Advances in the Diagnosis and Management of Psychotic Symptoms in Neurodegenerative Diseases: A Narrative Review

Background: Approximately 15% of older adults may experience psychotic phenomena. Primary psychiatric disorders that manifest with psychosis (delusions, hallucinations, and disorganized thought or behavior) account for less than half. Up to 60% of late-life psychotic symptoms are due to systemic medical or neurological conditions, particularly neurodegenerative diseases. A thorough medical workup including laboratory tests, additional procedures if indicated, and neuroimaging studies is recommended. This narrative review summarizes current evidence regarding the epidemiology and phenomenology of psychotic symptoms encountered as part of the neurodegenerative disease continuum (including prodromal and manifest stages). Results: Prodromes are constellations of symptoms that precede the onset of overt neurodegenerative syndromes. Prodromal psychotic features, particularly delusions, have been associated with an increased likelihood of receiving a neurodegenerative disease diagnosis within several years. Prompt prodrome recognition is crucial for early intervention. The management of psychosis associated with neurodegenerative diseases includes behavioral and somatic strategies, although evidence is scarce and mostly limited to case reports, case series, or expert consensus guidelines, with few randomized controlled trials. Conclusion: The complexity of psychotic manifestations warrants management by interprofessional teams that provide coordinated, integrated care.

Elevated Mood States in Patients With Parkinson's Disease Treated With Deep Brain Stimulation: Diagnosis and Management Strategies

OBJECTIVE

Deep brain stimulation (DBS) is an effective surgical treatment for patients with Parkinson's disease (PD). DBS therapy, particularly with the subthalamic nucleus (STN) target, has been linked to rare psychiatric complications, including depression, impulsivity, irritability, and suicidality. Stimulation-induced elevated mood states can also occur. These episodes rarely meet DSM-5 criteria for mania or hypomania.

METHODS

The investigators conducted a chart review of 82 patients with PD treated with DBS.

RESULTS

Nine (11%) patients developed stimulation-induced elevated mood. Five illustrative cases are described (all males with STN DBS; mean age=62.2 years [SD=10.5], mean PD duration=8.6 years [SD=1.6]). Elevated mood states occurred during or shortly after programming changes, when more ventral contacts were used (typically in monopolar mode) and lasted minutes to months. Four patients experienced elevated mood at low amplitudes (1.0 V/1.0 mA); all had psychiatric risk factors (history of impulse-control disorder, dopamine dysregulation syndrome, substance use disorder, and/or bipolar diathesis) that likely contributed to mood destabilization.

CONCLUSIONS

Preoperative DBS evaluations should include a thorough assessment of psychiatric risk factors. The term "stimulation-induced elevated mood states" is proposed to describe episodes of elevated, expansive, or irritable mood and psychomotor agitation that occur during or shortly after DBS programming changes and may be associated with increased goal-directed activity, impulsivity, grandiosity, pressured speech, flight of ideas, or decreased need for sleep and may persist beyond stimulation adjustments. This clinical phenomenon should be considered for inclusion in the bipolar disorder category in future DSM revisions, allowing for increased recognition and appropriate management.

Prefrontal Physiomarkers of Anxiety and Depression in Parkinson's Disease

Objective: Anxiety and depression are prominent non-motor symptoms of Parkinson’s disease (PD), but their pathophysiology remains unclear. We sought to understand their neurophysiological correlates from chronic invasive recordings of the prefrontal cortex (PFC).

Methods: We studied four patients undergoing deep brain stimulation (DBS) for their motor signs, who had comorbid mild to moderate anxiety and/or depressive symptoms. In addition to their basal ganglia leads, we placed a permanent prefrontal subdural 4-contact lead. These electrodes were attached to an investigational pulse generator with the capability to sense and store field potential signals, as well as deliver therapeutic neurostimulation. At regular intervals over 3–5 months, participants paired brief invasive neural recordings with self-ratings of symptoms related to depression and anxiety.

Results: Mean age was 61 ± 7 years, mean disease duration was 11 ± 8 years and a mean Unified Parkinson’s Disease Rating Scale, with part III (UPDRS-III) off medication score of 37 ± 13. Mean Beck Depression Inventory (BDI) score was 14 ± 5 and Beck Anxiety Index was 16.5 ± 5. Prefrontal cortex spectral power in the beta band correlated with patient self-ratings of symptoms of depression and anxiety, with r-values between 0.31 and 0.48. Mood scores showed negative correlation with beta spectral power in lateral locations, and positive correlation with beta spectral power in a mesial recording location, consistent with the dichotomous organization of reward networks in PFC.

Interpretation: These findings suggest a physiological basis for anxiety and depression in PD, which may be useful in the development of neurostimulation paradigms for these non-motor disease features.

Ages at Onset of Anxiety and Depressive Disorders in Parkinson's Disease

OBJECTIVE

Parkinson's disease (PD) is a quintessential neuropsychiatric condition in which anxiety and depressive symptoms are common and may precede motor manifestations. The authors explored the ages at onset of anxiety and depressive disorders among patients with PD evaluated by psychiatrists at a deep brain stimulation center.

