Tool In Psychiatry Research Articles

EPA-0280 – Can brain stem audiometry be used as a diagnostic tool in psychiatry?

Introduction Prior studies have suggested that patients suffering from schizophrenia and ADHD may process certain sound stimuli in the brainstem in an unusual manner. When these patient groups have been examined with the electrophysiological method of brainstem audiometry, some studies have found illness-specific aberrations. Such aberrations may also exist for patients suffering from bipolar disorder. Aims To explore the use of the method of brainstem audiometry as a diagnostic tool in psychiatry. Methods 5 individuals with confirmed clinical diagnoses of schizophrenia, ADHD, and bipolar disorder, respectively, were examined with brainstem audiometry in a non-blind, comparative study. The data derived from the patient groups was compared to data from a control population according to a previously arranged data algorithm (SD-BERA). Results There was a full match between clinical diagnosis and diagnosis by means of brain stem audiometry for 4 of the 5 patients suffering from schizophrenia (1 mismatch), 4 of the 5 patients suffering from bipolar disorder (1 patient was given a second audiometric diagnosis of schizophrenia), and 3 of the 5 patients suffering from ADHD (1 patient was given a second audiometric diagnosis of bipolar disorder and 1 patient was a mismatch). Conclusions Brainstem audiometry shows promise as a diagnostic tool, but blinded studies are needed to examine the diagnostic properties and validity of this method.

Memory manipulation as a therapeutic tool in psychiatry

Memory manipulation as a therapeutic tool in psychiatry

Pattern analysis as the diagnostic tool in psychiatry

Pattern analysis as the diagnostic tool in psychiatry

The Medication Recommendation Tracking Form: A novel tool for tracking changes in prescribed medication, clinical decision making, and use in comparative effectiveness research

This paper describes the development and use of the Medication Recommendation Tracking Form (MRTF), a novel method for capturing physician prescribing behavior and clinical decision making. The Bipolar Trials Network developed and implemented the MRTF in a comparative effectiveness study for bipolar disorder (LiTMUS). The MRTF was used to assess the frequency, types, and reasons for medication adjustments. Changes in treatment were operationalized by the metric Necessary Clinical Adjustments (NCA), defined as medication adjustments to reduce symptoms, optimize treatment response and functioning, or to address intolerable side effects. Randomized treatment groups did not differ in rates of NCAs, however, responders had significantly fewer NCAs than non-responders. Patients who had more NCAs during their previous visit had significantly lower odds of responding at the current visit. For each one-unit increase in previous CGI-BP depression score and CGI-BP overall severity score, patients had an increased NCA rate of 13% and 15%, respectively at the present visit. Ten-unit increases in previous Montgomery Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS) scores resulted in an 18% and 14% increase in rates of NCAs, respectively. Patients with fewer NCAs had increased quality of life and decreased functional impairment. The MRTF standardizes the reporting and rationale for medication adjustments and provides an innovative metric for clinical effectiveness. As the first tool in psychiatry to track the types and reasons for medication changes, it has important implications for training new clinicians and examining clinical decision making. (ClinicalTrials.gov number NCT00667745).

Virtual Patients as Novel Teaching Tools in Psychiatry

Virtual Patients as Novel Teaching Tools in Psychiatry

P-1332 - Motor neurological soft signs and verbal fluency among patients with schizophrenia: a significant correlation

Neurological soft signs (NSS) are subtle indicator of brain dysfunction which are present in excess among patients with schizophrenia. Its clinical significance remains unclear despite extensive researches. To determine the proportion of schizophrenia patients who have motor NSS and then to compare the verbal fluency between these two groups; with and without motor NSS. This cross-sectional study utilized the Brief Motor Scale (BMS) to investigate the presence of motor NSS in 80 schizophrenia patients attended Universiti Kebangsaan Malaysia Medical Centre (UKMMC) psychiatric clinic. The diagnosis was confirmed by Mini International Neuropsychiatic Interview (MINI). Symptomatology and abnormal motor movement were assessed using the Brief Psychiatric Rating Scale (BPRS) and Abnormal Involuntary Movement Scale (AIMS) respectively. A brief verbal fluency test was administered. Bivariate and multivariate analyses were applied to look for any relationship between study factors. Majority of schizophrenia patients (68.8%) in this study have motor NSS. The motor NSS were correlated with verbal fluency. Verbal fluency was the only factor that remained significantly correlated with motor NSS after multivariate analysis. The assessment of motor NSS represents a brief, inexpensive and meaningful tool in psychiatry. Together with verbal fluency, it has the potential as an illness marker and a link between neurobiological research and clinical practice.

