Proposed Recommendations for the Management of Depression in Adults with Epilepsy: An Expert Consensus.

INTRODUCTION: Experts agree that there is a need for protocols to guide health professionals on how to best manage psychiatric comorbidities in patients with epilepsy (PWE). We aimed to develop practical recommendations for key issues in the management of depression in PWE. METHODS: This was a qualitative study conducted in four steps: (1) development of a questionnaire on the management of depression in PWE to be answered; (2) literature review and, if evidence from guidelines/consensus or systematic reviews was available, drafting initial recommendations; (3) a nominal group methodology for reviewing initial recommendations and formulating new recommendations on those issues without available evidence; and (4) drafting and approving the final recommendations. A scientific committee (one neurologist and one psychiatrist) was responsible for the development of the project and its scientific integrity. The scientific committee selected a panel of experts (nine neurologists and nine psychiatrists with experience in this field) to be involved in the nominal group meetings and to formulate final recommendations. RESULTS: Fifteen recommendations were formulated. Four on the screening and diagnosis: screening and diagnosis of depression, evaluation of the risk of suicide, and diagnosis of depression secondary to epilepsy; nine on the management of depression: referral to a psychiatrist, selection of the antiseizure medication, change of antiseizure medication, antidepressant treatment initiation, selection of antidepressant, use of antidepressants during pregnancy, use of psychotherapy, antidepressant treatment duration, and discontinuation of antidepressant treatment; two on the follow-up: duration of the follow-up under usual conditions, and follow-up of patients at risk of suicide. CONCLUSION: We provide recommendations based on expert opinion consensus to help healthcare professionals assess depression in PWE. The detection and treatment of major depressive disorders are key factors in improving epilepsy outcomes and avoiding suicide risk.

Hematoma subdural diagnosticado como ingesta medicamentosa en paciente con esquizofrenia / Subdural haematoma diagnosed as drug ingestion in patient with schizophrenia

Objetivo: Subrayar la importancia de una exploración exhaustiva para el diagnóstico de procesos intraparenquimatosos en pacientes con antecedentes de patología psiquiátrica. Caso clínico Varón de 56 años con antecedentes de esquizofrenia ingresado a urgencias por somnolencia, dificultad para la deambulación y temblor de miembro superior derecho. Se sospecha por medicina interna, de secundarismos neurológicos tras intento autolítico mediante ingesta farmacológica. Resultados Tras la exploración del estado mental por psiquiatría, se amplía el estudio mediante tomografía axial computarizada (TC) que revela un hematoma subdural agudo (HSA). La atrofia cortical en pacientes con esquizofrenia predispone a la acumulación de sangre intracerebral y al retardo en los síntomas y el diagnóstico de estos procesos aumentando el riesgo vital. Conclusiones Es fundamental una correcta anamnesis y la inclusión de pruebas de imagen cerebrales para el diagnóstico diferencial del HSA en pacientes con esquizofrenia. (AU)

Objective: To underline the importance of thorough examination in diagnosing intraparenchymal processes in patients with a history of psychiatric disease. Clinical case A 56-year-old male with a history of schizophrenia was taken to the emergency department with somnolence, difficulty in walking and right-arm tremor. The internal medicine department suspected to be secondary neurological symptoms after attempted to self-harm through ingestion of drugs. Results After the psychiatric department had examined the patient's mental state, a CT scan was performed that revealed an acute subdural haematoma (ASH). Cortical atrophy in patients with schizophrenia favours the accumulation of intracerebral blood and a delay in the symptoms and diagnosis of these processes, increasing the risk to life. Conclusions Accurate anamnesis and brain imaging tests are essential for the differential diagnosis of ASH in patients with schizophrenia. (AU)

Marchiafava-Bignami disease in a patient with schizophrenia and alcohol use disorder.

Substance-related disorders are the most frequent comorbidity in schizophrenia. Concretely, alcohol is the most commonly consumed substance after tobacco. Patients with schizophrenia with this comorbidity have a worse clinical course and can develop serious neuropsychiatric complications. One of them, Marchiafava-Bignami disease (MBD) can be incorrectly diagnosed as a decompensation of their mental disorder.

NOTA CLÍNICA: Enfermedad deMarchiafava-Bignami en un paciente con esquizofrenia y trastorno por uso de alcohol / CLINICAL NOTE: Marchiafava-Bignami disease in a patient with schizophrenia and alcohol use disorder

Introducción: Los trastornos por abuso de sustancias sonla comorbilidad más frecuente en la esquizofrenia, siendo elalcohol, concretamente, la sustancia más frecuentementeconsumida tras el tabaco. Los pacientes con esquizofreniaque presentan esta comorbilidad presentan una peor evolución clínica y pueden desarrollar graves complicaciones neuropsiquiátricas. Una de ellas, la enfermedad de Marchiafava-Bignami (EMB), puede ser erróneamente diagnosticadacomo una descompensación del trastorno mental, conllevando graves consecuencias.Método. Se presenta el caso de un varón de 51 años,diagnosticado de esquizofrenia y trastorno por consumode alcohol. Experimentó síntomas neuropsiquiátricos agudos por los que se sospechó una descompensación de suesquizofrenia. Dada la presentación clínica atípica y susantecedentes médicos, se sospechó una patología orgánicay se realizó una prueba de imagen cerebral en la que sediagnosticó una EMB.Conclusiones. La EMB es una entidad clínica infrecuenteque debe formar parte del diagnóstico diferencial en pacientes con trastorno por consumo de alcohol que experimenten síntomas neuropsiquiátricos atípicos. (AU)

