Comorbidity between neurological illness and psychiatric disorders

Risk of Psychiatric Morbidity in Psychosexual Disorders in Male Patients: A Nationwide, Cohort Study in Taiwan

This study aimed to investigate the association between males with psychosexual disorders (PSDs) and the risk of developing psychiatric disorders. A total of 34,972 enrolled patients, with 8,743 subjects who had suffered from PSD and 26,229 controls (1:3) matched for age and index year, from Taiwan’s Longitudinal Health Insurance Database (LHID) from 2000 to 2015, selected from the National Health Insurance Research Database (NHIRD). After adjusting all the confounding factors, the multivariate Cox regression model was used to compare the risk of developing psychiatric disorders, between the PSD and non-PSD groups, during the 15 years of follow-up. Of the all enrollees, 1,113 in the PSD cohort and 2,611 in the non-PSD cohort (1,180.96 vs. 954.68 per 100,000 person-year) developed psychiatric disorders. Multivariate Cox regression model survival analysis revealed that, after adjusting for gender, age, monthly income, urbanization level, geographic region, and comorbidities, the adjusted hazard ratio (HR) was 2.448 (95% CI [2.227, 2.633], p < .001). PSD has been associated with the increased risk in anxiety disorders, depressive disorders, bipolar disorders, sleep disorders, and psychotic disorders, respectively. Sexual dysfunctions, paraphilia, and gender identity disorders were associated with the overall psychiatric disorders with adjusted HRs as 1.990 (p < .001), 11.622 (p < .001), and 5.472 (p < .001), respectively. Male patients who suffered from PSD have a higher risk of developing psychiatric disorders, and this finding should be considered as a timely reminder for the clinicians to provide much more attention for these patients because of their mental health issues.

Risk factors of mortality in older patients with dementia in psychiatric care

OBJECTIVE

To examine the mortality risk, and its risk factors, of older patients with dementia in psychiatric care.

METHODS

We constructed a cohort of dementia patients through data linkage of four Dutch registers: the Psychiatric Case Register Middle Netherlands (PCR-MN), the hospital discharge register, the population register, and the national cause of death register. All dementia patients in PCR-MN aged between 60 and 100 years between 1 January 2000 and 31 December 2010 were included. Risk factors of mortality were investigated using Cox proportional hazard regression models with adjustment for age, sex, setting of care, nationality, marital status, dementia type, and psychiatric and somatic comorbidities.

RESULTS

In total, 4297 patients were included with a median age of 80 years. The 1-year, 3-year, and 5-year mortality were 16.4%, 44.4%, and 63.5%, respectively. Determinants that increased the 1-year mortality were: male sex (adjusted hazard ratio [HR]: 1.49; 95% confidence interval [95% CI], 1.26-1.76), higher age (HR 1.08; 95% CI, 1.07-1.09), inpatient psychiatric care (HR 1.52; 95% CI, 1.19-1.93), more somatic comorbidities (HR 1.67; 95% CI, 1.49-1.87), and cardiovascular disease separately (HR 1.54; 95% CI, 1.30-1.82). Results for 3-year and 5-year mortality were comparable. Living together/married increased the 3- and 5-year mortality, and Dutch nationality increased the 5-year mortality. There were no differences in mortality with different types of psychiatric comorbidity.

CONCLUSION

Mortality of dementia patients in psychiatric care was high, much higher than mortality in the general older population. The results of this study should raise awareness about their unfavourable prognosis, particularly older patients, men, inpatients, and patients with more somatic comorbidity.

Medical Etiologies of Secondary Psychosis in Children and Adolescents

This is an updated review of child and adolescent somatic disorders associated with psychosis/psychotic symptoms, organized into neurologic, infectious, genetic, inborn errors of metabolism, autoimmune, rheumatologic, endocrine, nutritional, metabolic, and iatrogenic categories. When possible clinical manifestations or types of psychotic symptoms and proposed neuropathogenesis causing the neuropsychiatric symptoms are included. In some cases, the psychiatric symptoms may be the first presentation of the disease. The authors hope that this review will aid child and adolescent psychiatrists in considering alternative etiologies of youth presenting with psychosis and encourage appropriate physical examination, history, and further work-up when suspected.

