A population-based study of the incidence of delusional infestation in Olmsted County, Minnesota, 1976-2010.

BACKGROUND: Delusional infestation (DI) is a well-recognized clinical entity but there is a paucity of reliable data concerning its epidemiology. Knowledge of the epidemiology is fundamental to an understanding of any disease and its implications. Epidemiology is most accurately assessed using population-based studies, which are most generalizable to the wider population in the U.S. and worldwide. To our knowledge, no population-based study of the epidemiology (particularly incidence) of DI has been reported to date. OBJECTIVES: To determine the incidence of delusional infestation (DI) using a population-based study. METHODS: Medical records of Olmsted County residents were reviewed using the resources of the Rochester Epidemiology Project to confirm the patient's status as a true incident case of DI and to gather demographic information. Patients with a first-time diagnosis of DI or synonymous conditions between 1 January 1976 and 31 December 2010 were considered incident cases. RESULTS: Of 470 identified possible diagnoses, 64 were true incident cases of DI in this population-based study. The age- and sex-adjusted incidence was 1·9 [95% confidence interval (CI) 1·5-2·4] per 100 000 person-years. Mean age at diagnosis was 61·4 years (range 9-92 years). The incidence of DI increased over the four decades from 1·6 (95% CI 0·6-2·6) per 100 000 person-years in 1976-1985 to 2·6 (95% CI 1·4-3·8) per 100 000 person-years in 2006-2010. CONCLUSIONS: Our data indicate that DI is a rare disease, with incidence increasing across the life span, especially after the age of 40 years.

Affective disorders and suicide risk: a reexamination.

OBJECTIVE: In 1970, Guze and Robins published a meta-analysis of suicide in patients with affective illness that inferred a lifetime risk of 15%. Since then, this figure has been generalized to all depressive disorders and cited uncritically in many papers and textbooks. The authors argue for an alternative estimate of suicide risk and question the generalizability of the Guze and Robins estimate. METHOD: The authors sorted studies obtained through a literature search that included data pertaining to suicide occurrence in affective illness into one of three groups: outpatients, inpatients, or suicidal inpatients. Suicide risks were calculated meta-analytically for these three groups, as well as for two previously published collections. RESULTS: There was a hierarchy in suicide risk among patients with affective disorders. The estimate of the lifetime prevalence of suicide in those ever hospitalized for suicidality was 8.6%. For affective disorder patients hospitalized without specification of suicidality, the lifetime risk of suicide was 4.0%. The lifetime suicide prevalence for mixed inpatient/outpatient populations was 2.2%, and for the nonaffectively ill population, it was less than 0.5%. CONCLUSIONS: The percentage of subjects dead due to suicide (case fatality prevalence) is a more appropriate estimate of suicide risk than the percentage of the dead who died by suicide (proportionate mortality prevalence). More important, it is well established that patients with affective disorders suffer a higher risk of suicide relative to the general population. However, no risk factor, including classification of diagnostic subtype, has been reliably shown to predict suicide. This article demonstrates a hierarchy of risk based on the intensity of the treatment setting. Given that patients with a hospitalization history, particularly when suicidal, have a much elevated suicide prevalence over both psychiatric outpatients and nonpatients, the clinical decision to hospitalize in and of itself appears to be a useful indicator of increased suicide risk.

Bupropion-induced erythema multiforme.

The high rate of dermatologic adverse effects associated with bupropion use may extend to its sustained-release preparation, currently prescribed extensively for smoking cessation as well as for treatment of depressive conditions. We report what we believe to be the first case, in a 31-year-old woman, of erythema multiforme after administration of sustained-release bupropion (Wellbutrin SR) for treatment of depression. This report emphasizes that prescribers must aggressively follow up their patients who have rashes or urticaria, discontinuing the medication as soon as erythema multiforme is suspected and watching closely for the emergence of potentially life-threatening dermatologic conditions.

Maintaining quality of life at the end of life.

Despite the successful growth of the hospice movement during the past 30 years in the United States, almost 85% of Americans continue to die in hospitals or nursing homes. While the benefits of palliative care principles are well established, palliative care interventions remain underused in clinical practice in the settings in which most Americans die. Our premise is that physicians as a group perpetuate end-of-life suffering rather than ease the transition from life to death. We also believe that maintaining quality of life (QOL) at the end of life requires a multidimensional approach orchestrated by physicians drawing on the full range of available physical, psychological, social, and spiritual interventions. This article defines the meaning of QOL at the end of life and then examines the ramifications of failing to attend to QOL concerns in dying patients. It reviews strategies that physicians can use to advance palliative care approaches, thereby reducing terminally ill patients' suffering in the institutions in which most die.

