Current Psychiatry

CASE: Depressed and hopeless

Ms. D, age 69, has a 20-year history of bipolar II disorder, for which she is taking citalopram, 30 mg/d. She presents to her outpatient psychotherapist with a chief complaint of depressed mood. The therapist refers her for psychiatric hospitalization and electroconvulsive therapy consultation. Upon admission, Ms. D reports that her depressed mood has worsened over the past 5 weeks after a trip to the Dominican Republic. Ms. D had a negative encounter with airport security that she attributed to her 2 artificial knees and caused her to miss her flight. She endorses poor appetite, loss of energy, anhedonia, difficulty concentrating, poor memory, and feelings of hopelessness.

Ms. D reports increasingly frequent panic attacks as well as intermittent right-sided discomfort, unusual noxious smells, and increased falls. She says the falls likely are a result of new bilateral lower extremity weakness coupled with long-standing imbalance. Ms. D says she has experienced brief occasions of foul-smelling odors while showering without evidence of an offending substance. She also reports a mild, occipitally located headache.

Four years ago, Ms. D was hospitalized for a depressive episode without psychotic features and diagnosed with generalized anxiety disorder, for which she is taking clonazepam, 1.5 mg/d. Her last hypomanic episode was several years ago, and was characterized by increased energy with decreased need for sleep, flight of ideas, increased productivity, and impulsivity. Her medical history includes non-insulin dependent diabetes mellitus, chronic low back pain, hyperlipidemia, arthritis, and gastroesophageal reflux disease; her medications include pioglitazone, 30 mg/d, oxybutynin, 15 mg/d, rosuvastatin, 20 mg/d, losartan, 50 mg/d, and omeprazole, 20 mg/d. She also had bilateral knee replacements 9 years ago and an L4-S1 spinal fusion 11 years ago. She has no history of head injuries or seizures. Ms. D’s father had major depressive disorder, her mother died of a cerebrovascular accident at an unknown age, and her brother died of a myocardial infarction at age 52.

The authors’ observations

A striking aspect of Ms. D’s presenting complaints was her intermittent experience of foul smells. Although olfactory hallucinations can occur with psychotic and affective states, they also may be harbingers of an organic etiology involving the temporal lobe.¹ Olfactory hallucinations associated with a psychiatric disorder often have an accompanying delusional belief regarding the cause of the smell.²

Olfactory hallucinations have been associated with migraines, epilepsy, and Parkinson’s disease.^1-3 Neoplasms, cerebrovascular events, or traumatic brain injuries that result in focal mesial temporal lobe lesions can present as a partial complex seizure with olfactory or gustatory hallucinations and progress to automatisms.⁴ Characteristic odors in these hallucinations are unpleasant; patients with temporal lobe epilepsy describe the smells as “bad,” “rotten,” “sickening,” and “like burning food.”² Ms. D’s report of unusual smells warranted consideration of an organic etiology for her mood change and a thorough neurologic examination.

EVALUATION: Neurologic signs

At the time of admission, Ms. D has a blood pressure of 127/68 mm Hg, heart rate of 74 beats per minute, respiratory rate of 16 breaths per minute, and temperature of 36.5°C. Neurologic examination reveals a left facial droop of unknown duration. Motor strength is weak throughout with left-sided focal weakness. Ms. D’s daughter notes that her mother’s smile appears “funny” in her admission photograph but is unsure when the asymmetry in her facial appearance began. Ms. D had been ambulatory before admission. Nursing staff observes Ms. D leans toward her left side and exhibits possible left-sided neglect during the first 12 hours of hospitalization.

When asked about her facial droop, Ms. D replies that she had not noticed any change in her appearance lately. She does not appear to be concerned about her worsening ambulation. On hospital day 2, Ms. D seems to have difficulty using utensils to eat breakfast. Ms. D is dismissive of her worsening motor function and asks to be left alone to finish her meal.

The authors’ observations

Ms. D’s focal neurologic deficits and complaint of a headache on admission were concerning because they could be caused by a cerebrovascular event or space-occupying brain lesion with potential for increased intracranial pressure. Neurologic examination with evaluation for papilledema is indicated, followed by medical transport to the closest medical center for emergent brain imaging. Neither Ms. D nor her daughter could pinpoint the onset of Ms. D’s left-sided facial droop, which precluded administering tissue plasminogen activator for a potential acute ischemic stroke.⁵

Ms. D’s case prompted us to consider what constitutes timely brain imaging in a patient who presents with psychiatric symptoms. Several neurologic conditions may present first with neurobehavioral symptoms before findings on physical exam. Two series of autopsies conducted >70 years ago at psychiatric hospitals found incidences of brain tumors of 3.45%⁶ and 13.5%.⁷ In a 5-year retrospective study, 21% of meningioma cases presented with psychiatric symptoms alone.⁸ These historical cases suggest that affective, behavioral, and psychotic symptoms may be the only clinical indicators of brain lesions that merit surgery.^9-11

Imaging and radiation exposure

With the advent of CT scans in the 1970s, psychiatrists gained a new method of investigating potential structural CNS pathology in patients presenting with psychiatric symptoms. The dramatic increase in CT scan use in recent years and resulting radiation exposure is responsible for 1.5% to 2% of all cancers in the United States.^12,13 Certainly, physicians must balance the advantage of early detection of brain lesions with cost-effectiveness and exposure to radiation.¹⁴

There is no consensus regarding use of brain imaging in a patient who presents with new-onset psychiatric symptoms. Certainly, patients with localizing neurologic deficits or symptoms of increased intracranial pressure should undergo brain imaging. As for psychiatric patients without neurologic findings, Filley and Kleinschmidt-DeMasters¹⁵ provide recommendations based on their 1995 case series, and other authors have recommended imaging for patients age ≥40¹⁶ vs ≥50^17,18 who present with atypical mental status changes.

OUTCOME: Scan, then surgery

Ms. D’s head CT reveals a large right-sided temporoparietal low-density lesion with 8-mm left lower midline shift (Figure). She undergoes a right temporal craniotomy with resection of the mass, which is confirmed by surgical pathology to be a glioblastoma multiforme World Health Organization grade 4 tumor. Postoperative MRI shows evidence of infarction in the right posterior cerebral artery distribution and residual tumor is identified on follow-up imaging. Ms. D is referred to radiation oncology, where she receives a prognostic median life expectancy of 14 months with radiation and temozolomide treatment.¹⁹

Figure: Ms. D’s MRI results
MRI with contrast shows a large right temporal heterogeneous mass consistent with glioblastoma multiforme

The authors’ observations

Glioblastoma is a rare cancer that comprises 25% of all malignant nervous system tumors.²⁰ It is associated with a poor prognosis, with a <30% relative survival rate for adults at 1 year and 3% at 5 years.²⁰ Headaches, seizures, motor weakness, and progressive neurologic deficits are common symptoms of glioblastoma at diagnosis.²⁰ Ms. D was offered the standard of care treatment for a high-grade glioma, including surgical resection followed by concomitant external-beam radiotherapy and chemotherapy.²¹

Consider structural brain lesions in patients who present with neurobehavioral symptoms, although most of these patients will be diagnosed with a primary psychiatric disorder. Ms. D had a known psychiatric disorder that predated the onset of neurologic symptoms and diagnosis of a rare brain cancer. Before she developed neurologic signs, Ms. D experienced symptoms uncharacteristic of her previous depressive episodes, including olfactory hallucinations, that provided an early indicator of a CNS lesion. Consider brain imaging in patients of any age who do not respond to medications targeting the presumed psychiatric diagnosis to ensure that insidious brain tumors are not missed (Table 1).¹⁵

Table 1

When to order neuroimaging for psychiatric patients

Compared with cerebrovascular lesions, neoplasms are more difficult to clinically correlate with their anatomic location. Neurobehavioral symptoms are more frequently associated with tumors originating in the frontal lobe or temporolimbic regions of the brain. The 3 types of frontal lobe syndromes are dorsolateral, orbitofrontal, and medial-frontal (Table 2).¹⁵ Temporolimbic tumors may present with hallucinations, mania, panic attacks, or amnesia. A meta-analysis found a statistically significant association between anorexia and hypothalamic tumors.²² Reports of neuropsychiatric symptoms that respond to pharmacologic treatment further confound the clinical picture.¹⁶

Table 2

Frontal lobe syndromes

It is uncommon for a patient with a long-standing mood disorder to develop a primary brain cancer. However, Ms. D’s case serves as an important reminder to consider medical comorbidities in our aging psychiatric population. In particular, a patient who develops unusual symptoms or does not respond to previously effective treatments should be more closely examined and the differential diagnosis broadened.

Related Resources

• MD Anderson Cancer Center. Brain tumor videos and podcasts. www.mdanderson.org/patient-and-cancer-information/cancer-information/cancer-types/brain-tumor/videos-and-podcasts/index.html.
• Braun CM, Dumont M, Duval J, et al. Brain modules of hallucination: an analysis of multiple patients with brain lesions. J Psychiatry Neurosci. 2003;28(6):432-449.

