Suicidal ideation and depressive symptoms in an urban post-partum maternity setting: a retrospective cohort study.

BACKGROUND: Fifteen percent of women worldwide experience depression in the perinatal period. Suicide is now one of the leading causes of maternal mortality in developed countries. Internationally, many healthcare systems screen post-natal women for depressive symptoms and suicidal ideation to facilitate early assessment and intervention. To our knowledge, no Irish data exists on the prevalence of suicidal ideation in this cohort. AIMS: To evaluate the prevalence of suicidal ideation and depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS) in post-natal women attending a large Dublin maternity hospital. METHODS: A retrospective cohort study was conducted. Women were randomly selected by delivery date over a 6 month period. Demographic and medical information was collected from their booking visit and discharge summary data. EPDS results at discharge post-partum were examined. RESULTS: Data was collected on 643 women. Post-partum, 19 women (3.4%) had experienced suicidal ideation in the previous 7 days. Just over half of these women also had high EPDS scores (>12). Overall, 29 women (5.2%) screened positive for depression (EPDS score > 12). CONCLUSIONS: The rate of suicidal ideation is in line with the published international data and emphasises the need for all clinicians to inquire about such thoughts. Training of midwifery and obstetric staff is required. Maternity units should have a policy on the management of suicidal ideation and risk. The prevalence of depressive symptoms post-partum was comparatively low in our study. This could suggest that antenatal screening and early intervention, which are integral parts of the perinatal mental health service, are effective. However, due to limitations of the study, it could also reflect an under-representation of depressive symptom burden in this cohort.

Munchausen's syndrome--more common than we realize?

Munchausen's syndrome is a condition whereby a patient deliberately simulates symptoms of an illness in order to gain admission to hospital and gain the sick role. It is an uncommon condition and is possibly underdiagnosed. This case-series examines the cases of three patients with Munchausen's syndrome who presented to a Dublin hospital within a four-month period. Two of the presentations involved the feigning of psychiatric symptoms. It is important that clinicians not only in psychiatry, but in all medical specialities have an awareness of this disorder, so that unnecessary procedures and treatments may be avoided.

Neuroleptic malignant syndrome: a diagnosis easily missed.

A woman admitted with psychotic depression developed a number of physical problems. Urinary incontinence, headache, neck stiffness and breathing difficulties were all treated separately but were later found to be part of the neuroleptic malignant syndrome. Treatment of the disorder led to complete recovery. We review the criteria for diagnosis of this serious disorder and some differential diagnoses.

The management of medically unexplained symptoms.

Medically unexplained symptoms occur in up to 50% of new medical out-patients. Health care seeking may not be related to the presence of physical disease but may reflect social problems, psychological disturbance, or frank psychiatric disorder. Management of unexplained physical symptoms depends on the duration of symptoms. If acute, exclusion of physical disease, as well as providing symptomatic care, is a priority. The patient's fears of illness need to be addressed and an explanation in simple terms of the symptoms provided. Adverse life situations should be identified and, where possible, rectified. Psychiatric disorders require appropriate treatment. When symptoms are chronic, conservative management is required to contain the symptoms and avoid iatrogenic problems.

CA 125 as a tumour marker in epithelial ovarian cancer.

CA 125, a high molecular weight glycoprotein, was measured in sera from patients with epithelial ovarian cancer, patients with benign gynaecological disease and in patients with non-ovarian adenocarcinomas. High levels (greater than 35 U/ml) were found in 48/50 patients with active ovarian cancer but in only 3/26 patients who had an ovarian cancer previously diagnosed but who were apparently disease free. 6/23 patients with non-ovarian adenocarcinomas as well as 4/18 patients with benign gynaecological disease also had elevated levels. CA 125 levels were higher in serious than non-serous ovarian cancers and tended to increase with increasing stage. In all of 19 patients with ovarian cancer who responded to treatment CA 125 levels fell while 17/20 with progressive disease showed a rise. In 7/8 patients, serial determination of CA 125 showed a rise before the clinical detection of recurrence, the median lead-time being 3.5 months. We conclude that CA 125 is an excellent marker in the management of patients with epithelial ovarian cancers.

A bilateral antidiuresis to renal artery infusion of prostaglandin E1 in dogs treated with phenylbutazone.

