Neurological disease, emotional disorder, and disability: they are related: a study of 300 consecutive new referrals to a neurology outpatient department

Mental health outcomes of encephalitis: An international web-based study

BACKGROUND AND PURPOSE

Acute encephalitis is associated with psychiatric symptoms. Despite this, the extent of mental health problems following encephalitis has not been systematically reported.

METHODS

We recruited adults who had been diagnosed with encephalitis of any aetiology to complete a web-based questionnaire.

RESULTS

In total, 445 respondents from 31 countries (55.1% UK, 23.1% USA) responded. Infectious encephalitis constituted 65.4% of cases, autoimmune 29.7%. Mean age was 50.1 years, 65.8% were female, and median time since encephalitis diagnosis was 7 years. The most common self-reported psychiatric symptoms were anxiety (75.2%), sleep problems (64.4%), mood problems (62.2%), and unexpected crying (35.2%). Self-reported psychiatric diagnoses were common: anxiety (44.0%), depression (38.6%), panic disorder (15.7%), and posttraumatic stress disorder (PTSD; 21.3%). Severe mental illnesses such as psychosis (3.3%) and bipolar affective disorder (3.1%) were reported. Self-reported diagnosis rates were broadly consistent with results from the Psychiatric Diagnostic Screening Questionnaire. Many respondents also reported they had symptoms of anxiety (37.5%), depression (28.1%), PTSD (26.8%), or panic disorder (20.9%) that had not been diagnosed. Rates of psychiatric symptoms did not differ between autoimmune and infectious encephalitis. In total, 37.5% respondents had thought about suicide, and 4.4% had attempted suicide, since their encephalitis diagnosis. More than half of respondents (53.5%) reported they had no, or substandard, access to appropriate mental health care. High rates of sensory hypersensitivities (>75%) suggest a previously unreported association.

CONCLUSIONS

This large international survey indicates that psychiatric symptoms following encephalitis are common and that mental health care provision may be inadequate. We highlight a need for proactive psychiatric input.

The Impact of Depression, Anxiety and Personality Disorders on the Outcome of Patients with Functional Limb Weakness - Individual Patient Data Meta-Analysis

OBJECTIVE

Psychiatric comorbidities such as depression, anxiety, and personality disorders are common in patients with functional limb weakness/paresis (FND-par). The impact of these conditions on the prognosis of FND-par has not been systematically reviewed. The aim of this study was to identify a potential prognostic effect of comorbid depression, anxiety, and/or personality disorder on prognosis in patients with FND-par.

METHODS

A systematic review was performed to identify studies that reported measures of baseline depression, anxiety, and/or personality disorder, and physical disability. An individual patient data meta-analysis was subsequently performed.

RESULTS

Eight studies comprising 348 individuals were included (7 prospective cohorts; 1 case-control study). There was heterogeneity in sample size, follow-up duration, and treatment modality. Depression and anxiety were present in 51.4% and 53.0% of FND-par patients, respectively. In individuals whose FND-par improved, there was no significant difference between those with versus without depression (52.6% vs 47.4%, p = 0.69) or those with versus without anxiety (50.3% vs 49.7%, p = 0.38). Meta-analysis showed no clear impact of baseline depression or anxiety per se [pooled OR for depression 0.85 (95%CI 0.50-1.45; p = 0.40) and anxiety 0.84 (95%CI 0.51-1.38; p = 0.91)]; and of depression or anxiety severity [pooled OR for depression 1.23 (95%CI 0.63-2.39; p = 0.91) and anxiety 1.40 (95%CI 0.70-2.78; p = 0.58)] on FND-par outcome. Insufficient data were available to assess the impact of personality disorders.

CONCLUSION

We found no evidence that depression or anxiety influenced outcome in FND-par. Large-scale, prospective studies in FND-par, and other FND subtypes, are needed to fully contextualize the impact of concurrent mental health concerns on outcomes.

Validation of a comorbidity questionnaire in patients with neurological disorders

Rational

Several tools exist to assess comorbidities in neurological disorders, the most widely used being the Charlson Comorbidity Index (CCI), but it has several limitations. The Comorbidity and General Health Questionnaire (CGHQ) is a newly designed tool, which includes additional comorbidities associated with health-related quality of life (HR-QOL) and outcomes in neurological disorders.

Aims and objectives

To assess the feasibility and validity of the CGHQ in patients with neurological disease.

Method

Two hundred patients attending a general neurological clinic were invited to complete the CGHQ along with the EQ-5D-5L questionnaire. The CCI was simultaneously completed by the assessor. CGHQ comorbidity scores were compared with CCI, symptom burden and EQ-5D-5L scores.

Results

The CGHQ captured 22 additional comorbidities not included on the CCI and more comorbidities were endorsed on the CGHQ. The CGHQ correlated weakly to moderately with CCI comorbidity scores. While both the CGHQ and CCI correlated negatively with the EQ-5D-5L Visual Analogue Scale, only the CGHQ correlated negatively with the EQ-5D-5L summary index. The CGHQ but not the CCI correlated strongly and positively with symptom burden scores.

Conclusion

The CGHQ allows a more comprehensive assessment of comorbidities than the CCI and better correlates with patients' overall symptom burden and HR-QOL in neurological patients.

Effect of web-implemented exercise interventions on depression and anxiety in patients with neurological disorders: a systematic review and meta-analysis

Introduction

Web-implemented exercise intervention is the latest and innovative method to improve people's mental health. Currently, many studies have proven that web-implemented interventions are effective to improve depression and anxiety in adults. However, the influence of different web-implemented exercise interventions on depression and anxiety in patients with neurological disorders is still unclear.

Objective

The study aims to systematically summarize the type and content of web-implemented exercise interventions and quantify the effect of different web-implemented exercise interventions on depression and anxiety in patients with neurological disorders.