Drug Brand Names

• Citalopram • Celexa
• Clonazepam • Klonopin
• Losartan • Cozaar
• Omeprazole • Prilosec
• Oxybutynin • Ditropan
• Pioglitazone • Actos
• Rosuvastatin • Crestor
• Temozolomide • Temodar

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE: Depressed and hopeless

Ms. D, age 69, has a 20-year history of bipolar II disorder, for which she is taking citalopram, 30 mg/d. She presents to her outpatient psychotherapist with a chief complaint of depressed mood. The therapist refers her for psychiatric hospitalization and electroconvulsive therapy consultation. Upon admission, Ms. D reports that her depressed mood has worsened over the past 5 weeks after a trip to the Dominican Republic. Ms. D had a negative encounter with airport security that she attributed to her 2 artificial knees and caused her to miss her flight. She endorses poor appetite, loss of energy, anhedonia, difficulty concentrating, poor memory, and feelings of hopelessness.

Ms. D reports increasingly frequent panic attacks as well as intermittent right-sided discomfort, unusual noxious smells, and increased falls. She says the falls likely are a result of new bilateral lower extremity weakness coupled with long-standing imbalance. Ms. D says she has experienced brief occasions of foul-smelling odors while showering without evidence of an offending substance. She also reports a mild, occipitally located headache.

Four years ago, Ms. D was hospitalized for a depressive episode without psychotic features and diagnosed with generalized anxiety disorder, for which she is taking clonazepam, 1.5 mg/d. Her last hypomanic episode was several years ago, and was characterized by increased energy with decreased need for sleep, flight of ideas, increased productivity, and impulsivity. Her medical history includes non-insulin dependent diabetes mellitus, chronic low back pain, hyperlipidemia, arthritis, and gastroesophageal reflux disease; her medications include pioglitazone, 30 mg/d, oxybutynin, 15 mg/d, rosuvastatin, 20 mg/d, losartan, 50 mg/d, and omeprazole, 20 mg/d. She also had bilateral knee replacements 9 years ago and an L4-S1 spinal fusion 11 years ago. She has no history of head injuries or seizures. Ms. D’s father had major depressive disorder, her mother died of a cerebrovascular accident at an unknown age, and her brother died of a myocardial infarction at age 52.

The authors’ observations

A striking aspect of Ms. D’s presenting complaints was her intermittent experience of foul smells. Although olfactory hallucinations can occur with psychotic and affective states, they also may be harbingers of an organic etiology involving the temporal lobe.¹ Olfactory hallucinations associated with a psychiatric disorder often have an accompanying delusional belief regarding the cause of the smell.²

Olfactory hallucinations have been associated with migraines, epilepsy, and Parkinson’s disease.^1-3 Neoplasms, cerebrovascular events, or traumatic brain injuries that result in focal mesial temporal lobe lesions can present as a partial complex seizure with olfactory or gustatory hallucinations and progress to automatisms.⁴ Characteristic odors in these hallucinations are unpleasant; patients with temporal lobe epilepsy describe the smells as “bad,” “rotten,” “sickening,” and “like burning food.”² Ms. D’s report of unusual smells warranted consideration of an organic etiology for her mood change and a thorough neurologic examination.

EVALUATION: Neurologic signs

At the time of admission, Ms. D has a blood pressure of 127/68 mm Hg, heart rate of 74 beats per minute, respiratory rate of 16 breaths per minute, and temperature of 36.5°C. Neurologic examination reveals a left facial droop of unknown duration. Motor strength is weak throughout with left-sided focal weakness. Ms. D’s daughter notes that her mother’s smile appears “funny” in her admission photograph but is unsure when the asymmetry in her facial appearance began. Ms. D had been ambulatory before admission. Nursing staff observes Ms. D leans toward her left side and exhibits possible left-sided neglect during the first 12 hours of hospitalization.

When asked about her facial droop, Ms. D replies that she had not noticed any change in her appearance lately. She does not appear to be concerned about her worsening ambulation. On hospital day 2, Ms. D seems to have difficulty using utensils to eat breakfast. Ms. D is dismissive of her worsening motor function and asks to be left alone to finish her meal.

The authors’ observations

Ms. D’s focal neurologic deficits and complaint of a headache on admission were concerning because they could be caused by a cerebrovascular event or space-occupying brain lesion with potential for increased intracranial pressure. Neurologic examination with evaluation for papilledema is indicated, followed by medical transport to the closest medical center for emergent brain imaging. Neither Ms. D nor her daughter could pinpoint the onset of Ms. D’s left-sided facial droop, which precluded administering tissue plasminogen activator for a potential acute ischemic stroke.⁵

Ms. D’s case prompted us to consider what constitutes timely brain imaging in a patient who presents with psychiatric symptoms. Several neurologic conditions may present first with neurobehavioral symptoms before findings on physical exam. Two series of autopsies conducted >70 years ago at psychiatric hospitals found incidences of brain tumors of 3.45%⁶ and 13.5%.⁷ In a 5-year retrospective study, 21% of meningioma cases presented with psychiatric symptoms alone.⁸ These historical cases suggest that affective, behavioral, and psychotic symptoms may be the only clinical indicators of brain lesions that merit surgery.^9-11

Imaging and radiation exposure

With the advent of CT scans in the 1970s, psychiatrists gained a new method of investigating potential structural CNS pathology in patients presenting with psychiatric symptoms. The dramatic increase in CT scan use in recent years and resulting radiation exposure is responsible for 1.5% to 2% of all cancers in the United States.^12,13 Certainly, physicians must balance the advantage of early detection of brain lesions with cost-effectiveness and exposure to radiation.¹⁴

There is no consensus regarding use of brain imaging in a patient who presents with new-onset psychiatric symptoms. Certainly, patients with localizing neurologic deficits or symptoms of increased intracranial pressure should undergo brain imaging. As for psychiatric patients without neurologic findings, Filley and Kleinschmidt-DeMasters¹⁵ provide recommendations based on their 1995 case series, and other authors have recommended imaging for patients age ≥40¹⁶ vs ≥50^17,18 who present with atypical mental status changes.

OUTCOME: Scan, then surgery

Ms. D’s head CT reveals a large right-sided temporoparietal low-density lesion with 8-mm left lower midline shift (Figure). She undergoes a right temporal craniotomy with resection of the mass, which is confirmed by surgical pathology to be a glioblastoma multiforme World Health Organization grade 4 tumor. Postoperative MRI shows evidence of infarction in the right posterior cerebral artery distribution and residual tumor is identified on follow-up imaging. Ms. D is referred to radiation oncology, where she receives a prognostic median life expectancy of 14 months with radiation and temozolomide treatment.¹⁹

Figure: Ms. D’s MRI results
MRI with contrast shows a large right temporal heterogeneous mass consistent with glioblastoma multiforme

The authors’ observations

Glioblastoma is a rare cancer that comprises 25% of all malignant nervous system tumors.²⁰ It is associated with a poor prognosis, with a <30% relative survival rate for adults at 1 year and 3% at 5 years.²⁰ Headaches, seizures, motor weakness, and progressive neurologic deficits are common symptoms of glioblastoma at diagnosis.²⁰ Ms. D was offered the standard of care treatment for a high-grade glioma, including surgical resection followed by concomitant external-beam radiotherapy and chemotherapy.²¹

Consider structural brain lesions in patients who present with neurobehavioral symptoms, although most of these patients will be diagnosed with a primary psychiatric disorder. Ms. D had a known psychiatric disorder that predated the onset of neurologic symptoms and diagnosis of a rare brain cancer. Before she developed neurologic signs, Ms. D experienced symptoms uncharacteristic of her previous depressive episodes, including olfactory hallucinations, that provided an early indicator of a CNS lesion. Consider brain imaging in patients of any age who do not respond to medications targeting the presumed psychiatric diagnosis to ensure that insidious brain tumors are not missed (Table 1).¹⁵

Table 1

When to order neuroimaging for psychiatric patients

Compared with cerebrovascular lesions, neoplasms are more difficult to clinically correlate with their anatomic location. Neurobehavioral symptoms are more frequently associated with tumors originating in the frontal lobe or temporolimbic regions of the brain. The 3 types of frontal lobe syndromes are dorsolateral, orbitofrontal, and medial-frontal (Table 2).¹⁵ Temporolimbic tumors may present with hallucinations, mania, panic attacks, or amnesia. A meta-analysis found a statistically significant association between anorexia and hypothalamic tumors.²² Reports of neuropsychiatric symptoms that respond to pharmacologic treatment further confound the clinical picture.¹⁶

Table 2

Frontal lobe syndromes

It is uncommon for a patient with a long-standing mood disorder to develop a primary brain cancer. However, Ms. D’s case serves as an important reminder to consider medical comorbidities in our aging psychiatric population. In particular, a patient who develops unusual symptoms or does not respond to previously effective treatments should be more closely examined and the differential diagnosis broadened.

