Self-reported depressive symptoms following treatment with corticosteroids and sedative-hypnotics

Characterisation of Benzodiazepine Use in an Older Population Registered in Family Health Units in the Region of Minho, Portugal

Benzodiazepines are the most frequently consumed psychotropic drugs among older persons. This pharmacological class has been advised against in this group, due to the various risks associated with its use in an older population. This study seeks to determine the prevalence of benzodiazepine use in a non-institutionalized older population over the age of 75 that is registered in Family Health Units (USF) in the region of Minho, Portugal, as well as to characterize these patients and understand the link between benzodiazepine use and chronic medication use, risk of falls, and level of physical and functional dependence. The data extracted from the clinical records registered in the SAM^® were analyzed using the Statistical Package for the Social Sciences (SPSS). A sample of 700 patients was obtained. These patients presented a mean age of 82.3 years, 62.7% were female, 95.3% were physically independent, and 38.0% were functionally independent. Almost half of the elder persons presented a moderate (36.9%) or high (11.4%) risk of falls. 37.9% of the patients were chronic benzodiazepines users, using between 1 and 3 active substances belonging to this pharmacological class, with a higher rate of use among women (p < 0.001) and elder persons. There was a statistically significant association among the use of benzodiazepines, a functional independence, and a higher risk of falls. These pioneering findings in Portugal reveal a high prevalence of benzodiazepine use in the population studied and warn about the specific characteristics of said population and the importance in reducing the risks associated with the inappropriate prescription of these drugs.

Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies

Falls are the leading cause of injuries among older adults, aged 65 years and older. Furthermore, falls are an increasing public health problem because of ageing populations worldwide due to an increase in the number of older adults, and an increase in life expectancy. Numerous studies have identified risk factors and investigated possible strategies to prevent (recurrent) falls in community-dwelling older people and those living in long-term care facilities. Several types of drugs have been associated with an increased fall risk. Since drugs are a modifiable risk factor, periodic drug review among older adults should be incorporated in a fall prevention programme.

Psychiatric side effects of medications prescribed in internal medicine

Several pharmacological treatments used in internal medicine can induce psychiatric side effects (PSEs) that mimic diagnoses seen in psychiatry. PSEs may occur upon withdrawal or intoxication, and also at usual therapeutic doses. Drugs that may lead to depressive, anxious, or psychotic syndromes include corticosteroids, isotretinoin, levo-dopar mefloquine, interferon-a, and anabolic steroids, as well as some over-the-counter medications. PSEs are often difficult to diagnose and can be very harmful to patients. PSEs are discussed in this review, as well as diagnostic clues to facilitate their identification.

The influence of depression on treatment for methamphetamine use

OBJECTIVE

To determine whether the presence of comorbid depression influences response to psychological treatment for methamphetamine use.

DESIGN

Randomised controlled clinical trial.

SETTING AND PARTICIPANTS

Our study was conducted between 2001 and 2005 at two sites in Australia: the Hunter Region of New South Wales and the city of Brisbane, Queensland. The 214 participants, who were all using methamphetamine at least once a week in the month prior to the study, were self-referred or referred from health services or drug and alcohol clinical services. Participants were divided into two groups based on whether or not they had depressive symptoms at baseline.

INTERVENTIONS

The control group received only a self-help booklet; the two treatment groups received either two or four counselling sessions involving cognitive behaviour therapy and motivational interviewing techniques to manage methamphetamine use.

MAIN OUTCOME MEASURES

Changes in methamphetamine use and depression at 5 weeks and 6 months after baseline.

RESULTS

Over 70% of participants met criteria for depression at baseline, and depression was associated with significantly greater severity of methamphetamine use and related issues. Benzodiazepine use was significantly higher among depressed than non-depressed participants. Reductions in methamphetamine use between baseline and 5 weeks were independently predicted by comorbid depression, in favour of increased change among those with baseline depression. Depressed participants who received three or four counselling sessions showed a significant reduction in depression at 5 weeks. However, reductions in methamphetamine use and depression compared with baseline were no longer evident at 6 months.

