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Query: UMLS:C0011570 (depression)
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The Psychiatry department of the University Hospital Centre of Lille has developed, over the last 10 years, a treatment network for psychiatric disorders during pregnancy or in the post-partum period. There are liaison consultations in the maternity department, screening and management of psychopathological disorders in the perinatal period, training of midwives, support of patients seeking genetic counselling, collaboration with teams providing "medically-assisted procreation", etc. For severe disorders of the post-partum period (severe depression, serious alteration of mother-child interaction, puerperal psychosis), the Psychiatry department has a specialized unit where 3 "mother-child" groups can be admitted. This unit is particularly effective if the patients and their family understand this healthcare system and stick to it to a certain extent. Even if improvements are always possible, cases in which situations occur as an emergency, are when dysfunctions are most frequently seen. On 7th December 1998, a Crisis Intervention Unit (CIU) was created with 15 short-term beds, for stays up to 72 hours. The CIU was opened in the Psychiatry department, close to the main Accident and Emergency department, with 2 aims: firstly to provide a setting and resources for a number of emergency psychiatric situations, and secondly to provide a place and time for crisis situations which we admit to the unit, with a view to facilitating interaction and to propose in certain cases a process of crisis intervention, which later continues on an outpatient basis. After being open for a year, the CIU has proved to be an improvement to all of the healthcare services which are available. It should be noted that the situations which need highly specialized resources in such a short time, are those which cause the most acute problems. This is at times when the emergency services network, with its internal logic, require another network based on a different logic, that the interface problems are at their most acute. The situations reported here, which require a fluid interface between the emergency services and the "mother-child" networks, are examples. We report 3 clinical situations, which illustrate 3 possibilities of action: the first, in which 2 successive stays in the CIU allowed an admission to the "mother-child" unit in satisfactory conditions, the second, in which overall management was based on hospitalization in the Obstetrics department and several visits to our Unit, and the last one, in which the whole medico-psycho-social approach was set up after a single stay of 3 days. Since the opening of Crisis Intervention Unit, around 1,000 patients have been treated there; 37 were women with difficulties with their pregnancy, 17 of whom required direct intervention by the "mother-child" team. The contexts were: 5 prenatal depressions, 4 post-partum depressions, 3 cases of hyperemesis gravidarum, 5 rejections of pregnancy and/or situations at risk of infanticide. The almost constant suicidal risk should be noted, or even attempted suicide, at the time of admission to the CIU. The other 20 women had psychopathological disorders linked to sterility, medically-assisted pregnancy, termination of pregnancy or pregnancy in women suffering from long-term somatic illnesses (insulin-dependent diabetes, lupus, etc.). When a psychopathological episode occurs during pregnancy, it is essential to preserve the developing relationship with the child in an intermediate place, in a healthcare perspective and to prevent any future impairment of the quality of the mother-child relationship by the psychiatric disorder. The Crisis Intervention Unit is not an emergency "mother-child" unit. Other French experiences have been reported, an example being mother-baby hospitalization in a crisis centre. The aim of our interventions is not the same, and our local context, together with the availability of a healthcare network on different floors, which is specific and close-by, allows this approach. Also, the contribution of Liaison Psychiatry in emergency situations should not be minimized. It is necessary to work in collaboration with the obstetricians. In fact, the chance to work with us was given by asking for a hospitalization in the Obstetric unit, during the prepartum period of pregnancies with a psychiatric risk. This way of proceeding allows somatic monitoring in hospital to be performed, whenever the risk run by the mother and/or the child requires it. This "analogue" procedure, however preventative it may be, does not always allow specific treatment of the psychiatric disorders to be given, despite liaison psychiatry interventions. Our interventions are not a specialized "mother-child" unit, or a substitute for Liaison Psychiatry, but they are specifically aimed at the context of the crisis. Obviously, it is precisely this dimension of the crisis which makes the other types of management temporarily unsuitable. This new working framework, with the simple possibility of admitting women and interacting with them in a crisis situation, with the aid of the competence of "mother-child" teams, most often seems to allow an alternative to hospitalization in the Psychiatry department, at the same time keeping up quality management of problems linked to the pregnancy or post-partum period. The specificity of the CIU, with its project of taking the special psychiatric vulnerability of pregnancy into account, makes sure that the psychopathological aspects of the crisis situation and the physiological aspects of adaptation reactions to the perinatal period are not neglected, but that are respected by this type of interaction/intervention.
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PMID:[Value of a consultation center and crisis intervention in addressing psychiatric disorders in the perinatal period]. 1196 46

