A Unique Delusion with Depression in Early Stage of Neurocognitive Disorder Due to Vascular Disease: Considerations for Clinicians.

As global aging becomes more prominent, neurocognitive disorders (NCD) incidence has increased. Patients with NCD usually have an impairment in one or more cognitive domains, such as attention, planning, inhibition, learning, memory, language, visual perception, and spatial or social skills. Studies indicate that 50-80% of these adults will develop neuropsychiatric symptoms (NPS), such as apathy, depression, anxiety, disinhibition, delusions, hallucinations, and aberrant motor behavior. The progression of NCD and subsequent NPS requires tremendous care from trained medical professionals and family members. The behavioral symptoms are often more distressing than cognitive changes, causing caregiver distress/depression, more emergency room visits and hospitalizations, and even earlier institutionalization. This signifies the need for early identification of individuals at higher risk of NPS, understanding the trajectory of their NCD, and exploring treatment modalities. In this case report and review, we present an 82-year-old male admitted to our facility for new-onset symptoms of depression, anxiety, and persecutory delusions. He has no significant past psychiatric history, and his medical history is significant for extensive ischemic vascular disease requiring multiple surgeries and two episodes of cerebrovascular accident (CVA). On further evaluation, the patient was diagnosed with major NCD, vascular subtype. We discuss differential diagnoses and development of NPS from NCD in order to explain the significance of more thorough evaluation by clinicians for early detection and understanding of NCD prognosis.

The role of anxiety and emotional stress as a risk factor in treatment-resistant hypertension.

Depression and anxiety are both known to be co-morbid with coronary heart disease. Given the high prevalence of coronary heart disease today, specifically the aspect of hypertension, it seems more important than ever to investigate whether or not treatment of these co-morbidities can have an effect on reducing hypertension. This article summarizes the limited amount of literature that has been published in this area and highlights what we believe to be a missing key element that will guide our own future research in this area.

Attempted Suicide in a Parkinsonian Patient Treated with DBS of the VIM and High Dose Carbidopa-Levodopa.

INTRODUCTION: Parkinson's disease (PD) is a complex disease that is often treated with dopaminergic medications such as carbidopa-levodopa and now with innovative interventions such as deep brain stimulation (DBS). While PD frequently presents with depression and apathy, research must elucidate whether its treatment modalities have an additive or synergistic effect that can lead to an increased suicide risk. DBS has been associated with depression, behavioral changes, and suicidality while dopaminergic treatment has also been shown to cause behavioral changes such as hypersexuality and impulsivity. Considering the now frequent practice of utilizing both DBS and carbidopa-levodopa to treat PD, it is crucial to understand how to properly manage PD patients who are displaying this overlap in symptomology. CASE REPORT: A 56-year-old Caucasian male with a 6-year diagnosis of PD who was being treated with high dose carbidopa-levodopa and left DBS of the ventral intermediate nucleus (VIM) presented after a suicide attempt. The patient was found to be severely depressed and had exhibited behavioral changes in the weeks leading up to the attempt. Imaging was performed to assess positional changes of DBS and carbidopa-levodopa dosage adjusted while under close observation in the inpatient unit. The patient was started on fluoxetine to treat the depressive symptoms and was eventually discharged with close monitoring. DISCUSSION: With PD and DBS being associated with behavioral changes and depressive symptoms and carbidopa-levodopa therapy being linked to behavioral changes such as impulsivity, it is important that these patients be closely monitored and research analyzes how these factors may interact and lead to an increased risk of suicide. Furthermore, when symptoms appear, a clear protocol must be established on managing these patients. We therefore recommend an approach that utilizes imaging to assess any changes in DBS placement, dose management of carbidopa-levodopa, and behavior monitoring in an inpatient setting.