Psychosomatics 46:153-186, April 2005
© 2005 The Academy of Psychosomatic Medicine
Academy of Psychosomatic Medicine: Proceedings From the 51st Annual Meeting
November 18–21, 2004, Marco Island, Florida
Abstracts
Scientific Poster Session
1. Major Depression, Adjustment Disorders, and Posttraumatic Stress Disorder in Terminally Ill Cancer Patients: Associated and Predictive Factors
T. Akechi, MD, PhD; T. Okuyama, MD, PhD; Y. Sugawara, MD; T. Nakano, MD; Y. Shima, MD; Y. Uchitomi, MD, PhD
Background: Few studies have examined the psychological distress of terminally ill cancer patients. This study attempted to determine the prevalence of adjustment disorder, major depression, and posttraumatic stress disorder (PTSD) among terminally ill cancer patients, to identify factors that contribute to these disorders, and to determine how they change longitudinally. Methods: Consecutive terminally ill cancer patients were recruited. Patients were assessed for psychiatric disorders by structured clinical interview at the time of their registration with a palliative care unit (PCU) (baseline) and again at the time of their PCU admission (follow-up). Biomedical and psychosocial factors that could contribute to psychiatric disorders were evaluated. Results: The proportions of patients (N=209) who received a diagnosis of adjustment disorder, major depression, and PTSD at baseline were 16.3%, 6.7%, and 0%, respectively. Of the patients evaluated at follow-up (N=85), 10.6% received a diagnosis of adjustment disorder and 11.8% received a diagnosis of major depression. Lower performance status, concern about being a burden to others, and lower satisfaction with social support were significantly associated with adjustment disorder and major depression at baseline. From baseline to follow-up, changes in the diagnosis of adjustment disorder and major depression occurred in 30.6% of the patients. Only the baseline Hospital Anxiety and Depression Scale score was significantly predictive of adjustment disorder and major depression at follow-up. Conclusions: The factors underlying psychological distress are multifactorial. Early intervention to treat subclinical anxiety and depression may prevent subsequent psychological distress.
References
1. Block SD: Assessing and managing depression in the terminally ill patient. Ann Intern Med 2000; 132: 209–218
2. Gurevich M, Devins GM, Rodin GM: Stress response syndromes and cancer: conceptual and assessment issues. Psychosomatics 2002; 43:259–281[Abstract/Free Full Text]
2. Multicenter Study of Alcohol and Substance Use in Liver Transplant Candidates
T.P. Beresford, MD, FAPM; A. DiMartini, MD, FAPM; B. Martin, BA; J. Alfers, BA; L. Clapp, MS, RN
Background: Liver transplant centers face an increasing number of transplant candidates with comorbid substance use disorders. As these patients often require posttransplant care specific to their substance use, it is important for clinicians to know patients’ substance use histories. In the interest of finding out which substances are being used by liver transplant candidates, the authors surveyed candidates at three transplant centers to obtain details about their current and past substance use. Methods: Questionnaires were mailed to subjects on transplant waiting lists at three sites: University of Colorado, University of Pittsburgh, and Mount Sinai Medical Center (MSMC). Results: A total of 120 subjects filled out questionnaires: 44 at the Colorado site, 46 at the Pittsburgh site, and 30 at MSMC. Eighty-nine (74%) subjects reported ever using a substance of abuse (Table 1). Of subjects reporting past alcohol use (N=75), 36 (48%) reported having used at least one other substance. Conclusions: The most common substances used in this group of liver transplant candidates were alcohol, cigarettes, and tetrahydrocannabinol. These findings were consistent across all three sites. As many as one-third of liver transplant candidates are likely to report polysubstance use or abuse.
References
1. Beresford TP: The neuropsychiatry of liver and other solid organ transplantation. Liver Transpl 2001; 7(suppl):S36-S45
2. Beresford TP: The limits of philosophy in liver transplantation. Transpl Int 2001; 14:176–179[CrossRef][Medline]
3. Alcohol and Tobacco Use in Liver Transplant Candidates: A Multicenter Study
T.P. Beresford, MD, FAPM ; A. DiMartini, MD, FAPM; B. Martin, BA; J. Alfers, BA; L. Clapp, MS, RN
Background: Liver transplant centers face an increasing number of transplant candidates with comorbid alcohol, tobacco, and other substance use disorders. Both alcohol and tobacco use can increase posttransplant mortality. The authors hypothesized that less frequent alcohol use would characterize primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) cases versus all other liver pathologies (hepatitis C virus, hepatitis B virus, alcoholic cirrhosis, cryptogenic cirrhosis). Methods: Questionnaires were given to subjects on transplant waiting lists at three sites: University of Colorado, University of Pittsburgh, and Mount Sinai Medical Center (MSMC). Results: A total of 120 subjects provided responses: 44 at the Colorado site, 46 at the Pittsburgh site, and 30 at MSMC. Eighty-nine (74%) subjects reported ever using a substance of abuse. Of subjects reporting past alcohol use (N=75), 36 (48%) reported having used at least one other substance. Only cigarette use distinguished subjects with PBC and PSC from subjects with all other liver pathologies over all time periods: lifetime (Table 1), within the last year (3% versus 22%; p<0.01, odds ratio=8.5), and within the last month (3% versus 18%; p<0.05, odds ratio=6.9). Conclusions: Although alcohol use was common among all diagnostic categories, tobacco presented significantly greater risk for recent use while awaiting transplant among subjects for whom alcohol disorders were more likely to have resulted in liver pathology. This finding suggests a possible substitution of nicotine for alcohol in these cases.
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TABLE 1. Lifetime Use of Substances by Liver Transplant Candidates (N=120) With Primary Biliary Cirrhosis (PBC) or Primary Sclerosing Cholangitis (PSC) and With All Other Livers Pathologies
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References
1. Beresford TP: The neuropsychiatry of liver and other solid organ transplantation. Liver Transpl 2001; 7(suppl):S36-S45
2. Beresford TP: The limits of philosophy in liver transplantation. Transpl Int 2001; 14:176–179
4. Drinking and Hepatitis C Virus Transmission Risk in Liver Transplant Candidates: Cross-Center Data
T.P. Beresford, MD, FAPM; A. DiMartini, MD, FAPM; B. Martin, BA; J. Alfers, BA; L. Clapp, MS, RN
Background: Previous studies have reported that the prevalence of hepatitis C virus (HCV) is seven to 10 times greater among alcohol-dependent persons than in the general population, supposedly because of parenteral viral transmission. However, the great majority of alcohol-dependent persons do not use drugs parenterally. The authors examined risk factors for HCV among persons applying for liver transplantation. Methods: A total of 120 patients awaiting liver transplant in Denver, New York, and Pittsburgh were surveyed with a questionnaire that assessed substance use, HCV infection and possible exposure routes, and basic demographic characteristics. A total of 109 (91%) subjects provided data on both HCV status and alcohol use. These subjects were grouped by whether they never (N=36) versus ever (N=73) had drunk alcohol and by risk factors for HCV. High-risk subjects reported having 1) contact with a contaminated needle, 2) a blood transfusion before 1990, 3) tattoos, or 4) acupuncture treatments. Low-risk subjects reported none of these factors. Results: In the alcohol use group, 41 (56%) subjects were high-risk subjects and 32 (44%) were low-risk subjects. In the group with no alcohol use, 16 (44%) subjects were high-risk subjects and 20 (56%) were low-risk (n.s., chi-square test). Drinking status predicted HCV status in low-risk subjects (p<0.01, Fisher’s exact test). Low-risk alcohol users were 8.6 times more likely to be HCV-positive than nondrinkers (95% confidence interval=1.0–73.8) (Table 1). Alcohol use did not exert a differential effect among high-risk subjects. For nondrinkers, high risk status accounted for all but one HCV case (p=0.001, Fisher’s exact test, odds ratio=15). Among drinkers, high risk status did not exert a statistical effect. Conclusions: These data suggest that up to one-third of low-risk drinkers contract HCV through routes of infection that are unexplained. It is also possible that heavy, sustained drinking confers a vulnerability to HCV that route of infection alone cannot explain.