Related Resources

• MD Anderson Cancer Center. Brain tumor videos and podcasts. www.mdanderson.org/patient-and-cancer-information/cancer-information/cancer-types/brain-tumor/videos-and-podcasts/index.html.
• Braun CM, Dumont M, Duval J, et al. Brain modules of hallucination: an analysis of multiple patients with brain lesions. J Psychiatry Neurosci. 2003;28(6):432-449.

Drug Brand Names

• Citalopram • Celexa
• Clonazepam • Klonopin
• Losartan • Cozaar
• Omeprazole • Prilosec
• Oxybutynin • Ditropan
• Pioglitazone • Actos
• Rosuvastatin • Crestor
• Temozolomide • Temodar

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE: Depressed and hopeless

Ms. D, age 69, has a 20-year history of bipolar II disorder, for which she is taking citalopram, 30 mg/d. She presents to her outpatient psychotherapist with a chief complaint of depressed mood. The therapist refers her for psychiatric hospitalization and electroconvulsive therapy consultation. Upon admission, Ms. D reports that her depressed mood has worsened over the past 5 weeks after a trip to the Dominican Republic. Ms. D had a negative encounter with airport security that she attributed to her 2 artificial knees and caused her to miss her flight. She endorses poor appetite, loss of energy, anhedonia, difficulty concentrating, poor memory, and feelings of hopelessness.

Ms. D reports increasingly frequent panic attacks as well as intermittent right-sided discomfort, unusual noxious smells, and increased falls. She says the falls likely are a result of new bilateral lower extremity weakness coupled with long-standing imbalance. Ms. D says she has experienced brief occasions of foul-smelling odors while showering without evidence of an offending substance. She also reports a mild, occipitally located headache.

Four years ago, Ms. D was hospitalized for a depressive episode without psychotic features and diagnosed with generalized anxiety disorder, for which she is taking clonazepam, 1.5 mg/d. Her last hypomanic episode was several years ago, and was characterized by increased energy with decreased need for sleep, flight of ideas, increased productivity, and impulsivity. Her medical history includes non-insulin dependent diabetes mellitus, chronic low back pain, hyperlipidemia, arthritis, and gastroesophageal reflux disease; her medications include pioglitazone, 30 mg/d, oxybutynin, 15 mg/d, rosuvastatin, 20 mg/d, losartan, 50 mg/d, and omeprazole, 20 mg/d. She also had bilateral knee replacements 9 years ago and an L4-S1 spinal fusion 11 years ago. She has no history of head injuries or seizures. Ms. D’s father had major depressive disorder, her mother died of a cerebrovascular accident at an unknown age, and her brother died of a myocardial infarction at age 52.

The authors’ observations

A striking aspect of Ms. D’s presenting complaints was her intermittent experience of foul smells. Although olfactory hallucinations can occur with psychotic and affective states, they also may be harbingers of an organic etiology involving the temporal lobe.¹ Olfactory hallucinations associated with a psychiatric disorder often have an accompanying delusional belief regarding the cause of the smell.²

Olfactory hallucinations have been associated with migraines, epilepsy, and Parkinson’s disease.^1-3 Neoplasms, cerebrovascular events, or traumatic brain injuries that result in focal mesial temporal lobe lesions can present as a partial complex seizure with olfactory or gustatory hallucinations and progress to automatisms.⁴ Characteristic odors in these hallucinations are unpleasant; patients with temporal lobe epilepsy describe the smells as “bad,” “rotten,” “sickening,” and “like burning food.”² Ms. D’s report of unusual smells warranted consideration of an organic etiology for her mood change and a thorough neurologic examination.

EVALUATION: Neurologic signs

At the time of admission, Ms. D has a blood pressure of 127/68 mm Hg, heart rate of 74 beats per minute, respiratory rate of 16 breaths per minute, and temperature of 36.5°C. Neurologic examination reveals a left facial droop of unknown duration. Motor strength is weak throughout with left-sided focal weakness. Ms. D’s daughter notes that her mother’s smile appears “funny” in her admission photograph but is unsure when the asymmetry in her facial appearance began. Ms. D had been ambulatory before admission. Nursing staff observes Ms. D leans toward her left side and exhibits possible left-sided neglect during the first 12 hours of hospitalization.

When asked about her facial droop, Ms. D replies that she had not noticed any change in her appearance lately. She does not appear to be concerned about her worsening ambulation. On hospital day 2, Ms. D seems to have difficulty using utensils to eat breakfast. Ms. D is dismissive of her worsening motor function and asks to be left alone to finish her meal.

The authors’ observations

Ms. D’s focal neurologic deficits and complaint of a headache on admission were concerning because they could be caused by a cerebrovascular event or space-occupying brain lesion with potential for increased intracranial pressure. Neurologic examination with evaluation for papilledema is indicated, followed by medical transport to the closest medical center for emergent brain imaging. Neither Ms. D nor her daughter could pinpoint the onset of Ms. D’s left-sided facial droop, which precluded administering tissue plasminogen activator for a potential acute ischemic stroke.⁵

Ms. D’s case prompted us to consider what constitutes timely brain imaging in a patient who presents with psychiatric symptoms. Several neurologic conditions may present first with neurobehavioral symptoms before findings on physical exam. Two series of autopsies conducted >70 years ago at psychiatric hospitals found incidences of brain tumors of 3.45%⁶ and 13.5%.⁷ In a 5-year retrospective study, 21% of meningioma cases presented with psychiatric symptoms alone.⁸ These historical cases suggest that affective, behavioral, and psychotic symptoms may be the only clinical indicators of brain lesions that merit surgery.^9-11

Imaging and radiation exposure

With the advent of CT scans in the 1970s, psychiatrists gained a new method of investigating potential structural CNS pathology in patients presenting with psychiatric symptoms. The dramatic increase in CT scan use in recent years and resulting radiation exposure is responsible for 1.5% to 2% of all cancers in the United States.^12,13 Certainly, physicians must balance the advantage of early detection of brain lesions with cost-effectiveness and exposure to radiation.¹⁴

There is no consensus regarding use of brain imaging in a patient who presents with new-onset psychiatric symptoms. Certainly, patients with localizing neurologic deficits or symptoms of increased intracranial pressure should undergo brain imaging. As for psychiatric patients without neurologic findings, Filley and Kleinschmidt-DeMasters¹⁵ provide recommendations based on their 1995 case series, and other authors have recommended imaging for patients age ≥40¹⁶ vs ≥50^17,18 who present with atypical mental status changes.

OUTCOME: Scan, then surgery

Ms. D’s head CT reveals a large right-sided temporoparietal low-density lesion with 8-mm left lower midline shift (Figure). She undergoes a right temporal craniotomy with resection of the mass, which is confirmed by surgical pathology to be a glioblastoma multiforme World Health Organization grade 4 tumor. Postoperative MRI shows evidence of infarction in the right posterior cerebral artery distribution and residual tumor is identified on follow-up imaging. Ms. D is referred to radiation oncology, where she receives a prognostic median life expectancy of 14 months with radiation and temozolomide treatment.¹⁹

Figure: Ms. D’s MRI results
MRI with contrast shows a large right temporal heterogeneous mass consistent with glioblastoma multiforme

The authors’ observations

Glioblastoma is a rare cancer that comprises 25% of all malignant nervous system tumors.²⁰ It is associated with a poor prognosis, with a <30% relative survival rate for adults at 1 year and 3% at 5 years.²⁰ Headaches, seizures, motor weakness, and progressive neurologic deficits are common symptoms of glioblastoma at diagnosis.²⁰ Ms. D was offered the standard of care treatment for a high-grade glioma, including surgical resection followed by concomitant external-beam radiotherapy and chemotherapy.²¹

Consider structural brain lesions in patients who present with neurobehavioral symptoms, although most of these patients will be diagnosed with a primary psychiatric disorder. Ms. D had a known psychiatric disorder that predated the onset of neurologic symptoms and diagnosis of a rare brain cancer. Before she developed neurologic signs, Ms. D experienced symptoms uncharacteristic of her previous depressive episodes, including olfactory hallucinations, that provided an early indicator of a CNS lesion. Consider brain imaging in patients of any age who do not respond to medications targeting the presumed psychiatric diagnosis to ensure that insidious brain tumors are not missed (Table 1).¹⁵

Table 1

When to order neuroimaging for psychiatric patients

Compared with cerebrovascular lesions, neoplasms are more difficult to clinically correlate with their anatomic location. Neurobehavioral symptoms are more frequently associated with tumors originating in the frontal lobe or temporolimbic regions of the brain. The 3 types of frontal lobe syndromes are dorsolateral, orbitofrontal, and medial-frontal (Table 2).¹⁵ Temporolimbic tumors may present with hallucinations, mania, panic attacks, or amnesia. A meta-analysis found a statistically significant association between anorexia and hypothalamic tumors.²² Reports of neuropsychiatric symptoms that respond to pharmacologic treatment further confound the clinical picture.¹⁶

Table 2

Frontal lobe syndromes

It is uncommon for a patient with a long-standing mood disorder to develop a primary brain cancer. However, Ms. D’s case serves as an important reminder to consider medical comorbidities in our aging psychiatric population. In particular, a patient who develops unusual symptoms or does not respond to previously effective treatments should be more closely examined and the differential diagnosis broadened.