Comorbid Bipolar Disorder and Migraine: From Mechanisms to Treatment

Bipolar disorder (BD) is a severe psychiatric disorder characterized by recurrent episodes of manic/hypomanic or depressive symptoms and euthymic periods, with some patients suffering a gradual deterioration of illness and consequent cognitive deficits during the late stage. Migraine is a disease generally without abnormal medical examinations, neurological examinations or laboratory studies, and the diagnosis is made based on the retrospective demonstration of headache features and groupings of disease-associated symptoms. The epidemiology of comorbid BD and migraine is high and it is obligatory to find effective treatments to improve the prognosis. Recent investigations demonstrated that the close relationship between BD and migraine significantly increased the rapid cycling rates of both BD and migraine in patients. Although the detailed mechanism is complex and largely unclear in comorbid BD and migrain, genetic factors, neurotransmitters, altered signaling pathways, disturbances of inflammatory cytokines, and mitochondrial dysfunction are risk factors of BD and migraine. Particularly these two diseases share some overlapping mechanisms according to previous studies. To this end, we call for further investigations of the potential mechanisms, and more efforts are underway to improve the treatment of people with comorbid BD and migraine. In this review, we provide an overview of the potential mechanisms in patients with BD or migraine and we further discuss the treatment strategies for comorbid BD and migraine and it is obligatory to find effective treatments to improve the prognosis. This work will provide insights for us to know more about the mechanisms of comorbid BD and migraine, provides new therapeutic targets for the treatment and give clinicians some guidance for more appropriate and beneficial treatment.

Psychiatric aspects of posttraumatic epilepsy: A still unexplored area

Traumatic brain injury (TBI) represents one of the most common causes of death and disability in young people, and posttraumatic epilepsy (PTE) accounts for 10% to 20% of all symptomatic epilepsies. However, PTE is still a relatively underappreciated condition. This paper aimed at reviewing current knowledge about psychiatric comorbidities of PTE, looking in particular at the nature of the relationship between TBI, psychiatric problems, and epilepsy, at the phenomenology of psychiatric disorders in PTE, and how to manage them. Data on psychiatric comorbidities of PTE are almost nonexistent, and this is a paradox considering that TBI itself is burdened by a number of cognitive and psychiatric sequelae, which can profoundly affect the everyday life of these patients. Preliminary data seem to suggest that the bidirectional relationship between epilepsy and psychiatric disorders is maintained in TBI and people with a psychiatric condition at the time of the TBI, or as a consequence of it, are at increased risk of developing PTE and vice versa. However, a number of questions are still unanswered concerning the genetic and environmental contributors, the phenomenology of psychiatric disorders in PTE, and how to prevent and address them properly. Further research in this area is urgently needed in order to provide the best possible care to people with PTE. Special Issue: Epilepsy & Behavior's 20th Anniversary.

Selective serotonin reuptake inhibitors and risk of epilepsy after traumatic brain injury - A population based cohort study

OBJECTIVE

Traumatic brain injury (TBI) is common and associated with a marked increased risk of developing epilepsy. Animal studies indicate that treatment with selective serotonin reuptake inhibitors (SSRIs) may increase the risk of epilepsy after TBI. The aim of this study was to investigate whether use of SSRIs modifies the risk of epilepsy after TBI.

METHODS

This was a cohort study of 205,715 persons, who suffered a TBI in Denmark from 1996 to 2013. For each person with TBI, we matched 10 reference persons (N = 2,057,150) who were alive on the day of TBI and who had the same age and gender but had no history of TBI. We used a stratified Cox regression to calculate the relative risk of epilepsy after TBI for persons exposed to TBI, SSRI or both after adjustment for income, civil status, medical and neurological comorbidities, severe mental disease, and substance abuse.

