Salivary Cortisol Awakening Response as a Predictor for Depression Severity in Adult Patients with a Major Depressive Episode Performing a Daily Exercise Program

<b><i>Introduction:</i></b> The hypothalamic-pituitary-adrenal axis function in depression has been the subject of considerable interest, and its function has been tested with a variety of methods. We investigated associations between saliva cortisol at awakening and the 24-h urine cortisol output, both measured at study baseline, with endpoint depression scores. <b><i>Methods:</i></b> Patients were admitted to a psychiatric inpatient ward with a major depressive episode and were started on fixed duloxetine treatment. They delivered saliva samples at awakening and 15, 30, and 60 min post-awakening and sampled urine for 24 h. Subsequently, they started a daily exercise program maintained for a 9-week period. Clinician-rated depression severity was blindly assessed with the Hamilton Depression Rating 6-item subscale (HAM-D₆). The cortisol awakening response was quantified by the area under the curve with respect to the ground (AUC_G) and with respect to the rise (AUC_I) using saliva cortisol levels in the 1-h period after awakening. Analysis of expected associations between depression severity, AUC_G, AUC_I, exercise, and 24-h cortisol output was performed in a general linear model. <b><i>Results:</i></b> In all, 35 participants delivered saliva or 24-h urine samples. The mean age was 49.0 years (SD = 11.0) with 48.6% females with a mean baseline HAM-D₆ score of 12.2 (SD = 2.3). In a statistical model investigating the association between HAM-D₆ at week 9 as a dependent variable and AUC_I, concurrent HAM-D₆, gender, smoking, and exercise volume as covariates, we found a significant effect of AUC_I, concurrent HAM-D₆, and exercise. The following statistics were found: AUC_I (regression coefficient 0.008; <i>F</i> value = 9.1; <i>p</i> = 0.007), concurrent HAM-D₆ (regression coefficient 0.70; <i>F</i> value = 8.0; <i>p</i> = 0.01), and exercise (regression coefficient −0.005; <i>F</i> value = 5.7; <i>p</i> = 0.03). The model had an <i>R</i>² of 0.43. The association between HAM-D₆ endpoint scores and the AUC_I showed that higher AUC_I values predicted higher HAM-D₆ endpoint values. The association between HAM-D₆ endpoint scores and the exercise level showed that a high exercise level was associated with lower HAM-D₆ endpoint values. <b><i>Conclusion:</i></b> The results thus showed that high AUC_I values predicted less improvement of depression and high exercise levels predicted more improvement of depression. These findings need to be confirmed in larger samples to test if more covariates can improve prediction of depression severity.

Individual Factors Underlying Suicidal Behaviors in Patients with Borderline Personality Disorder: A Qualitative Study

Background: Borderline personality disorder (BPD) is associated with a high risk of suicide. Limited information is available on the individual factors underlying suicidal behaviors, especially suicide attempts (SAs), in Iranian patients with BPD. Objectives: This study aimed to analyze the individual factors underlying suicidal behaviors in patients with BPD. Methods: This was a qualitative descriptive study that was conducted from May 2020 to February 2021 in Tehran and Karaj, Iran, on 23 participants, including 14 patients with BPD and seven mental health professionals, as well as two members of their families. The research environment included psychiatric inpatient wards, psychiatric emergencies, and psychiatric clinics. Participants were selected through purposive sampling. Data were collected using semi-structured interviews and were analyzed using conventional content analysis. Results: Data analysis revealed five main themes and 15 sub-themes related to the individual factors underlying the identification and prediction of the risk for suicidal behaviors and SAs. The extracted themes included “psychological pain and loneliness”, “defects in the distinction and integration of emotions”, “unconventional behavior and emotion”, “pervasive incompatibility”, and “breakdown of the self-integrity”. Conclusions: The BPD is a complex and challenging disorder in which patients with BPD usually tend to engage in suicidal behaviors, and with the emergence of individual factors underlying the occurrence of such behaviors, appropriate preventive measures and interventions can be taken to reduce suicide-related behaviors such as suicidal thoughts and planning, as well as SAs.

Reliability And Validity of The Psychiatric Inpatient Patient Experience Questionnaire – Continuous Electronic Measurement (PIPEQ-CEM)

BackgroundThe increasing emphasis on patient-centred care has accelerated the demand for high-quality assessment instruments, but the development and application of measures of the quality of care provided for mental health have lagged behind other areas of medicine. The main objective of this study was to determine the psychometric properties of the Psychiatric Inpatient Patient Experience Questionnaire – Continuous Electronic Measurement (PIPEQ-CEM), which consists of large-scale measurements from a Norwegian population. The change from cross-sectional surveys to continuous measurements necessitated further validation of the instrument. The secondary objective was to develop a short version of the PIPEQ-CEM. MethodsThe data included responses from the first year of continuous measurement, and included adult inpatients (age ≥18 years) who received specialized mental healthcare from 191 different sections in Norway (n=3,249). Missing data, ceiling effects, factor structure and internal consistency levels were assessed. The short scale was developed by exploring missing items, ceiling effects, results from exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), and item performance from item response theory (IRT) analyses.Results Psychometric testing supported previous results and illustrated that the PIPEQ-CEM comprises three empirically based scales with good internal consistency, reliability and validity, and covers structure and facilities, patient-centred interactions, and outcomes. A seven-item short form was developed, which provides an efficient approach for brief yet comprehensive measurements that can be applied in the future. ConclusionThe PIPEQ-CEM can be recommended for use in future national surveys that assess patient experience with inpatient psychiatric care in Norway and in other countries with similar healthcare systems. The short form can be applied where respondent burden and cognitive load are crucial issues. The obtained results illustrate the detailed information about an instrument that can be obtained using a combination of EFA, CFA and IRT.