METHODS

Psychiatric diagnoses and ages at onset were collected via clinical interviews. The ages at PD diagnosis were ascertained by chart review. Onset ages for anxiety and depressive disorders (overall and for specific disorders) were compared with patients' ages at PD diagnosis by using t tests. Onset ages for major depressive disorder (MDD), generalized anxiety disorder (GAD), and panic disorder were compared with typical onset ages in the general population by using the sign test. A total of 108 patients (66.7% men; age 63.7 years [SD=8.9]) were included in the analysis.

RESULTS

Anxiety and depressive disorders occurred significantly earlier than PD diagnoses. Among patients whose anxiety and depression predated motor symptoms, the mean age at onset of anxiety disorders was 25.6 years earlier, and the mean age at onset of depressive disorders was 17.6 years earlier compared with the mean age at PD diagnosis (both p values <0.0001). Median onset ages for MDD (p<0.0001), GAD (p=0.0002), and panic disorder (p=0.0005) were significantly higher than typical median onset ages in the general population.

CONCLUSIONS

These results may indicate that neurodegenerative changes are present in parts of the brainstem reticular core and limbic system before motor circuits are affected to a degree that causes motor symptoms. Psychiatrists should be mindful that onset of MDD, GAD, and panic disorder after age 45 might signal a neurodegenerative movement disorder such as PD.

A Historical Review of Key Events and Components of Faculty and Professional Development in Psychiatry

Psychiatry's evolution has entailed clinical, educational, research, and administrative missions. Faculty development efforts concern ways in which professional identity, attitudes and skills are transmitted and enhanced from generation to generation. Top-down efforts by national and international organizations and bottom-up movements by individuals in numerous local settings have helped faculty and guided the profession forward. Organizations have provided new faculty with access to mentors and peers across the country, training opportunities, and up-to-date information on emerging scientific, pedagogical, and regulatory trends. Additional innovations and evaluation regarding best practices for faculty development initiatives in psychiatry are needed.

The Many Roads to Mindfulness: A Review of Nonmindfulness-Based Interventions that Increase Mindfulness

Objectives: Mindfulness-based interventions (MBIs) have become increasingly popular for treating various physical and mental disorders. An increase in mindfulness levels through the teaching of mindfulness meditation is the most well-studied mechanism of MBIs. Recent studies, however, suggest that an increase in mindfulness is also observed in physical or psychosocial interventions not explicitly labeled as MBIs, or what the authors call non-MBIs. The authors aimed to review what non-MBIs can increase mindfulness levels despite not explicitly teaching mindfulness meditation. Design: The authors conducted a literature search for studies that included a non-MBI study arm measuring pre- and postintervention mindfulness levels using one of the following eight validated self-reported mindfulness questionnaires: Five-Faceted Mindfulness Questionnaire, Mindful Awareness and Attention Scale, Freiburg Mindfulness Inventory, Toronto Mindfulness Scale, Philadelphia Mindfulness Scale, Kentucky Inventory of Mindfulness Skills, Child and Adolescent Mindfulness Measure, and Cognitive and Affective Mindfulness Scale-Revised. The authors identified 69 non-MBI study arms from 51 independent studies of the non-MBI itself or as active controls of an MBI under investigation. The authors documented or calculated, if not provided, effect sizes (ES) for changes in mindfulness levels following these interventions. Results: Among the 69 non-MBI arms, 36 showed no effect for change in mindfulness (ES <0.20), 3 were indeterminate (no ES available or unable to calculate), 13 had small effects (0.20 < ES <0.5), 13 had medium effects (0.50 < ES <0.80), 3 had large effects (0.80 < ES <1.3), and 1 had a very large effect (ES >1.3) for change in mindfulness. Conclusions: Analysis of the characteristics of non-MBIs with significant increases in mindfulness levels suggested some commonalities between MBIs and non-MBIs, shedding light on a spectrum of mindfulness-related interventions and the possibility that there are many roads to developing mindfulness.

Telepsychiatry for patients with movement disorders: a feasibility and patient satisfaction study

Background

Telemedicine is a convenient health service delivery modality for patients with movement disorders, including Parkinson's disease (PD), but is currently underutilized in the management of associated psychiatric symptoms. This study explored the feasibility of and patient satisfaction with telepsychiatry services at an academic movement disorders center.

Methods

All patients seen by telepsychiatry between January and December 2017 at the UCSF Movement Disorders and Neuromodulation Center were invited to participate. Participation was voluntary. Patients received an initial survey after the first telepsychiatry visit and satisfaction surveys after each visit. Survey responses were collected online via Research Electronic Data Capture (REDCap). Frequencies were calculated for categorical variables, and means and standard deviations were generated for continuous variables.

Results

Thirty-three patients (79% with PD; 72% Medicare recipients; 64% men; mean age, 61.1 ± 10.5 years; mean distance to clinic, 79.9 ± 81.3 miles) completed a total of 119 telepsychiatry and 62 in-person visits. Twenty-two initial surveys and 50 satisfaction surveys (from 21 patients) were collected. Patients were very satisfied with the care (95%), convenience (100%), comfort (95%), and overall visit (95%). Technical quality was somewhat lower rated, with 76% patients reporting they were very satisfied, while 19% were satisfied. All patients would recommend telemedicine to friends or family members.

Conclusions

Telepsychiatry is a feasible option for patients with movement disorders, leading to high patient satisfaction and improved access to care. Technical aspects still need optimization. Whenever available, telepsychiatry can be considered in addition to in-person visits. Future studies with larger samples should explore its impact on patient care outcomes and caregiver burden.

