Effects of Propofol and Propofol-Remifentanil Combinations on Haemodynamics, Seizure Duration and Recovery during Electroconvulsive Therapy.

OBJECTIVE: This study aimed to evaluate the effects of adding different doses of remifentanil to propofol treatment compared with propofol alone with regard to parameters, including the seizure duration, haemodynamic changes and recovery time, in patients undergoing electroconvulsive therapy (ECT). METHODS: This study was designed as a self-controlled, prospective, double-blind investigation of 17 patients between the ages of 20 and 65 years who had planned treatment with ECT at a psychiatric clinic. Group P (propofol) was administered 10 mL of normal saline after 0.5 mg kg-1 intravenous (IV) bolus of propofol. Group R I (propofol plus remifentanil-1) was administered 1.5 µg kg-1 of remifentanil, and group R II (propofol plus remifentanil-2) was given 2 µg kg-1 of remifentanil after 0.5 mg kg-1 IV bolus of propofol. The haemodynamic variables after seizure and the seizure duration were recorded. Time to return to spontaneous respiration, eye opening and achieving Aldrete score >9 were recorded. RESULTS: The electroencephalography seizure duration was significantly longer in groups R I (34.7±13 s) and R II (34.9±12) than in group P (24±7.5). Motor seizure duration was longer in groups R I (29.70±12.8) and R II (28.1±10) than in group P (21±7.3). The amount of total propofol was 121±21 mg in group P, 69.4±2 mg in group R I and 67±17 mg in group R II. Times to eye opening, following simple commands, and achieving Aldrete score >9 were significantly shorter in groups R I and R II than in group P. CONCLUSION: ECT is a safe and effective treatment for patients with psychiatric disorders. Propofol-remifentanil anaesthesia prolongs the seizure duration and shortens the recovery time, suggesting that this combination may particularly be well suited for use in this patient group.

Self-Management Training in Chronic Obstructive Lung Disease Improves the Quality of Life.

OBJECTIVES: Management of chronic obstructive pulmonary disease (COPD) includes interventions such as improving skills in coping with the disease. We aimed to examine the effect of self-management training on the quality of life and functional parameters in patients with moderate to severe COPD. MATERIALS AND METHODS: Sixty-one consecutive patients with COPD were recruited in the study prospectively. The patients were randomized into two groups: self-management training (n=31) and standard care (n=30). Each patient was evaluated by spirometry, COPD assessment test (CAT), St George's respiratory questionnaire (SGRQ), hospital anxiety and depression scale (HADS), modified British Medical Research Council (mMRC) dyspnea scale, and short form-36 (SF-36). A team of physiotherapists, psychologists, pulmonary disease specialists, and dietitians provided self-management training and biweekly counseling via phone. At the end of three months, both the groups were re-evaluated using the same assessment parameters. RESULTS: We found no significant difference between the baseline demographic characteristics of the self-management training and standard care groups. We observed a reduction in CAT (p<0.001), SGRQ impact (p=0.013), activity subscales (p<0.001) and the total scores (p=0.020), and HADS anxiety (p=0.012) and depression (p=0.014) scores in the self-management training group after the education session. A significant increase in SF-36 physical function score was also observed (p=0.008). No significant improvement in the functional parameters was observed in either group; however, the change in FEV1 was more pronounced in the self-management training group than in the control group (p=0.017). The hospital readmissions and 1-year survival rates were similar for both the groups after receiving education (p>0.05). CONCLUSION: Our results suggest that the self-management training of the patients with COPD improves the quality of life and reduces the symptoms of depression and anxiety. Therefore, at the least, self-management training should be done as the first step of pulmonary rehabilitation in patients with COPD who cannot access pulmonary rehabilitation facilities.

[A new approach to the treatment of delirium: atypical antipsychotics]. / Deliryum Tedavisinde Yeni Bir Yaklasim: Atipik Antipsikotikler.