CONCLUSIONS

Over the short term, comorbid depression did not negatively affect response to treatment, with some evidence of a dose-response treatment effect for reduction in depression. This was not maintained at 6 months, indicating that methamphetamine-focused treatment may not enable people with comorbid depression to make sustained improvement at the level of their counterparts without depression.

TRIAL REGISTRATION NUMBER

ACTRN12611000355976.

Depression in multiple sclerosis: reactive or endogenous?

Multiple sclerosis is associated with high rates of depression. The extent to which this is related to living with chronic illness or part of the disease process remains unclear. This question was investigated by comparing rates of depression in MS with those in rheumatoid arthritis, which involves similar physical and psychosocial stressors but without central nervous system involvement. The study involved an on-line survey, which included measures of depression not confounded by somatic symptoms, medication use, self-reported physical functioning, pain, and other demographic variables. Results indicated that disease group (multiple sclerosis, rheumatoid arthritis) independently predicted depression above and beyond demographic and disease-related variables. Results support the hypothesis that depression in MS is partly determined by direct neurological consequences of the condition.

Chronic corticosterone administration down-regulates metabotropic glutamate receptor 5 protein expression in the rat hippocampus

Several lines of evidence suggest a dysfunctional glutamate system in major depressive disorder (MDD). Recently, we reported reduced levels of metabotropic glutamate receptor subtype 5 (mGluR5) in postmortem brains in MDD, however the neurobiological mechanisms that induce these abnormalities are unclear. In the present study, we examined the effect of chronic corticosterone (CORT) administration on the expression of mGluR5 protein and mRNA in the rat frontal cortex and hippocampus. Rats were injected with CORT (40 mg/kg s.c.) or vehicled once daily for 21 days. The expression of mGluR5 protein and mRNA was assessed by Western blotting and quantitative real-time PCR (qPCR). In addition, mGluR1 protein was measured in the same animals. The results revealed that while there was a significant reduction (-27%, P=0.0006) in mGluR5 protein expression in the hippocampus from CORT treated rats, mRNA levels were unchanged. Also unchanged were mGluR5 mRNA and protein levels in the frontal cortex and mGluR1 protein levels in both brain regions. Our findings provide the first evidence that chronic CORT exposure regulates the expression of mGluR5 and are in line with previous postmortem and imaging studies showing reduced mGluR5 in MDD. Our findings suggest that elevated levels of glucocorticoids may contribute to impairments in glutamate neurotransmission in MDD.

A systematic review of research examining benzodiazepine-related mortality

PURPOSE

This paper will review literature examining the association of benzodiazepine use and mortality.

METHODS

An extensive literature review was undertaken to locate all English-language published articles that examine mortality risk associated with use of benzodiazepines from 1990 onwards.

RESULTS

Six cohort studies meeting the criteria above were identified. The results were mixed. Three of the studies assessed elderly populations and did not find an increased risk of death associated with benzodiazepine use, whereas another study of the general population did find an increased risk, particularly for older age groups. A study of a middle aged population found that regular benzodiazepine use was associated with an increased mortality risk, and a study of 'drug misusers' found a significant relationship between regular use of non-prescribed benzodiazepines and fatal overdose. Three retrospective population-based registry studies were also identified. The first unveiled a high relative risk (RR) of death due to benzodiazepine poisoning versus other outcomes in patients 60 or older when compared to those under 60. A positive but non-significant association between benzodiazepine use and driver-responsible fatalities in on-road motor vehicle accidents was reported. Drug poisoning deaths in England showed benzodiazepines caused 3.8% of all deaths caused by poisoning from a single drug.

CONCLUSION

On the basis of existing research there is limited data examining independent effects of illicit benzodiazepine use upon mortality. Future research is needed to carefully examine risks of use in accordance with doctors' prescriptions and extra-medical use.