The Psychiatric Assessment and Brief Intervention Program: Partnering With Primary Care Providers

Objective

To present the structure and outcomes to date for the Psychiatric Assessment and Brief Intervention (PABI), a pilot program developed at University of California, San Francisco, to improve access of primary care patients to mental health services. PABI offers diagnostic evaluations and brief (up to 3 months) evidence-based treatment, including pharmacologic management and psychotherapy, to medical patients 18 years of age and older. Core PABI features are ensuring prompt access, actively partnering with patients and referring providers, and coordinating seamless transitions of care.

Methods

Demographic and clinical variables and outcome indicators were collected for all patients seen in PABI from October 2015 to June 2017. Descriptive statistics and mixed-effects linear models were used to analyze the data.

Results

During the study period, 139 patients (54% women, mean [SD] age of 48.2 [17.5] years) with a mean of 2 DSM-5 psychiatric diagnoses each (range, 1-5) were seen. Mean time to access was 8 days, with a mean length of stay in the program of 11 weeks. Compared to baseline, final behavioral health measure scores showed significant improvement: the mean Patient Health Questionnaire-9 score decreased by 5.9 points (95% CI, 4.6-7.2), and the mean 7-item Generalized Anxiety Disorder scale score was 4.4 points lower (95% CI, 3.2-5.6; both P values < .0001).

Conclusions

This brief psychiatric treatment program provides prompt access to quality mental health care for patients with medical comorbidities. Results to date suggest that this program leads to significantly improved clinical outcomes. Further research is needed to determine its long-term sustainability and generalizability.

Improving Mental Health Training for Primary Care Residents: A Resident-Led Educational Intervention

Objective

Psychiatric training in family medicine residency programs is necessary but not always sufficient. A brief educational intervention was designed to help improve family medicine residents' knowledge, comfort, and attitudes in delivering mental health care.

Methods

A 6-hour didactic curriculum was taught by 2 psychiatry residents to family medicine residents between February and April 2015. Preintervention and postintervention surveys assessed participant demographics, knowledge, comfort levels, and attitudes regarding treating patients with psychiatric illness. Descriptive statistics were used to summarize results. Relationships between the sessions attended and preintervention and postintervention knowledge, comfort, and attitudes were investigated.

Results

Of 24 eligible residents, 15 completed each of the surveys preintervention and postintervention. Psychiatric knowledge scores were similar in the preintervention (mean score = 70%, SD = 15%) and postintervention (mean score = 69%, SD = 16%) groups. A significant positive correlation emerged between the number of didactic sessions attended and postintervention comfort levels (Spearman rank correlation coefficient: ρ = 0.61, P = .02). The number of sessions attended was also positively associated with postintervention knowledge scores, although this did not reach statistical significance (ρ = 0.40, P = .16). No relationship emerged between the number of sessions attended and participant attitudes (F₂,₁₂ = 1.88, P = .19).

Conclusions

A brief, resident-led educational intervention positively impacted family medicine residents' comfort in managing patients with psychiatric comorbidities. Further research is needed to establish the sustainability of gains and the impact of such educational interventions on patient care outcomes.

Psychiatric disorders among women with the fragile X premutation without children affected by fragile X syndrome

Several studies have demonstrated increased rates of anxiety and depressive disorders among female carriers of the fragile X premutation. However, the majority of these studies focused on mothers of children with fragile X syndrome, who experience higher rates of parenting stress that may contribute to the emergence of these disorders. The present study compared psychiatric symptom presentation (utilizing measures of current symptoms and lifetime DSM-IV Axis I disorders) in 24 female carriers without affected children (mean age = 32.1 years) to 26 non-carrier women from the community (mean age = 30.5 years). We also examined the association between CGG repeat size (adjusted for X activation ratio) and mRNA, with severity of psychiatric symptoms. Women with the premutation reported significantly elevated symptoms of anxiety, depression, interpersonal sensitivity, obsessive-compulsiveness, and somatization relative to controls during the past week. Carriers had significantly higher rates of lifetime social phobia (42.3%) compared to controls (12.5%); however, this comparison did not remain significant after multiple comparison adjustment. Rates of other psychiatric disorders were not significantly elevated relative to controls, though it should be noted that lifetime rates among controls were much higher than previously published population estimates. Although the sample is relatively small, the study of this unique cohort suggests the premutation confers risk for mood and anxiety disorders independent of the stress of parenting children with FXS. Screening for psychiatric disorders in women with the premutation, even before they become parents, is important and highly encouraged. © 2016 Wiley Periodicals, Inc.

Risk Factors for Cognitive Impairment in Fragile X-Associated Tremor/Ataxia Syndrome

Fragile X-associated tremor/ataxia syndrome (FXTAS) is a late-onset neurodegenerative disease with motor, psychiatric, and cognitive manifestations that occurs in carriers of the fragile X mental retardation 1 ( FMR1) gene premutations. This was a retrospective chart review of 196 individuals (127 men and 69 women) with FXTAS. Forty-six (23%) participants were cognitively impaired, of whom 19 (10%) had dementia. Risk factors for dementia were examined (CGG repeat size; alcohol, benzodiazepine, and opioid use; diabetes; hyperlipidemia; hypertension; hypothyroidism; obesity; sleep apnea; surgeries with general anesthesia; depression; family history of dementia). Thirteen individuals with FXTAS and dementia were then compared to 13 cognitively intact individuals matched on age, gender, and FXTAS stage. CGG repeat size was significantly higher (mean = 98.5, standard deviation [SD] = 22.2) in the dementia group, compared to the cognitively intact group (mean = 81.6, SD = 11.5; P = .0256). These results show that CGG repeat size is a risk factor for FXTAS dementia.

