Psychiatric complications of treatment with corticosteroids: review with case report

Mood Disorders

PURPOSE OF REVIEW

This comprehensive review of mood disorders brings together the past and current literature on the diagnosis, evaluation, and treatment of the depressive and bipolar disorders. It highlights the primary mood disorders and secondary neurologic causes of mood disorders that are commonly encountered in a clinical setting. As the literature and our understanding evolve, recent additions to the current literature are important to bring forth to the readers.

RECENT FINDINGS

Advancements in clinical medicine have strengthened our understanding of the associations of neurologic and psychiatric diseases. This article highlights the medications frequently used with newly identified mood disorders and the common side effects of these medications. A paradigm shift has moved toward newer treatment modalities, such as the use of ketamine, repetitive transcranial magnetic stimulation, and complementary and alternative medicine. The risks and benefits of such therapies, along with medications, are reviewed in this article.

SUMMARY

Mood disorders are extraordinarily complex disorders with significant association with many neurologic disorders. Early identification of these mood disorders can prevent significant morbidity and mortality associated with them. With further expansion of pharmacologic options, more targeted therapy is possible in improving quality of life for patients.

Clozapine and COVID-19: A Case Report and Clinical Considerations

BACKGROUND

The emergence of coronavirus SARS-CoV-2, and the subsequent global epidemic of COVID-19, brought with it innumerable new clinical experiences across all medical specialties, and psychiatry is no exception. Individuals with serious mental illness, in particular schizophrenia and related disorders, may be especially susceptible to coronavirus infection given the overlapping risk factors of vulnerable sociodemographic status, increased challenges with quarantining requirements, and limited compliance with "respiratory etiquette." The case presented here describes a patient with schizophrenia who was being managed on clozapine and who developed symptomatic COVID-19 infection. Special care was taken to ensure that potential interactions between clozapine and the associated COVID-19 treatments were safe for the patient's mental and physical wellbeing.

CASE PRESENTATION

A 71-year-old schizophrenic Caucasian male is being managed with clozapine. While hospitalized, the patient was screened positive for COVID-19 and was admitted to the ICU due to his declining respiratory status. He was treated with both remdesivir and prednisone. He was able to fully recover from his COVID-19 infection.

CONCLUSION

The authors review the clinical characteristics of the case, highlighting both the overlapping synergistic effects and antagonistic influences of clozapine therapy in combination with COVID-19 and its associated treatments. A review of the literature offers an opportunity to examine various frameworks for individualized clinical decision-making while making the case for greater epidemiologic research into the optimal management of individuals with a psychotic disorder who are diagnosed with COVID-19 infection.

Inflammatory Bowel Disease and Patients With Mental Disorders: What Do We Know?

Inflammatory bowel disease (IBD) is a multisystemic disease with a wide range of extraintestinal manifestations in both ulcerative colitis and Crohn’s disease, while increasing evidence supports the interaction between gut and central nervous system, described as “gut-brain axis”. According to epidemiological studies, it seems that patients with IBD present more frequently with impaired mental status compared to the general population, leading to diagnostic and management problems in this group of patients. The association between IBD and mental disorders, such as dementia and autism spectrum disorders, has not been fully clarified; genetic factors and the gut-brain axis seem to be involved. The purpose of this review is to present and analyze the epidemiological data about this issue, describe the possible pathogenetic mechanisms and discuss some considerations about the management of patients with IBD and impaired mental status.

Adverse Effects of Long-Term Oral Corticosteroids in the Department of Dermatology, Antananarivo, Madagascar

BACKGROUND

Long-term oral corticosteroids have an important role in dermatological care in Madagascar. However, significant adverse effects have been associated with continuous exposure to oral corticosteroids.

OBJECTIVE

We aim to assess the adverse effects of long-term corticosteroid therapy in patients seen in the Department of Dermatology at the University Hospital Joseph Raseta Befelatanana Antananarivo (UH/JRB), Madagascar, and to identify the risk factors associated with these adverse effects.

METHODS

A cross-sectional study was conducted during 4 months to assess the adverse effects of long-term corticosteroid therapy in patients seen in the Department of Dermatology. Patients treated with oral corticosteroids for more than 3 months were included in our study.

RESULTS

The prevalence of long-term use of oral corticosteroids in the Department of Dermatology of UH/JRB was 34.28%. A total of 51 patients were included and adverse effects occurred in 64.70% of this population. Repetitive infections and cutaneous adverse reactions were the most frequent adverse effects, in 23.52% and 11.76% of cases, respectively. There were no correlations between age, gender, type of disease treated, the molecule used or daily dose and the risk of adverse effects. Patients who received a corticosteroid dose of more than 40 mg daily (longer than 3 months) or a high cumulative dose of corticosteroids had a high risk of adverse effects.

CONCLUSION

Repetitive infections and cutaneous adverse reactions are the most frequent adverse effects of long-term oral corticosteroid use. Prescribing the lowest effective dose may reduce the risk of these adverse effects. Furthermore, prevention of the adverse effects of corticosteroids through diet, calcium and vitamin D supplementation is strongly recommended during long-term oral corticosteroid therapy.

Don't forget me in amidst of COVID-19 pandemic: A case series and review of literature on steroid associated psychiatric manifestations

There is a sudden upsurge in the use of steroids due to the ongoing COVID-19 pandemic, especially in patients with severe or critical COVID-19 infection. There are reports of excessive use of steroids, both in terms of use in patients who do not require the same and use in doses higher than the recommended. There are reports of the emergence of different adverse outcomes of excessive steroid use in the form of diabetes mellitus and a higher incidence of mucormycosis. However, little attention has been paid to the mental health impact of the use of steroids. This review attempts to evaluate the existing data in terms of incidence of psychiatric side effects of steroids, and the risk factors for steroid associated psychiatric manifestations. Additionally, an attempt is made to discuss the pathogenesis of steroid-associated psychiatric side effects and why it is likely that the incidence of psychiatric side effects may be more in patients with COVID-19 infection. There is a need to improve the awareness about the psychiatric side effects of steroids, both among the physicians and mental health professionals, as in any patient presenting with new-onset psychiatric symptoms while having COVID-19 infection or during the post-COVID-19 infection phase, a possibility of steroid associated side effect needs to be considered.

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There is a sudden upsurge in the use of steroids due to the ongoing COVID-19 pandemic, especially in patients with severe or critical COVID-19 infection.

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Little attention has been paid to the mental health impact of the use of steroids in patients with COVID-19; This narrative review attempts to evaluate the existing data in terms of incidence of psychiatric side effects of steroids, and the risk factors.

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The pathogenesis of steroid-associated psychiatric side effects and why it is likely that the incidence of psychiatric side effects may be more in patients with COVID-19 infection is discussed.

