A Retrospective Study of Students Referred to a Psychiatric Clinic at a College Counseling Center in Appalachia.

OBJECTIVES: This study describes the clinical problems and psychiatric diagnoses of college students who sought services at a student counseling clinic and were subsequently referred for evaluation by a psychiatrist. Several important psychiatric problems present before leaving for college that could mandate the selection of a college with psychiatric services at the university or nearby community. This study confirms the importance of having psychiatric consultation available in addition to the range of counseling services found in a campus mental health clinic. METHODS: We conducted a retrospective chart review of 150 patients who were referred for psychiatric care from an on-campus mental health clinic at an Appalachian university (Marshall University). Demographic and clinical data were collected, entered into SPSS version 24, and analyzed. RESULTS: The most common diagnosis was that of a depressive disorder (76.7%). The next most common was an anxiety disorder (60.7%). In addition, 43.3% of students had suicidal ideation within 1 month preceding their appointment with the psychiatrist, 24% had attempted suicide at least once in their life, and 36% had a history of nonsuicidal self-harm. Almost 81% had prior psychiatric diagnoses, and of those, 22% had a history of inpatient psychiatric care. CONCLUSIONS: These results indicate that this student sample referred for psychiatric treatment has significant psychiatric illness. Our findings also confirm the need for the availability of psychiatric consultation as a part of college mental health services. Those students most in need of psychiatric consultation had almost all received psychiatric treatment and almost half had suicidal ideation in the month preceding the appointment with the psychiatrist. The specific problems that may lead a student applying to college to take into consideration the availability of psychiatric services include a previous psychiatric hospitalization, previous suicidal ideation that had already come to the attention of a mental health professional, or a previous diagnosis of depressive disorder or anxiety disorder.

Buspirone for the treatment of dementia with behavioral disturbance.

Behavioral disturbances are common but serious symptoms in patients with dementia. Currently, there are no FDA approved drugs for this purpose. There have been case reports and small case series of the use of buspirone. In this retrospective study, we review 179 patients prescribed buspirone for treatment of behavioral disturbance in dementia to better characterize the efficacy and potential side effects. All patients prescribed buspirone for behavioral disturbance due to dementia from a geropsychiatric outreach program were reviewed. Data was collected and analyzed using SPSS. One hundred-seventy-nine patients met criteria for the study with a mean age of 83.8 + 7. Alzheimer's dementia was the most common dementia (n = 61; 34.1%) followed by mixed dementia (n = 50, 27.9%) then vascular type (n = 31; 17.3%). Behavioral disturbances were mainly verbal aggression (n = 125; 69.8%), and physical aggression (n = 116; 64.8%). Using the Clinical Global Impression scale, 68.6% of patients responded to buspirone, with 41.8% being moderately to markedly improved. The mean dose of buspirone was 25.7 mg ± 12.50. Buspirone appears to be effective in treating behavioral disturbances in dementia. Future prospective and double blinded studies are needed.

Conversion Disorder in an Appalachian Community.

OBJECTIVES: Conversion disorder (CD) is believed to be the manifestation of physical and/or neurological symptoms for primary gain without an identifiable organic cause. Although it is believed to be more common in rural areas, the literature examining this claim is sparse. To our knowledge, no study has been published evaluating the prevalence of CD in a rural Appalachian population. The aim of this study was to characterize and determine the prevalence of CD per Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria in a rural Appalachian psychiatric consultation service and to compare this population with control patients from the same service. METHODS: We performed a retrospective chart review of all patients diagnosed as having CD per Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria on a psychiatric consultation service at a rural Appalachian academic medical center during a 13-month time period. For each case, two consecutive control patients were selected from the same service and time span. RESULTS: There were 21 cases and 42 controls in this study, with a CD prevalence rate of 6.0% (N = 21/351). Sociodemographic, comorbidity, and recent symptomatology data were obtained. Compared with controls, cases were significantly younger and were more likely to have a history of sexual abuse, seizure disorder, antiepileptic use, neurologic referral, electroencephalogram, magnetic resonance imaging of the brain, and history of CD. We found it interesting that fewer cases reported alcohol and drug use. CONCLUSIONS: The observed prevalence of 6.0% does not support the historical theory that CD is more prevalent in rural or lower socioeconomic populations. Our data add to the characterization of the Appalachian CD population.

Hyperammonemia associated with valproic acid use in elderly psychiatric patients.

Valproic acid (VPA) is associated with hyperammonemia; however, little is known about this phenomenon in the geriatric psychiatric population. Of 12 such patients prescribed VPA, 83.3% had elevated ammonia. This occurred in the absence of elevated liver enzymes, and there was no association of VPA serum-level to hyperammonemia.

Screening for depression in elderly hemodialysis patients.