Methods

Four literature databases (PubMed, Web of Science, China National Knowledge Infrastructure, and WanFang data) were searched. The literature search considered studies published in English or Chinese before October 13, 2022. Randomized controlled trials (RCTs) that participants accepted web-implemented interventions were included. Two authors independently extracted data and assessed the risk of bias for included studies. Standardized mean differences (SMD) with 95% CI were used to integrate the effect size.

Results

16 RCTs (a total of 963 participants) were included. The results showed that web-implemented exercise intervention had a significant effect on depression (SMD = -0.80; 95% CI, -1.09 to -0.52; I2 = 75%; P < 0.00001) and anxiety (SMD = -0.80; 95% CI, -1.23 to -0.36; I2 = 75%; P = 0.0003) in patients with a neurological disorder. The subgroup analysis showed that the effectiveness of the web-implemented exercise intervention was influenced by several factors, such as web-implemented exercise intervention type, component, and intervention duration.

Conclusion

Web-implemented exercise intervention has a relieving effect on depression and anxiety symptoms in patients with neurological disorders. Additionally, the intervention type, intervention duration, and component can influence the effect size.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier: CRD42023409538.

Cognitive Behavioral Therapy: Principles, Science, and Patient Selection in Neurology

Cognitive behavioral therapy (CBT) is a widely used therapeutic modality in general psychiatric practice. In this review, we consider its application to neurological disorders. We examine the basic framework of CBT-that symptoms, emotions, thoughts, and behaviors are all interrelated and that therapeutic interventions that lead to change in thoughts or behavior may have the potential to reduce symptoms or emotional distress. We also outline specific methodological issues to consider when reading or planning studies of CBT interventions, highlighting important topics pertaining to quality control, control group selection, dropouts, and generalizability. We then review the evidence base for CBT's use across a range of neurological disorders. In doing so, we highlight where there is a clear evidence base, and where it is a technique with potential. The review is targeted at a general neurology audience as introduction to the topic not as an advanced guide for expert practitioners.

Functional neurological disorder: Engaging patients in treatment

Patients with a functional neurological disorder can be difficult to engage in treatment. The reasons for this are complex and may be related to physician, patient and health care system issues. Providers contribute to difficulties in treatment engagement by giving confusing explanations for the patient symptoms, stigmatizing patients, and not allowing patients time to voice their questions and concerns. Patient factors include a lack of engagement after an explanation of the diagnosis, resistance to treatment, family/work dynamics and prior negative experiences with the health care system. The scarcity of providers skilled in the treatment of functional neurological disorder is yet another hurdle. This article will define these barriers and discuss good clinical practices to help improve outcomes by tackling those challenges and discuss why for many patients an integrated care team approach is needed.

Why Biological Psychiatry Hasn't Delivered Yet - and Why Neurology Knows

It is increasingly recognized that neuroscience has not delivered the revolutionary clinical possibilities for psychiatry that had been promised. Explanations differ, however: some proponents emphasize the divide between biopsychosocial psychiatry and mechanistic neurology. Others rely on further basic experimental neuroscience as only the most elementary level of explanation will allow us to fully understand and treat mental disorders. From a clinical-neuropsychological perspective, I shall argue that both views are mistaken. Diagnosis and treatment of neurological diseases demands a biopsychosocial perspective similar to psychiatry. Acknowledging this might help to bring both disciplines together and improve clinical outcome.

Decreased Autonomic Reactivity and Psychiatric Comorbidities in Neurological Patients With Medically Unexplained Sensory Symptoms: A Case-Control Study

Up to 48% of patients with medically unexplained symptoms seen in neurological practice suffer from sensory symptoms, which could be of functional nature or secondary to psychiatric disorders. These patients show high medical care utilization causing elevated healthcare costs. Despite the high prevalence, little is known about clinical characteristics and pathophysiological mechanisms. For functional disorders such as irritable bowel syndrome, a reduction of heart rate variability (HRV) has been shown, suggesting a dysfunction of the autonomic nervous system (ANS). The aim of this study was to investigate psychological data and functional changes of the ANS in patients with medically unexplained sensory symptoms (MUSS). In this exploratory pilot study, 16 patients (11 females, 31.6 ± 11.9 years) with MUSS, who were recruited at a single tertiary neurological center, underwent a structured clinical interview (SCID) to evaluate psychiatric comorbidities. Patients and age- and sex-matched healthy volunteers filled in questionnaires, and individual sensory thresholds (perception, pain) were detected by quantitative sensory testing (QST). HRV was assessed at baseline and under three different experimental conditions (tonic pain stimulus, placebo application, cold-face test). All tests were repeated after 6–8 weeks. SCID interviews revealed clinical or subclinical diagnoses of psychiatric comorbidities for 12 patients. Questionnaires assessing somatization, depression, anxiety, and perceived stress significantly discriminated between patients with MUSS and healthy controls. While there was no difference in QST, reduced ANS reactivity was found in patients during experimental conditions, particularly with regard to vagally mediated HRV. Our pilot study of neurological patients with MUSS reveals a high prevalence of psychiatric comorbidities and provides evidence for altered ANS function. Our data thus give insight in possible underlying mechanisms for these symptoms and may open the door for a better diagnostic and therapeutic approach for these patients in the future.

Psychiatric Comorbidities in Functional Movement Disorders: A Retrospective Cohort Study

Background

Functional movement disorders (FMD) are characterized by abnormal movements and motor symptoms incongruent with a known structural neurologic cause. While psychological stressors have long been considered an important risk factor for developing FMD, little is known about the impact of psychiatric comorbidities on disease manifestations or complexity.

Objectives

To compare characteristics of FMD patients with co-occurring mood and trauma-related psychiatric conditions to FMD patients without psychiatric conditions.

Methods

We performed a retrospective cohort study of patients seen in the University of Colorado Health system between January 1, 2015 and December 31, 2019. Patients were included if they had a diagnosis of FMD, determined by ICD-10 coding and ≥1 phenomenology-related diagnostic code (tremor, gait disturbances, ataxia, spasms, and weakness), and at least one encounter with a neurology specialist. Fisher's exact and unpaired t-tests were used to compare demographics, healthcare utilization, and phenomenologies of patients with psychiatric conditions to those with none.