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There is a need to improve the awareness about the psychiatric side effects of steroids, both among the physicians and mental health professionals, as in any patient presenting with new-onset psychiatric symptoms while having COVID-19 infection or during the post-COVID-19 infection phase, a possibility of steroid associated side effect needs to be considered.

Synthetic corticosteroids as tryptophan hydroxylase stabilizers

Background: Clinically, corticosteroids are used mainly for their immune-modulatory properties but are also known to influence mood. Despite evidence of a role in regulating tryptophan hydroxylases (TPH), key enzymes in serotonin biosynthesis, a direct action of corticosteroids on these enzymes has not been systematically investigated. Methodology & results: Corticosteroid effects on TPHs were tested using an in vitro assay. The compound with the strongest modulatory effect, beclomethasone dipropionate, activated TPH1 and TPH2 with low micromolar potency. Thermostability assays suggested a stabilizing mechanism, and computational docking indicated that beclomethasone dipropionate interacts with the TPH active site. Conclusion: Beclomethasone dipropionate is a stabilizer of TPHs, acting as a pharmacological chaperone. Our findings may inspire further development of steroid scaffolds as putative antidepressant drugs.

A Case Report of Kratom-Induced Psychosis

This case report details a patient with a complex medical history who was brought for psychiatric evaluation. An abrupt switch in Kratom use patterns was identified as the most likely causative factor of his symptoms. Adrenal insufficiency and posttraumatic stress disorder (PTSD) were considered both in the differential and potential confounding factors in his presentation. This paper discusses current Kratom use trends in the United States, the drug's legal status, and the common reasons patients may use it. Additionally, research gaps regarding the safety and efficacy of Kratom's use for self-medication are addressed.

Medicolegal Considerations Regarding Steroid Use in Otolaryngology: A Review of the Literature

OBJECTIVE

To review the literature on corticosteroid use and provide recommendations on patient counseling and/or consent to promote judicious prescribing and reduce the incidence of corticosteroid-related lawsuits.

METHOD

A conventional literature search of PubMed on corticosteroid-related medicolegal cases was undertaken. Search terms included "medicolegal," "otolaryngology," and "adrenocorticosteroids." A medical subjects headings search with the keywords "adrenal cortex hormones" and "jurisprudence" was also performed.

RESULTS

Corticosteroids have been reported as the third most frequent medication involved in malpractice claims, oftentimes leading to disproportionately costly payments. The most common specialties found to be involved in corticosteroid related medicolegal cases included dermatology (12%), primary care (10%), and neurologists or neurosurgeons (6%). The most common complications encountered were avascular necrosis (39%), changes in mood (16%), infection (14%), and vision changes (14%). Only a few cases corticosteroid-related litigation regarding otolaryngologists were identified. More frequent causes for otolaryngology claims were intraoperative complications, deficits in diagnoses, and failures or delays in treatment. Three medicolegal pitfalls regarding corticosteroid use were identified from this review included: (1) insufficient advising, (2) lack of or incomplete informed consent, and (3) the significance of the patient-physician relationship.

CONCLUSION

Despite the scarcity of corticosteroid-related medicolegal literature pertaining to otolaryngologists, corticosteroids are one of the most widely prescribed medications in the field of otolaryngology and have been shown to have a high rate of medical malpractice claims in medicine. Counseling and consenting the patient, as well as developing a strong physician-patient relationship, are integral processes in addressing any adverse effects occurring during therapy, and may also help to decrease the incidence and success of litigation against otolaryngologists.

Cannabidiol-Driven Alterations to Inflammatory Protein Landscape of Lipopolysaccharide-Activated Macrophages In Vitro May Be Mediated by Autophagy and Oxidative Stress

Background: The nonpsychotropic phytocannabinoid cannabidiol (CBD) presents itself as a potentially safe and effective anti-inflammatory treatment relative to clinical standards. In this present study, we compare the capacity of CBD to the corticosteroid dexamethasone (Dex) in altering the secreted protein landscape of activated macrophages and speculate upon the mechanism underpinning these alterations. Materials and Methods: Human THP-1 monocytes were differentiated into macrophages (THP-1 derived macrophages [tMACs]), activated with lipopolysaccharide (LPS), and then treated with 5, 10, 25, 50, or 100 μM CBD or 10 μM Dex for 24 h. Following treatment, cytotoxicity of CBD and protein expression levels from culture supernatants and from whole cell lysates were assessed for secreted and intracellular proteins, respectively. Results: High concentration (50 and 100 μM) CBD treatments exhibit a cytotoxic effect on LPS-activated tMACs following the 24-h treatment. Relative to the LPS-activated and untreated control (M[LPS]), both 25 μM CBD and 10 μM Dex reduced expression of pro-inflammatory markers-tumor necrosis factor alpha, interleukin 1 beta, and regulated on activation, normal T cell expressed and secreted (RANTES)-as well as the pleiotropic marker interleukin-6 (IL-6). A similar trend was observed for anti-inflammatory markers interleukin-10 and vascular endothelial growth factor (VEGF). Dex further reduced secreted levels of monocyte chemoattractant protein-1 in addition to suppressing IL-6 and VEGF beyond treatments with CBD. The anti-inflammatory capacity of 25 μM CBD was concurrent with reduction in levels of phosphorylated mammalian target of rapamycin Ser 2448, endothelial nitric oxide synthase, and induction of cyclooxygenase 2 relative to M(LPS). This could suggest that the observed effects on macrophage immune profile may be conferred through inhibition of mammalian target of rapamycin complex 1 and ensuing induction of autophagy. Conclusion: Cumulatively, these data demonstrate cytotoxicity of high concentration CBD treatment. The data reported herein largely agree with other literature demonstrating the anti-inflammatory effects of CBD. However, there is discrepancy within literature surrounding efficacious concentrations and effects of CBD on specific secreted proteins. These data expand upon previous work investigating the effects of CBD on inflammatory protein expression in macrophages, as well as provide insight into the mechanism by which these effects are conferred.

Trichotillomania in a child with nephrotic syndrome: An unusual steroid induced psychiatric manifestation

Steroid-induced psychosis is a known serious adverse effect seen commonly in adults but less commonly in children. We present a seven-year-old girl with steroid-dependent nephrotic syndrome who developed abnormal behaviour, trichotillomania, alopecia and mood changes. She was investigated to rule out other causes and treated with tapering steroids, fluoxetine and olanzapine. A marked improvement was noted after two months. Patients on long term or high dose steroids should be monitored for adverse psychological effects of steroids, as early recognition and intervention can improve the outcome.

