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.
View this table:
[in this window]
[in a new window]
|
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
|
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.
View this table:
[in this window]
[in a new window]
|
TABLE 1. Hepatitis C Virus (HCV) Status and History of Alcohol Use Among Liver Transplant Candidates at Low Risk for HCV (N=52)a
|
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.
View larger version (70K):
[in this window]
[in a new window]
|
FIGURE 1. Risk-Benefit Spectrum in Interferon Treatment of Patients With Hepatitis C Virus and Psychiatric Disorders
|
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 purposely produced in the patient by another individual. Most commonly, this syndrome presents with a mother producing medically significant symptoms in her child. The diagnosis of Munchausen by proxy is rarely suspected and, therefore, commonly missed. Most accounts in the psychiatric and medical literature describe cases in which there is simulation of a nonpsychiatric disorder. The authors present a case of a 14-year-old boy whose mother brought him to the pediatric emergency room on three consecutive nights for evaluation of bipolar mania. His primary symptoms were racing thoughts, not sleeping, and increased energy level. During the third night, he disclosed that his mother gave him medication that made him feel "hyper," and his toxicology screen was found to be positive for amphetamines. On hearing the results of the toxicology screen, the mother fled the emergency room. It is felt that this is a case of Munchausen by proxy with the production of psychiatric symptoms. A review of the current literature about this topic revealed only 15 other case reports of this phenomenon. The authors believe that it is important for consultation-liaison psychiatrists to be aware of this variant of Munchausen by proxy. As with the more common medical presentations of this syndrome, a psychiatric presentation may also be overlooked.
References
1. Schreier HA: Factitious disorder by proxy in which the presenting problem is behavioral or psychiatric. J Am Acad Child Adolesc Psychiatry 2000; 39:668–670[CrossRef][Medline]
2. Fisher GC, Mitchell I, Murdoch D: Munchausen’s syndrome by proxy: the question of psychiatric illness in a child. Br J Psychiatry 1993; 162:701–703[Free Full Text]
28. Neuroleptic Malignant Syndrome or Malignant Catatonia: A Case Discussion
R.G. Shankar, MD; D. Tabacaru, MD; K.S. Beizai, MD; M.B. Tobin, MD; R.C. Kores, PhD
The authors report a case of a young man with schizophrenia who presented with what appeared to be neuroleptic malignant syndrome. He had not received antipsychotic medications for some months preceding his presentation. He also was found to have encephalitis. This case illustrates the importance of including malignant catatonia in the differential diagnosis. Neuroleptic malignant syndrome is an uncommon, potentially life-threatening idiosyncratic reaction to neuroleptic medications. The syndrome can present in a variety of ways, making definitive diagnosis difficult. The most common symptoms include hyperthermia, muscle rigidity, mental status changes, autonomic activation, and an elevated creatine phosphokinase level. Caroff and colleagues(1) have proposed criteria for the diagnosis of neuroleptic malignant syndrome. These criteria emphasize that neuroleptic malignant syndrome is a diagnosis of exclusion. Cases of neuroleptic malignant syndrome that are unrelated to antipsychotic use have been reported, including cases related to the use of dopamine-depleting agents in patients with Parkinson’s disease or Alzheimer’s disease and some cases of serotonin syndrome.(2) Of interest in the differential diagnosis of neuroleptic malignant syndrome is malignant catatonia, especially when there has been no recent antipsychotic use. Malignant catatonia has been associated with a variety of medical conditions. Features of malignant catatonia include hyperthermia, mental status changes, and rigidity. Death may occur. This case highlights the need for inclusion of malignant catatonia in the differential diagnosis of neuroleptic malignant syndrome.
References
1. Caroff SN, Mann SC, Lazarus A, Sullivan KL, MacFadden W: Neuroleptic malignant syndrome: diagnostic issues. Psychiatr Ann 1991; 21:130–147
2. Mann S, Caroff SN, Keck P, Lazarus A: Neuroleptic Malignant Syndrome and Related Conditions, 2nd ed. Arlington, Va, American Psychiatric Publishing, 2003
29. Benefits of an Electronic Consultation-Liaison Standardized Note System: Improved Patient Evaluation, Resident Education, and Reduced Administrative Burden
C.L. Sola, DO; S.M. Sampson, MD; J.M. Bostwick, MD, FAPM
Objective: The purpose of the study was to develop and implement a standardized electronic consultation-liaison note program and determine whether use of this system reduces the time required to document a complete psychiatry consultation. Methods: An electronic note production system, available institutionally, was customized to meet the specific requirements of a psychiatric consultation note. Specific attention was given to diagnoses common in the consultation-liaison service in order to permit efficient documentation of issues related to delirium, competency evaluations, and depression in medical patients with a complex presentation. Residents were taught to use this note system, and the time required to produce a handwritten versus an electronic note was compared. Comments were elicited regarding the use of this system. Results: Overall, residents were able to learn the system quickly and use it efficiently. The standardized nature of the note ensured that all aspects of a full consultation-liaison psychiatry evaluation were performed. Documentation was more time-efficient and more consistently thorough. Conclusions: Implementation of this electronic note system was well received by the residents and led to more efficient and thorough documentation of psychiatric consultations. The use of this program has clear educational benefits in that it reinforces the thorough collection of data and key components of the mental status examination. By making documentation more consistent and efficient, this program decreases administrative burden.
References
1. Alexander T, Bloch S: The written report in consultation-liaison psychiatry: a proposed schema. Aust N Z J Psychiatry 2002; 36:251–258[CrossRef][Medline]
2. Rundell J (ed): Textbook of Consultation-Liaison Psychiatry, First Edition. Washington, DC, American Psychiatric Press, 1996
30. Do Implantable Cardioverter-Defibrillators Induce Anxiety?
C.L. Sola, DO; J.M. Bostwick, MD, FAPM; P. Brady, MD
Since its approval by the United States Food and Drug Administration in 1985, the implantable cardioverter-defibrillator (ICD) has supplanted antiarrhythmic drug therapy as the standard of care for patients with potentially lethal ventricular dysrhythmias. This trend has resulted largely from improvements in the safety and tolerability of the device, compared to adverse drug responses associated with commonly employed medications. As ICD indications have broadened, and the number of patients receiving the device has dramatically increased, more attention has been directed to the specific sequelae of its use. The authors reviewed the literature on the quality of life and psychiatric symptoms created or revealed in the population of patients receiving ICD implantation. Although relatively scant, the literature consistently revealed a host of psychiatric disturbances that affect up to 87% of ICD recipients. Depressive and anxious symptoms predominate, with as many as 38% of patients experiencing anxiety sufficient to meet formal diagnostic criteria for an anxiety disorder. In the absence of information about premorbid anxiety disorders in this population, psychological theories such as classical and operant conditioning, learned helplessness, and distorted cognitive appraisal have been proposed to assist in conceptualizing new-onset anxiety disorders in this specific population. Small trials have deployed psychosocial interventions, including support groups and cognitive behavior therapy, with mixed results. A paucity of prospective data in the literature underscores the need for more prospective research to assess this population. In particular, little is known about what premorbid features might predict a worse prognosis, other than a suggestion that younger patients and those receiving multiple ICD shocks are at greater risk. Given the clear need for a prospective study assessing predictive features of patients who may or may not have preexisting anxiety disorders, the authors have begun such a study at the Mayo Clinic, which performs approximately 900 implantations per year. Anxiety and quality-of-life measures are used pre- and post-ICD implantation to assess premorbid and emergent anxiety disorders in this population. Pilot data from the first 50 subjects are presented; the authors intend to enroll 250 subjects.
References
1. Glikson M, Friedman PA: The implantable cardioverter defibrillator. Lancet 2001; 357:1107–1117[CrossRef][Medline]
2. Urizar GG Jr, Sears SF, Handberg E, Conti JB: Psychosocial intervention for a geriatric patient to address fears related to implantable cardioverter defibrillator discharges. Psychosomatics 2004; 45:140–144[Free Full Text]
31. Avery D. Weisman Psychiatric Consultation Service: Recipient of the Alan Stoudemire Award for Innovation and Excellence in Consultation-Liaison Education
T.A. Stern, MD, FAPM
The Psychiatric Consultation Service at Massachusetts General Hospital, under the direction of Theodore A. Stern, M.D., F.A.P.M., is and has been a key player in the institution’s training of psychiatric residents, psychiatric fellows, and medical students. Moreover, it has served as a template for the Academy of Psychosomatic Medicine’s "Recommended Guidelines for Consultation-Liaison Psychiatry Training in Psychiatry Residency Programs." Founded in 1956 by Avery Weisman, and with one psychiatric resident, Tom Hackett, the service performed 130 consultations in its first year. Over the years, several hundred residents and students have been actively involved in the service; more than 75 fellows have graduated from the fellowship program. The service has provided training in the essentials of consultation psychiatry and an in-depth curriculum of neuropsychiatry. The service has been blessed with brilliant and charismatic leaders, including Avery Weisman, Tom Hackett, Ned Cassem, and George Murray. Despite the reduction in hospital beds, the service performs nearly 3,000 initial consultations per year (as well as several thousand additional follow-up visits) for medical and surgical inpatients. The service’s staff provide consultations for 8%–10% of all adults admitted to Massachusetts General Hospital. Three functions provided by the consultation service are patient care, teaching, and research. Joint research projects have cemented relationships with members of other disciplines. Each case is reviewed at rounds (2 hours on each of 3 days per week for residents; 1 hour on each of 4 days per week for fellows), and bedside instruction is a mainstay of teaching. Observation of a variety of interviewing styles is encouraged; unique styles of bedside teaching invigorate the process. At the beginning of the rotation, a 25-hour series of introductory lectures on practical aspects of consultation psychiatry is conducted. Each trainee also delivers two formal (45-minute) reviews of the literature that are elaborated on by a senior discussant. These weekly psychosomatic conferences produce presentations of high quality and also lead to improved speaking skills and to professional publications. Moreover, they form the beginning of specialized interests and expertise for residents and fellows. Lectures are also provided each month to medical house officers on topics at the interface of medicine, primary care, and psychiatry. Salary support is given to members of our staff for their work in the medical intensive care unit, the Cancer Center, and the Transplantation Service. Moreover, based on the working relationships established by the consultation-liaison service, the physicians’ organization of the hospital has refused to negotiate with third-party payers who are interested in carving out psychiatric care; this decision highlights the support received by the entire department and its value to the hospital’s physicians and their patients.