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TABLE 1. Hepatitis C Virus (HCV) Status and History of Alcohol Use Among Liver Transplant Candidates at Low Risk for HCV (N=52)a
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References
1. Beresford TP: The neuropsychiatry of liver and other solid organ transplantation. Liver Transpl 2001; 7(suppl): S36-S45
2. Beresford TP: The limits of philosophy in liver transplantation. Transpl Int 2001; 14:176–179
5. Prevalence and Demographics of Prescription Opioid-Related Admissions to a University Teaching Hospital
J.A. Berman, MD; J. Matthews, BS; J. Korvach, BS; C.E. Skotzko, MD, FAPM; B. Sussner, PhD; R. Chong, MD
Objective: The goal of the study was to examine the prevalence of and demographic characteristics associated with admission related to prescription opioid medication use among patients at a tertiary care university-affiliated teaching hospital. Background: Findings of the 2002 National Survey on Drug Use and Health and data from the Drug Abuse Warning Network revealed a significant increase in the nonmedical use of prescription medications over the past decade. Increased admissions related to use of pain medications such as hydromorphone, oxycodone, and fentanyl have been especially alarming. Although the problem has been well documented at the national level, local and regional data are essential to characterize populations at risk and formulate specific interventions for this growing problem. Methods: The medical records of all patients admitted to Robert Wood Johnson University Hospital in New Brunswick, N.J., for opioid-related diagnoses in 2002 were reviewed and divided into two opioid categories: heroin and prescription opioid medications. Patient characteristics examined included gender and length of hospitalization. Independent sample t tests were used to identify any significant differences between the two opioid groups. Results: Of the 89 patients admitted for opioid-related diagnoses for whom complete drug use data were available, 31 (34.8%) were admitted for use of an opioid other than heroin. These results are consistent with national data. They represent a significant prescription opioid abuse problem among patients admitted to this hospital. There were no significant differences between men and women in type of drug used (t=–0.91, df=78, p=0.37) (two-tailed) or average length of stay (t=0.95, df=78, p=0.34) (two-tailed). The average length of stay was significantly longer for the patients with prescription opioid use (mean=2.65 days, SD=3.02) than for the patients who were heroin users (mean=1.22 days, SD=1.01) (t=–3.27, df=87, p=0.002) (two-tailed). Discussion and Conclusions: Prescription opioids are most often obtained by prescription for legitimate medical reasons. Addiction and nonmedical use are unforeseen and unanticipated consequences. Opioid medications can play an important role in pain management, but clinicians must always be aware of the potential for abuse and dependence that can be equally as devastating as that commonly associated with illicit opioids such as heroin. However, no treatment protocols and programs have been developed to address the needs of prescription opioid abusers who often suffer comorbid pain disorders. The results of this study suggest that 1) further research is needed to determine differences in length of use and comorbid medical and psychiatric disorders in prescription opioid abusers, and 2) there is a need for targeted psychosocial and biological interventions specifically for prescription medication abuse. These interventions should take into account the unique position that prescription opioid medications play as both medically necessary drugs and potential drugs of abuse and misuse.
References
1. Overview of Findings From the 2002 National Survey on Drug Use and Health. DHHS Publication No (SMA) 03–3774, NHSDA Series H-21. Rockville, Md, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2003
2. Emergency Department Trends From the Drug Abuse Warning Network, Final Estimates 1995–2002. DHHS Publication No (SMA) 03–3780, DAWN Series D-24. Rockville, Md, Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2003
6. The Distinction Between Demoralization and Anhedonia in People With Terminal Illness
D.M. Clarke, MBBS, PhD, MAPM; D. Kissane, MD; G.C. Smith, MD, FAPM; T. Trauer, PhD
Depressive states are common in medically ill patients, but they are ill-defined. In a replication of a previous study, the authors examined the latent structure of depressive symptoms in patients with terminal cancer (N=137) and patients with motor neuron disease (N=134). Factor analysis of symptoms revealed distinct dimensions of anhedonia and demoralization. Anhedonia was characterized by the loss of interest and pleasure in usual activities and by social withdrawal. Demoralization was characterized by despondency, helplessness, hopelessness, despair, feelings of being unable to cope, and wishing not to be alive. Demoralization scores were significantly higher in the motor neuron disease group, and higher demoralization scores were associated with younger age, an avoidance and confrontation style of coping, and lower levels of family cohesion and relational support. Anhedonia scores were higher in the cancer group, and higher anhedonia scores were associated with worse physical functioning, resignation, and absence of a belief in God. Both anhedonia and demoralization were associated with trait anxiety and a past history of psychiatric problems.
References
1. Clarke DM, Kissane DW: Demoralization: its phenomenology and importance. Aust N Z J Psychiatry 2002; 36:733–742[CrossRef][Medline]
2. Fava GA, Freyberger HJ, Bech P, Christodoulou G, Sensky T, Theorell T, Wise TN: Diagnostic criteria for use in psychosomatic research. Psychother Psychosom 1995; 63:1–8[Medline]
7. A Comparison of Psychosocial and Physical Functioning in Patients With Motor Neuron Disease and Metastatic Cancer
D.M. Clarke, MBBS, PhD, MAPM; G.C. Smith, MD, FAPM; T. Trauer, PhD
A comparison was made of 134 patients with motor neuron disease recruited from specialist neurology centers and 137 patients with metastatic cancer recruited at referral to palliative care services. Although depression scores were similar in the two groups, the patients with motor neuron disease were significantly more demoralized and the cancer patients were significantly more anhedonic. Compared with the cancer patients, the patients with motor neuron disease overall were of slightly younger age, had worse physical functioning, had less pain, and had more social support. They also had greater resignation, hopelessness, and suicidal ideation than cancer patients. Global functioning as measured by the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12) was more impaired in the patients with motor neuron disease.
References
1. Centers AC: Beyond denial and despair: ALS and our heroic potential for hope. J Palliat Care 2001; 17:259–264[Medline]
2. Ming KE, Goldstein LN, Leigh PN: The psychological impact of motor neuron disease. Psychol Med 1994; 24:625–632[Medline]
8. Selective Serotonin Reuptake Inhibitors for Patients With Metastatic Carcinoid Disease: Report of Three Cases
T.J. Dolenc, MD; M.D. Williams, MD
Background: Carcinoid tumors originate from the neuroendocrine cells throughout the body and produce various substances, including serotonin. Because depression frequently occurs in patients with metastatic carcinoid tumors, it is not uncommon for a psychiatrist to be asked to recommend an appropriate antidepressant treatment for these patients. Concerns have been expressed about the use of serotonergic agents, such as selective serotonin reuptake inhibitors (SSRIs), in this patient population because of fears that these agents may exacerbate the carcinoid syndrome symptoms. Methods: The authors conducted a chart review of three patients with metastatic carcinoid tumors whose depression was treated with an SSRI. Two patients, a 64-year-old woman and a 68-year-old man, were treated with 20 mg/day of paroxetine and 40 mg/day of paroxetine, respectively. The third patient, a 75-year-old man, was treated with 20 mg/day of fluoxetine. The carcinoid characteristics and treatment course for each patient were examined, and the patients’ psychiatric history, history of antidepressant treatment, and emergence of side effects with SSRI treatment were determined. Results: None of the three patients experienced significant adverse effects during treatment with an SSRI. One patient, the 64-year-old woman, had long-standing carcinoid syndrome, the symptoms of which did not intensify with paroxetine treatment. Conclusions: The results support the view that SSRIs can be used in patients with metastatic carcinoid disease. Patients with carcinoid disease should be closely followed during SSRI treatment to allow for early detection of adverse medication effects and emergence of carcinoid syndrome symptoms.
