The Psychological Impact on Relatives of Critically Ill Patients: The Influence of Visiting Hours.

OBJECTIVES: To identify the psychologic impact of admission to the ICU on the relatives of critically ill patients, the influence of coping, and the factors involved. DESIGN: We performed a cohort study with repeated measures evaluation using descriptive and comparative bivariate and multivariate analyses. SETTINGS: An adult ICU of a third-level complexity hospital. PATIENTS: The family members of patients (maximum of three per patient) staying longer than 3 days. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Psychologic impact was assessed using two subgroups of psychologic distress: anxiety (by the State-Trait Anxiety Inventory) and depression (by the Beck Depression Inventory). Satisfaction and coping were assessed by the Critical Care Family Needs Inventory and the Brief Coping Orientations to Problems Experienced Inventory, respectively. We included 104 family members; psychologic distress was high at admission (72% had anxiety, 45% had depression, and 42% had both) but decreased at discharge (34% had anxiety, 23% had depression, and 21% had both). The risk factors related to psychologic impact were severity (anxiety: Acute Physiology and Chronic Health Evaluation score ≥ 18 points: relative risk [RR], 2; 95% CI, 1-4; p = 0.03), invasive mechanical ventilation (anxiety: RR, 1.9; 95% CI, 1-3.6; p = 0.04), recent psychotropic medication use by relatives (depression: RR, 1.6; 95% CI, 1-2.9; p = 0.05), a restrictive visiting policy (anxiety: RR, 5.7; 95% CI, 2-10.4; p = 0.002), no emotion-focused coping strategy (anxiety: strategy < 11 points, RR, 6.1; 95% CI, 1.2-52; p = 0.01), and functional impairment (depression: Barthel index ≤ 60 points, RR, 7.4; 95% CI, 1.7-26.3; p = 0.01). CONCLUSIONS: The psychologic impact from admission to the ICU on family members is high. Visiting hours is the main modifiable factor to reduce the impact.

Deep Brain Stimulation of the Nucleus Accumbens, Ventral Striatum, or Internal Capsule Targets for Medication-Resistant Obsessive-Compulsive Disorder: A Multicenter Study.

BACKGROUND: Deep brain stimulation of the nucleus accumbens, ventral striatum, or internal capsule region has shown a 45%-60% response rate in adults with severe treatment-refractory obsessive-compulsive disorder, regardless of which target is used. We sought to improve the effectiveness of deep brain stimulation by placing the electrode along a trajectory including these 3 targets, enabling a change of stimulation site depending on the patient's response. METHODS: This study used the medical records of 14 patients from 4 different Spanish institutions: 7 from the Hospital Universitario La Princesa, 3 from the Hospital Universitario Central de Asturias, 2 from Hospital Universitario Fundación Jiménez Díaz, and 2 from Hospital Universitari Son Espases. All patients were operated on under the same protocol. Qualitative and quantitative data were collected. RESULTS: Of 14 patients, 11 showed significant improvement in obsessive-compulsive disorder symptoms, as evident in a reduction ≥35% in Yale-Brown Obsessive Compulsive Scale scores following stimulation relative to preoperative scores. Seven patients responded to stimulation at the nucleus accumbens (the first area we set for stimulation), whereas 4 patients needed to have the active contact switched to the internal capsule to benefit from stimulation. CONCLUSIONS: Deep brain stimulation of the nucleus accumbens, internal capsule, and ventral striatum significantly benefited our cohort of patients with medication-resistant obsessive-compulsive disorder. Electrode insertion through the 3 main targets might confer additional therapeutic efficacy.

Deep brain stimulation for aggressiveness: long-term follow-up and tractography study of the stimulated brain areas.