References
1. Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF (eds): Massachusetts General Hospital Handbook of General Hospital Psychiatry, Fifth Edition. St. Louis, Mosby/Elsevier, 2004
2. Stern TA, Herman JB, Slavin PL (eds): The MGH Guide to Primary Care Psychiatry, Second Edition. New York, McGraw-Hill, 1998
3. Stern TA, Sekeres MA (eds): Facing Cancer: A Complete Guide for People With Cancer, Their Families, and Caregivers. New York, McGraw-Hill, 2004
32. Immediate Switching of Antidepressant Therapy: Results From a Clinical Trial of Duloxetine
M.M. Wohlreich, MD; M. Wilson, MS; C. Mallinckrodt, PhD; J. Greist, MD; P. Delgado, MD; M. Fava, MD
Background: Approximately one-half of all treated depressed patients fail to show adequate response to their initially prescribed antidepressant medication. Switching to another medication represents one possible next-step approach for patients who are nonresponsive or partially responsive to the initially prescribed antidepressant. However, specific techniques for switching between antidepressants have not been well studied. The authors examined the efficacy and tolerability associated with a switch from a selective serotonin reuptake inhibitor (SSRI) or venlafaxine to duloxetine. Methods: All patients in this open-label study met the DSM-IV criteria for major depressive disorder. The treatment regimen of patients (N=88) exhibiting suboptimal response to or poor tolerability of their current antidepressant medication (citalopram, fluvoxamine, paroxetine, sertraline, or venlafaxine, within moderate dose ranges) was switched to a regimen of 60 mg of duloxetine once daily without intermediate tapering or titration. A comparator group (N=67) that included patients not currently receiving antidepressant medication (untreated patients) began duloxetine therapy at a dose of 60 mg once daily. All patients were required to take the initial dose of 60 mg once daily for 1 week. During the remaining 7 weeks of the study period, the duloxetine dose could be titrated from 60 mg once daily (minimum) to 120 mg once daily (maximum), with 90 mg once daily as an intermediate dose. The dose could be increased only if the patient’s 17-item Hamilton Depression Rating Scale total score was >7. Safety assessments included monitoring of discontinuation rates, treatment-emergent adverse events, and changes in vital signs. Efficacy measures included the 17-item Hamilton depression scale, the Hamilton Anxiety Rating Scale, and Clinical Global Impression (CGI) severity scale. Results: The efficacy of duloxetine in patients whose treatment regimen was switched did not differ significantly from that observed in untreated patients who started duloxetine therapy (Hamilton depression scale score: mean change=–12.3 versus –12.6; Hamilton Anxiety Rating Scale score: mean change=–9.36 versus –9.55; CGI severity scale score: mean change=–1.94 versus –2.12; p>0.30 for all comparisons). However, the rate of discontinuation because of adverse events among patients whose treatment regimen was switched to duloxetine was significantly lower than that in untreated patients initiating duloxetine therapy (4.5% versus 17.9%; p=0.008). Treatment-emergent adverse events occurring in 10% of patients in both treatment groups were nausea, headache, dry mouth, insomnia, and diarrhea. Patients whose regimen was switched to duloxetine reported significantly lower rates of nausea and fatigue, compared with untreated patients initiating duloxetine. Conclusions: The efficacy of duloxetine in patients whose treatment regimen was switched from another antidepressant was very similar to that observed in untreated patients initiating duloxetine therapy. Immediate switching from an SSRI or venlafaxine to duloxetine (at a dose of 60 mg once daily) was well tolerated.
References
1. Fava M, Davidson KG: Definition and epidemiology of treatment-resistant depression. Psychiatr Clin North Am 1996; 19:179–200[CrossRef][Medline]
2. Fava M: Management of nonresponse and intolerance: switching strategies. J Clin Psychiatry 2000; 61(suppl 2):10–12
33. Gender Differences in Social Support Following Coronary Revascularization
C.L. Woodman, MD; J. Spertus; S. Mallemala; J. House; M. Garg
Background: Social support is an important determinant of outcome in coronary disease. Gender differences in social support after revascularization have not been described. The purpose of this study was to explore gender differences in social support after coronary revascularization. Methods: This observational, prospective cohort study was conducted at a single institution and included 495 coronary artery revascularization patients (271 with percutaneous coronary intervention [PCI] and 224 with coronary bypass grafting [CABG]). The patients were followed monthly for 6 months and evaluated with the ENRICHD Social Support Inventory. Repeated-measures analyses of variance, with adjustment for age, was used to assess and compare changes in social support over time for men and women. Results: Baseline social support scores were similar for men and women undergoing CABG (women: mean=29.3, SD=4.0; men: mean=30.3, SD=5.0; p=0.16). Among patients undergoing PCI, women had lower social support scores than men (women: mean=27.5, SD=5.0; men: mean=29.8, SD=4.5; p<0.001). Women experienced significant drops in their social support after both CABG (baseline mean=29.3, SD=4.0; 6-month mean=26.7, SD=6.0; p=0.001) and PCI (baseline mean=27.5, SD=5.0; 6-month mean=25.5, SD=6.0; p<0.001). In contrast, the social support scores of men did not change after CABG (baseline mean=30.3, SD=5.0; 6-month mean=30.1, SD=5.0; p=0.23) or PCI (baseline mean=29.8, SD=4.5; 6-month mean=29.5, SD=5.0; p=0.70). The slopes of the social support scores over time, with adjustment for age, were significantly negative for women (–0.27 and –0.42 points/month after PCI and CABG, respectively; p<0.05 for both) and flat for men (–0.04 and –0.02 points/month after PCI and CABG, respectively; p>0.5 for both). Conclusions: Women who undergo coronary revascularization experience decreases in social support after their procedures. Gender-specific interventions are needed to preserve, improve, or enhance social support for women undergoing coronary revascularization.
References
1. Spertus JA, Bliven BD, Farner M, Gillen A, Hewitt T, Jones P, McCallister BD: Integrating baseline health status data collection into the process of care. Jt Comm J Qual Improv 2001; 27:369–380[Medline]
2. Vaccarino V, Lin ZQ, Kasl SV, Mattera JA, Roumanis SA, Abramson JL, Krumholz HM: Sex differences in health status after coronary bypass surgery. Circulation 2003; 108:2642–2647[Abstract/Free Full Text]
34. Defining Distress Experienced by Caregivers of Cardiac Patients: Preliminary Data
B. Yanowitz; L. Clemow; C.E. Skotzko, MD, FAPM
Objective: Intrigued by prior studies of distress in caregivers of patients with Alzheimer’s disease, the authors examined the effect on caregivers of caring for a patient with cardiovascular illness. By elucidating areas of distress and correlating them with variables such as age, gender, quality of relationship, life satisfaction, economic support, education, and the severity/chronicity of cardiac disease, the authors hoped to provide a better understanding of the stresses associated with caregiving in cardiac disease and to provide a basis for developing targeted interventions that may then be tested. Methods: A preliminary group of 22 caregivers (recruitment is ongoing) were enrolled while their loved ones were either hospitalized or returning for outpatient treatment. In addition to providing demographic data, the participants completed the Perceived Stress Scale (PSS), Dyadic Adjustment Scale (DAS), Caregiver Burden Scale (CBS), and the Brief Symptom Inventory (BSI). Results: Sixteen women and six men participated. The men were older than the women (mean age=67 years, compared with 51 years for the women). Preliminary data suggested that adult children living in the home increased the burden felt by the caregiver. This result was unanticipated, because it was thought that the presence of adult children in the home would decrease the amount of burden the caregiver experienced. BSI scores demonstrated dramatic differences in distress experienced by parental caregivers. Conclusions: These initial data offer some suggestion of the complex relationships associated with caregiving for cardiac patients. To develop appropriate interventions, a better understanding of the idiosyncrasies associated with this role is needed. This preliminary assessment provided clues to the stress and responsibilities engendered in this activity.
