[Railway suicide and the proximity of psychiatric hospitals: a scoping review]. / Spoorsuïcide en de aanwezigheid van psychiatrische ziekenhuizen: een scoping review.

BACKGROUND: The proximity of a psychiatric hospital to a railway infrastructure is a risk factor for railway suicide. Due to limited research results, no systematic reviews have extensively investigated the determinants of this association. AIM: Scoping review of the current scientific knowledge on the institutional, patient-related and rail- and environment-related determinants of rail suicide in proximity of psychiatric hospitals and of existing preventive measures taken by rail managers in Belgium and the Netherlands. METHOD: A literature search was conducted using the PubMed, Embase, Web of Science, and Scopus databases. Relevant policy documents were requested from railroad administrators. RESULTS: Residential patients with a severe psychiatric disorder are at increased risk of railway suicide. Poor continuity of care and various rail and environmental factors appear to be other relevant risk factors. The rail sector in Belgium and the Netherlands appears to take specific measures to prevent rail suicide in the hotspots located near psychiatric hospitals. CONCLUSION: Despite certain consistent findings about the population at risk for railway suicide, there is a clear need for more research concerning other possible determinants and the effectiveness of suicide prevention programs within a psychiatric context.

[The impact of high indoor temperatures on cognitive performance within the work setting: a systematic review]. / Hoge omgevingstemperatuur en cognitieve prestaties binnen werksetting: systematische review.

BACKGROUND: Workplace guidelines exclusively focus on the impact of high indoor temperatures on physical work. There are no concrete recommendations in this regard concerning mental work. AIM: To investigate to what extent high ambient temperatures can have an impact on cognitive performance within a work setting, which cognitive skills or tasks are impacted, and to what extent the results found can be transposed to the work setting of the psychiatrist. METHOD: A literature search was conducted using the PubMed, Embase, and Web of Science databases. RESULTS: A total of 17 studies were included. Although results were inconsistent, reaction time and processing speed appeared to be the most sensitive cognitive skills to elevated ambient temperatures. Higher cognitive functions such as logical and abstract reasoning were more resistant. The temperature range for optimal cognitive functioning generally appeared to be between 22°C and 24°C. CONCLUSION: Temperatures above 24°C can have a negative impact on cognitive performance within a work setting. Given that reaction speed and processing speed are particularly affected, this could possibly have an impact in the work setting of the psychiatrist when making crucial decisions. However, due to the limited ecological validity of the included studies, unequivocal conclusions remain difficult.

[Do clothes make the psychiatrist? Psychiatrists and patients on psychiatrists' dress style and form of address]. / Maken de kleren de psychiater? Psychiaters en patiënten over kleding en aanspreekvorm.

BACKGROUND: Both the way a psychiatrist dresses and the way he gets addressed can have an impact on the therapeutic relationship. Most psychiatrists have stopped wearing white coats and dress less formally than before. AIM: To identify psychiatrists’ and patients’ preferences regarding psychiatrists’ style of dress and form of address. To test if certain styles of dress are linked to competence or accessibility. METHODS: A total of 143 respondents, of which 35 psychiatrists and 108 patients, filled out structured questionnaires with pictures. RESULTS: Psychiatrists, and both minor and adult patients, preferred psychiatrists to dress formally while elderly patients prefer them to wear white coats. The formal dress style and white coat were perceived as more competent than the informal style. Psychiatrists thought a white coat is regarded less accessible than a formal dress style and a formal dress style less accessible than an informal one. Adult patients regarded a white coat as less accessible than formal and informal dress styles. In elderly and minor patients no differences were seen in perceived accessibility for the three dress styles. Both psychiatrists and patients preferred a psychiatrist to be addressed with ‘doctor’ and a patient with his/her first name. CONCLUSIONS: It seems a good choice for a psychiatrist to go formally dressed, let them be addressed by their title, and address patients by their first name.

Sex-specifics of ECT outcome.