RESULTS

The risk of epilepsy was 5.61 times higher for persons who used SSRI at time of TBI (adjusted Hazard Ratio (aHR): 5.61 (95% CI: 4.88; 6.45)), 3.23 times higher for persons who had a TBI but did not use SSRI at time of TBI (aHR: 3.23 (95% CI: 3.12;3.35)), and 1.31 times higher for persons who used SSRI but had no TBI (aHR: 1.31 (95% CI: 1.18; 1.45)) compared to persons unexposed to both TBI and SSRI.

CONCLUSIONS

This large population based cohort study showed that people using SSRI at the time of a TBI had higher risk of developing epilepsy compared to people not using SSRI at the time of TBI. The results are in line with those of animal studies and calls for further studies to evaluate whether the association is due to SSRIs or to the underlying disease (e.g. depression or anxiety).

Antioxidant treatment after epileptogenesis onset prevents comorbidities in rats sensitized by a past stressful event

OBJECTIVE

Unresolved past stressful events can induce a state of vulnerability to epilepsy and comorbidities. Using an experimental model of stress-induced vulnerability to depression, we tested whether an antioxidant treatment applied after the onset of epileptogenesis was disease modifying and could prevent the occurrence of comorbidities.

METHODS

We used social defeat (SD) to trigger a state of vulnerability in half of the SD-exposed population of rats. One month after SD, we used repeated injections of kainic acid to trigger status epilepticus (SE). One subset of animals was treated after SE during 2 weeks with Tempol, a strong antioxidant. Supradural 24/7 recordings were used to assess the development of epilepsy. We assessed spatial and nonspatial memory as well as a depressionlike profile 6 weeks after SE.

RESULTS

Serum brain-derived neurotrophic factor (BDNF) levels decreased after SD in all animals and recovered to pre-SD levels 1 month later in half of them (SDN group). The other half kept low serum BDNF levels (SDL group). At that stage, SDN and SDL animals do not present a depressionlike profile. The SDL group was more sensitive than the SDN group to epileptogenic conditions. Following SE, the SDL group displayed accelerated epileptogenesis, a depressionlike profile, and severe cognitive deficits as compared to SDN rats. Transient Tempol treatment was disease-modifying, reducing the number of seizures, and prevented the development of comorbidities in the SDL group. Tempol treatment normalized oxidative stress in the SDL group to SDN levels.

SIGNIFICANCE

This study illustrates the disease-modifying effect of antioxidant treatment after the onset of epileptogenesis in a population rendered vulnerable by past stressful events. The transient treatment decreased seizure burden and had long-term effects, preventing the occurrence of a depressionlike profile and cognitive deficits. We propose that vulnerability to comorbidities can be reversed after the onset of epilepsy.

Increased risk of neurodegenerative dementia in women with migraines: A nested case-control study using a national sample cohort

The present study aimed to evaluate the association between migraines and dementia.Data were collected from 11,438 dementia participants who were 1:4 matched by age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia with 45,752 controls from the Korean National Health Insurance Service-National Sample Cohort from 2002 to 2013. Dementia was diagnosed using the International Classification of Disease-10 (ICD-10) codes (G30 or F00). For the integrity of diagnoses, we included only participants ≥60 years old who had been diagnosed with an ICD-10 code twice or more during ambulatory visits for the same episode. For migraine (ICD-10 code, G43), we included participants who had visited outpatient clinics twice or more for the same episode. In both dementia and control groups, a previous history of migraine was investigated.Approximately 7.7% (881/11,438) of patients in the dementia group and 6.3% (2888/45,752) of those in the control group had a history of migraine (P < .001). The crude and adjusted odds ratios (ORs) for migraine with dementia was 1.22 (95% confidence interval [CI] = 1.13-1.32, P < .001) and 1.13 (95% CI = 1.05-1.23, P = .002), respectively. In the subgroup analyses according to age and sex, women demonstrated a significantly higher adjusted OR for migraine with dementia, whereas men did not exhibit an association between migraine and dementia.In a nested case-control study using a national sample cohort, migraine increased the risk of dementia in women.