Delirium is a common neuropsychiatric syndrome that involves a number of symptoms including diffuse cognitive impairment, delusions, hallucinations, mood lability and disturbances in the sleep-wake cycle. It occurs in 10-30% of hospitalized medically ill patients. Delirium is also associated with a prolonged hospital stay and increased functional decline and morbidity and mortality rates, particularly if it is unrecognized and untreated. Management of the symptoms of delirium involves non-pharmacological and pharmacological interventions. Until recently, typical antipsychotics and benzodiazepines were commonly used in the pharmacological treatment of delirium. The extrapyramidal and anticholinergic side effects of typical antipsychotics and the negative effects of benzodiazepines on cognitive functions limit their use in delirium patients, who are generally old and who have other medical problems. Atypical antipsychotics have been shown to be effective in the treatment of psychotic symptoms. Although there are a number of studies showing their efficacy, most studies have some limitations such as small sample size and absence of control groups. Upon reviewing the studies of the treatment of delirium with atypical antipsychotics, it has been observed that the efficacy and safety of risperidone and olanzapine were shown in randomized trials, and the efficacy and safety of quetiapine were shown in case reports and retrospective studies, and it was shown that the side effect over the QT interval limits the use of ziprasidone in delirium treatment. Suggestions were made in the light of the literature on the use of atypical antipsychotics in the treatment of delirium.

[Factorial structure, validity, and reliability of the Turkish temperament and character inventory]. / Mizaç ve Karakter Envanteri'nin Türkçe Formunun Faktör Yapisi, Geçerlik ve Güvenilirligi.

OBJECTIVE: To assess the factorial structure, reliability and validity of the Turkish version of the Temperament and Character Inventory (TCI), a 240-item, self-report, paper-and-pencil test, and true-false format inventory based on Cloninger's psychobiological model of personality. It measures the four higher-order temperament dimensions and three character dimensions. METHOD: Using samples consisting of 470 healthy volunteers and 544 psychiatric patients, psychometric features were explored. RESULTS: The internal consistency of the scales was good (Cronbach alpha coefficients between 0.68 and 0.84), but weak for Reward dependence (0.55) and Persistence (0.56). The factor structures of the temperament and character dimensions, explored separately, were in agreement with the hypothesized constructs, except for the scales NS1 (Novelty Seeking 1 = exploratory excitability) and SD4 (Self-directedness 4 -- self-acceptance). The present study also confirmed that the TCI scales were weakly related among themselves. On the whole, psychiatric patients had higher harm avoidance and lower self-directedness, persistence, cooperativeness, and self-transcendence scores than the normal subjects. Gender differences were also found for different dimensions. CONCLUSION: The findings of this study suggest that the TCI can be applied in the investigation of psychiatric and normal populations.

[Neurobiological consequences of early life stressors]. / Erken yasam stresörlerinin nörobiyolojik sonuçlari.

This article reviews the neurobiological effects of psychosocial stress. In the first part, the results of childhood traumas, neurobiological models which explain the effects of psychosocial stress and animal studies on this subject are introduced. In a number of studies, an increase in the adulthood prevalence of depression, anxiety disorders and other psychiatric disorders was shown in children who were exposed to early life stress. Pre-clinical and clinical studies have shown that early life stressors cause endocrine, autonomous and behavioral stress responses as a result of permanent sensitivity in corticotropin releasing factor and other neurotransmitter systems in the central nervous system. As a result of this sensitivity, repeating stressors may play an important role in the pathogenesis of depression, anxiety disorders and psychophysiologic disorders. In contrast with the numerous studies investigating the long term effects of early life stressors on the brain, there are very few studies investigating the acute effects of these stressors. In spite of these limitations, it is known that psychosocial stressors may cause different neurobiological results in adults and children. After reviewing the relationship between psychosocial stressors and the neurobiology of affective disorders, it is explained how psychosocial stresses cause sensitivities in the central nervous system and how these sensitivities cause illness. These interactions have implications for treatment in the light of the explained mechanisms. In the last part of the article, new treatment strategies developed for correcting the effects of stress on the central nervous system are introduced.

Psychiatric epidemiology in Turkey: main advances in recent studies and future directions.

