Pseudotumour cerebri, CSF rhinorrhoea and the role of venous sinus stenting in treatment

We present a case of pseudotumour cerebri (PTC), which is important as it illustrates the effects of chronically raised CSF pressure, the relationship between PTC and venous sinus obstruction and the successful treatment of PTC using a venous sinus stent. A 38-year-old woman, previously diagnosed with PTC and unsuccessfully treated 10 years previously re-presented with spontaneous CSF rhinorrhoea. Imaging revealed dramatic changes of chronically raised CSF pressure and a defect in the anterior cranial fossa. The CSF leak was corrected surgically and a lumbo-peritoneal shunt inserted to correct a large postoperative subgaleal CSF collection. Direct retrograde cerebral venography (DRCV) demonstrated venous sinus obstruction due to a filling defect. This was associated with a pressure gradient and a high superior sagittal sinus pressure. The venous sinus obstruction was successfully treated with a venous sinus stent and the lumbo-peritoneal shunt was removed. Chronically raised CSF pressure in untreated cases of PTC may cause widespread changes in the skull, which in this case, culminated in a spontaneous CSF leak despite relatively mild headache and visual symptoms. Furthermore, cases of PTC secondary to venous sinus obstruction may be successfully treated using venous sinus stenting. The index of suspicion for venous sinus stenosis or obstruction should be raised in the investigation of patients with PTC.

Differential effectiveness of newer and older antidepressants appears mediated by an age effect on the phenotypic expression of depression

OBJECTIVE

A possible mechanism whereby the serotonin reuptake inhibitor (SSRI) antidepressants may not (overall) be as effective as the tricyclic (TCA) antidepressants is explored.

METHOD

Clinical psychiatrists rated the effectiveness of past antidepressant medications in a clinical panel study of patients with a major depressive disorder, with 200 having previously received a TCA and 219 an SSRI.

RESULTS

Analyses indicated decreased SSRI effectiveness with age in those with the melancholic subtype. TCA effectiveness appeared uninfluenced by age and depressive subtype.

CONCLUSION

Findings suggest why the broader-based TCAs may be more effective than the SSRIs in implicating age and depressive subtype influences.

Gender differences in depression risk and coping factors in a clinical sample

OBJECTIVE

To examine gender differences in depression risk and coping factors in a clinical sample of patients with a diagnosis of DSM-IV major depression.

METHOD

Patients were assessed for substance use and abuse, family history of psychiatric disorder, interpersonal depressogenic factors and lifetime history of anxiety disorders. Trait anxiety, coping styles when depressed, parental bonding, marital features and personality style were also measured. Patients were reassessed at 12-month follow-up.

RESULTS

There were few gender differences in experience of depression (either in duration, type or severity prior to treatment) in a group with established episodes of major depression but women reported more emotional arousability when depressed. Women reported higher rates of dysfunctional parenting and childhood sexual abuse, and rated their partners as less caring and as more likely to be a depressogenic stressor. Men were more likely to have a generalized anxiety disorder at assessment, to use recreational drugs prior to presentation. Men were rated as having a more rigid personality style and 'Cluster A' personality traits both at assessment and follow-up.

CONCLUSION

There were few gender differences in severity or course of established episodes of major depression. Gender differences were related to levels of arousal, anxiety disorders, and repertoires for dealing with depression, rather than depressive symptoms per se.

Examining the utility of a temperament model for modelling non-melancholic depression

OBJECTIVE

Depression is currently modelled dimensionally, along severity, duration and recurrency dimensions. An alternative model allows dimensional expressions of temperament and personality to influence risk to onset as well as persistence. Here, we examine the utility of a temperament model.

METHOD

A questionnaire assessing temperament dimensions and a number of depression variables was administered to a large routine general practice sample and with the temperament measure also completed by a small clinical sample.