Psychiatric manifestations of neurologic diseases: Etiology, phenomenology, and treatment

Understanding the etiology and meaning of behavioral symptomatology in the context of neurologic disease, and choosing the most effective intervention is a vexing task. This introduction summarizes the history of our understanding of the relationship between behavioral symptoms and primary neurologic conditions, and considers the ways in which both psychiatric and neurologic disorders occurring simultaneously may inform both knowledge of etiology and treatment decisions.

Monitoring And Managing Depression In Adolescents With Epilepsy: Current Perspectives

Epilepsy is associated with a significantly increased risk of developing depressive disorder during adolescence. On the other hand, depression is highly detected in adolescents with epilepsy. These findings highlight the importance of early identification and proper management of comorbid depression in adolescent age. The prevalence of depressive disorders in adolescents with epilepsy ranges between 8 and 35% and is higher than the general population of the same age. The relationship between epilepsy and depression is complex and potentially bidirectional, thereby suggesting a common underlying pathophysiology. Furthermore, failure to detect and treat depressive disorder mostly in adolescence could lead to several negative implications such as an increased risk of suicidal ideation or behavior and poor quality of life. A number of methods are available to detect depressive disorder, such as psychiatric or psychological assessments, structured or semi-structured interviews, and self-report screening tools. Thus, physicians should be able to regularly screen depressive symptoms in youths with epilepsy. Recently, the NDDI-E-.Y inventory has been developed from the adult NDDI-E, and has been validated in many countries. NDDI-E-Y has showed reliable validity, being a brief screening tool (12 items) that can be easily included in routine epilepsy care. The first step to be considered for the management of depressive disorder in adolescents with epilepsy is to consider potential reversible causes of anxiety and depression (i.e., a new AEDs; seizure control). Secondly, great attention has to be given to the education of the child/adolescent and his/her family, trying to improve knowledge about epilepsy as well as to decrease parental stress and improving the child's sense of competence. Pharmacological treatment should also be considered in adolescents diagnosed with depression.

Neurologists' Assessment of Mental Comorbidity in Patients With Vertigo and Dizziness in Routine Clinical Care-Comparison With a Structured Clinical Interview

Background: Mental health comorbidities are frequent in patients with vertigo and dizziness. The current study was conducted in a specialized interdisciplinary university center for vertigo and dizziness. Clinical routines consist of a structured work-up in which neuro-otological and neurological tests are performed to first detect possible organic vestibular deficits. In addition, psychiatric disorders and comorbidities are considered. The study aimed to evaluate neurologists' awareness of psychiatric next to somatic disorders within patients' first examination in terms of diagnostic congruence between neurologists' diagnoses and structured clinical assessment of mental disorders.

Methods: The study involved 392 patients. Diagnostic evaluation included (a) structured history-taking (including psychosocial anamnesis), neurological, and neuro-otological diagnostics conducted by neurologists and (b) a structured clinical interview for mental disorders (SCID-I) conducted by psychologists and final-year medical or psychology students. Cohen's Kappa was calculated to determine agreement rates regarding depression and anxiety disorders; additionally, sensitivity and specificity were evaluated.

Results: Neurologists' assessments led to at least one psychiatric diagnosis among the main diagnoses in 40 (10.2 %) patients, whereas the structured clinical interview led to at least one DSM-IV psychiatric diagnosis in 174 (44.4%) of the patients. Agreement was low (κ < 0.2); sensitivity was low (15%) but specificity was high (98%).

Conclusions: Agreement between the diagnosis of neurologists and structured clinical interviews for psychiatric disorders is low. Since psychiatric disorders are frequent in vertigo and dizziness and tend to take a chronic course, improving early recognition and implementing appropriate care concepts is vital.

