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Postpartum depression (PPD) is an irritable, severely depressed mood that occurs within 4 weeks of giving birth and possibly as late as 30 weeks postpartum. Manifestations include crying spells, insomnia, depressed mood, fatigue, anxiety, and poor concentration. Patients may experience mild, moderate, or severe symptoms. Many psychosocial stressors may have an impact on the development of PPD. Recent studies conclude that the majority of factors are largely social in nature. The greatest risk is in women with a history of depression or other affective illness and in those who have experienced depression during past pregnancies. Women with significant risk factors should be followed closely in the postpartum period. The severity of symptoms and degree of impairment guide the approach to treatment. Treatment should begin with psychotherapy and advance to pharmacotherapy if needed; however, many patients benefit from concomitant treatment with both psychotherapy and medication. Common forms of psychotherapy include interpersonal therapy and short-term cognitive-behavioral therapy. Postpartum depression demands the same pharmacologic treatment as major depression does, with similar doses as those given to patients with nonpuerperal depression. It is essential to use an adequate dose of antidepressants in a duration sufficient to ensure complete recovery. Mothers should continue medication for 6 to 12 months postpartum to ensure a complete recovery. Inadequate treatment of depression puts women at risk for the sequelae of untreated affective illness, and the depression may become chronic, recurrent, and/or refractory. Family physicians are key players in the detection and treatment of PPD owing to the nature of the disease and the tendency for new mothers to negate their feelings as something other than a treatable psychiatric illness.
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PMID:A Review of Postpartum Depression. 1501

Insomnia is a frequent symptom in the general population; numerous studies have proven this. In the past years, classifications have gradually given more emphasis to daytime repercussions of insomnia and to their consequences on social and cognitive functioning. They are now integrated in the definition of insomnia and are used to quantify its severity. If the daytime consequences of insomnia are well known at the clinical level, there are few epidemiological data on this matter. The aim of this study was to assess the daytime repercussions of insomnia complaints in the general population of France. A representative sample (n=5,622) aged 15 or older was surveyed by telephone with the help of the sleep-EVAL expert system, a computer program specially designed to evaluate sleep disorders and to manage epidemiological investigations. Interviews have been completed for 80.8% of the solicited subjects (n=5,622). The variables considered comprised insomnia and its daytime repercussions on cognitive functioning, affective tone, daytime sleepiness and diurnal fatigue. Insomnia was found in 18.6% of the sample. The prevalence was higher in women (22.4%) than in men (14.5%, p<0.001) with a relative risk of 1.7 (95% confidence interval 1.5 to 2) and was twice more frequent for subjects 65 years of age or older compared to subjects younger than 45 years. Approximately 30% of subjects reporting insomnia had difficulties initiating sleep. Nearly 75% of insomnia complainers reported having a disrupted sleep or waking up too early in the morning and about 40% said they had a non-restorative sleep. Repercussions on daytime functioning were reported by most insomnia subjects (67%). Repercussions on cognitive functioning changed according age, number of insomnia symptoms and the use of a psychotropic medication. A decreased efficiency was more likely to be reported by subjects between 15 and 44 years of age (OR: 2.9), those using a psychotropic (OR: 1.5), those reporting at least three insomnia symptoms (OR: 1.4) and women (OR: 1.4). The highest probability of the appearance of concentration difficulties was found in subjects younger than 65 Years, having a depressive disorder and using a psychotropic (15-44 years: OR 19.1; 45-64 years: OR 46.6). Difficulties maintaining attention were 15 times higher in subjects aged between 45 and 64 who were using a psychotropic and had also a depressive disorder. Memory difficulties were three times more likely to be reported by subjects using a psychotropic. At the affective level, irritability was 10 times more likely to be reported by subjects younger than 65 Years who were also using a psychotropic and had a depressive disorder. Independent of the presence of a mental disorder and the use of a psychotropic, subjects between 15 and 44 Years were five times more likely to be irritable following a bad sleep. Feeling depressed after a bad night's sleep was 18 times more likely to occur in subjects aged between 45 and 64 who were using a psychotropic and had a depressive disorder. Feeling anxious after a bad night's sleep was seven times more likely to occur in subjects with a depressive disorder. Daytime sleepiness was reported by approximately 20% of insomnia subjects. This rate was relatively comparable among gender, age groups, presence/absence of a mental disorder and use or not of a psychotropic. However, taking into account the interaction between age, use of a psychotropic and the presence of a mental disorder, subjects younger than 65 years, using a psychotropic and having a depressive disorder were at least 10 times more likely to report daytime sleepiness. Subjects who were suffering the most diurnal symptoms of insomnia were those younger than 65 years. Several factors can be evoked to explain this fact. These subjects were, for the most part, likelier to have a stricter sleep/wake schedule because of constraints imposed by work, studies, child care, etc. Subjects older than 65 Years were generally retired and therefore less prone to sleepiness and to cognitive difficulties. Insomnia consequences were limited due to their inactivity. Complementary studies should be undertaken to describe the daytime repercussions of insomnia for this specific age group of the general population and to measure these repercussions.
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PMID:[Daytime consequences of insomnia complaints in the French general population]. 1523 19