RESULTS

'Anxious worrying' and 'irritable' dimensions were identified as internalizing and externalizing expressions of a trait anxiety dimension, three other 'temperament' dimensions (i.e. 'introversion', 'self-centred' and 'obsessive') were refined, while a 'self-blame' dimension intruded into the factor analytic solution. High scores on the 'anxious worrying' dimension were associated with all depression parameters. The 'irritable', 'introversion' and 'self-blame' dimensions were less clearly linked with depression variables, while higher scores on the 'self-centred' and 'obsessional' dimensions did not appear to increase the chance of depression onset, persistence or recourse to treatment.

CONCLUSION

A temperament-based approach appears to have some conceptual utility in modelling depression, and particularly, the non-melancholic disorders. It is likely, however, to require complementing with refined at-risk personality dimensions.

Cognitive-based measures screening for depression in the medically ill: the DMI-10 and the DMI-18

OBJECTIVE

We suggest that the identification of depression in the medically ill (DMI) might be improved by focussing on cognitive features.

METHOD

We recruited 302 patients to complete our provisional cognitive-based measure. Subsets also completed one of two comparator screening measures, either the Hospital and Anxiety Depression Scale (HADS) or the Beck Depression Inventory for Primary Care (BDI-PC). One hundred and sixty patients were then assessed by a psychiatrist who estimated whether they were 'clinically depressed' and who also administered a standardized interview for depression (the CIDI).

RESULTS

Analyses identified items discriminating clinically depressed and non-depressed individuals, allowing development of brief (10-item) and extended (18-item) measures. The two new measures were compared with the HADS and the BDI-PC in discriminating depressed and non-depressed medically ill patients.

CONCLUSION

A cognitive construct-based approach to assessing depression in the medically ill appears strongly supported. We provide brief (DMI-10) and extended (DMI-18) measures that appear to have utility as screening instruments. Consideration of the discriminating items may also assist clinical decision making.

Cranial venous outflow obstruction in the pseudotumour syndrome: incidence, nature and relevance

This study reports a retrospective analysis of the evidence of cranial venous outflow pathology in 188 patients with pseudotumour syndrome (PTS) investigated over the period 1968-1999. Standard methods of investigation appropriate to the period were used, i.e. cerebral angiography, CT and MR scanning. Recently, some patients had specific venous studies including intraluminal cranial venous sinus pressure measurements. A sub-group (25 patients) was investigated for haematological abnormalities. The overall incidence of cranial venous outflow abnormality was 19.7% (37 cases). In decades, related to the predominant investigative method, the figures were: to 1979, 4.2% (2 cases); to 1989, 15.0% (8 cases); to 1999, 31.0% (27 cases). A cause of the venous abnormality was identified in 20 cases, most commonly haematological and iatrogenic. In 17 patients (all females) no cause was identified. Fifteen of the 25 patients (60%) tested specifically were found to have a haematological abnormality, although no correlation was shown between this and a demonstrable venous outflow abnormality. The conclusion was drawn that there is a high incidence (close to one-third) of venous outflow abnormalities in PTS with detailed investigation. Issues of mechanism and therapy are discussed.

Olanzapine augmentation in the treatment of melancholia: the trajectory of improvement in rapid responders

It has been suggested that the atypical antipsychotic drugs may induce a rapid improvement in individuals with melancholic depression. This might reflect a specific or non-specific effect on mood and other parameters. To examine this issue, ten consecutive patients, for whom olanzapine augmentation was judged a clinically appropriate strategy, were asked to complete daily ratings of depression severity and component features for 1 week. Of the six rapid responders, there was a 52% group improvement in the first day and 89% improvement at 1 week. Item analyses suggested the most rapid impact was evident for insomnia, compared to a slower and linear improvement in depressed mood. Such findings may assist in an understanding of the mechanisms underlying augmentation with atypical neuroleptic drugs.