Demographic and clinical factors associated with psychiatric inpatient admissions during the COVID-19 pandemic

Objective: The COVID-19 pandemic may cause a major mental health impact. We aimed to identify demographic or clinical factors associated with psychiatric admissions where COVID-19 was attributed to contribute to mental state, compared to admissions which did not. Methods: A retrospective cohort study was undertaken of inpatients admitted to Northern Psychiatric Unit 1, Northern Hospital in Melbourne, Victoria, Australia during 27/02/2020 to 08/07/2020. Data were extracted for participants who identified COVID-19 as a stressor compared to participants who did not. Fisher’s exact test and Mann-Whitley rank sum test were used. Results: Thirty six of 242 inpatients reported the COVID-19 pandemic contributed to mental ill health and subsequent admission. Reasons given included social isolation, generalized distress about the pandemic, barriers to support services, disruption to daily routine, impact on employment, media coverage, re-traumatization, cancelled ECT sessions, loss of loved ones, and increased drug use during the lockdown. Chronic medical conditions or psychiatric multimorbidity were positively associated and smoking status was negatively associated with reporting the COVID-19 pandemic as a contributor to mental ill health. Conclusion: Screening and identifying vulnerable populations during and after the global disaster is vital for timely and appropriate interventions to reduce the impact of the pandemic worldwide.

Influence of Depression and Personality on Social Functioning in Older Adults

Among older adults there is significant comorbodity between depression and personality pathology and both are associated with poorer social functioning. Personality pathology is associated with greater prevalence, poorer recovery, and a higher likelihood of recurrence of depression in older adults. This study is a secondary analysis examining the relationships between personality traits associated with personality pathology (i.e. high neuroticism and low agreeableness), depression, and social functioning across older adults surveyed in primary care and psychiatric inpatient settings (N = 227). Individual variable as well as interaction models were examined. Higher neuroticism (FChange [1,217] = 40.119, p &lt; .001), lower agreeableness (FChange [1,217] = 20.614, p &lt; .001), and clinical status (i.e. primary care vs. psychiatric inpatient) (FChange [1,217] = 19.817, p &lt; .001) were associated with poorer social functioning. Clinical status moderated the relationships between neuroticism and social functioning (B = -.0147, p = . 0341) and between agreeableness and social functioning (B = .0268, p = .0015). Interaction effects were not observed between neuroticism and depression or agreeableness and depression as they relate to social functioning. However, depression severity was observed to mediate the relationship between neuroticism and social functioning [Indirect effect = .0212, 95% CI = .0141, .0289]. These findings highlight the importance of accounting for depression and clinical status in the assessment and treatment of older adults with personality pathology. Findings warrant future research focused upon mechanisms through which personality pathology and depression influence functional status in older adults.

Risk Assessment of Electroconvulsive Therapy in Clinical Routine: A 3-Year Analysis of Life-Threatening Events in More Than 3,000 Treatment Sessions

Background: Extensive research has reported that electroconvulsive therapy (ECT) can be highly effective in approximately 80% of patients suffering from depression. Its clinical use is mainly limited by historical objections and the concern about unwanted adverse effects (AEs), including serious and potentially life-threatening adverse events (pLTAEs), induced either by ECT or by anesthesia. Objective risk estimation is, therefore, a decisive factor in determining an indication for ECT.Methods: This paper presents a retrospective analysis of 3-year safety protocols and patient files of 157 patients who received a total of 3,106 ECT applications in a psychiatric inpatient setting at a psychiatric community hospital. This patient group comprises 5.3% of inpatients admitted with comparable diagnoses. Adverse events were analyzed from standardized safety protocols and patient files with a focus on pLTAEs.Results: Adverse events were reported for 30 (19.1%) of the 157 participants during 39 (6.1%) of 641 hospital stays. Serious pLTAEs occurred during three electroconvulsive stimulations in three patients, who needed action through the administration of medication or mechanical respiration. No patient suffered permanent damage to health, and no patient died. The incidence of these and other AEs was independent of sex, age, and diagnosis of patients, and anesthesia medication. Minor AEs occurred more often with higher stimulus doses and an increasing number of treatments.Conclusion: The low incidence rate of 0.097% of serious pLTAEs that require medical action may allow the conclusion that ECT is a rather safe treatment when performed in a controlled setting. The beneficial risk profile of ECT performed in the standard care of psychiatric hospitals suggests a more generous indication of this treatment method. We recommend that ECT facilities collect individual safety data to allow a reliable judgment of their institutional ECT risk profile.

An Overview on Borderline Personality Disorder

Borderline Personality Disorder (BPD) is a psychiatric disease marked by unstable interpersonal relationships, fear of abandonment, difficulty regulating emotions, feelings of emptiness, persistent dysphoria or sadness, impulsivity, and increased risk-taking behaviors. The prevalence of borderline personality disorder has been reported at 11 percent in the psychiatric outpatient community and as high as 20% in the psychiatric inpatient population. Patients with BPD have a high rate of morbidity, which makes medical treatment more difficult. Although the role of genetics in BPD is unclear, inheritance of BPD appears to be considerable. Life events are also found to play a role in the development of BPD. The most important risk factor for the development of BP is childhood trauma. Symptoms that have been present since adolescence or early adulthood and manifest in a variety of settings are used to make the diagnosis. There are no lab or imaging tests available to aid in the diagnosis. Patients with borderline personality disorder benefit from three evidence-based treatments. Mentalizing-based therapy (MBT). Dialectical behavior therapy (DBT) and transference-focused psychotherapy (TFP). In this review we will be discussing epidemiology, etiology, clinical features diagnosis and treatment of BPD.