Preventing suicidal behavior in patients with multiple sclerosis: a scoping review

INTRODUCTION

Suicidal behavior is a relatively rare occurrence among patients with multiple sclerosis (MS). Nonetheless, it is important to identify and be aware of the constituting risk factors to prevent suicidal behavior among vulnerable patients. Areas covered: This scoped review will shortly outline well-known biological and psychosocial risk factors for suicidal behavior among MS patients and suggest preventive initiatives. The preventive strategies should include a close monitoring of MS pharmacotherapy to prevent progression, and awareness and early identification of psychosocial risk factors across a variety of heathcare and social instances the patient may encounter during their life with the disease. The staff in these instances should be educated in detecting the MS patients at increased risk and refer them to relevant healthcare instances, including the general practitioner, neurologists, psychiatrist, etc. In addition, referral to social instances to support educational, vocational, and home environment to the state of the disease is of utmost importance. Expert commentary: Enhancing quality of life for as long as possible by these means may be held to reduce the risk for psychosocial problems and hence suicidal behavior.

Assessment of components included in published societal perspective or QALY outcome economic analyses for antiepileptic drug treatment in chronic epilepsy

INTRODUCTION

Antiepileptic drug (AED) treatments seek to control seizures with minimal or no adverse effects, effects which can substantially impact costs and outcomes for patients, caregivers, and third party payers. The First and Second Panel on Cost-Effectiveness in Health and Medicine recommend inclusion of a societal reference case, even in studies conducted from a healthcare sector perspective, for comparability of findings across studies. Cost and outcome evaluation components include direct medical, non-direct medical-related (e.g. patient-time and transportation costs for treatment) and non-healthcare sectors (e.g. lost productivity).

AREAS COVERED

Guided by Second Panel recommendations, this review developed an overall impact inventory and detailed adverse effect impact inventory to assess the scope and methods in published economic evaluations of AED treatments for adults with chronic epilepsy. Societal perspective evaluations or evaluations that utilized quality-adjusted life-years (QALYs) as an outcome were reviewed. The majority of reviewed articles were healthcare sector perspective studies, methods for estimating QALYs varied widely, and a minority considered specific AED treatment adverse effects.

EXPERT COMMENTARY

Only considering a healthcare sector perspective fails to provide full information for patients on AED treatments. Using an impact inventory to guide study scope and design will facilitate full reporting of costs and benefits.

Epilepsy

Epilepsy affects all age groups and is one of the most common and most disabling neurological disorders. The accurate diagnosis of seizures is essential as some patients will be misdiagnosed with epilepsy, whereas others will receive an incorrect diagnosis. Indeed, errors in diagnosis are common, and many patients fail to receive the correct treatment, which often has severe consequences. Although many patients have seizure control using a single medication, others require multiple medications, resective surgery, neuromodulation devices or dietary therapies. In addition, one-third of patients will continue to have uncontrolled seizures. Epilepsy can substantially impair quality of life owing to seizures, comorbid mood and psychiatric disorders, cognitive deficits and adverse effects of medications. In addition, seizures can be fatal owing to direct effects on autonomic and arousal functions or owing to indirect effects such as drowning and other accidents. Deciphering the pathophysiology of epilepsy has advanced the understanding of the cellular and molecular events initiated by pathogenetic insults that transform normal circuits into epileptic circuits (epileptogenesis) and the mechanisms that generate seizures (ictogenesis). The discovery of >500 genes associated with epilepsy has led to new animal models, more precise diagnoses and, in some cases, targeted therapies.