Results

Our review identified 551 patients with a diagnosis of FMD who met inclusion criteria. Patients with psychiatric conditions (N = 417, 75.7%) had increased five-year healthcare utilization (mean emergency room encounters 9.9 vs. 3.5, P = 0.0001) and more prevalent non-epileptic seizures (18.2% vs. 7.5%, P = 0.001). Suicidal ideation (8.4%) and self-harm (4.1%) were only observed amongst patients with comorbid psychiatric conditions.

Conclusions

Patients with FMD and comorbid psychiatric conditions require more healthcare resources and have greater disease complexity than patients without psychiatric illness. This may have implications for treatment of patients without comorbid psychiatric conditions who may benefit from targeted physiotherapy alone.

When Mind Meets the Brain: Essentials of Well-Coordinated Management of Psychiatric Disorders in Neurological Diseases

BACKGROUND

The management of psychiatric disorders in neurological diseases (PDND) creates special challenges that cannot be adequately addressed by either psychiatry or neurology alone. However, the literature on clinician-friendly recommendations on how to coordinate neurological and psychiatric care is limited.

OBJECTIVE

This narrative review will provide practical instructions on how to efficiently integrate psychiatric and neurological care in inpatient management of PDND.

METHODS

We reviewed articles published as recently as January, 2021 in five electronic databases. We included articles that assessed human care, focused on adults, and examined how to better coordinate care between different medical specialties, particularly, between psychiatry and neurology.

RESULTS

Eighty-four manuscripts were included in this review, of which 23 (27%) discussed general principles of well-coordinated care of PDND in inpatient settings (first part of this review), and 61 (73%) were used to provide recommendations in specific neurological diseases (second part of this review).

CONCLUSIONS

General principles of well-coordinated care of PDND include recommendations for both the primary team (usually neurology) and the consulting team (psychiatry). Primary teams should delineate a specific question, establish roles, and follow up on the recommendations of the consulting team. Consultants should do their independent assessment, be organized and specific in their recommendations, and anticipate potential problems. One of the most important aspect to develop well-coordinated care is the establishment of clear, frank and, preferably oral, communication between the teams. Practical difficulties in the management of PDND include pharmacodynamic and pharmacokinetic interactions as well as mutual dependency between psychiatry and neurology.

Functional stroke symptoms: A prospective observational case series

OBJECTIVE

Functional symptoms are a common mimic of stroke in acute stroke settings, but there are no guidelines on how to manage such patients and scant research on their clinical profile. We explore the presentation of patients with functional stroke symptoms at admission and 2-month follow-up.

METHODS

We conducted a prospective observational study across four SE London acute stroke units, with two-month follow-up. Demographic information, clinical data and GP attendances were recorded. Patients completed self-report measures: Cognitive Behavioural Responses Questionnaire short version, Brief Illness Perception Questionnaire, Hospital Anxiety and Depression Scale, Work and Social Adjustment Scale and Short Form Health Survey.

RESULTS

Fifty-six patients (mean age: 50.9 years) were recruited at baseline; 40 with isolated functional symptoms, the remaining functional symptoms in addition to stroke. Thirty-one completed self-report follow-up measures. Of 56 participants, 63% were female. Patients presented symptoms across modalities, with unilateral and limb weakness the most frequent. There was inconsistent and ambiguous recording of symptoms on medical records. Approximately 40% of patients reported levels of anxiety and depression above the threshold indicating a probable diagnosis. Higher anxiety was associated with greater resting or all-or-nothing behaviours, embarrassment avoidance and symptom focussing on the CBRQ. Only SF-36 physical functioning improved at follow-up. Less than 50% who responded at follow-up were accessing a treatment, though 82% had ongoing symptoms.

CONCLUSION

Patients with functional symptoms in stroke settings report substantial distress, associated with cognitive-behavioural responses to symptoms. Follow-up data suggest recovery can be slow, indicating access to supportive interventions should be improved.

Misidentification of Acute Psychiatric Symptoms in the Emergency Room: Clinical Experience in China

Introduction: Patients who come to the emergency department because of acute psychiatric symptoms are often not admitted to the correct department timely. The purpose of this study is to identify the clinical characteristics of patients with acute psychiatric symptoms in order to achieve early and correct triage in the emergency room. Methodology: We conducted a cross-analysis of inpatients who first came to the emergency department with acute psychiatric symptoms and then admitted to the department of neurology or psychiatry between years 2012 and 2018. Among them, 70 patients were rediagnosed and retransferred, with 38 patients to the department of neurology and 32 patients to the department of psychiatry. The clinical characteristics, laboratory examination, and Neuropsychiatric Inventory (NPI) were analyzed. Results: Patients who were rediagnosed with neurological diseases were more prone to have somatic symptoms (headache, dizziness) (P < 0.05). Because of the atypical early clinical manifestations in the emergency room, fever and positive neurological signs do not necessarily represent the diagnosis of neurological diseases. On the other hand, the absence of these manifestations does not guarantee the diagnosis of psychiatric illness. According to NPI, abnormal behaviors, changes in appetite, and sleep disturbances were more obvious in patients with neurological diseases (P < 0.05), whereas patients with psychiatric disorders often showed prominent irritability (P < 0.05). Conclusions: Acute psychiatric symptoms are usually complex and diverse. The triage and diagnosisshould be based on multiple factors. After triage, clinical symptoms should be dynamically observed.

