In This Issue
An epidemiological study by Fardet et al. (CME, p. Original article: 491) of British general practice patients who received oral glucocorticoids showed that patients who received these drugs were seven times as likely to attempt suicide as were patients with the same illness who did not receive steroids (figure). The increase was most prominent in younger people. Mania and delirium were also significantly more common, particularly in older men. Neuropsychiatric effects were more common in patients receiving higher doses and those with previous mental disorders. Brown (p. Original article: 447) notes in an editorial that this is the first large-scale study of the effects of steroids, with over 300,000 patients exposed to the drugs.
Neuropsychiatric effects of glucocorticoids vary by patient age and sex (Fardet et al., p. 491)
Hospitalized elderly patients with delirium have increased connectivity between the prefrontal cortex and posterior cingulate as observed by Choi et al. (p. Original article: 498), as well as reduced connectivity with dopaminergic and cholinergic neurons. After 6 days of antipsychotic drugs, patients' symptoms decreased by half. Dopaminergic and cholinergic functional innervation was also restored. However, the abnormal cortical connectivity continued, consistent with early partial resolution of delirium but persistence of significant cognitive psychopathology. Gaudreau (p. Original article: 450) points out in an editorial that there has been only one well-controlled therapeutic trial for delirium since 1996 and notes that a surrogate consent procedure made this research possible for these gravely disabled patients.
A placebo-controlled study of 100 outpatients with mixed heroin-amphetamine addiction showed that implanted naltrexone, designed to block opiate effects for 8–10 weeks, led to 52% of patients remaining in treatment and 38% having urine samples free of both drugs at 10 weeks, compared to 28% remaining and 16% drug free for the placebo implant. Tiihonen et al. (p. Original article: 531) report that use of other substances, such as alcohol, did not increase. The number needed to treat, i.e., number of patients who have to be treated for one to benefit, was three. In an editorial, Penetar (p. Original article: 455) points out that a puzzling aspect of the study is that craving decreased in both treated and placebo groups, even though remission rates differed. Naltrexone did decrease euphoria in patients who continued to use amphetamine.
Zanarini et al. (p. Original article: 476) describe the course over 16 years of borderline and other axis II personality disorders. Nearly everyone achieves remission of symptoms, but the time to remission is much slower with borderline disorder. Only half the borderline disorder patients, compared to most of the other axis II patients, ever achieve full psychosocial recovery, and relapse is common. Obesity is also common, probably because of medications. Soloff and Chiappetta (CME, p. Original article: 484) note that failure to achieve psychosocial recovery is associated with increased suicide attempts. In an editorial, Paris (p. Original article: 445) points out that psychiatrists who see very sick personality disorder patients in crisis are often surprised that the long-term outcome is better than the outcome for bipolar disorder.
Premenstrual dysphoric disorder affects 2%–5% of premenopausal women. Criteria proposed for DSM-5 include the occurrence of at least five symptoms in most menstrual cycles during the past year, such as affective lability, irritability, depressed mood, anxiety, loss of interest, lethargy, changes in appetite or sleep, loss of control, or bloating. These symptoms need to begin the week before and improve a few days after menses onset. Other exclusion and inclusion criteria are described by Epperson et al. (p. Original article: 465). Response to serotonin reuptake inhibitors as well as to oral contraceptives containing the progestin drospirenone is noted.