1. In acute experiments, high levels of endogenous prostaglandins, provoked by operative stress, could obscure or alter the actions of infused prostaglandins on the kidney. For this reason we decided to compare the effects of infusing prostaglandin E(1) into the renal artery of the dog before and after the administration of phenylbutazone, a prostaglandin synthetase inhibitor.2. Infusion of prostaglandin E(1) into the left renal artery of the pre-phenylbutazone treated dog undergoing a mannitol diuresis increased renal plasma flow, glomerular filtration rate and the excretion of salt and water. The findings are in general agreement with those reported by others.3. Following phenylbutazone administration the vascular and saluretic actions of prostaglandin E(1) were unchanged but a reduced diuretic effect was observed. The response to a low dose of prostaglandin E(1) (0.05 mug/min) was reduced from 1.46 +/- 0.15 to 0.96 +/- 0.16 ml./min (P < 0.001) and the response to a high dose (0.5 mug/min) from 1.82 +/- 0.19 to 0.99 +/- 0.31 ml./min (P < 0.002).4. A significantly less dilute urine was excreted during prostaglandin infusion in the dog after phenylbutazone treatment than before. The reduction in the diuretic response was of the same order as the decrease in the free water clearance response, while the increase in osmolar clearance was unchanged.5. In water-loaded dogs treated with phenylbutazone, infusion of prostaglandin E(1) into the left renal artery had a biphasic effect on urine output from the left kidney. An initial diuretic response to a low dose of prostaglandin E(1) disappeared with the infusion of higher doses, and antidiuresis developed in the immediate post-infusion period.6. As prostaglandin was infused into the left kidney progressive antidiuresis was seen in the non-infused right kidney.7. It is concluded that endogenous prostaglandins do not obscure or alter the vascular and saluretic actions of intrarenal prostaglandin E(1). The findings question the proposed link between the vascular and saluretic actions of this compound.8. It is suggested that the reduced diuretic effect of prostaglandin E(1) in series no. 1, and the antidiuresis in the water-loaded dogs, are caused by the release of endogenous ADH. It is further suggested that phenylbutazone unmasks this release by removing the endogenous prostaglandins. If these deductions are correct, the findings support the anti-ADH role assigned to endogenous prostaglandins by Anderson, Berl, McDonald & Schrier (1975).

The role of prostaglandins in cholinergic neurotransmission in the guinea pig.

Prostaglandins have contrasting effects on neurotransmission at different cholinergic nerve endings. This is a report on the role of prostaglandins in a number of cholinergic preparations from the guinea pig. In the isolated ileum PGE1 (2 X 10(-10) to 5 X 10(-8) M) potentiated the response to electrical stimulation of the cholinergic nerves. PGE1 (10(-7 M) caused an increase in tone followed by a period of transient inhibition of twitch height. Responses to simulation of the ileum with drugs were not potentiated by PGE1. Responses of atropinized or plexus-free muscle to electrical stimulation were also not potentiated by PGE1. Acetylsalicylic acid (2.5 X 10(-4) M) diminished the twitch response and the output of acetylcholine from the ileum. Both effects were reversed by PGE1. Qualitatively similar observations were made on the trachea. It is concluded that prostaglandins facilitate acetylcholine release in the ileum and trachea. PGE1 diminished the effect of vagal stimulation on the heart rate. The response to stimulation of the phrenic nerve was not affected.

Individual facial areas in the human circulatory response to immersion.

Heart rate (HR) and forearm blood flow (FBF) during 30 sec. breath holding (BH) were recorded in 10 healthy men. (1) during whole face immersion (FI) in water between 5 and 30°C; (2) during FI with waterproof film covering the face (five subjects); (3) with certain facial areas covered with insulating masks; (4) during immersion of selected uncovered facial areas. HR and FBF decreased during BH in air; bradycardia increased on FI, becoming greater as water temperature was reduced. FI bradycardia was greater at each temperature, except 30°C, compared to FI without wetting. Insulation of nose, nose and eyes or nose, eyes and mouth on immersion at 15°C. led to reduced bradycardia compared to whole FI. Selective immersion (15°C.) of uncovered nose, mouth or cheek had little effect on HR compared to whole FI. FBF changes on 'dry' immersion and with selective insulation or immersion were variable and did not parallel HR changes.