The disability profile of patients with schizophrenia in psychiatric hospital and community settings in Singapore

The disability profile of persons with schizophrenia in Singapore and how disability levels vary in patients cared for in the community and in the long-stay wards of a state mental hospital were studied using the Life Skills Profile (LSP). The inter-rater reliability of the LSP assessed by the intraclass correlation coefficient (ICC), was lower than in the Australian studies. The test-retest ICCs for the total LSP score and the five subscale scores were satisfactory for the hospitalised subjects and for the community psychiatric nurse subjects, but generally poor for the community care facility subjects. The average ICCs were lower compared to the Australian study. Female hospitalised subjects but not male hospitalised subjects returned higher disability scores on all LSP scales compared to community subjects. This study provided some preliminary data on the usefulness and validity of the LSP in a multi-ethnic Asian setting like Singapore. If the LSP is used as a measure of disability in schizophrenia, it would appear that ratings should only be made by those who know the subject well, and that raters should be formally trained mental health professionals.

Indicators of suicide over 10 years in a specialist mood disorders unit sample

BACKGROUND

There are few firm data to guide the clinician in identifying individual depressed patients who may be at high risk for completing suicide. In particular, there have been few prospective studies of well-characterized depressed patients to determine indicators of such future events.

METHOD

Eight hundred thirteen patients with a major depressive episode (DSM-III, DSM-III-R, or DSM-IV criteria) were assessed in detail in a specialist Mood Disorders Unit (MDU) over a 10-year period. Follow-up at the end of that period (mean = 5.1 years) confirmed that 31 patients (3.8%) had completed suicide. The suicide completers were compared on a broad range of clinical and demographic variables obtained at baseline with (1) the total remaining depressed sample, (2) 31 age- and sex-matched subjects who were confirmed to be alive and had never attempted suicide, and (3) 24 age- and sex-matched living subjects who had made at least 1 suicide attempt.

RESULTS

The most consistent finding, across all 3 comparisons, was that the suicide completers were more likely to have been inpatients at the time of the index MDU assessment. Other characteristics of completers were a greater number of prior admissions for depression, being older and in a relationship, and being male and married or female and single. Somewhat paradoxically, suicide completers also evidenced fewer previous suicide attempts and less suicidal ideation compared with living subjects who had attempted suicide at the time of index assessment.

CONCLUSION

Overall, we were able to find few predictors of later suicide in this sample. Those who completed suicide demonstrated evidence of more severe illness over a lifetime (for example, having more admissions). but revealed less suicidal ideation at the time of the index MDU assessment. While these features were statistically significant, they are of limited usefulness in predicting suicide in an individual patient.

Mental health literacy survey of psychiatrically and generally trained nurses employed in a Singapore psychiatric hospital

Mental health literacy studies consider the capacity of respondents to recognize certain psychiatric disorders, judge the comparative utility of a range of interventions, and make estimates about outcome and prognostic issues. We report such a study involving a sample of nursing staff employed at a large psychiatric institution in Singapore, and who were provided with separate brief vignettes of mania, schizophrenia and depression. Subjects were highly accurate in 'diagnosing' schizophrenia, less accurate for depression and even less accurate in diagnosing mania. Depression was alternately diagnosed as stress, mania was most commonly misdiagnosed as schizophrenia, and for both psychotic conditions, a percentage returned non-psychotic diagnoses. In terms of treatment options, staff distinctly favoured a 'medical model' and viewed traditional and alternative healing options as distinctly harmful. Analyses contrasted psychiatrically trained and generally trained nurses, but identified few significant differences. Such information has the potential to shape the education and training of mental health professional staff, as well as provide important insights about how nurses may diagnose, view and favour alternative treatments and strategies to assist those with common psychiatric disorders.

Men who commit rape in Singapore

INTRODUCTION

Rape is regarded as one of the most serious forms of sexual assault, yet there has been a lack of clinical information on convicted rapists in Singapore. This paper attempts to confirm the hypotheses that rapists come from disordered backgrounds, from large families and are poorly educated. We further hypothesize that they are more likely to have a history of antisocial behaviour and to have had recent exposure to pornography.

METHODS

Rapists serving sentence in a Singapore prison were compared with 2 control groups, one consisting of violent non-sexual offenders and another comprising non-violent non-sexual offenders.

RESULTS

Rapists tended to be men in their late thirties who rape women in their early twenties. A large majority of the rapists and their victims are known to each other. Rapists are more likely to come from large, disordered families, attaining low educational levels but seemingly less antisocial when compared with the controls. More rapists and violent controls reported recent viewing of pornography before committing their offenses.