Mapping prodromal psychosis: A critical review of neuroimaging studies

The onset of schizophrenia is usually preceded by a prodromal phase characterized by functional decline and subtle prodromal symptoms, which include attenuated psychotic phenomena, cognitive deterioration and a decline in socio-occupational function. Preventive interventions during this phase are of great interest because of the impressive clinical benefits. However, available psychopathological criteria employed to define a high risk state for psychosis have low validity and specificity. Consequently there is an urgent need of reliable neurocognitive markers linked to the pathophysiological mechanisms that underlie schizophrenia. Neuroimaging techniques have rapidly developed into a powerful tool in psychiatry as they provide an unprecedented opportunity for the investigation of brain structure and function. This review shows that neuroimaging studies of the prodromal phases of psychosis have the potentials to identify core structural and functional markers of an impending risk to psychosis and to clarify the dynamic changes underlying transition to psychosis and to address significant correlations between brain structure or function and prodromal psychopathology. Additionally, neurochemical methods can address the key role played by neurotransmitters such as dopamine and glutamate during the psychosis onset. To conclude, multimodal neuroimaging may ultimately clarify the neurobiology of the prodromal phases by the integration of functional, structural and neurochemical findings.

Therapeutic Drug Monitoring in Child and Adolescent Psychiatry*

Psychopharmacotherapy in children and adolescents is characterized by an increased susceptibility for adverse events and an increased risk of ineffective treatment due to specific age-dependent and developmental characteristics in comparison to adults. Dosing in paediatric psychiatric patients requires careful handling, since the dose recommendations for adults can not simply be extrapolated to minors because of pharmacokinetic and pharmacodynamic differences. In addition, psychopharmacotherapy in children and adolescents is hampered by lack of high quality evidence on efficacy and safety in many indications and subsequently a high degree of off-label use. Therapeutic Drug Monitoring (TDM) is an established and useful tool in psychiatry to individualize and optimize the outcomes (efficacy/safety balance) of psychopharmacological drug treatment in the individual patient by dose adjustments based upon measured serum concentrations. In children and adolescents the administration of psychotropic drugs is a general indication for performing TDM. However, TDM studies specific in these age groups are necessary to identify age and indication specific therapeutic ranges of serum concentrations. Systematic collection of data on drug exposure, serum concentrations and clinical characteristics as well as outcomes can generate such practice-based evidence. A German-Swiss-Austrian competence network for TDM in child and adolescent psychiatry using a multi-centre internet-based data infrastructure was founded to document and collect demographic, safety and efficacy data as well as blood concentrations of psychotropic drugs in children and adolescents (further information: www.tdm-kjp.com).

Electro-convulsive Therapy: A Few Lingering Thoughts/Doubts!

Byline: M. Reddy Electro-convulsive therapy (ECT) was introduced in 1938 and has been in continuous use since then as a tool for therapeutic neuromodulation in the treatment of various psychiatric disorders. ECT celebrates its 74th birthday this year and is neither tired nor retired as a treatment modality. It remains an important component in the armamentarium of biological therapeutic tools in psychiatry. ECT remains invaluable, and can be termed life saving, in the management of patients with acute suicidal risk, severely retarded depression, catatonia, etc. ECT differs from psychopharmacology in several clinically relevant aspects: action on electrical depolarization and not at receptors at synapses, independent of renal clearance, hepatic metabolism, compliance of patient, drug interactions, etc. [sup][1] As of today there is no single unifying explanation how ECT works so well in a variety of conditions. Since its introduction in 1938 there were several advances in the practice of ECT with introduction of modified ECT, brief pulse and ultrabrief pulse current, unilateral electrode placement, seizure threshold titration, etc. with the goal to increase efficacy and minimize the risk, special focus being on minimizing cognitive side effects. Risk of death with ECT is relatively low at 1 in 10,000 patients. At Asha hospital, Hyderabad, about 30,000 patients received ECT in the last 8 years, mostly modified, without any mortality (oral communication). Amnesia, both anterograde and retrograde, remains a significant troublesome side effect. Generally it is transient but some reports comment on many patients having incomplete recovery in retrograde amnesia. [sup][2] The reasonable safety of unmodified ECT has been well described. [sup][3],[4],[5],[6],[7] The safety profile of ECT remains neighbors's (other biological treatments) envy. Scalia et al. [sup][8] reported the case of a 92-year-old woman who had received 91 ECTs in her lifetime and showed no pathological effects at postmortem examination of her brain when she died of other causes. Dwork et al. [sup][9] reported no evidence of any significant neuro-pathological lesions in nonhuman primates after receiving multiple ECTs. Broadly ECT can be categorized based on the phase of treatment: *Acute (phase) ECT - till response/remission *Continuation (phase) ECT (C - ECT) - few weeks/months after remission to prevent relapse *Maintenance (phase) ECT (M - ECT) - few months or longer to prevent recurrence ECT is used in the management of depression and every psychotic disorder in psychiatry, though depression remains the most common indication. The Consortium for esearch in ECT (CORE) reported a 75% remission in depression [sup][10] which is supported by the UK ECT Review group. [sup][11] Patients with psychotic subtype of depression respond much higher. [sup][12] But there are reports that success rates in community hospital settings have been less at 30-45% as reported by Prudic et al. . [sup][13] There was another report by Sackeim et al. [sup][14] that documented remission rates in depression with ECT at 54%. Another interesting component of this study was that without any form of maintenance treatment 84% of patients relapsed at the end of 6-month follow-up. The CORE group also reported 46% relapse at the end of 6 months. One of their recommendations underscores the need to treat to wellness and not prematurely terminate the acute course of ECT. The clinical utility of continuation ECT and maintenance ECT was well discussed by Andrade et al. [sup][15] and Kellner et al. [sup][16] Most guidelines recommend ECT only for resistant depression and at a much later stage in the treatment process. The National Institute for Clinical Excellence (NICE) guidelines recommend restriction of ECT only for patients with severe depression and state that ECT is not recommended as maintenance therapy. [sup][17] ECT is underutilized as a treatment modality by some psychiatrists, at some institutions and in some geographical locations of the world. …