New-onset psychosis due to COVID-19

This is a case report of a middle-aged man with no psychiatric history who presented with severe anxiety and psychotic symptoms from COVID-19. Following his discharge from intensive care unit, he was unable to sleep, was increasingly agitated and was observed hitting his head off the walls, causing haematomas. He remained highly anxious and developed paranoid delusions and auditory and tactile hallucinations, needing admission to a psychiatric ward. Treatment with antipsychotic medication gradually improved his symptoms in a few weeks. This case report highlights the new onset of psychosis due to COVID-19 infection. It demonstrates the importance of early identification and treatment of neuropsychiatric complications within an acute hospital setting. Furthermore, there is a need for research in this area to help in the prevention and treatment of such psychiatric complications due to COVID-19.

Association Between Dexamethasone and Delirium in Critically Ill Patients: A Retrospective Cohort Study of a Large Clinical Database

BACKGROUND

Delirium is a common complication in intensive care unit (ICU) patients, and it can significantly increase the length of hospital stay and cost. Dexamethasone is widely used in various inflammatory diseases and must be used with caution in critically ill patients. Previous studies have shown that the effect of corticosteroid use on the development of delirium in critically ill patients is still controversial, and there is inconclusive conclusion about the effect of dexamethasone on delirium in such patients. Therefore, this study aimed to confirm the effect of dexamethasone use and the dose on the incidence of delirium and patient prognosis in critically ill patients through a large cohort study.

METHODS

A retrospective cohort study was conducted using data extracted from the Medical Information Mart for Intensive Care III database, which is a large and freely available database of all 46,476 patients who visited Beth Israel Deaconess Medical Center in Boston, Massachusetts, USA and were admitted to the ICU between 2001 and 2012. The primary outcome was the development of delirium, using multivariate logistic regression analysis to reveal the relationship between dexamethasone and delirium. Secondary endpoints were in-hospital mortality, ICU mortality, total length of stay, and length of ICU stay, and the relationship between dexamethasone and prognosis was assessed with Cox proportional hazards models. Propensity score matching with 1:1 grouping was used to eliminate the effect of confounders on both cohorts. The locally weighted scatter plot smoothing technique was used to investigate the dose correlation between dexamethasone and outcomes, subgroup analysis was used to account for heterogeneity, and different correction models and propensity matching analysis were used to eliminate potential confounders.

RESULTS

Finally, 38,509 patients were included, and 2204 (5.7%) used dexamethasone. No significant statistical difference was observed in basic demographic information after propensity score matching between the two study groups. A significantly higher incidence of delirium (5.0% versus 3.4%, P < 0.001), increased in-hospital mortality (14.9% versus 10.3%, P < 0.001), ICU mortality (9.0% versus 7.5%, P = 0.008), and longer length of stay and ICU stay were observed in patients taking dexamethasone compared with those not taking dexamethasone. Multivariate logistic and Cox regression analyses confirmed that dexamethasone was significantly associated with delirium (adjusted odds ratio = 1.48, 95% confidence interval [CI] = 1.09-2.00, P = 0.012), in-hospital mortality (adjusted hazard ratio = 1.19, 95% CI = 1.02-1.40, P = 0.032), and ICU mortality (adjusted hazard ratio = 1.62, 95% CI = 1.22-2.15, P = 0.001). Compared with critically ill patients using high-dose dexamethasone, the risk of delirium was lower in the dose less than the 10 mg group, and patients using 10-14 mg may be associated with a lower risk of in-hospital death and the least ICU mortality, length of hospital stay, and ICU stay.

CONCLUSIONS

This study demonstrated that the use of dexamethasone in critically ill patients exacerbated the occurrence of delirium while increasing the risk of in-hospital death, ICU death, and length of hospital stay, with a lower risk of delirium and a shorter total length of hospital stay with low-dose dexamethasone than with larger doses.

Volatile and Intravenous Anesthetics for Brain Protection in Cardiac Surgery: Does the Choice of Anesthesia Matter?

Postoperative neurologic complications have a significant effect on morbidity, mortality, and long-term disability in patients undergoing cardiac surgery. The etiology of brain injury in patients undergoing cardiac surgery is multifactorial and remains unclear. There are several perioperative causative factors for neurologic complications, including microembolization, hypoperfusion, and systemic inflammatory response syndrome. Despite technologic advances and the development of new anesthetic drugs, there remains a high rate of postoperative neurologic complications. Moreover, despite the strong evidence that volatile anesthesia exerts cardioprotective effects in patients undergoing cardiac surgery, the neuroprotective effects of volatile agents remain unclear. Several studies have reported an association of using volatile anesthetics with improvement of biochemical markers of brain injury and postoperative neurocognitive function. However, there is a need for additional studies to define the optimal anesthetic drug for protecting the brain in patients undergoing cardiac surgery.

Safety of epidural steroids: a review

Spine disease is one of the most common musculoskeletal diseases, especially in an aging society. An epidural steroid injection (ESI) is a highly effective treatment that can be used to bridge the gap between physical therapy and surgery. Recently, it has been increasingly used clinically. The purpose of this article is to review the complications of corticosteroids administered epidurally. Common complications include: hypothalamic-pituitary-adrenal (HPA) axis suppression, adrenal insufficiency, iatrogenic Cushing's syndrome, hyperglycemia, osteoporosis, and immunological or infectious diseases. Other less common complications include psychiatric problems and ocular ailments. However, the incidence of complications related to epidural steroids is not high, and most of them are not serious. The use of nonparticulate steroids is recommended to minimize the complications associated with epidural steroids. The appropriate interval and dosage of ESI are disputed. We recommend that the selection of appropriate ESI protocol should be based on the suppression of HPA axis, which reflects the systemic absorption of the corticosteroid.

Hallucinations: diagnosis, neurobiology and clinical management

Hallucinations are important diagnostic symptoms in schizophrenia, but also occur in other medical and neuropsychiatric conditions. Not all patients with hallucinations are psychotic. There has been a surge of interest in the topic of hallucinations, as new research data have begun to reveal their neurobiology. Hallucinogenic molecules may also serve as new scaffolds for the development of new psychotropic drugs. We searched and reviewed recent literature, focusing on the refinement of clinical management, which was inspired by new data regarding the neurobiology of hallucination subtypes. We concluded that the successful management of hallucinations depends on accurate differential diagnosis to identify subtypes, which would then determine the most appropriate treatment.

Response to the Novel Corona Virus (COVID-19) Pandemic Across Africa: Successes, Challenges, and Implications for the Future

BACKGROUND

The COVID-19 pandemic has already claimed considerable lives. There are major concerns in Africa due to existing high prevalence rates for both infectious and non-infectious diseases and limited resources in terms of personnel, beds and equipment. Alongside this, concerns that lockdown and other measures will have on prevention and management of other infectious diseases and non-communicable diseases (NCDs). NCDs are an increasing issue with rising morbidity and mortality rates. The World Health Organization (WHO) warns that a lack of nets and treatment could result in up to 18 million additional cases of malaria and up to 30,000 additional deaths in sub-Saharan Africa.