OBJECTIVE: Electroconvulsive therapy (ECT) is the most effective treatment for patients with severe major depressive disorder (MDD). Given the known sex differences in MDD, improved knowledge may provide more sex-specific recommendations in clinical guidelines and improve outcome. In the present study we examine sex differences in ECT outcome and its predictors. METHODS: Clinical data from 20 independent sites participating in the Global ECT-MRI Research Collaboration (GEMRIC) were obtained for analysis, totaling 500 patients with MDD (58.6 % women) with a mean age of 54.8 years. Severity of depression before and after ECT was assessed with validated depression scales. Remission was defined as a HAM-D score of 7 points or below after ECT. Variables associated with remission were selected based on literature (i.e. depression severity at baseline, age, duration of index episode, and presence of psychotic symptoms). RESULTS: Remission rates of ECT were independent of sex, 48.0 % in women and 45.7 % in men (X2(1) = 0.2, p = 0.70). In the logistic regression analyses, a shorter index duration was identified as a sex-specific predictor for ECT outcome in women (X2(1) = 7.05, p = 0.01). The corresponding predictive margins did show overlapping confidence intervals for men and women. CONCLUSION: The evidence provided by our study suggests that ECT as a biological treatment for MDD is equally effective in women and men. A shorter duration of index episode was an additional sex- specific predictor for remission in women. Future research should establish whether the confidence intervals for the corresponding predictive margins are overlapping, as we find, or not.

[Neural networks in late life depression]. / Neurale netwerken bij depressie op latere leeftijd.

BACKGROUND: Major depression is associated with activity and connectivity changes of multiple neural networks that correlate to the clinical manifestation. The chronic and recurrent course of late -life depression (LLD) suggests a possible role for structural brain changes in these network alterations. Recent evolutions in brain imaging permits to investigate neural networks in LLD on multiple levels. AIM: To provide an overview of the structural, functional and molecular changes seen in imaging studies of LLD. METHOD: Narrative review. RESULTS: The neurobiology of LLD includes specific grey and white matter changes and dysfunctions in three neural networks that can be correlated to LLD symptomatology. Some patients show signs of accelerated or pathological brain aging. These provide a possible neurobiological underpinning for poor treatment response. CONCLUSION: Imaging studies show various neurobiological changes that contribute to neural network dysfunction in LLD.

A longitudinal study of the association between basal ganglia volumes and psychomotor symptoms in subjects with late life depression undergoing ECT.

Psychomotor dysfunction (PMD) is a core element and key contributor to disability in late life depression (LLD), which responds well to electroconvulsive therapy (ECT). The neurobiology of PMD and its response to ECT are not well understood. We hypothesized that PMD in LLD is associated with lower striatal volume, and that striatal volume increase following ECT explains PMD improvement. We analyzed data from a two-center prospective cohort study of 110 LLD subjects (>55 years) receiving ECT. Brain MRI and assessment of mood, cognition, and PMD was performed 1 week before, 1 week after, and 6 months after ECT. Volumetry of the caudate nucleus, putamen, globus pallidus, and nucleus accumbens was derived from automatically segmented brain MRIs using Freesurfer®. Linear multiple regression analyses were used to study associations between basal ganglia volume and PMD. Brain MRI was available for 66 patients 1 week post ECT and in 22 patients also six months post ECT. Baseline PMD was associated with a smaller left caudate nucleus. One week after ECT, PMD improved and volume increases were detected bilaterally in the caudate nucleus and putamen, and in the right nucleus accumbens. Improved PMD after ECT did not relate to the significant volume increases in these structures, but was predicted by a nonsignificant volume change in the right globus pallidus. No volume differences were detected 6 months after ECT, compared to baseline. Although PMD is related to lower striatal volume in LLD, ECT-induced increase of striatal volume does not explain PMD improvement.

Understanding electroconvulsive therapy-related anxiety: a prospective study.

AIMS OF STUDY: Although electroconvulsive therapy (ECT)-related anxiety is experienced by a significant proportion of patients, it remains understudied. Our aim was to study the course of ECT-related anxiety during ECT. METHODS: Seventy-four patients with unipolar or bipolar depression, referred for ECT, were included. ECT-related anxiety was assessed the morning before each ECT session using the ECT-related Anxiety Questionnaire (ERAQ). RESULTS: Female patients reported more anxiety than men (F(1,64.6) = 3.95, P = 0.05). Patients with a psychotic depression were more anxious before the start of ECT (F(64.8) = 4.57, P = 0.04), but experienced a significant decrease in ECT-related anxiety (t(63.9) = -3.63, P = 0.0006), whereas patients with a non-psychotic depression remained stable on anxiety during their ECT course (t(63,9) = 0.76, P = 0.45). In addition, we found a significant correlation between the decrease of ECT-related anxiety and the decrease of depression-severity (r = 0.35; P = 0.04). CONCLUSION: There are individual differences in ECT-related anxiety trajectories during ECT. Both female patients and patients with psychotic depression experienced more ECT-related anxiety before the start of ECT. The severity of ECT-related anxiety decreased significantly in patients with a psychotic depression, but remained stable in patients without a psychotic depression during ECT. In addition, patients who showed a stronger decrease in depression-severity also showed a stronger decrease in ECT-related anxiety. A better understanding of ECT-related anxiety trajectories can help in designing anxiety-reducing interventions.