Association between depressive symptoms and use of HMG-CoA reductase inhibitors (statins), corticosteroids and histamine H(2) receptor antagonists in community-dwelling older persons: cross-sectional analysis of a population-based cohort

BACKGROUND

Strong evidence supporting the existence of causal associations of drug use with depression is often lacking from empirical studies. Limited evidence suggests an inverse association of use of HMG-CoA reductase inhibitors (statins) with depressive symptoms. Sparse and sometimes conflicting data in this respect have also been reported for corticosteroids, histamine H(2) receptor antagonists and antihypertensive agents.

OBJECTIVE

To identify associations between use of different drug classes and depressive symptoms in community-dwelling older patients and to determine whether any such associations varied between young-old and old-old patients.

METHOD

We analysed cross-sectional data from a population-based cohort of 2804 older adults aged > or =55 years, in whom specific drug use was systematically identified from self-reports and physical inspection of medication labels. Depressive symptoms were determined using the 15-item Geriatric Depression Scale (GDS), with a GDS score > or =5 defining the presence of depressive symptoms.

RESULTS

Multivariate analysis controlling for the confounding effects of risk factors and correlates of depression revealed significant associations between depressive symptoms and use of statins (odds ratio [OR] 0.71; 95% CI 0.52, 0.97), histamine H(2) receptor antagonists for patients aged <65 years (OR 4.67; 95% CI 1.59, 13.74) and, in participants aged > or =65 years, systemic corticosteroids (OR 4.02; 95% CI 1.12, 14.42). No convincing associations between the presence of depressive symptoms and use of antihypertensives, antiparkinsonism drugs, NSAIDs and tranquilizers/hypnotic/sedatives were demonstrated.

CONCLUSION

The evidence in this study suggests a possible protective effect of statin use on depressive symptoms, and affirms a positive association between depressive symptoms and corticosteroid use, especially in the older elderly. Use of H(2) receptor antagonists was also associated with depressive symptoms, probably through their link with underlying dyspeptic syndromes.

Association between improvement in depression, reduced benzodiazepine (BDZ) abuse, and increased psychotropic medication use in methadone maintenance treatment (MMT) patients

We had evaluated the depressive symptoms severity of 75 former heroin addicts in methadone maintenance treatment (MMT) using the 21-item Hamilton rating scale for depression (21-HAM-D) and re-assessed 63 of them 1.6+/-0.3 years later. The second mean 21-HAM-D score was lower than the first (11.8+/-8.4 versus 17.4+/-6.2, p<0.0005). Benzodiazepine (BDZ) abuse was lower although not significantly (p=0.06) during the month preceding the second analysis (32/63, 50.8%) than the month preceding the first one (40/63, 63.5%). Psychotropic medication usage was higher at the second assessment than at the first one (50/63, 79.4% versus 27/63, 42.9%, p<0.0005). 21-HAM-D score reduced significantly over time among 13 "no psychotropic medication" patients (13.5+/-6.3 versus 6.8+/-6.8, p=0.005) and in 27 who started medication following the first assessment (19.3+/-3.8 versus 11.0+/-8.4, p<0.0005), but not in those who were already taking any medication before the first assessment (17.7+/-7.0 versus 15.0+/-8.0, p=n.s). 21-HAM-D score reduced in all BDZ groups but scores were still highest in the 32 patients who continued BDZ abuse (19.4+/-5.6 versus 15.2+/-7.7) followed by 14 who stopped it (16.8+/-6.4 versus 9.6+/-9.1) and were lowest in 17 patients who never abused BDZ (14.2+/-5.2 versus 7.2+/-6.4) (repeated measured, time and group effect, each p<0.0005). Predictors for being depressed at follow-up were pre-existing depression only. Stopping BDZ abuse and starting psychotropic treatment was associated with a reduction of depressive symptoms among MMT patients.