BACKGROUND: Depression is common and associated with increased morbidity and mortality in elderly (≥65 years) hemodialysis patients. Beck's Depression Inventory (BDI) and the Geriatric Depression Scale (GDS) have been used in different cohorts to screen for depression. OBJECTIVES: We aimed to evaluate the 15-item GDS (GDS-15) as such a tool in elderly hemodialysis patients and compare it with BDI, a previously validated tool in younger hemodialysis patients. DESIGN: Cross-sectional study. SETTING: Four out-patient hemodialysis units; 1 based in a university hospital and 3 based in the community. PARTICIPANTS: Hemodialysis patients aged 65 years and older. INTERVENTION: Both tools were administered to all participants, and a geriatric psychiatrist blinded to the results evaluated them for depression by the gold standard psychiatric interview. MEASUREMENTS: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for both tools were assessed against the psychiatric interview (n = 62). RESULTS: Patients who were depressed according to the psychiatric interview had significantly higher GDS-15 and BDI scores compared to those not depressed (p < 0.01 both). ROC curves showed high predictive accuracy of the GDS-15 and BDI (area under the curve: 0.808 and 0.729) versus the psychiatric interview. The GDS-15 cutoff with the best diagnostic accuracy was 5 with a sensitivity of 63%, specificity of 82%, PPV of 60% and NPV of 83%. The BDI cutoff with the best diagnostic accuracy was 10 with a sensitivity of 68%, specificity of 77%, PPV of 57% and NPV of 85%. CONCLUSION: These results provide evidence that the GDS-15 shows validity in comparison to a gold standard and can be used to screen for depression in the elderly hemodialysis population.

Dementia in Women.

Despite the progress made in the understanding of the etiology, neuropathophysiology, and treatment of different types of dementia, such disorders continue to pose huge health problems worldwide. The differential effect of the burden of disease on women is just being realized. These effects range from direct effects of the disease processes themselves, the way women experience the disease, and the caregiver burden. This article provides a brief overview of the available information on this topic.

A Case Series: Adjunctive Treatment of Major Depressive Disorder in the Geriatric Population with the Methylphenidate Patch.

Major depressive disorder can affect anyone regardless of age. In geriatric populations depression is often overlooked and untreated, which subsequently may lead to serious consequences. Almost one third of elderly patients with depression fail to respond to initial treatment and require adjunctive treatment. Methylphenidate is one such option, which is seldom used in the geriatric population to treat depression despite reports of improvement in symptoms of mood within a brief period of time. Methylphenidate is also available in a patch formulation that can be used in patient's nonadherent to the medication, which is reported to be an issue in as many as 75% of the geriatric population. Here we present three geriatric patients who were diagnosed with recurrent severe major depressive disorder without psychotic features. The three patients responded well with methylphenidate as adjunctive treatment to conventional antidepressants.

Successful treatment of hallucinations associated with sensory impairment using gabapentin.

Sensory impairment hallucinations, such as visual hallucinations with visual loss, may not respond to traditional treatments such as antipsychotics. In this case series, the authors describe four patients with either visual or musical hallucinations associated with sensory impairment who were successfully treated with gabapentin.

Validity, sensitivity and specificity of the mentation, behavior and mood subscale of the UPDRS.

OBJECTIVE: The unified Parkinson's disease rating scale (UPDRS) is the most widely used tool to rate the severity and the stage of Parkinson's disease (PD). However, the mentation, behavior and mood (MBM) subscale of the UPDRS has received little investigation regarding its validity and sensitivity. Three items of this subscale were compared to criterion tests to examine validity, sensitivity and specificity. METHODS: Ninety-seven patients with idiopathic PD were assessed on the UPDRS. Scores on three items of the MBM subscale, intellectual impairment, thought disorder and depression, were compared to criterion tests, the telephone interview for cognition status (TICS), psychiatric assessment for psychosis and the geriatric depression scale (GDS). Non-parametric tests of association were performed to examine concurrent validity of the MBM items. The sensitivities, specificities and optimal cutoff scores for each MBM item were estimated by receiver operating characteristic (ROC) curve analysis. RESULTS: The MBM items demonstrated low to moderate correlation with the criterion tests, and the sensitivity and specificity were not strong. Even using a score of 7.0 on the items of the MBM demonstrated a sensitivity/specificity of only 0.19/0.48 for intellectual impairment, 0.60/0.72 for thought disorder and 0.61/0.87 for depression. Using a more appropriate cutoff of 2.0 revealed sensitivities of 0.01, 0.38 and 0.13 respectively. DISCUSSION: The MBM subscale items of intellectual impairment, thought disorder and depression are not appropriate for screening or diagnostic purposes. Tools such as the TICS and the GDS should be considered instead.

"Capgras" Delusions Involving Belongings, Not People, and Evolving Visual Hallucinations Associated with Occipital Lobe Seizures.