References
1. Noyer CM, Schwartz BM: Sertraline, a selective serotonin reuptake inhibitor, unmasking carcinoid syndrome. Am J Gastroenterol 1997; 92:1387–1388[Medline]
2. Major LF, Brown GL, Wilson WP: Carcinoid and psychiatric symptoms. South Med J 1973; 66:787–790[Medline]
9. Citalopram-Induced Diplopia
K. Dorell, MD; M.A. Cohen, MD, FAPM; R.G. Hoffman, MD, FAPM; S. Hupikar, MD; J.M. Gorman, MD
The authors report the case of an HIV-positive woman who developed diplopia that was presumed to result from intake of citalopram, a selective serotonin reuptake inhibitor (SSRI). The rapid resolution of the diplopia after discontinuation of citalopram suggests a correlation between the adverse effect and the drug. The authors found no case reports of citalopram-induced diplopia in the literature, and, to their knowledge, this report is the first report of any ocular side effect with citalopram. The underlying etiology of this event remains unclear but might involve ocular serotonergic interneuronal fibers. It is important to mention that diplopia is one of the neuro-ophthalmic manifestations that can be observed in patients with HIV infection. The etiologic agents of diplopia in HIV-positive patients can be identified with HIV itself, opportunistic pathogens, or other related conditions. The rapid resolution of diplopia after discontinuation of citalopram in this case makes an underlying CNS pathology unlikely. The diagnosis of citalopram-induced diplopia will certainly remain controversial until further evidence of a cause-and-effect relationship emerges in a greater number of patients. However, we believe that patients and physicians should be aware of the potential induction of diplopia by citalopram and other SSRIs. More research is needed on use of psychotropic medications in patients with HIV, because of the multitude of psychiatric diagnoses in this population and possible interactions between psychotropic medications and highly active antiretroviral therapy (HAART).
References
1. Keller MB: Citalopram therapy for depression: a review of 10 years of European experience and data from US clinical trials. J Clin Psychiatry 2000; 61:896–908[Medline]
2. Seminari E, Cocchi L, Antoniazzi E, Giacchino R, Maserati R: Clinical significance of diplopia in HIV infection: assessment of a personal caseload and review of the literature. Minerva Med 1996; 87:515–523[Medline]
10. Effect of Escitalopram on Measures of Fatigue and Pain in Hepatitis C
O.C. Gleason, MD; W.R. Yates, MD, FAPM; M. Philipsen, BA
Background/Objectives: Fatigue is a common problem among patients with hepatitis C virus (HCV). In many patients, fatigue is the presenting symptom prior to diagnosis. Furthermore, fatigue is a troubling side effect of interferon therapy used in the management of HCV and has negative effects on quality-of-life issues. This study examined the effect of escitalopram on measures of quality of life, including energy and fatigue, pain, social functioning, and perceived limitations related to physical health in subjects with HCV. Methods: Study subjects received starting doses of 10 mg/day of escitalopram. Upward dose adjustments were allowed no sooner than 4 weeks into the study. The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) was administered at baseline and at 2, 4, and 8 weeks. Results: Eighteen subjects (12 female subjects and six male subjects) participated in the study. The mean daily dose of escitalopram at endpoint was 13.57 mg. Statistically significant improvements were seen in subscales of the SF-36 assessing energy/fatigue (baseline mean=21.33, endpoint mean=43.33; p<0.01), pain (baseline mean=40.17, endpoint mean=59.17; p<0.006), social functioning (baseline mean=35.83, endpoint mean=62.50; p<0.005), and limitations due to physical health (baseline mean=38.33, endpoint mean=56.67; p<0.02). Conclusions: Escitalopram may have a beneficial effect on symptoms of fatigue and pain and improve perceived social functioning in patients with HCV.
References
1. Dwight MM, Kowdley KV, Russo JE, Ciechanowski PS, Larson AM, Katon WJ: Depression, fatigue, and functional disability in patients with chronic hepatitis C. J Psychosom Res 2000; 49:311–317[CrossRef][Medline]
2. McDonald J, Jayasuriya J, Bindley P, Gonsalvez C, Gluseska S: Fatigue and psychological disorders in chronic hepatitis C. J Gastroenterol Hepatol 2002; 17:171–176[CrossRef][Medline]
11. Delirium Motoric Subtypes
A.K. Gupta, MD; S.M. Saravay, MD, FAPM; P.T. Trzepacz, MD, FAPM; P. Chirayu, MD
Background: Delirium is a common neuropsychiatric disorder, affecting 15%–20% of patients admitted to general hospitals. It has wide-ranging symptoms and a significant effect on morbidity. The existence of "hyperactive," "hypoactive," and "mixed" motoric subtypes of delirium has been widely accepted. However, the proportion of subtypes of delirium varies according to the methods of measurement and the population studied. In addition, the relationship between motoric profiles and other delirium symptoms remains unclear. Methods: The authors retrospectively reviewed the cases of 100 patients with delirium in a general hospital who were rated prospectively with the Delirium Rating Scale (DRS-98) and for whom a clinical judgment of the etiology as definitive, likely, or probable was made during the consultation. This is the initial report from a single site of a multisite study. Statistical Methods: Pearson’s product-moment correlation was used to measure the linear association of "hyperactive" and "hypoactive" subtypes with a set of psychological variables (e.g., mood lability). Means among subgroups of patients were compared with two-sample independent t tests. Results: According to the defined criteria, 36% of patients had the hyperactive subtype, 16% had the hypoactive subtype, and 48% had the mixed subtype. Ratings of hyperactivity were correlated with sleep/wake disturbance (r=0.27, p<0.007) and mood lability (r=0.27, p<0.007). Ratings of hypoactivity were correlated with language disturbance (r=0.32, p<0.003). Despite the small number of subjects in the analysis of the relationship between etiologies and motoric subtypes, comparison of the means with t tests indicated some trends toward hyperactive symptoms in patients with drug intoxication/withdrawal and hypoactive symptoms in patients with metabolic disturbances, systemic infections, and organ insufficiency.
References
1. Meagher DJ, Trzepacz PT: Motoric subtypes of delirium. Semin Clin Neuropsychiatry 2000; 5:75–85[Medline]
2. Meagher DJ, O’Hanlon D, Trzepacz PT: Relationship between symptoms and motoric subtype of delirium. J Neuropsychiatry Clin Neurosci 2000; 12:51–56[Abstract/Free Full Text]
3. Camus V, Gonthier R, Dubos G, Schwed P, Simeone I: Etiologic and outcome profiles in hypoactive and hyperactive subtypes of delirium. J Geriatr Psychiatry Neurol 2000; 13:38–42[Abstract/Free Full Text]
12. Knowledge and Beliefs About Tuberculosis Among First-Degree Relatives of Tuberculosis Patients
A. Ilgazli, MD; A. Çorapçio lu, MD; O. Tümer, MD; M. Ozkan, MD
Background: Knowledge and beliefs about tuberculosis among people without the disease could vary in different populations. In particular, false beliefs about the nature of the disease may result in social isolation and psychological problems in tuberculosis patients. To explore this issue, the authors examined knowledge and beliefs about tuberculosis among first-degree relatives of tuberculosis patients. Methods: A questionnaire including questions on knowledge and beliefs about tuberculosis was filled out by 496 first-degree relatives of tuberculosis patients. Results: The 496 subjects included 240 male subjects (48.3%) and 256 female subjects (51.7%) with a mean age of 40.6 years (SD=14.8, range=14–87); 23.4% did not know that tuberculosis is spread through droplet infection, 17.4% did not believe that tuberculosis is a treatable disease, 42.5% believed that contagiousness continued even though the patient is receiving regular treatment, 70.4% believed that good nutrition is more effective than medications in treating the disease, 57.7% said they would be uncomfortable if they had to travel a long way in a bus near a patient, 38.5% said they would be uncomfortable if they had to live in a neighborhood near to a patient, 66.3% said they would not have their hair cut by a barber who had tuberculosis, and 53.8% said they would be uncomfortable if they had to work in the same room with a patient.