Benzodiazepine use and physical disability in community-dwelling older adults

OBJECTIVES

To determine whether benzodiazepine use is associated with incident disability in mobility and activities of daily living (ADLs) in older individuals.

DESIGN

A prospective cohort study.

SETTING

Four sites of the Established Populations for Epidemiologic Studies of the Elderly.

PARTICIPANTS

This study included 9,093 subjects (aged > or =65) who were not disabled in mobility or ADLs at baseline.

MEASUREMENTS

Mobility disability was defined as inability to walk half a mile or climb one flight of stairs. ADL disability was defined as inability to perform one or more basic ADLs (bathing, eating, dressing, transferring from a bed to a chair, using the toilet, or walking across a small room). Trained interviewers assessed outcomes annually.

RESULTS

At baseline, 5.5% of subjects reported benzodiazepine use. In multivariable models, benzodiazepine users were 1.23 times as likely as nonusers (95% confidence interval (CI) = 1.09-1.39) to develop mobility disability and 1.28 times as likely (95% CI = 1.09-1.52) to develop ADL disability. Risk for incident mobility was increased with short- (hazard ratio (HR) = 1.27, 95% CI = 1.08-1.50) and long-acting benzodiazepines (HR = 1.20, 95% CI = 1.03-1.39) and no use. Risk for ADL disability was greater with short- (HR = 1.58, 95% CI = 1.25-2.01) but not long-acting (HR = 1.11, 95% CI = 0.89-1.39) agents than for no use.

CONCLUSION

Older adults taking benzodiazepines have a greater risk for incident mobility and ADL disability. Use of short-acting agents does not appear to confer any safety benefits over long-acting agents.

The Goldman Consensus statement on depression in multiple sclerosis

BACKGROUND

In January 2002 the New York City Chapter of the National Multiple Sclerosis Society convened a panel of experts to review the issue of depressive affective disorders associated with multiple sclerosis (MS). This Consensus Conference was supported by a grant from the Goldman family of New York City.

RESULTS

The panel reviewed summaries of current epidemiologic, neurobiologic, and therapeutic studies having to do with depressive disorders among MS patient populations. Depressive disorders occur at high rates among patients with MS, and there is reason to believe that the immunopathology of the disease is involved in the clinical expression of affective disorders. The depressive syndromes of MS have a major, negative impact on quality of life for MS sufferers, but are treatable. At the present time, most MS patients with depression do not receive adequate recognition and treatment.

CONCLUSIONS

The Goldman Consensus Conference Study Group provides recommendations for improved screening, diagnosis, and clinical management for depressive affective disorders among patients suffering from MS.

Usage des benzodiazépines chez les personnes âgées : état des connaissances

Cet article passe en revue la littérature concernant la dépendance aux benzodiazépines (BZD) chez la population des personnes âgées de 65 ans et plus. Alors que les conséquences négatives reliées à l’utilisation prolongée des BZD sont bien connues, le phénomène de la dépendance à ces substances chez cette population l’est beaucoup moins. Il n’existe toujours pas de consensus autour de la définition du problème. L’usage continu des BZD peut être davantage problématique chez les personnes âgées pour qui la tolérance aux agents chimiques diminue avec l’âge. Les facteurs de risque impliqués dans l’usage chronique sont une combinaison interactive entre les caractéristiques des aînés et celles des médecins prescripteurs. Des pistes de recherche étayées sur un changement paradigmatique sont lancées afin de bonifier la recherche dans ce domaine.

Benzodiazepine utilization patterns in Alzheimer's disease patients

BACKGROUND

Benzodiazepines (BZD) are commonly prescribed in the elderly. Persons with dementia may be at a greater risk of adverse reactions of BZD such as cognitive impairment.

OBJECTIVE

To assess the prevalence of BZD use in Alzheimer's disease patients and to examine patient and drug-characteristics associated with this use.

