Status epilepticus in a patient treated with olanzapine and mirtazapine.

OBJECTIVE: Few cases of seizures associated with olanzapine therapy and even fewer with mirtazapine have been published, most of them in patients with confounding risk factors. Our objective was to report a case of Status epilepticus in a patient receiving olanzapine and mirtazapine, with no previous history of seizure and no confirmed underlying cause for seizure. CASE SUMMARY: A 48-year-old white, psychotic woman developed generalized tonic-clonic seizures that progressed to Status epilepticus during hospitalization. 4 days before the incident, mirtazapine (30 mg) was added to the treatment, while 2 days before the incident, the treatment switched from quetiapine to olanzapine, and mirtazapine was increased to 60 mg. No other toxic, metabolic, electrolyte or anatomic abnormality was identified. After discontinuation of olanzapine, the patient remained seizure-free. CONCLUSION: To our knowledge, this is the second reported case of Status epilepticus that has been associated with the use of olanzapine, while only one report of seizures, but none of Status epilepticus connected to mirtazapine is found in the literature. Although olanzapine has infrequently been associated with epileptogenic risk, it should be used cautiously especially when concomitant medication or other predisposing factors exist.

Is it possible to predict the long-term response to venlafaxine with the use of biological markers and psychophysiological methods?

INTRODUCTION: The present study investigated whether it is possible to predict the medium term response to venlafaxine using biological markers and psychophysiological methods. MATERIAL: Fourteen (14) patients aged 21-60 years suffering from Major Depression according to DSM-IV were included in the study. METHODS: The SCAN v 2.0 and the IPDE were used to assist clinical diagnosis. Patients were investigated with electrooculogram (EOG), Pattern-Reversal Visual Evoked Potentials (PR-VEPs), Dexamethasone Suppression Test (DST), D-fenfluramine Challenge Test, and brain Single Photon Emission Tomography (SPECT). Venlafaxine 150-225 mg per os daily was administered. The follow-up period was 2 years. STATISTICAL ANALYSIS: Chi-square test and ANOVA were used for the analysis of data. RESULTS: There was a lower left globus pallidus regional cerebral blood flow in patients with better response. On the contrary, chronic patients were closer to normality. DISCUSSION: The results of the current study provide preliminary evidence concerning our ability to predict response to venlafaxine and to understand its way of action.

Beneficial effect of long-acting injectable risperidone on the neurocognitive deficit of a schizophrenic patient: A case report.

We report the case of a 37-year-old female patient suffering from schizophrenia, disorganized type. Adherence to treatment was always a major problem. During the last 2 years the patient was disorganized and was refusing treatment. Since the patient was already receiving a very high (double) dose per os, it was decided to administer two 50 ml ampoules of long-acting, injectable risperidone plus 5 mg of haloperidol per os daily. After 80 days of treatment, all positive, negative and even neurocognitive symptoms improved markedly. Extrapyramidal side effects did not appear at any stage of treatment. The most impressive neurocognitive improvement concerned the clock drawing test, which was in parallel with her improvement in both the positive and negative symptoms of the PANSS.

Treatment guidelines for bipolar disorder: a critical review.

INTRODUCTION: The development of treatment guidelines emerged as an important element so as to standardize treatment and to provide clinicians with algorithms, which would be able to carry research findings to the everyday clinical practice. MATERIAL AND METHOD: The MEDLINE was searched with the combination of each one of the key words 'mania', 'manic', 'bipolar', 'manic-depression', 'manic-depressive' with 'treatment guidelines'. RESULTS: The search was updated until March 1st, 2004 and returned 224 articles. Twenty-seven papers concerning the publication of treatment algorithms were traced. DISCUSSION: Despite supposedly being evidence-based, guidelines for the treatment of bipolar disorder vary significantly across committees or working groups. Overall, however, at the first stage of the mania/hypomania algorithm, monotherapy with lithium, divalproex sodium or olanzapine is generally recommended. At latter stages combination therapy is strongly recommended. It is clearly stated that in bipolar depression antidepressants should be used only in combination with antimanic agents in order to avoid switching of phases. During the maintenance phase all patients should receive antimanic agents, while some may need the addition of antidepressants. The most recent guidelines emphasize the use of atypical antipsychotics for mania and lamotrigine for depression. The main problem with guidelines is that they are rapidly outdated and that the evidence base relies mainly on registration monotherapy trials that hardly reflect treatment in routine clinical conditions. CONCLUSION: Treatment guidelines may be useful to avoid non-evidence-based treatment decisions, but they are quickly out-of-date and may not fully apply to the clinical setting. The more recent guidelines point the value of atypical antipsychotics, lithium, and valproate in the treatment of mania; the role of lithium, lamotrigine, and olanzapine as options for maintenance therapy; and the scarcity of options for the treatment of bipolar depression. Psychoeducation is also supported by most guidelines as an adjunctive treatment.