References
1. Van Horn E, Fleury J, Moore S: Family interventions during the trajectory of recovery from cardiac event: an integrative literature review. Heart Lung 2002; 31:186–198[CrossRef][Medline]
2. Gage-Rancoeur DM, Purden MA: Daughters of cardiac patients: the process of caregiving. Can J Nurs Res 2003; 35:90–105[Medline]
Concurrent Paper Sessions
SESSION A: Issues in Long-Term Care and Geriatric Patients
Incidence, Risk Factors, and Phenomenology of PTSD in Patients With Moderate to Severe Traumatic Brain Injury
J.R. Fann, MD; C. Bombardier, PhD; N. Temkin, PhD; P. Esselman, MD; E. Pelzer, BS; M. Keogh, BS; S. Dikmen, PhD
Background: Anxiety is common after moderate to severe traumatic brain injury. The epidemiology of posttraumatic stress disorder (PTSD) after traumatic brain injury is controversial, because impaired memory is associated with traumatic brain injury. Few studies have examined the epidemiology and phenomenology of PTSD longitudinally by using standardized instruments. Objectives: The purpose of this study was to determine 1) the incidence of PTSD in patients admitted to a trauma unit for moderate to severe traumatic brain injury; 2) the medical, psychiatric, and demographic risk factors for PTSD in this population; and 3) the phenomenology of PTSD symptoms in this population. Methods: In this prospective cohort study, patients were interviewed by telephone monthly from 1 to 6 months after hospitalization for traumatic brain injury. Demographic and clinical data were obtained at admission from medical records, patients, and family members. The study was conducted at Harborview Medical Center (HMC) in Seattle, a level-1 trauma center serving Washington, Idaho, Montana, and Alaska. A total of 124 adult, English-speaking patients admitted to HMC with moderate to severe traumatic brain injury, as determined by a Glasgow Coma Scale (GCS) score < 13 and/or computerized tomography evidence of acute injury, participated in the study. Measures included the PTSD Checklist—Civilian Version (PCL-C) and the Patient Health Questionnaire modules for major depressive disorder, panic disorder, and other anxiety disorders. Data on patients’ past psychiatric history were obtained. Results: The incidence of PTSD was 11.3% over 6 months. The peak prevalence of PTSD occurred 1 month after traumatic brain injury (12.5%). Among all patients, 72.9% reported an inability to recall whether they felt terrified or helpless during the traumatic event. Univariate analysis revealed current major depression (p<0.0001) and other anxiety disorder (p<0.0001), blood alcohol level >0.08 (p<0.05), past PTSD (p<0.001), and any psychiatric history (p<0.05) to be significantly associated with the occurrence of PTSD. Overall PTSD symptom severity was syndromal (PCL-C score >45) in 3.7% of patients and subsyndromal (PCL-C score <45) in 96.3% of patients. Patients with syndromal severity rated their general health as significantly worse than patients with subsyndromal severity (p=0.0001). Among all assessments over the 6-month study period, rates of PTSD symptom cluster endorsement were 22.6% for arousal symptoms, 20.0% for intrusive symptoms, and 8.2% for avoidance and numbing symptoms. The most common specific PTSD symptoms were trouble falling asleep (22.4%); being superalert, watchful, or on guard (21.9%); and irritable or angry outbursts (19.3%). Conclusions: PTSD is uncommon in the 6 months after moderate to severe traumatic brain injury. Major depression or generalized anxiety after traumatic brain injury, alcohol intoxication at the time of injury, and evidence of past psychiatric history are associated with PTSD after traumatic brain injury. PTSD symptom clusters of persistent increased arousal and trauma reexperiencing and PTSD symptoms of trouble falling asleep and hypervigilance are not uncommon. Patients with more severe PTSD symptoms report worse general health.
References
1. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA: Psychometric properties of the PTSD checklist (PCL). Behav Res Ther 1996; 34:669–673[CrossRef][Medline]
2. Bryant RA, Marosszeky JE, Crooks J, Gurka JA: Posttraumatic stress disorder after severe traumatic brain injury. Am J Psychiatry 2000; 157:629–631[Abstract/Free Full Text]
Caregiver Mood and Assessment of Patient Depression in Alzheimer’s Disease
P.B. Rosenberg, MD; C.G. Lyketsos, MD, FAPM; M.M. Mielke, BS
Background: Clinicians and researchers have long noted the need for caregiver input into the assessment of depression and other neuropsychiatric symptoms in Alzheimer’s disease. However, there are persistent discrepancies between caregiver and patient input, with caregivers tending to rate depressive symptoms higher than patients.(1) Because caregivers of Alzheimer’s disease patients often have depressive symptoms themselves, it is possible that caregivers’ input may be biased by their mood and sense of burden in caregiving. The authors sought to assess the effect of caregivers’ mood and burden on patients’ mood, comparing results from measures that utilize significant input from caregivers with results from measures that do not. In addition, the authors sought to assess the stability of the effect of caregivers’ mood on patients’ mood measured longitudinally over the course of a treatment study. Methods: Forty-four patients with major depression and Alzheimer’s disease were enrolled in a 12-week randomized, double-blind, placebo-controlled trial of sertraline.(2) Thirty-six patients completed the trial (21 patients who were taking sertraline and 15 who received placebo). At baseline and at 3, 6, 9, and 12 weeks, caregivers were administered the Beck Depression Inventory and the Screen for Caregiver Burden. Patients were administered the Hamilton Depression Rating Scale, which does not utilize caregiver input, as well as two scales that utilize caregiver input—the Cornell Scale for Depression in Dementia and the Neuropsychiatric Inventory. Univariate and multiple regression analyses were performed for each time point, with caregiver measures as the independent variables and patient measures as the dependent variables. Repeated-measures analysis of variance was performed to assess the effect of time on caregiver measures. Results: Caregiver mood and burden accounted for 9%–13% of the variance in patient mood variables at baseline; the score on the Cornell Scale for Depression in Dementia was influenced more by caregiver mood and burden than were the scores on the Neuropsychiatric Inventory depression domain and the Hamilton depression scale. However, the effect of caregiver mood and burden on patient mood variables declined after the baseline assessment and was no longer significant at the follow-up evaluations. Caregiver mood and burden declined significantly over the course of the study, but there was no effect of treatment condition on this improvement. Conclusions: As expected, caregiver mood and burden accounted for a modest but statistically significant proportion of variance in patient mood variables only at baseline in a 12-week treatment study. After baseline, the caregiver and patient variables were no longer significantly associated. Although both caregiver mood and patient mood improved,(2) the improvements were not correlated. The authors hypothesize that either caregivers or interviewers became more able to distinguish patient and caregiver mood with repeated assessment. This finding implies that clinicians assessing depression in Alzheimer’s disease may need to repeat assessments to obtain a more objective evaluation.
References
1. Burke WJ, Roccaforte WH, Wengel SP, McArthur-Miller D, Folks DG, Potter JF: Disagreement in the reporting of depressive symptoms between patients with dementia of the Alzheimer type and their collateral sources. Am J Geriatr Psychiatry 1998; 6:308–319[Medline]
2. Lyketsos CG, DelCampo L, Steinberg M, Miles Q, Steele CD, Munro C, Baker AS, Sheppard JM, Frangakis C, Brandt J, Rabins PV: Treating depression in Alzheimer disease: efficacy and safety of sertraline therapy, and the benefits of depression reduction: the DIADS. Arch Gen Psychiatry 2003; 60:737–746[Abstract/Free Full Text]
Do Cortisol Abnormalities Mediate the Effects of Hopelessness and Depression on the Health of Older Mexican and European Americans?
S.L. Stern, MD; H.P. Hazuda, PhD; M.A. Javors, PhD; J.P. Hatch, PhD; M.J. Lichtenstein, MD
Objectives: The purpose of the study was to ascertain whether abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis might help to explain the increased mortality that has been reported in older persons with hopelessness or depression. Methods: The authors obtained a morning (8:00–9:00 a.m.) and an evening (8:00–9:00 p.m.) saliva sample from 92 Mexican American and European American participants in the San Antonio Longitudinal Study of Aging (SALSA), an epidemiologic survey. After assaying the samples for cortisol by using a commercially available immunoassay kit, the authors calculated the variance, defined as the difference between the morning and evening values divided by their mean. Cortisol variables were correlated with scores on the Beck Hopelessness Scale and the Geriatric Depression Scale, completed by the participants in English or Spanish approximately 1–3 weeks before the date of sample collection. Nonparametric statistics were used in the data analysis because the cortisol values were not normally distributed. Results: Forty-eight (52%) subjects were women, and 52 (57%) were Mexican American. Participants’ ages ranged from 73 to 85 years. There was no significant association between gender, ethnicity, age, education, or household income and any of the cortisol variables. The authors did find significant negative correlations between the total Beck Hopelessness Scale score and both morning cortisol values (r=–0.24, p<0.05) and variance (r=–0.29, p<0.01), i.e., the more hopeless a subject was, the lower was his or her morning cortisol level and the lower was the variance between the morning and evening levels. No significant correlations were found between the total Geriatric Depression Scale score and any of the cortisol variables, but the 12 participants who scored 11 (the usual cutoff point for probable depression) had significantly lower morning cortisol levels than the nondepressed subjects (mean=0.27, SD=0.14, compared with mean=0.66, SD=1.67; p<0.01) and a significantly smaller variance (mean=0.48, SD=0.91, compared with mean=0.91, SD=0.76; p<0.05). Evening cortisol values did not correlate with either hopelessness or depression. Conclusions: These data suggest that older persons with symptoms of hopelessness or depression may have a dysregulated HPA axis, characterized by a flattened daily cortisol curve (little difference between morning and evening values) and relatively low morning cortisol concentrations. Because both a flattened cortisol curve and low cortisol levels may be associated with adverse health effects, the findings could, in part, explain the mechanisms by which hopelessness and depression are associated with increased mortality in elderly persons.
