Genetic analysis of low BMI phenotype in the Utah Population Database.

The low body mass index (BMI) phenotype of less than 18.5 has been linked to medical and psychological morbidity as well as increased mortality risk. Although genetic factors have been shown to influence BMI across the entire BMI, the contribution of genetic factors to the low BMI phenotype is unclear. We hypothesized genetic factors would contribute to risk of a low BMI phenotype. To test this hypothesis, we conducted a genealogy data analysis using height and weight measurements from driver's license data from the Utah Population Data Base. The Genealogical Index of Familiality (GIF) test and relative risk in relatives were used to examine evidence for excess relatedness among individuals with the low BMI phenotype. The overall GIF test for excess relatedness in the low BMI phenotype showed a significant excess over expected (GIF 4.47 for all cases versus 4.10 for controls, overall empirical p-value<0.001). The significant excess relatedness was still observed when close relationships were ignored, supporting a specific genetic contribution rather than only a family environmental effect. This study supports a specific genetic contribution in the risk for the low BMI phenotype. Better understanding of the genetic contribution to low BMI holds promise for weight regulation and potentially for novel strategies in the treatment of leanness and obesity.

Executive function in eating disorders: the role of state anxiety.

OBJECTIVE: We examined the influence of depression and anxiety on executive function in individuals with a DSM-IV diagnosis of anorexia nervosa-restricting type, anorexia nervosa-binge-eating/purging type, bulimia nervosa, or eating disorder not otherwise specified. METHOD: We assessed 106 women after their inpatient treatment in an eating disorders program. All participants were nutritionally stable at the time of testing. RESULTS: Thirty percent of the total sample showed impaired performance on one or more tests of executive function. No differences in executive function were observed among diagnostic groups. Anxiety scores accounted for significant variance in performance for all groups. DISCUSSION: Executive function deficits were found in a minority of our sample, with significant variance in performance accounted for by self-reported anxiety. State anxiety appears to contribute to diminished executive function in women with eating disorders.

Early-onset Major Depressive Disorder in men is associated with childlessness.

METHODS: The self-reported number of children was compared for men and women from the National Epidemiologic Survey of Alcoholism and Related Conditions Survey (NESARC). Subjects with a diagnosis of major depressive disorder or bipolar disorder were compared to those without an axis I disorder. The effect of age, gender, marriage and diagnostic status on number of children was completed using multivariate analyses. RESULTS: Men with a history of major depressive disorder but not bipolar disorder reported higher rates of childlessness and lower mean number of children. This reduced number of children was related to an early age of onset of MDD. Thirty percent of men with an age of onset of MDD before 22 were childless compared to only 18.9% of men without an axis I disorder (Odds ratio=1.82, 95% CI=1.45-2.27). No effect of mood disorder on number of children was found in women with major depression or bipolar disorder. DISCUSSION: This study suggests that an early age of onset of major depressive disorder contributes to childlessness in men.

Phenomenology and epidemiology of panic disorder.

BACKGROUND: Panic disorder is a common and severe psychiatric disorder. The estimated current prevalence rate for panic disorder is 1% to 2% of the adult population. Panic disorder is commonly accompanied by major depression, substance use disorders, and other anxiety disorders. Female gender, low socioeconomic status, and anxious childhood temperament are common risk factors for panic disorder. Panic disorder can produce marked distress and impairment and is associated with significant suicide risk. Panic disorder appears to increase risk for all-cause mortality because it may increase risk for cardiovascular disease.

Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface.

BACKGROUND: In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use. METHOD: The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties. CONCLUSION: Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.

Rate of inpatient weight restoration predicts outcome in anorexia nervosa.

OBJECTIVE: To examine weight restoration parameters during inpatient treatment as predictors of outcome in anorexia nervosa (AN). METHOD: Adolescent and adult females admitted for inpatient eating disorder treatment were recruited for an ongoing longitudinal study. This analysis examined several weight restoration parameters as predictors of clinical deterioration after discharge among participants with AN. RESULTS: Rate of weight gain was the only restoration parameter that predicted year 1 outcome. Clinical deterioration occurred significantly less often among participants who gained >or=0.8 kg/week (12/41, 29%) than those below this threshold (20/38, 53%) (chi(2) = 4.37, df = 1, p = .037) and remained significant after adjustment for potential confounders. DISCUSSION: Weight gain rate during inpatient treatment for AN was a significant predictor of short-term clinical outcome after discharge. It is unclear whether weight gain rate exerts a causal effect or is rather a marker for readiness to tolerate weight restoration and engage in the recovery process.

Attention-deficit hyperactivity symptoms and disorder in eating disorder inpatients.