CONCLUSION

The demonstrated similarities between rapists and violent controls lend support to the view that rape is an act of violence carried out in a sexual manner rather than a sexual act violently expressed.

Depression in Singapore: failure to demonstrate an age effect on clinical features

OBJECTIVES

Studies comparing older and younger depressed patients have variably identified differing and similar clinical feature patterns, an inconsistency requiring clarification and explanation. If influential, age may have a true phenotypic effect or be a secondary influence reflecting depressive sub-type differences. If age is primarily influential, then, after controlling for depressive sub-type differences its effect should impact on clinical features - even in non-western regions.

METHODS

We therefore undertook a study in Singapore, comparing 42 elderly and 28 younger patients of a Singapore psychiatric hospital, and with the diagnostic sub-type profile similar across the age-based groups.

RESULTS

Despite the elderly group being some 35 years older, both at first episode and when surveyed, and having a distinctly higher rate of physical disorders, few clinical differences were identified. While the elderly group reported a less severe depressed mood and more 'somatic' symptoms, analyses indicated that such differences were accounted for by education and language factors, and were compatible with the view that Chinese subjects historically report depression more 'somatically'.

CONCLUSION

We conclude that, in a non-western, largely Chinese sample of depressed patients, few differences in the phenotypic expression of depression were identified, perhaps reflecting similar distributions of depressive sub-types across the groups, an issue which may have muddied interpretation of western studies.

Late-onset depression: genetic, vascular and clinical contributions

BACKGROUND

Neuropsychiatric research needs to examine the relationships between aetiological, genotypic and clinical risk factors and behavioural phenotypes. These relationships can now be examined in older patients with depressive disorders.

METHODS

Key behavioural features, clinical and vascular risk factors and putative genotypes for late-onset neurodegenerative disorders and/or vascular disease were recorded in 78 older patients with depression (mean age = 549 years, S.D. = 14.1) and 22 healthy control subjects (mean age = 55.5 years, S.D. = 9.6).

RESULTS

Two or more vascular risks were more common in older patients (65% v. 26% of control subjects, P < 0.01), and in patients with late-onset disorders (82% v. 57% in patients with early-onset disorders, P < 0.05). Patients with late-onset depression had a higher prevalence of the homozygous or heterozygous forms of the C677T mutation of the methylenetetrahydrofolate reductase enzyme (MTHFR)(74% v. 48% in patients with early-onset disorders, P < 0.05). In a multivariate model, only presence of the MTHFR gene mutation predicted late-onset depression (odds ratio = 3.8, 95% CI = 1.1-12.9). Neither apolipoprotein E epsilon 4 or epsilon 2 was associated with depression, late-onset depression, cognitive impairment, or psychomotor change. Patients with apolipoprotein E epsilon 4 were less likely to have psychotic forms of depression.

CONCLUSIONS

Patients with late-onset depression had an increased rate of the C677T MTHFR gene mutation and other vascular risk factors. This suggests that a proportion of these patients may have genetically-determined and/or other vascular aetiologies. Patients at risk of these disorders may be assisted by currently-available preventative strategies.

Development of guidelines to facilitate improved support of South Asian carers by primary health care teams

BACKGROUND

Evidence based guidelines are regarded as an appropriate basis for providing effective health care, but few guidelines incorporate the views of users such as carers.

AIM

To develop guidelines to assist primary health care teams (PHCTs) in their work with carers within South Asian communities.

METHODS

The guidelines were drawn up by a development group consisting of members of teams in areas with South Asian communities (Leicester and Bradford). The teams were invited to make their recommendations based on a systematic review of literature on minority ethnic carers and the findings of a study of the needs and experiences of local South Asian carers. A grading system was devised to enable the teams and a group of expert peer reviewers to assess the quality of evidence in support of each recommendation.