Shared mechanisms of epilepsy, migraine and affective disorders

Since the nineteenth century several clinical features have been observed in common between migraine and epilepsy (such as episodic attacks, triggering factors, presence of aura, frequent familiarity), but only in recent years researchers have really engaged in finding a common pathogenic mechanism. From studies of disease incidence, we understand how either migraine among patients with epilepsy or epilepsy among migraine patients are more frequent than in the general population. This association may result from a direct causality, by the same environmental risk factors and/or by a common genetic susceptibility. Ischemic events are the most frequent direct causes, especially among women and elderly people: migraine can lead to silent or clinically considerable strokes, and these ones could explain the increased risk of developing epilepsy in people with a history of migraine. Head injuries can lead headache, often with migraine characteristics, and seizures. But there are also many idiopathic cases. The comorbidity migraine-epilepsy might be explained in these cases by a neuronal hyperexcitability, which increases the risk of both diseases: a higher concentration of extracellular glutamate, the main excitatory neurotransmitter, leads in fact as a result a Cortical Spreading Depression (the pathophysiological mechanism at the base of aura) and convulsions; antiepileptic drugs such as topiramate are, therefore, used also in migraine prophylaxis. A genetic link between these two diseases is particularly evident in familial hemiplegic migraine: mutations of ATP1A2, SCN1A and CACNA1A genes, identified in this disease, have also been involved in different types of epilepsy and febrile seizures. The channelopathies, especially engaging sodium and potassium ions, can be the common pathogenic mechanism of migraine and epilepsy. Both migraine and epilepsy also have, compared to the general population, a higher prevalence and incidence of affective disorders such as anxiety, depression and suicidal ideation. Anxiety and depression can be part of symptoms that accompany migraine or seizures. Female patients with a long history of illness and frequent attacks are the most at risk. The impact of these diseases on the quality of life is the most obvious cause of these disorders, furthermore some antiepileptic drugs can have depressive effects on mood; the anxious-depressive disorders often result from the interaction between iatrogenic and psychosocial factor with common neurobiological pathogenesis. A chronic lowering of 5-HT (serotonin) levels has been demonstrated both in migraineurs and in depressed patients; amitriptyline and venlafaxine are the most indicated drugs in the treatment of migraine with comorbid depression currently. Likewise imbalance in dopamine levels has been also demonstrated: a D2 receptor genotype has been directly related to comorbidity migraine-depression. In women, hormonal fluctuations are also crucial, especially in the post-partum and late luteal phase, when the estrogenic reduction, associated with up-regulation of SNPs and down-regulation of serotonergic and GABAergic systems, increases the risk of migraine and depression. Furthermore, central sensitization phenomena have been highlighted in both diseases, and result in a progressive increase in the frequency of attacks up to chronicity and the consequent development of drug resistance and overuse. Further studies will be necessary to deepen the close relationship between these three diseases.

Epilepsy as a Network Disorder (1): What can we learn from other network disorders such as autistic spectrum disorder and mood disorders?

Epilepsy is a neurologic condition which often occurs with other neurologic and psychiatric disorders. The relation between epilepsy and these conditions is complex. Some population-based studies have identified a bidirectional relation, whereby not only patients with epilepsy are at increased risk of suffering from some of these neurologic and psychiatric disorders (migraine, stroke, dementia, autism, depression, anxiety disorders, Attention deficit hyperactivity disorder (ADHD), and psychosis), but also patients with these conditions are at increased risk of suffering from epilepsy. The existence of common pathogenic mechanisms has been postulated as a potential explanation of this phenomenon. To reassess the relationships between neurological and psychiatric conditions in general, and specifically autism, depression, Alzheimer's disease, schizophrenia, and epilepsy, a recent meeting brought together basic researchers and clinician scientists entitled "Epilepsy as a Network Disorder." This was the fourth in a series of conferences, the "Fourth International Halifax Conference and Retreat". This manuscript summarizes the proceedings on potential relations between Epilepsy on the one hand and autism and depression on the other. A companion manuscript provides a summary of the proceedings about the relation between epilepsy and Alzheimer's disease and schizophrenia, closed by the role of translational research in clarifying these relationships. The review of the topics in these two manuscripts will provide a better understanding of the mechanisms operant in some of the common neurologic and psychiatric comorbidities of epilepsy.