Association between hippocampal volume change and change in memory following electroconvulsive therapy in late-life depression.

OBJECTIVE: Electroconvulsive therapy (ECT)-induced hippocampal volume change (HVC) has been repeatedly described in recent years. The similar time course of HVC and ECT-related cognitive effects suggest a relation, that is to date, understudied. This study investigates whether HVC following ECT predicts the change in memory performance six months after the end of the ECT treatment. METHODS: Hippocampal volume (HV) was measured via high-resolution 3D T1-weighted images in 88 patients with late-life depression, within 1 week before and after ECT. Memory performance was assessed before and six months after ECT. Multiple linear regression was used to examine whether change in memory performance could be predicted based on ECT-induced changes in HV. RESULTS: Larger right absolute HVC predicts less pronounced improvement on the VAT (visual memory) in the whole sample. For the 8-Word Test (verbal memory), Category Fluency Test (semantic memory), and MMSE, the effect is only present in patients who switched from right unilateral to bitemporal stimulation after six ECT sessions. Absolute HVC in the left hemisphere was not significantly related to cognitive change. CONCLUSION: A larger absolute change in right HV during ECT is associated with less improvement in memory performance up to 6 months post-ECT.

Long-term neurocognitive functioning after electroconvulsive therapy in patients with late-life depression.

OBJECTIVE: There is ongoing concern about the possible negative impact of ECT on neurocognitive functioning in older patients. In this study, we aimed to characterize the long-term cognitive effects of ECT in patients with late-life depression, using an extensive neuropsychological battery. METHODS: A total of 110 patients aged 55 years and older with unipolar depression, referred for ECT were included. The neuropsychological test battery was assessed prior to ECT and 6 months after the last ECT session. RESULTS: There were no statistically significant group-level changes from baseline to 6 months post-ECT in any of the neuropsychological measurements. Individual differences in cognitive performance were detected using the Reliable Change Index. CONCLUSION: Patients with late-life depression do not show deleterious cognitive effects 6 months following an ECT index course, although there are considerable differences at an individual level. Clinicians should not hesitate to prescribe ECT in older patients, as most of these patients will tolerate the treatment course and a small group will even experience a cognitive enhancement. However, clinicians should be aware that a small group of patients can experience cognitive side-effects. Further study is needed to predict which patients have a higher risk of developing cognitive side-effects.

The course of apathy in late-life depression treated with electroconvulsive therapy; a prospective cohort study.

OBJECTIVES: Apathy, a lack of motivation, is frequently seen in older individuals, with and without depression, with substantial impact on quality of life. This prospective cohort study of patients with severe late-life depression treated with electroconvulsive therapy (ECT) aims to study the course of apathy and the predictive value of vascular burden and in particular white matter hyperintensities on apathy course. METHODS: Information on apathy (defined by a score of >13 on the Apathy Scale), depression severity, vascular burden, and other putative confounders was collected in at 2 psychiatric hospitals on patients with late-life depression (aged 55 to 87 years, N = 73). MRI data on white matter hyperintensities were available in 52 patients. Possible risk factors for apathy post-ECT were determined using regression analyses. RESULTS: After treatment with ECT, 52.0% (26/50) of the depression remitters still suffered from clinically relevant apathy symptoms. In the entire cohort, more patients remained apathetic (58.9%) than depressed (31.5%). Presence of apathy post-ECT was not associated with higher age, use of benzodiazepines, or severity of apathy and depression at baseline. Less response in depressive symptomatology after ECT predicted post-treatment apathy. The presence of vascular disease, diabetes mellitus and smoking, and white matter hyperintensities in the brain was not associated with post-treatment apathy. CONCLUSIONS: Apathy may perpetuate in individual patients, despite remission of depressive symptoms. In this cohort of patients with late-life depression, post-ECT apathy is not associated with white matter hyperintensities.

[ResPECT - a decade of Flemish-Dutch ECT research]. / ResPECT ­ een decennium Vlaams-Nederlands onderzoek naar elektroconvulsietherapie.