OBJECTIVE: The objective of this study was to determine the prevalence of attention-deficit hyperactivity disorder (ADHD) symptoms and a DSM-IV ADHD diagnosis in women admitted for treatment of an eating disorder. METHOD: One hundred eighty-nine inpatient women with an eating disorder were interviewed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and ADHD interview from the Multi-international Psychiatric Interview (MINI). RESULTS: Twenty-one percent of the sample reported at least six current ADHD symptoms, but the estimated prevalence rate for a diagnosis of ADHD in this population was only 5.8% (95% CI: 2.6%-9.5%). Most current ADHD inattentive symptoms appeared after childhood suggesting late-onset non-ADHD origins. Current inattention symptoms in those without a diagnosis of ADHD correlated with higher BMI (p < .0001), symptoms of bulimia nervosa and current level of depression symptoms (p = .025). DISCUSSION: Although current ADHD symptoms were commonly endorsed in this population, clinicians should carefully examine for childhood symptom-onset of ADHD.

Clinical utility of the Hopkins Competency Assessment Test on an inpatient geropsychiatry unit.

This study examined the clinical use of routine administration of the Hopkins Competency Assessment Test on an inpatient geropsychiatry unit. The purpose was to determine whether the Hopkins Competency Assessment Test results influenced the psychiatrist's capacity assessment or confidence in that determination. The test was administered to all patients admitted voluntarily during an 18-week period. The attending psychiatrist determined treatment consent capacity and rated confidence in that determination, before and after review of the test results. Fifty seven patients were assessed. After review of the test results, the psychiatrist's capacity rating changed in only 2 (3.5%) cases. However, the test increased the psychiatrist's confidence ratings, particularly among the patients with cognitive impairment. The Hopkins Competency Assessment Test is not suited for routine administration among geropsychiatry inpatients. However, the test may serve a role as a supplementary tool for assessing treatment consent capacity among patients with evidence of cognitive impairment.

Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: results from STAR*D.

BACKGROUND: Whether the acute outcomes of major depressive disorder (MDD) treated in primary (PC) or specialty care (SC) settings are different is unknown. OBJECTIVE: To compare the treatment and outcomes for depressed outpatients treated in primary versus specialty settings with citalopram in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (www.star-d.org), a broadly inclusive effectiveness trial. DESIGN: Open clinical trial with citalopram for up to 14 weeks at 18 primary and 23 specialty sites. Participants received measurement-based care with 5 recommended treatment visits, manualized pharmacotherapy, ongoing support and guidance by a clinical research coordinator, the use of structured evaluation of depressive symptoms and side effects at each visit, and a centralized treatment monitoring and feedback system. PARTICIPANTS: A total of 2,876 previously established outpatients in primary (n = 1091) or specialty (n = 1785) with nonpsychotic depression who had at least 1 post-baseline measure. MEASUREMENTS AND MAIN RESULTS: Remission (Hamilton Depression Rating Scale for Depression [Hamilton] or 16-item Quick Inventory of Depressive Symptomatology-Self-Rated [QIDS-SR(16)]); response (QIDS-SR(16)); time to first remission (QIDS-SR(16)). Remission rates by Hamilton (26.6% PC vs 28.0% SC, p = .40) and by QIDS-SR(16) (32.5% PC vs 33.1% SC, p = .78) and response rates by QIDS-SR(16) (45.7% PC vs 47.6% SC, p = .33) were not different. For those who reached remission or response at exit, the time to remission (6.2 weeks PC vs 6.9 weeks SC, p = .12) and to response (5.5 weeks PC vs 5.4 weeks SC, p = .97) did not differ by setting. CONCLUSIONS: Identical remission and response rates can be achieved in primary and specialty settings when identical care is provided.

Clinical features of depression in outpatients with and without co-occurring general medical conditions in STAR*D: confirmatory analysis.

BACKGROUND: Concurrent medical comorbidity influences the accurate diagnosis and treatment of major depressive disorder (MDD). OBJECTIVE: The objective of this study was to validate previous findings from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study using a confirmation analysis in a previously unanalyzed cohort. DESIGN: Baseline cross-sectional case-control study of patients enrolling in a prospective randomized multistage treatment study of nonpsychotic MDD. SETTING: Fourteen regional U.S. centers representing 18 primary care and 23 psychiatric practices. PARTICIPANTS: 2541 outpatients with DSM-IV nonpsychotic MDD. MEASUREMENTS: Sociodemographic status, medical illness ratings, psychiatric status, quality of life, and DSM-IV depression symptom ratings. RESULTS: The prevalence of significant general medical comorbidity in this population was 50.0% (95% CI = 48.1% to 52.0%), consistent with findings reported for the first cohort. Concurrent significant medical comorbidity was associated with older age, lower income, unemployment, limited education, and longer duration of index depressive episode. The group with significant medical comorbidity reported higher rates of somatic symptoms, gastrointestinal symptoms, sympathetic arousal, and leaden paralysis. These results were generally consistent between the 2 cohorts from STAR*D. CONCLUSIONS: Major depressive disorder with concurrent general medical conditions is associated with a specific sociodemographic profile and pattern of depressive symptoms. This association has implications for diagnosis and clinical care.