From Industry to Generativity: The First 12 Years of the Association for Academic Psychiatry Master Educator Program

OBJECTIVE

This study presents a mixed-methods evaluation of the first 12 years of the Association for Academic Psychiatry (AAP) Master Educator (ME) program, developed in 2003 to help academic psychiatrists hone their skills as educators. Participants attend two 3-h workshops at the annual meeting, organized in 3-year cycles, for a total of 18 h. Core topics include assessment, curriculum design, and program evaluation.

METHODS

Overall session rating scores from 2003 to 2014 were analyzed using descriptive statistics. A 20-question survey was sent to 58 program graduates in October 2014, exploring participant perspectives on the impact of the ME program on their careers and on the educational programs they were affiliated with. Survey responses were analyzed quantitatively (for multiple choice questions) and qualitatively (for open-ended questions).

RESULTS

The mean overall session scores ranged between 4.1 and 4.9 (on a Likert-type scale of 1-5) for each 3-year cycle. Twenty-nine graduates completed the survey (50 % response rate). Survey responses indicated a positive perception of the impact of the ME program on participants' careers. Most respondents noted improvement in their teaching methods and curriculum development skills and being able to link educational theory with their individual practices. There was a significant increase in perceived confidence, leadership, and further contributions to their educational milieu. Fifteen (52 %) participants also reported generative behaviors that directly impacted others, such as developing new programs, enhancing existing programs at their institutions, or contributing to national educational efforts.

CONCLUSION

The AAP ME program has demonstrated significant benefit over its 12 years of existence. This program represents one strategy to sustain and grow an international community of like-minded educators working to develop their own and future generations' skills in providing high-quality education in psychiatry.

Clinically significant psychiatric symptoms among male carriers of the fragile X premutation, with and without FXTAS, and the mediating influence of executive functioning

OBJECTIVES

To clarify the neuropsychiatric phenotype of fragile X-associated tremor/ataxia syndrome (FXTAS), and assess the extent to which it is mediated by the dysexecutive syndrome that is a major feature of the disorder.

METHODS

We examined the prevalence of clinically meaningful psychiatric symptoms among male carriers of the fragile X premutation, with and without FXTAS, in comparison with men with a normal allele. Measures included the Neuropsychiatric Inventory (NPI), Symptom Checklist-90-R (SCL-90-R), and the Behavioral Dyscontrol Scale, a measure of executive functioning. Between-group differences were evaluated using logistic regression, followed by a mediation analysis with ordinary least squares regression to assess the contribution of dysexecutive syndrome to the observed psychiatric domains.

RESULTS

Men with FXTAS showed higher rates of clinically significant symptoms overall and in specific domains: somatization, obsessive compulsive, depression, anxiety, psychoticism, agitation/aggression, apathy/indifference, irritability, and nighttime behavior problems. Post hoc analyses suggested that findings of psychoticism among men with FXTAS may be associated with participants' accurate acknowledgment of cognitive and physical dysfunction, rather than reflecting psychosis. Asymptomatic carriers showed no evidence of clinically significant psychiatric symptoms, but when all carriers were compared with men having a normal FMR1 allele, executive function deficits were found to mediate scores in several domains on both NPI and SCL-90-R.

CONCLUSIONS

Building on prior research, the results provide evidence that the psychiatric phenotype for men includes clinically meaningful depression, hostility, and irritability, in association with behavioral and attentional disinhibition. It is likely that these problems reflect the effects of impaired executive functioning.

Care Seeking Patterns Among Women Who Have Experienced Gender-Based Violence in Afghanistan

This study explored patterns of abuse and care seeking among women victims of gender-based violence (GBV) in Afghanistan. Individual, semi-structured interviews were conducted with 22 Afghan women ( M age = 19 years) living in a shelter for victims of GBV. Interviews were analyzed thematically. Participants reported experiencing multiple forms of abuse. The majority received medical treatment for abuse-related health concerns. However, less than half reported abuse to health care providers or were asked by health care providers about the context of their injuries. Strategies to improve health care responses to GBV are needed to ensure safety and support for Afghan women.

The office of student wellness: innovating to improve student mental health

OBJECTIVE

Despite increasing mental health needs among medical students, few models for effective preventive student wellness programs exist.

METHODS

This paper describes a novel approach developed at the University of California (UC) Davis School of Medicine: the Office of Student Wellness (OSW).

RESULTS

Improved access and mental health service utilization have been documented, with over half of all students receiving support and clinical care. UC Davis student satisfaction mean scores on the Association of American Medical Colleges Graduation Questionnaire wellness questions have reached or exceeded national average over the last 4 years, since the OSW was founded.

CONCLUSIONS

This program may serve as a blueprint for other medical schools in developing effective student wellness programs.