Related Resources

• MD Anderson Cancer Center. Brain tumor videos and podcasts. www.mdanderson.org/patient-and-cancer-information/cancer-information/cancer-types/brain-tumor/videos-and-podcasts/index.html.
• Braun CM, Dumont M, Duval J, et al. Brain modules of hallucination: an analysis of multiple patients with brain lesions. J Psychiatry Neurosci. 2003;28(6):432-449.

Drug Brand Names

• Citalopram • Celexa
• Clonazepam • Klonopin
• Losartan • Cozaar
• Omeprazole • Prilosec
• Oxybutynin • Ditropan
• Pioglitazone • Actos
• Rosuvastatin • Crestor
• Temozolomide • Temodar

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Discuss this article at www.facebook.com/CurrentPsychiatry

Arranging coverage and adjusting workload duties before taking an extended leave of absence from clinical practice—eg, for vacation, family leave, medical illness—can be challenging. During extended absences, clinicians depend on colleagues for assistance. In clinical settings such as residency training programs, arranging coverage for a maternity leave could be complicated by differences in attitudes toward pregnancy.¹ However, an anticipated leave allows for advanced planning that can help ease transfer of care.

A smooth transition

Begin planning far in advance of your leave date because complications may necessitate a sudden, early departure. All clinical documentation, such as progress notes, should be completed so that a covering colleague can seamlessly assume patient care. It may be helpful to create a spreadsheet of all patients’ information, including name, contact number, diagnoses, medications, and a risk category (eg, low to high), along with notes—eg, lab results that need to be followed up on or labs to be ordered. This spreadsheet can be updated weekly and kept in a secure location so colleagues can access it in case your leave begins earlier than anticipated. To reduce workload burden on covering colleagues, it may be helpful to see as many stable, medication-only patients as possible before you leave to ensure that you have provided enough refills to cover the duration of your leave, assuming these patients typically are seen every other month or less.

It may be helpful to arrange for colleagues to take on a greater proportion of new consultations within the practice as the leave draws closer, because usually this is not a good time to begin treating new patients. However, it may be desirable for you to see a greater proportion of 1-time consultations, such as pre-surgical evaluations and second-opinion consultations. If time allows, arrange meetings among yourself, the colleague who will be covering for you, and high-risk patients before your leave. This can help promote familiarity and comfort between patients and the covering physician and increase the likelihood that patients in crisis will reach out to the covering physician. In some cases it may be advisable to consider a patient’s diagnosis, treatment history, and past experiences when selecting which colleague will provide care, assuming a choice is available—ie, female patients with a history of sexual trauma may feel more comfortable with a female physician.

Although taking an extended leave of absence from clinical practice can present many practical challenges, working with colleagues in advance can help promote a smoother transition of care and decrease workload burden.

Disclosure

Dr. Troy reports no financial, relationship with any company whose, products are mentioned in this article, or with manufacturers of competing, products.

Discuss this article at www.facebook.com/CurrentPsychiatry

Arranging coverage and adjusting workload duties before taking an extended leave of absence from clinical practice—eg, for vacation, family leave, medical illness—can be challenging. During extended absences, clinicians depend on colleagues for assistance. In clinical settings such as residency training programs, arranging coverage for a maternity leave could be complicated by differences in attitudes toward pregnancy.¹ However, an anticipated leave allows for advanced planning that can help ease transfer of care.

A smooth transition

Begin planning far in advance of your leave date because complications may necessitate a sudden, early departure. All clinical documentation, such as progress notes, should be completed so that a covering colleague can seamlessly assume patient care. It may be helpful to create a spreadsheet of all patients’ information, including name, contact number, diagnoses, medications, and a risk category (eg, low to high), along with notes—eg, lab results that need to be followed up on or labs to be ordered. This spreadsheet can be updated weekly and kept in a secure location so colleagues can access it in case your leave begins earlier than anticipated. To reduce workload burden on covering colleagues, it may be helpful to see as many stable, medication-only patients as possible before you leave to ensure that you have provided enough refills to cover the duration of your leave, assuming these patients typically are seen every other month or less.

It may be helpful to arrange for colleagues to take on a greater proportion of new consultations within the practice as the leave draws closer, because usually this is not a good time to begin treating new patients. However, it may be desirable for you to see a greater proportion of 1-time consultations, such as pre-surgical evaluations and second-opinion consultations. If time allows, arrange meetings among yourself, the colleague who will be covering for you, and high-risk patients before your leave. This can help promote familiarity and comfort between patients and the covering physician and increase the likelihood that patients in crisis will reach out to the covering physician. In some cases it may be advisable to consider a patient’s diagnosis, treatment history, and past experiences when selecting which colleague will provide care, assuming a choice is available—ie, female patients with a history of sexual trauma may feel more comfortable with a female physician.

Although taking an extended leave of absence from clinical practice can present many practical challenges, working with colleagues in advance can help promote a smoother transition of care and decrease workload burden.

Disclosure

Dr. Troy reports no financial, relationship with any company whose, products are mentioned in this article, or with manufacturers of competing, products.

Discuss this article at www.facebook.com/CurrentPsychiatry

Arranging coverage and adjusting workload duties before taking an extended leave of absence from clinical practice—eg, for vacation, family leave, medical illness—can be challenging. During extended absences, clinicians depend on colleagues for assistance. In clinical settings such as residency training programs, arranging coverage for a maternity leave could be complicated by differences in attitudes toward pregnancy.¹ However, an anticipated leave allows for advanced planning that can help ease transfer of care.

A smooth transition

Begin planning far in advance of your leave date because complications may necessitate a sudden, early departure. All clinical documentation, such as progress notes, should be completed so that a covering colleague can seamlessly assume patient care. It may be helpful to create a spreadsheet of all patients’ information, including name, contact number, diagnoses, medications, and a risk category (eg, low to high), along with notes—eg, lab results that need to be followed up on or labs to be ordered. This spreadsheet can be updated weekly and kept in a secure location so colleagues can access it in case your leave begins earlier than anticipated. To reduce workload burden on covering colleagues, it may be helpful to see as many stable, medication-only patients as possible before you leave to ensure that you have provided enough refills to cover the duration of your leave, assuming these patients typically are seen every other month or less.

It may be helpful to arrange for colleagues to take on a greater proportion of new consultations within the practice as the leave draws closer, because usually this is not a good time to begin treating new patients. However, it may be desirable for you to see a greater proportion of 1-time consultations, such as pre-surgical evaluations and second-opinion consultations. If time allows, arrange meetings among yourself, the colleague who will be covering for you, and high-risk patients before your leave. This can help promote familiarity and comfort between patients and the covering physician and increase the likelihood that patients in crisis will reach out to the covering physician. In some cases it may be advisable to consider a patient’s diagnosis, treatment history, and past experiences when selecting which colleague will provide care, assuming a choice is available—ie, female patients with a history of sexual trauma may feel more comfortable with a female physician.

Although taking an extended leave of absence from clinical practice can present many practical challenges, working with colleagues in advance can help promote a smoother transition of care and decrease workload burden.

Disclosure

Dr. Troy reports no financial, relationship with any company whose, products are mentioned in this article, or with manufacturers of competing, products.

As a psychiatrist who incorporates diet and dietary supplements in my practice, I appreciated the excellent review of omega-3 fatty acids for psychiatric illness (Current Psychiatry, September 2012, p. 40-45; http://bit.ly/1ApTrXC). It’s far better to support normal biochemistry and avoid side effects whenever possible.

However, regarding treatment of borderline personality disorder (BPD), the author stated that omega-3 fatty acids are ineffective. I have found them clinically useful for BPD. In the 2003 study the author cited, Zanarini et al¹ concluded “E-EPA [ethyl-eicosapentaenoic acid] is a nutriceutical agent that is both well tolerated and may be efficacious for the treatment of moderately disturbed women with borderline personality disorder. Ninety percent of those taking this compound were able to complete the entire 8-week trial and reported no clinically relevant side effects. Those treated with this compound also experienced a significantly greater reduction in their overall aggression as well as their depressive symptoms than those treated with placebo.” These results suggest that omega-3 fatty acids may be an effective monotherapy for women with moderately severe BPD.

Hyla Cass, MD
Private Practice
Pacific Palisades, CA

The author responds

Dr. Cass is correct. Zanarini et al did suggest that omega-3 fatty acids are beneficial in reducing aggression and depressive symptoms in women with moderate borderline personality disorder who were not prescribed other psychotropics. However, the study was small (N = 30), and further research is needed to support these findings.

