Chronic Psychiatric Conditions Research Articles

O-46 - Group CBT of anxiety disorders

Anxiety disorders are chronic psychiatric conditions with a low rate of natural remission, producing substantial decreases in the quality of life and numerous specific social role impairment and disabilities. Over past 15 years, behavioral, cognitive, and cognitive behavioral procedures (primarily exposure and cognitive reconstruction based treatments) were found to be effective in the treatment of anxiety disorders.The purpose of this mini workshop is to present the main principals and techniques of a short-term group cognitive behavioral therapy for these patients. In our work, we combine education, cognitive reconstruction, behavioural experiments, exposure therapy, social skills training and problem solving approach. This program will demonstrate how to provide significant improvement even for those with the most severe anxiety disorders.Participants will learn theoretically and practically in exercises:(1) The cognitive and behavioral models of anxiety disorders(2) The main principles of group cognitive behavioral therapy for anxiety disorders(3) How to use CBT techniques useful for anxiety disorders in group:(4) Cognitive reconstruction; - social skills training with role playing; - behavioral experiments and exposure (including imaginal exposure); - problem solving. By the project IGA, MZ CR NT 11047-4/2010.

Selecting Appropriate Treatment for Patients Who Are Nonresponsive to Initial Therapy

Depression can be a chronic illness, and several treatment steps are often needed to achieve sustained symptom remission and return patients to premorbid levels of functioning. Patients with chronic depressive illness, early onset, concurrent psychiatric or medical conditions, difficult psychosocial problems, or comorbid melancholic and anxious features may require additional treatment steps. Next-step strategies, after optimizing the dose and extending the treatment trial of the initial antidepressant, include switching antidepressants, adding another antidepressant, and augmenting with a nonantidepressant agent.

Modelling the consumption of anxiolytics and its addictive behaviour

Background: Population-based anxiolytics consumption (AX) is a widely debated subject because long-term AX may lead to tolerance and addiction. This study aims to obtain mathematical models that identify the various behaviours in AX prescription in accordance with gender, age and the continuous prescription of other drugs associated with chronic diseases. Methods: Data were obtained from an electronic prescriptions database ( n = 12,211,992 ) received by patients ( n = 504,224 ) visiting the Primary Health Care Centres in the province of Castellón (East Spain) in 2009. A linear regression model was used to explain the number of defined daily doses (DDD) of AX prescribed in accordance with age, gender and more than 5 prescriptions of any drug associated with chronic diseases other than AX. We used the logistic regression model to quantify the joint influence of the explanatory variables on the likelihood (L) of prescribing increasingly high DDD of AX. Results: The mean annual DDD per patient was 133.13, and the DDD prescribed was 38.06 day/1000 inhabitants. Few differences, although significant, in prescriptions per gender were observed; males received fewer prescriptions than females. Conversely, differences in age groups were substantial; the older subjects become, the higher the prescribed DDD, although these differences disappeared after the age of 65. AX use was also positively associated with the presence of comorbidity: depression, psychosis and epilepsy. Sporadic AX prescriptions were not associated with any factor, except continuous use. Conclusions: The prevalence of prescribing AX in the general population visiting the primary health centres in Castellón is over 16%. Prescriptions and the DDD of AX are barely higher for females than for males, and age is the most influential factor; the older the patient, the higher the number of prescribed DDD. The likelihood of potentially addictive behaviours is higher among the elderly and patients with comorbidity, mainly those patients with other chronic psychiatric conditions.

Ethics and Informed Consent of Vagus Nerve Stimulation (VNS) for Patients with Treatment-Resistant Depression (TRD)

Since the Nuremberg trials (1947–1949), informed consent has become central for ethical practice in patient care and biomedical research. Codes of ethics emanating from the Nuremberg Code (1947) recognize the importance of protecting patients and research subjects from abuses, manipulation and deception. Informed consent empowers individuals to autonomously and voluntarily accept or reject participation in either clinical treatment or research. In some cases, however, the underlying mental or physical condition of the individual may alter his or her cognitive abilities and compromise the informed consent process. This is particularly true in chronic psychiatric conditions such as Treatment-Resistant Depression (TRD), where individuals may fail to respond to traditional antidepressant treatments (e.g., psychotherapy, pharmacotherapy). Moreover, it may raise further concerns for an individual’s motivation to consent and the level of understanding of the treatment or research procedure. This paper focuses on the informed consent process for Vagus Nerve Stimulation (VNS) in the treatment of individuals diagnosed with TRD. Specifically, the paper addresses how depression may affect the decision-making capacity of an individual and the potential ethical and legal impact of failure to appreciate the seven elements of the consenting process (competence, voluntariness, disclosure, recommendation, understanding, decision, and authorization). To ensure the protection of vulnerable individuals with psychiatric disorders such as TRD and promote ethical behavior in biomedical research and patient care while avoiding potential legal pitfalls, we propose a paradigm that requires a stringent evaluation process of decision-making capacity for informed consent.