Buspirone as an antidote to SSRI-induced bruxism in 4 cases.

BACKGROUND: One hypothesis to explain selective serotonin reuptake inhibitor (SSRI)-induced bruxism states that SSRIs increase extrapyramidal serotonin levels, thereby inhibiting dopaminergic pathways controlling movement. Previous reports have emphasized buspirone's postsynaptic dopaminergic effect as a partial antidote to the suppressed dopamine levels. CASE REPORTS: Four patients, recently started on treatment with the SSRI sertraline, presented with new-onset complaints attributable to SSRI-induced bruxism. All 4 responded to adjunctive buspirone, a serotonin-1A (5-HT1A) receptor agonist, with relief of bruxism and associated symptoms. DISCUSSION: We expand the hypothesis put forth in previous reports by proposing that buspirone is not only acting postsynaptically in the extrapyramidal system, but also presynaptically on serotonergic neurons that influence masticatory modulation in the mesocortical tract. Our 4 cases support the concept of buspirone acting as a full agonist at the presynaptic 5-HT1A somatodendritic receptors located on the cell bodies of raphe serotonergic neurons that project to the ventral tegmental area (VTA) of the midbrain. These serotonergic neurons modulate the firing of the mesocortical tract, which itself projects from the VTA to the prefrontal cortex and acts on masticatory muscle activity through inhibiting spontaneous movements such as bruxism. While the literature is confusing and contradictory on definitions of bruxism and etiologies of incompletely understood movement disorders, we believe SSRI-induced bruxism is best conceptualized as a form of akathisia.

Development of brief stress management support groups for couples undergoing in vitro fertilization treatment.

OBJECTIVE: To develop and assess the efficacy of couples stress management groups offered concurrently with IVF treatment. DESIGN: Couples in IVF treatment were given the option of participating in a biweekly stress management group. SETTING: The IVF treatment clinic at Wilford Hall Medical Center, San Antonio, Texas. PATIENT(S): One or both members of 17 couples participated in the program in one of four group cycles. INTERVENTION(S): A cognitive behavioral treatment model was used to help couples process their feelings and cognitions about the impact of infertility on their life and explore their expectations about their future options for becoming parents. MAIN OUTCOME MEASURE(S): Couples were asked to anonymously evaluate the efficacy of the group after they had completed their IVF cycle. RESULT(S): Participants reported that the group helped them deal with the stress of infertility and that they valued the social bonds they formed with other group members. CONCLUSION(S): These data suggest that brief focused group therapy, offered while couples are undergoing IVF, is an effective way to help people deal with the stress of infertility treatment.

Why we need military psychiatrists: 20th century U.S. Military psychiatry and proposal for the future.

Military psychiatrists perform distinct military functions that contribute substantially to effective troop performance and cohesion. Three historic approaches to combat psychiatry and the limitations of these approaches are described. A new model is proposed in which military psychiatrists, during war, treat psychiatric casualties by combining lessons learned from past wars with current concepts of deployed medical operations and clinical psychiatry. In peacetime, through their pro-active undertakings, military psychiatrists sustain capabilities to perform combat operations and operations other than war. And finally, military psychiatrists are situated best to deal with specific cross-cultural factors that affect military life. Thus, military psychiatry is a unique mission requiring specialized skills and perspectives. It is optimally practiced by those committed to military life and supportive of its missions.

The many faces of confusion. Timing and collateral history often hold the key to diagnosis.

Recognition of a patient's state of confusion is only the beginning of a clinical odyssey that can implicate a huge spectrum of diagnostic possibilities. Among these are delirium, depression, dementia, and sensory deprivation. However, with appropriate physical examination and laboratory studies, collateral history, and clarification of time course for the symptom complex, the cause of confusion need not remain confusing.

Psychopharmacological treatment of delirium to restore mental capacity.

The authors report four patient cases of delirium in which medications were used to restore mental capacity when life-or-death treatment decisions were required. Although extensive literature on substituted judgment exists for delirium and depression compromising capacity to make competent decisions, the authors could locate no articles proposing aggressive delirium treatment for restoring patients' capacity to participate in their own care. Without surgical intervention, all four of the authors' patients faced imminent death. Without psychopharmacologic banishment of the patients' deliria, proxies would have been asked whether the patients should undergo potentially lifesaving but high-risk procedures. The patients would have lost the opportunity to express their wishes about heroic lifesaving medical measures.