Evaluating the quality of websites offering information on female hypoactive sexual desire disorder.

This study evaluates websites relevant to female hypoactive sexual desire disorder (HSDD). Its primary aim is to evaluate the quality of Internet HSDD information. One hundred and one websites, identified through simple Google searches, were scored using a tool incorporating expert consensus-derived quality criteria for HSDD. The tool included structural criteria such as currency, authorship, and disclosure of competing interests. It also included performance criteria, evaluating accuracy, and comprehensiveness, and was adapted from a published website evaluation tool for diabetes. For each website, a quality index score with a potential range from 1 to 5 (1 = poor, 5 = excellent) was calculated, and the websites were rank ordered using this score. Quality index scores ranged from 1.68 to 4.64, with 75% of websites scoring at or below 3.27. Test-retest reliability was moderate (n = 24, r = 0.6601, P = .0004). Rank ordering of the websites by quality index allowed identification of the top five highest quality websites. The majority of HSDD websites' quality scores fell in the score range from 1 to 3, indicating room for improvement in the quality of websites that address HSDD. Website evaluation tools utilizing both structural and performance quality criteria may help clinicians to assist their patients in assessing the quality of Internet health information.

Preventing relapse of major depression during interferon-alpha therapy for hepatitis C--A pilot study.

Depression is common in hepatitis C, exacerbated by interferon, and is a major reason for discontinuing interferon therapy. We aimed to determine (1) whether patients with a history of major depression could complete a course of peginterferon alpha-2a and ribavirin if pretreated with escitalopram and (2) the relapse rate of depression during the course of therapy in these subjects. Ten patients were enrolled in the study and treated with escitalopram. The Hamilton Depression Rating Scale (Ham-D) and other psychiatric scales were administered throughout the study. There were no statistically significant increases in mean Ham-D scores. No subjects were discontinued from the study due to depression relapse. Nine of 10 subjects maintained remission of depression throughout the study. We conclude that pretreatment with escitalopram in subjects with major depressive disorder in remission may prevent recurrence of major depression during a course of interferon and ribavirin therapy for hepatitis C.

A pilot study of psychiatry resident psychotherapy competency: the impact of resident attitude and demographics.

OBJECTIVE: In psychiatry education, psychotherapy knowledge, skills, and attitudes are new competency objectives. METHODS: Two faculty members independently ranked psychiatry residents for psychotherapy competency. A rank of 1 indicated the most competency and a rank of 15 indicated the least competency for the resident psychotherapist. Several demographic and attitudinal variables of the residents were examined for relationships with psychotherapy competence. RESULTS: When the competency rankings of the two faculty members were compared, they demonstrated a high level of agreement (spearman r = 0.74, p = 0.0016). Of the variables studied, resident age (r = .61, p = .015) and personal attitude toward psychotherapy (S=29, p = .026) were significantly associated with psychotherapy competency. Both variables remained independently significant after statistical adjustment. CONCLUSIONS: Our study indicates that psychiatry resident attitude and age may influence psychotherapy competency. These markers for psychotherapy competency may assist training programs with resident selection parameters and may enhance psychotherapy educational strategies for residents predicted to require assistance in achieving competency.

Validity of the distinction between primary and secondary substance use disorder in patients with bipolar disorder: data from the first 1000 STEP-BD participants.

The validity of a primary/secondary substance use disorder (SUD) distinction was evaluated in the first 1000 patients enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder. Patients with primary SUD (n = 116) were compared with those with secondary SUD (n = 275) on clinical course variables. Patients with secondary SUD had fewer days of euthymia, more episodes of mania and depression, and a greater history of suicide attempts. These findings were fully explained by variations in age of onset of bipolar disorder. The order of onset of SUDs was not linked to bipolar outcomes when age of onset of bipolar disorder was statistically controlled. The primary/secondary distinction for SUD is not valid when variations in the age of onset of the non-SUD are linked to course characteristics.

Major depressive disorder in hepatitis C: an open-label trial of escitalopram.