Imaging the effects of rTMS-induced cortical plasticity

Repetitive Transcranial Magnetic Stimulation (rTMS) paradigms are showing increasing promise as tools for neurorehabilitation in a variety of chronic neurological and psychiatric conditions. However, the mechanisms by which they modulate cortical activation are still not completely understood. In this review we summarize what non-invasive magnetic resonance imaging techniques can tell us about the cortical effects of rTMS - from changes at a cellular level within the stimulated motor cortex, to modulating activation patterns within the wider motor network. We discuss how variation in these effects in stroke patients may inform our understanding of how rTMS could improve function in these patients.

Participation-Engagement: A Philosophically Based Heuristic for Prioritizing Clinical Interventions in the Treatment of Comorbid, Complex, and Chronic Psychiatric Conditions

We propose Participation-Engagement (PAR-EN) as a philosophically based heuristic for prioritizing interventions in comorbid, complex, and chronic psychiatric conditions. Drawing from 1) the sociologist Talcott Parsons, 2) the continental-philosophical tradition, and 3) our own previous work (Davidson & Shahar, 2009; Shahar, 2004, 2006), we argue that participation in personally meaningful life goals represents a hallmark of mental health. Symptoms and vulnerabilities that impede such participation should therefore be targeted vigorously, whereas others which do not pose such imminent threats should assume a secondary focus, if at all. Winnicott's (1987) notion of the spontaneous gesture, the importance of daily activities as reflecting patients' participation, and the dialectics of interpersonal relatedness and self-definition, are introduced as guidelines for implementing PAR-EN. Implications for clinical assessment and the therapeutic relationship are discussed.

Increases in Medicare Prescription Drug Plan Costs Attributable to Psychotropic Medications

Older patients may regard some medications, particularly psychotropic medications, as discretionary compared with what they perceive as more "essential " nonpsychiatric medications. Patients' concerns about psychotropic medication costs under Medicare Part D may reinforce these impressions. The authors examined which Medicare prescription drug plans (PDPs) would be least expensive for beneficiaries considering the costs of 1) all medications; and 2) only nonpsychiatric medications. The authors collected data from the PDP online comparison tool provided by the Centers for Medicare and Medicaid Services (CMS). Hypothetical Medicare beneficiaries. The authors examined four clinical scenarios from older outpatients with both chronic medical and psychiatric conditions (including psychosis, bipolar disorder, depression, and dementia with behavioral disturbances). The authors examined data from all 160 plans available in CMS PDP regions in May 2007. There were frequent discrepancies in the least expensive PDPs within region, depending on considering the costs of all medications, or just nonpsychiatric medications. In the clinical scenarios, patients selecting a PDP based on nonpsychiatric medications alone would pick an unnecessarily more expensive plan 74%-100% of the time (when they took any brand name medication), suggesting that excluding psychiatric medications from PDP choices may be excessively costly. However, brand name psychotropic medications significantly increased the costs of the least expensive plans. The latter finding might persuade patients to avoid taking needed psychiatric medication due to cost. This research highlights the complexity that patients with psychiatric and cognitive disorders face when choosing a Medicare PDP. Policymakers and clinicians should be aware of the tradeoffs that beneficiaries with psychiatric disorders face when making PDP plan choices.