References
1. Rosmond R, Dallman M, Bjorntorp P: Stress-related cortisol secretion in men: relationships with abdominal obesity and endocrine, metabolic, and hemodynamic abnormalities. J Clin Endocrinol Metab 1998; 83:1853–1859[Abstract/Free Full Text]
2. Raison CL, Miller AH: When not enough is too much: the role of insufficient glucocorticoid signaling in the pathophysiology of stress-related disorders. Am J Psychiatry 2003; 160:1554–1565[Abstract/Free Full Text]
Long-Term (2-Year) Effectiveness of Collaborative Care for Late-Life Depression
J. Unützer, MD; W.J. Katon, MD, FAPM; E. Hunkeler, MA; C. Callahan, MD; J. Williams, Jr., MD; L. Harpole, MD, MPH; M. Hoffing, MD
Background: Few depressed older adults receive effective treatment in primary care. The authors present new 2-year follow-up data from project IMPACT, the largest quality improvement trial for late-life depression in general medical settings to date. Methods: The authors enrolled a multiethnic group of 1,801 older adults with major depression or dysthymia from 18 primary care clinics across the United States in a randomized trial to evaluate a collaborative care model for late-life depression. The intervention participants had access to a primary-care-based depression care manager with backup from a team psychiatrist and a primary care expert for 12 months. The comparison patients received care as usual. All participants were independently assessed at baseline and at 3, 6, 12, 18, and 24 months. Results: During the initial 12 months, the intervention participants reported more adequate depression treatment, less depression, and better functioning than the patients who received care as usual. Even after intervention resources were withdrawn in the second year, the participants who had received the intervention continued to have significantly less depression and better functioning. At 24 months, 460 (55%) intervention patients were taking antidepressants, compared to 344 (41%) patients in usual care (p<0.001). A total of 290 (34%) intervention patients reported at least a 50% reduction in depressive symptoms from baseline, compared to 196 (23%) in usual care (p<0.01). Over 2 years, the intervention patients had 103 more depression-free days than the patients who received care as usual (p<0.01). Approximately one-half of these additional depression-free days were accrued during the second year of the study, a time when the study intervention was no longer available. Compared with the patients who received usual care, the intervention patients reported significantly better functioning on the physical functioning component score of the Medical Outcomes Study 12-item Short-Form Health Survey at 12 (p<0.01) and 24 (p=0.03) months. Conclusions: The IMPACT collaborative care model was feasible and significantly more effective than usual care for a diverse population of depressed older adults. Significant differences in depression and functioning persisted a full year after IMPACT resources were no longer available.
References
1. Callahan CM: Quality improvement research on late life depression in primary care. Med Care 2001; 39:772–784[CrossRef][Medline]
2. Unützer J, Katon WJ, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noel PH, Lin EH, Arean PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C, IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) Investigators: Collaborative care management of late-life depression: a randomized controlled trial. JAMA 2002; 288:2836–2845[Abstract/Free Full Text]
Depression Is a Significant Risk for Feeding Tube Placement in Nursing Home Residents Without Dementia
T. Rabinowitz, MD, FAPM; R.N. Jones, ScD; K.M. Murphy, PhD
Background: For many elders, feeding tube placement may signal the beginning of a downward spiral with respect to autonomy, function, and life expectancy. Rather than prolonging life or enhancing quality of life, these devices may be a noxious encumbrance accepted by patients who are too depleted by one or more chronic or acute illnesses to effectively advocate on their own behalf or to resist pressures from well-meaning loved ones, nurses, or physicians. The authors were interested in learning whether depression might be a risk factor for feeding tube placement, given that associated symptoms may include apathy, despondency, and lack of initiative—all possible reasons why an affected elder might not refuse feeding tube placement. Methods: Included in the study were 1,225 persons admitted to a large research and training nursing home between 1994 and 2002. The study participants 1) did not have feeding tubes at admission, 2) did not have an advance directive regarding nutritional approach, 3) were not comatose at admission, and 4) were not severely impaired in daily decision making at admission. Residents were assessed repeatedly at approximately 2- or 3-month intervals during the research period by using the Minimum Data Set for long-term care. Depression was defined with the Minimum Data Set Depression Rating Scale; an additive sum of seven Minimum Data Set depression symptoms, each scored 0, 1, or 2, reflected the frequency with which symptoms occurred (range=0–14). A score of 2 or higher identifies persons with significant depression. Control variables in this study included age, gender, level of depression, clinical complexity, level of cognitive functioning, and presence of dementia symptoms. The authors used survival analysis techniques, including Cox’s proportional hazards models, to examine the relationship between depression, control variables, and risk of feeding tube placement. Results: Feeding tubes were placed in 29 residents, for an incidence of about 10 feeding tube placements per 1,000 person-years of residence. Feeding tubes were placed between postadmission months 3 and 65; half of the residents for whom feeding tubes were placed had the procedure before postadmission month 19. Risk of feeding tube placement was much higher among persons with depression (Minimum Data Set Depression Rating Scale score 2) in the preceding assessment period. Among resident assessments indicating the placement of a feeding tube, the prevalence of depression symptoms in the preceding assessment was 72% (95% confidence interval [CI]=56%–87%). For the remainder of resident assessments, the prevalence of depression symptoms was 49% (95% CI=47%–49%). The hazard ratio for depression symptoms was 2.7 (p<0.02, 95% CI=1.2–6.2). This magnitude of effect was not substantially altered by adjustments for control variables, including age, gender, baseline health and cognitive factors, and time-varying and lagged health and cognitive factors. There was no evidence that the risk of feeding tube placement associated with depression varied with time in residence. Depression was very common among the residents in the study. The prevalence of depression at admission was 31% (95% CI=29%–34%), and the incidence among those admitted without depression was about 450 per 1,000 person-years of residence. Episodes of depression endured between 2 weeks and 72 months, with a median of 8 months, but for half the study group, the range was between 3 and 22 months (interquartile range). The population attributable risk percentage for feeding tube placement given depression was 27%, which implies that if depression is causally related to feeding tube placement, the incidence of feeding tube placement could be reduced by about 25% if depression is adequately treated or the mechanism linking depression and feeding tube placement is effectively eliminated. Conclusions: These findings lend strong support to the need for competent geriatric psychiatry consultation for nursing home residents. If depression (a common problem in nursing home residents) is detected and treated promptly, feeding tube placement might be avoided in a sizeable proportion of these elders. This outcome would have a significant positive effect on quality of life for this frail and often overlooked population.
References
1. Mitchell SL, Kiely DK, Hamel MB: Dying with advanced dementia in the nursing home. Arch Intern Med 2004; 164:321–326[Abstract/Free Full Text]
2. Gillick MR: Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 2000; 342:206–210[Free Full Text]
Development and Evaluation of a Best Practice Initiative to Improve Nursing Home Quality in Management of Depression
K.M. Murphy, PhD; T. Rabinowitz, MD, FAPM; S. Nonemaker, MS, RN; J.N. Morris, PhD
Depression affects almost two-thirds of long-stay nursing home residents and is associated with considerable morbidity and impaired quality of life. Quality concerns regarding failure to diagnose; inadequate treatment and monitoring; and unnecessary cognitive, functional, and health decline are widespread among residents and their families, regulatory agencies, and the general public. Although published best-practice clinical guidelines for assessment and treatment are readily available, nursing homes are poorly prepared to provide the necessary services. The authors developed, implemented, and evaluated the effectiveness of a depression management program in achieving improved nursing home care quality for depression and commonly associated problems. The program was designed as a systems-based, facility-wide intervention in which all staff (including housekeepers) were trained in the use of screening, assessment, and treatment protocols that were based on published clinical guidelines, where available. The study was conducted in eight average-quality nursing homes (four with the intervention and four with "usual care"). All non-Medicare residents were eligible for participation. At each intervention site, nursing home staff implemented the program with the assistance of initial training and regular on-site and telephone consultation with nurse educators from the research team. Facility staff implemented the following procedures: quarterly screening of all residents for participation in the program based on the Minimum Data Set Depression Rating Scale scores; protocols for evaluating associated signs and symptoms often associated with depression in this population (e.g., suicidal ideation, untreated pain, cognitive decline); protocols for care planning and follow-up evaluation, including when to consult with a psychiatrist and how to monitor the effectiveness and side effects of pharmacological treatment; and quality monitors for assuring adherence to these and other study protocols. After detection and assessment of depression, nursing home staff were directed to report their findings to the resident’s primary physician and develop interdisciplinary, individualized care plans utilizing resources available at each facility to address seven issues associated with depression: safety, pain, sleep disorders, weight loss and dehydration, social isolation, withdrawal from activities once enjoyed, and family educational needs. Emphasis was also placed on the value of social support, including how to communicate with depressed elders and how to discuss difficult topics (e.g., suicide). To evaluate study outcomes, the authors conducted a cross-sectional comparison of pre- and postintervention quality at the facility level using seven Centers for Medicare and Medicaid Mega-Quality Indicators derived from computerized longitudinal Minimum Data Set Version 2.0 resident assessments completed by facility staff. The analyses included data for all residents at each facility at baseline (January to March 2002), compared with those at follow-up (January to March 2003). Over 12 months, the intervention nursing homes achieved an 8% improvement in depression quality indicator rates, compared with an 18% decline in the usual-care nursing homes. Although the intervention nursing homes improved their communication and weight loss quality indicator rates (by 6% and 10%, respectively), the usual-care nursing homes declined in these areas (by 42% and 100%, respectively). The most dramatic areas of improvement for the intervention group occurred in resident activity involvement (69%) and pain management (61%). Nurses at intervention sites reported feeling more knowledgeable and empowered in discussing cases with consultation psychiatrists, particularly regarding the use and side effects of antidepressants. These findings demonstrate the feasibility and effectiveness of a multifaceted, systems approach to support nursing home staff in introducing strategies for improving the quality of care for depressed nursing home residents.