OBJECTIVE: Initial studies applying deep brain stimulation (DBS) of the posteromedial hypothalamus (PMH) to patients with pathological aggressiveness have yielded encouraging results. However, the anatomical structures involved in its therapeutic effect have not been precisely identified. The authors' objective was to describe the long-term outcome in their 7-patient series, and the tractography analysis of the volumes of tissue activated in 2 of the responders. METHODS: This was a retrospective study of 7 subjects with pathological aggressiveness. The findings on MRI with diffusion tensor imaging (DTI) in 2 of the responders were analyzed. The authors generated volumes of tissue activated according to the parameters used, and selected those volumes as regions of interest to delineate the tracts affected by stimulation. RESULTS: The series consisted of 5 men and 2 women. Of the 7 patients, 5 significantly improved with stimulation. The PMH, ventral tegmental area, dorsal longitudinal fasciculus, and medial forebrain bundle seem to be involved in the stimulation field. CONCLUSIONS: In this series, 5 of 7 medication-resistant patients with severe aggressiveness who were treated with bilateral PMH DBS showed a significant long-lasting improvement. The PMH, ventral tegmental area, dorsal longitudinal fasciculus, and medial forebrain bundle seem to be in the stimulation field and might be responsible for the therapeutic effect of DBS.

Depressive symptoms in early- and late-onset older bipolar patients compared with younger ones.

OBJECTIVES: The aim of this study was to determine clinical and outcome differences between older bipolar patients with early onset (EO) and late onset (LO) of the illness and between younger and EO older patients with a bipolar disorder under long-term treatment in an outpatient clinical setting. METHODS: Three hundred ninety-five bipolar I and II outpatients were followed up for up to 7.7 years. Of these, 213 younger (<50 years) and 88 older (>60 years) patients were included. In the older subsample, 50 EO patients (onset <50 years) versus 38 LO patients (≥50 years) were analyzed. Likewise, younger versus EO older patients were compared. RESULTS: The likelihood of LO older patients of being bipolar II was higher than for EO older patients. They were also diagnosed earlier than EO older patients. No other clinical differences at baseline and at the prospective follow-up were found. Compared with younger patients, EO older patients had more frequent depressive symptoms at baseline, suffered more major depressive episodes in the previous year and in the prospective follow-up, received more antidepressants at baseline, had higher rates of medical comorbid conditions and were less likely to be tobacco smokers. CONCLUSIONS: Older patients constitute a meaningful proportion of bipolar patients under treatment. EO older patients suffered significantly from more frequent depressive symptoms than younger ones. LO older patients were predominantly bipolar II. So as bipolar illness progressed, depressive symptomatology became more frequent and manic episodes were less severe. Copyright © 2016 John Wiley & Sons, Ltd.

[Not Available]. / Tratamiento quirúrgico de la anorexia nerviosa resistente al tratamiento médico.

Gracias a los avances técnicos en técnicas neuroquirúrgicas, y debido a que el diagnóstico y la clasificación de las enfermedades psiquiátricas han evolucionado significativamente a lo largo de las últimas décadas, se están desarrollando tratamientos a nivel experimental para aquellos pacientes resistentes al manejo conservador.La anorexia nerviosa es una enfermedad de prevalencia creciente, con la tasa de mortalidad más elevada dentro de los trastornos psiquiátricos, y con aproximadamente un 20% de pacientes que presentan una evolución tórpida. Para estos pacientes que no responden a manejo conservador, la estimulación cerebral profunda ha surgido como una alternativa terapéutica, si bien la literatura especializada al respecto es escasa.A continuación presentamos una revisión de la fisiopatología de la anorexia nerviosa, así como de los distintos tratamientos neuroquirúrgicos realizados a lo largo de la historia. Se detalla la perspectiva de tratamiento quirúrgico actual, así como los aspectos éticos que se han de considerar en relación con el surgimiento de estas nuevas terapias.