Psychometric deviance in personality traits as assessed by the Minnesota Multiphasic Personality Inventory (MMPI; Dahlstrom, Welsh, & Dahlstrom, 1982) was compared between adopted-away, high-risk (HR) offspring of schizophrenic biologic mothers and low-risk (LR) controls. A subsample of the Finnish Adoptive Family Study (Tienari et al., 2000) included 60 HR adoptees and 76 LR control adoptees who were tested by the MMPI before the onset of any psychiatric disorder at the mean age of 24 years. The HR group was found to be distinguishable based on deviant scores on the scales HOS and HYP, indicating emotional unresponsiveness, restricted affectivity, and decreased energy. These may also be considered possible premorbid and prodromal signs of future schizophrenia among the HR adoptees.
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PMID:Psychometric deviance measured by MMPI in adoptees at high risk for schizophrenia and their adoptive controls. 1527 92

We investigated the efficacy of Qi therapy as a non-pharmacological treatment for various symptoms presented by Korean combat veterans of the Vietnam War with Agent Orange Sequelae. Nine subjects volunteered to receive 30 minutes of Qi therapy, twice per day for 7 days. There was marked improvement in 89% of the patients with impaired physical activity, 86% of those with psychological disorder, 78% of those with heavy drug use, and 67% of those with fatigue, indigestion and high blood glucose levels. This data suggests that Qi therapy combined with conventional treatment has positive effects in reducing and managing the pain, psychosomatic disorders, and substance abuse in patients with Agent Orange Sequelae. We cannot completely discount the possible influence of the placebo effect, and more objective, clinical measures are needed to study the long-term effects of Qi therapy.
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PMID:External Qi therapy to treat symptoms of Agent Orange Sequelae in Korean combat veterans of the Vietnam War. 1534 29

To determine the prevalence and effects of depression on health status among elderly outpatients with heart failure, the authors conducted a 6-month prospective cohort study of 139 older outpatients with heart failure managed in primary care and 80 of their spouses. Primary care heart failure diagnosis was confirmed through chart review. The Primary Care Evaluation of Mental Disorders psychiatric diagnostic interview and Hamilton Depression Rating Scale were administered by phone. EQ-5D feeling thermometer, Medical Outcomes Study Short Form 36-Item Questionnaire, Kansas City Cardiomyopathy Questionnaire, and heart failure symptom severity questionnaires were administered by self-report. Depression diagnoses at baseline were: major depression and/or dysthymia (n=12, 9%), minor depression (n=14, 10%), and no depression (n=113, 81%). After adjusting for age, gender, and medical comorbidity, these depression groups differed by repeated measures analysis of covariance on most health status measures including the EQ-5D feeling thermometer; Medical Outcomes Study Short Form 36-Item Questionnaire general health and physical role function subscales; Kansas City Cardiomyopathy Questionnaire total score, symptom total, physical limitations, and quality of life subscales; as well as severity of chest pain and fatigue. Depression has significant and persistent effects on health status of elderly patients with heart failure, including heart failure symptoms, physical and role function, and quality of life. This may help explain why depression has been associated with increased health care utilization and costs in this population.
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PMID:Depression and health status in elderly patients with heart failure: a 6-month prospective study in primary care. 1536 85