References
1. Ali SS, Rabbani F, Siddiqui UN, Zaidi AH, Sophie A, Virani SJ, Younus NA: Tuberculosis: do we know enough? a study of patients and their families in an out-patient hospital setting in Karachi, Pakistan. Int J Tuberc Lung Dis 2003; 7:1052–1058[Medline]
2. Liefooghe R, Baliddawa JB, Kipruto EM, Vermeire C, De Munynck AO: From their own perspective: a Kenyan community’s perception of tuberculosis. Trop Med Int Health 1997; 2:809–821[CrossRef][Medline]
13. Diabetes and Lipid Profile Risks With Neuroleptics: Reanalysis of 2–5-Year Outcome
R.C. Joseph, MD, FAPM; N. Danforth, MD; G.S. Goren, MD; M. Kardos, MD; A.R. Szekely, BA; R.J. Steingard, MD; K.J. Rosenquist, BS; G. Wyshak, PhD; D.J. Hsu, BS; T.B. Pardo, AB; S.N. Ghaemi, MD
Objective: The goal of the study was to assess risk of diabetes or hypercholesterolemia with conventional versus atypical neuroleptics. Methods: The authors performed a cross-sectional assessment of hemoglobin A1c, fasting blood sugar (FBS), and lipid profile values in patients with bipolar disorder (32%) and schizophrenic disorders (68%) who received antipsychotic monotherapy for  3 months. Assessments were made in patients receiving clozapine (N=31), olanzapine (N=18), risperidone (N=13), and conventional antipsychotics (N=11). The mean duration of treatment was 3.4 years. Patients with preexisting diabetes were excluded. Data were analyzed with univariate analyses and multivariate linear regression models to adjust for confounders and to identify predictors. Covariates included in the analyses were body mass index (BMI), family history of diabetes, duration of treatment, gender, age, diagnosis, ethnicity, and comorbid physical illness. Results: For diabetes risk, univariate analyses suggested that the highest hemoglobin A1c values occurred in patients treated with clozapine (mean=6.7, SD=0.4). Significant predictors of hemoglobin A1c values were BMI, ethnicity (lower in whites), and duration of treatment. With adjustment for these factors, clozapine was not markedly associated with elevated hemoglobin A1c values. Differences in FBS values were not associated with antipsychotic type in any analysis. For hypercholesterolemia risk, univariate analyses did not identify any statistically significant associations. However, in the regression model, higher past cholesterol level was the main predictor for a current hypercholesterolemia diagnosis. In whites, antipsychotic type was also a predictor, with evidence that olanzapine was associated with the highest adjusted cholesterol levels (olanzapine: mean= 202.1 mg/dl, SD=36.8; conventional neuroleptics: mean=164.5 mg/dl, SD=36.8). All differences were seen with total cholesterol but not with high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, or triglycerides. Conclusions: Antipsychotic type did not predict risk of diabetes after adjustment for other variables. The strongest predictor of hyperglycemia appeared to be ethnicity. After adjustment for other variables, most notably past hypercholesterolemia and ethnicity, antipsychotic type, specifically olanzapine, was associated with higher total cholesterol levels.
References
1. McIntyre RS, McCann SM, Kennedy SH: Antipsychotic metabolic effects: weight gain, diabetes mellitus, and lipid abnormalities. Can J Psychiatry 2001; 46:273–281[Medline]
2. Koro CE, Fedder DO, L’Italien GJ, Weiss S, Magder LS, Kreynbuhl J, Revicki D, Buchanan RW: An assessment of the independent effects of olanzapine and risperidone exposure on the risk of hyperlipidemia in schizophrenic patients. Arch Gen Psychiatry 2002; 59:1021–1026[Abstract/Free Full Text]
14. The Next Generation: Health Plan and Clinical Integration of General Medical and Behavioral Science
R.G. Kathol, MD, FAPM
This presentation summarizes claims data showing that the 11% of members who use behavioral health benefits have twice the total claims expenditures as those who use none; that 60% of those expenditures is for general medical and pharmacy, not behavioral health services; and that these expenditures persist over time. At least a part of this substantial and costly interaction of behavioral and general medical service use, which accounts for 24% of all claims expenditures in a sample of more than 200,000 members, can be attributed to cost shifting arising from the barriers introduced by the separate management of behavioral health service use. Independent general medical and behavioral health services and claims management functionally and financially discourage cross-disciplinary coordination of care; use ineffective member handoffs between general medical and behavioral health customer service and care management staff for members with complex, usually high-cost illness; and define behavioral health benefits by number of treatments rather than by access to outcome-changing interventions. The author delineates the clinically and financially important interaction between general medical and behavioral health service use and explores potential strategies for future care coordination and cost reduction, including 1) collaboration with a subcontracted carved-out managed behavioral health organization, 2) bringing behavioral health in-house using existing separate contracting and administrative procedures (carving-in behavioral health), and 3) transitioning behavioral health management to a system in which it is handled like other medical specialties—e.g., ophthalmology, obstetrics, pediatrics, etc.—at the health plan level. The author discusses the ability of these health plan models to support clinically integrated general medical and behavioral health services.
References
1. Rosenheck RA, Druss B, Stolar M, Leslie D, Sledge W: Effect of declining mental health service use on employees of a large corporation. Health Aff (Millwood) 1999; 18:193–203[Abstract]
2. Oxman TE, Dietrich AJ, Williams JW Jr, Kroenke K: A three-component model for reengineering systems for the treatment of depression in primary care. Psychosomatics 2002; 43:441–450[Abstract/Free Full Text]
15. Factitious Disorders With Physical Symptoms: The Significance of a Comorbid Psychiatric Disorder
L.E. Krahn, MD, FAPM; M. Reinade; M.K. O’Connor, MD
Background: Factitious disorder with physical symptoms remains a poorly understood and little researched psychiatric condition. Factitious disorder is a psychiatric condition in which patients seek to receive medical treatment.(1) Affected patients knowingly create the impression of a medical disease; however, they may not have insight into the underlying emotional distress that leads them to seek medical care. Physicians initially view the patient as having medical needs, and potentially there may be a delay in recognizing the patient’s psychiatric needs. Nonetheless, a subset of patients with factitious disorder have one or more coexisting psychiatric disorders.(2) In these cases, physicians may have a higher index of suspicion that psychiatric issues are playing a role in the patient’s presentation for medical care. In this study, patients with factitious disorder with and without coexisting psychiatric disorder were compared. The hypothesis was that patients with a coexisting psychiatric disorder will differ from those who have isolated factitious disorder in terms of the course of their physical symptoms. Methods: This study was approved by the Mayo Foundation institutional review board. The study methods were described in detail in a previous report.(2) The subjects included a series of 93 patients seen over a 21-year time span. Two raters agreed on subject eligibility on the basis of DSM-IV criteria as well as the absence of somatoform disorder and medical disorder. Patients with factitious disorder with psychological features or mixed features were excluded. Data were collected regarding the presence or absence of any additional psychiatric disorders. Patients with a coexisting or past psychiatric disorder (32%) in addition to factitious disorder with physical symptoms were compared to those without (68%) by using multiple logistic regression analysis. For this analysis, chemical dependency was not counted as a psychiatric disorder. Results: The patients with factitious disorder with physical symptoms as well as another psychiatric disorder reported more surgical procedures than subjects without a coexisting psychiatric disorder (p<0.05). Conclusions: This retrospective study tested a new hypothesis in a preliminary way. The analysis revealed only one difference between the two groups. No data were available regarding whether patients with a coexisting psychiatric disorder were more readily recognized by the primary service, more accepting of psychiatric treatment, or had a better treatment outcome. A prospective study of patients with factitious disorder is needed to more effectively test the hypothesis and to determine whether differences regarding willingness to accept psychiatric treatment exist between these two subgroups.