Tratamiento quirúrgico de la anorexia nerviosa resistente al tratamiento médico / Surgical treatment of medication-resistant anorexia nervosa

Gracias a los avances en técnicas neuroquirúrgicas, y debido a que el diagnóstico y la clasificación de las enfermedades psiquiátricas han evolucionado significativamente a lo largo de las últimas décadas, se están desarrollando tratamientos a nivel experimental para aquellos pacientes resistentes al manejo conservador. La anorexia nerviosa es una enfermedad de prevalencia creciente, con la tasa de mortalidad más elevada dentro de los trastornos psiquiátricos, y con aproximadamente un 20% de pacientes que presentan una evolución tórpida. Para estos pacientes que no responden a manejo conservador, la estimulación cerebral profunda ha surgido como una alternativa terapéutica, si bien la literatura especializada al respecto es escasa. A continuación presentamos una revisión de la fisiopatología de la anorexia nerviosa, así como de los distintos tratamientos neuroquirúrgicos realizados a lo largo de la historia. Se detalla la perspectiva de tratamiento quirúrgico actual, así como los aspectos éticos que se han de considerar en relación con el surgimiento de estas nuevas terapias (AU)

Given the advances experienced in neurosurgical techniques, and because the diagnosis and classifi cation of psychiatric diseases has evolved over the past decades, new experimental treatments are arising to treat a greater number of medication-resistant psychiatric patients. Among psychiatric diseases, anorexia nervosa has the highest mortality rate, and approximately 20% of patients experience torpid outcomes. For these patients who do not respond to conservative management, deep brain stimulation has arisen as an alternative option, although studies are still scarce. We review the pathophysiology of anorexia nervosa, as well as the various neurosurgical treatments that have been performed throughout history. The prospect of current surgical treatments is detailed, as well as the ethical aspects to consider regarding the emergence of these new therapies (AU)

Estimulación cerebral para el trastorno obsesivo-compulsivo resistente a tratamiento médico / Deep brain stimulation for drug-resistant obsessive-compulsive disorder

Aproximadamente un 10% de los pacientes con trastorno obsesivo-compulsivo tienen formas crónicas muy incapacitantes de la enfermedad, resistentes a las terapias conservadoras actuales, lo que conlleva un deterioro significativo para su calidad de vida y altas tasas de suicidio. Para estos pacientes se dispone de nuevas terapias efectivas mediante tratamiento neuroquirúrgico. A continuación revisamos de forma exhaustiva las técnicas neuroquirúrgicas actuales y las tasas de remisión y efectos adversos, con sus aspectos metodológicos fundamentales. La realización de pequeñas lesiones en dianas específicas del circuito límbico, como la cingulotomía, la capsulotomía, la tractotomía subcaudada o la leucotomía límbica, está siendo sustituida por la estimulación cerebral profunda mediante electrodos en estas dianas, lo que permite efectuar una terapia reversible y adaptable a las necesidades del paciente. Además, el desarrollo de la neuroimagen y el mejor conocimiento de los circuitos cerebrales han permitido la identificación de nuevas dianas para la neuroestimulación en este trastorno, con buenos resultados. La investigación debe continuar progresando para mejorar el tratamiento de los pacientes con trastorno obsesivo-compulsivo resistente (AU)

Approximately 10% of patients with obsessive-compulsive disorder have very disabling chronic forms of the disease, which are resistant to all current conservative therapies. These patients experience a significant deterioration in their quality of life and high rates of suicide. The development of new effective neurosurgical treatments has led to an improvement in a significant percentage of patients that would otherwise have remained severely disabled. We comprehensively review remission rates, adverse effects and fundamental methodological aspects of the current neurosurgical techniques for medication resistant obsessive-compulsive disorder. The making of small lesions in specific targets of the limbic circuit, such as cingulotomy, capsulotomy, limbic leucotomy and subcaudate tractotomy, is being replaced by deep brain stimulation through electrodes located in these targets, which is reversible and adaptable to every patient's need. Furthermore, the development of neuroimaging techniques and a better understanding of brain circuits in the last decades, have allowed the identification of new targets for neurostimulation in this disorder, with good results. Research must continue in order to help in the treatment of medication-resistant obsessive-compulsive disorder (AU)

Seasonality, smoking and history of poor treatment compliance are strong predictors of dropout in a naturalistic 6 year follow-up of bipolar patients.