We present two Japanese cases of involutional lipoatrophy. The first case is that of a 30-year-old woman, who first appeared at our hospital complaining of a localized, well-demarcated depression, approximately 3 x 4 cm in size, normal to slightly erythematous in coloration, on the lateral side of the left upper arm (Fig. 1a). The condition was asymptomatic, and she had noticed this anomaly a month prior to consultation. She received intramuscular injections of corticosteroids of unknown dosage at the affected site for the treatment of allergic rhinitis 4 months prior to her present consultation. The second patient, a 23-year-old woman, appeared at our hospital complaining of a similar macule 4 x 4 cm in size, which she noticed several weeks prior to her most recent consultation. She had no history of injury or injection at the site before the development of the condition (Fig. 1b). She had been under treatment for atopic dermatitis since early childhood and was treated only with topical applications of white petrolatum containing 2% salicylic acid for the past several years. In order to rule out the possibility of acquired partial lipodystrophy associated with localized scleroderma, lupus profundus and the other connective tissue diseases, a histological examination was performed for both patients. Histopathological analysis of the region exhibited a well-defined fat lobule composed of numerous small adipocytes (Fig. 1c) embedded in hyaline connective tissue. Edema and dilated capillaries were noticeable in the subcutaneous tissue surrounding the area. Inflammatory cells were not prominent, although mononuclear cells were observed in both patients. No epidermal change was seen in either patient. Direct and indirect immunofluorescence studies revealed no deposits of immunoreactants in the skin of either patient. Immunohistochemical studies with the antibody against macrophage (anti-CD68 antigen; DAKO.) showed that positive cells were scattered around blood vessels and shrunken lipocytes in the subcutaneous tissues (Fig. 1d). Most of these cells in the fat lobules were also positive for mucin stains such as Alcian blue. No abnormal findings came to light in the ordinary hematological and blood chemistry examinations of both patients. The autoantibody screening tests using antinuclear, anti-DNA, anticentromere, and anti-Scl-70 antibodies were negative in both patients.
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PMID:Two Japanese cases of localized involutional lipoatrophy. 1201 Mar 46

Accurate identification of depression in patients with systemic lupus erythematosis (SLE) is particularly complicated because the vegetative symptoms of depression also reflect core features of this autoimmune disease. Self-reported symptoms in patients with SLE (n = 103) and community control subjects (n = 136) were examined with the British Columbia Major Depression Inventory and the Beck Depression Inventory-II. The patients with lupus obtained higher scores on most items of the former inventory. A logistic regression analysis assessed whether a subset of these items were uniquely related to group membership. Clinically significant fatigue was much more common in patients with lupus than in the control group. Two items relating to sleep disturbance also entered the equation as unique predictors. The three-variable model resulted in 85% of the control subjects and 66% of the patients being correctly classified. A subset of patients with depression, according to the Beck inventory (17 or higher), were selected (n = 41). Their most frequently endorsed symptoms on the British Columbia Inventory were fatigue (90.2%), trouble failing asleep (70.7%), cognitive difficulty (61%), and psychomotor slowing (58.5%). Only 29.3% reported significant sadness. 15% of these subjects were classified as not depressed, 46% as possibly depressed, and 39% as probably depressed on the British Columbia Inventory. It is advisable to assess whether patients are experiencing significant sadness or loss of interest before concluding that a high score on a screening test corresponds to probable depression.
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PMID:Screening for depression in systemic lupus erythematosus with the British Columbia Major Depression Inventory. 1215 Mar 89

In total, 189 consecutive women diagnosed with SLE were evaluated using the ACR 1990 criteria for fibromyalgia. Patients were classified into three subgroups. The fibromyalgia group (FM) included patients experiencing pain on palpation in at least 11 of the 18 tender points examined, as well as having a history of widespread pain for at least three months. Patients who were noted to have pain in fewer than four quadrants with less than 11 of 18 tender points were considered to have regional pain (RP). All patients who did not meet criteria for either FM or RP were classified as having no pain (NP). Measurement of SLE disease activity, sleep complaints, depression, fatigue severity and health status were performed. Only 18 of the SLE patients (9.5%) (95% CI 5.3-14%) fulfilled the ACR criteria for the classification of FM. Of the patients, 106 (56.1%) fulfilled criteria for RP and had a number of tender points of 5.4 +/- 3.4, and the rest of the patients (34.4%) had no tenderness at specific tender point sites. Age, body mass index, educational level and disease duration were comparable between the groups. FM and RP groups had different patterns of symptoms prevalence, with dysmenorrhea being more distinctive for FM. Sleep disturbances were more severe in the FM than in the RP group. Daytime complaints such as sleepiness, fatigue and depression were similar for RP and FM groups, but patients with FM reported more disability. Fibromyalgia is not common in Mexican patients with SLE and has a different pattern of symptoms in RP and NP patients. These data add evidence that ethnicity can play an important role in FM manifestations.
Lupus 2004
PMID:Prevalence and factors associated with fibromyalgia in Mexican patients with systemic lupus erythematosus. 1487 Sep 11