BACKGROUND: Depression is a common condition associated with hepatitis C and may be induced by interferon alfa, the primary treatment for hepatitis C. Depression is also a major barrier to the initiation of such treatment. This study examined the effect of escitalopram on measures of depression, quality of life, and tests of liver function in subjects with comorbid hepatitis C and depression. METHOD: Subjects with DSM-IV major depressive disorder and hepatitis C were included in this open-label study. The recruitment period was from October 2002 through February 2004. Treatment status with regard to interferon therapy was neither an inclusion nor an exclusion criterion. Subjects received escitalopram for 8 weeks starting at 10 mg/day. Dosage adjustments up to 20 mg/day were made after week 4, as deemed clinically necessary. Scores on the 17-item Hamilton Rating Scale for Depression (HAM-D-17) and the Clinical Global Impressions-Severity of Illness scale (CGI-S) and results of liver function tests (AST, ALT, GGT) were obtained at baseline, 2 weeks, 4 weeks, and 8 weeks. Medical Outcomes Study Short Form Health Survey (SF-36) ratings and Hopkins Symptom Checklist-90-Revised (SCL-90-R) scores were obtained at baseline and week 8. RESULTS: Eighteen subjects (12 female, 6 male) participated in this study. The mean daily dose of escitalopram at endpoint was 12.78 mg. Mean HAM-D-17 scores decreased significantly with treatment (t = 8.535, df = 17, p < .0001). Statistically significant improvement was also demonstrated on many subscales of the SF-36, the SCL-90-R, and the CGI-S. Tests of liver function showed no significant changes. CONCLUSION: These results suggest that depression in patients with hepatitis C may be effectively and safely treated with escitalopram.

Primary care specialty, resident status, and male gender correlate with controlled drug contract use.

OBJECTIVE: With prescription drug abuse rising, physicians are often ambivalent about prescribing controlled drugs. To address their concerns, physicians widely use controlled drug contracts (CDC); however, CDC use is poorly studied. This preliminary study characterizes CDC users and identifies factors associated with CDC use. METHOD: Data were collected from a Web-based survey of University of Oklahoma College of Medicine medical trainee and faculty attitudes and prescribing practices regarding controlled drugs. Recruited via e-mail, participants submitted responses anonymously for a 6-week period from January through March 2004. Associations between demographic variables and participants' responses were analyzed using chi2 analysis to determine correlates of CDC use. Demographic variables included training status (medical student, resident, or faculty), age, gender, and faculty specialty. Variables of interest derived from the survey were CDC use, how respondents compared the risks and benefits of controlled drugs, and patient diagnosis. RESULTS: One hundred ninety-six surveys were submitted, with an estimated response rate of 20% to 30%. CDC use correlated with male gender (p = .0099), resident status (p = .0099), primary care specialty among faculty (p = .0001), and risk/benefit assessment (p = .04) but not patient diagnosis (p = .19) or participant age (p = .40). CONCLUSIONS: Despite limitations, the study findings suggest that a physician's gender, training status, medical specialty, and comparison of the risks and benefits of controlled drugs are factors that determine CDC use.

Clinical features of depressed outpatients with and without co-occurring general medical conditions in STAR*D.

BACKGROUND: A significant percentage of patients with major depressive disorder (MDD) suffer from concurrent general medical conditions (GMCs). OBJECTIVE: The objective of this preliminary report was to describe the rates of co-occurring significant GMCs and the clinical correlates and symptom features associated with the presence of GMCs. DESIGN: Baseline cross-sectional case-control study of patients enrolling in a prospective randomized multistage treatment study of MDD. SETTING: Fourteen regional U.S. centers representing 19 primary care and 22 psychiatric practices. PATIENTS: One thousand five hundred outpatients with DSM-IV nonpsychotic MDD. MEASUREMENTS: Sociodemographic status, medical illness ratings, psychiatric status, quality of life and DSM-IV depression symptom ratings. RESULTS: The prevalence of significant medical comorbidity in this population was 52.8% (95% CI 50.3-55.3%). Concurrent significant medical comorbidity was associated with older age, lower income, unemployment, limited education, longer duration of index depressive episode and absence of self-reported family history of depression. Somatic symptoms common in MDD were endorsed at a higher rate in those with GMCs. Those without a GMC had higher rates of endorsement of impaired mood reactivity, distinct mood quality and interpersonal sensitivity. CONCLUSIONS: Concurrent GMCs are common among outpatients with MDD in both primary care and specialty settings. Concurrent GMCs appear to influence the severity and symptom patterns in MDD and describe a vulnerable population with sociodemographic challenges to effective assessment and treatment.

The impact of fear of HIPAA violation on patient care.

The deadline for compliance with the privacy rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was April 14, 2003. Understandably, many psychiatrists and other mental health providers have been focusing on compliance. This brief report discusses the negative impact of efforts to implement HIPAA on patient care in a community-based mental health system. Three cases highlight several issues: fear of violating HIPAA, failure to understand HIPAA's privacy regulations, and ethical concerns. The authors discuss the key issues and address implications for practice. Several recommendations are offered for maintaining excellent patient care while complying with HIPAA.