Mary Morreale, MD
Assistant Professor
Department of Psychiatry
Wayne State University
Detroit, MI

As a psychiatrist who incorporates diet and dietary supplements in my practice, I appreciated the excellent review of omega-3 fatty acids for psychiatric illness (Current Psychiatry, September 2012, p. 40-45; http://bit.ly/1ApTrXC). It’s far better to support normal biochemistry and avoid side effects whenever possible.

However, regarding treatment of borderline personality disorder (BPD), the author stated that omega-3 fatty acids are ineffective. I have found them clinically useful for BPD. In the 2003 study the author cited, Zanarini et al¹ concluded “E-EPA [ethyl-eicosapentaenoic acid] is a nutriceutical agent that is both well tolerated and may be efficacious for the treatment of moderately disturbed women with borderline personality disorder. Ninety percent of those taking this compound were able to complete the entire 8-week trial and reported no clinically relevant side effects. Those treated with this compound also experienced a significantly greater reduction in their overall aggression as well as their depressive symptoms than those treated with placebo.” These results suggest that omega-3 fatty acids may be an effective monotherapy for women with moderately severe BPD.

Hyla Cass, MD
Private Practice
Pacific Palisades, CA

The author responds

Dr. Cass is correct. Zanarini et al did suggest that omega-3 fatty acids are beneficial in reducing aggression and depressive symptoms in women with moderate borderline personality disorder who were not prescribed other psychotropics. However, the study was small (N = 30), and further research is needed to support these findings.

Mary Morreale, MD
Assistant Professor
Department of Psychiatry
Wayne State University
Detroit, MI

As a psychiatrist who incorporates diet and dietary supplements in my practice, I appreciated the excellent review of omega-3 fatty acids for psychiatric illness (Current Psychiatry, September 2012, p. 40-45; http://bit.ly/1ApTrXC). It’s far better to support normal biochemistry and avoid side effects whenever possible.

However, regarding treatment of borderline personality disorder (BPD), the author stated that omega-3 fatty acids are ineffective. I have found them clinically useful for BPD. In the 2003 study the author cited, Zanarini et al¹ concluded “E-EPA [ethyl-eicosapentaenoic acid] is a nutriceutical agent that is both well tolerated and may be efficacious for the treatment of moderately disturbed women with borderline personality disorder. Ninety percent of those taking this compound were able to complete the entire 8-week trial and reported no clinically relevant side effects. Those treated with this compound also experienced a significantly greater reduction in their overall aggression as well as their depressive symptoms than those treated with placebo.” These results suggest that omega-3 fatty acids may be an effective monotherapy for women with moderately severe BPD.

Hyla Cass, MD
Private Practice
Pacific Palisades, CA

The author responds

Dr. Cass is correct. Zanarini et al did suggest that omega-3 fatty acids are beneficial in reducing aggression and depressive symptoms in women with moderate borderline personality disorder who were not prescribed other psychotropics. However, the study was small (N = 30), and further research is needed to support these findings.

Mary Morreale, MD
Assistant Professor
Department of Psychiatry
Wayne State University
Detroit, MI

Beneath the current haze of the election buzz, a national anticipatory panic is building up because of the looming “fiscal cliff,” when massive government budget cuts are expected to have grave ramifications and bleak economic and existential repercussions.

Individuals from all political affiliations are frantically demanding that lawmakers do something to avoid a disastrous plunge into chaos for government institutions.

Paradoxically and inexplicably, nothing is being done so far to circumvent this impending doom scenario. A sword of Damocles is hanging over the nation, held, as the legend goes, at the pommel by a single hair of a horse’s tail!

I often feel that’s also what is happening in psychiatry. We are facing not 1, but multiple serious and disruptive challenges, crises, and threats to our profession and our patients. It evokes a grim image of multiple Damocles’ swords hanging over us. We do not seem to be doing anything tangible to avoid these dangerous and injurious swords. I quietly fear that living in imminent danger has become the “new normal” for psychiatry. That’s actually a euphemism for “massive denial.” We all seem to be going on with our lives as if we are not heading to our own version of a “fiscal cliff.” The apathy, inaction, and lack of a sense of urgency by “organized psychiatry” are astonishing, given the critical need for urgent action.

Consider the following swords of Damocles hanging over psychiatry:

• Down-to-the-bone budget cuts in public psychiatry with inadequate resources in community mental health and public hospitals.
• Severe bed shortages: psychiatry has dropped from the most overbedded medical specialty in the 1960s to the most underbedded one, with devastating adverse effects on acutely ill patients who need inpatient treatment.
• Unabating incarceration and criminalization of seriously mentally ill patients as a substitute for hospitalization or care at residential facilities.
• A chronic shortage of psychiatrists, which is fueling the argument by some mental health professions with no medical or advanced nursing background that they should be permitted to “acquire” prescription privileges, as if prescribing is a skill independent from the extensive training of 4 years of medical school plus 4 years of psychiatric training. The consequences for disabled patients will be low-quality, even dangerous care.
• The low rate of medical students choosing psychiatry as a career. The shortage of psychiatrists will worsen if attrition from retirement or mortality is not offset by substantial annual infusions of newly minted psychiatrists.
• The deplorably short life span of patients with severe mental illness—25 years less than non-mentally ill individuals—mainly attributable to excess cardiovascular risk and lack of access to adequate primary care as part of community mental health management.
• An anemic pipeline of psychiatric residents choosing careers as teachers or researchers. Huge student loans and lack of mentorship are only some of the reasons residents select clinical work over academic careers.
• Withdrawal of several major pharmaceutical companies from research and development to discover new psychiatric drugs. It would be more judicious to engage and partner with them instead of demonizing them simply because they are the only entities that design, develop, test, and produce psychiatric medications. The unmet needs in psychiatry are enormous, especially because 80% of DSM-IV-TR psychiatric disorders have no FDA-approved medication.
• A lack of coalescence and cohesiveness of psychiatrists in the United States. We have fragmented into small organizations and factions, speaking with several faint voices instead of one powerful voice. Other disciplines are far better organized and can lobby more effectively for their causes.
• A lack of participation by psychiatrists in their professional organizations and low support for political action committees to navigate the agenda of psychiatry at the local, state, and national levels. The image and influence of psychiatry can be bolstered only by ongoing member donations and the reverse will occur without consistent member support.
• The persistent stigma of mental illness that continues to haunt our patients, inhibits treatment-seeking, and undermines treatment adherence. Despite magnificent advances in the medical basis of mental disorders, psychiatric illnesses are not regarded with the same acceptance and understanding as other medical disorders.
• A frustrating lag in translating the veritable explosion in basic neuroscience discoveries into clinical applications for diagnosis or therapeutics. Psychiatry could benefit greatly if a sufficient number of well-funded translational researchers get involved. A partnership between the National Institute of Mental Health (NIMH)and the pharmaceutical industry can expedite this translation, but has yet to happen.

This list of “dangling swords” may appear daunting and overwhelming but if we shed our apathy and unite, we can parry their threats and emerge stronger. I do not claim to have the answers but I do have an abiding faith in the collective wisdom and abilities of my fellow psychiatrists, if they decide to mobilize. The root of our “fiscal cliff” is our chronic inaction, passivity, and lack of cohesiveness and a passionate pursuit of our shared goals. We better wake up and act soon before these Damocles’ swords start falling and inflicting their exquisite pain.

Beneath the current haze of the election buzz, a national anticipatory panic is building up because of the looming “fiscal cliff,” when massive government budget cuts are expected to have grave ramifications and bleak economic and existential repercussions.

Individuals from all political affiliations are frantically demanding that lawmakers do something to avoid a disastrous plunge into chaos for government institutions.

Paradoxically and inexplicably, nothing is being done so far to circumvent this impending doom scenario. A sword of Damocles is hanging over the nation, held, as the legend goes, at the pommel by a single hair of a horse’s tail!

I often feel that’s also what is happening in psychiatry. We are facing not 1, but multiple serious and disruptive challenges, crises, and threats to our profession and our patients. It evokes a grim image of multiple Damocles’ swords hanging over us. We do not seem to be doing anything tangible to avoid these dangerous and injurious swords. I quietly fear that living in imminent danger has become the “new normal” for psychiatry. That’s actually a euphemism for “massive denial.” We all seem to be going on with our lives as if we are not heading to our own version of a “fiscal cliff.” The apathy, inaction, and lack of a sense of urgency by “organized psychiatry” are astonishing, given the critical need for urgent action.