References
1. American Geriatrics Society; American Association for Geriatric Psychiatry: Consensus statement on improving the quality of mental health care in US nursing homes: management of depression and behavioral symptoms associated with dementia. J Am Geriatr Soc 2003; 51:1287–1298[CrossRef][Medline]
2. Burrows AB, Morris JN, Simon SE, Hirdes JP, Phillips C: Development of a minimum data set-based depression rating scale for use in nursing homes. Age Ageing 2000; 29:165–172[Abstract/Free Full Text]
SESSION B: Consultation: Cancer, Delirium, and Pain
Psychoactive Medications and Risk of Delirium in Hospitalized Cancer Patients
J-D Gaudreau, MD, PhD; P. Gagnon, MD, FRCP(C); F. Harel, MSc; M-A Roy, MD, FRCP(C); A. Tremblay, MD, FRCP(C)
Background: Psychoactive medications are biologically plausible and potentially modifiable risk factors of delirium. To date, however, research findings are inconsistent regarding their association with delirium. The purpose of this study was to examine the association between risk of delirium and exposure to anticholinergics, benzodiazepines, corticosteroids, and opioids. Methods: A total of 145 hospitalized cancer patients were followed up with repeated assessments with the Nursing Delirium Screening Scale for up to 4 weeks for incident delirium. Detailed data on exposure to psychoactive medications were obtained daily. The strength of the association between exposure to psychoactive medications and delirium was expressed as a hazard ratio in univariate and multivariate analyses conducted with Cox’s regression models. All medication variables were coded as time-dependent covariates. Whenever possible, exposure was computed by using cumulative daily doses in equivalents; dichotomous cutoff values were determined. Results: During follow-up (median=9.9 days), 30 patients became delirious (20.7%). Delirium was associated with a history of delirium (p=0.0001) and the presence of hepatic metastases (p=0.009) at admission. Analysis of the effect of medications was done with adjustment for these factors. Patients exposed to daily doses of benzodiazepines above 1 mg (hazard ratio=2.79, 95% confidence interval [CI]=1.14–6.82), of corticosteroids above 20 mg (hazard ratio=3.71, 95% CI=1.12–12.30), or of opioids above 180 mg (hazard ratio=3.58, 95% CI=1.15–11.11) had higher risks for delirium. No associations between anticholinergics and risk for delirium were observed. Conclusions: Exposure to opioids, corticosteroids, and benzodiazepines is independently associated with an increased risk of delirium in hospitalized patients.
References
1. Marcantonio ER, Juarez G, Goldman L, Mangione CM, Ludwig LE, Lind L, Katz N, Cook EF, Orav EJ, Lee TH: The relationship of postoperative delirium with psychoactive medications. JAMA 1994; 272:1518–1522[Abstract/Free Full Text]
2. Ljubisavljevic V, Kelly B: Risk factors for development of delirium among oncology patients. Gen Hosp Psychiatry 2003; 25:345–352[CrossRef][Medline]
Psychiatric Comorbidity Diminishes Opioid Analgesia in Low Back Pain
A.D. Wasan, MD; G. Davar, MD; R. Jamison, PhD
Background: Psychiatric comorbidity affects approximately 50% of all patients with chronic low back pain and diminishes the effectiveness of many treatments.(1) Increased attention to and awareness of pain may mediate the link between psychiatric comorbidity and poor treatment outcome. This pathology consists primarily of depression, anxiety related to pain, and neuroticism, which often occur together in some combination of symptoms.(1) It is not known if psychiatric comorbidity is associated with diminished opioid analgesia in patients with chronic, noncancer pain. Given the explosion in prescribing oral opioids for chronic low back pain, this question is particularly salient. This study tested the hypothesis that psychiatric comorbidity diminishes opioid analgesia in patients with discogenic low back pain. Methods: The study included 60 patients with chronic discogenic low back pain, confirmed by evaluation of two pain medicine physicians and corroborated by magnetic resonance imaging. The study participants were not taking opioids. In a double-blind, placebo-controlled, random crossover study, subjects were given intravenous morphine (4–6 mg dosed by ideal body weight) and placebo. Patients were stratified into three groups of psychiatric symptom severity (low, moderate, and high) on the basis of composite scores on scales measuring depression severity (Beck Depression Inventory), anxiety related to pain (Pain Anxiety Symptom Scale), and neuroticism (NEO Personality Inventory). To be in the high psychiatric symptom severity group, subjects had to have elevations greater than the 75th percentile on at least two of the three measures. Subjects received intravenous morphine or placebo in random order on separate visits and completed a 0–10 pain rating along with lumbar flexion/extension measurements every 20 minutes for 3 hours. The primary outcome measure was percentage of maximum summed pain intensity differences (% MaxSPID). Data were also gathered on multiple secondary outcomes, including pain relief ratings and affective and sensory pain changes. Results: Twenty subjects in the high psychiatric symptom severity group, 20 in the moderate severity group, and 20 in the low severity group completed the study. There were nonsignificant differences in age, sex distribution, baseline pain ratings (mean=6.1), pain medications used, and morphine dose (5.0 mg). For morphine analgesia, analysis of variance revealed that the low severity group had 59% MaxSPID, compared with only 35.8% in the high severity group (p=0.002). For placebo analgesia, the low severity group had 10.1% MaxSPID, compared with 23.6% in the high severity group (p=0.06). When the effect of placebo analgesia was subtracted from the effect of morphine analgesia, the results were 48% MaxSPID in the low severity group versus 17.5% in the high severity group (p<0.001). Conclusions: High levels of psychiatric comorbidity are associated with diminished opioid analgesia in patients with discogenic low back pain. Both lower analgesia in response to morphine and greater analgesia in response to placebo in the high psychiatric symptom severity group contributed to this conclusion. The lack of significant findings in the moderate psychiatric symptom severity group suggests that there is a threshold level of psychopathology that predicts poor opioid analgesia. These results have implications for the prescription of oral opioids in patients with chronic pain and psychiatric comorbidity. They also give impetus for the investigation of mechanisms by which affective illness diminishes opioid analgesia, as well as for a longitudinal study of oral opioid effectiveness in relation to psychiatric comorbidity.
Reference
1. Clark MR, Cox TS: Refractory chronic pain. Psychiatr Clin North Am 2002; 25:71–88[CrossRef][Medline]
The Use of Simulated Patients to Assess Primary Care Physicians’ Treatment of Depression
S.A. Epstein, MD, FAPM; L.M. Hooper, PhD; K. Weinfurt, PhD; W. Harless, PhD; L.A. Cooper, MD
Background: Some primary care physicians provide less than optimal care for depression. The provision of key educational messages regarding antidepressant treatment has been associated with improved outcomes.(1) Similarly, primary care patients have clearly been shown to benefit from psychotherapeutic treatment of depression.(2) In this study, the authors sought to describe variations in depression care for simulated patients with identical depression symptoms assessed by a regional sample of primary care physicians. Methods: Participating in the study were 319 randomly selected primary care physicians (participation rate=67%; 53% were family physicians and 47% were internists; 60% were male; 45% were European American, 37% were African American, 18% were of other ethnicities). Actors were hired to play the role of a depressed patient in the context of a primary care office visit. These vignettes were taped and transferred to CD-ROM to be used during the interview with the physician-participants. At the time of the interview, each physician interacted with a CD-ROM vignette of one patient with depression. Although each patient had identical explicit depression symptoms, patients varied along the following dimensions: medical illness comorbidity (recovering from myocardial infarction versus healthy), attributional style (somatic versus psychological), attitude toward depression treatment (accepting versus resistant), race (African American versus white), and gender. In a semistructured interview, the physicians were asked about 1) leading diagnoses; 2) additional essential information that they would want to obtain regarding the patient’s clinical condition; and 3) leading treatment recommendations, including the provision of key educational messages. Results: For these patients with clear presentations of depression, almost all of the physicians (98%) made a diagnosis of depression. The physicians varied regarding the additional essential information they would need about the patient, besides what was presented in the CD-ROM vignette. Thirty-four percent stated they would want to know if the patient had experienced a prior depressive episode, 2% wanted to know about history of bipolar symptoms, 34% about suicidal ideation, and 9% about current and/or previous sexual dysfunction. Forty-three percent indicated that they would want to obtain thyroid function tests. Eighty-five percent recommended an antidepressant, and among these physicians, 85% prescribed a selective serotonin reuptake inhibitor. Some physicians stated that their antidepressant treatment would also include key educational messages about 1) sexual side effects (mentioned by 42% of physicians), 2) gastrointestinal side effects (59%), 3) sleep-related side effects (31%), 4) delay before reaching therapeutic effect (59%), 5) the need to take medication every day (14%), 6) the need to take medication even if feeling better (6%), and 7) the need to take medication for at least 6 months (13%). Fifty-four percent of the physicians reported that they would refer the patient to a mental health provider (i.e., 17% would refer to a psychiatrist, 30% to a psychologist, 9% to a social worker, 44% to a practitioner in a specialty not specified) for counseling or psychotherapy. Twenty-one percent of the physicians indicated that they would conduct office-based counseling themselves. Conclusions: Primary care physicians often recommend antidepressants for the treatment of depression. There is wide variability regarding the provision of key educational messages associated with antidepressant treatment. Similarly, there is variation in the extent to which psychotherapy is incorporated into primary care physicians’ recommendations for depression care. Thus, some primary care physicians may benefit from further education regarding the optimal management of depression.