Helping psychiatry residents cope with patient suicide

OBJECTIVE

Every clinical specialty has its own high risk patient challenges that threaten to undermine their trainees' professional identity, evolving sense of competence. In psychiatric training, it is patient suicide, an all-too frequently encountered consequence of severe mental illness that may leave the treating resident perplexed, guilt-ridden, and uncertain of their suitability for the profession. This study evaluates a patient suicide training program aimed at educating residents about patient suicide, common reactions, and steps to attenuate emotional distress while facilitating learning.

METHODS

The intervention was selected aspects of a patient suicide educational program, "Collateral Damages,"-video vignettes, focused discussions, and a patient-based learning exercise. Pre- and post-survey results were compared to assess both knowledge and attitudes resulting from this educational program. Eight psychiatry residency training programs participated in the study, and 167 of a possible 240 trainees (response rate = 69.58 %) completed pre- and post-surveys.

RESULTS

Knowledge of issues related to patient suicide increased after the program. Participants reported increased awareness of the common feelings physicians and trainees often experience after a patient suicide, of recommended "next" steps, available support systems, required documentation, and the role played by risk management.

CONCLUSIONS

This patient suicide educational program increased awareness of issues related to patient suicide and shows promise as a useful and long overdue educational program in residency training. It will be useful to learn whether this program enhances patient care or coping with actual patient suicide. Similar programs might be useful for other specialties.

Memantine for fragile X-associated tremor/ataxia syndrome: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

Memantine, an uncompetitive N-methyl-d-aspartate receptor antagonist, is currently approved by the US Food and Drug Administration for the treatment of moderate to severe Alzheimer's disease. Anecdotal reports have suggested that memantine may improve neurologic and cognitive symptoms of individuals with the neurodegenerative disease fragile X-associated tremor/ataxia syndrome (FXTAS); however, its efficacy and safety in this population have not been assessed in a controlled trial.

METHOD

Individuals with FXTAS aged 34-80 years were enrolled in a randomized, double-blind, placebo-controlled, 1-year trial between September 2007 and August 2012. Inclusion required definite, probable, or possible FXTAS in clinical stages 1-5 according to previously published criteria. Primary outcome measures were the Behavioral Dyscontrol Scale (BDS) score and CATSYS intention tremor severity.

RESULTS

Ninety-four participants were randomized from 205 screened; of those, 43 and 45 started treatment with memantine (titrated to 10 mg twice daily) and placebo, respectively. Thirty-four participants receiving memantine and 36 receiving placebo completed the 1-year endpoint assessment (n = 70). Intention-to-treat analysis showed no improvement with respect to intention tremor severity (mean [SD] values with memantine vs placebo: 1.05 [0.73] vs 1.89 [2.19], P = .047) or BDS score (16.12 [5.43] vs 15.72 [3.93], P = .727) at follow-up. Post hoc analyses of participants with early FXTAS (stage ≤ 3), those with late FXTAS (stage > 3), and those in different age groups (≤ 65 years and > 65 years) also indicated no significant improvement. More frequent mild adverse events were observed in the placebo group, while more frequent moderate adverse events occurred in the memantine group (P = .007).

CONCLUSION

This randomized, double-blind, placebo-controlled trial of memantine for individuals with FXTAS showed no benefit compared to placebo with respect to the selected outcome measures.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00584948.

Towards an Understanding of Neuropsychiatric Manifestations in Fragile X Premutation Carriers

Fragile X-associated disorders (FXD) are a group of disorders caused by expansion of non-coding CGG repeat elements in the fragile X (FMR1) gene. One of these disorders, fragile X syndrome (FXS), is the most common heritable cause of intellectual disability, and is caused by large CGG repeat expansions (>200) resulting in silencing of the FMR1 gene. An increasingly recognized number of neuropsychiatric FXD have recently been identified that are caused by 'premutation' range expansions (55-200). These disorders are characterized by a spectrum of neuropsychiatric manifestations ranging from an increased risk of neurodevelopmental, mood and anxiety disorders to neurodegenerative phenotypes such as the fragile X-associated tremor ataxia syndrome (FXTAS). Here, we review advances in the clinical understanding of neuropsychiatric disorders in premutation carriers across the lifespan and offer guidance for the detection of such disorders by practicing psychiatrists and neurologists.

Abnormal semantic processing in females with fragile X-associated tremor/ataxia syndrome

Fragile X-associated tremor/ataxia syndrome (FXTAS), a neurodegenerative disorder, affects fragile X (FMR1) gene premutation carriers in late life. Studies have shown cognitive impairments in FXTAS including executive dysfunction, working memory and visuospatial deficits. However, less is known about cognition in females with FXTAS. Thus, we examined semantic processing and verbal memory in female FXTAS patients with event-related potentials (ERPs) and neuropsychological testing. Sixty-one females (34 FXTAS, Mage  = 62.7; 27 controls, Mage  = 60.4) were studied with 32-channel ERPs during a category judgment task in which semantically congruous (50%) and incongruous items were repeated approximately 10-140 seconds later. N400 and P600 amplitude data were submitted to analysis of covariance. Neuropsychological testing demonstrated lower performance in verbal learning and executive function in females with FXTAS. Event-related potential analyses showed a significant reduction of the N400 congruity effect (incongruous - congruous) in the FXTAS group. The N400 congruity effect reduction in females with FXTAS was mainly due to increased N400 amplitude to congruous new words. No significant abnormalities of the N400 repetition effect or the P600 repetition effect were found, indicating preserved implicit memory and verbal memory, respectively, in females with FXTAS. The decreased N400 congruity effect suggests abnormal semantic expectancy and/or semantic network disorganization in female FXTAS patients. The enhanced N400 amplitude to congruous new words may reflect decreased cognitive flexibility among FXTAS women, making access to less typical category exemplar words more difficult.