Consider the following swords of Damocles hanging over psychiatry:

• Down-to-the-bone budget cuts in public psychiatry with inadequate resources in community mental health and public hospitals.
• Severe bed shortages: psychiatry has dropped from the most overbedded medical specialty in the 1960s to the most underbedded one, with devastating adverse effects on acutely ill patients who need inpatient treatment.
• Unabating incarceration and criminalization of seriously mentally ill patients as a substitute for hospitalization or care at residential facilities.
• A chronic shortage of psychiatrists, which is fueling the argument by some mental health professions with no medical or advanced nursing background that they should be permitted to “acquire” prescription privileges, as if prescribing is a skill independent from the extensive training of 4 years of medical school plus 4 years of psychiatric training. The consequences for disabled patients will be low-quality, even dangerous care.
• The low rate of medical students choosing psychiatry as a career. The shortage of psychiatrists will worsen if attrition from retirement or mortality is not offset by substantial annual infusions of newly minted psychiatrists.
• The deplorably short life span of patients with severe mental illness—25 years less than non-mentally ill individuals—mainly attributable to excess cardiovascular risk and lack of access to adequate primary care as part of community mental health management.
• An anemic pipeline of psychiatric residents choosing careers as teachers or researchers. Huge student loans and lack of mentorship are only some of the reasons residents select clinical work over academic careers.
• Withdrawal of several major pharmaceutical companies from research and development to discover new psychiatric drugs. It would be more judicious to engage and partner with them instead of demonizing them simply because they are the only entities that design, develop, test, and produce psychiatric medications. The unmet needs in psychiatry are enormous, especially because 80% of DSM-IV-TR psychiatric disorders have no FDA-approved medication.
• A lack of coalescence and cohesiveness of psychiatrists in the United States. We have fragmented into small organizations and factions, speaking with several faint voices instead of one powerful voice. Other disciplines are far better organized and can lobby more effectively for their causes.
• A lack of participation by psychiatrists in their professional organizations and low support for political action committees to navigate the agenda of psychiatry at the local, state, and national levels. The image and influence of psychiatry can be bolstered only by ongoing member donations and the reverse will occur without consistent member support.
• The persistent stigma of mental illness that continues to haunt our patients, inhibits treatment-seeking, and undermines treatment adherence. Despite magnificent advances in the medical basis of mental disorders, psychiatric illnesses are not regarded with the same acceptance and understanding as other medical disorders.
• A frustrating lag in translating the veritable explosion in basic neuroscience discoveries into clinical applications for diagnosis or therapeutics. Psychiatry could benefit greatly if a sufficient number of well-funded translational researchers get involved. A partnership between the National Institute of Mental Health (NIMH)and the pharmaceutical industry can expedite this translation, but has yet to happen.

This list of “dangling swords” may appear daunting and overwhelming but if we shed our apathy and unite, we can parry their threats and emerge stronger. I do not claim to have the answers but I do have an abiding faith in the collective wisdom and abilities of my fellow psychiatrists, if they decide to mobilize. The root of our “fiscal cliff” is our chronic inaction, passivity, and lack of cohesiveness and a passionate pursuit of our shared goals. We better wake up and act soon before these Damocles’ swords start falling and inflicting their exquisite pain.

Beneath the current haze of the election buzz, a national anticipatory panic is building up because of the looming “fiscal cliff,” when massive government budget cuts are expected to have grave ramifications and bleak economic and existential repercussions.

Individuals from all political affiliations are frantically demanding that lawmakers do something to avoid a disastrous plunge into chaos for government institutions.

Paradoxically and inexplicably, nothing is being done so far to circumvent this impending doom scenario. A sword of Damocles is hanging over the nation, held, as the legend goes, at the pommel by a single hair of a horse’s tail!

I often feel that’s also what is happening in psychiatry. We are facing not 1, but multiple serious and disruptive challenges, crises, and threats to our profession and our patients. It evokes a grim image of multiple Damocles’ swords hanging over us. We do not seem to be doing anything tangible to avoid these dangerous and injurious swords. I quietly fear that living in imminent danger has become the “new normal” for psychiatry. That’s actually a euphemism for “massive denial.” We all seem to be going on with our lives as if we are not heading to our own version of a “fiscal cliff.” The apathy, inaction, and lack of a sense of urgency by “organized psychiatry” are astonishing, given the critical need for urgent action.

Consider the following swords of Damocles hanging over psychiatry:

• Down-to-the-bone budget cuts in public psychiatry with inadequate resources in community mental health and public hospitals.
• Severe bed shortages: psychiatry has dropped from the most overbedded medical specialty in the 1960s to the most underbedded one, with devastating adverse effects on acutely ill patients who need inpatient treatment.
• Unabating incarceration and criminalization of seriously mentally ill patients as a substitute for hospitalization or care at residential facilities.
• A chronic shortage of psychiatrists, which is fueling the argument by some mental health professions with no medical or advanced nursing background that they should be permitted to “acquire” prescription privileges, as if prescribing is a skill independent from the extensive training of 4 years of medical school plus 4 years of psychiatric training. The consequences for disabled patients will be low-quality, even dangerous care.
• The low rate of medical students choosing psychiatry as a career. The shortage of psychiatrists will worsen if attrition from retirement or mortality is not offset by substantial annual infusions of newly minted psychiatrists.
• The deplorably short life span of patients with severe mental illness—25 years less than non-mentally ill individuals—mainly attributable to excess cardiovascular risk and lack of access to adequate primary care as part of community mental health management.
• An anemic pipeline of psychiatric residents choosing careers as teachers or researchers. Huge student loans and lack of mentorship are only some of the reasons residents select clinical work over academic careers.
• Withdrawal of several major pharmaceutical companies from research and development to discover new psychiatric drugs. It would be more judicious to engage and partner with them instead of demonizing them simply because they are the only entities that design, develop, test, and produce psychiatric medications. The unmet needs in psychiatry are enormous, especially because 80% of DSM-IV-TR psychiatric disorders have no FDA-approved medication.
• A lack of coalescence and cohesiveness of psychiatrists in the United States. We have fragmented into small organizations and factions, speaking with several faint voices instead of one powerful voice. Other disciplines are far better organized and can lobby more effectively for their causes.
• A lack of participation by psychiatrists in their professional organizations and low support for political action committees to navigate the agenda of psychiatry at the local, state, and national levels. The image and influence of psychiatry can be bolstered only by ongoing member donations and the reverse will occur without consistent member support.
• The persistent stigma of mental illness that continues to haunt our patients, inhibits treatment-seeking, and undermines treatment adherence. Despite magnificent advances in the medical basis of mental disorders, psychiatric illnesses are not regarded with the same acceptance and understanding as other medical disorders.
• A frustrating lag in translating the veritable explosion in basic neuroscience discoveries into clinical applications for diagnosis or therapeutics. Psychiatry could benefit greatly if a sufficient number of well-funded translational researchers get involved. A partnership between the National Institute of Mental Health (NIMH)and the pharmaceutical industry can expedite this translation, but has yet to happen.

This list of “dangling swords” may appear daunting and overwhelming but if we shed our apathy and unite, we can parry their threats and emerge stronger. I do not claim to have the answers but I do have an abiding faith in the collective wisdom and abilities of my fellow psychiatrists, if they decide to mobilize. The root of our “fiscal cliff” is our chronic inaction, passivity, and lack of cohesiveness and a passionate pursuit of our shared goals. We better wake up and act soon before these Damocles’ swords start falling and inflicting their exquisite pain.

Discuss this article at www.facebook.com/CurrentPsychiatry

Postpartum depression (PPD)—emergence of a major depressive episode after childbirth—has broad negative consequences for the mother, baby, and other family members. The time of onset after delivery for a depressive episode to be considered postpartum is debatable, but the DSM-IV-TR specifier states that onset within 4 weeks of childbirth is considered postpartum. PPD can impact many aspects of child development, including mother-infant attachment, cognitive development, and behavior.^1-3

An estimated 10% of women who have given birth experience PPD.^4,5 The risk of PPD is particularly high among women who have had previous episodes of PPD or major depressive disorder (MDD). Other risk factors include stressful life events, depression and/or anxiety during pregnancy, family history of PPD, and obstetrical complications.^6-8 Anxiety disorders are common in postpartum women, and anxiety symptoms often are prominent in PPD.⁹

Despite the prevalence of PPD and its serious consequences, few studies have addressed antidepressant treatment. In this article we discuss screening and treating PPD and considerations for breast-feeding mothers. Click here for results of an open-label trial of escitalopram for PPD we conducted in which patient recruitment was challenging.

Screening for PPD: A good start

Initiatives by state governments and health care providers have led to programs in which universal screening for PPD has been implemented. Screening provides a mechanism for early detection and intervention. The Edinburgh Postnatal Depression Scale¹⁰ is a self-rated, 10-item scale developed for the postpartum setting, and its use increases identification of PPD at postpartum obstetrics visits.¹¹ Other screening tools such as the Patient Health Questionnaire-9 also are commonly used. Despite the success of screening programs in attempting the feasibility of screening, it is unclear if the identification of women who may be experiencing PPD increases their engagement in treatment. Studies have demonstrated that even when depressive symptoms suggesting a PPD episode are identified in the postpartum period, many women still do not receive treatment.^12,13 Studies of PPD screening programs have not demonstrated that screening itself improves treatment engagement or improves outcomes.^12,13

Psychotherapy: An effective option

Psychotherapy is an important first-line option for PPD, particularly because of considerations of medication exposure during breast-feeding and many women are reluctant to take antidepressants while breast-feeding.¹⁶ Interpersonal psychotherapy and cognitive-behavioral therapy (CBT) have been most studied for PPD, and both appear effective for prevention and acute treatment of PPD.^17-20 Although psychotherapy alone may be sufficient for some women, for others, medication may be an important first-line treatment, depending on symptom severity, access to psychotherapy, and personal preference.