OBJECTIVE

Document current prevalence and mortality rates from COVID-19 alongside economic and other measures to reduce its spread and impact across Africa. In addition, suggested ways forward among all key stakeholder groups.

OUR APPROACH

Contextualise the findings from a wide range of publications including internet-based publications coupled with input from senior-level personnel.

ONGOING ACTIVITIES

Prevalence and mortality rates are currently lower in Africa than among several Western countries and the USA. This could be due to a number of factors including early instigation of lockdown and border closures, the younger age of the population, lack of robust reporting systems and as yet unidentified genetic and other factors. Innovation is accelerating to address concerns with available equipment. There are ongoing steps to address the level of misinformation and its consequences including fines. There are also ongoing initiatives across Africa to start addressing the unintended consequences of COVID-19 activities including lockdown measures and their impact on NCDs including the likely rise in mental health disorders, exacerbated by increasing stigma associated with COVID-19. Strategies include extending prescription lengths, telemedicine and encouraging vaccination. However, these need to be accelerated to prevent increased morbidity and mortality.

CONCLUSION

There are multiple activities across Africa to reduce the spread of COVID-19 and address misinformation, which can have catastrophic consequences, assisted by the WHO and others, which appear to be working in a number of countries. Research is ongoing to clarify the unintended consequences given ongoing concerns to guide future activities. Countries are learning from each other.

Psychiatric comorbidity in individuals with bullous pemphigoid and all bullous disorders in the Danish national registers

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune blistering skin disease that takes a profound physical and mental toll on those affected. The aim of the study was to investigate the bidirectional association between BP and all bullous disorders (ABD) with a broad array of psychiatric disorders, exploring the influence of prescribed medications.

METHODS

This nationwide, register-based cohort study encompassed 6,470,450 individuals born in Denmark and alive from 1994 to 2016. The hazard ratios (HRs) of a subsequent psychiatric disorder in patients with BP/ABD and the reverse exposure and outcome were evaluated.

RESULTS

Several psychiatric disorders were associated with increased risk of subsequent BP (4.18-fold for intellectual disorders, 2.32-fold for substance use disorders, 2.01-fold for schizophrenia and personality disorders, 1.92-1.85-1.49-fold increased risk for organic disorders, neurotic and mood disorders), independent of psychiatric medications. The association between BP and subsequent psychiatric disorders was not significant after adjusting for BP medications, except for organic disorders (HR 1.27, CI 1.04-1.54). Similar results emerged with ABD.

CONCLUSION

Psychiatric disorders increase the risk of a subsequent diagnosis of BP/ABD independent of medications, whereas medications used for the treatment of BP/ABD appear to account for the subsequent onset of psychiatric disorders. Clinically, an integrated approach attending to both dermatological and psychiatric symptoms is recommended, and dermatologists should remain vigilant for early symptoms of psychiatric disorders to decrease mental health comorbidity.

Severe acute respiratory syndrome coronavirus 2 may be an underappreciated pathogen of the central nervous system

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) causes a highly contagious respiratory disease referred to as COVID‐19. However, emerging evidence indicates that a small but growing number of COVID‐19 patients also manifest neurological symptoms, suggesting that SARS‐CoV‐2 may infect the nervous system under some circumstances. SARS‐CoV‐2 primarily enters the body through the epithelial lining of the respiratory and gastrointestinal tracts, but under certain conditions this pleiotropic virus may also infect peripheral nerves and gain entry into the central nervous system (CNS). The brain is shielded by various anatomical and physiological barriers, most notably the blood–brain barrier (BBB) which functions to prevent harmful substances, including pathogens and pro‐inflammatory mediators, from entering the brain. The BBB is composed of highly specialized endothelial cells, pericytes, mast cells and astrocytes that form the neurovascular unit, which regulates BBB permeability and maintains the integrity of the CNS. In this review, potential routes of viral entry and the possible mechanisms utilized by SARS‐CoV‐2 to penetrate the CNS, either by disrupting the BBB or infecting the peripheral nerves and using the neuronal network to initiate neuroinflammation, are briefly discussed. Furthermore, the long‐term effects of SARS‐CoV‐2 infection on the brain and in the progression of neurodegenerative diseases known to be associated with other human coronaviruses are considered. Although the mechanisms of SARS‐CoV‐2 entry into the CNS and neurovirulence are currently unknown, the potential pathways described here might pave the way for future research in this area and enable the development of better therapeutic strategies.

Steroid-induced Psychosis in Adolescent Patient with Crohn's Disease

Crohn’s disease is a chronic inflammatory disease that involves the upper and lower gastrointestinal tracts, including the oral cavity. For the conventional treatment of inflammatory bowel diseases, steroids are usually used as induction therapy, and azathioprine is used as maintenance therapy. Steroids are associated with various side effects. Under rare circumstances, they can even cause psychotic symptoms, and reports on steroid-induced psychosis in the pediatric population are few. Here, we report the first case of steroid-induced psychosis in a 16-year-old female with Crohn’s disease administered with steroids as induction therapy in South Korea. She showed psychotic symptoms, including auditory hallucination, loosening of association, and idea of reference, after 2 weeks of administering prednisolone 60 mg/day. One week after steroid discontinuation, the patient gradually recovered and was treated with quetiapine. Therefore, pediatricians should be aware of serious psychiatric adverse effects when administering corticosteroids for various indications.

Pitolisant protects mice chronically treated with corticosterone from some behavioral but not metabolic changes in corticosterone-induced depression model

PURPOSE

Histamine H₃ receptor ligands may have antidepressant and anxiolytic effects. They can also compensate for metabolic disorders, which affect glucose or triglyceride levels. In previous studies, we have shown that pitolisant, a histamine H₃ receptor antagonist/inverse agonist and σ1 receptor agonist, prevented the development of certain metabolic and depressive-like disorders in mice that have been treated chronically with olanzapine.

METHODS

As a continuation of our previous experiments, this study aimed to investigate the antidepressant- and anxiolytic-like activity of pitolisant in mice using the corticosterone-induced depression model. The forced swim and the elevated plus maze tests were used as behavioral endpoints. We also studied the effect pitolisant had on the level of acetoacetic acid in the urine as well as the glucose tolerance and body weight of the mice that had been administered corticosterone.

RESULTS

Pitolisant (10 mg/kg b.w.) did not prevent depressive-like behavior in mice during the chronic corticosterone administration but did counteract anxiety-like behavior, whilst fluoxetine (10 mg/kg) was shown to protect the mice from both of these behaviors. None of the treatments that were used in the study showed an effect on the locomotor activity of the mice. Pitolisant did not prevent an increase in acetoacetic acid levels in the urine, nor did it improve glucose tolerance in the tested mice.