Psychiatric Comorbidity in Neurological Disorders: Towards a Multidisciplinary Approach to Illness Management in the United Arab Emirates

Aim: To determine the prevalence of mood and anxiety disorders in undiagnosed patients attending neurological services, and detect rates of referral to and attendance of psychiatric services. Methods: Depressive symptoms and anxiety were assessed in 395 adult patients with primary diagnoses of neurological disorders. The Patient Health Questionnaire nine-item depression scale (PHQ-9), and Generalized Anxiety Disorder seven-item scale (GAD-7) were administered. Demographic details of the patients were recorded. Referral to and attendance of psychiatric services were recorded for patients scoring within the clinical range of depression and anxiety disorders (scores > 10). Results: There was a 39% prevalence rate of depressive symptoms, 34% rate of anxiety, and 35.4% concurrent rate of both disorders in this cohort. The referral rate to psychiatric services was 33.6%, and attendance rate was 47.8%. There was significant association between severity of psychiatric symptoms and referral to psychiatric services, as well as significant association between comorbid psychiatric symptoms and attendance to psychiatric services. Conclusion: Our results indicate similar prevalence rates of comorbid psychiatric symptoms to studies carried out in the Middle East and North Africa (MENA) region and relatively high attendance and referral rates to psychiatric services. Implications: The results shed light on the clinical profile of patients in this region and support the need for integrated collaborative medical services. Moreover, findings have important implications for health care policies pertaining to resource distribution and funding.

Positive clinical signs in neurological diseases - An observational study

Many patients with organic neurological disease have symptoms and signs that are unexplained by their disease condition. We attempted to explore the prevalence of positive clinical signs in patients with various organic neurological diseases. We performed a prospective uncontrolled observational study on the presence of 7 positive signs in adults with various organic neurological diseases that were admitted to our tertiary care hospital. This observation was performed during their neurological examination in those who provided consent, could comprehend and lacked terminal illness or profound weakness that limited their ability to perform these tasks. We dichotomized them into two groups based on the presence of these signs. Out of 190 patients that were evaluated between 2014 and 2015, 37 patients had at least one positive sign. On univariate analysis: young age, female gender, prior anxiety, history of childhood abuse, identification of sensory deficits on examination and lack of imaging correlation with clinical localization were identified as risk factors for these positive signs. On multivariate analysis, anxiety (OR 2.88, 95% CI 1.11-7.49, p = 0.03) and presence of sensory deficits on examination (OR 5.81, 95% CI 2.36-14.32, p ≤ 0.001) were associated with these positive signs. Positive signs are common in patients with organic neurological diseases that have anxiety or sensory deficits and may imply a component of functional overlay. Large studies are required to understand its pathophysiology and impact on future outcomes.

Effectiveness of Manual Treatment on Pregnancy Symptoms: Usefulness of Manual Treatment in Treating Pregnancy Symptoms

Objectives

To determine the usefulness of manual treatment in reducing or eliminating pregnancy symptoms during first and second trimester.

Methods

Manual treatment of the cervical and thoracic spine was performed in a group of 115 pregnant women who developed pregnancy symptoms during normal pregnancy. A rotational traction of the cervical spine was applied. Patients in whom the treatment was unsuccessful underwent second round of treatment after a pause of a minimum 3 days. Patients for whom the treatment was initially successful but later relapsed also repeated whole procedure. Pregnancy symptoms analyzed in this study were heartburn, nausea, vomiting, dizziness, headache, insomnia, neck pain, hyperosmia and hypersalivating.

Results

Manual treatment successfully treated pregnancy symptoms in 91 (79.1%) patients, it was partially successful for 22 (19.1%), and unsuccessful for 2 patients (1.7%) after the first treatment. After the second treatment, out of a total 56 patients, the treatment was completely successful in 40 (71.4%), partially successful in 14 (25%), and unsuccessful in 2 (3.6%) patients. The highest success rate was in eliminating headache (97.3%), vomiting (95.9%), dizziness (94.5%), nausea (92.9%), neck pain (92.9%), insomnia (91.9%), heartburn (88.8%), hyperosmia (78.5%) and hyper salivating (78%).

Conclusion

Manual therapy in pregnancy is a drugless, etiological, usually highly effective therapy. It is a low cost, rapid, safe, and well tolerated treatment for pregnancy symptoms which frequently has an immediate effect, thus making it an optimal treatment for pregnancy symptoms.

Barriers and Facilitators for Guidelines with Depression and Anxiety in Parkinson’s Disease or Dementia

Notre principal objectif était de comprendre les barrières et les facilitateurs associés à l’application de guides de pratique clinique (GPC) de haute qualité pour la dépression et l’anxiété chez les patients atteint de démence ou de la maladie de Parkinson (MP). Des groupes de discussion et des entrevues ont été réalisés avec des participants atteints de démence ou de la MP, leurs soignants et les médecins impliqués dans les soins de ces patients à Calgary (Alberta). Le cadre conceptuel des domaines théoriques et le Behaviour Change Wheel ont été utilisés pour guider la collecte des données et l’analyse du cadre conceptuel. Au total, 33 médecins, 7 patients et leurs aidants ont participé à l’étude. Les barrières et les facilitateurs pour l’application des recommandations des GPC liées au diagnostic, à la gestion et à l’utilisation des lignes directrices ont été rapportés. L’insuffisance des données concernant les troubles anxieux et dépressifs dans la démence et la MP constituaient un thème dominant dans les résultats. Ce constat était particulièrement évident en matière de troubles anxieux. Les patients ont aussi mentionné des difficultés à communiquer leurs symptômes et à accéder aux services. Bien que des guides de pratiques soient disponibles, les médecins éprouvent quelques difficultés dans l’application de certaines recommandations, ces difficultés étant surtout dues au manque de données probantes disponibles.

Neuropsychiatry: Towards a Philosophy of Praxis

Neuropsychiatry is a specialized clinical, academic and scientific discipline with its field located in the borderland territory between neurology and psychiatry. In this article, we approach the theoretical definition of neuropsychiatry, and in order to address the practical aspects of the discipline, we describe the profile of a neuropsychiatric liaison service in the setting of a large hospital for neurological diseases in a middle-income country. An audit of consecutive in-patients requiring neuropsychiatric assessment at the National Institute of Neurology and Neurosurgery of Mexico is reported, comprising a total of 1212 patients. The main neurological diagnoses were brain infections (21%), brain neoplasms (17%), cerebrovascular disease (14%), epilepsy (8%), white matter diseases (5%), peripheral neuropathies (5%), extrapyramidal diseases (4%), ataxia (2%), and traumatic brain injury and related phenomena (1.8%). The most frequent neuropsychiatric diagnoses were delirium (36%), depressive disorders (16.4%), dementia (14%), anxiety disorders (8%), frontal syndromes (5%), adjustment disorders (4%), psychosis (3%), somatoform disorders (3%), and catatonia (3%). The borderland between neurology and psychiatry is a large territory that requires the knowledge and clinical skills of both disciplines, but also the unique expertise acquired in a clinical and academic neuropsychiatry program.

Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis

OBJECTIVES

Depression and depressive symptoms are common mental disorders that have a considerable effect on patients' health-related quality of life and satisfaction with medical care, but the prevalence of these conditions varies substantially between published studies. The aim of this study is to conduct a systematic review and meta-analysis to provide a precise estimate of the prevalence of depression or depressive symptoms among outpatients in different clinical specialties.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES AND ELIGIBILITY CRITERIA

The PubMed and PsycINFO, EMBASE and Cochrane Library databases were searched to identify observational studies that contained information on the prevalence of depression and depressive symptoms in outpatients. All studies included were published before January 2016. Data characteristics were extracted independently by two investigators. The point prevalence of depression or depressive symptoms was measured using validated self-report questionnaires or structured interviews. Assessments were pooled using a random-effects model. Differences in study-level characteristics were estimated by meta-regression analysis. Heterogeneity was assessed using standard χ² tests and the I² statistic. The study protocol has been registered with PROSPERO under number CRD42017054738.

RESULTS

Eighty-three cross-sectional studies involving 41 344 individuals were included in this study. The overall pooled prevalence of depression or depressive symptoms was 27.0% (10 943/41 344 individuals; 95% CI 24.0% to 29.0%), with significant heterogeneity between studies (p<0.0001, τ²=0.3742, I²=96.7%). Notably, a significantly higher prevalence of depression and depressive symptoms was observed in outpatients than in the healthy controls (OR 3.16, 95% CI 2.66 to 3.76, I²=72.0%, χ ² =25.33). The highest depression/depressive symptom prevalence estimates occurred in studies of outpatients from otolaryngology clinics (53.0%), followed by dermatology clinics (39.0%) and neurology clinics (35.0%). Subgroup analyses showed that the prevalence of depression and depressive symptoms in different specialties varied from 17.0% to 53.0%. The prevalence of depression and depressive symptoms was higher among outpatients in developing countries than in outpatients from developed countries. Moreover, the prevalence of depression and depressive symptoms in outpatients slightly decreased from 1996 to 2010. Regarding screening instruments, the Beck Depression Inventory led to a higher estimate of the prevalence of depression and depressive symptoms (1316/4702, 36.0%, 95% CI 29.0% to 44.0%, I²=94.8%) than the Hospital Anxiety and Depression Scale (1003/2025, 22.0%, 95% CI 12.0% to 35.0%, I²=96.6%).

CONCLUSION

Our study provides evidence that a significant proportion of outpatients experience depression or depressive symptoms, highlighting the importance of developing effective management strategies for the early identification and treatment of these conditions among outpatients in clinical practice. The substantial heterogeneity between studies was not fully explained by the variables examined.

Cerebellar ataxia and intrathecal baclofen therapy: Focus on patients´ experiences

Elucidating patients´ experiences of living with chronic progressive hereditary ataxia and the symptomatic treatment with intrathecal baclofen (ITB) is the objective of the current study. A multicenter qualitative study with four patients included due to the rare combination of hereditary ataxia and ITB therapy was designed to elucidate participants’ experiences through semi-structured interviews. The transcribed text was analyzed according to content analysis guidelines. Overall we identified living in the present/ taking one day at a time as the main theme covering the following categories: 1) Uncertainty about the future as a consequence of living with a hereditary disease; The disease; 2) Impact on life as a whole, 3) Influence on personal life in terms of feeling forced to terminate employment, 4) Limiting daily activities, and 5) ITB therapy, advantages, and disadvantages. Uncertainty about the future was the category that affected participants’ personal life, employment, and daily activities. The participants’ experience of receiving ITB therapy was expressed in terms of improved quality of life due to better body position and movement as well as better sleep and pain relief.

Post-marketing observational program of the effectiveness of fluvoxamine for the treatment of depression in patients with neurological disorders: the FRIENDS study

In a prospective, non-blinded, uncontrolled, multicenter, post-marketing, observational study (FRIENDS; NCT02043197), fluvoxamine (50-300 mg/day for 90 days) was effective for the treatment of depression in 299 adult patients (age ≥18 years) with neurological disorders at baseline. The therapeutic effect of fluvoxamine was measured by means of changes in the Hospital Anxiety and Depression Scale depression and anxiety scores (HADS-D and HADS-A, respectively), global severity of illness, and clinical condition (measured using the Clinical Global Improvement [CGI] scale). The mean HADS-D subscale score at baseline in the per-protocol cohort (n=296) was 11.7±3.1 points and the corresponding mean HADS-A score was 12.6±3.2. Significant (P<0.0001) improvements in both scores were recorded during fluvoxamine treatment and later follow-up. Most patients (>85%) recorded reductions versus baseline in both indices. In the CGI-based assessment, most evaluated patients (>200) experienced moderate to very substantial clinical improvement, with no or limited side effects. Significant improvements were also recorded in the exploratory outcomes of sleep quality, assessed using the Insomnia Severity Index, and cognitive function, assessed using the Montreal Cognitive Assessment (P<0.0001 vs baseline for both). No death or serious adverse drug reactions were reported during the study. The results of this observational study affirm that fluvoxamine is effective and well tolerated for the treatment of depression in the context of neurological disorders. The effects on the exploratory endpoints of this research merit evaluation in controlled trials.

Behavioural and psychiatric symptoms in cognitive neurology

Behavioural and psychiatric symptoms (BPS) are frequent in neurological patients, contribute to disability, and decrease quality of life. We recorded BPS prevalence and type, as well as any associations with specific diagnoses, brain regions, and treatments, in consecutive outpatients examined in a cognitive neurology clinic.