DESIGN

Cross-sectional study.

PARTICIPANTS

Five thousand community-dwelling and institutionalized patients initiating a treatment with tacrine for a mild to moderate Alzheimer's disease and included in the tacrine-study (Paco cohort).

MEASUREMENTS

Patient characteristics and BZD use recorded at the inclusion.

MAIN OUTCOME

Use of BZD during the 3 months prior to inclusion.

RESULTS

The 3-month prevalence of ever use of BZD was 20%. After controlling for age and gender, there was a non-significant inverse association between BZD use and a score of Mini-Mental Status Evaluation (MMSE) below 24 (OR: 0.88, 95% CI: 0.71-1.09), and significant inverse association with an increased number of chronic conditions (OR: 0.73, 95% CI: 0.58-0.91). Higher use of BZD was associated with higher level of overall drug consumption (OR: 2.3, 95% CI: 1.97-2.80).

CONCLUSION

Alzheimer's disease patients are frequently prescribed BZD. A low score of MMSE (< 24) is associated with a decreased use of BZD. These results suggest important differences in BZD use patterns among persons with Alzheimer's disease.

Benzodiazepine Use and Physical Performance in Community-Dwelling Older Women

OBJECTIVES

To determine whether benzodiazepine use in older women increased the risk of decline in physical function.

DESIGN

A four-year prospective cohort study.

SETTING

The communities of Iowa and Washington counties, Iowa.

PARTICIPANTS

Eight hundred eighty-five women aged 70 and older who had completed physical performance tests in 1988 and 1992.

MEASUREMENTS

Benzodiazepine use was determined during in-home interviews and classified by dose, duration, indication for use, and half-life. Physical performance tests included an assessment of standing balance, walking speed (8-foot distance), and repeated chair raises.

RESULTS

Ninety (10.2%) reported benzodiazepine use at baseline. After adjustment for baseline physical performance score and potential confounders, benzodiazepine use was associated with a greater decline in physical performance over 4 years than nonuse (beta=-1.16; standard error (SE)=0.25; P<.001). The use of higher-than-recommended dose was related to decline (beta=-2.26; SE=0.47; P<.001), and use of lower doses was not (beta=-0.53; SE=0.46; P=.246). Long-term use (>or=3 years) was related to decline (beta=-1.65; SE=0.34; P<.001), whereas recent and past use were not. Similar results were obtained when restricting the sample to those without disability at baseline.

CONCLUSION

This study provides evidence that older women who used benzodiazepines were at risk for decline in physical performance. Subgroup analyses indicated that risk was greater with use of higher-than-recommended doses or for long duration (>or=3 years). These findings highlight the importance of using benzodiazepines at the lowest effective dose for a limited duration in older women.

Is the use of benzodiazepines associated with incident disability?

OBJECTIVES

This study examined the association between benzodiazepine use and incident disability with an emphasis on elucidating whether the underlying health conditions that result in benzodiazepine use (confounding factors) or intrinsic adverse effects of benzodiazepine use were responsible for functional decline.

DESIGN

Cohort study with follow-up of 4 to 5 years.

SETTING

A health maintenance organization (HMO) in western Washington.

PARTICIPANTS

Individuals aged 65 and older from a random sample of HMO enrollees who participated in a health promotion intervention trial (n = 1,519).

MEASUREMENTS

Benzodiazepine use was ascertained from computerized pharmacy records. Self-reported functional status was assessed using a six-item physical function scale ranging from vigorous activity to self-care activities of daily living (ADLs). Two outcomes were examined: decline in overall physical function and limitations in self-care ADLs. Multivariate models were examined that included demographic characteristics, health status, and health behaviors that were likely to be confounders. Several analyses were conducted to examine whether benzodiazepine use or confounding factors were responsible for functional decline.