Hemispheric specialization for language in the congenitally blind: the influence of the Braille system.

The functional cerebral organization of two groups of congenitally blind persons of different age and schooling was studied by testing their dichotic listening to pairs of digits. The younger congenitally blind group showed a comparable level of performance to their control counterparts; however, older subjects shifted their initial right ear advantage to an increased left ear performance as they progressed in the mastery of the Braille system. As this system is founded on spatial strategies, we can conclude that this shift is related to the activation of some right hemispheric linguistic mechanisms.

The relationship between job stress, burnout and clinical depression.

The definition and phenomenological features of 'burnout' and its eventual relationship with depression and other clinical conditions are reviewed. Work is an indispensable way to make a decent and meaningful way of living, but can also be a source of stress for a variety of reasons. Feelings of inadequate control over one's work, frustrated hopes and expectations and the feeling of losing of life's meaning, seem to be independent causes of burnout, a term that describes a condition of professional exhaustion. It is not synonymous with 'job stress', 'fatigue', 'alienation' or 'depression'. Burnout is more common than generally believed and may affect every aspect of the individual's functioning, have a deleterious effect on interpersonal and family relationships and lead to a negative attitude towards life in general. Empirical research suggests that burnout and depression are separate entities, although they may share several 'qualitative' characteristics, especially in the more severe forms of burnout, and in vulnerable individuals, low levels of satisfaction derived from their everyday work. These final issues need further clarification and should be the focus of future clinical research.

Dependence on zolpidem in high dose.

There are some indications that zolpidem is open to potential abuse. We present four cases of former drug or alcohol abusers with personality disorders, who all developed dependence on zolpidem in high dose.

Remission rates with venlafaxine extended release in Greek outpatients with generalized anxiety disorder. A double-blind, randomized, placebo controlled study.

The primary endpoints in this study were the remission rates [final Hamilton Rating Scale for Anxiety (HAM-A) total score < or =7] and reduction from baseline in the HAM-A total score in patients with generalized anxiety disorder (GAD) and no associated depression. Patients with GAD (DSM-IV and HAM-A total score >18) were randomly assigned to treatment with venlafaxine XR or placebo for 8 weeks. A 1-week placebo run-in period preceded the double-blind phase. Patients with a >20% drop in their total HAM-A score during the run-in period, were excluded from the double-blind phase. All patients started therapy with 75 mg/day venlafaxine XR or matched placebo. Patients with less than 30% decrease in their HAM-A total score at the end of the second week, doubled their dose. Patients on the 150 mg/day dose underwent a 1-week taper period. Of the 24 patients in the venlafaxine XR group, 62.5% achieved remission versus 9.1% in the placebo group (P=0.0006). The mean decrease from baseline in HAM-A total score was 19.2 points for the venlafaxine XR group and 10.8 points for the placebo group (P<0.001). Eleven placebo-treated patients and seven venlafaxine XR treated patients doubled their dose at the end of the second week of double-blind treatment. No patient interrupted therapy because of side-effects. No changes in systolic or diastolic blood pressure were observed. Venlafaxine XR 75-150 mg/day was well tolerated. The remission rates achieved with venlafaxine 75-150 mg/day in non-depressed GAD patients were high with good tolerability.

Reliability, validity and psychometric properties of the Greek translation of the Major Depression Inventory.

BACKGROUND: The Major Depression Inventory (MDI) is a brief self-rating scale for the assessment of depression. It is reported to be valid because it is based on the universe of symptoms of DSM-IV and ICD-10 depression. The aim of the current preliminary study was to assess the reliability, validity and psychometric properties of the Greek translation of the MDI. METHODS: 30 depressed patients of mean age 23.41 (+/- 5.77) years, and 68 controls patients of mean age 25.08 (+/- 11.42) years, entered the study. In 18 of them, the instrument was re-applied 1-2 days later and the Translation and Back Translation made. Clinical diagnosis was reached with the use of the SCAN v.2.0 and the International Personality Disorders Examination (IPDE). The Center for Epidemiological Studies-Depression (CES-D) and the Zung Depression Rating Scale (ZDRS) were applied for cross-validation purposes. Statistical analysis included ANOVA, the Spearman Product Moment Correlation Coefficient, Principal Components Analysis and the calculation of Cronbach's alpha. RESULTS: Sensitivity and specificity were 0.86 and 0.94, respectively, at 26/27. Cronbach's alpha for the total scale was equal to 0.89. The Spearman's rho between MDI and CES-D was 0.86 and between MDI and ZDRS was 0.76. The factor analysis revealed two factors but the first accounted for 54% of variance while the second only for 9%. The test-retest reliability was excellent (Spearman's rho between 0.53 and 0.96 for individual items and 0.89 for total score). CONCLUSION: The current study provided preliminary evidence concerning the reliability and validity of the Greek translation of the MDI. Its properties are similar to those reported in the international literature, but further research is necessary.