METHOD

A retrospective analysis of 843 consecutive patients was performed, including a review of BPS, diagnosis, sensory impairment, lesion topography (neuroimaging), and treatment. The total sample was considered, and the cognitive impairment (CI) group (n=607) was compared to the non-CI group.

RESULTS

BPS was present in 59.9% of the patients (61.3% in the CI group, 56.4% in the non-CI group). One BPS was present in 31.1%, two in 17.4%, and three or more in 11.4%. BPS, especially depression and anxiety, are more frequent in women than in men. Psychotic and behavioural symptoms predominate in subjects aged 65 and older, and anxiety in those younger than 65. Psychotic symptoms appear more often in patients with sensory impairment. Psychotic and behavioural symptoms are more prevalent in patients with degenerative dementia; depression and anxiety in those who suffer a psychiatric disease or adverse effects of substances; emotional lability in individuals with a metabolic or hormonal disorder; hypochondria in those with a pain syndrome; and irritability in subjects with chronic hypoxia. Behavioural symptoms are more frequent in patients with anomalies in the frontal or right temporal or parietal lobes, and antipsychotics constitute the first line of treatment. Leaving standard treatments aside, associations were observed between dysthymia and opioid analgesics, betahistine and statins, and between psychotic symptoms and levodopa, piracetam, and vasodilators.

Severe headache as a presenting complaint in sigmoid sinus thrombosis complicated by functional overlay

An otherwise serious and potentially fatal organic condition may present with a co-existing strong functional component. We encountered a female patient who presented with bouts of severe headache over the occipital region, associated with blurring of vision. Initially, non-contrast computed tomography (CT) scan (Brain) showed normal study, and she was deemed as having functional symptoms. Later, magnetic resonance imaging (MRI) (Brain) showed filling defect in right sigmoid sinus and magnetic resonance (MR) venography confirmed right sigmoid sinus thrombosis. On adequate anticoagulation, she did not improve and still had bouts of severe headache, although no longer associated with impaired vision. The treating neurophysician concluded that symptoms could no longer be accounted for by the organic condition. Overt and covert psychosocial stressors were found to be present in a detailed psychological exploration. Psychological intervention effectively controlled the headache. Thus, functional overlay can complicate the clinical picture in a severe organic condition and may require active psychiatric intervention over and above medical treatment.

The role of a neuropsychiatry clinic in a tertiary referral teaching hospital: a 2-year study

OBJECTIVES

Mental disorder is common among individuals with neurological illness. We aimed to characterise the patient population referred for psychiatry assessment at a tertiary neurology service in terms of neurological and psychiatric diagnoses and interventions provided.

METHODS

We studied all individuals referred for psychiatry assessment at a tertiary neurology service over a 2-year period (n= 82).

RESULTS

The most common neurological diagnoses among those referred were epilepsy (16%), Parkinson's disease (15%) and multiple sclerosis (8%). The most common reasons for psychiatric assessment were low mood or anxiety (48%) and medically unexplained symptoms or apparent functional or psychogenic disease (21%). The most common diagnoses among those with mental disorder were mood disorders (62%), and neurotic, stress-related and somatoform disorders, including dissociative (conversion) disorders (28%). Psychiatric diagnosis was not related to gender, neurological diagnosis or psychiatric history.

CONCLUSION

Individuals with neurological illness demonstrate significant symptoms of a range of mental disorders. There is a need for further research into the characteristics and distribution of mental disorder in individuals with neurological illness, and for the enhancement of integrated psychiatric and neurological services to address the comorbidities demonstrated in this population.

A psychodynamic perspective on treatment of patients with conversion and other somatoform disorders

Conversion disorder, the development of symptoms of neurological disease with no organic basis, is a challenge for mental health professionals to diagnose and treat effectively. There are well-established predisposing factors, such as female sex, childhood trauma, and alexithymia, but less clear is how to approach the subjective suffering that is symbolized with the symptom rather than consciously recognized. While there are overlapping comorbidities such as depression and anxiety that may be treated with medication, psychotherapy is the primary effective treatment for patients with adequate capacity to engage in the process. This article addresses means of identifying patients who might benefit from psychotherapy (along with medication in some instances) as well as some guidelines for conducting psychotherapy, with case examples.

Medically unexplained symptoms, illness perception and childhood experience in neurology outpatients

Objectives: Up to one third of patients presenting to neurology outpatients clinics have medically unexplained symptoms, but the aetiology of such symptoms is not well understood. In the current study we sought to investigate the role of anxiety, depression, cognitive factors and early experience in the development of medically unexplained symptoms.

Method: Fifty-seven new patients presenting to a neurology outpatients clinic were studied. Demographic details were recorded and a Hospital Anxiety and Depression Scale, an Illness Perception Questionnaire, and a Childhood Development Questionnaire were administered. An assessment was made by trained medical investigators as to whether the patients symptoms were medically unexplained or accounted for by organic pathology.

Results: We found that 17 out of 56 patients (30%) had medically unexplained symptoms. Such patients complained of a greater number of symptoms, were more anxious, were more likely to have a past history of depression, and were more likely to attribute their illness to stress than patients with a presumed organic basis for their disease. They were also more likely to have been in foster care as children. High levels of depression and anxiety were strongly associated with the number of physical symptoms and the perceived negative consequences of the illness.

Conclusions: The recognition and treatment of anxiety and depressive disorders may contribute to the management of patients with medically unexplained symptoms. Open discussion of beliefs regarding aetiology are also likely to be of benefit regardless of the presence or absence of organic pathology.

Is there anything distinctive about epileptic deja vu?

BACKGROUND

Déjà vu can occur as an aura of temporal lobe epilepsy and in some psychiatric conditions but is also common in the general population. It is unclear whether any clinical features distinguish pathological and physiological forms of déjà vu.