Hypophysitis is an inflammatory disease of the pituitary gland that clinically and radiologically mimics pituitary tumors. We report here a case of xanthogranulomatous hypophysitis mimicking a pituitary neoplasm.A 65-yr-old woman presented with weight loss, fatigue, and visual disturbance. Computed tomography demonstrated a round cystic low-density mass with calcification in the sella. A T1-weighted magnetic resonance imaging scan showed most of the mass as hyperintense. The capsule of the mass was strongly enhanced by gadolinium. Endocrinologic examination revealed hypocorticism and hypothyroidism. Diabetes insipidus (DI) developed after the administration of hydrocortisone. The patient also had hallucination and delusions of persecution. Transsphenoidal surgery was performed. Histologic examination of the removed tissue showed central necrosis surrounded by accumulation of foamy cells and epithelioid cells. Several multinucleated giant cells were also seen. The foamy cells and epithelioid cells were immunopositive for Kp-1, a marker of macrophages. The patient made an uneventful postoperative recovery. Although DI and hypofunction of adenohypophysis persisted, the visual disturbance and psychiatric disorder were resolved. We have described an unusual inflammatory lesion of the pituitary in the sellar region that was mimicking neoplasm. A high level of clinical suspicion of inflammatory disorders is necessary for correct diagnosis and optimal management.
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PMID:Xanthogranulomatous hypophysitis mimicking a pituitary neoplasm. 1568 60

This review discusses the clenching-grinding spectrum from the neuropsychiatric/neuroevolutionary perspective. In neuropsychiatry, signs of jaw clenching may be a useful objective marker for detecting or substantiating a self-report of current subjective emotional distress. Similarly, accelerated tooth wear may be an objective clinical sign for detecting, or substantiating, long-lasting anxiety. Clenching-grinding behaviors affect at least 8 percent of the population. We argue that during the early paleolithic environment of evolutionary adaptedness, jaw clenching was an adaptive trait because it rapidly strengthened the masseter and temporalis muscles, enabling a stronger, deeper and therefore more lethal bite in expectation of conflict (warfare) with conspecifics. Similarly, sharper incisors produced by teeth grinding may have served as weaponry during early human combat. We posit that alleles predisposing to fear-induced clenching-grinding were evolutionarily conserved in the human clade (lineage) since they remained adaptive for anatomically and mitochondrially modern humans (Homo sapiens) well into the mid-paleolithic. Clenching-grinding, sleep bruxism, myofacial pain, craniomaxillofacial musculoskeletal pain, temporomandibular disorders, oro-facial pain, and the fibromyalgia/chronic fatigue spectrum disorders are linked. A 2003 Cochrane meta-analysis concluded that dental procedures for the above spectrum disorders are not evidence based. There is a need for early detection of clenching-grinding in anxiety disorder clinics and for research into science-based interventions. Finally, research needs to examine the possible utility of incorporating physical signs into Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition posttraumatic stress disorder diagnostic criteria. One of the diagnostic criterion that may need to undergo a revision in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition is Criterion D (persistent fear-circuitry activation not present before the trauma). Grinding-induced incisor wear, and clenching-induced palpable masseter tenderness may be examples of such objective physical signs of persistent fear-circuitry activation (posttraumatic stress disorder Criterion D).
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PMID:The clenching-grinding spectrum and fear circuitry disorders: clinical insights from the neuroscience/paleoanthropology interface. 1578 58