Bipolar disorder is a highly recurrent disease which requires long-term treatment. Dropout is a major problem, poorly understood. The objectives of this study were to know the risk of dropout of a cohort of bipolar patients under ambulatory treatment and to identify the clinical profile of patients more likely to abandon the follow-up. A sample of 285 BD I and II patients was followed up for a mean of 2.87 years. A significant proportion of patients failed regular follow-up. The dropout rates were 6.3 % at three months, 12.7 % at 6 months, and 17.6, 27.2, 37.3, 44.0, 47.2 and 49.0 % at 1, 2, 3, 4, 5 and 6 years respectively. Very few variables at baseline predicted dropout. Patients under 35 years of age were more likely to dropout than older cases. Seasonality, smoking and specially history of poor treatment compliance were strong predictors of dropout. Given the magnitude of dropout, additional early clinical interventions should be considered for high-risk patients.

Understanding bipolar disorder in late life: clinical and treatment correlates of a sample of elderly outpatients.

The aim of this study was to examine the demographic, clinical, and treatment correlates of bipolar disorder (BD) in outpatients 65 years or older and to compare patients with BD subtype I (BD-I) versus BD subtype II (BD-II) and patients with early onset (EO; <=50 years old) versus late onset (LO; >50 years old) of the illness. Sixty-nine consecutive outpatients with BD were included. Diagnosis was delayed for a mean of 14.1 years, significantly longer in patients with EO (18.6 years) than with LO (3.3 years). Mild to moderate depressive symptoms were detected in 29% of the patients. The patients were receiving a mean of 3 different psychotropic medications. Antidepressantswere more frequently prescribed to patients with BD-II than to patients with BD-I (75.80% vs. 48.60%) and to patients with EO (71.7%) than to LO (35.3%). Geriatric BD has similar clinical characteristics with those of younger ages, and these do not seem to greatly differ with subtype or age of onset.

Long-term results of posteromedial hypothalamic deep brain stimulation for patients with resistant aggressiveness.

OBJECT: Erethism describes severe cases of unprovoked aggressive behavior, usually associated with some degree of mental impairment and gross brain damage. The etiology can be epileptic, postencephalitic, or posttraumatic, or the condition can be caused by brain malformations or perinatal insults. Erethism is often refractory to medication, and patients must often be interned in institutions, where they are managed with major restraining measures. The hypothalamus is a crucial group of nuclei that coordinate behavioral and autonomic responses and play a central role in the control of aggressive behavior. Deep brain stimulation (DBS) of the posteromedial hypothalamus (PMH) has been proposed as a treatment for resistant erethism, although experience with this treatment around the world is scarce. The objective of this study was to examine the long-term outcome of PMH DBS in 6 patients with severe erethism treated at the authors' institution. METHODS: Medical records of 6 patients treated with PMH DBS for intractable aggressiveness were reviewed. The therapeutic effect on behavior was assessed by the Inventory for Client and Agency Planning preoperatively and at the last follow-up visit. RESULTS: Two patients died during the follow-up period due to causes unrelated to the neurosurgical treatment. Five of 6 patients experienced a significant reduction in aggressiveness (the mean Inventory for Client and Agency Planning general aggressiveness score was -47 at baseline and -25 at the last follow-up; mean follow-up 3.5 years). Similar responses were obtained with low- and high-frequency stimulation. In 4 cases, the patients' sleep patterns became more regular, and in 1 case, binge eating and polydipsia ceased. One of the 3 patients who had epilepsy noticed a 30% reduction in seizure frequency. Another patient experienced a marked sympathetic response with high-frequency stimulation during the first stimulation trial, but this subsided when stimulation was set at low frequency. A worsening of a previous headache was noted by 1 patient. There were no other side effects. CONCLUSIONS: In this case series, 5 of 6 patients with pathological aggressiveness had a reduction of their outbursts of violence after PMH DBS, without significant adverse effects. Prospective controlled studies with a larger number of patients are needed to confirm these results.