PSYCHIATRIC DISORDERS ASSOCIATED WITH FXTAS

Carriers of the FMR1 premutation (with 55-200 CGG repeats) may present with multiple medical and psychiatric disorders. Middle-aged carriers (males more often than females) may suffer from fragile X-associated tremor/ataxia syndrome (FXTAS). FXTAS is a newly discovered neurodegenerative disease characterized by intention tremor and ataxia, along with several other neurological features. Psychiatric manifestations are common in premutation carriers of both genders and include attention deficits, anxiety, depression, irritability, impulse dyscontrol, and substance abuse or dependence. Major depressive disorder, panic disorder with or without agoraphobia, generalized anxiety disorder, social phobia, and specific phobia are among the psychiatric diagnoses often encountered in premutation carriers, including those with FXTAS. Later in the course of the illness, cognitive deficits (including dementia) may occur. In this paper, we discuss common psychiatric phenotypes in FXTAS, based on a thorough review of the literature, as well as our own research experience. Symptomatic pharmacologic treatments are available, although disease modifying agents have not yet been developed.

Caregiver Burden in Fragile X Families

Complex caregiving issues occur in multigenerational families carrying the fragile X mutation and premutation. The same family members may care for children or siblings with fragile X syndrome (FXS) and for elderly parents with fragile X-associated tremor/ataxia syndrome (FXTAS). Family caregivers experience anxiety, depression, neglect of personal health care needs, employment difficulties, and loss of social support, leading to isolation and further psychiatric consequences. There is growing awareness of caregiver burden with regard to parents of children with FXS, but much less is known about the needs of informal caregivers of patients with FXTAS. In this paper, we review the available literature to date and provide suggestions for further exploration of caregivers' needs. Evidence-based strategies to address these needs are included. Many more research studies exploring caregiver burden in multigenerational fragile X families are needed, as well as studies aimed at investigating interventions and their impact on reduction.

Ages of Onset of Mood and Anxiety Disorders in Fragile X Premutation Carriers

OBJECTIVE

FMR1 premutation carriers of both genders have a high lifetime prevalence of anxiety and depressive disorders, however little is known regarding the onset ages of these conditions. This study compared onset ages of mood and anxiety disorders in premutation carriers with typical onset ages of the same disorders in the general population.

METHODS

Eighty-one premutation carriers (42% men; average age 62, SD 10) with and without FXTAS completed the Structured Clinical Interview for DSM-IV-TR. Onset ages of mood and anxiety disorders were compared to the corresponding typical population onset ages using the signed rank test.

RESULTS

Overall median onset ages of MDD (46 years old, p < 0.0001), panic disorder (40 years old, p = 0.0067), and specific phobia (11.5 years old, p = 0.0003) were significantly higher in premutation carriers compared to the general population. Median MDD onset ages in male carriers (52 years old) and those with FXTAS (49.5 years old) were significantly higher relative to the general population (median 32, both p < 0.0001). Tremor and ataxia emerged significantly later than MDD and the anxiety disorders studied.

CONCLUSION

Depressive and anxiety disorders in premutation carriers have a later onset compared to the general population, but precede the onset of motor symptoms. This may be due to progressive mRNA toxicity in the limbic system, white matter changes leading to neuronal dysconnectivity, and interaction with environmental factors. Psychosocial factors may be protective. Further research is needed to understand the full spectrum of psychiatric phenotypes in FMR1 premutation carriers.

Postpartum Depression in Women with the FMR1 Premutation

BACKGROUND

Psychiatric disorders in women with the FMR1 premutation are common and include attention deficit hyperactivity disorder, anxiety, depression, and eating disorders. This pilot study explored the risk factors for postpartum depression (PPD) in women with the premutation.

METHODS

We conducted a chart review of 50 women premutation carriers with major depressive disorder who had children. Of these, 7 women had a history of major depressive episodes in the postpartum period. The PPD and non-PPD groups were characterized descriptively based on women's age at the time of the psychiatric evaluation, race, ethnicity, education level, IQ, CGG repeat size, comorbid psychiatric conditions, parity, and number of children with fragile X syndrome (FXS). Exact logistic regression was used to analyze the relationship between the number of children with FXS and the risk of PPD.

RESULTS

The PPD and non-PPD groups were similar on all variables examined, with the exception of the number of affected children. Each of the 7 women with PPD had at least one child with FXS, whereas a third of the women without PPD had no affected children. For each additional affected child, the risk of PPD increased by 158% (exact odds ratio 2.58, 95% CI 0.99-7.59). Further studies are needed to replicate these findings and to better characterize PPD in female premutation carriers.

