Adjunctive risperidone treatment in post-traumatic stress disorder: a preliminary controlled trial of effects on comorbid psychotic symptoms.

Positive and negative symptoms of psychosis may be common in patients with chronic post-traumatic stress disorder (PTSD), but few studies have investigated the use of antipsychotic agents in these patients. This preliminary study examined the potential efficacy of risperidone in treating psychotic symptoms associated with chronic PTSD. In a 5-week, prospective, randomized, double-blind, placebo-controlled trial, adjunctive risperidone treatment was assessed in 40 combat veterans with chronic PTSD and comorbid psychotic features. Most patients were receiving antidepressants and some other psychotics with doses of concurrent medications held constant for at least 1 month prior to and during the study. Thirty-seven patients completed at least 1 week of treatment with risperidone or placebo. The Positive and Negative Syndrome Scale (PANSS) and the Clinician Administered PTSD Scale (CAPS) were used to assess symptoms. The PANSS was the primary outcome measure. At treatment endpoint, risperidone-treated patients showed a significantly greater decrease from baseline, albeit modest, in psychotic symptoms (PANSS total scores) than placebo-treated patients (P < 0.05). CAPS ratings declined significantly in both groups but did not differ significantly between groups. However, CAPS re-experiencing subscale scores had greater improvement in the risperidone-treated patients at week 5 (P < 0.05, completer analysis) with a trend towards greater improvement versus placebo a endpoint (P < 0.1, LOCF). Risperidone was well tolerated with minimal extrapyramidal symptoms. These preliminary results support studying the potential efficacy of risperidone for treating global psychotic symptoms associated with chronic PTSD with a suggestion that core re-experiencing symptoms may also be responsive. Further research using randomized, controlled trial designs in larger patient groups are needed to define more adequately the role of risperidone and other atypical agents in PTSD.

Implementation of a college-wide GME core curriculum.

As health care delivery and its associated costs have been scrutinized carefully over the past decade, educational institutions have been expected to demonstrate how a particular educational requirement such as residency training brings benefit to the purchasers and users of their health care services. As part of this trend, the Accreditation Council for Graduate Medical Education recently enacted new accreditation standards mandating the inclusion of curricular elements that expose residents to basic concepts and principles of the non-technical areas of health care across a variety of topics, including ethics, cost containment, socioeconomics, medical-legal issues, communication skills, research design, statistics, and critical review of the medical literature. The authors report the efforts at the Medical University of South Carolina to overcome obstacles and successfully implement an institution-wide core curriculum program, dealing with the kinds of topics mentioned above, across 47 specialty and subspecialty programs with over 500 residents and fellows. The seminal events and critical strategies are described, along with lessons learned along the way. The following were key elements to success: (1) adhering to a strategic plan assigning oversight of residency education to the graduate medical education (GME) office; (2) gaining strong support from the dean and other college officials; (3) creating a stepwise centralization of residencies in college via the GME committee; (5) making the first core curriculum element one that had an excellent chance to succeed; (6) having core curriculum sessions begin in evenings and weekends to not interfere with regular curriculum, but later, when the value of the curriculum became evident to departments, moving the sessions to be within the week; (7) having the philosophy of the GME office be to maintain a flexible approach and serve departments.

Effects of bupropion sustained-release on sexual functioning and nocturnal erections in healthy men.

Many antidepressants are known to cause adverse sexual effects. Bupropion is an antidepressant with fewer reported adverse sexual effects. Studies of sexual side effects are often confounded by psychiatric and medical conditions affecting sexual function. In this study, the effects of bupropion on subjective and objective sexual functioning were measured in healthy men. Thirteen men without psychiatric or medical illness completed a 2-week, placebo-controlled, double-blind, crossover trial of bupropion sustained-release 300 mg/day. Subjects had a 1-week washout period between trials. Sexual function was measured using a validated, self-administered questionnaire and the RigiScan, an instrument measuring nocturnal penile tumescence and rigidity. No differences were found in self-reported sexual function, number of erections, total erection time, or penile rigidity in subjects taking bupropion compared with those taking placebo or baseline. These findings support that bupropion does not have subjective adverse sexual side effects and does not affect nocturnal erections in healthy men.

Absenteeism and productivity among mental health employees.

We examined archival data to test the hypothesis that absenteeism is inversely related to work productivity among mental health employees at a Veterans Affairs Medical Center outpatient clinic. Results provided partial support for this hypothesis in that there was an inverse correlation between one measure of productivity and the percentage of sick and family care leave taken on Mondays and Fridays (r=.54). No significant relationship between work productivity and total sick and/or family care leave was found, although there was a trend in that direction (r=.34). These data suggest that mental health clinicians who use high levels of sick and/or family care leave are not necessarily unproductive workers. However, high percentages of absenteeism on Mondays and Fridays may represent a red flag for identifying under-performing clinicians. Examination of absenteeism patterns may prove useful for administrators. Management policy strategies to reduce absenteeism are suggested.

A controlled trial of daily left prefrontal cortex TMS for treating depression.