The evidence regarding the co-morbidity of chronic hepatitis C, psychiatric illness and intravenous drug abuse is reviewed from the literature. Also the occurrence and the treatment of psychiatric side effects during treatment with interferon in patients with a history of drug abuse are reviewed. There is insufficient evidence for a specific hepatitis C induced depression or fatigue, but a direct link between hepatitis C and cerebral dysfunction is not excluded. Immune system activation rather than drug use may explain cerebral symptoms. In HCV positive substance users anxiety and depression are more prevalent than in HCV negative substance users. During treatment with regular or pegylated (PEG) interferon depression is a frequent side effect (ca 30%) and occurs independently from pre-existing psychiatric disorders or drug abuse. A history of drug abuse per se does not increase the risk of depression as a side effect of interferon treatment. It is extremely important to monitor symptoms of depression in the early weeks of treatment and to start antidepressant treatment as early as possible. Antidepressants should be continued throughout the interferon treatment period. There are insufficient data to assess these situations in which preventive antidepressant treatment should be started before interferon treatment. Clinical judgement can, however, lead to preventive antidepressant treatment, even at subclinical levels of depression. A cut off score of > 10 on the Beck Depression Inventory before interferon treatment is associated with a higher risk of depression during treatment. Both selective serotonin reuptake inhibitors and other classes of antidepressants can be used.
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PMID:Hepatitis C, interferon alpha and psychiatric co-morbidity in intravenous drug users (IVDU) : guidelines for clinical practice. 1583 90

BACKGROUND: We previously demonstrated that a computerized psychiatric screening interview (the PRIME-MD) can be used in the Emergency Department (ED) waiting room to identify patients with mental illness. In that trial, however, informing the ED physician of the PRIME-MD results did not increase the frequency of psychiatric diagnosis, consultation or referral. We conducted this study to determine whether telling the patient and physician the PRIME-MD result would result in the majority of PRIME-MD-diagnosed patients being directed toward treatment for their mental illness. METHODS: In this single-site RCT, consenting patients with non-specific somatic chief complaints (e.g., fatigue, back pain, etc.) completed the computerized PRIME-MD in the waiting room and were randomly assigned to one of three groups: patient and physician told PRIME-MD results, patient told PRIME-MD results, and neither told PRIME-MD results.The main outcome measure was the percentage of patients with a PRIME-MD diagnosis who received a psychiatric consultation or referral from the ED. RESULTS: 183 (5% of all ED patients) were approached. 123 eligible patients consented to participate, completed the PRIME-MD and were randomized. 95 patients had outcomes recorded. 51 (54%) had a PRIME-MD diagnosis and 8 (16%) of them were given a psychiatric consultation or referral in the ED. While the frequency of consultation or referral increased as the intervention's intensity increased (tell neither = 11% (1/9), tell patient 15% (3/20), tell patient and physician 18% (4/22)), no group came close to the 50% threshold we sought. For this reason, we stopped the trial after an interim analysis. CONCLUSION: Patients willingly completed the PRIME-MD and 54% had a PRIME-MD diagnosis. Unfortunately, at our institution, informing the patient (and physician) of the PRIME-MD results infrequently led to the patient being directed toward care for their psychiatric condition.
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PMID:Failure of a patient-centered intervention to substantially increase the identification and referral for-treatment of ambulatory emergency department patients with occult psychiatric conditions: a randomized trial [ISRCTN61514736]. 1588 62

Psychiatric disorders have been associated with poor outcome in individuals with chronic fatigue syndrome (CFS). This study examines the impact of psychiatric disorders on outcome of cognitive-behavioural therapy (CBT). Psychiatric diagnoses were assessed with a structured psychiatric interview in a CBT trial of 270 people with CFS. Lifetime and current psychiatric disorders were found in 50 and 32% respectively. No significant differences in fatigue severity and functional impairment following treatment were found between participants with and without psychiatric diagnoses.
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PMID:Effect of psychiatric disorders on outcome of cognitive-behavioural therapy for chronic fatigue syndrome. 1605 33


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