Evidence for antidepressants

Randomization to placebo is rare in PPD trials. Most trials have used open-label designs because placebo arms pose ethical dilemmas considering the impact of PPD on a mother and her baby. In a randomized study of sertraline or nortriptyline for PPD, both drugs were similarly efficacious.²² In another study comparing paroxetine monotherapy and paroxetine plus CBT for PPD, both groups experienced significant improvement in depression and anxiety symptoms, with no difference between groups at endpoint.²³ Open-label trials have suggested antidepressants’ efficacy, although some studies have included small sample sizes (Table 1).^20-27

Table 1

Antidepressants for PPD: Summary of the evidence

Breast-feeding considerations

From a nutritional standpoint, breast-feeding is optimal for a newborn. However, for some women, breast-feeding is difficult and stressful, and new mothers may experience this difficulty as failure. Some women prefer not to breast-feed, and others may prefer to formula feed if they require pharmacotherapy, particularly if the medication has not been well studied in breast-feeding patients. Some women may decline to take medications if they are breast-feeding out of concern for the baby’s exposure via breast milk and prefer to try nonpharmacologic approaches first. Many mothers with PPD need to be reassured that stopping breast-feeding may be exactly what is needed if the experience is contributing to their PPD or making them uncomfortable accepting pharmacotherapy when indicated. Maternal mental health is more important than breast-feeding to the health and wellness of the mother-baby dyad.

Table 2

Considerations for antidepressant use during breast-feeding

The psychiatrist’s role

PPD has great public health significance because it affects a large number of women and their families. Screening during obstetrical visits or in other settings may increase identification of women who are suffering from PPD. In order for this screening to lead to meaningful changes, women must receive timely and expert evaluations for PPD and treatment that is efficacious and accessible.

Diagnosis and treatment: 4 pearls

Verify the diagnosis. Many women who present with postpartum depressive symptoms may have previously unrecognized bipolar disorder, and many women presenting with a primary complaint of anxiety have PPD.^33,34

Discuss breast-feeding. This topic is important in assessing the risks and benefits of antidepressants in postpartum women, but many women also experience breast-feeding as a topic with emotional valence of its own and may need support with infant feeding.

Meet the patient where she is. Patient preferences strongly influence PPD treatment decisions. Women with similar clinical presentations may have strong preferences for different treatments.

Make treatment accessible. Postpartum women may find it challenging to engage in treatment. Treatment plans need to be feasible for women who are depressed while caring for a newborn. On-site childcare, home visits, Internet communication, and other accommodations that may facilitate treatment should be considered at a systems level.

Related Resources

• American College of Obstetricians and Gynecologists. Screening for depression during and after pregnancy. www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Screening_for_Depression_During_and_After_Pregnancy.
  
• Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci. 2011;13(1):89-100.
  
• Dennis CL, Stewart DE. Treatment of postpartum depression, part 1: a critical review of biological interventions. J Clin Psychiatry. 2004;65(9):1242-1251.
  
• Dennis CL. Treatment of postpartum depression, part 2: a critical review of nonbiological interventions. J Clin Psychiatry. 2004;65(9):1252-1265.
  
• Cohen LS, Wang B, Nonacs R, et al. Treatment of mood disorders during pregnancy and postpartum. Psychiatr Clin North Am. 2010;33(2):273-293.
  

• Bupropion • Wellbutrin, Zyban
  
• Citalopram • Celexa
  
• Desvenlafaxine • Pristiq
  
• Duloxetine • Cymbalta
  
• Escitalopram • Lexapro
  
• Fluoxetine • Prozac
  
• Fluvoxamine • Luvox
  
• Mirtazapine • Remeron
  
• Nefazodone • Serzone
  
• Nortriptyline • Aventyl, Pamelor
  
• Paroxetine • Paxil
  
• Sertraline • Zoloft
  
• Venlafaxine • Effexor
  

Dr. Joffe has received grant or research support from Cephalon/Teva, and is a consultant to Noven and Sunovion.

Dr. Cohen has received research support from AstraZeneca, Bayer HealthCare Pharmaceuticals, Bristol-Myers Squibb, Forest Laboratories, GlaxoSmithKline, National Institute of Mental Health, National Institute on Aging, National Institutes of Health, Ortho-McNeil Janssen, and Pfizer and has served on an advisory board for PamLab LLC.

Discuss this article at www.facebook.com/CurrentPsychiatry

Postpartum depression (PPD)—emergence of a major depressive episode after childbirth—has broad negative consequences for the mother, baby, and other family members. The time of onset after delivery for a depressive episode to be considered postpartum is debatable, but the DSM-IV-TR specifier states that onset within 4 weeks of childbirth is considered postpartum. PPD can impact many aspects of child development, including mother-infant attachment, cognitive development, and behavior.^1-3

An estimated 10% of women who have given birth experience PPD.^4,5 The risk of PPD is particularly high among women who have had previous episodes of PPD or major depressive disorder (MDD). Other risk factors include stressful life events, depression and/or anxiety during pregnancy, family history of PPD, and obstetrical complications.^6-8 Anxiety disorders are common in postpartum women, and anxiety symptoms often are prominent in PPD.⁹

Despite the prevalence of PPD and its serious consequences, few studies have addressed antidepressant treatment. In this article we discuss screening and treating PPD and considerations for breast-feeding mothers. Click here for results of an open-label trial of escitalopram for PPD we conducted in which patient recruitment was challenging.

Screening for PPD: A good start

Initiatives by state governments and health care providers have led to programs in which universal screening for PPD has been implemented. Screening provides a mechanism for early detection and intervention. The Edinburgh Postnatal Depression Scale¹⁰ is a self-rated, 10-item scale developed for the postpartum setting, and its use increases identification of PPD at postpartum obstetrics visits.¹¹ Other screening tools such as the Patient Health Questionnaire-9 also are commonly used. Despite the success of screening programs in attempting the feasibility of screening, it is unclear if the identification of women who may be experiencing PPD increases their engagement in treatment. Studies have demonstrated that even when depressive symptoms suggesting a PPD episode are identified in the postpartum period, many women still do not receive treatment.^12,13 Studies of PPD screening programs have not demonstrated that screening itself improves treatment engagement or improves outcomes.^12,13

Psychotherapy: An effective option

Psychotherapy is an important first-line option for PPD, particularly because of considerations of medication exposure during breast-feeding and many women are reluctant to take antidepressants while breast-feeding.¹⁶ Interpersonal psychotherapy and cognitive-behavioral therapy (CBT) have been most studied for PPD, and both appear effective for prevention and acute treatment of PPD.^17-20 Although psychotherapy alone may be sufficient for some women, for others, medication may be an important first-line treatment, depending on symptom severity, access to psychotherapy, and personal preference.

Evidence for antidepressants

Randomization to placebo is rare in PPD trials. Most trials have used open-label designs because placebo arms pose ethical dilemmas considering the impact of PPD on a mother and her baby. In a randomized study of sertraline or nortriptyline for PPD, both drugs were similarly efficacious.²² In another study comparing paroxetine monotherapy and paroxetine plus CBT for PPD, both groups experienced significant improvement in depression and anxiety symptoms, with no difference between groups at endpoint.²³ Open-label trials have suggested antidepressants’ efficacy, although some studies have included small sample sizes (Table 1).^20-27

Table 1

Antidepressants for PPD: Summary of the evidence

Breast-feeding considerations

From a nutritional standpoint, breast-feeding is optimal for a newborn. However, for some women, breast-feeding is difficult and stressful, and new mothers may experience this difficulty as failure. Some women prefer not to breast-feed, and others may prefer to formula feed if they require pharmacotherapy, particularly if the medication has not been well studied in breast-feeding patients. Some women may decline to take medications if they are breast-feeding out of concern for the baby’s exposure via breast milk and prefer to try nonpharmacologic approaches first. Many mothers with PPD need to be reassured that stopping breast-feeding may be exactly what is needed if the experience is contributing to their PPD or making them uncomfortable accepting pharmacotherapy when indicated. Maternal mental health is more important than breast-feeding to the health and wellness of the mother-baby dyad.

Table 2

Considerations for antidepressant use during breast-feeding

The psychiatrist’s role

PPD has great public health significance because it affects a large number of women and their families. Screening during obstetrical visits or in other settings may increase identification of women who are suffering from PPD. In order for this screening to lead to meaningful changes, women must receive timely and expert evaluations for PPD and treatment that is efficacious and accessible.

Diagnosis and treatment: 4 pearls

Verify the diagnosis. Many women who present with postpartum depressive symptoms may have previously unrecognized bipolar disorder, and many women presenting with a primary complaint of anxiety have PPD.^33,34

Discuss breast-feeding. This topic is important in assessing the risks and benefits of antidepressants in postpartum women, but many women also experience breast-feeding as a topic with emotional valence of its own and may need support with infant feeding.