METHODS

50 epileptic patients with ictal déjà vu, 50 non-epileptic patients attending general neurology clinics and 50 medical students at Edinburgh University were recruited. Data were collected on demographic factors, the experience of déjà vu using a questionnaire based on Sno's Inventory for Déjà Vu Experiences Assessment, symptoms of anxiety and depression using the Hospital Anxiety and Depression Scale as well as seizure characteristics, anti-epileptic medications, handedness, EEG and neuroimaging findings for epileptic patients.

RESULTS

73.5% of neurology patients, 88% of students and (by definition) all epilepsy patients had experienced déjà vu. The experience of déjà vu itself was similar in the three groups. Epileptic déjà vu occurred more frequently and lasted somewhat longer than physiological déjà vu. Epilepsy patients were more likely to report prior fatigue and concentrated activity, associated derealisation, olfactory and gustatory hallucinations, physical symptoms such as headaches, abdominal sensations and fear. After controlling for study group, anxiety and depression scores were not associated with déjà vu frequency.

CONCLUSIONS

Déjà vu is common and qualitatively similar whether it occurs as an epileptic aura or normal phenomenon. However ictal déjà vu occurs more frequently and is accompanied by several distinctive features. It is distinguished primarily by 'the company it keeps'.

Headache and neurological disease in pregnancy

A review of the approach in pregnancy to a very commonly encountered neurological disorder (headache), along with less commonly encountered neurological entities that none the less deserve the obstetrician's attention. Definitions of specific disorders and differential diagnoses are reviewed, along with treatment options and pregnancy-associated morbidities. Headache is reviewed first including the common primary headaches migraine and tension-type headache. The disabling neurological disorders-multiple sclerosis, cerebral palsy, and spinal cord injury are grouped due to common morbidities affecting pregnancy. Finally, Bell palsy is also reviewed.

Migraine diagnosis: screening items, instruments, and scales

Migraine is a common and disabling disorder with a 1-year prevalence of 4.5-6% in men and 14.5-18% in women. The diagnosis of migraine is usually made according to the second edition of the International Classification of Headache Disorders (ICHD-2) criteria; however, not all physicians are familiar with the diagnostic criteria. Underdiagnosis remains a major issue in general practice, resulting in inadequate treatment. Several instruments are designed to improve the diagnosis of migraine, to identify the comorbid psychological disturbances, to measure the burden and disability, and to access any reduction in quality of life (QoL) that occurs due to migraine attacks with good reliability and validity. Furthermore, the disability and QoL measured by certain instruments serve as surrogate targets when treating migraines. In this review, we examine the instruments that are in common use in daily practice and current research on migraines, focusing on the purpose of each instrument, clinical applications, pitfalls in interpretation, and, if any, minimally clinically important difference(s) (MCID). In general, a structured intake form and a headache diary are recommended in approaching patients with headache. In addition, ID-Migraine, a three-item screening test, has been validated in primary care settings as a way to improve the rapid diagnosis of migraine. The Visual Aura Rating Scale (VARS) is helpful for the diagnosis of migraine with aura. In addition, migraine is commonly associated with psychiatric comorbidities, which can be assessed by the Beck Depression Inventory (BDI), 9-item Patient Health Questionnaire (PHQ-9), and Hospital Anxiety and Depression Scale (HADS). To evaluate the impact of migraines, disability can be assessed using the Migraine Disability Assessment Questionnaire (MIDAS). Reduction in QoL can be evaluated using the Migraine-Specific Quality of Life Survey (MSQ 2.1), European Quality of Life-Five Dimensions (EQ-5D), or Short-Form 36 (SF-36). Despite all these instruments, proper selection and interpretation of each instrument remain crucial.

Headache in pregnancy: a nuisance or a new sense?

Headache is a very commonly encountered symptom in pregnancy and is usually due to primary headache disorders which are benign in nature. It can however be quite debilitating for some women who may need therapeutic treatment of which there are several options safe to use in pregnancy. It is equally important though to recognise that headache may be a sign of serious underlying pathology. This paper aims to provide a clinically useful guidance for differentiation between primary and secondary headaches in pregnancy. The primary headache disorders and their management in pregnancy are explored in depth with brief overviews of the causes for secondary headaches and their further investigation and management.

Long-term depression is a stroke risk factor

Kocer E, Kocer A, Degirmenci Y, Eryılmaz M. Long-term depression is a stroke risk factor.

Background and Aim: Only a few studies have evaluated depression prevalence in pre-stroke period in comparison to controls. We investigated this association based on a hospitalised stroke population.

Methods: One hundred and forty-eight stroke patients were evaluated. The presence of depression was compared with those of 100 healthy controls without stroke, from the same region. Depression was accepted as present or not present after history and clinical evaluation according to Diagnostic and Statistical Manual of Mental Disorders-IV. Socio-demographic variables, other stroke risk factors and the time of diagnosis of depression (how many year or month they got depression) were recorded.

Results: Gender and mean age of patients and controls were similar in comparison. Depression was diagnosed in 27 patients and 24 controls (p > 0.05). The time period passed after diagnosis of depression was longer in stroke patients in comparison to controls (p < 0.001).

Conclusions: The risk of stroke should be considered in elderly with long-term depression. This indicates that treatment of depression is another factor which should be considered in prevention of brain stroke.

Computerised cognitive behavioural therapy (cCBT): a possible treatment for mood disorders experienced by people with neurological conditions?

Mood disorders such as depression occur relatively often following the diagnosis of a range of neurological conditions. Recent studies reviewing the prevalence of depression amongst people with a neurological condition have shown that approximately one third report clinically significant levels of depression (Carson, Ringbauer, MacKenzie, Warlow, & Sharpe, 2000; Williams et al., 2003). In particular, people with a diagnosis of a cerebrovascular disorder or a neurological condition with additional cognitive impairments, have been found to be the most likely to report symptoms of depression (Williams et al., 2003). However, despite the evidence that a large proportion of people with neurological conditions experience mood disorders, there are currently limited resources available to treat them.