Controversies in the occurrence and implications of headache in patients suffering from systemic lupus erythematosus (SLE) triggered us to conduct an extensive literature search in order to answer five clinical questions. (i) Is headache prevalence higher in SLE patients than in the general population? (ii) Is 'lupus headache' a separate entity? (iii) Is there a distinct pathogenetic mechanism of headache in SLE? (iv) Is headache related to CNS involvement or general SLE activity? (v) Is headache related to anxiety- and depression-like symptoms in SLE? All published articles reporting data from >30 SLE patients were classified into four classes (I, IIa, IIb and III) by the quality of their evidence. We found no prospective controlled study (class I), but we identified seven controlled (class II) and 28 uncontrolled studies (class III) that retrospectively investigated the occurrence of headache in SLE patients. Eight out of 35 studies applied the International Headache Society (IHS) criteria for headache classification, whereas only four uncontrolled studies investigated paediatric SLE populations (class III). Pooled data from eight studies (controlled and uncontrolled) that used the IHS criteria show that 57.1% of SLE patients reported any type of headache (migraine 31.7% and tension-type headache 23.5%). Pooled data from seven controlled studies showed that the prevalence of all headache types, including migraine, was not different from controls. Insufficient evidence was found for the concept of 'lupus headache'. No particular pathogenetic mechanism of headache in adult SLE patients has been identified, nor an association between headache and the disease status, including CNS involvement. There is no good evidence that headache is associated with anxiety and depression in SLE. Insufficient data (class III) do not allow safe conclusions for headache among paediatric SLE patients. These findings suggest that the occurrence of headache in adult SLE patients does not itself require further investigation and that headache in those patients should be classified according to IHS criteria and managed as primary headache if there is no specific indication of a role for SLE in the patient. These recommendations should be verified by a properly controlled and prospective study in both adult and paediatric populations.
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PMID:A meta-analysis for headache in systemic lupus erythematosus: the evidence and the myth. 1504 89

Anxiety and depression of unknown etiology are frequent complications of the systemic autoimmune disease lupus erythematosus (SLE). To elucidate key pathogenic factors we study the "autoimmunity-associated behavioral syndrome" (AABS) in lupus-prone MRL-lpr mice. Based on the evidence that serum levels of the neuroactive cytokine interferon-gamma (IFN-gamma) are increased both in human and murine forms of SLE, the present study examines whether sustained IFN-gamma production in non-autoimmune mice induces deficits comparable to AABS, particularly in tasks reflective of emotional reactivity and motivated behavior. For this purpose, wild-type and IFN-gamma knockout C57BL/6J mice were infected with adenovirus carrying the cDNA for murine IFN-gamma (i.p. 2 x 10(8) pfu of virus per mouse) and shortly thereafter tested in the behavioral battery used in the detection of AABS. Serum levels of IFN-gamma were found to peak 24 h after the infection, normalized within 5 days. Although all infected animals showed reduced food/water intake and body weight, the recovery rate was slower in groups injected with IFN-gamma virus. No deficits were observed in the models of anxiety, but blunted responsiveness in the sucrose preference test (a putative model of anhedonia) lasted well beyond the IFN-gamma clearance period. These results suggest that a relatively brief elevation in systemic IFN-gamma levels impairs ingestive behavior and leads to prolonged changes in motivated behavior. As such, they are consistent with the hypothesis that upregulation in synthesis of pro-inflammatory cytokines contributes to induction of AABS and more specifically, to limbic system dysfunction during lupus-like disease.
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PMID:Behavioral effects of infection with interferon-gamma adenovector. 1508 23

The Disease Repercussion Profile (DRP) was developed for use with patients with rheumatoid arthritis (RA) and has been shown to be a valid and clinically useful assessment of patient-perceived handicap. This study aimed to determine whether the Disease Repercussion Profile was also suitable for use with patients with systemic lupus erythematosus (SLE). Sixty patients with a definite diagnosis of SLE from a consultant rheumatologist were recruited into the study. They completed a series of questionnaires that assessed quality of life, depression, anxiety, attitudes towards the illness and the DRP. Results showed that patients with SLE endorsed each of the six spheres of the DRP as being frequently affected by their illness. Activity was most often endorsed. Both relationships and social activity were equally frequently adversely affected, and more often affected than the remaining spheres of finance, emotions and appearance. However, as in RA, when any area of function was affected, it was rated as very important to the individual. Indicators of quality of life were reliably related to all areas of function, as was depression and attitudes towards illness. The present study indicates that the DRP does have relevance for patients with SLE. Strong correlations between quality of life indicators, depression, attitudes towards illness and DRP subscales and total score indicate that this measure is a valid tool to assess the effect of illness on individuals with SLE.
Lupus 2004
PMID:Validity of the disease repercussion profile in patients with systemic lupus erythematosus. 1530 69

