Nortriptyline-Induced Room Tilt Illusion.

Room tilt illusion (RTI) is a rare and transient perceptual disturbance in which an individual perceives their surroundings as having been rotated or tilted, usually at 90 or 180 degrees. Primarily linked with vestibular disorders and neurological lesions, this report details the only reported occurrence of the RTI phenomena in nortriptyline use for treatment-refractory depression. The patient developed RTI six days after starting the medication and the disturbance resolved after medication cessation. Although the mechanism behind such a phenomenon with medication use has not been elucidated, its etiology may rest on the effect of tricyclic antidepressants on the vestibulo-thalamo-cortical system and visual-vestibular integration. Clinicians should be aware of the potential for such a medication-induced perceptual disturbance, especially in the workup for more serious etiologies in elderly patients with co-morbidities.

Residual or re-emergent impaired insight into delusions following remission is unrelated to later relapse during a randomized clinical trial of continuation pharmacotherapy for psychotic depression - The STOP-PD II Study.

BACKGROUND: Impaired insight into delusions is associated with a lower probability of remission of psychotic depression, independent of illness severity. The relationship between participant characteristics and impaired insight into delusions in remitted psychotic depression, and whether impaired insight is associated with risk of relapse of psychotic depression during continuation pharmacotherapy were examined. METHODS: Data were analyzed from 126 participants in the STOP-PD II study who experienced sustained remission of psychotic depression during 8-week stabilization treatment with sertraline plus olanzapine and were then randomized to 36 weeks of continuation treatment with sertraline plus either olanzapine or placebo. Insight into delusions was assessed with the Resolution of Delusions Scale (RODS). Linear regression analyses examined the associations between participant characteristics and insight into delusions. Cox proportional-hazards models examined whether i) change in RODS during stabilization treatment; or ii) RODS at the end of stabilization treatment predicted risk of relapse during 36 weeks of continuation treatment. RESULTS: Severity of psychosis before initiation of treatment was the only participant characteristic associated with the change in insight during stabilization treatment. Neither change in insight during stabilization treatment nor insight at the end of stabilization treatment was associated with risk of relapse. LIMITATIONS: Insufficient statistical power and the lack of variability in RODS scores at the time of randomization may have contributed to the absence of a relationship between RODS and risk of relapse. CONCLUSION: Residual or reemergent insight impairment following acute treatment does not preclude patients from sustaining remission of psychotic depression in a randomized placebo-controlled trial.

Differentiating Childhood-Onset Schizophrenia From Other Childhood Disorders.

Childhood-onset schizophrenia (COS) is a rare disorder in which symptoms of schizophrenia occur before the age of 13 years. This disorder often has a complicated presentation that can mimic other childhood disorders including post-traumatic stress disorder (PTSD), autism spectrum disorder (ASD), major depressive disorder (MDD) with psychosis, and generalized anxiety disorder (GAD) among others. This is further complicated by the low prevalence rate of COS which limits understanding of the disorder. Accurate and timely diagnosis is crucial as failure to do so has adverse implications for long-term treatment outcomes and prognosis. In this study, a rare case of a 12-year-old girl with childhood-onset schizophrenia and key findings that help differentiate it from other childhood disorders are reviewed to guide diagnosis and treatment.

Functional outcome and service engagement in major depressive disorder with psychotic features: comparisons with schizophrenia, schizoaffective disorder and bipolar disorder in a 6-year follow-up of the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS).

OBJECTIVE: While long-term outcome following a first psychotic episode is well studied in schizophrenia (SZ), schizoaffective disorder (SA), and bipolar disorder (BD), major depressive disorder with psychotic features (MDDP) has received less investigation. This study compares MDDP with SZ, SA, and BD at 6-year follow-up. METHODS: At 6 years after a first psychotic episode, follow-up data on psychopathology, functioning, quality of life, and service engagement were obtained for 27 cases of MDDP in comparison to 60 SZ, 27 SA, and 35 BD. RESULTS: Positive psychotic symptoms were less prominent in MDDP and BD than in SZ and SA. Negative symptoms, impaired functioning, and reduction in objectively determined quality of life were less prominent in MDDP and BD, intermediate in SA and most prominent in SZ. However, subjectively determined quality of life was indistinguishable across diagnoses. Service engagement was highest for MDDP, intermediate for SA and BD, and lowest for SZ. CONCLUSIONS: At 6-year follow-up, these diagnoses are characterized by quantitative rather than qualitative differences in psychopathology, functionality, quality of life, and service engagement, with considerable overlap between them. These findings suggest that MDDP should join SZ, SA, and BD in a milieu of psychosis that transcends arbitrary boundaries.

Epidemiological and clinical characterization following a first psychotic episode in major depressive disorder: comparisons with schizophrenia and bipolar I disorder in the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS).

While recent research on psychotic illness has focussed on the nosological, clinical, and biological relationships between schizophrenia and bipolar disorder, little attention has been directed to the most common other psychotic diagnosis, major depressive disorder with psychotic features (MDDP). As this diagnostic category captures the confluence between dimensions of psychotic and affective psychopathology, it is of unappreciated heuristic potential to inform on the nature of psychotic illness. Therefore, the epidemiology and clinical characteristics of MDDP were compared with those of schizophrenia and bipolar disorder within the Cavan-Monaghan First Episode Psychosis Study (n = 370). Epidemiologically, the first psychotic episode of MDDP (n = 77) was uniformly distributed across the adult life span, while schizophrenia (n = 73) and bipolar disorder (n = 73) were primarily disorders of young adulthood; the incidence of MDDP, like bipolar disorder, did not differ between the sexes, while the incidence of schizophrenia was more common in males than in females. Clinically, MDDP was characterized by negative symptoms, executive dysfunction, neurological soft signs (NSS), premorbid intellectual function, premorbid adjustment, and quality of life similar to those for schizophrenia, while bipolar disorder was characterized by less prominent negative symptoms, executive dysfunction and NSS, and better quality of life. These findings suggest that what we currently categorize as MDDP may be more closely aligned with other psychotic diagnoses than has been considered previously. They indicate that differences in how psychosis is manifested vis-à-vis depression and mania may be quantitative rather than qualitative and occur within a dimensional space, rather than validating categorical distinctions.