Discapacidad en pacientes bipolares ancianos en tratamiento ambulatorio. Variables asociadas(AU) / Variables associated with disability in elderly bipolar patients on ambulatory treatment

Discapacidad en pacientes bipolares ancianos en tratamiento ambulatorio. Variables asociadas(AU)

Introduction. Studies on adult bipolar patients have demonstrated a disability associated with the bipolar disorder, even in euthymic patients, but there is a lack of data in the elderly population. Material and method. A cross-sectional, multicentre study on a consecutive sample of ambulatory bipolar patients (DSM-IV-TR criteria), aged 65 years or over. Retrospective and cross-sectional sociodemographic and clinical data were collected, as well as the Clinical Global Impression for Bipolar Modified scale (CGI-BP-M) and the level of disability using the World Health Organisation Disability Assessment Schedule (WHO/DAS). The disability was assessed globally and by areas. The presence of a moderate to maximum disability compared to a mild to no disability was considered a dependent variable. Results. A moderate to maximum global disability was present in 43.6% of the sample. By areas, occupational functioning was the area most frequently affected, and personal care the least affected. The only variables which were associated with disability were the presence of medical comorbidity (P = .01), increased age (P = .005) global clinical severity (P = .0001) and in the depressive pole (P = .03). There was no relationship between clinical subtype, duration of the disease, number of previous episodes, number of hospitalisations, or other clinical variables and the degree of disability. Conclusions. These data underline the need to establish specific therapeutic strategies in the approach to depressive symptoms and medical comorbidity, with the aim of minimising the disability in elderly bipolar patients. Given the lack of current data, new studies are needed with larger samples and control groups(AU)

[Variables associated with disability in elderly bipolar patients on ambulatory treatment]. / Discapacidad en pacientes bipolares ancianos en tratamiento ambulatorio. Variables asociadas.

INTRODUCTION: Studies on adult bipolar patients have demonstrated a disability associated with the bipolar disorder, even in euthymic patients, but there is a lack of data in the elderly population. MATERIAL AND METHOD: A cross-sectional, multicentre study on a consecutive sample of ambulatory bipolar patients (DSM-IV-TR criteria), aged 65 years or over. Retrospective and cross-sectional sociodemographic and clinical data were collected, as well as the Clinical Global Impression for Bipolar Modified scale (CGI-BP-M) and the level of disability using the World Health Organisation Disability Assessment Schedule (WHO/DAS). The disability was assessed globally and by areas. The presence of a moderate to maximum disability compared to a mild to no disability was considered a dependent variable. RESULTS: A moderate to maximum global disability was present in 43.6% of the sample. By areas, occupational functioning was the area most frequently affected, and personal care the least affected. The only variables which were associated with disability were the presence of medical comorbidity (P = .01), increased age (P = .005) global clinical severity (P = .0001) and in the depressive pole (P = .03). There was no relationship between clinical subtype, duration of the disease, number of previous episodes, number of hospitalisations, or other clinical variables and the degree of disability. CONCLUSIONS: These data underline the need to establish specific therapeutic strategies in the approach to depressive symptoms and medical comorbidity, with the aim of minimising the disability in elderly bipolar patients. Given the lack of current data, new studies are needed with larger samples and control groups.

Crisis no epilépticas de origen psicógeno en una unidad de cirugía de la epilepsia / Psychogenic non-epileptic seizures in an epilepsy surgery unit