BACKGROUND: There is increasing clinical and scientific interest in electroconvulsive therapy (ECT). AIM: To provide an overview of the main research findings of the Flemish-Dutch research consortium ResPECT. METHOD: We report on our review of the relevant literature. RESULTS: Our studies confirm that ECT is one of the most efficient treatments for depression in later life and for depression with psychotic features. Older people with age-related brain pathology can respond well to ECT. It is still preferable to apply a standard pulse-width because this increases the efficacy of the treatment and minimises the cognitive impact. Even vulnerable older people can react favourably to ECT. CONCLUSION: Recent findings of the ResPECT consortium are providing new insights that are applicable in daily clinical practice. Research into mechanisms of action can also increase our understanding of the pathophysiology of severe depression.

Personality disorders in older adults: emerging research issues.

Empirical research focusing on personality disorders (PDs) among older adults is mainly limited to studies on psychometric properties of age-specific personality tests, the age neutrality of specific items/scales, and validation of personality inventories for older adults. We identified only two treatment studies-one on dialectical behavior therapy and one on schema therapy-both with promising results among older patients despite small and heterogeneous populations. More rigorous studies incorporating age-specific adaptations are needed. Furthermore, in contrast to increasing numbers of psychometric studies, the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 pays little attention to the characteristics of older adults with PDs. Moreover, the constructs "personality change due to another medical condition" and "late-onset personality disorder" warrant further research among older adults. These needs will become even more pressing given the aging society worldwide.

[Cenesthetic schizophrenia revisited]. / Coenesthetische schizofrenie uit de vergeethoek.

BACKGROUND: In 1957 Huber introduced the concept 'cenesthetic schizophrenia', a subtype of schizophrenia that is characterised primarily by aberrant bodily sensations. Clinical practice shows that patients with schizophrenia frequently suffer from disturbed bodily sensations. Nevertheless, the current 1CD-10 en DSM-IV classifications pay hardly any attention to symptoms of this kind. AIM: To describe the characteristics of cenesthetic schizophrenia. METHOD: We obtained background information from historical literature and the PubMed database. We also report a case-study in which a patient experienced atypical physical symptoms which closely resembled those that characterised Huber's cenesthetic schizophrenia. RESULTS: Huber's description led to new insights into the development and course of schizophrenia where the main focus was on the patient's subjectively experienced symptomatology. Both the background literature and the case-study show that the time has come for a revaluation of cenesthetic schizophrenia. CONCLUSION: We recommend that cenesthetic schizophrenia be included as a subtype within the spectrum of schizophrenia. Further longitudinal research is needed into other characteristics of this type of schizophrenia, its etiopathogenesis and the currently available therapeutical options.

[Aripiprazole-induced parkinsonism in a 64-year-old female patient diagnosed with bipolar disorder]. / Door aripiprazol geïnduceerd parkinsonisme bij een 64-jarige patiënte met een bipolaire stoornis.

A 64-year-old female patient, diagnosed with bipolar disorder, developed parkinsonism 18 days after aripiprazole had been initiated. Twenty-six days after the patient had stopped taking aripiprazole the parkinson syndrome disappeared completely. Aripiprazole is usually associated with a low incidence of extrapyramidal symptoms. So far, little is known about the pathophysiology of parkinsonism and the possible role of aripiprazole. The case-study includes some hypotheses and recommendations.

[The Charles Bonnet syndrome and dementia]. / Het syndroom van Charles Bonnet en dementie.

An 83-year-old visually impaired woman was admitted to the hospital because of complex visual hallucinations. Her symptoms were indicative of the Charles Bonnet syndrome (CBS). On the basis of this case we explore the relationship between CBS and dementia and discuss the different opinions on this topic.

[Clozapine-induced agranulocytosis and Sweet's syndrome in a 74-year-old female patient. A case study]. / Clozapinegeïnduceerde agranulocytose en het syndroom van Sweet bij een 74-jarige patiënte.

A 74-year-old psychotic female patient who was treated with clozapine developed Sweet's syndrome followed by agranulocytosis from which she later died. A link between these two conditions seems unlikely. Sweet's syndrome is characterised by an acute onset of fever, leukocytosis and erythematous plaques with dense neutrophilic infiltrates. Frequent counting of the numbers of neutrophiles is advisable when skin disorders appear during treatment with clozapine.