RESULTS

Benzodiazepine use was significantly associated with incident loss of physical function (hazard ratio (HR) = 1.51, 95% confidence interval (CI) = 1.02-2.24) in the fully adjusted model. Although use of benzodiazepines was associated with limitations in ADLs, it was not significant when adjusting for other factors (HR = 1.71, 95% CI = 0.87-3.34). Several of our findings suggest that the health conditions leading to benzodiazepine use may partly or fully explain these associations: (1) use of anxiolytic benzodiazepines (HR = 1.95, 95% CI = 1.24-3.07), but not hypnotic agents (HR = 1.21, 95% CI = 0.73-2.00), was associated with functional decline; (2) adjustment for health status variables minimized these associations; and (3) there was little evidence of dose response.

CONCLUSIONS

A modestly increased risk for decline in physical function was associated with benzodiazepine use, especially of anxiolytic agents. The health conditions that result in benzodiazepine use may be more important in the pathogenesis of disability than benzodiazepine use itself. Although there are many reasons for avoiding benzodiazepines in older adults, it is still unclear whether use contributes independently to functional decline.

Case-control study of severe life threatening asthma (SLTA) in adults: psychological factors

BACKGROUND

Severe life threatening asthma (SLTA) is important in its own right and as a proxy for asthma death. In order to target hospital based intervention strategies to those most likely to benefit, risk factors for SLTA among those admitted to hospital need to be identified. Adverse psychological factors are purported risk factors for asthma death and SLTA /near fatal asthma. A study was undertaken to determine whether, in comparison with patients admitted to hospital with acute asthma, those with SLTA have specific adverse psychological factors.

METHODS

A case-control study was undertaken. Cases (n=77) were admitted to the intensive care unit with SLTA (mean (SD) pH 7.17 (0.15), PaCO(2) 10.7 (5.0) kPa). Controls (n=239) were admitted to general wards with acute asthma and were matched only by date of index attack. An interviewer administered questionnaire was undertaken 24-48 hours after admission. A random sample of community based asthmatics was recruited to provide normative data on asthmatics for comparison with cases and hospital controls.

RESULTS

The risk of SLTA increased with age (OR 1.04/year, 95% CI 1.01 to 1.07) and was less for women (OR 0.36, 95% CI 0.20 to 0.68). These variables were controlled for in all further analyses. There was a high prevalence of psychological disorder in both cases and matched controls, but there was no difference in prevalence of caseness for anxiety or depression, total (or individual) life events in last 12 months, availability of general or disease specific social support, nor in any of the domains of the Attitudes and Beliefs about Asthma Questionnaire (emotional (mal) adjustment, doctor-patient relationship, stigma, self-efficacy). Cases (SLTA) were less likely to have had previous emotional counselling (25% v. 35%, p<0.05). However, when comparison was made with a community based group of asthmatic patients, those admitted to hospital with acute asthma (SLTA and hospital controls) had a higher prevalence of anxiety and depression, higher total life events, and higher prevalence of certain specific life events.

CONCLUSIONS

There was considerable psychological morbidity generally (and anxiety specifically) in those admitted with acute asthma. Specific adverse psychological factors were not risk factors for SLTA, when comparison was made with those admitted to hospital with acute asthma, but adverse psychological factors were a risk factor for hospitalisation for acute asthma (including SLTA). Psychological risk factors for adverse events in asthma are dependent both on the type of event under study and the comparison group used.

Exogenous corticosteroids and major depression in the general population

OBJECTIVE

An existing literature suggests that corticosteroid exposures are associated with an elevated level of depressive symptoms in various clinical populations. The objective of this study was to evaluate this association in a general population sample.

METHODS

Data from a large-scale Canadian health survey were used in this analysis. The survey sample included 73,402 subjects over the age of 12 from the general Canadian population. The survey interview included a short-form version of the Composite International Diagnostic Interview (CIDI) section evaluating major depressive episodes. All estimates were weighted to account for unequal selection probabilities, and variance estimates were calculated using methods accounting for the survey design.