Illness intrusiveness in anorexia nervosa

Objective “Illness intrusiveness” refers to illness-induced lifestyle disruptions. The primary aim of the current study was to compare the level of illness intrusiveness in anorexia nervosa (AN) to that reported in a variety of other chronic medical and psychiatric conditions. A secondary aim was to compare the two subtypes of AN (binge/purge vs. restricting) in terms of the nature and extent of illness intrusiveness. A final goal was to examine changes in the level of illness intrusiveness in AN following successful completion of specialized inpatient treatment. Methods The participants were a consecutive series of 121 female inpatients with AN who were admitted to a specialized inpatient unit for treatment of the eating disorder. Assessments took place before and after inpatient treatment and at 3-month follow-up. Results At baseline, illness intrusiveness scores for AN patients were significantly higher than those reported by women in the medical and psychiatric comparison groups. Overall, illness intrusiveness scores decreased (i.e., improved) significantly following successful completion of inpatient treatment. Among patients with the restricting subtype, scores continued to improve during follow-up, whereas this was not the case among patients with the binge–purge subtype of AN, whose scores did not change significantly during follow-up. Conclusion Despite being notoriously ambivalent about change, these findings suggest that AN patients perceive their illness to be highly disruptive to a variety of life domains, even more so than patients with other chronic medical and psychiatric conditions.

Hipertensión arterial resistente

Resistant hypertension, defined as a persistent blood pressure over 140/90 mmHg despite the use of three antihypertensive drugs including a diuretic, is unusual. The diagnosis requires ruling out initially pseudoresistance and a lack of compliance with treatment. Ambulatory blood pressure recording allow the recognition of white coat hypertension. When there is a clinical or laboratory suspicion, secondary causes of hypertension should be discarded. Excessive salt intake, the presence of concomitant diseases such as diabetes mellitus, chronic renal disease, obesity, and psychiatric conditions such as panic attacks, anxiety and depression, should also be sought. The presence of target organ damage requires a more aggressive treatment of hypertension. Recent clinical studies indicate that the administration of aldosterone antagonists as a fourth therapeutic line provides significant additional blood pressure reduction, when added to previous antihypertensive regimens in subjects with resistant hypertension. The possible blood pressure lowering effects of prolonged electrical activation of carotid baroreceptors is under investigation

Resistant hypertension

Resistant hypertension, defined as a persistent blood pressure over 140/90 mmHg despite the use of three antihypertensive drugs including a diuretic, is unusual. The diagnosis requires ruling out initially pseudoresistance and a lack of compliance with treatment. Ambulatory blood pressure recording allow the recognition of white coat hypertension. When there is a clinical or laboratory suspicion, secondary causes of hypertension should be discarded. Excessive salt intake, the presence of concomitant diseases such as diabetes mellitus, chronic renal disease, obesity, and psychiatric conditions such as panic attacks, anxiety and depression, should also be sought. The presence of target organ damage requires a more aggressive treatment of hypertension. Recent clinical studies indicate that the administration of aldosterone antagonists as a fourth therapeutic line provides significant additional blood pressure reduction, when added to previous antihypertensive regimens in subjects with resistant hypertension. The possible blood pressure lowering effects of prolonged electrical activation of carotid baroreceptors is under investigation.

Measurement-based care for refractory depression: A clinical decision support model for clinical research and practice

Despite years of antidepressant drug development and patient and provider education, suboptimal medication dosing and duration of exposure resulting in incomplete remission of symptoms remains the norm in the treatment of depression. Additionally, since no one treatment is effective for all patients, optimal implementation focusing on the measurement of symptoms, side effects, and function is essential to determine effective sequential treatment approaches. There is a need for a paradigm shift in how clinical decision making is incorporated into clinical practice and for a move away from the trial-and-error approach that currently determines the “next best” treatment. This paper describes how our experience with the Texas Medication Algorithm Project (TMAP) and the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial has confirmed the need for easy-to-use clinical support systems to ensure fidelity to guidelines. To further enhance guideline fidelity, we have developed an electronic decision support system that provides critical feedback and guidance at the point of patient care. We believe that a measurement-based care (MBC) approach is essential to any decision support system, allowing physicians to individualize and adapt decisions about patient care based on symptom progress, tolerability of medication, and dose optimization. We also believe that successful integration of sequential algorithms with MBC into real-world clinics will facilitate change that will endure and improve patient outcomes. Although we use major depression to illustrate our approach, the issues addressed are applicable to other chronic psychiatric conditions including comorbid depression and substance use disorder as well as other medical illnesses.