CONCLUSION

Although literature data indicates that there is significant potential for finding an antidepressant and anti-diabetic drug among the histamine H₃ and σ1 receptor ligands, in our study, pitolisant was shown to only slightly compensate for corticosterone-induced abnormalities. However, further research will be required to study pitolisant's anxiolytic-like activity.

Psychiatric Adverse Events Associated With Infliximab: A Cohort Study From the French Nationwide Discharge Abstract Database

Introduction

Infliximab (IFX) was the first anti-tumor necrosis factor (TNFα) antibody to be used in the treatment of severe chronic inflammatory diseases, such as Crohn’s disease and rheumatoid arthritis. A number of serious adverse drug reactions are known to be associated with IFX use; they include infections, malignancies, and injection site reactions. Although a few case reports have described potential psychiatric adverse events (including suicide attempts and manic episodes), the latter are barely mentioned in IFX’s summary of product characteristics. The objective of the present retrospective study was to detect potential psychiatric adverse events associated with IFX treatment by analyzing a national discharge abstract database.

Materials and Methods

We performed an historical cohort study by analyzing data from the French national hospital discharge abstract database (PMSI) between 2008 and 2014. All patients admitted with one of the five diseases treated with IFX were included.

Results

Of the 325,319 patients included in the study, 7,600 had been treated with IFX. The proportion of hospital admissions for one or more psychiatric events was higher among IFX-exposed patients (750 out of 7,600; 9.87%) than among non-exposed patients (17,456 out of 317,719; 5.49%). After taking account of potential confounders in the cohort as a whole, a semi-parametric Cox regression analysis gave an overall hazard ratio (HR) [95% confidence interval] (CI) of 4.5 [3.95; 5.13] for a hospital admission with a psychiatric adverse event during treatment with IFX. The HR (95%CI) for a depressive disorder was 4.97 (7.35; 6.68). Even higher risks were observed for certain pairs of adverse events and underlying pathologies: psychotic disorders in patients treated for ulcerative colitis (HR = 5.43 [2.01; 14.6]), manic episodes in patients treated for severe psoriasis (HR = 12.6 [4.65; 34.2]), and suicide attempts in patients treated for rheumatoid arthritis (HR = 4.45 [1.11; 17.9]).

Discussion

The present retrospective, observational study confirmed that IFX treatment is associated with an elevated risk of psychiatric adverse events. Depending on the disease treated, physicians should be aware of these potential adverse events.

Late-onset mania associated with corticosteroids and small cell lung carcinoma

Episodes of mania typically occur in the context of bipolar disorder, with an average age of onset of 25 years. A condition with identical symptoms, known as secondary mania, generally occurs in isolation in older adults and has an identifiable organic etiology. Here, we report a 57-year-old man who presented to the emergency department with a 3 weeks history of sudden onset mania with psychotic symptoms. He had no previous psychiatric history, and his presentation coincided with the initiation of a course of steroids. Despite the absence of physical symptoms, investigations revealed a previously undetected adrenocorticotropic hormone-releasing small cell lung carcinoma that led to his death within months. This case highlights the complexity of distinguishing primary from secondary mania when it occurs after the peak incidence period of early adulthood. Undertaking a comprehensive medical workup is generally recommended.

Depression and Anxiety in Patients with Bullous Pemphigoid: Impact and Management Challenges

Bullous pemphigoid is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. It is also associated with high mortality and poor prognosis due to advanced age of the patients and coexisting comorbidities. There is a dearth of data in the literature regarding depression and anxiety among those patients. The objective of this brief review is to discuss the intertwining relationship between depression and anxiety with bullous pemphigoid.

Selective effects of dorsal raphé nucleus glucocorticoid receptor deletion on depression-like behavior in female C57BL/6J mice

We have shown differing effects of glucocorticoid receptor (GR) deletion from the dorsal raphé nucleus (DRN) and locus coeruleus (LC) on depression-relevant behavior in male mice, but DRN GR deletion has not been tested in female mice. Female floxed GR mice were given DRN injections of AAV2/9 pseudotype viral vectors transducing Cre recombinase to produce DRN GR gene deletion (Cre) and compared with mice receiving DRN injections of AAV2/9 transducing green fluorescent protein (GFP). Social interaction, a measure of depression-like withdrawal, was unaffected by DRN GR deletion, but forced swim immobility, a measure of despair-like passivity, was reduced in female Cre vs. GFP mice. Behavioral effects were not attributable to changes in basal corticosterone or LC GR deletion. Combined with our prior studies, the current findings suggest that DRN GR have sex-independent effects to promote forced swim immobility, but influence social interaction only in male mice. Differential effects of DRN GR deletion in female mice may provide insight into the greater incidence of depression and specific depression symptoms in women.

The Montreal Cognitive Assessment Test: A Useful Tool in Screening of Cognitive Impairment in Patients With Systemic Lupus Erythematosus

BACKGROUND/OBJECTIVE

Systemic lupus erythematosus (SLE) is an inflammatory, chronic, and multisystemic disease, which may be associated with a wide range of neuropsychiatric manifestations, including cognitive impairment. Cognitive evaluations based on screening tests might identify early SLE-related cognitive alterations. The aim of this study was to evaluate and to compare the efficacy of three screening tests (Montreal Cognitive Assessment [MoCA], Mini Mental State Examination [MMSE], Cognitive Symptom Inventory [CSI]) against the gold standard (neuropsychological battery), in order to identify the most efficient screening test for cognitive impairment in patients with SLE.

METHODS

This observational cross-sectional study recruited 44 patients, from August to December 2017, who were diagnosed with SLE according to the Systemic Lupus International Collaborating Clinics (SLICC) Criteria 2012, and had no medical or psychiatric comorbidities. The patients were evaluated using the MoCA, MMSE, CSI, and the gold standard. Spearman's correlation and area under the curve analysis were performed; p < 0.05 was considered significant.

RESULTS

The MoCA test showed the highest correspondence with the gold standard (AUC = 99.4%, p < 0.001), sensitivity (84%), and specificity (100%). This was followed by the MMSE (AUC = 92.6%, p < 0.001; sensitivity, 54.8%; specificity, 100%) and the CSI (AUC = 30.6%, p < 0.05; sensitivity, 54.8%; specificity, 30.76%).

CONCLUSION

The MoCA is a brief, easily applied screening test that is highly effective for detecting cognitive impairment in SLE patients. It could be useful in clinical follow-up as a tool for early detection of cognitive alterations.