Paradigm Shifts in the Neuropsychology of Epilepsy

This article reviews the major paradigm shifts that have occurred in the area of the application of clinical and experimental neuropsychology to epilepsy and epilepsy surgery since the founding of the International Neuropsychological Society. The five paradigm shifts discussed include: 1) The neurobiology of cognitive disorders in epilepsy - expanding the landscape of syndrome-specific neuropsychological impairment; 2) pathways to comorbidities: bidirectional relationships and their clinical implications; 3) discovering quality of life: The concept, its quantification and applicability; 4) outcomes of epilepsy surgery: challenging conventional wisdom; and 5) Iatrogenic effects of treatment: cognitive and behavioral effects of antiepilepsy drugs. For each area we characterize the status of knowledge, the key developments that have occurred, and how they have altered our understanding of the epilepsies and their management. We conclude with a brief overview of where we believe the field will be headed in the next decade which includes changes in assessment paradigms, moving from characterization of comorbidities to interventions; increasing development of new measures, terminology and classification; increasing interest in neurodegenerative proteins; transitioning from clinical seizure features to modifiable risk factors; and neurobehavioral phenotypes. Overall, enormous progress has been made over the lifespan of the INS with promise of ongoing improvements in understanding of the cognitive and behavioral complications of the epilepsies and their treatment. (JINS, 2017, 23, 791-805).

A person-centred approach in medicine to reduce the psychosocial and existential burden of chronic and life-threatening medical illness

The psychiatric, psychosocial, and existential/spiritual pain determined by chronic medical disorders, especially if in advanced stages, have been repeatedly underlined. The right to approach patients as persons, rather than symptoms of organs to be repaired, has also been reported, from Paul Tournier to Karl Jaspers, in opposition and contrast with the technically-enhanced evidence-based domain of sciences that have reduced the patients to 'objects' and weakened the physician's identity deprived of its ethical value of meeting, listening, and treating subjects. The paper will discuss the main psychosocial and existential burden related to chronic and advanced medical illnesses, and the diagnostic and therapeutic implications for a dignity preserving care within a person-centred approach in medicine, examined in terms of care of the person (of the person's whole health), for the person (for the fulfilment of the person's health aspirations), by the person (with physicians extending themselves as total human beings), and with the person (working respectfully with the medically ill person).

Depression in epilepsy, migraine, and multiple sclerosis: Epidemiology and how to screen for it

Purpose of review

To provide an overview of the epidemiology of depression in chronic neurologic conditions that can affect individuals throughout the lifespan (epilepsy, migraine, multiple sclerosis [MS]) and examine depression screening tools for adults with these conditions.

Recent findings

Depression is common in neurologic conditions and can be associated with lower quality of life, higher health resource utilization, and poor adherence to treatment. It affects around 20%-30% of those with epilepsy, migraine, and MS, and evidence for a bidirectional association exists for each of these conditions. Depression screening tools generally perform well in neurologic conditions, but are not without limitations.

Summary

Depression is a major contributor to poor outcomes in epilepsy, migraine, and MS. Although psychiatric resources are scarce globally, this is no reason to ignore depression in neurologic conditions. Depression screening tools are available in neurology and should be considered in clinical practice.

Perioperative Risk in Patients With Epilepsy Undergoing Total Joint Arthroplasty

BACKGROUND

Epilepsies is a spectrum of brain disorders ranging from severe, life threatening, and disabling to more benign, but little is known about its impact in the perioperative arthroplasty setting. We sought to determine whether epileptic patients undergoing elective total joint arthroplasty (TJA) would be at increased risk for in-hospital complications and death, prolonged stay, and nonroutine discharge.

METHODS

Using discharge records from the Nationwide Inpatient Sample (2002-2011), we identified 6,054,344 patients undergoing elective primary TJA, of whom 31,865 (0.5%) were identified as having epilepsy. Comparisons of perioperative outcomes were performed by multivariable logistic regression modeling.