Capgras syndrome is characterized by the delusional belief that a familiar person has been replaced by a visually similar imposter or replica. Rarely, the delusional focus may be objects rather than people. Numerous etiologies have been described for Capgras to include seizures. Similarly, visual hallucinations, both simple and complex, can occur secondary to seizure activity. We present, to our knowledge, the first reported case of visual hallucinations and Capgras delusions for objects that developed secondary to new onset occipital lobe epilepsy. We then discuss the possible underlying neurologic mechanisms responsible for the symptomatology.

Tobacco Use and Associated Factors in Patients Presenting to a Psychiatric Emergency Room.

BACKGROUND: Rates of cigarette smoking among the public and individuals with mental illness have been well documented. Studies have demonstrated that prevalence of smoking among individuals with mental illness remains elevated compared to the general population and as a distinct subgroup, individuals with mental illness consume more than a third of cigarettes sold in the U.S. However, information on rates of smoking among patients presenting to a psychiatric emergency room (ER) is lacking. This study assesses this understudied population for smoking prevalence and associated factors. METHODS: A retrospective chart review of 203 distinct psychiatric ER patients was conducted. Demographics, tobacco use, substance use, psychiatric diagnoses, and family history were noted and analyzed with SPSS. RESULT: Tobacco use rates were noted to be nearly fifty percent and significant associations were found with active suicidal ideation, alcohol use disorders, illicit drug use disorders, and history of prior psychiatric hospitalization. CONCLUSION: Tobacco use among psychiatric ER patients is much higher than that of the general population and associated with active suicidal ideations, alcohol use disorders, and illicit substance use disorders. These findings should be considered in the evaluation and expectant management of these patients by their clinicians and healthcare providers.

Dementia in Women.

Despite the progress made in the understanding of the etiology, neuropathophysiology, and treatment of different types of dementia, such disorders continue to pose huge health problems worldwide. The differential effect of the burden of disease on women is just being realized. These effects range from direct effects of the disease processes themselves, the way women experience the disease, and the caregiver burden. This article provides a brief overview of the available information on this topic.

Severe recurrent hypothermia in an elderly patient with refractory mania associated with atypical antipsychotic, valproic acid and oxcarbazepine therapy.

Hypothermia is a rare but serious condition that has been associated with various psychiatric medications. We present a 76-year-old woman with refractory mania who developed multiple episodes of severe hypothermia associated with several psychiatric medications including olanzapine, quetiapine, valproic acid and oxcarbazepine. These episodes resolved following discontinuation of the agents. The patient had never experienced hypothermia before, despite having been on these or similar agents for many years. With traditional treatments for mania not feasible, other medications were used to treat her including lithium, clonazepam, gabapentin and the novel protein kinase c inhibitor tamoxifen. The regimen resulted in some success and importantly, without triggering hypothermia. This case alerts clinicians to the rare side effect of hypothermia in response to various psychiatric medications, the fact that patients can suddenly develop this intolerance and suggests possible medications that may be used safely without triggering hypothermia.

Characteristics of telephone calls in a psychiatric outpatient practice.

OBJECTIVE: The goal of this study was to document the volume and characteristics of telephone calls from patients in an outpatient psychiatric clinic. METHODS: Telephone calls from a psychiatric resident's patients were logged over a 6-month period. Information collected included sex of the caller, reason for the call, deemed importance of the call, primary psychiatric diagnosis, and insurance type. RESULTS: A total of 291 calls occurred during the 6-month period, with an average of 2.4 calls per work day. The physician deemed 1.5% of calls to be an emergency and 15% to be urgent. Of the resident's total case load of 115 patients over the 6 month period, 29% (n = 33) of patients never made physician-patient telephone contact. Female patients were significantly more likely to call than males. Requests for medication refills were the most frequent type of call (38%). The mean number of calls per patient in the caseload was significantly different across diagnostic groups, with patients with personality disorders and anxiety spectrum disorders making more calls than other groups. There was no significant difference in the volume of telephone calls between patients with private health insurance and those without. CONCLUSION: This study may be of particular interest to physicians and managed care systems who are interested in reimbursement for telephone psychiatry. This study confirms and extends the previously reported association between certain psychiatric disorders (personality disorders, anxiety spectrum disorders) and relative frequency of telephone calls to the physician. In addition, the high volume of calls for prescription refills is an important issue in telephone management.

Substance Use Disorders in Elderly Admissions to an Academic Psychiatric Inpatient Service over a 10-Year Period.