References
1. Lin EH, Katon WJ, Simon GE, Von Korff M, Bush TM, Rutter CM, Saunders KW, Walker EA: Achieving guidelines for the treatment of depression in primary care: is physician education enough? Med Care 1997; 35:831–842[CrossRef][Medline]
2. Meredith LS, Mazel RM: Counseling for depression by primary care providers. Int J Psychiatry Med 2000; 30:343–365[CrossRef][Medline]
Referrals to a New Consultation Service for Parents With Cancer
A.C. Muriel, MD; M. Beiser, BA; S. Durant, EdD; C. Moore, PhD; S. Swick, MD; P.K. Rauch, MD
Background: The National Cancer Institute estimates that 24% of adults with cancer have children under age 18 years, yet parenting issues are rarely considered when addressing the psychiatric and psychosocial needs of these medically ill adults. In response to clinical need at the Massachusetts General Hospital Cancer Center, the authors established a new parent guidance consultation service. Now 5 years old, the Parenting at Challenging Times (PACT) program is funded by institutional and philanthropic support and is staffed by three child psychiatrists and two child psychologists for a total of two full-time-equivalent staff members. Methods: The service receives referrals from any member of the multidisciplinary health care team. Demographic information and presenting problems are documented at the time of intake. Results: During a 9-month period, 106 families were referred. Fifty-nine percent of ill parents were mothers, and the mean age of the children in the referred families was 11 years (range 0–18 years). Patients were referred during all stages of illness, most commonly either at the time of diagnosis (27%) or near the end of life (24%). Patients were also referred during phases of active treatment (19%) or in the transition to palliative care (10%). Referrals most often came from the treating oncologist (26%), oncology social worker (18%), or palliative care physician (13%). The full range of cancer disease sites is represented, with a majority of patients having thoracic cancers (25%), breast cancer (19%), or brain tumors (9%). Presenting concerns were frequently related to how to communicate with children about the illness (24%) and how to enhance children’s coping with the illness and disruptions to family life (21%). Patients also presented with significant concerns about end-of-life issues (19%) and specific problem behaviors among the children (18%). The number of visits per family ranged from one to >10, with a bimodal distribution based on clinical need. Conclusions: A hospital-based parent guidance program can provide valuable consultation to parents with cancer as well as to the multidisciplinary health care team. Medical patients who are parents have specific needs in relation to their children that can contribute to significant emotional distress. Procedures for addressing parenting issues should be part of all comprehensive psychosocial care plans for adults with cancer and other serious illnesses.
References
1. National Health Interview Survey, 1992. Hyattsville, Md, National Center for Health Statistics, 1992
2. Rauch PK, Muriel AC, Cassem NH: Parents with cancer: who’s looking after the children? J Clin Oncol 2002; 20:4399–4402[Free Full Text]
Psychotropics, Opioids, and Other Medications in Palliative Care: Dosage Differences Between Hospices and General Hospitals
P. Gagnon, MD, FRCP(C); F. Tardif, MSc; P. Allard, MD, FRCP(C), PhD; B. Gagnon, MD; C. Mérette, PhD; L. Croteau, MA; C. Edmond, MSc; C. Soulard, RN
Background: Clinical experience reveals that palliative care units located in freestanding hospices have different medication prescription practices than hospices located in general hospitals. Yet, no data or systematic comparison of prescription practices have been reported so far. These differential practices may shed light on how practitioners medically approach death and may have significant clinical, psychosocial, and ethical implications. Objective: The purpose of this study was to compare medication dosages between hospice and general-hospital palliative care units, including dosages of psychotropics, opioids, and other related medications. Methods: Cancer patients (N=350) in three hospices and patients (N= 750) in four general-hospital palliative care units in Québec and Ontario were followed prospectively from May 2002 to March 2004. Data on medication dosages were collected daily from admission until the patient’s death or discharge. Opioid, benzodiazepine, corticosteroid, and antipsychotic doses were converted in equivalent units (mg of subcutaneous morphine, lorazepam by mouth, dexamethasone by mouth, and haloperidol by mouth). The frequency of the use of co-analgesic and anticholinergic prescriptions was also recorded. Results: No differences were found between hospice and hospital patients regarding demographic characteristics (sex, age), performance status, life expectancy, primary cancer sites, metastatic spread, and vital organ failures. The frequency of opioid, antipsychotic, corticosteroid, and anticholinergic prescriptions was similar in the hospices and the hospitals. However, opioid doses were nearly twice as high in the hospitals, compared to the hospices (127.4 mg/day per patient of morphine equivalents versus 71.2 mg/day per patient; p< 0.001). Methadone represented 13% of all opioid prescriptions in the hospitals, compared to nearly none in the hospices. Doses of benzodiazepines were also higher in the hospitals, compared to the hospices (5.2 mg of lorazepam equivalents/day versus 2.7 mg/day; p<0.001). Midazolam was administered six times more often in the hospitals than in the hospices. On the other hand, antipsychotic doses were higher in the hospices than in the hospitals (3.0 mg/day of haloperidol equivalents versus 2.3 mg/day; p< 0.001). Methotrimeprazine was the most frequently used antipsychotic in the hospitals (40% of all antipsychotic prescriptions), and haloperidol was the most frequently used antipsychotic in the hospices (65%). Benzodiazepines and co-analgesics were prescribed more frequently in the hospices (0.79 prescriptions/patient-day of benzodiazepines for hospices, compared to 0.4 for hospitals; p<0.001) (0.29 prescriptions/patient-day of co-analgesics for hospices versus 0.13 for hospitals; p<0.001). A weak but significant correlation was observed between doses of opioids and doses of antipsychotics (r=0.24), benzodiazepines (r=0.22), and corticosteroids (r=0.19) (p<0.001 for all). Conclusions: For apparently similar cancer palliative care populations, 1) opioids and benzodiazepines were prescribed in a significantly higher dosage in hospitals, compared to hospices; 2) antipsychotics were prescribed in a significantly higher dosage in hospices, compared to hospitals; 3) there were differences in the types of opioids, antipsychotics, and benzodiazepines prescribed in hospices, compared to hospitals; 4) there was a weak but significant correlation between dosage of opioids and dosage of antipsychotics, benzodiazepines, and corticosteroids; and 5) these differences may reveal a greater sedation profile of medications in hospitals, compared to hospices.
References
1. Hollen CJ, Hollen CW, Stolte K: Hospice and hospital oncology unit nurses: a comparative survey of knowledge and attitudes about cancer pain. Oncol Nurs Forum 2000; 27:1593–1599[Medline]
2. Lammi U-K, Kosunen E, Kellokumpu-Lehtinen P: Palliative cancer care in two health centres and one hospice in Finland. Support Care Cancer 2000; 9:25–31
Clinical Presentation of Delirium in Patients Undergoing Hematopoietic Stem Cell Transplantation
J.R. Fann, MD; C.M. Alfano, PhD; B.E. Burington, MS; S. Roth-Roemer, PhD; W.J. Katon, MD, FAPM; K.L. Syrjala, PhD
Background: Delirium is common in patients undergoing hematopoietic stem cell transplantation and has been associated with considerable morbidity and excess mortality in diverse groups of patients. Although delirium can be successfully treated, it is largely unrecognized and undiagnosed. Recognizing delirium in patients undergoing hematopoietic stem cell transplantation is difficult without understanding the clinical presentation of delirium in these patients. Objectives: In this study, the authors 1) used factor analytic techniques to describe the major groups of delirium symptoms presented by patients who experienced a delirium episode; 2) examined the time course of these symptoms in patients with delirium, compared to those without delirium; and 3) investigated the comorbidity of delirium symptoms and distress. Methods: In this prospective cohort study, patients were assessed for delirium three times per week during the 30 days posttransplantation. Distress and pain were assessed at each delirium assessment. The subjects were 90 adult patients with malignancies admitted to Fred Hutchinson Cancer Research Center in Seattle from 1997 to 1999 for their first allogeneic or autologous stem cell transplantation. Study measures included the Delirium Rating Scale, Memorial Delirium Assessment Scale, Confusion Assessment Method, Profile of Mood States, and a Likert-style pain scale. Results: Delirium episodes occurred in 50% of patients, and prevalence peaked at the end of the second week posttransplantation. Mean episode duration was approximately 10 days. Factor analysis of delirium symptoms revealed three groups of symptoms representing 1) psychosis/behavior (e.g., hallucinations, delusions, psychomotor disturbance), 2) cognition (e.g., disorientation, short-term memory disturbance), and 3) mood/consciousness (e.g., mood lability, sleep/wake cycle disturbance). These factors accounted for 18%, 16%, and 10% of the variance, respectively. The vast majority of delirium was of a hypoactive subtype. Delirium episodes were characterized by rapid onset of psychomotor and sleep/wake cycle disturbance that persisted and cognitive symptoms that continued to worsen throughout much of the episode. Common distress symptoms that were comorbid with delirium included fatigue and anger. Conclusions: The results describe the clinical presentation of delirium in patients undergoing hematopoietic stem cell transplantation. The findings can be used to aid clinicians in recognizing delirium in these patients so that it can be effectively treated and further morbidity and potentially mortality can be avoided.
References
1. Fann JR, Roth-Roemer S, Burlington B, Katon W, Syrjala K: Delirium in patients undergoing hematopoietic stem cell transplantation: incidence and pretransplantation risk factors. Cancer 2002; 95:1971–1981[CrossRef][Medline]
2. Meagher DJ, O’Hanlon D, O’Manony E, Casey PR, Trzepacz PT: Relationship between symptoms and motoric subtype of delirium. J Neuropsychiatry Clin Neurosci 2000; 12:51–56
SESSION C: Psychiatric Issues in Internal Medicine and Primary Care
The Use of Deep Brain Stimulation in Severe Treatment Refractory Obsessive-Compulsive Disorder
D.A. Malone, Jr., MD, FAPM; B. Greenberg, MD; A. Rezai, MD; S. Rasmussen, MD; N.A. Shapira, MD; K. Foote, MD; M. Okun, MD; S. Rauch, MD; W. Goodman, MD
Approximately 10% of patients with obsessive-compulsive disorder (OCD) are disabled by their condition because their disorder is completely refractory to traditional medical and psychotherapeutic treatments. Neurosurgical procedures such as cingulotomy and anterior capsulotomy have been used with some success in this patient population. Deep brain stimulation is a nonablative, reversible, and adjustable method of stimulating specific brain areas. A collaborative work group at the Cleveland Clinic Foundation, Butler Hospital/Brown University, and the University of Florida has begun a trial study of the safety and efficacy of deep brain stimulation targeting the anterior limb of the internal capsule. The decision to target this region was based on prior experience with gamma knife capsulotomy and the initial experience with deep brain stimulation for OCD of Nuttin and colleagues. Before surgery, patients received a multidisciplinary assessment and an independent review of diagnosis, prior treatment adequacy, and consent capacity. Bilateral deep brain stimulation leads were placed in the anterior limb of the anterior capsule and adjacent ventral striatum. Six-month follow-up data are available for 10 patients thus far. Four of the 10 patients met the stringent response criteria of a 35% reduction in Yale-Brown Obsessive Compulsive Scale score. An additional three patients had a decrease of 25% or more. Four of 10 patients achieved a 50% reduction in Hamilton Depression Rating Scale score. Improvements in rating scale scores were accompanied by overall improvements in global functioning. Persistent adverse effects have been infrequent, although acute stimulation-related side effects can occur.