Suicidal attempts by prescription drug overdose in the elderly: a study of 44 cases

A series of 44 consecutive elderly, admitted to a busy general hospital following deliberate self-poisoning, is reviewed for associated medical and psychosocial factors. In all but 3 cases the act involved an overdose of drugs prescribed for the treatment of a chronic medical and/or psychiatric disorder. Women outnumbered men by 2.7 to 1. There was high proportion of chronic psychiatric (80%, mostly depressive) and medical (60%) conditions. Chronic stress from the physical illness, social isolation, or tacit family conflict were common and seemed instrumental in the self-poisoning act. Most attempts were carried out around the weekend and during winter. One man succumbed to complications of the overdose but the rest of the patients recovered. Psychosocial (especially depressive) and medical vulnerability, plus availability of prescribed drugs, were the most important determinants of suicidal behavior among these elderly attempters.

The Art of Prescribing. Antidepressants in Late-Life Depression: Prescribing Principles

Ms. Antai-Otong, I am a psychiatric nurse practitioner currently employed in a large primary care clinic. My greatest challenge with older adults suspected of being depressed is their hesitancy to admit they are depressed or unwillingness to take antidepressants. I have started some of these patients on antidepressants and had mixed results. Please provide some guidelines for treating depression in older adults with coexisting medical conditions. Depression is a common companion of chronic medical illnesses and frequently goes unrecognized and untreated, resulting in high morbidity and mortality. Depression is unrecognized and underdiagnosed in approximately 16% of older patients seen in primary care settings (Unutzer, 2002). Typically, older adults deny being depressed, minimize symptom severity, fail to recognize common subjective experiences, such as anhedonia, fatigue, and concentration difficulties associated with this disorder, and hesitate to accept their illness due to social stigma and effects of stoicism. Cultural and generational influences also impact how older adults perceive mental health services. Due to the growing number of individuals 65 and older with coexisting medical and psychiatric conditions, particularly depression, seeking health care in vast practice settings, advanced practice psychiatric nurses must collaborate with primary care providers and develop holistic care that addresses coexisting chronic medical and psychiatric conditions.

P.2.c.034 Escitalopram versus nortriptyline in the treatment of painful physical symptoms in patients with major depression

Despite years of antidepressant drug development and patient and provider education, suboptimal medication dosing and duration of exposure resulting in incomplete remission of symptoms remains the norm in the treatment of depression. Additionally, since no one treatment is effective for all patients, optimal implementation focusing on the measurement of symptoms, side effects, and function is essential to determine effective sequential treatment approaches. There is a need for a paradigm shift in how clinical decision making is incorporated into clinical practice and for a move away from the trial-and-error approach that currently determines the “next best” treatment. This paper describes how our experience with the Texas Medication Algorithm Project (TMAP) and the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial has confirmed the need for easy-to-use clinical support systems to ensure fidelity to guidelines. To further enhance guideline fidelity, we have developed an electronic decision support system that provides critical feedback and guidance at the point of patient care. We believe that a measurement-based care (MBC) approach is essential to any decision support system, allowing physicians to individualize and adapt decisions about patient care based on symptom progress, tolerability of medication, and dose optimization. We also believe that successful integration of sequential algorithms with MBC into real-world clinics will facilitate change that will endure and improve patient outcomes. Although we use major depression to illustrate our approach, the issues addressed are applicable to other chronic psychiatric conditions including comorbid depression and substance use disorder as well as other medical illnesses.

Letters

Back to table of contents Previous article Next article LettersFull AccessRobert B. Millman, M.D.Robert B. MillmanSearch for more papers by this author, M.D.Published Online:1 Oct 2004https://doi.org/10.1176/appi.ps.55.10.1183-aAboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: At the outset of my psychiatric training, John Talbott was the first faculty member I met who was committed to the principles and practices of community psychiatry. At the Payne Whitney Clinic, at that time, there were not many others who shared those interests. John was deeply interested in the provision of reasonable care to patients who were chronically mentally ill, often impoverished, and generally underserved. He was even interested in patients who had drug and alcohol abuse and dependence problems. Whereas organized psychiatry and psychiatrists were often reluctant to accept responsibility for the care of these apparently unattractive and perhaps incurable patients, John recognized that the drug use disorders were inextricably intertwined with other acute and chronic psychiatric conditions. He well understood the remarkable prevalence of comorbid disorders and actively sought interventions that might be effective on a large scale.And John is unique in the way he communicates his interests and enthusiasms. He is a charismatic, generous, and powerful leader and teacher. He brought me and many others in, and encouraged my involvement in committees, in the journal, and in our peerless board examiner group. That examiner group was a thing of beauty—responsible, incredibly hard working, and really fun, just like John.I believe that John Talbott has significantly influenced the care of underserved patient populations and enhanced the pool of interested academic and clinical psychiatrists who care for these individuals.Dr. Millman is the Saul P. Steinberg distinguished professor of psychiatry and public health and chief of the division of community and public health programs at Cornell University's Joan and Sanford I. Weill Medical College in New York City. FiguresReferencesCited byDetailsCited ByNone Volume 55Issue 10 October 2004Pages 1183-a-1183 Metrics History Published online 1 October 2004 Published in print 1 October 2004