Introducción. Las crisis no epilépticas de origen psicógeno (CNEP) suponen un porcentaje muy elevado de pacientes en diversas unidades de cirugía de la epilepsia. Objetivos. Analizar las características de los pacientes con CNEP y compararlos con los pacientes epilépticos; estudiar la respuesta de los primeros a la aplicación de placebo y discutir el abordaje multidisciplinar de estos pacientes. Pacientes y métodos. Se evaluaron retrospectivamente 408 pacientes candidatos a cirugía de la epilepsia en los últimos nueve años. Todos los pacientes se estudiaron mediante electroencefalografía de scalp, resonancia magnética, tomografía computarizada por emisión de fotón único interictal y videoelectroencefalografía.Resultados. Los pacientes se adscribieron a los siguientes grupos diagnósticos: epilépticos (90,2%), pacientes con CNEP o sin crisis ni signos de epilepsia (6,4%) y pacientes en los que no se pudieron registrar crisis epilépticas, pero con signos de epilepsia (3,4%). No se encontraron diferencias entre pacientes con CNEP y epilépticos en la edad, frecuencia media, distribución de las crisis o tratamiento farmacológico, pero sí en el tiempo de comienzo, más precoz en las CNEP. En los pacientes con CNEP (n = 15) se demostró la presencia de epilepsia o manifestaciones irritativas en 10 casos. En la mayoría de casos (n = 13) se trataba de mujeres y sólo cinco tenían antecedentes de trastornos psiquiátricos leves, que no estaban presentes en el grupo de pacientes exclusivamente con CNEP. En cuatro casos se llevó a cabo la inducción con placebo, que resultó positiva. Conclusión. Se requiere un abordaje multidisciplinar para la correcta evaluación y tratamiento de los pacientes con CNEP (AU)

Introduction. The psychogenic non-epileptic seizures (PNES) represent a significant percentage of patients in different units of epilepsy surgery. Aims. To analyze the characteristics of patients with PNES and compared with epileptic patients, to analyze the early response to the application of placebo and to discuss the multidisciplinary approach to these patients. Patients and methods. 408 patients, candidates for epilepsy surgery in the last nine years, were retrospectively evaluated. All patients were studied with scalp electroencephalography, magnetic resonance imaging, interictal single photon emission computed tomography and video-EEG. Results. Patients were ascribed to the following diagnostic groups: epileptics (90.2%), patients with PNES and/or without seizures or signs of epilepsy (6.4%) and patients for whom no seizures were recorded, but showed signs of epilepsy (3.4%). There were no differences between patients with PNES and epileptic respect to age, average frequency, distribution of seizures or drug treatment, but the time of onset was earlier in PNES. Patients with PNES (n = 15) revealed the presence of epilepsy or irritative manifestations in 10 cases. Most (n = 13) were women and only five had a history of mild psychiatric disorders that were not present in the group of patients exclusively with PNES. In four cases was carried out an induction with placebo, which was positive. Conclusion. A multidisciplinary approach is required for the proper evaluation and treatment of patients with PNES (AU)

[Psychogenic non-epileptic seizures in an epilepsy surgery unit]. / Crisis no epilépticas de origen psicógeno en una unidad de cirugía de la epilepsia.

INTRODUCTION: The psychogenic non-epileptic seizures (PNES) represent a significant percentage of patients in different units of epilepsy surgery. AIMS. To analyze the characteristics of patients with PNES and compared with epileptic patients, to analyze the early response to the application of placebo and to discuss the multidisciplinary approach to these patients. PATIENTS AND METHODS: 408 patients, candidates for epilepsy surgery in the last nine years, were retrospectively evaluated. All patients were studied with scalp electroencephalography, magnetic resonance imaging, interictal single photon emission computed tomography and video-EEG. RESULTS: Patients were ascribed to the following diagnostic groups: epileptics (90.2%), patients with PNES and/or without seizures or signs of epilepsy (6.4%) and patients for whom no seizures were recorded, but showed signs of epilepsy (3.4%). There were no differences between patients with PNES and epileptic respect to age, average frequency, distribution of seizures or drug treatment, but the time of onset was earlier in PNES. Patients with PNES (n = 15) revealed the presence of epilepsy or irritative manifestations in 10 cases. Most (n = 13) were women and only five had a history of mild psychiatric disorders that were not present in the group of patients exclusively with PNES. In four cases was carried out an induction with placebo, which was positive. CONCLUSION: A multidisciplinary approach is required for the proper evaluation and treatment of patients with PNES.