Some observations on psychiatric research

Principles of sound research design are too often incompletely applied in scientific investigations. Physicians may fail to evaluate journal articles for quality of research, comparability among studies, and clinical relevance. For many investigators quick publishable experiments take precedence over those with rigorous methods. Clinicians and researchers are becoming more aware of these concerns. Students should be taught the skills necessary to interpret scientific reading. Greater attention should be given to correct research design, and authors should fully explain both the procedures of a study, and its relevance. Fewer published articles and more review papers or commentaries might also stimulate better research quality.

Recognition and treatment of rabbit syndrome, an uncommon complication of neuroleptic therapies

Rabbit syndrome is an uncommon, tongue-sparing, orofacial movement disturbance, rapid and regular in nature and associated with prolonged use of neuroleptics. Two cases reports illustrate how anticholinergic agents successfully treat the disorder. The syndrome is distinguished from tardive dyskinesia, which tends to be exacerbated by anticholinergic agents.

Alcohol abuse and attention deficit disorder

The prevalence of alcohol abuse among the fathers, and ADD in family members, of 22 adult psychiatric patients with persistent attention deficit disorder was found to be significantly higher than in 20 matched controls. Further research is necessary to determine the reasons for, and clinical implications of, these associations.

Toxoplasma encephalitis in Haitian adults with acquired immunodeficiency syndrome: a clinical-pathologic-CT correlation

The clinical data, histologic findings, and computed tomographic (CT) abnormalities in eight adult Haitians with toxoplasma encephalitis were analyzed retrospectively. Diagnosis was established by identification of Toxoplasma gondii on autopsy in five and brain biopsy in three specimens and subsequently confirmed by the immunoperoxidase method. All these patients, six of whom had been in the United States for 24 months or less, had severe idiopathic immunodeficiency syndrome. All were lymphopenic and six were on treatment for tuberculosis when the toxoplasma encephalitis developed. All patients were studied with CT when they developed an altered mental status and fever associated with seizures and/or focal neurologic deficits. Scans before treatment showed multiple intraparenchymal lesions in seven and a single lesion in the thalamus in one. Ring and/or nodular enhancement of the lesions was found in six and hypodense areas in two. Progression of abnormalities occurred on serial studies. These CT findings that were best shown on axial and coronal thin-section double-dose contrast studies were useful but not diagnostically pathognomonic. In patients with similar clinical presentation CT is recommended to identify focal areas of involvement and to guide brain biopsy or excision so that prompt medical therapy of this often lethal infection can be instituted.

Psychiatric presentations of hyperthyroidism

Hyperthyroidism is often confused with psychiatric illnesses. Undiagnosed hyperthyroidism sometimes results in inappropriate use of psychotropic medications. Delay in therapy markedly worsens the prognosis for recovery, but complications can be prevented by early treatment. Prompt recognition of hyperthyroidism through thyroid function screening is good medical practice in the evaluation of patients with psychiatric symptoms.

Drug therapy for depression in the elderly

Depression is common in the geriatric population, but recovery rates are gratifying. Safe treatment requires attention to the effects of aging on pharmacokinetics and close monitoring. Antidepressants are the drugs most commonly used; to the standard tricyclic drugs have now been added a tetracyclic and a triazolopyridine. Monoamine oxidase inhibitors and lithium are second-choice options; a benzodiazepine is not generally required. Dosages should be lower than conventionally prescribed. Side effects of antidepressant drugs are common, the most important being slowing of cardiac conduction times and the most common being anticholinergic manifestations, such as dry mouth and tachycardia. Some of the more recently introduced antidepressants may have more advantageous side-effect profiles than the older agents.

Combined trimipramine/phenelzine treatment of depression: case report

Trimipramine was found safe, effective, and free of complications when used in combination with the MAOI phenelzine in the treatment of a case of refractory depression. Trimipramine co-administration with phenelzine may be an efficacious alternative pharmacotherapy for selected cases when synergistic antidepressant therapies are indicated.

Antidepressant pharmacotherapy

Antidepressant drugs are indicated for prolonged depression accompanied by the typical physiologic dysfunctions. They are not recommended for grief reactions. Suicide potential is actively monitored. Pregnancy requires special attention. The most significant risks of antidepressant therapy are cardiac conduction prolongation and anticholinergic effects. Overdoses are dangerous. Antidepressants are prescribed only after a careful work-up, and therapy is continued in a supervised manner with close observation for side effects.

Is lithium bad for the kidneys?

Lithium alters renal physiology (e.g. polyuria) and is nephrotoxic in severe intoxications. With proper precautions, lithium was otherwise presumed safe through the mid-1970's. In 1977, the controversial question arose whether lithium may induce a chronic renal disease documented by biopsy. Later, similar lesions were demonstrated in affective disturbance patients never exposed to lithium. The possible role of lithium as an inducer of kidney damage is undetermined; but concern for the kidney in lithium patients is expressed. Better pre-lithium patient selection and renal work-up, lower serum lithium levels, and closer clinical and laboratory follow-up are advised.

Lithium's effects on the kidney

Although lithium was known to cause changes in renal physiology, it was considered safe until reports in late 1977 suggested that it may induce chronic irreversible nephropathy. Later reports documented similar lesions in non-lithium-treated patients with affective disturbances. Thus, the data are inconclusive. Concern for the kidney during lithium therapy is now greater than it was originally, but confidence in lithium's safety is higher than it has been for the past four years. Physician appreciation of the foregoing factors, careful patient selection, and informed consent are important in lithium therapy. An understanding of lithium use in patients in a low-sodium state or on diuretic therapy and avoidance and treatment of lithium intoxication are advocated. Good prelithium workups and closer monitoring of patients on long-term lithium therapy are recommended.