References
1. Reich P, Gottfried L: Factitious disorders in a teaching hospital. Ann Int Med 1983; 99:240–247
2. Krahn L, Li H, O’Connor M: Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry 2003; 160:1163–1168[Abstract/Free Full Text]
16. Impaired Glucose Metabolism in Obese and Non-Obese Subjects With Schizophrenia Treated With Olanzapine
P.M. Louie, MD; D.C. Henderson, MD; D.D. Nguyen, PhD; T.B. Daley, MPH; C. Borba, MPH; M.T. Weber, PhD; D. Allison, PhD; D.C. Goff, MD
Objective: The goal of this study was to examine glucose metabolism by using a frequent sampled intravenous glucose tolerance test (FSIVGTT) in both obese and non-obese adults with schizophrenia or schizoaffective disorder treated with olanzapine. Methods: A cross-sectional study of 25 nondiabetic olanzapine-treated adults was performed. Fourteen subjects were classified as non-obese, with a body mass index (BMI) <30 kg/m2, and 11 were classified as obese, with BMI 30 kg/m2. A nutritional assessment and FSIVGTT were conducted with each subject. Primary outcome measures included the insulin sensitivity index (SI) and glucose effectiveness measure (SG). Results: Subjects in the obese and non-obese groups were similar in age, gender, ethnicity, and diagnosis. The mean BMI values were 25.43 kg/m2 (SD=2.98) in the non-obese group and 31.81 kg/m2 (SD=1.33) in the obese group. The SI and SG values of both groups were lower than normal mean values in the general population measured by FSIVGTT. There were no statistically significant differences in SI (p=0.08) or SG (p=0.77) between the obese and non-obese groups. Conclusions: Both obese and non-obese subjects with schizophrenia and schizoaffective disorder treated with olanzapine demonstrated evidence of insulin resistance and impaired glucose utilization, thereby increasing their risk for diabetes mellitus and cardiovascular disease. The findings suggest that olanzapine treatment may be associated with a direct impairment of glucose metabolism that is independent of, but worsened by, obesity.
References
1. Bergman RN: Lilly lecture 1989. Toward physiological understanding of glucose tolerance: minimal-model approach. Diabetes 1989; 38:1512–1527[Abstract]
2. Henderson DC, Louie P, Daley TB, Allison D, Copeland P, Nathan D, Hayden D, Goff D: Glucose metabolism in schizophrenia patients treated with atypical antipsychotics: a frequent sampled intravenous glucose tolerance test and minimal model analysis (abstract). Paper presented at the International Congress of Biological Psychiatry, Sydney, Australia, Feb 9–13, 2004
17. The Impact of Attachment Style and the Physician-Patient Relationship on Adherence to Medication Treatment in HIV Disease
J.D. Maggi, MD; S.B. Rourke, PhD; G. Devins, PhD; G. Rodin, MD
Background: A critical determinant of treatment success in patients with HIV/AIDS is a patient’s ability to adhere to highly active antiretroviral therapy (HAART). Nonadherence to antiretroviral medications can result in viral breakthrough and worsen disease outcomes. Several factors that affect a person’s ability to adhere to medications have been identified. Despite the identification of these factors, nonadherence continues to be a problem. Objectives: The overall objectives of this study were 1) to determine if attachment style in patients with HIV disease and the patient’s relationship with the physician predicts adherence to HAART medications and 2) to determine if the relationship between attachment style and adherence to HAART medications is mediated by the patient’s perception of his/her relationship with the physician. Methods: Ninety-eight patients from five university hospital infectious disease clinics, an HIV primary care clinic, and AIDS service organizations in a large city consented to participate. Of these, 82 patients met the inclusion criteria. The following measures were completed at baseline: Individual Medication Monitor (IMM), Revised Adult Attachment Scale (RAAS), Physician-Patient Relationship Inventory, sociodemographic questionnaire, clinical questionnaire (Centers for Disease Control and Prevention HIV classification, AIDS diagnosis, medication side effects index, clinical site), Beck Depression Inventory, Alcohol User Disorders Identification Test, Drug Abuse Screening Test, and Provisions of Social Relations Scale. In addition, data on HIV viral load and CD4 cell count were obtained. Over the next 9 months, an average of 11 IMM scores were obtained. Descriptive statistics are presented for baseline demographic and clinical characteristics. A chi-square test was used to evaluate the relationship between adherence to HAART and HIV viral load. Multivariate statistics were used to evaluate the data related to the study objectives. Results: Participants were primarily male, single, gay/lesbian, unemployed, with an income below $17,000/year in Canadian dollars. A total of 42.7% of participants missed less than 1% of HAART doses, 78.0% missed less than 5% of HAART doses, and 22.0% missed 5% of HAART doses. Adherence to HAART and HIV viral load were not significantly related (Pearson  2=1.05, df=1, N=82, n.s.). However, in a subgroup of subjects, a two-way contingency table was used to evaluate whether those who missed >2 doses for >2 weeks were more likely to have a detectable HIV viral load, compared to those who did not have this pattern of nonadherence; this relationship approached statistical significance (Pearson 2=2.70, df=1, N=61, p=0.10). None of the background variables were significantly related to HAART adherence. Multiple regression analysis revealed that the amount of variance accounted for by attachment style, physician characteristics, and the patient’s perception of the doctor-patient relationship was not statistically significant. Post hoc analysis revealed that as attachment insecurity increased, patients’ perception of their relationship with their physician became more negative, as did patients’ reports of social support. In the multiple regression analysis, attachment accounted for 6.2% of the variance in predicting the physician-patient relationship. Conclusions: The study results do not support the hypothesis that attachment and the physician-patient relationship predict HAART adherence.
References
1. Ciechanowski PS, Katon WJ, Russo JE, Walker EA: The patient-provider relationship: attachment theory and adherence to treatment in diabetes. Am J Psychiatry 2001; 158:29–35[Abstract/Free Full Text]
2. Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAuliffe TL: Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychol 2000; 19:124–133[CrossRef][Medline]
18. Anticipating Death While Preparing to Survive: A Proposed Model of Care for Patients With Amyloidosis Awaiting Cardiac Transplantation at Mayo Clinic
P. Netzel, MD; S.G. Jowsey, MD
The care of patients facing end-of-life issues has received increasing attention, especially among the cancer population, for whom quality-of-life interventions have been found to be successful. Transplantation teams typically focus on the survival of the patient while the patient may be struggling with existential, spiritual, psychological, and other end-of-life issues. Patients who are at high risk for death while awaiting transplantation face a paradox: they are preparing to survive with a transplanted organ while anticipating their death on the waiting list. Patients with restrictive cardiomyopathy secondary to primary amyloidosis are an example of a high-risk patient population. Amyloidosis patients who are listed for cardiac transplantation have longer inpatient stays before transplant, greater comorbidity, and increased mortality pretransplant and posttransplant. Often these patients have been healthy before the onset of symptoms and face a rapid deterioration in physical functioning. After cardiac transplantation, stem cell transplantation is required to cease the progression of the disease. Mayo Clinic is one of the few centers providing transplantation to patients with restrictive cardiomyopathy secondary to primary amyloidosis. The authors propose a model of integrated care with these aims: 1) to provide care by a multidisciplinary team whose goal is to decrease the psychological and physical distress faced by the transplant candidates and 2) to improve quality of life with interventions that target problem solving, symptom management, psychosocial support, and spiritual issues. The authors identified a model in which patients with amyloid cardiac disease would be enrolled in an Amyloid Care Program involving a multidisciplinary team that includes assessments by social work, religious services, physical therapy, recreational therapy, and nursing specialists with expertise in the care of transplant patients. The program also includes an initial psychiatric evaluation by a board-certified psychiatrist utilizing a semistructured interview; a behavioral modification protocol to optimize nutrition, physical activity, and sleep hygiene; and symptom management that addresses common problems encountered by patients with prolonged hospital stays. The model emphasizes social support through support groups, discussion of existential issues, meetings with other transplant recipients and the certified nurse specialist, and monitoring of participation by the patient in all elements of the program. Strategies for monitoring the response to the interventions by using validated rating scales are also proposed. In summary, patients with amyloidosis constitute a unique transplant population because of the acute onset of symptoms, the rapid deteriorating course, and the poor prognosis. The proposed model of care addresses the distress caused by facing end-of-life issues while awaiting transplantation, which is an area that has been essentially unrecognized. Other high-risk transplant populations may benefit from similar interventions. The model also extends to other medically ill populations, including patients with AIDS, cancer, end-stage pulmonary disease, renal disease, and cardiac disease.