P03-363 - Motor neurological soft signs are strongly correlated with verbal fluency among patients with schizophrenia attending UKMMC psychiatric clinic

IntroductionNeurological soft signs (NSS) are subtle indicator of brain dysfunction, which are present in excess among patients with schizophrenia. Its clinical significance remains unclear despite extensive researches.ObjectiveTo determine the proportion of schizophrenia patients who have motor NSS and then to compare the performance in verbal fluency between these two groups; with and without motor NSS.MethodThis cross-sectional study utilized the Brief Motor Scale (BMS) to investigate the presence of motor NSS in 80 schizophrenia patients attended Universiti Kebangsaan Malaysia Medical Centre (UKMMC) psychiatric clinic. The diagnosis was confirmed by Mini International Neuropsychiatic Interview (MINI). Symptomatology and abnormal motor movement were assessed using the Brief Psychiatric Rating Scale (BPRS) and Abnormal Involuntary Movement Scale (AIMS) respectively. A brief battery of cognitive tests covering aspects of attention, working memory and executive function was administered. Bivariate and multivariate analyses were applied to look for any relationship between study factors.ResultsMajority of schizophrenia patients (68.8%) in this study have motor NSS. The motor NSS were correlated with verbal fluency, digit span forward, digit span backward, and trail making B but not with trail making A (p < 0.05). However, verbal fluency was the only factor that remained significantly correlated with motor NSS after multivariate analysis.ConclusionsThe assessment of motor NSS represents a brief, inexpensive and meaningful tool in psychiatry. Together with verbal fluency, it has the potential as an illness marker and a link between neurobiological research and clinical practice.

The use of videoconferencing with patients with psychosis: a review of the literature

Videoconferencing has become an increasingly viable tool in psychiatry, with a growing body of literature on its use with a range of patient populations. A number of factors make it particularly well suited for patients with psychosis. For example, patients living in remote or underserved areas can be seen by a specialist without need for travel. However, the hallmark symptoms of psychotic disorders might lead one to question the feasibility of videoconferencing with these patients. For example, does videoconferencing exacerbate delusions, such as paranoia or delusions of reference? Are acutely psychotic patients willing to be interviewed remotely by videoconferencing? To address these and other issues, we conducted an extensive review of Medline, PsychINFO, and the Telemedicine Information Exchange databases for literature on videoconferencing and psychosis. Findings generally indicated that assessment and treatment via videoconferencing is equivalent to in person and is tolerated and well accepted. There is little evidence that patients with psychosis have difficulty with videoconferencing or experience any exacerbation of symptoms; in fact, there is some evidence to suggest that the distance afforded can be a positive factor. The results of two large clinical trials support the reliability and effectiveness of centralized remote assessment of patients with schizophrenia.