RESULTS

A statistically significant elevation in major depression prevalence was observed in corticosteroid-treated subjects. The estimated 12-month period prevalence of major depression was approximately three times as high in corticosteroid treated vs. non-treated subjects irrespective of age, gender and perceived health.

CONCLUSIONS

In the general population, persons taking corticosteroids have a higher frequency of major depression than non-exposed subjects. Because this was an analysis of cross-sectional survey data, causal inference is not possible. However, the existence of an epidemiological association, in conjunction with information from the broader literature, suggests that corticosteroid exposure may be a determinant of depressive disorders in the general population.

Long-term continuous use of benzodiazepines by older adults in Quebec: prevalence, incidence and risk factors

OBJECTIVE

To determine the prevalence and incidence of long-term use of benzodiazepines and to assess patient-, prescriber-, and drug-related risk factors.

DESIGN

Cohort study.

PARTICIPANTS

1,423 community-dwelling older adults in Quebec who participated in the Canadian Study of Health and Aging (CSHA1).

MEASUREMENTS

Patient characteristics were obtained from the CSHA1 database. These were linked to provincial health insurance data to ascertain benzodiazepine use and prescriber characteristics.

MAIN OUTCOME MEASURE

Use of benzodiazepines for at least 135 of the first 180 days following initiation of use.

RESULTS

Twelve-month prevalence of long-term continuous use, standardized by age and gender to the Quebec population, was 19.8%. Twelve-month cumulative incidence of long-term continuous use was 1.9%. Older patients were more likely to proceed to long-term continuous use.

CONCLUSIONS

Risk of long-term continuous use of benzodiazepines seems to increase with age. This association was found to be independent of gender, health status, anxiety, cognitive status, benzodiazepine type, and physician characteristics.

Corticosteroid-induced adverse psychiatric effects: incidence, diagnosis and management

Reports of corticosteroid-induced adverse psychiatric effects began to appear in the literature soon after the introduction of these medications in the 1950s. Unfortunately, early studies relied on informal classification and measurement procedures and tended to utilise nonspecific descriptive terminology (such as steroid psychosis'). A growing number of contemporary investigations have begun to address these problems. However, the literature remains surprisingly undeveloped from a pharmacoepidemiological perspective, consisting largely of case reports and case series. The objective of this review is to summarise published data concerning corticosteroid-induced adverse psychiatric effects. A clinical perspective will be adopted since opportunities to minimise the impact of corticosteroid-induced adverse effects tend to present themselves most readily within the sphere of clinical management. Some of the psychiatric adverse effects of corticosteroids are mild, and not necessarily clinically significant. However, several serious psychiatric syndromes can be caused by corticosteroids: substance-induced mood disorders (with depressive, manic and mixed features), substance-induced psychotic disorders and delirium. While certain clinical groups may be at greater risk of corticosteroid-induced adverse psychiatric effects, corticosteroid-induced psychiatric toxicity is remarkably unpredictable. The literature regarding prevention and treatment of corticosteroid-induced adverse psychiatric effects is poorly developed. As a result, the emphasis of this review is on clinical and epidemiological evidence linking specific adverse effects to corticosteroid medications. However, clinical reports do provide some practical guidance for prevention and treatment, and these are summarised as well. A variety of pharmacological strategies for treatment and prevention have been proposed. Education and support also appear to be important, and perhaps neglected.

Alpha-1-noradrenergic neurotransmission, corticosterone, and behavioral depression

BACKGROUND

Impaired brain alpha-1 noradrenergic neurotransmission has been implicated in some of the symptoms of depressive illness but has been difficult to investigate experimentally because of the insensitivity of current animal models of depression. The present experiment addressed this problem by examining the effects of pharmacologic blockade and corticosteroid-induced desensitization of alpha-1 receptors on two newer, more sensitive models in mice: the inhibition of nest-leaving and the tail suspension tests (TST).