Impact of obesity on health-related quality of life in patients with chronic illness.

To determine the association between overweight and obesity and health-related quality of life (HRQOL) in patients with chronic conditions typical of those seen in general medical practice, after accounting for the effects of depression and medical comorbidities. Cross-sectional analysis of data from the Medical Outcomes Study. Offices of physicians practicing family medicine, internal medicine, endocrinology, cardiology, and psychiatry in three U.S. cities. We surveyed 2,931 patients with chronic medical and psychiatric conditions. The patients completed a self-administered questionnaire at enrollment and had complete data on height and weight. Body mass index (BMI), chronic medical conditions, and depression were obtained by structured interview. Health-related quality of life was measured by the SF-36 Health Survey. Patients who were overweight (BMI 25.0-29.9 kg/m2), patients with class I obesity (BMI 30.0-34.9 kg/m2), and patients with class II-III obesity (BMI > or = 35 kg/m2) had significantly lower adjusted physical function scores (by 3.4, 7.8, and 13.8 points, respectively) compared with nonoverweight patients. Patients with class I and class II-III obesity also had significantly lower adjusted general health perceptions scores (by 2.8 and 4.4 points, respectively) and lower adjusted vitality scores (by 4.0 and 7.1 points, respectively), compared with nonoverweight patients. No significant differences between nonoverweight, overweight, and obese patients were observed for the mental health scale. Women with elevated BMI had significantly lower HRQOL scores compared with the scores of obese men in several domains. Additionally, blacks with elevated BMI had significantly lower scores than whites in several domains of HRQOL. Overweight and obesity have the largest association with physical function measures. Recent national standards, which have lowered the threshold for defining overweight, identify patients who are more likely to have clinically significant reductions in HRQOL and functional impairment.

Detection of benzodiazepines in human hair by radioimmunoassay.

In this preliminary investigation, we sought to determine whether a standard benzodiazepine radioimmunoassay (RIA) could detect three benzodiazepines in human hair. Hair samples of 20-50 strands (minimum 10 mg) were cut from eight patients receiving diazepam, two patients receiving alprazolam, three patients receiving lorazepam, and two negative controls. Samples were treated with ethanol and phosphate buffer washes at 37 degrees C to remove external contamination. The protein hair matrix was destroyed using proprietary procedures, then analyzed with Abuscreen RIA designed to detect various benzodiazepines and their metabolites, using oxazepam as a reference standard. Patients were hospitalized in a locked psychiatric facility. Twelve patients with chronic psychiatric conditions who had received therapeutic dosages of benzodiazepines for 1-11 months were included in the sample. One outpatient who reported heavy prior diazepam use was also included. Detection of benzodiazepines was well above a 1.5 ng/10 mg cutoff level with the Abuscreen assay. Diazepam was readily detected, but alprazolam and lorazepam were not detected. There is no test that can currently determine duration and extent of prior benzodiazepine use. Hair analysis for diazepam offers a potential, new clinical and research tool for characterizing prior level and extent of usage.

Incorporating Structured Learning Therapy into Occupational Therapy Treatment of Chronic Psychiatric Patientse

Role playing activities, when incorporated into a group experience, have been shown to enhance social skills development in patients with chronic psychiatric conditions. This approach, adapted from the psychological therapeutic model of Structured Learning Therapy, addresses interpersonal skill development at three distinct levels: rudimentary interpersonal skills, community interpersonal skills, and abstract intepersonal skills. Unique to this therapeutic model is the concept of the patient taking an active role in formulating the dialogues used in each role playing situation.