with an estimated prevalence among psychiatric inpatients of about 10%. At times, it is life-threatening especially in its malignant form when complicated by fever and autonomic disturbances. Catatonia can accompany many different psychiatric illnesses and somatic diseases. In order to recognize the catatonic syndrome, apart from thorough and repeated observation, a clinical examination is needed. A screening instrument, such as the Bush-Francis Catatonia Rating Scale, can guide the clinician through the neuropsychiatric examination. Although severe and life-threatening, catatonia has a good prognosis. Research on the treatment of catatonia is scarce, but there is overwhelming clinical evidence of the efficacy of benzodiazepines, such as lorazepam, and electroconvulsive therapy.

Electroconvulsive therapy in a Hungarian academic centre (1999-2010)

BACKGROUND

Since the 1930s, the Department of Psychiatry and Psychotherapy at Semmelweis University (DPPSU) in Budapest has played a leading role in convulsive therapy in Hungary. The aim of this study was to describe the pattern of ECT use at the DPPSU over an 11-year period.

SUBJECTS AND METHODS

Analysis of the medical notes of all patients treated with ECT in this academic centre between 1999 and 2009.

RESULTS

During the study period, 28,230 patients were admitted to the DPPSU, of whom 457 (1.6%) received ECT. More than 50% of patients receiving ECT were diagnosed with schizophrenia. The percentage of female patients receiving ECT significantly exceeded that of the male patients, above what was expected in view of the diagnostic mix.

CONCLUSION

The data indicate that in the first decade of the 21(th) century, ECT use shows a declining tendency in this Hungarian academic centre. The mean number of treatment sessions was relatively low and nearly the same across diagnostic groups. ECT was mainly used as a last resort for treatment-resistant patients. In the majority of cases, bifronto-temporal brief pulse stimulation was applied. Seizures were monitored with EEG and EMG.

When do psychiatric side effects emerge during antiviral treatment of hepatitis C?

BACKGROUND

This retrospective study aimed to determine the time-frame regarding the first appearance of psychiatric side effects in the course of antiviral treatment and the subsequent referral to consultation-liaison psychiatric services.

SUBJECTS AND METHODS

Medical records of patients receiving combined antiviral treatment with alpha interferon and ribavirin for hepatitis C at a hepatology outpatient clinic and referred to psychiatric consultation between April 2000 and July 2011 were scrutinized.

RESULTS

Time between the initiation of antiviral treatment and the first appearance of psychiatric symptoms was 10.64±10.68 weeks. Patients were referred to psychiatric examination 16.1±12.7 weeks after antiviral treatment had been commenced. The time frame of the emergence of psychiatric symptoms and the referral for psychiatric consultation did not correlate with the patients' age or sex. No relationship between substance/alcohol abuse and psychiatric history and the timing of psychiatric side effects and their assessment were found.

CONCLUSIONS

This study confirmed that psychiatric side effects appear late in the course of combined antiviral treatment arising after 10.64±10.68 weeks the treatment started. The results also showed that some patients' psychiatric symptoms appeared immediately after the beginning of the antiviral therapy. This finding underlines the importance of monitoring patients' psychiatric condition as soon as antiviral treatment commences.

[Antidepressant treatment associated hyponatremia -- case report]

Hyponatremia is a potential side-effect of antidepressants that was observed most frequently in connection with compounds acting on the serotonin system. Risk of hyponatremia was found to be higher in the elderly. Authors report a case of a 65-year old male patient who was treated with venlafaxine-mirtazapine combination for recurrent depression. Severe hyponatremia, requiring intensive care, emerged in connection with the treatment. The authors emphasize the importance of the regular checking of serum sodium levels during antidepressant treatment, especially in elderly patients.