METHODS

Male mice were administered either prazosin, betaxolol, atipamezole, corticosterone, or repeated restraint stress prior to measurement of either nest-leaving or TST. General behavioral function was assessed in horizontal wire, swim, and latency to escape footshock tests.

RESULTS

Prazosin increased depressive behavior in the nest-leaving and TSTs, whereas corticosterone and restraint stress did so only in the more sensitive nest-leaving test. Betaxolol also reduced nest-leaving, suggestive of an alpha-1 beta-1 receptor synergy. The effects of these agents could not be attributed to hypotension, sedation, or general behavioral impairment.

CONCLUSIONS

The fact that a reduction in alpha-1 noradrenergic neurotransmission increases depressive behavior, coupled with the fact that this change can result from elevated corticosteroid secretion, provides further support for a role of this factor in depressive illness. As not all alpha-1 functions are reduced in depression, it is likely that only a subgroup or specific locality of alpha-1 receptors are affected.

Psychological factors in severe chronic asthma

OBJECTIVE

Levels of psychological distress, social support factors, and emotional adjustment to illness were measured in a sample of patients with severe asthma. These were then examined in terms of their interrelationships and their ability to predict self-management knowledge.

METHOD

A sample of 80 patients was recruited from a hospital-based asthma clinic designed for patients with severe asthma. Thirty-four percent of consecutive attenders approached took part. Morbidity and asthma management were recorded from case records. Anxiety, depression, social support, emotional adjustment to asthma and asthma knowledge were measured using self-report instruments selected for their acceptability and ease of administration.

RESULTS

Twenty-five percent of the sample had possible or definite caseness for anxiety; 10.3% had possible or definite caseness for depression. Twenty-five percent had inadequate social support in some way. Three independent attitudinal factors were found: emotional maladjustment to asthma, the doctor-patient relationship, and asthma-related stigma. Level of asthma knowledge was very low. None of the measures of psychosocial function chosen were predictive of asthma knowledge.

CONCLUSIONS

Levels of asthma knowledge were dangerously low, despite apparently adequate educational initiatives. In addition, patients with severe asthma have high levels of distress, particularly of anxiety, even between attacks. Their attitudes to their illness are multifactorial, and are significantly correlated with emotional distress, morbidity indices and some demographic factors. While this may point the way to interventions designed to relieve patients' distress, the hypothesis that this might in turn relate to practical asthma knowledge was not confirmed.

Depressive symptoms attributable to medication exposure in a medical inpatient population

OBJECTIVE

Exposure to certain drugs-angiotensin-converting enzyme inhibitors, beta-blockers, calcium channel blockers, corticosteroids. H2 blockers, and sedative hypnotics-may be associated with an increased risk of depression. These drugs are commonly used in inpatient medical therapeutics. Since population attributable risk (PAR) is generally related both to strength of association and to the frequency of exposure to a risk factor, the PAR of depressive symptoms associated with these drug exposures is potentially high. The objective of this study was to estimate the depressive symptoms population attributable risk percent (PAR%) in a medical inpatient population.

METHODS

A prospective cohort design was used in this study. Nondepressed, nondrug-exposed subjects (N = 178) were selected from a series of 369 newly admitted medical inpatients at the Calgary General Hospital. Eighty-six of these 178 subjects were prescribed one of the drugs in question, forming an exposed cohort. The remaining subjects formed a nonexposed cohort. Depressive symptoms and associated psychosocial variables were measured in both subgroups during the hospital stay.

RESULTS

Seventeen of the 86 exposed subjects and 5 of the 92 nonexposed subjects developed incident depressive symptoms during their stay in hospital. The PAR% associated with drug exposure (56.0%) exceeded that associated with poverty (17.9%) or unemployment (21.7%).

CONCLUSIONS

Drug exposures may have a sizeable impact on the incidence of depressive symptoms in medical inpatient populations.