Objective. There is a paucity of research on substance use disorders (SUDs) in the elderly psychiatric population. This study examines SUDs in a geriatric psychiatry inpatient service over a 10-year period. Methods. Data from 1788 elderly psychiatric inpatients from a ten-year period was collected. Variables collected included psychiatric diagnoses, SUD, number of psychiatric admissions, and length of stay. Those with and without a SUD were compared using Chi-Square or Student's t-test as appropriate using SPSS. Results. 11.7% (N = 210) of patients had a SUD, and the most common substance was alcohol at 73.3% (N = 154) or 8.6% of all admissions. Other SUDs were sedative-hypnotics (11%), opiate (2.9%), cannabis (1%), tobacco (1.4%), and unspecified SUD (38.6%). SUD patients were significantly younger, divorced, male, and less frequently readmitted and had shorter lengths of stay. The most common comorbid diagnoses were major depression (26.1%), bipolar disorder (10.5%), and dementia (17.1%). Conclusions. Over 10% of psychogeriatric admissions were associated with a SUD, with alcohol being the most common. Considering the difficulties in diagnosing SUD in this population and the retrospective study design, the true prevalence in elderly psychiatric inpatients is likely higher. This study adds to sparse literature on SUD in elderly psychiatric patients.

A Study of Visual Hallucinations in Alzheimer's Disease.

The authors screened 98 patients with probable Alzheimer's disease for visual hallucinations. Each patient with visual hallucinations was matched by cognitive score to two patients without visual hallucinations and compared on variables including visual acuity and visual agnosia. Eighteen (18.4%) of the patients were found to have visual hallucinations. Variables significantly associated with hallucinations included older age, female sex, decreased visual acuity, and presence of visual agnosia. Although having a history of visual disorder approached statistical significance, logistic regression analysis revealed that three variables: age, visual acuity in the "best eye," and visual agnosia, correctly classified 91% of patients as hallucinators vs. non-hallucinators. This work supports a growing body of research showing a relationship between visual hallucinations and the visual system across a variety of disorders.

A Retrospective Chart Review of Lithium Side Effects in a Geriatric Outpatient Population.

The charts of 114 elderly outpatients with mood disorders treated with lithium were reviewed to determine the incidence of side effects. Patients had been treated with lithium for an average of 7.5 years, with an average serum lithium level of 0.5. Overall, 61.4% of patients experienced side effects from lithium at some point in their treatment, but only 0.11 side effects occurred per patient per year. Two (1.8%) patients had to discontinue lithium because of side effects and four (3-5%) required hospitalization. Delirium was the most common side effect noted (19.3%). Side effects occurred both at low ("subtherapeutic") and higher serum lithium levels. Variables significantly associated with experiencing side effects included male sex and higher serum lithium level. Hypothyroidism was significantly associated with longer length of time in years treated with lithium.

Attitudes of elderly subjects toward "truth telling" for the diagnosis of Alzheimer's disease.

This study expands on previous research regarding attitudes of older adults toward disclosure of the diagnosis of Alzheimer's disease (AD). Two hundred patients 65 years or older completed a questionnaire assessing opinions about being told the diagnosis of AD versus cancer. Most responded they wanted to be told if they had AD or terminal cancer (92% for AD, 86.5% for cancer, P = .06). Those with personal experience with AD were significantly less likely to want to know themselves if they had AD than were those without personal experience (P < .0001). A variety of reasons were given for wanting to be told the diagnosis of AD, including a small minority (1.7%) who would consider suicide. Although these results appear to support recent American Medical Association guidelines favoring disclosure of a dementia diagnosis, complex issues remain. Further research is needed to develop guidelines for physicians in disclosing dementia diagnoses that includes outcome studies of disclosure to patients.

Caring for the elderly female psychiatric patient.

With the growth of the elderly population, and the female elderly population in particular, healthcare providers will see increasing numbers of elderly women with psychiatric disorders. To properly care for this group of patients, better understanding is needed not only of group differences in this patient population but also of the differences in each individual, as they age, given their unique life experiences, cohort effects, medical comorbidity, social situation, and personality traits. Understandably, these characteristics will interact with psychiatric disorders in ways that may increase the challenge to correctly diagnose and treat these patients. In addition, understanding late life changes, the prevalence of various mental disorders and the sometimes unique presentation of mental disorders in this age group is required to better diagnose and treat this population.

Abnormal thyroid stimulating hormone (TSH) in psychiatric long-term care patients.

The objective of the study was to find the prevalence of thyroid dysfunction in long-term care patients referred to psychiatry. We reviewed 868 charts of long-term care residents referred for psychiatric consultation to the university-based psychiatry outreach service. Data obtained were demographics, psychiatric and thyroid diagnoses, and TSH data. Of 868 patients, 10.8% had elevated TSH, 8% in those with a prior diagnosis of hypothyroidism. TSH was low in 0.07%. Elevated TSH was associated with female gender (p<0.001) and a trend with psychosis (p=0.056). No association was found with depression or behavioral disturbance in this study.