References
1. Nuttin BJ, Gabriel LA, Cosyns PR, Meyerson BA, Andreewitch S, Sunaert SG, Maes AF, Dupont PJ, Gybels JM, Gielen F, Demeulemeester HG: Long-term electrical capsular stimulation in patients with obsessive-compulsive disorder. Neurosurgery 2003; 52:1263–1274[CrossRef][Medline]
2. OCD-DBS Collaborative Group: Deep brain stimulation for psychiatric disorders. Neurosurgery 2002; 51:519
Randomized, Placebo-Controlled, Double-Blind Trial of Paroxetine Controlled Release in Irritable Bowel Syndrome
P.S. Masand, MD, FAPM; A.A. Patkar, MD; E. Dube, PhD; S. Krulewicz, MA; S. Alamy, MD; M. Evenden, MD; M. Formal, MBA; I. Varia, MD
Objective: Open-label studies have suggested a possible therapeutic role for selective serotonin reuptake inhibitors (SSRIs) in irritable bowel syndrome. The authors used a double-blind, placebo-controlled design to examine the efficacy and safety of paroxetine controlled release (CR) in the treatment of irritable bowel syndrome. Methods: Enrollment of 72 subjects has been completed in an ongoing, double-blind, parallel-group, prospective study followed by an open-label extension phase. Fifty-seven subjects with a diagnosis of irritable bowel syndrome were randomly assigned to receive 12.5–50 mg/day of paroxetine CR or placebo for 12 weeks. Efficacy was measured by a 2-point or greater reduction in Clinical Global Impression (CGI) improvement scale score and a 1-point or greater reduction in CGI severity scale score from baseline to end of treatment, with the last observation carried foward. Two-tailed t tests, chi-square tests, and analysis of variance were used to compute between-group differences and effect sizes. Results: The mean age of the subjects was 49 years, 73% were women, and 77% were Caucasian. Ten (17.5%) subjects dropped out of the study. The dropout rate was similar in the drug and placebo groups. Analysis of data for 47 patients showed that 16 (73%) subjects in the paroxetine group had a 2-point or greater improvement in CGI improvement scale score, compared to seven (27%) subjects in the placebo group (p=0.003, Fisher’s exact test). Fifteen of 22 (68%) subjects receiving paroxetine CR had a 1-point or greater reduction in CGI severity scale score, compared to six of 25 (24%) subjects receiving placebo (p=0.003, Fisher’s exact test). Irritable bowel syndrome patients with primary complaints of diarrhea, constipation, or both were equally likely to respond to paroxetine CR. The mean paroxetine CR dose was 33 mg/day. There were no significant between-group differences in the prevalence of sexual side effects (paroxetine group: 22%, placebo group: 12%), sedation (paroxetine group: 9%, placebo group: 16%), dry mouth (paroxetine group: 26%, [chplacebo group: 12%), nausea (paroxetine group: 17%, placebo group: 24%). Conclusions: Paroxetine CR appears to be well tolerated, and its effects, as measured by CGI scale scores, are superior to placebo in the treatment of irritable bowel syndrome. The authors plan further analysis of data from self-reported efficacy measures to clarify the overall efficacy of paroxetine CR. However, it seems that SSRIs may have a therapeutic role in reducing symptoms of irritable bowel syndrome in clinical populations.
References
1. Masand PS, Kaplan D, Gupta S, Shandary A, Nasra F, Kline M, Margo K: Major depression and irritable bowel syndrome (IBS): is there a relationship? J Clin Psychiatry 1995; 56:363–367[Medline]
2. Jones BW, Moore DJ, Robinson SM, Song F: A systematic review of tegaserod for the treatment of irritable bowel syndrome. J Clin Pharm Ther 2002; 27:343–352[CrossRef][Medline]
A Randomized, Double-Blind, Placebo-Controlled Trial: Paroxetine CR (Paxil CR) in Fibromyalgia
A. Patkar, MD; P.S. Masand, MD, FAPM; W. Jiang, MD; S. Krulewicz, MA; E. Dube, PhD; C. Purcell, MS; C. McMorran; K. Peindl, PhD
Objective: Fibromyalgia is a relatively common disorder that fails to respond to pharmacological interventions in a significant proportion of patients. The authors investigated the efficacy and tolerability of paroxetine controlled release (CR) in the treatment of fibromyalgia in a 12-week randomized, placebo-controlled, double-blind design. Methods: One hundred eighty subjects with a diagnosis of fibromyalgia were screened, and 116 were randomly assigned to receive 12.5–62.5 mg/day of paroxetine CR or placebo for 12 weeks. The primary efficacy measure was defined as a 25% or greater reduction in scores on the Fibromyalgia Impact Questionnaire from randomization to end of treatment. Secondary efficacy measures included the Clinical Global Impression (CGI) improvement and severity scales and a visual analogue scale for pain. Data were evaluated by using an intent-to-treat analysis with the last observation carried forward and Kaplan-Meier survival models. Results: A diagnosis of current depressive disorders accounted for nearly 48% of the screen failures. Eighty-five (73%) subjects completed the 12-week study. Ninety-four percent of the subjects were female, 71% were Caucasian, 58% were married, and 63% were employed. The mean age was 48 years. There were no significant differences in baseline characteristics between the drug and placebo groups. On the primary efficacy measure of a 25% or greater reduction in Fibromyalgia Impact Questionnaire score, significantly more patients in the paroxetine CR group (57%) had a treatment response, compared to the placebo group (33%) (p<0.02). Survival analysis of Fibromyalgia Impact Questionnaire scores showed that paroxetine CR was superior to placebo over the study period (Breslow likelihood=15.75, p=0.001). Consistent with the changes in Fibromyalgia Impact Questionnaire scores, the paroxetine CR group showed a greater improvement in CGI improvement scale scores (58%), compared to the placebo group (25%) (p=0.002). However, there were no significant differences between the drug and placebo groups on the measures of 25% and 50% reduction in the visual analogue scale pain scores. The mean dose of paroxetine CR was 32.3 mg/day. The side effect profile was generally mild; drowsiness (31% versus 6%; p<0.02) and dry mouth (36% versus 9%; p=0.009) were reported more frequently in the paroxetine CR group. Conclusions: Paroxetine CR appears to be efficacious and well tolerated in the treatment of fibromyalgia and may have a therapeutic role in reducing symptoms of fibromyalgia in clinical populations.
References
1. Patkar AA, Bilal L, Masand PS: Management of fibromyalgia. Curr Psychiatry Rep 2003; 5:218–224[Medline]
2. Barkhuizen A: Rational and targeted pharmacologic treatment of fibromyalgia. Rheum Dis Clin North Am 2002; 28:261–290[CrossRef][Medline]
Primary Care Clinicians Effectively Treat Patients With Medically Unexplained Symptoms: A Clinical Trial
R.C. Smith, MD; J.S. Lyles, PhD; J. Goddeeris, PhD; J.C. Gardiner, PhD; A. Hodges, MA; C. Collins, RN; C. Sirbu, MS; C. Lein, MS; F.C. Dwamena, MD; C.W. Given, PhD; B. Given, PhD
Background: For patients with medically unexplained symptoms, research data support short-term specialty care. Primary care clinicians have no proven, long-term treatment. The authors hypothesized that an intensive 12-month intervention by primary care clinicians would produce improvement in patients with medically unexplained symptoms, who have a high rate of utilization of medical care. Methods: From a large staff model health maintenance organization, the authors identified high-utilizing patients from the information system and then identified patients with medically unexplained symptoms by using a systematic chart rating procedure, which was conducted by three senior medical residents who were blind to study purpose. Four nurse practitioners received 84 hours of initial training and then conducted the intervention as primary caretakers, receiving supervision individually and in groups during treatment. The nurse practitioners primarily relied on an evidence-based method for the provider-patient relationship, and they integrated this method with cognitive behavior and pharmacological treatment principles that have been proven effective in specialty settings. The patients had 12 scheduled visits and phone calls as well as additional visits when necessary. Data were collected at baseline and at 6 and 12 months; the primary endpoint was a clinically significant 4-point improvement in the mental component summary score of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) at 12 months postbaseline. At the same times, data were collected by using measures of physical function (SF-36), depression (Center for Epidemiologic Studies Depression Scale), anxiety (State-Trait Anxiety Inventory), psychosomatic symptoms, and patient satisfaction with the provider-patient relationship; the latter measure is a published 25-item questionnaire with four factors that evaluate patients’ satisfaction with providers’ open-endedness, empathy, ability to inspire confidence, and overall impression. The evaluation used intent-to-treat analysis and logistic regression analysis; variables associated with a 4-point improvement in the SF-36 mental component summary score in univariate testing (p 0.20) were entered into a model that retained variables that were significant at p0.10. Results: Rater agreement with the gold standard for entry into the study (differentiating organic disease symptoms from unexplained symptoms) was 97.6%. Of the 206 subjects entered, 200 completed the study (97% retention). Patients averaged 13.6 visits in the year preceding the study, 79.1% were women, and the average age was 47.7 years. Forty-eight treatment and 34 comparison patients improved at 12 months (odds ratio=1.92, 95% confidence interval [CI]=1.08–3.40; p=0.02). The relative benefit was 1.47 (95% CI=1.05–2.07), and the number needed to treat was 6.4 (95% CI=0.89–11.89). In addition to treatment (p=0.02), the following baseline measures predicted improvement on the mental component summary score: severe mental dysfunction (p0.001), severe body pain (p=0.04), nonsevere physical dysfunction (p=0.003), and advanced education (p=0.02) (c-statistic=0.76). Finally, patients’ satisfaction with the provider-patient relationship was highly significant at both 6 and 12 months after baseline for nurse practitioners’ open-endedness (p=0.0001), empathy (p= 0.0001), ability to inspire confidence (p=0.003), and overall impression (p= 0.0001). There were no adverse effects of treatment. Conclusions: A long-term, relationship-based intervention by primary care clinicians led to clinically significant improvement in patients with medically unexplained symptoms and to marked increases in patients’ satisfaction with the provider-patient relationship.