RESULTS

Patients with epilepsy were associated with increased in-hospital mortality (odds ratio [OR] 2.03, 95% confidence interval [CI] 1.57-2.62) and morbidity, including (in decreasing order of magnitude of effect estimate): mechanical ventilation (OR 1.74, 95% CI 1.56-1.94), induced mental disorder (OR 1.70, 95% CI 1.56-1.85), stroke (OR 1.63, 95% CI 1.23-2.15), pneumonia (OR 1.34, 95% CI 1.21-1.49), and ileus or gastrointestinal events (OR 1.26, 95% CI 1.12-1.42). Epilepsy was associated with higher risk for blood transfusion (OR 1.30, 95% CI 1.27-1.33), prolonged hospital stay (OR 1.14, 95% CI 1.11-1.17), and nonroutine discharge (OR 1.54, 95% CI 1.50-1.58). We found no association with inpatient thromboembolic events, acute renal failure, and myocardial infarction.

CONCLUSION

Patients with epilepsy are at increased risk for early postoperative complications (especially mechanical ventilation, induced mental disorder, and stroke) and resource utilization after elective joint arthroplasty. Greater awareness of epilepsy and its health consequences may contribute to improvements in the perioperative management of TJA patients.

Bupropion interferes with the image diagnosis of Parkinson's disease

Major depressive disorder (MDD) and Parkinson's disease (PD) share symptoms such as tremor. Bupropion, a norepinephrine-dopamine reuptake inhibitor, shows weak dopamine transporter (DAT) occupancy. We report here on a patient with MDD whose hand tremors might have been misdiagnosed as PD by single-photon emission computed tomography (SPECT) under bupropion use. A 66-year-old male patient with MDD had been receiving bupropion 150 mg per day for 6 months. His mood symptoms improved partially with bupropion treatment, however, hand tremors persisted. The neurological examination revealed bilateral hand tremors without other typical signs for PD. The SPECT using Tc-99m TRODAT-1 revealed decreased DAT binding capacity in bilateral striata. Under the impression of atypical PD, the patient was advised to take anti-Parkinson's drug. Bupropion was discontinued for 14 days to confirm the test. The follow-up SPECT after 14 days found improvement for the uptake ratio of striata. From then onward, the anti-Parkinson's drug was not used due to the lack of typical sign(s) for PD. The patient's mental and physical status remained stable without worsening of hand tremors during follow-up. Tc-99m TRODAT-1 SPECT is helpful for the evaluation of DAT and the diagnosis of PD. However, the interpretation of the SPECT image might be biased by the use of certain drugs such as bupropion for its binding to DAT. Bupropion may decrease the Tc-99m TRODAT-1 binding to DAT. The effect of drugs on DAT should be carefully assessed while interpreting the Tc-99m TRODAT-1 image. Our findings suggest that all drugs that may alter DAT occupancy should be listed as the reference for Tc-99m TRODAT-1 image reading.

A Comparison of Treatment-Seeking Behavioral Addiction Patients with and without Parkinson's Disease

The administration of dopaminergic medication to treat the symptoms of Parkinson's disease (PD) is associated with addictive behaviors and impulse control disorders. Little is known, however, on how PD patients differ from other patients seeking treatments for behavioral addictions. The aim of this study was to compare the characteristics of behavioral addiction patients with and without PD. N = 2,460 treatment-seeking men diagnosed with a behavioral addiction were recruited from a university hospital. Sociodemographic, impulsivity [Barratt Impulsiveness Scale (BIS-11)], and personality [Temperament and Character Inventory-Revised (TCI-R)] measures were taken upon admission to outpatient treatment. Patients in the PD group were older and had a higher prevalence of mood disorders than patients without PD. In terms of personality characteristics and impulsivity traits, PD patients appeared to present a more functional profile than PD-free patients with a behavioral addiction. Our results suggest that PD patients with a behavioral addiction could be more difficult to detect than their PD-free counterparts in behavioral addiction clinical setting due to their reduced levels of impulsivity and more standard personality traits. As a whole, this suggests that PD patients with a behavioral addiction may have different needs from PD-free behavioral addiction patients and that they could potentially benefit from targeted interventions.