Rheumatoid arthritis and neurodegenerative dementia: a nested case-control study and a follow-up study using a national sample cohort

OBJECTIVES

The present study evaluated the associations between rheumatoid arthritis (RA) and neurodegenerative dementia using a Korean national sample cohort.

METHODS

We designed two studies using the Korean National Health Insurance Service-National Sample Cohort from 2002 to 2013. Study I included participants with dementia matched 1:4 with controls and analyzed the participants' history of RA. Study II included participants with RA matched 1:4 with controls and analyzed the occurrence of dementia. RA was defined by the presence of relevant ICD-10 codes (M05 or M06) and medication histories. Neurodegenerative dementia was defined using ICD-10 codes (G30 or F00). Crude and adjusted odds ratios (ORs) were analyzed using conditional logistic regression analyses. Crude and adjusted hazard ratios (HRs) were analyzed using the stratified Cox proportional hazard model. Subgroup analyses were performed on groups stratified by age and sex.

RESULTS

The adjusted ORs for RA were 0.96 (95% CI = 0.78-1.16, P = 0.644) in the dementia group in study I. The adjusted HRs for dementia were 0.91 (95% CI = 0.76-1.10, P = 0.319) in the RA group in study II. No subgroup analysis reached the statistical significance level.

CONCLUSION

We could not identify any significant relationship between RA and dementia.Key Points• Two studies were conducted to identify the relationship between rheumatoid arthritis and dementia using national cohort data.• Neither study showed any association between rheumatoid arthritis and dementia.

The human stress response

The human stress response has evolved to maintain homeostasis under conditions of real or perceived stress. This objective is achieved through autoregulatory neural and hormonal systems in close association with central and peripheral clocks. The hypothalamic-pituitary-adrenal axis is a key regulatory pathway in the maintenance of these homeostatic processes. The end product of this pathway - cortisol - is secreted in a pulsatile pattern, with changes in pulse amplitude creating a circadian pattern. During acute stress, cortisol levels rise and pulsatility is maintained. Although the initial rise in cortisol follows a large surge in adrenocorticotropic hormone levels, if long-term inflammatory stress occurs, adrenocorticotropic hormone levels return to near basal levels while cortisol levels remain raised as a result of increased adrenal sensitivity. In chronic stress, hypothalamic activation of the pituitary changes from corticotropin-releasing hormone-dominant to arginine vasopressin-dominant, and cortisol levels remain raised due at least in part to decreased cortisol metabolism. Acute elevations in cortisol levels are beneficial to promoting survival of the fittest as part of the fight-or-flight response. However, chronic exposure to stress results in reversal of the beneficial effects, with long-term cortisol exposure becoming maladaptive, which can lead to a broad range of problems including the metabolic syndrome, obesity, cancer, mental health disorders, cardiovascular disease and increased susceptibility to infections. Neuroimmunoendocrine modulation in disease states and glucocorticoid-based therapeutics are also discussed.

Acute-onset Mania in a Patient with Non-small Cell Lung Cancer

Mania is a mood disorder characteristic of certain psychiatric conditions and is exhibited by high energy, elevated mood, irritability, insomnia, and pressured speech. Though commonly attributed to bipolar and schizoaffective disorders, mania may be precipitated by other non-psychiatric conditions, including substance abuse, medications, metabolic disturbance, and organic brain pathology. Steroid-induced mania is not uncommon and may present with a number of psychiatric symptoms. Brain tumors presenting with predominantly psychiatric symptoms are a relatively uncommon cause of mania and may persist or recede with treatment. A case of mania in a cancer patient with brain metastasis and steroid use, with no prior history of mania, is discussed herein.

Steroid-induced psychosis

Steroid-induced psychosis is a well-documented phenomenon. It usually occurs with oral systemic steroid treatment and is more common at higher doses, although there are case reports of occurrence with local steroid injections. We report a case of a 35-year-old man with no previous history of psychosis who was seen for follow-up after a brief psychotic episode following an injection of 5 mg of dexamethasone into his scrotum the previous day. The injection was given to treat chronic pain from a combat injury.

Memory, stress, and the hippocampal hypothesis: Firefighters' recollections of the fireground

Nadel, Jacobs, and colleagues have postulated that human memory under conditions of extremely high stress is "special." In particular, episodic memories are thought to be susceptible to impairment, and possibly fragmentation, attributable to hormonally based dysfunction occurring selectively in the hippocampal system. While memory for highly salient and self-relevant events should be better than the memory for less central events, an overall nonmonotonic decrease in spatio/temporal episodic memory as stress approaches traumatic levels is posited. Testing human memory at extremely high levels of stress, however, is difficult and reports are rare. Firefighting is the most stressful civilian occupation in our society. In the present study, we asked New York City firefighters to recall everything that they could upon returning from fires they had just fought. Communications during all fires were recorded, allowing verification of actual events. Our results confirmed that recall was, indeed, impaired with increasing stress. A nonmonotonic relation was observed consistent with the posited inverted u-shaped memory-stress function. Central details about emergency situations were better recalled than were more schematic events, but both kinds of events showed the memory decrement with high stress. There was no evidence of fragmentation. Self-relevant events were recalled nearly five times better than events that were not self-relevant. These results provide confirmation that memories encoded under conditions of extremely high stress are, indeed, special and are impaired in a manner that is consistent with the Nadel/Jacobs hippocampal hypothesis.

Major Depressive Disorder in Medical Illness: A Review of Assessment, Prevalence, and Treatment Options

Major depression, as well as other depressive disorders, is commonly comorbid with other medical illnesses, particularly chronic and systemic medical illnesses. The co-occurrence of the disorders is so common that it challenges our notions of the meaning of comorbidity and our desire to neatly separate psychiatric and medical illnesses. The overlap between symptoms of physical illness and the neurovegetative symptoms of major depression and the initial normative emotional response to physical illness add to the challenge of accurate diagnosis and timely treatment of depression in the medically ill. We review the literature on the comorbidity of depression and the various medical illnesses, including diagnostic and treatment approaches. The differential diagnosis for major depression among medically ill patients should include delirium and medication-induced symptoms. We suggest that major depression itself may be best conceptualized as a systemic illness whose pathophysiology overlaps with other systemic medical illnesses. The initial treatment strategies for major depression in medical illness are like those for the general population; however, the comorbid medical illnesses may interfere with remission. To illustrate these points, we describe a patient with clinical characteristics covered in this review who experienced major depression as well as several chronic illnesses, including hypersensitivity pneumonitis, multiple sclerosis, chronic pain due to degenerative joint disease, and diabetes mellitus.