Neuropathological, clinical and molecular pathology in female fragile X premutation carriers with and without FXTAS

Fragile X-associated tremor/ataxia syndrome (FXTAS) is an adult-onset neurodegenerative disorder associated with premutation alleles of the fragile X mental retardation 1 (FMR1) gene. Approximately 40% of older male premutation carriers, and a smaller proportion of females, are affected by FXTAS; due to the lower penetrance the characterization of the disorder in females is much less detailed. Core clinical features of FXTAS include intention tremor, cerebellar gait ataxia and frequently parkinsonism, autonomic dysfunction and cognitive deficits progressing to dementia in up to 50% of males. In this study, we report the clinical, molecular and neuropathological findings of eight female premutation carriers. Significantly, four of these women had dementia; of the four, three had FXTAS plus dementia. Post-mortem examination showed the presence of intranuclear inclusions in all eight cases, which included one asymptomatic premutation carrier who died from cancer. Among the four subjects with dementia, three had sufficient number of cortical amyloid plaques and neurofibrillary tangles to make Alzheimer's disease a highly likely cause of dementia and a fourth case had dementia with cortical Lewy bodies. Dementia appears to be more common than originally reported in females with FXTAS. Although further studies are required, our observation suggests that in a portion of FXTAS cases there is Alzheimer pathology and perhaps a synergistic effect on the progression of the disease may occur.

Lifetime prevalence of mood and anxiety disorders in fragile X premutation carriers

OBJECTIVE

The authors studied the lifetime prevalence of DSM-IV-TR psychiatric disorders in a population of adults with the fragile X premutation.

METHOD

The Structured Clinical Interview for DSM-IV was conducted, from 2007-2008, in 85 individuals with the fragile X premutation, 47 with the fragile X-associated tremor/ataxia syndrome (FXTAS; 33 male, 14 female; mean age = 66 years) and 38 without FXTAS (16 male, 22 female; mean age = 52 years). Lifetime prevalence for mood and anxiety disorders among carriers with and without FXTAS was compared to available age-specific population estimates from the National Comorbidity Survey Replication (NCS-R).

RESULTS

Among participants with FXTAS, 30 (65%) met lifetime DSM-IV-TR criteria for a mood disorder; 24 (52%) met lifetime DSM-IV-TR criteria for an anxiety disorder. Among the non-FXTAS participants, there were 15 instances of lifetime mood disorder (42%) and 18 of lifetime anxiety disorder (47%). When compared to age-specific NCS-R data, the lifetime prevalences of any mood disorder (P < .0001), major depressive disorder (P < .0001), any anxiety disorder (P < .0001), panic disorder (P = .006), specific phobia (P = .0003), and posttraumatic stress disorder (P = .004) were significantly higher in participants with FXTAS. The lifetime rates of social phobia in individuals with the premutation without FXTAS were significantly higher than NCS-R data (P = .001).

CONCLUSIONS

This sample of carriers of the fragile X premutation had a notably high lifetime risk of mood and anxiety disorders. Mood and anxiety disorders may be part of the clinical phenotype of the fragile X premutation conditions, especially in carriers with FXTAS. Clinicians encountering these patients are advised to consider FXTAS as a neuropsychiatric syndrome as well as a neurologic disorder.

Assessment of patient and caregiver needs in fragile X-associated tremor/ataxia syndrome by utilizing Q-sort methodology

OBJECTIVES

Psychosocial stressors faced by patients with fragile X-associated tremor/ataxia syndrome (FXTAS) and their caregivers have not been systematically explored. FXTAS is a neurodegenerative disease occurring in approximately 45% of elderly male carriers and 8-16% of female carriers of the fragile X mental retardation one premutation. This study investigated the subjective needs of patients with FXTAS and their family caregivers, by utilizing Q-sort methodology.

METHOD

Patients with FXTAS and their caregivers seen during January 2005 to June 2007 participated. The Q-sort was composed of 17 (eight formal and nine informal) items, designed to explore emotional, informational, and instrumental needs of patients with FXTAS and their caregivers. Item scores were generated from 1 = least important to 7 = most important. Analysis included descriptive statistics for all the demographic and outcome variables. Generalized estimating equations were used to identify which of the need domains were perceived as most important by the participants.

RESULTS

A total of 24 patients (79% men, mean age 65.6 ± 6.4 years) with FXTAS and 18 caregivers (11% men, mean age 63.6 ± 6.2 years) completed the Q-sort. Both patients and caregivers rated informational needs as most important, followed by emotional and, finally, by instrumental needs. Participants lacked many important resources, in particular those addressing instrumental needs.

CONCLUSION

Providers should be educated and able to provide timely information and referrals to formal services, as well as to informal resources, including the National Fragile X Foundation online support network (www.fragilex.org).

Postpartum depression: an original survey of screening practices within a healthcare system

OBJECTIVE

This study evaluated the strategies for postpartum depression (PPD) screening by surveying healthcare providers at a US academic medical centre.

METHODS

A 10-question survey was administered to 251 Obstetrics/Gynaecology, Paediatrics, and Family Practice physicians, nurses and other healthcare professionals in April-June 2007. It explored PPD screening methods and familiarity with selected screening instruments (EPDS, PDSS and PHQ-9). Familiarity scores were assigned based on Likert scale ratings, from 1 (not familiar at all) to 5 (using it all the time). Score mean values and standard deviations were calculated for each screening tool, overall and across specialty and training status. Pearson chi-square analyses with discrete and categorical variables and ANOVA with continuous variables were conducted, followed by Tukey post hoc analyses to identify significant mean differences.