Introduction: Substance-related disorders are the mostfrequent comorbidity in schizophrenia. Concretely, alcohol isthe most commonly consumed substance after tobacco. Patients with schizophrenia with this comorbidity have a worseclinical course and can develop serious neuropsychiatriccomplications. One of them, Marchiafava-Bignami disease(MBD) can be incorrectly diagnosed as a decompensation oftheir mental disorder.Methods. A case of a 51-year-old man, diagnosed withschizophrenia and alcohol use disorder is presented. He experienced acute neuropsychiatric symptoms for which schizophrenia decompensation was suspected. Based on his atypical symptoms and medical history, a brain imaging test wasperformed and MBD was diagnosed.Conclusions. MBD is an infrequent clinical entity thatshould be part of differential diagnosis in patients with alcohol abuse disorder experiencing atypical neuropsychiatricsymptoms. (AU)

Psychiatric symptoms after temporal epilepsy surgery. A one-year follow-up study.

Psychiatric symptoms must be considered in patients with refractory temporal lobe epilepsy after epilepsy surgery. The main objectives of our study were to describe clinical and socio-demographical characteristics of a cohort of patients with pharmacoresistant temporal lobe epilepsy who underwent temporal lobe epilepsy surgery, and moreover, to evaluate possible risk factors for developing psychiatric symptoms. In order to achieve those goals, we conducted a prospective evaluation of psychopathology throughout the first year after surgery in a clinical sample of 72 patients, by means of three clinical rated measures; the Hamilton Anxiety Rating Scale (HARS), the Hamilton Depression Rating Scale (HDRS), and the Brief Psychiatric Rating Scale (BPRS). The psychopathological evaluations were performed by an experienced psychiatrist. A presurgical evaluation was done by a multidisciplinary team (that includes neurologist, psychiatrist, neurosurgeon, neurophysiologist, radiologists, and nuclear medicine specialist) in all patients. The decision to proceed to surgery was taken after a surgical meeting of all members of the Multidisciplinary Epilepsy Unit team. The psychiatrist conducted two postoperative assessments at 6months and 12months after surgery. The main finding was that past history of mental illness (patients who were receiving psychiatric treatment prior to the baseline evaluation) was a risk factor for anxiety, depression, and psychosis after temporal lobe epilepsy surgery.

Variables demográficas, clínicas y psicológicas que influyen en la falta de asistencia a la primera consulta en salud mental / Demographic, clinical, and psychological variables influencing non-attendance at first mental-health appointment

Objetivos. Identificar las variables demográficas, clínicas y psicológicas de tres grupos de pacientes tras haber sido remitidos a psiquiatría desde Atención Primaria: los que no llegan a solicitar fecha de visita, los que la solicitan y no acuden, y aquellos que la solicitan y acuden. Elaborar estrategias para evitar fallos de asistencia a las primeras consultas. Método. Estudio observacional secuencial de recogida durante 18 meses de datos de todos los pacientes derivados al Centro de Salud Mental. Instrumentos utilizados: petición de interconsulta, cuestionario clínico (SCL-90r de Derogatis), cuestionario de personalidad (EPI de Eysenck), hoja de registro de datos demográficos, y entrevista semiestructurada telefónica.Resultados. Las variables demográficas significativas fueron el estado civil, los pacientes casados acudían más a las primeras visitas y la presencia o no de hijos en casa, aquellos con hijos en casa acudieron más. Los de menor nivel de estudios solicitaron cita con menor frecuencia y los que disponían de teléfono, más. El resto de variables no resultaron significativas. No se obtuvieron variables psicológicas, ni clínicas que diferenciaran los tres grupos. El tiempo prolongado de espera y la mejoría clínica fueron las caúsas más frecuentes para no acudir tras haber solicitado cita, y la mejoría clínica y considerar que la derivación se había debido a un motivo insuficiente, en caso de no llegar a hacerlo. Conclusiones. Un 7% de los pacienes derivados a Salud Mental no llegan a solicitar cita. Los datos demográficos ofrecen resultados dispares. Los cuestionarios SCL-90 y EPI no permitieron determinar características clínicas y psicológicas de los pacientes “incumplidores”. Estrategias como disminuir las listas de espera, y revisar los criterios de derivación podrían resultar útiles para reducir el incumplimiento

Objectives. To identify the demographic, clinical, and psychological variables in three groups of patients who were referred to psychiatric services by primary-care services: those who do not request an appointment, those who request one but do not attend, and those who request one and attend. To design strategies to prevent non-attendance at first appointments. Method. An 18-month sequential observational study that recorded the data of all patients referred to the Mental Health Centre. Instruments used: inter-service referral form; a clinical questionnaire (the Derogatis SCL-90-R), a personality questionnaire (the Eysenck EPI), a demographic information form; and a semi-structured telephone interview. Results. The significant demographic variables were marital status and the presence of children in the home. Patients with lower educational levels requested appointments less frequently, and those with telephones requested them more frequently. The remaining variables were not statistically significant. No psychological or clinical variables were found to distinguish between the three groups of patients. The most frequent causes of non-attendance after requesting an appointment were long waiting times and clinical improvement, while the most frequent reasons for not requesting an appointment were clinical improvement and the belief that there were insufficient grounds for psychiatric referral. Conclusions. 7 percent of patients referred to Mental Health Services do not even request an appointment. Demographic data still offer disparate results. The SCL-90 and EPI questionnaires did not make it possible to identifv the clinical and psvchological characteristics of non-attending patients. Strategies such as shortening waiting lists and reviewing the criteria for referral could prove useful in reducing non-attendance