References
1. Bretscher M, Rummans T, Sloan J, Kaur J, Bartlett A, Borkenhagen L, Loprinzi C: Quality of life in hospice patients: a pilot study. Psychosomatics 1999; 40:309–313[Abstract/Free Full Text]
2. Dubrey SW, Burke MM, Khaghani A, Hawkins PN, Yacoub MH, Banner NR: Long term results of heart transplantation in patients with amyloid heart disease. Heart 2001; 85:202–207[Abstract/Free Full Text]
19. Prevalence of Depressive Symptoms in a Rural Population of Patients With Congestive Heart Failure
E. Norris, MD; Y. Xiang, MD; M. Rossi, MD; M. Kaufmann, MD
The prevalence of congestive heart failure in the United States is continuing to increase, and it was recently demonstrated that depressive symptoms were a strong predictor of short-term worsening in heart-failure-specific health status.(1) Depression rates have been shown to range from 11% to >40% in patients with stable congestive heart failure.(2) The purpose of this study was to assess the prevalence of depressive symptoms in a rural population of patients with stable congestive heart failure. Fifty-one patients were recruited through an outpatient cardiology practice in Allentown, Pennsylvania. Patients with a confirmed diagnosis of congestive heart failure were asked to participate and gave informed consent. After enrollment, patients completed a demographic questionnaire and the Zung Self-Rating Depression Scale, a 20-item, self-administered questionnaire with scores that range from 20 to 80. Patients with a score greater than 50 were considered to have depressive symptoms. Of the 51 patients in this study, 34 were male and 17 were female; the average age was 74 years. Among these patients, 18 (35%) indicated by a single yes/no question that they had depressive symptoms. Of these 18, nine patients were confirmed by chart review to have a history of depression, 12 were actively taking an antidepressant, and four had Zung depression scale scores consistent with mild to moderate depression. The average score of these four patients was 52.25, compared to a score 33.72 for the remaining 47 patients (p=0.0001). Of these four patients, three were taking antidepressants. There was no difference in Zung depression scale scores between the nine patients with a history of depression (mean=40.33, SD=10.43) and the 42 patients with no history of depression (mean=34.07, SD=6.35) (p=0.12). In addition, the mean Zung depression scale score of the 12 patients who were currently taking an antidepressant (mean=37.50, SD=10.41) did not differ significantly from that of the 39 patients who were not taking an antidepressant (mean= 34.46, SD=6.36) (p=0.39). In this preliminary study of the prevalence of depressive symptoms in a rural population of patients with congestive heart failure, the prevalence of active depressive symptoms was lower than expected, compared to the findings of other studies. Two possible explanations for these results include 1) that ongoing treatment with antidepressants may have decreased the prevalence of active depressive symptoms that were recorded by the Zung depression scale and 2) that the Zung depression scale is less sensitive in detecting depressive symptoms in elderly patients. However, if the 12 patients who were taking antidepressants were included with the one patient who was not taking an antidepressant but whose Zung depression scale score indicated depression, there were 13 patients (25%) who were depressed, which is consistent with other studies. Future areas of research include investigating more appropriate depressive screening questionnaires for elderly, medically ill patients and assessing treatment outcomes in the population of patients with congestive heart failure.
References
1. Rumsfield JS, Havranek EP, Masoudi FA, Peterson ED, Jones P, Tooley JF, Krumholz HM, Spertus JA, Cardiovascular Outcomes Research Consortium: Depressive symptoms are the strongest predictors of short-term declines in health status in patients with heart failure. J Am Coll Cardiol 2003; 42:1811–1817[Abstract/Free Full Text]
2. Havranek EP, Ware MG, Lowes BD: Prevalence of depression in congestive heart failure. Am J Cardiol 1999; 84:348–350[CrossRef][Medline]
20. Comparison of the Performance of Four Cancer-Related Fatigue Instruments: Validation Study of the Japanese Version of the Brief Fatigue Inventory
T. Okuyama, MD, PhD; X.S. Wang, MD; T. Akechi, MD, PhD; T.R. Mendoza, PhD; T. Hosaka, MD, PhD, FAPM; C.S. Cleeland, PhD; Y. Uchitomi, MD, PhD
Background: Fatigue has been recognized as one of the most distressing symptoms in cancer patients. Concise assessment is essential to managing this symptom. To that end, the Brief Fatigue Inventory (BFI), a nine-item questionnaire, was designed to assess fatigue in cancer patients. The purpose of this study was to examine the validity and reliability of the Japanese version of this scale (BFI-J), compared with previously validated fatigue scales. Patients and Methods: The authors randomly selected 252 cancer patients and presented them with the BFI-J, along with the Cancer Fatigue Scale; Profile of Mood States fatigue, vigor, and depression subscales; and European Organization for Research and Treatment of Cancer’s Quality of Life Questionnaire–Core 30 Items. Specifically, the reliability and construct, criterion, convergent, and discriminant vaidity of the scale were evaluated. Results: The BFI-J showed excellent validity and reliability. In particular, the minimum number of missing value rates proved that the scale is easy to administer. Factor analysis confirmed its single-dimensional structure as well as that of the original scale, indicating good construct validity. Patients with poor Eastern Cooperative Oncology Group performance status scores had higher BFI-J scores, which supported the scale’s discriminant validity. Conclusions: The BFI-J is a feasible measure of fatigue for use with Japanese cancer patients.
References
1. Okuyama T, Wang XS, Akechi T, Mendoza TR, Hosaka T, Cleeland CS, Uchitomi Y: Validation study of the Japanese version of the Brief Fatigue Inventory. J Pain Symptom Manage 2003; 25:106–117[CrossRef][Medline]
2. Okuyama T, Akechi T, Kugaya A, Okamura H, Shima Y, Maruguchi M, Hosaka T, Uchitomi Y: Development and validation of the Cancer Fatigue Scale: a brief, three-dimensional, self-rating scale for assessment of fatigue in cancer patients. J Pain Symptom Manage 2000; 19:5–14[CrossRef][Medline]
21. Comparison Survey of Primary Care and Oncology Providers in Managing Psychosocial Distress
W.F. Pirl, MD, FAPM; A. Muriel, MD; M. Beiser, BA; C. Moore, PhD
Background: The National Comprehensive Cancer Network (NCCN) has published guidelines for the management of psychosocial distress in cancer patients. Although there has been much work on the delivery of psychiatric services in primary care, few data are available on psychiatric care provided by medical specialists, such as oncologists, who work with populations with high rates of psychiatric comorbidity. This study surveyed oncology providers about the routine management of psychosocial distress in their practices and compared the findings to those for a group of primary care providers. Methods: All hospital-based oncology and primary care providers at a large urban teaching hospital (Massachusetts General Hospital) were sent a questionnaire that asked about their practices for screening, evaluating, and treating psychosocial distress, as well as their beliefs about the effect of psychosocial distress on patient outcomes. The questionnaire was completed anonymously, and an incentive lottery was offered for participants. Results: Forty-one percent of providers (148/355) returned completed surveys. The response rate was slightly higher for the oncology providers (44%, 91/209) than for the primary care physicians (39%, 57/146). Overall, 74% of the oncology providers reported that they routinely screen for psychosocial distress. This rate was similar to that for the primary care physicians (79%). Oncology nurse practitioners and palliative care physicians reported the highest rates of screening (100%), followed by medical oncologists (79%), surgeons (54%), and radiation oncologists (50%). Although providers reported high rates for screening for psychosocial distress, few actually used a screening instrument. Barriers to screening were also reported. Looking specifically at two types of distress—depression and family issues—there were differences between the two groups. Oncology providers reported screening for depresssion at a lower rate than primary care providers (69% and 91%, respectively) (p<0.05). Descriptive differences in treatment patterns for depression were also compiled. Although both groups reported similar knowledge of family composition, more oncology providers reported that they ask about family difficulties, compared with primary care providers (46% and 13%, respectively) (p<0.05). Discussion and Conclusions: Primary care and oncology providers reported similar rates of screening for distress. Primary care providers were more likely to report assessing for depression, and oncology providers were more likely to report asking about family issues. Although a high percentage of respondents reported that they conducted screening, very few used screening instruments. This study suggests that one area to target for improving patient care and increasing the uptake of the NCCN guidelines would be the use of a screening instrument, especially because the majority of providers reported the belief that distress negatively affects medical outcomes and expressed interest in screening.