References
1. Lyles JS, Hodges A, Collins C, Lein C, Given CW, Given B, D’Mello D, Osborn GG, Goddeeris J, Gardiner JC, Smith RC: Using nurse practitioners to implement an intervention in primary care for high utilizing patients with medically unexplained symptoms. Gen Hosp Psychiatry 2003; 25:63–73[CrossRef][Medline]
2. Smith RC, Lein C, Collins C, Lyles JS, Given B, Dwamena FC, Coffey J, Hodges A, Gardiner JC, Goddeeris J, Given CW: Treating patients with medically unexplained symptoms in primary care. J Gen Intern Med 2003; 18: 478–489
Depression and Its Association With C-Reactive Protein, Ferritin, Serum Albumin, and Hemoglobin/Hematocrit in Patients With Chronic Renal Disease
B. Kalender, MD; A. Çorapçiolu, MD; G. Körolu, MD; A. Yilmaz, MD
Background: Depression, which is the most common psychological disorder among patients with chronic renal disease, is commonly associated with poor oral intake, which can aggravate anemia and malnutrition in chronic dialysis patients. Furthermore, acute phase proteins might have a significant role in hypoalbuminemia in dialysis patients. The authors explored the association between depression and C-reactive protein, ferritin, serum albumin, and hemoglobin/hematocrit in patients with chronic renal disease. Methods: Sixty-eight patients who were receiving hemodialysis, 47 patients who were receiving continuous ambulatory peritoneal dialysis, and 26 patients who were receiving conservative management were enrolled into this study. Patients with acute illnesses were excluded. All patients were evaluated for the presence of depression by using the mood module of the Structured Clinical Interview for DSM-IV. Severity of depression was evaluated by means of the Beck Depression Inventory and the Hamilton Depression Rating Scale. Serum C-reactive protein, ferritin, albumin, hemoglobin, and hematocrit levels were measured. These parameters were compared between groups with and without depression by using the Mann-Whitney U test. Results: A total of 34 (24.1%) patients had depression. Age, gender, and duration of therapy were similar in patients with and without depression. Patients with depression had lower hemoglobin, hematocrit, and serum albumin levels and higher C-reactive protein and ferritin levels than patients without depression (Table 1).
References
1. Kalantar-Zadeh K, Rodriguez RA, Humphreys MH: Association between serum ferritin and measures of inflammation, nutrition and iron in haemodialysis patients. Nephrol Dial Transplant 2004; 19:141–149[Abstract/Free Full Text]
2. Chauveau P, Level C, Lasseur C, Bonarek H, Peuchant E, Montaudon D, Vendrely B, Combe C: C-reactive protein and procalcitonin as markers of mortality in hemodialysis patients: a 2-year prospective study. J Ren Nutr 2003; 13:137–143[CrossRef][Medline]
Comparison of Quality of Life and Depression in Renal Disease Patients Receiving Conservative Management, Hemodialysis, and Continuous Ambulatory Peritoneal Dialysis
B. Kalender, MD; A. Çorapçiolu, MD; S. Kurdolu, MD; A. Yilmaz, MD
Background: Quality of life is expected to be affected in patients with chronic renal disease both because of the presence of a chronic disease and because of concurrent depression. In this study, patients with chronic renal failure who were receiving conservative management (predialysis), chronic hemodialysis, and continuous ambulatory peritoneal dialysis (CAPD) were compared with healthy comparison subjects in terms of the presence of depression and quality of life. Methods: Twenty-six patients receiving conservative management, 68 receiving hemodialysis, 47 patients receiving CAPD, and 66 healthy comparison subjects were enrolled in the study. All patients were evaluated for the presence of depression by using the mood module of the Structured Clinical Interview for DSM-IV. Severity of depression was evaluated with the Beck Depression Inventory and Hamilton Depression Rating Scale. Quality of life was measured with the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), and subscale scores were calculated. The parameters were compared by using the Mann-Whitney U test. Results: Age, gender, and other demographic variables were similar in the study groups. The proportion of depressive patients was higher in the hemodialysis group, compared to the conservative management and CAPD groups (33.8%, 19.2%, and 12.8%, respectively). Beck Depression Inventory scores were lower in the CAPD group than in the conservative management group and the hemodialysis group (Table 1). All SF-36 subscale scores were lower in the three patient groups than in the comparison group. Among patient groups, the CAPD patients had the highest SF-36 subscale scores.
View this table:
[in this window]
[in a new window]
|
TABLE 1. Scores on Measures of Depression and Quality of Life in Chronic Renal Disease Patients Receiving Conservative Management, Hemodialysis, and Continuous Ambulatory Peritoneal Dialysis (CAPD) and in Healthy Comparison Subjects
|
References
1. Heiwe S, Clyne N, Dahlgren MA: Living with chronic renal failure: patients’ experiences of their physical and functional capacity. Physiother Res Int 2003; 8:167–177[CrossRef][Medline]
2. de Castro M, Caiuby AV, Draibe SA, Canziani ME: [Quality of life in chronic renal disease patients submitted to hemodialysis evaluated with SF-36 instrument]. Rev Assoc Med Bras 2003; 49:245–249 (Portuguese)
DLIN/Fischer Clinical Research Award
Postoperative Sedation Can Dramatically Alter the Development of Delirium After Cardiac Surgery
Jose R. Maldonado, MD, FAPM; Ashley Wysong, MS; Pieter J. van der Starre, MD; Thaddeus Block, MD; Bruce Reitz, MD
Background: In the United States, between 32% and 80% of cardiac surgery patients experience postoperative delirium. Failure to recognize delirium leads to increased morbidity and mortality and to prolonged hospital stays with associated complications, including infections, prolonged intubation and sedation, excessive use of CNS-depressant agents, and possible cognitive decline. The authors theorized that a significant factor in the induction of postoperative delirium is the choice of sedative. Methods: After approval from the center’s institutional review board and written informed consent, 90 patients undergoing elective cardiac surgery were included in a prospective, randomized trial. Surgical procedures included mitral valve repair/replacements, aortic valve repair/replacements, ascending aortic replacements, and aortic arch replacements. All participants underwent a battery of neuropsychiatric tests before surgery and received general anesthesia consisting of a combination of inhalation, intravenous sedatives, and opioids. Patients were randomly assigned to three postoperative sedation protocols started intraoperatively at sternal closure: dexmedetomidine (loading dose of 0.4 µg/kg, followed by 0.2–0.7 µg/kg per hour), propofol (25–50 µg/kg per minute), or fentanyl and midazolam (50–150 µg/hr and 0.5–2 mg/hr, respectively). In the intensive care unit (ICU), all patients were mechanically ventilated until the time that extubation was assessed to be appropriate. Patients were followed for the development of delirium (by using DSM-IV criteria and the Delirium Rating Scale) and neurocognitive deficits (by using the Mini-Mental State Examination [MMSE] and Trail Making Tests A and B). Results: There were no significant differences between treatment groups with respect to American Society of Anesthesiologists (ASA) risk classes, bypass time, clamp time, or lowest temperature achieved. All patients received general anesthesia consisting of the same set of inhalation and injectable agents. The incidence of delirium was 3% (1/30) for patients receiving dexmedetomidine, 50% (15/30) for patients receiving propofol, and 50% (15/30) for patients receiving fentanyl/midazolam (p<0.01). The delirious patients and the nondelirious patients differed in overall length of stay in the hospital (10.0 versus 7.1 days; p=0.001) and length of stay in the ICU (4.1 versus 1.9 days; p=0.001). In multiple logistic regression analyses, the postoperative sedation protocol was found to be the most important predictor of delirium, even after adjustment for age, sex, baseline MMSE score, and ASA risk class. Receiving dexmedetomidine conferred a 98% reduction in the odds of delirium over fentanyl/midazolam and a 99% reduction in the odds over propofol. Conclusions: Postoperative sedation with dexmedetomidine was associated with a substantially lower incidence of postoperative delirium, compared with the use of more conventional forms of postoperative sedation. The authors theorize that the benefits of dexmedetomidine may be attributed to its specific and unique pharmacological profile, including its action on a single receptor type, the significant decrease in adjuvant opioid requirement, the absence of anticholinergic side effects, and potential neuroprotective properties.
References
1. Scholz J, Tonner PH:  2-adrenoreceptor agonists in anaesthesia: a new paradigm. Curr Opin Anaesthesiol 2000; 13:437–442
2. Shinn JA, Maldonado JR: Performance improvement: increasing recognition and treatment of postoperative delirium. Prog Cardiovasc Nurs 2000; 3:114–115
Get information about faster international access.
Privacy Policy
Copyright © 2005
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