RESULTS

The teams agreed seven recommendations, graded according to available evidence and strength of opinion. External peer review supported the PHCTs' interpretation of evidence and their recommendations. The recommendations included consideration of communication and information for carers, coordination of care within teams, and recognition by team members of the roles of carers and their cultural and religious beliefs.

CONCLUSION

There are particular steps that PHCTs can take to improve their support of South Asian carers. It is possible to develop guidelines that take users' views into account and incorporate evidence from qualitative studies.

Development of a brief form of the Life Skills Profile: the LSP-20

OBJECTIVE

To develop a brief form of the Life Skills Profile (LSP) that incorporates all five subscales of the full form.

METHOD

A new short form of the LSP (LSP-20) was developed to incorporate all five subscales of the full form. The LSP-20 development was based on a reanalysis of data from previously published studies. These data sets were also reanalysed to determine any differential effects of numbers and percentages of items in the LSP-39, LSP-16 and LSP-20, comparability of scores of the different forms, of test-retest and interrater reliability, and validity of the LSP-20 by comparison with the Positive and Negative Syndrome Scale (PANSS).

RESULTS

A twenty-item short form of the LSP-39 (LSP-20) is described which retains 16 items of an earlier short form but which also reproduces the subscale concerned with disability associated with positive psychotic phenomena. The subscales correlated highly with their counterparts in the full form, interrater and test-retest reliabilities were comparable, and concurrent validity was good.

CONCLUSIONS

The LSP-20 is a brief form of a widely used instrument that offers equivalent coverage to the full form with sound empirical properties, though unlike the LSP-39, it can be scored in the direction of impairments or strengths. Therefore the LSP-20 may be more suited to routine service disability and aggregated outcome assessments, but less suited than the LSP-39 to detailed research, or to interactive use as part of service user's individual care planning and review.

Are atypical antipsychotic drugs also atypical antidepressants?

OBJECTIVE

To report a case series and review the psychopharmacology of the neuroleptic drugs to suggest that the atypical antipsychotic drugs may have an antidepressant action, at least for those patients with the melancholic subtype.

METHOD

We note the literature suggesting that the older (or typical) antipsychotic drugs were established as having antidepressant activity, describe an open study of some two dozen patients with a treatment-resistant melancholic depression, describe rapid resolution of depression and augmentation benefits associated with commencing an atypical antipsychotic drug in a percentage of subjects, and then review relevant psychopharmacological studies to consider whether there is a rationale for use of antipsychotic drugs to treat depression.

RESULTS

Of some two dozen patients treated with an atypical antipsychotic drug, almost immediate improvement was noted in four patients, and evidence of augmentation benefit obtained in another three patients.

CONCLUSIONS

Impressions from this case series are encouraging. However, as open clinical observational studies are problematic, controlled studies are required to establish whether the atypical antipsychotic drugs have a role in the management of certain expressions of depression, and, in particular, treatment-resistant melancholic depression.

Adolescent depression: a review

OBJECTIVE

To review the characteristic clinical, illness course and risk factors to adolescent depression.

METHOD

A literature review is provided with interpretive comments.

RESULTS

The clinical feature profile is likely to reflect the rarity of melancholic depression, while the non-melancholic "irritable hostile" pattern appears distinctly increased. A "reactive depressive disorder" is rare in those who get to psychiatric assessment, while comorbidity (e.g. anxiety and personality disorders, illicit drug use) is the rule. Aetiological determinants and the prognosis generally more relate to comorbid factors than to depression per se. Predisposing and precipitating psychological and social determinants are considered, while the efficacies of varying antidepressant strategies remain unclear apart from those with an "anxious" or "irritable" depression where selective serotonin re-uptake inhibitor medication has shown utility and where cognitive-behavioural therapy may be relevant.

CONCLUSIONS

For the majority who develop adolescent depression, its expression and outcome appear more a reflection of the propagating determinants, most commonly anxiety and personality style. The clinician should determine a treatment plan that not only addresses the depression but which identifies and addresses the contributing features.

The differential impact of age on the phenomenology of melancholia

BACKGROUND

We pursue an observation that age may influence the clinical features of melancholia and, in particular, psychomotor disturbance.