References
1. Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theobald DE, Edgerton S: Oncologists’ recognition of depression in their patients with cancer. J Clin Oncol 1998; 16:1594–1600[Abstract/Free Full Text]
2. National Comprehensive Cancer Network: NCCN practice guidelines for the management of psychosocial distress. Oncology 1999; 13:113–147[Medline]
22. Application of the Rational Opioid Use Tool in Chronic Pain Patients
C.T. Pratt, MD; C.M. Opremcak, MD
The consultation psychiatrist in the acute care hospital setting is frequently called on to manage the complex needs of patients admitted for various syndromes associated with chronic pain. Invariably, the question of opioid utilization arises, including various issues of implementation, continuation, taper, or detoxification. Furthermore, concerns about opioid utilization are complicated by subjective elements and patient/family emotionality, which make for difficult objective opinion formulation. The authors present a Rational Opioid Use Tool that easily scores the patients’ pain presentation on the basis of 10 dynamic dimensions influencing pain in major categorical groupings of pain patients: 1) pain mechanism clarity, 2) disability status/secondary gain reinforcement, 3) pain pathology, 4) pain intensity, 5) pain behavior, 6) victimization, 7) axis I category, 8) axis II category, 9) cognitive capability, and 10) addiction genetics. The straightforward assessment design, case examples, and scoring capability of the tool allow for the assessment of pain that goes beyond the view that pain is whatever the patient says it is and that approaches pain with much greater clarity and objectivity. It allows the clinician to make an informed decision about the use of opioids while demonstrating the "deeper look" expected of the psychiatrist at the bedside. The tool can be easily adapted to primary care settings and can serve as a decision making tool to support the avoidance of opioid implementation in particularly challenging cases involving patients with problematic opioid-using patterns, including patients with somatization syndromes, malingering pathologies, and axis II (primarily cluster B) presentations.
References
1. Mahoney ND, Devine JE, Andres D: Multidisciplinary treatment of benign chronic pain syndrome in substance abusing patients. Curr Rev Pain 1999; 3:321–331[Medline]
2. Savage SR: Assessment for addiction in pain-treatment settings. Clin J Pain 2002; 18(4 suppl):S28-S38
23. Psychiatric Assessment of Patients Seeking Bariatric Surgery for Obesity: Preliminary Report of Outcome and Implications
D. Ramchandani, MD, FAPM
Background: Preoperative psychiatric evaluation in obese patients seeking bariatric surgery is routinely ordered to screen patients who have unstable psychotic disorders or those who have exceedingly unrealistic expectations of surgical benefit. The author reports on the screening experience with 53 consecutive patients who sought bariatric surgery in an urban teaching hospital. Methods: The assessment consisted of a psychiatric interview and a review of psychiatric records, if the patient was in current psychiatric treatment. Telephone follow-up to date of 31 patients was done to assess physical and psychological outcome at least 12 months after the initial evaluation. Of the remaining 22 patients, seven have not yet been reached and 15 appear to be lost to follow-up. Results: Of the 53 patients examined between January 1, 2001, and March 1, 2003, 43 were women and 10 were men. Thirty-seven patients were age 30–50 years, 24 were currently married, 23 were single, and six were divorced. Four patients had significant medical morbidity, 18 had moderate medical problems, and the remaining 21 had minor or no other medical illness. The body mass index (BMI) of patients ranged from 31 to 68.5. Twenty-nine of the 53 patients had relatively minor psychiatric disorders such as dysthymia, cyclothymia, anxiety disorder, personality traits, low average IQ, or substance abuse. Ten patients appeared to have unrealistic expectations of benefit from surgery; five of these patients had no evidence of psychiatric disorder. Of the 31 patients reached for follow-up, 24 were women and seven were men. Thirty had undergone surgery, and 27 were at least 6 months postsurgery. Eighteen of the 31 patients had psychiatric disorders, and 13 had no psychiatric disorder. Only three of the 31 patients were unrealistic in their expectations from surgery. Twelve of the 22 patients who could not be reached had received a psychiatric diagnosis. The patient who decided not to have surgery was 62 years old and gave that reason as important in her decision. Five of 27 patients were disappointed with the outcome. All five of them received a psychiatric diagnosis at initial evaluation, but 12 of the remaining 22 patients also received psychiatric diagnoses. Four of the five had suffered significant postoperative complications. Four of the 22 patients who were satisfied with the outcome of surgery also had complications. Conclusions: The beneficial short-term outcome (6 months to 2 years) of surgery was unrelated to preoperative expectations from surgery. Patients who were disappointed with the outcome of surgery tended to have psychiatric morbidity and postoperative complications.
References
1. Powers PS, Rosemurgy AS, Coovert DL, Boyd FR: Psychosocial sequelae of bariatric surgery: a pilot study. Psychosomatics 1988; 29:283–288[Abstract/Free Full Text]
2. Hsu LKG, Benotti PN, Dwyer J, Roberts SB, Saltzman E, Shikora S, Rolls BJ, Rand W: Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosom Med 1998; 60:338–346[Abstract/Free Full Text]
24. Interferon Treatment of Hepatitis C Patients With Psychiatric Disorders: Evidence-Based, Risk-Benefit Assessment
M.A. Rifai, MD; D.L. Rosenstein, MD, FAPM
Background: Gastroenterologists make clinical risk-benefit assessments when offering interferon to treat chronic hepatitis C virus (HCV) infection. The fear of precipitating or worsening psychiatric comorbidity is a frequent trigger for psychiatric consultation to address the probability of interferon-induced neuropsychiatric side effects. Several risk factors are thought to increase the risk of interferon-associated psychiatric comorbidity, including a previous history of any psychiatric illness, a history of substance abuse, a family history of psychiatric illness, and a history of suicidal ideation. In contrast to the variable influence of these psychiatric risk factors, the decreased likelihood of sustained viral remission (SVR) from HCV in response to interferon is associated with several predictive and additive factors, including male gender, African American ethnicity, higher body mass index, advanced age (>40 years), higher HCV viral load, and HCV genotype 1. Case Presentations: Interferon is clearly indicated in the case of a 35-year-old slender white woman with no history of psychiatric illness who is infected with a low HCV viral load of either genotype 2 or 3 (Case 1). In the absence of advancing cirrhosis, interferon should be delayed in the case of a 50-year-old obese African American man with history of psychosis and substance use disorders who is infected with a high viral load of HCV genotype 1 (Case 2). Although these two cases present clinical scenarios at the opposite ends of the risk-benefit spectrum (Figure 1), the risk-benefit profile in the majority of patients with HCV and psychiatric comorbidities is in an intermediate zone. Prophylactic psychotropics might be offered if the woman in Case 1 had a history of major depressive disorder and was infected with a low viral load of HCV genotype 1. Biopsy-demonstrated cirrhosis might be a compelling reason to attempt interferon treatment in Case 2. Ongoing psychiatric follow-up is certainly indicated when a patient has one or more of the psychiatric risk factors listed earlier. In cases in which a low estimated likelihood of SVR from HCV is combined with an intermediate to low probability of psychiatric side effects, an evaluation incorporating the patient’s interferon treatment preference can help sway the decision. Conclusions: Evidence-based patient selection is paramount when treating patients with comorbid psychiatric illnesses and HCV in order to minimize interferon-associated morbidity and mortality (i.e., suicide). This model is intended to assist clinicians in making an individualized and balanced risk-benefit analysis by considering HCV disease-specific factors as well the potential for psychiatric complications before offering interferon treatment.