RESULTS

There were 131 completed surveys. Respondents were largely unfamiliar with PPD screening instruments, although Ob/Gyn providers were significantly more aware of each tool than were Paediatrics members. Preferred screening methods were symptom review (83%) and physical examination/observation (65%). Sixty-three per cent of respondents used multiple methods. Timing of screening varied across specialties. Paediatric providers screened earliest (0-4 weeks) of all respondents.

CONCLUSIONS

Healthcare providers typically screened for PPD using a combination of clinical methods and were less familiar with standardised instruments. Uniform screening protocols across specialties and targeted educational interventions are strongly recommended to promote better detection and collaborative management of PPD.

Clinician-educator tracks for residents: three pilot programs

OBJECTIVE

Over the past 30 years, clinician-educators have become a prominent component of medical school faculties, yet few of these individuals received formal training for this role and their professional development lags behind other faculty. This article reviews three residency tracks designed to build skills in teaching, curriculum development and assessment, education research, and career development to meet this need.

METHODS

The residency clinician educator tracks at University of Michigan, Baylor College of Medicine, and University of California Davis are described in detail, with particular attention to their common elements, unique features, resource needs, and graduate outcomes.

RESULTS

Common elements in the tracks are faculty mentorship, formal didactics, teaching opportunities, and an expectation of scholarly productivity. Essential resources include motivated faculty, departmental support, and a modest budget. Favorable outcomes include a high percentage of graduates in clinical faculty positions, teaching programs created by the residents, positive effects on recruitment, and enhancement of faculty identity as clinician educators.

CONCLUSION

Clinician-educator tracks in residency present a viable means to address the training needs of clinical track faculty. The programs described in this article provide a model to assist other departments in developing similar programs.

Gender differences in faculty development: a faculty needs survey

OBJECTIVE

The authors investigated professional development needs of faculty in the Department of Psychiatry and Behavioral Sciences at the University of California (UC) Davis, while also exploring any existing differences according to gender and academic rank.

METHODS

An online survey was sent to 75 faculty members, and 41 responses (17 women, 24 men) were collected. Respondents rated 29 items on a Likert scale, from "very important" to "not important" and ranked the top three items in order of importance.

RESULTS

Very important items included finding meaning in one's work, maintaining integrity and ethics, maintaining one's values and academic vitality, balancing personal and professional demands, a flexible work environment, and preventing and handling burnout. Results were similar across gender and rank.

CONCLUSION

UC Davis men and women academic psychiatrists in different career development stages have similar needs, although paths leading to personal and professional fulfillment may vary according to gender.

Conversion disorder in women with the FMR1 premutation

Women with fragile X mental retardation (FMR1) gene premutations (55-200 CGG repeats) were until recently believed to be unaffected. It is now known that up to 8% of older female FMR1 premutation carriers develop fragile X-associated tremor/ataxia syndrome (FXTAS). Female carriers may also develop primary ovarian insufficiency, thyroid disease, hypertension, seizures, peripheral neuropathy, and fibromyalgia. We present a 60-year-old woman with FMR1 premutation who had depression, anxiety, and conversion disorder with seizures. The FMR1 premutation with its associated mRNA toxicity is postulated as an underlying neurobiological mechanism of conversion symptoms, through functional and structural neural dysconnectivity.

Dementia in fragile X-associated tremor/ataxia syndrome (FXTAS): comparison with Alzheimer's disease

Neurocognitive deficits in fragile X-associated tremor/ataxia syndrome (FXTAS) involve attentional control, working memory, executive functioning, and declarative and procedural learning. To date, no studies comparing FXTAS with other dementias have been done. We characterize the dementia in FXTAS, comparing it with Alzheimer's disease. Retrospective chart review of 68 adults (50 men, 18 women) with FXTAS. 20 men with FXTAS dementia were matched by age, gender, and education to patients with mild Alzheimer's dementia (AD). Neuropsychological measures were compared between the two groups: Boston Naming Test (BNT), phonemic fluency (Controlled Oral Word Association Test), digit span forward (DSF) and backward (DSB). Comparisons were based on analysis of covariance and t-tests to assess significant differences between groups. 50% of men with FXTAS and no women were cognitively impaired. On mean scores of verbal fluency (22.83 in FXTAS vs. 28.83 in AD, P = 0.112), working memory (DSB, 4.80 in AD vs. 5.41 in FXTAS, P = 0.359), and language (BNT, 48.54 in AD vs. 54.20 in FXTAS, P = 0.089), there were no significant differences. Digit span forward, measuring attention, was significantly higher in subjects with FXTAS dementia (8.59, vs. 7.10 in AD, P = 0.010). Individuals with FXTAS have significant cognitive deficits, on the order of those in AD although the cognitive profiles in these dementias are not similar. Further research is needed to outline the neuropsychiatric profile in FXTAS and the correlation of genetic markers with the progression and severity of cognitive loss.

Society for women in academic psychiatry: a peer mentoring approach

OBJECTIVE

Despite an increasing presence of women in medicine, the percentage of women in academic psychiatry remains low. At the University of California, Davis, women represent two-thirds of psychiatry residents; however, the percentage of female faculty is one-third. This article presents a novel approach to the academic gender gap problem.

METHOD

The Society for Women in Academic Psychiatry (S.W.A.P.) is a peer mentoring group founded by junior women faculty.

RESULTS

S.W.A.P. results to date include educational products, departmental demographic changes, and climate improvement.

CONCLUSIONS

Although results are encouraging, more effort is needed to achieve a true culture change.