Physical health behaviours and health locus of control in people with schizophrenia-spectrum disorder and bipolar disorder: a cross-sectional comparative study with people with non-psychotic mental illness

BACKGROUND

People with mental illness experience high levels of morbidity and mortality from physical disease compared to the general population. Our primary aim was to compare how people with severe mental illness (SMI; i.e. schizophrenia-spectrum disorders and bipolar disorder) and non-psychotic mental illness perceive their: (i) global physical health, (ii) barriers to improving physical health, (iii) physical health with respect to important aspects of life and (iv) motivation to change modifiable high-risk behaviours associated with coronary heart disease. A secondary aim was to determine health locus of control in these two groups of participants.

METHODS

People with SMI and non-psychotic mental illness were recruited from an out-patient adult mental health service in London. Cross-sectional comparison between the two groups was conducted by means of a self-completed questionnaire.

RESULTS

A total of 146 people participated in the study, 52 with SMI and 94 with non-psychotic mental illness. There was no statistical difference between the two groups with respect to the perception of global physical health. However, physical health was considered to be a less important priority in life by people with SMI (OR 0.5, 95% CI 0.2-0.9, p = 0.029). There was no difference between the two groups in their desire to change high risk behaviours. People with SMI are more likely to have a health locus of control determined by powerful others (p < 0.001) and chance (p = 0.006).

CONCLUSIONS

People with SMI appear to give less priority to their physical health needs. Health promotion for people with SMI should aim to raise awareness of modifiable high-risk lifestyle factors. Findings related to locus of control may provide a theoretical focus for clinical intervention in order to promote a much needed behavioural change in this marginalised group of people.

Undiagnosed depression and its correlates in a predominantly immigrant Hispanic neurology clinic

OBJECTIVE

Previous studies have reported a high incidence of depression in neurology clinics, however areas where there are predominantly underserved immigrants have not been studied.

METHODS

Retrospective cohort study in an academic outpatient neurology clinic in Los Angeles, California. Newly referred patients (N=318) were assessed consecutively for depression using a PHQ-9 questionnaire, accompanied by review of the assessment of the depressive disorder.

RESULTS

The patient cohort consisted of 190 females (59%) and 130 males (41%), primarily of Hispanic descent (72%), with 8% Asian 11% white, and 5% African-American. Sixty-eight percent (68%) had depression, with 40% exhibiting moderate to severe depression. Patients who had moderate to severe depression (based on PHQ-9) were more likely to be unemployed (75.2% vs. 60.7%, p=0.008), dependent on government income (29.5% vs. 20.4%, p=0.06), and have headache or pain as the reason for referral (42.4% vs. 28.5%, p=0.03). Severity of depression also significantly correlated with current treatment by psychiatrist, current antidepressant use, and less independent living. Patients with moderate to severe depression were more likely to have made ER visits in the last 12 months (0.9 vs. 0.7, p=0.01) and were taking more medications (3.3 vs. 2.5, p=0.03), compared to patient with mild or no depression.

CONCLUSION

The presence of moderate to severe depression significantly correlated with socioeconomic status, use of emergency room, and presence of headache/pain. Neurology clinics with predominantly underserved immigrant patients have a disproportionate amount of depression, which may be related to socioeconomic factors resulting in overutilization of scarce healthcare resources.

Chronic fatigue syndrome: labels, meanings and consequences

In this month's issue, we report a survey of members of the Association of British Neurologists, which asked if they viewed chronic fatigue syndrome (CFS) as a neurological condition--84% of respondents did not. This is at odds with current classification in ICD-10. We discuss the difficulties of classifying CFS and myalgic encephalopmeylitis (ME), including historical and sociological factors, the pitfalls of the physical/psychological dichotomy and why classification matters to doctors and patients.

Anxiety disorders in headache patients in a specialised clinic: prevalence and symptoms in comparison to patients in a general neurological clinic

Data from several studies indicate an association of headache with anxiety disorders. In this study, we assessed and differentiated anxiety disorders in 100 headache patients by using the PSWQ (Penn State Worry Questionnaire) screening tool for generalised anxiety disorder (GAD) and the ACQ (Agoraphobic Cognitions Questionnaire) and BSQ (Body Sensation Questionnaire) for panic disorder (PD). Control groups were constructed: (1) on the basis of epidemiological studies on PD and GAD in the general population and (2) by including neurological patients. 37.0% of headache patients had a GAD. 27% of headache patients met the score for PD in the BSQ, 4.0% in the ACQ. Significant results were obtained in comparison to the general population (p < 0.001) and with regard to GAD in comparison with a sample of neurological patients (p < 0.005). The BSQ significantly correlated with the number of medication days (p < 0.005). The results confirm the increased prevalence of GAD in headache patients. PD seems to increase the risk of medication overuse.

The acceptability of computerised cognitive behavioural therapy for the treatment of depression in people with chronic physical disease: a qualitative study of people with multiple sclerosis

BACKGROUND

People with chronic physical conditions are at elevated risk of depression. Due to a shortage of Cognitive Behavioural Therapy (CBT) practitioners, computerised CBT (CCBT) is recommended for people with mild to moderate depression. We assessed the applicability of CCBT for the treatment of depression in people with multiple sclerosis (MS).

METHODS

Depth interviews with 17 people with MS and mild to moderate depression who used one of the two CCBT packages for either eight (Beating the Blues; n = 8) or five (MoodGym; n = 9) weekly sessions were analysed using 'Framework'.

RESULTS

Participants found CCBT-use burdensome due to their physical symptoms. In addition to perpetuating social isolation, the lack of human input meant some participants were unable to define problems, set goals or distinguish between events, thoughts and beliefs as required. CCBT did not legitimise their grief over losses concomitant with their MS. They characterised depression symptom inventories as contaminated by somatic symptoms of their MS. One CCBT package (MoodGym) was perceived as using inappropriate case material for people with the symptoms of MS.

CONCLUSIONS

It is likely that generic CCBT packages for the treatment of depression will need to be adapted for people with chronic physical conditions to maximise their potential for health benefit.