Meet the patient where she is. Patient preferences strongly influence PPD treatment decisions. Women with similar clinical presentations may have strong preferences for different treatments.

Make treatment accessible. Postpartum women may find it challenging to engage in treatment. Treatment plans need to be feasible for women who are depressed while caring for a newborn. On-site childcare, home visits, Internet communication, and other accommodations that may facilitate treatment should be considered at a systems level.

Related Resources

• American College of Obstetricians and Gynecologists. Screening for depression during and after pregnancy. www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Screening_for_Depression_During_and_After_Pregnancy.
  
• Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci. 2011;13(1):89-100.
  
• Dennis CL, Stewart DE. Treatment of postpartum depression, part 1: a critical review of biological interventions. J Clin Psychiatry. 2004;65(9):1242-1251.
  
• Dennis CL. Treatment of postpartum depression, part 2: a critical review of nonbiological interventions. J Clin Psychiatry. 2004;65(9):1252-1265.
  
• Cohen LS, Wang B, Nonacs R, et al. Treatment of mood disorders during pregnancy and postpartum. Psychiatr Clin North Am. 2010;33(2):273-293.
  

• Bupropion • Wellbutrin, Zyban
  
• Citalopram • Celexa
  
• Desvenlafaxine • Pristiq
  
• Duloxetine • Cymbalta
  
• Escitalopram • Lexapro
  
• Fluoxetine • Prozac
  
• Fluvoxamine • Luvox
  
• Mirtazapine • Remeron
  
• Nefazodone • Serzone
  
• Nortriptyline • Aventyl, Pamelor
  
• Paroxetine • Paxil
  
• Sertraline • Zoloft
  
• Venlafaxine • Effexor
  

Dr. Joffe has received grant or research support from Cephalon/Teva, and is a consultant to Noven and Sunovion.

Dr. Cohen has received research support from AstraZeneca, Bayer HealthCare Pharmaceuticals, Bristol-Myers Squibb, Forest Laboratories, GlaxoSmithKline, National Institute of Mental Health, National Institute on Aging, National Institutes of Health, Ortho-McNeil Janssen, and Pfizer and has served on an advisory board for PamLab LLC.

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Postpartum depression (PPD)—emergence of a major depressive episode after childbirth—has broad negative consequences for the mother, baby, and other family members. The time of onset after delivery for a depressive episode to be considered postpartum is debatable, but the DSM-IV-TR specifier states that onset within 4 weeks of childbirth is considered postpartum. PPD can impact many aspects of child development, including mother-infant attachment, cognitive development, and behavior.^1-3

An estimated 10% of women who have given birth experience PPD.^4,5 The risk of PPD is particularly high among women who have had previous episodes of PPD or major depressive disorder (MDD). Other risk factors include stressful life events, depression and/or anxiety during pregnancy, family history of PPD, and obstetrical complications.^6-8 Anxiety disorders are common in postpartum women, and anxiety symptoms often are prominent in PPD.⁹

Despite the prevalence of PPD and its serious consequences, few studies have addressed antidepressant treatment. In this article we discuss screening and treating PPD and considerations for breast-feeding mothers. Click here for results of an open-label trial of escitalopram for PPD we conducted in which patient recruitment was challenging.

Screening for PPD: A good start

Initiatives by state governments and health care providers have led to programs in which universal screening for PPD has been implemented. Screening provides a mechanism for early detection and intervention. The Edinburgh Postnatal Depression Scale¹⁰ is a self-rated, 10-item scale developed for the postpartum setting, and its use increases identification of PPD at postpartum obstetrics visits.¹¹ Other screening tools such as the Patient Health Questionnaire-9 also are commonly used. Despite the success of screening programs in attempting the feasibility of screening, it is unclear if the identification of women who may be experiencing PPD increases their engagement in treatment. Studies have demonstrated that even when depressive symptoms suggesting a PPD episode are identified in the postpartum period, many women still do not receive treatment.^12,13 Studies of PPD screening programs have not demonstrated that screening itself improves treatment engagement or improves outcomes.^12,13

Psychotherapy: An effective option

Psychotherapy is an important first-line option for PPD, particularly because of considerations of medication exposure during breast-feeding and many women are reluctant to take antidepressants while breast-feeding.¹⁶ Interpersonal psychotherapy and cognitive-behavioral therapy (CBT) have been most studied for PPD, and both appear effective for prevention and acute treatment of PPD.^17-20 Although psychotherapy alone may be sufficient for some women, for others, medication may be an important first-line treatment, depending on symptom severity, access to psychotherapy, and personal preference.

Evidence for antidepressants

Randomization to placebo is rare in PPD trials. Most trials have used open-label designs because placebo arms pose ethical dilemmas considering the impact of PPD on a mother and her baby. In a randomized study of sertraline or nortriptyline for PPD, both drugs were similarly efficacious.²² In another study comparing paroxetine monotherapy and paroxetine plus CBT for PPD, both groups experienced significant improvement in depression and anxiety symptoms, with no difference between groups at endpoint.²³ Open-label trials have suggested antidepressants’ efficacy, although some studies have included small sample sizes (Table 1).^20-27

Table 1

Antidepressants for PPD: Summary of the evidence

Breast-feeding considerations

From a nutritional standpoint, breast-feeding is optimal for a newborn. However, for some women, breast-feeding is difficult and stressful, and new mothers may experience this difficulty as failure. Some women prefer not to breast-feed, and others may prefer to formula feed if they require pharmacotherapy, particularly if the medication has not been well studied in breast-feeding patients. Some women may decline to take medications if they are breast-feeding out of concern for the baby’s exposure via breast milk and prefer to try nonpharmacologic approaches first. Many mothers with PPD need to be reassured that stopping breast-feeding may be exactly what is needed if the experience is contributing to their PPD or making them uncomfortable accepting pharmacotherapy when indicated. Maternal mental health is more important than breast-feeding to the health and wellness of the mother-baby dyad.

Table 2

Considerations for antidepressant use during breast-feeding

The psychiatrist’s role

PPD has great public health significance because it affects a large number of women and their families. Screening during obstetrical visits or in other settings may increase identification of women who are suffering from PPD. In order for this screening to lead to meaningful changes, women must receive timely and expert evaluations for PPD and treatment that is efficacious and accessible.

Diagnosis and treatment: 4 pearls

Verify the diagnosis. Many women who present with postpartum depressive symptoms may have previously unrecognized bipolar disorder, and many women presenting with a primary complaint of anxiety have PPD.^33,34

Discuss breast-feeding. This topic is important in assessing the risks and benefits of antidepressants in postpartum women, but many women also experience breast-feeding as a topic with emotional valence of its own and may need support with infant feeding.

Meet the patient where she is. Patient preferences strongly influence PPD treatment decisions. Women with similar clinical presentations may have strong preferences for different treatments.

Make treatment accessible. Postpartum women may find it challenging to engage in treatment. Treatment plans need to be feasible for women who are depressed while caring for a newborn. On-site childcare, home visits, Internet communication, and other accommodations that may facilitate treatment should be considered at a systems level.

Related Resources

• American College of Obstetricians and Gynecologists. Screening for depression during and after pregnancy. www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Screening_for_Depression_During_and_After_Pregnancy.
  
• Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci. 2011;13(1):89-100.
  
• Dennis CL, Stewart DE. Treatment of postpartum depression, part 1: a critical review of biological interventions. J Clin Psychiatry. 2004;65(9):1242-1251.
  
• Dennis CL. Treatment of postpartum depression, part 2: a critical review of nonbiological interventions. J Clin Psychiatry. 2004;65(9):1252-1265.
  
• Cohen LS, Wang B, Nonacs R, et al. Treatment of mood disorders during pregnancy and postpartum. Psychiatr Clin North Am. 2010;33(2):273-293.
  

• Bupropion • Wellbutrin, Zyban
  
• Citalopram • Celexa
  
• Desvenlafaxine • Pristiq
  
• Duloxetine • Cymbalta
  
• Escitalopram • Lexapro
  
• Fluoxetine • Prozac
  
• Fluvoxamine • Luvox
  
• Mirtazapine • Remeron
  
• Nefazodone • Serzone
  
• Nortriptyline • Aventyl, Pamelor
  
• Paroxetine • Paxil
  
• Sertraline • Zoloft
  
• Venlafaxine • Effexor
  

Dr. Joffe has received grant or research support from Cephalon/Teva, and is a consultant to Noven and Sunovion.

Dr. Cohen has received research support from AstraZeneca, Bayer HealthCare Pharmaceuticals, Bristol-Myers Squibb, Forest Laboratories, GlaxoSmithKline, National Institute of Mental Health, National Institute on Aging, National Institutes of Health, Ortho-McNeil Janssen, and Pfizer and has served on an advisory board for PamLab LLC.