Ethical considerations in clinical training, care and research in psychopharmacology

Psychopharmacology is a powerful tool in psychiatry; however, it is one that demands responsibility in order to deal with the ethical complexities that accompany advances in the field. It is important that questions are asked and that ethical mindfulness and sensitivity are developed along with clinical skills. In order to cultivate and deepen ethical awareness and subsequently solve issues in optimal fashion, investment should be made in the development of an ethical decision-making process as well as in education in the ethics of psychopharmacology to trainees in the field at all stages of their educational development. A clear approach to identifying ethical problems, engaging various ethical concepts in considering solutions and then applying these principles in problem resolution is demanded. An openness in identifying and exploring issues has become crucial to the future development and maturation of psychopharmacologists, both research and clinical. Consideration must be given to the social implications of psychopharmacological practice, with the best interests of patients always paramount. From both a research and clinical perspective, psychopharmacology has to be practised with fairness, sensitivity and ethical relevance to all. While ethical issues related to psychopharmacological practice are varied and plentiful, this review focuses on advances in technology and biological sciences, personal integrity, special populations, and education and training.

Machine learning classification with confidence: Application of transductive conformal predictors to MRI-based diagnostic and prognostic markers in depression

There is rapidly accumulating evidence that the application of machine learning classification to neuroimaging measurements may be valuable for the development of diagnostic and prognostic prediction tools in psychiatry. However, current methods do not produce a measure of the reliability of the predictions. Knowing the risk of the error associated with a given prediction is essential for the development of neuroimaging-based clinical tools. We propose a general probabilistic classification method to produce measures of confidence for magnetic resonance imaging (MRI) data. We describe the application of transductive conformal predictor (TCP) to MRI images. TCP generates the most likely prediction and a valid measure of confidence, as well as the set of all possible predictions for a given confidence level. We present the theoretical motivation for TCP, and we have applied TCP to structural and functional MRI data in patients and healthy controls to investigate diagnostic and prognostic prediction in depression. We verify that TCP predictions are as accurate as those obtained with more standard machine learning methods, such as support vector machine, while providing the additional benefit of a valid measure of confidence for each prediction.

Outliers on the Dose-Response Curve: How to Minimize This Problem Using Therapeutic Drug Monitoring, an Underutilized Tool in Psychiatry

This column continues the discussion of outliers on the dose-response curve begun in earlier columns. It focuses on therapeutic drug monitoring (TDM) as an underutilized tool in psychiatry to minimize this problem. The scientific rationale for dose adjustment based on TDM is presented and its efficiency is contrasted with dose adjustment based on clinical assessment of response. In current practice, the use of TDM with psychiatric drugs is generally restricted to drugs with narrow therapeutic windows or drugs imported into psychiatry from neurology where TDM is more commonly used. Examples of each of these types of drugs are cited.

PW01-73 - The impact of ethnicity and language needs on duration of admission to a psychiatric inpatient unit

IntroductionLanguage is the main investigative and communicative tool in psychiatry and adequate understanding of language is essential for thorough assessment by the clinician, and for patient satisfaction. Interference with communication impairs our ability to assess a patient comprehensively. In a Department of Health survey of British Asians in hospital, more than half had experienced difficulties in communication and reported dissatisfaction with existing interpretation services.Aims/objectivesAudit whether language needs and Ethnicity are addressed in an adult inpatient sample and evaluate consequent impact on hospital admission duration.MethodCasenotes of patients, who were identified as having language needs, were audited against National Institute for Mental Health in England(NIMHE) standards for the provision of an interpreter at every medical review(standard=100%). Electronic patient data was analysed for recording of ethnicity, language, admission duration and demographic data.ResultsSample size 3028. 3028(100%) had ethnicity recorded and 1434(47%) had spoken language recorded. Of 23 case notes audited, an interpreter was present on 28.3% of occasions. White British patients had average admission durations of 39.8 days compared to 53.7 days in Black/minority ethnic groups(BME). English speaking patients spent 43.4 days in hospital compared to 74.9 days for non-English speaking patients. BME/Non-English speaking patients spent 78.8 days in hospital compared to 42.1 days for English speaking/White British patients.ConclusionsThe study highlights an immediate need for addressing language/interpretation services within the trust. The implications of longer hospital admission duration on service user experience/dissatisfaction with services and financial implications for the Trust are evident. Further training for staff in cultural awareness and documentation of needs has been recommended.

Is computed tomography still useful as a neuroimaging tool in psychiatry?