When translational neuroscience fails in the clinic: Dexamethasone prior to virtual reality exposure therapy increases drop-out rates

Posttraumatic stress disorder (PTSD) is characterized by exaggerated expression of fear responses to danger and safety cues. Translational research suggests that dexamethasone facilitates fear extinction in animal and human fear conditioning models. For this randomized, placebo-controlled trial (N = 27), we aimed to translate these findings to the clinic by using virtual reality exposure (VRE) therapy for OEF/OIF/OND veterans with PTSD to determine whether dexamethasone will increase the efficacy of exposure therapy for VRE relative to placebo. VRE sessions involved imaginal exposure to the most traumatic war memories while viewing a computer-generated view of virtual Iraq or Afghanistan with multisensory stimulus options used to match patient's description of the trauma. VRE was effective in reducing PTSD symptoms but there was no interaction with dexamethasone. Drop-out rate was significantly higher in the dexamethasone group, with 10 of 13 (76.9%) participants in this group discontinuing, compared to only 4 of 14 (28.5%) in the placebo group, χ² = 6.31, p = 0.02. Results indicate that the dexamethasone group may have experienced an increase in PTSD symptoms, particularly re-experiencing, at session 2 following first drug administration. Contrary to study hypotheses, dexamethasone did not enhance exposure therapy outcomes and was associated with increased drop-out. This demonstrates potential pitfalls in translating neuroscience models to the clinic; future research carefully examining glucocorticoid mechanisms involved in therapy augmentation is warranted.

Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms

For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.

Glucocorticoids and the risk of schizophrenia spectrum disorder in childhood and adolescence - A Danish nationwide study

Glucocorticoids can have psychosis as a potential side effect, but have also been suggested to yield protective effects due to anti-inflammatory properties. Nonetheless, knowledge is sparse on the association between glucocorticoid treatment and development of psychosis, which we aimed to study in this first large-scale longitudinal study. Among all individuals born in Denmark 1995-2003 (n=597,257), we compared individuals who had redeemed ≥1 prescription for glucocorticoids to an active comparator group and a non-exposed group concerning subsequent development of schizophrenia spectrum disorders until 2013. Hazard rate ratios (HRR) were estimated using Cox regression adjusted for calendar year, age, gender, urbanization, somatic diseases, parental educational level and psychiatric history. The risk for a subsequent diagnosis of early-onset schizophrenia spectrum disorder (N=1141) was increased after exposure to both non-systemic (HRR=1.47; 95%-CI=1.25-1.73; N=371) and systemic glucocorticoids (HRR=1.66; 95%-CI=1.13-2.43; N=34), when compared to non-exposed individuals. Similar elevated risks were observed when comparing to the active comparator group, for schizophrenia and acute psychosis, and within an older cohort. The risk of psychosis was elevated the most within the first year after exposure to glucocorticoids (P<0.001) without any indication for a dose-response association. However, in individuals with asthma, exposure to glucocorticoids did not further increase the risk of psychosis. Glucocorticoid exposure was associated with an increased risk for psychotic disorders, which may be explained by an effect of the underlying somatic disease, such as asthma. A potential beneficial effect of glucocorticoids on psychotic symptoms should be investigated in clinical trials.

Resilience and depression/anxiety symptoms in multiple sclerosis and neuromyelitis optica spectrum disorder

BACKGROUND

Depression and anxiety are common in multiple sclerosis (MS) and recently, studies on these symptoms in neuromyelitis optica spectrum disorder (NMOSD) are increasing. Previous studies suggest that these symptoms have negative effects on the quality of life. Resilience has garnered more interest as one of the protective factors that works to prevent psychiatric symptoms in past decades. There exist a few studies, however, regarding the effects of resilience on these psychiatric symptoms in MS/NMOSD.

OBJECTIVE

The aim of this study was to clarify the relationships between resilience, psychiatric symptoms, and QOL in patients with MS/NMOSD.

METHOD

Seventy-seven patients with MS/NMOSD participated in this study. They completed several questionnaires (Beck Depression Inventory-Second edition, Hospital Anxiety and Depression Scale, the Japanese version of the Resilience scale [RS], and Japanese version of Multiple Sclerosis Quality of Life-54). We also collected demographic and clinical data including age, sex, physical disability level (measured with the Expanded Disability Status Scale [EDSS]), and disease duration of the participants.

RESULTS

The EDSS scores showed significant negative correlations with QOL, unlike disease duration, which did not correlate with either the psychiatric symptoms or QOL. Additionally, there was no significant correlation between RS scores and EDSS scores or disease duration. We also found that resilience showed a significant negative correlation with psychiatric symptoms, and positive correlation with QOL.

CONCLUSION

These results suggest that resilience may serve to prevent or reduce depression/anxiety symptoms and maintain the QOL regardless of the physical disability level.

Behavioral, Psychiatric, and Cognitive Adverse Events in Older Persons Treated with Glucocorticoids

Background: Since the introduction of glucocorticoids (GCs) in the physician's pharmacological arsenal, it has been known that they are a cause of behavioral or psychiatric adverse events (BPAE), as well as of cognitive problems. To the best of our knowledge, the relationship between these adverse events and GCs in older persons has never been evaluated, except through case-reports or series with few cases. In this paper, a review of the literature regarding BPAEs and cognitive disorders in older people treated with CSs is undertaken. Methods: A comprehensive literature search for BPAEs was carried out on the three main bibliographic databases: EMBASE, MEDLINE and PsycINFO (NICE HDAS interface). Emtree terms were: Steroid, steroid therapy, mental disease, mania, delirium, agitation, depression, behavior change, dementia, major cognitive impairment, elderly. The search was restricted to all clinical studies and case reports with focus on the aged (65+ years) published in any language since 1998. Results: Data on the prevalence of the various BPAEs in older patients treated with GCs were very scarse, consisting mainly of case reports and of series with small numbers of patients. It was hence not possible to perform any statistical evaluation of the data (including meta-analysis). Amongst BPAEs, he possibility that delirium can be induced by GCs has been recently been questioned. Co-morbidities and polypharmacy were additional risk factors for BPAEs in older persons. Conclusions: Data on BPAEs in older persons treated with GCs, have several unmet needs that need to be further evaluated with appropriately designed studies.

Psychiatric sequelae of corticosteroid use in hematology in Australia: A qualitative study

Despite widespread steroid usage for treating hematological conditions, minimal attention focuses on associated psychiatric side-effects. In the present study, we examined hematology patients' experiences of high-dose steroid treatment. This was undertaken by the use of a qualitative, descriptive design, which included convenience sampling and the inductive, cyclic, and constant comparative thematic analysis of interview transcripts. Eighteen patients participated, who were diagnosed with lymphoma, myeloma, leukemia, or idiopathic thrombocytopenia purpura. Four themes emerged: side-effects, misattribution of cause, self-management, and fragmented information. The study results revealed that hematology patients administered steroids can experience negligible to extensive erratic side-effects, with severe adverse repercussions. Psychological reactions to steroids are often misattributed. Patients mostly self-manage adverse effects experienced and receive only fragmented preparatory information, often not understanding steroid side-effects. Nurses could provide helpful "in the moment" education for inpatients who misunderstood steroid-related adverse effects, such as aggressive urges. Adverse repercussions for family were occasionally evident. Education, support, and ongoing care for patients experiencing adverse steroid side-effects are inadequate. Health professionals need to develop patient- and family-centered educational resources for potential, unpredictable, and usually adverse steroid side-effects.