Reliability, validity and psychometric properties of the Greek translation of the Zung Depression Rating Scale.

INTRODUCTION: The current study aimed to assess the reliability, validity and psychometric properties of the Greek translation of the Zung Depression Rating Scale (ZDRS). METHODS: The study sample included 40 depressed patients 29.65 +/- 9.38 years old and 120 normal comparison subjects 27.23 +/- 10.62 years old. In 20 of them (12 patients and 8 comparison subjects) the instrument was re-applied 1-2 days later. Translation and Back Translation was made. Clinical Diagnosis was reached by consensus of two examiners with the use of the SCAN v.2.0 and the IPDE. Statistical Analysis included ANOVA, the Pearson Product Moment Correlation Coefficient, Principal Components Analysis and Discriminant Function Analysis and the calculation of Cronbach's alpha (alpha) RESULTS: Both Sensitivity and specificity exceed 90.00 at 44/45, Chronbach's alpha for the total scale was equal to 0.09, suggesting that the scale covers a broad spectrum of symptoms. Factor analysis revealed five factors (anxiety-depression, thought content, gastrenterological symptoms, irritability and social-interpersonal functioning). The test-retest reliability was satisfactory (Pearson's R between 0.92). CONCLUSION: The ZDRS-Greek translation is both reliable and valid and is suitable for clinical and research use with satisfactory properties. Its properties are similar to those reported in the international literature, although the literature is limited. However one should always have in mind the limitations inherent in the use of self-report scales.

Reliability, validity and psychometric properties of the Greek translation of the Center for Epidemiological Studies-Depression (CES-D) Scale.

INTRODUCTION: The aim of the current study was to assess the reliability, validity and psychometric properties of the Greek translation of the Center for Epidemiological Studies- Depression Scale (CES-D). METHODS: 40 depressed patients 29.65 +/- 9.38 years old, and 120 normal controls 27.23 +/- 10.62 years old entered the study. In 20 of them (12 patients and 8 controls) the instrument was re-applied 1-2 days later. Translation and Back Translation was made. Clinical Diagnosis was reached by consensus of two examiners with the use of the SCAN v.2.0 and the IPDE. Statistical Analysis included ANOVA, the Pearson Product Moment Correlation Coefficient, Principal Components Analysis and Discriminant Function Analysis and the calculation of Cronbach's alpha (alpha) RESULTS: Both Sensitivity and specificity exceed 90.00 at 23/24, Chronbach's alpha for the total scale was equal to 0.95. Factor analysis revealed three factors (positive affect, irritability and interpersonal relationships, depressed affect and somatic complains). The test-retest reliability was satisfactory (Pearson's R between 0.45 and 0.95 for individual items and 0.71 for total score). CONCLUSION: The Greek translation of the CES-D scale is both reliable and valid and is suitable for clinical and research use with satisfactory properties. Its properties are similar to those reported in the international literature. However one should always have in mind the limitations inherent in the use of self-report scales.

Reliability and cultural applicability of the Greek version of the International Personality Disorders Examination.

BACKGROUND: The International Personality Disorders Examination (IPDE) constitutes the proposal of the WHO for the reliable diagnosis of personality disorders (PD). The IPDE assesses pathological personality and is compatible both with DSM-IV and ICD-10 diagnosis. However it is important to test the reliability and cultural applicability of different IPDE translations. METHODS: Thirty-one patients (12 male and 19 female) aged 35.25 +/- 11.08 years, took part in the study. Three examiners applied the interview (23 interviews of two and 8 interviews of 3 examiners, that is 47 pairs of interviews and 70 single interviews). The phi coefficient was used to test categorical diagnosis agreement and the Pearson Product Moment correlation coefficient to test agreement concerning the number of criteria met. RESULTS: Translation and back-translation did not reveal specific problems. Results suggested that reliability of the Greek translation is good. However, socio-cultural factors (family coherence, work environment etc) could affect the application of some of the IPDE items in Greece. The diagnosis of any PD was highly reliable with phi >0.92. However, diagnosis of non-specific PD was not reliable at all (phi close to 0) suggesting that this is a true residual category. Diagnosis of specific PDs were highly reliable with the exception of schizoid PD. Diagnosis of antisocial and Borderline PDs were perfectly reliable with phi equal to 1.00. CONCLUSIONS: The Greek translation of the IPDE is a reliable instrument for the assessment of personality disorder but cultural variation may limit its applicability in international comparisons.

Comparison of the diagnosis of melancholic and atypical features according to DSM-IV and somatic syndrome according to ICD-10 in patients suffering from major depression.