Movement disorders are not particularly common during pregnancy, with a few exceptions. RLS occurs most commonly followed by CG. Currently, with the incidence of rheumatic fever lower than previously, any woman who develops CG should be checked for illness other than rheumatic heart disease. The differential includes systemic lupus erythromatosis and antiphospholipid antibody syndrome. Regarding the use of dopaminergic agents, the dopamine agonist, pergolide, can be maintained during pregnancy for the treatment of PD, Segawa disease, and RLS. The use of levodopa and ropinirole should be limited during pregnancy because of the possible teratogenic effects. Amantadine is contraindicated during pregnancy. The data on selegiline are controversial; animal studies show possible serotonergic effects and teratogenic effects. If treatment is indicated in patients who have Tourette syndrome, the high potency neuroleptics drugs (haloperidol) are preferred to treat associated symptoms. Depression is a common comorbidity in patients who have PD, HD,Tourette syndrome, or other chronic neurologic diseases. Depression treatment during pregnancy is covered by Levy et al elsewhere in this issue. As discussed previously, most of the data on the use of drugs during pregnancy, especially the dopaminergic agents, are limited to animal studies and case reports. Therefore, it is in part left to the neurologist to decide on treatment based on the individual patient, clinical judgment, and inferences from animal studies and limited case reports.
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PMID:Movement disorders in pregnancy. 1547 67

As a consequence of the general improvement in the diagnosis and management of rheumatic diseases, patients achieve a better quality of life, with the possibility of a normal family life including one or more pregnancies. It is important, therefore, to consider the psychological aspects of these mothers' life and the influence of their chronic disease on their children is development. Several papers have reported the impact of systemic lupus erythematosus (SLE) on the quality of life. They found higher incidence of anxiety (from 15 to 45%) and depression (from 25 to 47%) compared to the general population. We have investigated the psychological influence of SLE on family planning, and we observed that it can interfere with physiological phenomena such as parenthood and the upbringing of children. The children of lupus mothers have a normal intelligence level for their age. What is emerging, however, is an increased incidence of learning disabilities compared to the general population. This observation suggests the importance of an early neuropsychological examination, in order to identify the children needing particular care. Therefore, psychological support seems to be an important help in the counseling of patients with rheumatic disease and in the future life of their children.
Lupus 2004
PMID:Pregnancy in patients with rheumatic diseases: psychological implication of a chronic disease and neuropsychological evaluation of the children. 1548 99

Headache is common in systemic lupus erythematosus with reported prevalence as high as 70%. The aims of this study were: to estimate the prevalence and types of headache in a sample of patients with systemic lupus erythematosus comparing it with rheumatoid arthritis, to determine clinical and serological associations. Eighty-one systemic lupus erythematosus and 29 rheumatoid arthritis consecutive patients seen in our outpatient clinic were interviewed. Headache was evaluated using the diagnostic criteria proposed by the International Headache Society. Additional evaluations were carried out in the 81 systemic lupus erythematosus patients including depression, disease activity, lupus damage, function disability, quality of life, and severity degree using a validated scales. We analysed the following autoantibodies: anti-double stranded DNA, anti-nucleosomes, anti-histones, anti-ribosomal P, anti-cardiolipin antibodies, anti-beta2-glycoprotein-I (GPI), and antinuclear antibodies. Forty-one per cent of systemic lupus erythematosus and 17% of rheumatoid arthritis patients suffered from headache (P = 0.02). No significant difference for any primary headache type between the two groups was found. Frequency of headache types in systemic lupus erythematosus patients was: migraine 24%, tensional-type headache 11%, and mixed headache 5%. In systemic lupus erythematosus patients the risk factors associated with headaches were Raynaud's phenomenon (OR 3.6; 95% CI 1.3-9.5; P = 0.009) and beta2GPI antibody positivity (OR 4.5; 95% CI 1.2-16.2; p = 0.016). We conclude that headache is more common in systemic lupus erythematosus than in rheumatoid arthritis patients and was independently associated with Raynaud's phenomenon and beta2GP-I antibodies.
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PMID:Prevalence and factors associated with headache in patients with systemic lupus erythematosus. 1556 14


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