Adverse psychiatric effects of non-psychotropic medications

Patients presenting to psychiatrists frequently have comorbid medical conditions for which they are receiving treatment. A range of medications used for treatment of these conditions can have adverse effects resembling psychiatric symptoms. This article presents the results of our review of the literature on psychiatric adverse effects of various non-psychotropic medications, and discusses the mechanisms of such effects, their assessment and management. Among the commonly prescribed drugs found to have psychiatric adverse effects are corticosteroids, anti-Parkinsonian drugs, anti-epileptics, antiretrovirals, antibiotics, anticancer drugs, analgesics, drugs targeting endocrine and cardiovascular disorders, immunosuppressants, skeletal muscle relaxants and bronchodilators. Some adverse effects are predictable and dose dependent, whereas others are rare and idiosyncratic, and psychiatrists need to be aware of them for accurate diagnosis and appropriate treatment.

Cultural and quality-of-life considerations when administering corticosteroids as a therapeutic strategy for African American women living with systemic lupus erythematosus

OBJECTIVE

This study investigated the association among corticosteroids, emotional health, physical health, and work/regular activities of daily living in an ethnically diverse sample of women with systemic lupus erythematosus.

METHODS

A secondary analysis of data from the Medical University of South Carolina Lupus Database was conducted between confirmed cases of lupus (n = 224) and controls (n = 60). The sample comprised 57 Caucasian Americans, 141 Gullah African Americans (a subpopulation of African Americans from the Sea Islands of South Carolina and Georgia), and 86 non-Gullah African Americans.

RESULTS

Emotional health outcomes were better for women with systemic lupus erythematosus compared with controls. High emotional health scores may be influenced by cultural factors such as masking emotion, disease-coping mechanisms, religion, and strong familial and social support. Although a significant association was not detected between emotional health and work/regular activities of daily living, relationships were significant after adjusting for corticosteroid use.

CONCLUSION

These findings suggest corticosteroid use does influence the strength of the association between emotional health and work/regular activities of daily living.

Delirium in the Intensive Care Unit: Incidence, Risk Factors, and Impact on Outcome

Background:

The incidence and risk factors for delirium vary among studies.

Objective:

We aimed to determine the incidence, risk factors, and impact on outcome of delirium in a medical Intensive Care Unit (ICU) in Tunisia using a prospective observational study.

Patients:

All consecutive patients admitted to the ICU between May 2012 and April 2013 were included if they were aged more than 18 years and had an ICU stay of more than 24 h. Patients who had a cardiac arrest or have a history of dementia or psychosis were excluded. Patients eligible for the study were evaluated by the medical staff to detect delirium using the CAM-ICU.

Results:

A total of 206 patients were included, 167 did not present delirium and 39 (19%) were analyzed for delirium. Delirious patients had a significantly longer duration of mechanical ventilation (10 days[6–20] vs. 2 days[0–7]) respectively and length of stay in ICU (21.5 days [10.5–32.5] vs. 8 days [5–13]), with no impact on mortality. Delirium was associated with high incidence of unintentional removal of catheters (39% vs. 9%; P < 0.0001), endotracheal tubes (18% vs. 1%; P < 0.0001), and urinary catheters (28% vs. 2%, P < 0.0001). In multivariable risk regression analysis, age (odds ratio [OR] = 4.1, 95% confidence interval [CI]: 1.39–12.21; P = 0.01), hypertension (OR = 3.3, 95% CI: 1.31–8.13; P = 0.011), COPD (OR = 3.5, 95% CI: 1.47–8.59; P = 0.005), steroids (OR = 2.8, 95% CI: 1.05–7.28; P = 0.038), and sedation (OR = 5.4, 95% CI: 2.08–13.9; P < 0.0001) were independent risk factors for delirium. We did not find a relationship between delirium and mortality.

Conclusion:

Delirium is frequent in the ICU and is associated with poor outcome. Several risk factors for delirium are linked to intensive care environment.

The relationship of depression in asthma-chronic obstructive pulmonary disease overlap syndrome

Purpose

To clarify the relationship between asthma–chronic obstructive pulmonary disease overlap syndrome (ACOS) and depression.

Methods

We identified 10,911 patients who received an ACOS diagnosis and concurrent treatment between January 2000 and December 2009. Subjects without ACOS were included in the non-ACOS cohort (n = 10,911). Cox proportional hazard regression analysis was performed to compare the risk of depression between the ACOS and non-ACOS cohorts.

Results

The risk of depression was higher in the ACOS cohort than in the non-ACOS cohort (adjusted hazard ratios (aHRs) = 1.67, 95% confidence interval [CI] = 1.48–1.88). In the ACOS cohort, the aHRs for depression were [2.44 (95% CI = 1.45–4.11); 2.36 (95% CI = 1.58–3.52)] in patients [aged 20–39 years; without comorbidity]. In the ACOS cohort, the aHRs for depression were 1.70 (95% CI = 1.51–1.93) and 1.84 (95% CI = 1.55–2.19) in patients without inhaled corticosteroids (ICSs) and oral steroids (OSs) use, respectively. Moreover, the aHRs for the risk of depression were 1.16 (95% CI = 0.95–1.41) and 1.12 (95% CI = 0.96–1.29) in patients with ICSs and OSs use, respectively.

Conclusion

The risk of depression is higher in ACOS patients, even in those without comorbidities or in young adults. The events of the depression were not significant difference in patients receiving the ICSs/OSs between the ACOS and the non-ACOS cohorts.

Steroid-induced mental disorders in cancer patients: a systematic review

Corticosteroids are a central part of many cancer treatment regimens. Neuropsychiatric toxicity has complicated their use, including an association with a spectrum of symptoms, from insomnia, cognitive impairment and mood symptoms, to severe mental disorders, including mania, psychosis and severe depression. Although steroid-induced mental disorders were first reported in medicine more than 60 years ago, there is a dearth of evidence available to date on optimal treatment and prevention to guide cancer clinicians. We completed a systematic review of the current evidence for therapeutic and prophylactic interventions of steroid-induced mental disorders in cancer. We searched Medline, Embase and PsycINFO and selected studies related to steroid-induced mental disorder. The studies found were limited to case series and case reports only.