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FIGURE 1. Risk-Benefit Spectrum in Interferon Treatment of Patients With Hepatitis C Virus and Psychiatric Disorders
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References
1. Yovtcheva S, Rifai MA, Moles JK, Van der Linden BJ: Psychiatric comorbidity among hepatitis C-positive patients. Psychosomatics 2001; 42:411–415[Abstract/Free Full Text]
2. Schaefer M, Schmidt F, Folwaczny C, Lorenz R, Martin G, Schindlbeck N, Heldwein W, Soyka M, Grunze H, Koenig A, Loeschke K: Adherence and mental side effects during hepatitis C treatment with interferon alfa and ribavirin in psychiatric risk groups. Hepatology 2003; 37:443–451[CrossRef][Medline]
25. Atypical Antipsychotic Agents and Risk Factors for Diabetes Mellitus: Comparing Schizophrenia and Bipolar Disorder Patients
M. Schwarz, PharmD; J.L. Cunningham, PharmD; M.M. Reese, MD
Background: Large retrospective studies in populations of patients with schizophrenia have found a higher risk of diabetes mellitus for patients taking atypical antipsychotic agents. The United States Food and Drug Administration (FDA) expressed concern about the relationship between atypical antipsychotic use and glucose abnormalities and requested a change in all antipsychotic medication labeling. The FDA stated that patients with risk factors for diabetes mellitus should undergo fasting glucose testing at baseline and periodically throughout treatment. The purpose of this study was to quantify the number of American Diabetes Association (ADA) risk factors for diabetes mellitus in a population of Mayo Medical Center patients taking atypical antipsychotic agents and to determine whether differences in the number of risk factors exist between patients with the diagnosis of schizophrenia and those with a diagnosis of bipolar disorder. Methods: After institutional review board approval, the authors retrospectively reviewed the records of 400 patients who were taking atypical antipsychotic agents in 2000–2002. The list of atypical antipsychotic agents prescribed during this time period included clozapine, olanzapine, quetiapine, risperidone, and ziprasidone. The patients were divided into two groups each of 100 male patients and 100 female patients with a diagnosis of schizophrenia or bipolar disorder and were matched for age and gender. Patient records were reviewed for the following ADA risk factors: 1) age 45 years, 2) body mass index (BMI) 25 kg/m2, 3) family history of diabetes mellitus, 4) race/ethnicity, 5) previously identified impaired fasting glucose (IFG) (fasting glucose values of 100–125 mg/dl) or impaired glucose tolerance (oral glucose tolerance test values of 140–200 mg/dl), 6) history of gestational diabetes mellitus or delivery of a baby weighing more than 9 lb, 7) hypertension, 8) hyperlipidemia, 9) polycystic ovary syndrome, and 10) a history of vascular disease. Results: The schizophrenia patients had a median of two diabetes mellitus risk factors, and the bipolar disorder patients had a median of three diabetes mellitus risk factors (p<0.05). Secondary to age being a risk factor for diabetes mellitus, the patients were grouped according to age (< 45 years and 45 years). A significant difference was found in the number of risk factors for female patients age < 45 years with a diagnosis of bipolar disorder, compared to schizophrenia patients (medians of two and one risk factors, respectively) (p<0.05), and for male patients age 45 years (medians of four and three risk factors, respectively) (p<0.05). A total of 75.25% of all patients had a BMI > 25 kg/m2, 44.5% had a BMI > 30 kg/m2, and 36% had a record of IFG test results. Conclusions: These findings demonstrate the high number of diabetes mellitus risk factors that are present in patients with schizophrenia and patients with bipolar disorder who are taking atypical antipsychotic agents. The findings highlight the need for baseline fasting blood glucose screening in these patients. Although use of concurrent medications was not assessed, high BMI values in patients with bipolar disorder may in part be related to the use of additional medications such as mood stabilizers, which may induce weight gain.
References
1. Buse J, Cavazzoni P, Hornbuckle K, Hutchins D, Breier A, Jovanovic L: A retrospective cohort study of diabetes mellitus and antipsychotic treatment in the United States. J Clin Epidemiol 2003; 56:164–170[CrossRef][Medline]
2. Wirshing DA, Boyd JA, Meng LR, Ballon JS, Marder SR, Wirshing WC: The effects of novel antipsychotics on glucose and lipid levels. J Clin Psychiatry 2002; 63:856–865[Medline]
26. The Revised Memorial Anxiety Scale for Prostate Cancer (MAX-PC-R): Validation of a Scale to Measure Anxiety in Men With Prostate Cancer
A.J. Roth, MD, FAPM; C. Nelson, PhD; B. Rosenfeld, PhD; A. Warshowsky, MA; N. O'Shea, RN; T. Reynolds, MA;S. Slovin, MD, PhD; J.C. Holland, MD, FAPM; H. Scher, MD; T. Curley-Smart, RN; W.S. Breitbart, MD, FAPM
Background: Identifying men with prostate cancer who might benefit from mental health treatment is a challenging task. The authors developed the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) to facilitate the identification and assessment of anxiety related to prostate cancer. A revised version of the scale was tested in a more clinically varied population to further validate the questionnaire and to determine clinically useful cutoff scores. The revised version consists of three subscales measuring general prostate cancer anxiety, anxiety related to prostate-specific antigen (PSA) levels in particular, and fear of recurrence. Methods: Ambulatory men with prostate cancer (N=367) were recruited from Memorial Sloan-Kettering Cancer Center. Before routine PSA tests, participants completed a baseline assessment packet that included the Hospital Anxiety and Depression Scale; the Distress Thermometer; the Functional Assessment of Cancer Therapy Scale, Prostate Module; the Generalized Anxiety Disorder Questionnaire; and measures of spirituality, religiosity, and urinary functioning. Follow-up evaluation with a subset of these scales was completed by mail 2 weeks after patients learned of the PSA test result. Results: Analysis of the revised MAX-PC revealed a high degree of internal consistency and test-retest reliability for the total score and the three subscales, although reliability was somewhat weaker for the PSA anxiety scale. Concurrent validity was demonstrated by correlations between the MAX-PC and measures of anxiety. A factor analysis confirmed the three-factor model. Men with unstable or changing PSA scores (regardless of direction) had higher anxiety levels than those with steady PSA levels. Multivariate analysis suggested that the revised MAX-PC, in contrast to general anxiety questionnaires, identifies anxiety specific to men with prostate cancer. Conclusions: The revised MAX-PC appears to be a valid and reliable measure of anxiety in men with prostate cancer receiving ambulatory care. The measure taps more specific aspects of anxiety than the general screening measures typically employed. Use of this measure in men with prostate cancer may help improve the detection of patients in need of focused mental health interventions.
References
1. Roth AJ, Rosenfeld B, Kornblith AB, Gibson C, Scher HI, Curley-Smart T, Holland JC, Breitbart W: The Memorial Anxiety Scale for Prostate Cancer (MAX-PC): validation of a new scale to measure anxiety in men with prostate cancer. Cancer 2003; 97:2910–2918[CrossRef][Medline]
2. Roth AJ, Kornblith A, Batel-Copel L, Peabody E, Scher H, Holland J: Rapid screening for psychologic distress in men with prostate carcinoma. Cancer 1998; 7:129–132
27. Munchausen by Proxy With Production of Psychiatric Symptoms
I. Schuermeyer, MD; D. Gould, MD
Munchausen syndrome is a form of factitious disorder in which the production of actual physical symptoms is intentional. Munchausen by proxy occurs when a patient’s symptoms are |