While melancholic (according to DSM) or somatic syndrome (according to ICD) has strong historical roots and substantial empirical verification, the concept of atypical features is relatively new and not sufficiently studied. The aim of the current study was to investigate the reliability of these diagnostic subcategories in patients suffering from major depression in Greece. Forty patients (eight males and 32 females) aged 19-60 years (mean 39.3, sd 12.2) suffering from major depression according to DSM-IV criteria were studied. SCAN v.2.0 was used to assess symptomatology. The presence of each criterion according to DSM-IV and ICD-10 was registered. Frequency tables were developed and factor and cluster analysis were performed. The results of the analysis suggest the existence of three syndromes which roughly reflect the melancholic and atypical but also propose a third, which can be considered as an 'undifferentiated' syndrome. The DSM demand that the existence of melancholic features be excluded first and then that diagnosis of atypical features be made was confirmed.

Neuropsychological consequences of the exposure of a group of telephonists to unusual auditory stimuli.

A group of 144 right-handed telephone operators reported a number of psychosomatic complaints after long-lasting unusual presentation of auditory stimuli to their left ears during working hours. The main finding of the study of their hemisphere organisation for verbal stimuli, as measured by dichotic listening to pairs of digits, is that the group displayed a clear shift of the right-ear preference to the left and differed significantly from the control group of 40 persons. The finding was verified by a follow-up study conducted eight years later.

Literacy and hemispheric specialization for language: dichotic listening in young functionally illiterate men.

The functional cerebral organization of young men who were defined as illiterate was studied by testing their dichotic listening for language stimuli. These functionally illiterate men showed greater right ear advantage for language stimuli than 50 educated subjects, a pattern already observed with completely illiterate persons of both sexes. This finding is consistent with the view that mastering written codes for language might be one of the most relevant parameters in hemispheric specialization when language is studied.

Functional brain organization in bipolar affective patients during manic phase and after recovery: a digit dichotic listening study.

To study the functional organization of the cerebral hemispheres in patients with bipolar psychosis using a verbal dichotic listening test for pairs of digits 26 patients were tested twice, during the acute expression of manic phase and after recovery. The patient group during the manic phase did not support the expected right-ear advantage of normal subjects on verbal dichotic tests but showed a statistically significant left-ear advantage, which shifted after recovery toward the typical normal asymmetry. Comparing patients during the manic phase and after recovery showed that the left-ear advantage as well as the shift in right-ear advantage after recovery was due to the reduction of left-ear performance. From the over-all neuropsychological findings for these patients mania may be hypothesized to be characterized by overactivation of the right hemisphere. This phaenomenon seems associated with acuteness of the symptoms of the psychotic disorder.

[Neurological soft signs in schizophrenia: correlations with age, sex, educational status and psychopathology].

Though the pathobiology of schizophrenia can be examined in multiple levels, the organic notion of brain disease suggests that neurological features will be present. One straightforward, inexpensive method of investigating brain dysfunction in schizophrenia is thought the bedside assessment of neurological abnormalities with a standard neurological examination. Neurological abnormalities are traditionally classified as "hard signs" (impairments in basic motor, sensory, and reflex behaviors, which do not appear to be affected in schizophrenia) and "soft signs", which refer to more complex phenomena such as abnormalities in motor control, integrative sensory function, sensorimotor integration, and cerebral laterality. Additionally, neurological soft signs (NSS) are minor motor and sensory abnormalities that are considered to be normal in the course of early development but abnormal when elicited in later life or persist beyond childhood. Soft signs also, have no definitive localizing significance but are indicative of subtle brain dysfunction. Most authors believe that they are a reflection not only of deficient integration between the sensory and motor systems, but also of dysfunctional neuronal circuits linking subcortical brain structures such as the basal ganglia, the brain stem, and the limbic system. Throughout the last four decades, studies have consistently shown that NSS are more frequently present in patients with schizophrenia than in normal subjects and non-psychotic psychiatric patients. However, the functional relevance of NSS remains unclear and their specificity has often been challenged, even though there is indication for a relative specificity with regard to diagnosis, or symptomatology. Many studies have considered soft signs as categorical variables thus hampering the evaluation of fluctuation with symptomatology and/or treatment, whereas other studies included insufficient number of assessed signs, or lacked a comprehensive assessment of extrapyramidal symptomatology. Factors such as sex, age or family history of schizophrenia, are said to influence the performance of neurological examination, whereas relative few studies have provided longitudinal follow-up data on neurological soft signs in a sufficient number of patients, in order to address a possible deterioration of neurological functions. Finally, one additional difficulty when analyzing the NSS literature lies in the diversity of symptoms that are evaluated in the studies and/or non-standardized procedures or scoring. We will review some basic issues concerning recurrent difficulties in the measurement and definition of soft signs, as well as controversies on the significance of these signs with respect to clinical subtyping of schizophrenia, and social and demographic variables.