An approach to symptoms at the interface of medicine and psychiatry: pain, insomnia, weight loss and anorexia, fatigue and forgetfulness, and sexual dysfunction

Factor Structures in the Depressive Symptoms Domains in the 9Q for Northern Thai Adults and Their Association with Chronic Diseases

Most of the common models to examine depression are one-factor models; however, previous studies provided several-factor structure models on each depressive symptom using the Patient Health Questionnaire-9 (PHQ-9). The Nine-Questions Depression-Rating Scale (9Q) is an alternative assessment tool that was developed for assessing the severity of depressive symptoms in Thai adults. This study aimed to examine the factor structure of this tool based on the factor structure models for the PHQ-9 provided in previous studies using confirmatory factor analysis (CFA). We also examined the association of chronic diseases and depressive symptoms using the Multiple Indicators Multiple Causes model among 1346 participants aged 19 years old or more without psychiatric disorders. The results show that the two-factor CFA model with six items in the cognitive-affective domain and three items in the somatic domain provided the best fit for depressive symptoms in the study population (RMSEA = 0.077, CFI = 0.953, TLI = 0.936). Dyslipidemia was positively associated with both cognitive-affective symptoms (β = 0.120) and somatic depressive symptoms (β = 0.080). Allergies were associated with a higher level of cognitive-affective depressive symptoms (β = 0.087), while migraine (β = 0.114) and peptic ulcer disease (β = 0.062) were associated with a higher level of somatic symptoms. Increased age was associated with a lower level of somatic symptoms (β = -0.088). Our findings suggested that considering depressive symptoms as two dimensions yields a better fit for depressive symptoms. The co-occurrence of chronic diseases associated with depressive symptoms should be monitored.

Thiamine Deficiency Neuropathy in a Patient with Malnutrition due to Melancholic Depression

Introduction

Melancholic depression is a daily clinical reality in psychiatry. It is a therapeutic emergency that can jeopardize life if not promptly and adequately treated. Apart from its high suicidal risk, complications related to the under-nourishment state are to be feared. Case Presentation. A 36-year-old woman was admitted with depressive symptoms, significant weight loss, and total functional impotence. Laboratory investigations revealed severe thiamine (vitamin B1) deficiency. An electromyography confirmed a sensory axonal neuropathy involving all four extremities suggesting a deficiency origin. Discussion. Vitamin and mineral deficiencies have been described in patients with malnutrition resulting from psychiatric illness (anorexia nervosa, eating disorders, severe depression, etc.). Thiamine is an essential cofactor in several biochemical pathways. Its deficiency can lead to neuropsychiatric morbidity.

Conclusion

In our case, the rapid weight loss facilitated a cascade of complications related to nutritional deficiencies. Based on our clinical observations and the literature, thiamine deficiency should be considered in the presence of malnutrition and vulnerability, both on an organic and psychiatric level.

Association between iron-deficiency anemia and depression: A web-based Japanese investigation

AIM

This web-based survey aimed to examine the relation between iron-deficiency anemia and depression in 11 876 Japanese participants.

METHODS

Participants consisted of 1000 individuals with self-reported history of depression (mean age, 41.4 ± 12.3 years; 499 women) and 10 876 population-based controls (mean age, 45.1 ± 13.6 years; 5185 women). The 6-item Kessler Scale (K6) score was used as a psychological distress scale. The design of the study was cross-sectional.

RESULTS

The rate of self-reported lifetime history of iron-deficiency anemia was higher in the depression group in both men (depression, 7.2%; control, 4.0%; P < 0.001; odds ratio [OR], 1.86; 95% confidence interval [CI], 1.30-2.68) and women (depression, 33.4%; control, 25.8%; P < 0.001; OR, 1.45; 95%CI, 1.19-1.76). The K6 score in participants with self-reported history of iron-deficiency anemia was higher in both the depression (P = 0.004) and control (P < 0.001) groups. In addition, in all participants, the rate of individuals who showed a K6 cut-off score of 13 or more was higher in those with a self-reported history of iron-deficiency anemia (P < 0.001; OR, 1.47; 95%CI, 1.31-1.65). Logistic regression analyses revealed that self-reported history of depression and the K6 score were positively associated with self-reported history of iron-deficiency anemia (all P < 0.01).

CONCLUSION

Self-reported history of iron-deficiency anemia was associated with self-reported history of depression. Furthermore, self-reported history of iron-deficiency anemia was associated with higher psychological distress.

Affective and cognitive rather than somatic symptoms of depression predict 3-year mortality in patients on chronic hemodialysis

Depression is more common in many medical conditions than among the general population and is associated with an increased risk of mortality. We aimed to determine whether somatic symptoms of depression were more predictive of mortality than affective and cognitive symptoms in hemodialysis patients. We conducted a prospective cohort study in which the survival outcomes of 151 subjects were followed for more than 3 years. Depression was assessed with the Taiwanese Depression Questionnaire (TDQ). Subjects with TDQ scores 19–54 (correlated with clinically significant depressive symptoms) and those with scores 15–18 had higher 3-year mortality rates than the two groups with lower scores (40.0%, 46.7%, 16.0% and 19.6%, p = 0.021, ANOVA). Affective and cognitive symptoms, including sadness, tenseness, indecisiveness and low self-confidence, and one somatic item (bodily discomfort) were associated with mortality. Affective and cognitive symptoms affected quality of life more than somatic symptoms. The somatic subscale was associated with female gender, low income and education, dialysis vintage, and low serum creatinine and albumin levels, whereas the affective and cognitive subscale was associated with less education and a low serum albumin level. In conclusion, affective and cognitive symptoms of depression may better predict long-term mortality in patients undergoing chronic hemodialysis than somatic symptoms.

Withdrawal of nonfutile life support after attempted suicide

End-of-life decision making is fraught with ethical challenges. Withholding or withdrawing life support therapy is widely considered ethical in patients with high treatment burden, poor premorbid status, or significant projected disability even when such treatment is not "futile." Whether such withdrawal of therapy in the aftermath of attempted suicide is ethical is not well established in the literature. We provide a clinical vignette and propose criteria under which such withdrawal would be ethical. We suggest that it is appropriate to withdraw life support, regardless of the cause of the critical illness or disability, when the following criteria are met: (1) Surrogates request withdrawal of care and the adequacy of surrogates is confirmed, (2) an external reasonability standard is met, (3) passage of time, perhaps 72 hours, to allow certainty regarding the patient's wishes, and (4) psychiatric morbidity should be considered as grounds for withdrawal only in truly treatment-refractory cases. Fundamentally, we believe the question to ask is, "If this were not an attempted suicide, would a request to withdraw care be reasonable?" We believe that under these circumstances, such withdrawal of life support, even in an individual who has attempted suicide, does not constitute physician assistance with suicide and is distinct from physician aid-in-dying in several important respects.