Computed tomography (CT) has played a pivotal role in psychiatry from its inception; however with the advent of other high-resolution noninvasive neuroimaging techniques such as MRI, the field has gone through a dramatic transformation. This article will explore the current role of CT in psychiatry. An extensive search of the published literature (1970 - 2008) was conducted, employing a number of databases and terms relevant to CT and imaging. At present CT is primarily used as a screening tool to exclude intracranial pathology. This is partly because it is widely available and less expensive than other imaging modalities. CT is unable to provide region-specific information like MRI and this has restricted its use in disorders in which functional disturbances are suspected, however it remains the preferred mode of investigation where gross structural abnormalities are suspected.

Foundation programme assessment tools in psychiatry

In line with Modernising Medical Careers (Department of Health, 2003), the foundation year programme aims to bridge the gap between undergraduate and specialist training. Psychiatry posts have been incorporated into the second year of this programme, with satisfactory progress of doctors being monitored via a range of workplace-based assessment tools. Learning that occurs in the context of the daily workplace is more likely to be relevant and reinforced, leading to better practice (Davis et al, 1995).

Graphology for the diagnosis of suicide attempts: a blind proof of principle controlled study

To evaluate the ability of two graphologists and two practising internists not trained in graphology to differentiate letters written by subjects who have attempted to commit suicide by self-poisoning and healthy volunteers, we performed a maximal blind controlled study vs. healthy volunteers. Forty fully recovered patients who had attempted to commit suicide and 40 healthy volunteers wrote and signed a short letter or story not related to the parasuicide or their mental health status. The evaluators classified the 80 letters as 'suicide' or 'no suicide' in an intention-to-treat analysis. Letters expressing sadness were subsequently excluded for a per-protocol analysis. Correct diagnosis of suicide and of healthy controls was made in, respectively, 32 of 40 and 33 of 40 letters by the graphologists and in 27 of 40 and 34 of 40 letters by the internists. After the exclusion of 12 letters expressing sadness, the sensitivity, specificity, positive predictive value and negative predictive value were, respectively, 73, 88, 81 and 82% for the graphologists and 53, 89, 80 and 71% for the internists. Both classified the letters with significantly more effectiveness than chance (p < 0.001) with no statistically significant difference between the two groups of evaluators. We concluded that graphological analysis is able to differentiate letters written by patients who attempt suicide from those written by healthy controls. This technique shows an acceptable degree of accuracy and could therefore become an additional discharge or decision-making tool in Psychiatry or Internal Medicine.

Chronic psychosocial stress and concomitant repetitive transcranial magnetic stimulation: effects on stress hormone levels and adult hippocampal neurogenesis

Background Repetitive transcranial magnetic stimulation is increasingly used as a therapeutic tool in psychiatry and has been demonstrated to attenuate the activity of the stress hormone system. Stress-induced structural remodeling in the adult hippocampus may provide a cellular basis for understanding the impairment of neural plasticity in depressive illness. Accordingly, reversal of structural remodeling might be a desirable goal for antidepressant therapy. The present study investigated the effect of chronic psychosocial stress and concomitant repetitive transcranial magnetic stimulation treatment on stress hormone regulation and hippocampal neurogenesis. Methods Adult male rats were submitted to daily psychosocial stress and repetitive transcranial magnetic stimulation (20 Hz) for 18 days. Cell proliferation in the dentate gyrus was quantified by using BrdU immunohistochemistry, and both the proliferation rate of progenitors and the survival rate of BrdU-labeled cells were evaluated. To characterize the activity of the hypothalamic-pituitary-adrenocortical system, plasma corticotropin and corticosterone concentrations were measured. Results Chronic psychosocial stress resulted in a significant increase of stress hormone levels and potently suppressed the proliferation rate and survival of the newly generated hippocampal granule cells. Concomitant repetitive transcranial magnetic stimulation treatment normalized the stress-induced elevation of stress hormones; however, despite the normalized activity of the hypothalamic-pituitary-adrenocortical system, the decrement of hippocampal cell proliferation was only mildly attenuated by repetitive transcranial magnetic stimulation, while the survival rate of BrdU-labeled cells was further suppressed by the treatment. Conclusions These results support the notion that attenuation of the hypothalamic-pituitary-adrenocortical system is an important mechanism underlying the clinically observed antidepressant effect of repetitive transcranial magnetic stimulation, whereas this experimental design did not reveal beneficial effects of repetitive transcranial magnetic stimulation on adult hippocampal neurogenesis.

Transcranial magnetic stimulation as a therapeutic tool in psychiatry: what do we know about the neurobiological mechanisms?

Transcranial magnetic stimulation as a therapeutic tool in psychiatry: what do we know about the neurobiological mechanisms?