METHODS

Two large clinical databases were amalgamated allowing the clinical features of 124 depressed subjects meeting DSM-III-R and clinical criteria for melancholia to be contrasted with 218 subjects diagnosed as having a non-melancholic depression by both criteria sets. Psychomotor disturbance was assessed by the CORE measure and by seven classical endogeneity symptoms of melancholia which, when summed, created a ENDOG score.

RESULTS

There was no impact of age on ENDOG scores in either the melancholics or non-melancholics. In the melancholics, increasing age was associated with increasing CORE scores and with agitation scale scores in particular. In a set of discriminant function analyses seeking to identify the comparative utility of a set of predictors of melancholic (versus non-melancholic) groups, age was significant, and while CORE and ENDOG scores were individual predictors, their combined entry established that the CORE score alone made the ENDOG score redundant, and that the addition of age then made little impact.

CONCLUSIONS

Melancholia appears to have a later age of onset than non-melancholic depression, while its phenotypic expression appears to change with age, with psychomotor disturbance being more distinct in older subjects. Such an effect may have a number of clinical implications, including possible differential effects of varying antidepressant treatments.

The influence of an uncaring partner on the type and outcome of depression

BACKGROUND

We seek to clarify recent inconsistent research findings in relation to the Intimate Bond Measure (IBM), where low IBM care scores have been held to be over-represented in non-melancholic depression and to predict a poor depressive episode outcome.

METHODS

A sample of 82 subjects meeting DSM criteria for a major depressive episode lasting less than 2 years, took part in a 1-year follow-up study. The IBM was completed at initial assessment and depression severity assessed at baseline and at follow-up assessment, allowing a measure of "outcome".

RESULTS

A significantly greater proportion of DSM-defined non-melancholic than melancholic depressives perceived their partner as providing deficient care and were classified as being in a dysfunctional relationship, seemingly unrelated to demographic differences or by depression severity, chronicity or recurrence. IBM scores were again established as independent of a number of putative distorting influences, such as depression severity and "neuroticism". Although the IBM failed to significantly predict outcome, there was a clear trend for greater improvement in those in IBM care score-defined "functional relationships".

LIMITATIONS

The study failed to assess the change in patients' perceptions of care over time, which may have contributed to the failure to replicate past findings in relation to outcome.

CONCLUSIONS

The significance of examining the relevance of psychosocial factors such as deficient intimacy to separate depressive sub-types is highlighted. Implications of these findings for clinical intervention and future research studies are discussed.

Early and late onset depression in old age: different aetiologies, same phenomenology

BACKGROUND

Phenomenological differences between older patients with early onset (EO; onset of first major depressive episode before 60 years) and late onset (LO) depression have been inconsistent but, if real, may reflect differences in aetiology. We aimed to compare aetiological factors, phenomenology and cognitive function in older patients with depression by age of onset.

METHODS

Subjects were all patients > or =60 years old (n=73) from 407 consecutive attenders to a Mood Disorders Unit, diagnosed with DSM-III-R Major Depressive Episode, at or close to the nadir of their episode. Putative risk factors were assessed by structured interview. Psychological morbidity and depressive symptoms were assessed by the 21-item Hamilton Rating Scale for Depression, CORE rating of psychomotor disturbance, Newcastle Endogeneity Scale, Zung Depression Scale and General Health Questionnaire. Cognition was assessed by tests of memory, attention, executive function and motor speed.

RESULTS

Personality abnormalities, a family history of psychiatric illness and dysfunctional past maternal relationships were significantly more common in EO depression. The two age of onset groups were essentially similar in terms of depressive sub-type and severity, phenomenology, history of previous episode, and in neuropsychological performance.

LIMITATIONS

Use of self-report data, moderate sample size, sample not age-matched, tertiary referral patients.

CONCLUSIONS

EO and LO depression are similar phenotypically, but differ aetiologically. The pursuit of mechanisms which predispose depressive episodes may be heuristically more valuable than further investigation of individual depressive features in distinguishing early from late onset depression.