OBJECTIVE: To overview and evaluate the main findings, methodological shortcomings, and time trends of the recent psychiatric epidemiology studies in Turkey, as well as to provide areas prone for development in forthcoming research. METHOD: PubMed and Turkish Psychiatry Index were screened to identify relevant studies. Any epidemiological study from 2000 to 2012 with a general population or unique sub-population sample was included. Papers and results were classified as depression, anxiety, psychotic, dissociative, conversion, personality, alcohol and substance abuse, and trauma-related disorders, and common geriatric disorders. RESULTS: There are various epidemiological studies on various psychiatric disorders in Turkey. However, there are main shortcomings and trends in research that subsequently stagnate current psychiatric epidemiological research. First, epidemiological studies were mainly conducted for academic purposes, not for addressing epidemiological issues or issues of health policy. Second, studies mainly focused on particular fields and institutions, which led to non-systematic accumulation of epidemiological results. Third, although Turkey is a natural laboratory of social conflicts and disasters, there were few studies with a focus on probable outcomes. Fourth, high-quality epidemiological studies with disseminating results tended to decrease, even in common mental disorders such as depression. Fifth, there were very few epidemiological studies using contemporary designs such as follow-up, genetic, or biomarker data in the general-population. CONCLUSION: Although psychiatric epidemiological studies of the last decade provide a suitable ground for future challenges, current trends in this research area has tended to stagnate, despite the potential for unique contributions. Forthcoming studies and researchers may notice novel methodological developments in epidemiology, with a growing attention on rapid urbanization, natural disasters, social conflicts, and migration.

Mental Findings in Trauma Victims.

INTRODUCTION: In medico-legal evaluation of trauma patients, the bio-psychological effects of the trauma and the severity of the injuries require to be evaluated. In this study, assuming the fact that psychiatric assessment is not taken into consideration in physical trauma cases, we planned to show the presence of psychological trauma in our medico-legally evaluated patients who presented with different types of traumas and to review the mental findings and diagnoses in trauma victims. METHOD: We retrospectively analyzed the hospital records of 1975 patients aged 18 years or older who presented to the Department of Forensic Medicine at Dokuz Eylül University School of Medicine for medico-legal evaluation between 1999 and 2009. Psychiatric assessment was performed in 142 patients by the Department of Psychiatry. The data contained in medico-legal reports and patient records were then examined with respect to patients' age, gender, nature of traumatic events, psychiatric diagnoses, descriptive characteristics of the patients, severity of trauma and past history of mental disorder and trauma experience. Results of the medicolegal evaluations were also analyzed. RESULT: Of the 142 patients, 80 (56.3%) were female and their average age was 40.30±17.17 years. The most frequent traumatic events were traffic accidents (29.6%) and violence-related blunt force trauma (28.9%). When the distribution of the most common psychiatric diagnoses was examined, it was found that anxiety disorders were found in 69 cases (48.6%), adjustment disorders were found in 16 cases (11.3%) and mood disorders were found in 12 cases (8.5%). Among anxiety disorders, acute stress disorder (n=39) and post-traumatic stress disorder (PTSD) (n=27) were the most common ones. In 27 cases of the 142, it was determined that, psychiatric symptoms and findings did not meet the diagnostic criteria of any psychiatric disorder. Diagnosis of psychiatric disorder was not significantly related with traumatic experiences, comorbidity, marriage status, education level or lack of health insurance. CONCLUSION: We assume elucidating the presence of a psychological trauma is crucial not only for the health benefit but also for legal rights of the patient. The necessity of considering merely the international diagnostic criteria in determining the existence of psychiatric trauma and its severity level can bring forth some difficulties in medico-legal evaluation.

Family focused treatment for patients with bipolar disorder in Turkey: a case series.

Family-focused therapy (FFT) is a 9-month, 21-session structured psychoeducational treatment for bipolar disorder. Several US-based studies have documented its efficacy as adjunctive to medication for depression stabilization and relapse prevention. However, FFT has never been applied outside of the United States. The objective of this case series is to explore the applicability of FFT in a non-Western culture. Ten patients with bipolar disorder and their family members attended the 9-month FFT as adjunctive to pharmacotherapy in an outpatient specialty clinic in Izmir, Turkey. Patients improved in Global Assessment of Functioning Scores and Clinical Global Impression Scores from pre- to posttreatment. Case studies are given, which illustrate the differences between Western and non-Western families coping with bipolar disorder. FFT was easily applied to a Turkish sample with few changes in format or focus. Adaptations included substitution of oral for written therapeutic tasks or homework assignments. Randomized controlled trials are needed to test the clinical effectiveness of FFT and other psychosocial interventions in non-Western cultures.