BACKGROUND: Transcranial magnetic stimulation (TMS) is a new technology for noninvasively stimulating the brain. Several studies have suggested that daily stimulation of the left prefrontal cortex with TMS for 2 weeks has probable antidepressant effects. We conducted a parallel-design, double-masked, sham-controlled study to address whether 2 weeks of daily TMS over the left prefrontal cortex has antidepressant activity greater than sham. METHODS: Thirty medication-free adult outpatients with nonpsychotic, major depressive (n = 21) or bipolar (n = 9) (depressed phase) disorder who were in a current major depression (Hamilton Rating Scale for Depression [HRSD] 21-item score of >18) were treated each weekday for 2 weeks. Subjects were randomly assigned to receive either daily active (20 subjects) or sham (10 subjects) stimulation. Additionally, the 20 active subjects were equally divided between slower (5 Hz) and faster (20 Hz) frequency treatment. Antidepressant response was defined as greater than a 50% improvement in the baseline HRSD. RESULTS: Active TMS resulted in significantly more responders (9/20) than did sham (0/10) (chi(2) = 6.42, p <.01). The number of responders did not differ significantly between the two active cells (3/10 faster and 6/10 slower). Expressed as a percent change from baseline, active TMS subjects had significantly greater improvement on the Beck Depression Inventory as well as the Hamilton Anxiety Rating Scale than did those who received sham. CONCLUSIONS: Daily left prefrontal TMS for 2 weeks significantly reduced depression symptoms greater than did sham. The two forms of active TMS treatment did not differ significantly.

Psychotic features in chronic posttraumatic stress disorder and schizophrenia: comparative severity.

Psychotic features are frequent in combat veterans with chronic posttraumatic stress disorder (PTSD), may correlate with severity of PTSD symptoms, and may reflect a distinct subtype of the disorder. These psychotic features include auditory and visual hallucinations and delusional thinking that is usually paranoid in nature. Psychotic features may be under-recognized in chronic PTSD because patients are reluctant to report these symptoms and because they may not have overt changes in affect or bizarre delusions characteristic of other psychoses, e.g., schizophrenia. To further assess these phenomena, we compared clinical ratings on the Positive and Negative Syndrome Scale (PANSS) and other assessments, including the Clinical Global Impression Scale and the Structured Clinical Interview with Psychotic Screen, in veterans meeting DSM-IV criteria for chronic PTSD with well-defined comorbid psychotic features (N = 40) or chronic schizophrenia (N = 40). The patients with schizophrenia had modestly higher composite PANSS scores and positive symptom scores although average scores in both groups were moderate to severe in intensity. Negative symptom and general psychopathology subscale scores were comparable in both groups. Regarding specific positive symptoms, hallucinations were comparable between groups in severity; however, schizophrenia patients had slightly more intense delusions and conceptual disorganization. These data further validate the occurrence of positive as well as negative symptoms of psychosis in chronic PTSD in a range of severity that may approach that of patients with schizophrenia. Although meeting DSM-IV criteria for two different major psychiatric disorders, these two patient populations were remarkably similar with respect to not only positive but also negative symptoms.

An overview of side effects caused by typical antipsychotics.

Typical antipsychotics often combine efficacy in treating antipsychotic illnesses with a side effect profile that can affect every system of the body and range from the annoying-photosensitivity and jaundice, for example-to the disabling-seizures and blindness, among others-to the potentially fatal-agranulocytosis and neuroleptic malignant syndrome. The side effects of conventional antipsychotics are associated with effects at CNS transmission and receptor sites and appear in relation to dose levels and potency of the drug. Characteristics of patients-including gender, age, and comorbid medical illness-can make them more or less susceptible to particular antipsychotic side effects. Side effects influence patient quality of life and affect patient compliance with medications. This article will consider the physiologic systems affected by conventional neuroleptics, the sexual and reproductive side effects of typical antipsychotics, and the central nervous side effects of the conventional neuroleptics in the light of these concerns.

Panic disorder in schizophrenia.

OBJECTIVE: To determine the frequency of panic attacks and panic disorder in patients with chronic schizophrenia or schizoaffective disorder. METHOD: Fifty-three male outpatients meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for chronic schizophrenia or schizoaffective disorder were administered sections of the Structured Clinical Interview for DSM-IV (SCID). If panic attacks were reported, patients were queried about treatment and about onset relative to psychotic symptoms. RESULTS: Forty-nine patients were sufficiently organized to participate in the evaluation. Twenty-one (43%) experienced panic attacks, and 16 (33%) had current or past panic disorder. Eight (50%) of the 16 with panic disorder had been treated for panic. Substance dependence was not associated with having panic attacks or current or past panic disorder. Patients with paranoid schizophrenia were more likely than patients with schizoaffective or undifferentiated schizophrenia to have experienced panic attacks (57% versus 20%, chi 2 = 6.0, P < 0.02) or panic disorder (47% versus 10%, chi 2 = 6.9, P < 0.01). CONCLUSION: Panic attacks and panic disorder are common in men with schizophrenia or schizoaffective disorder. Panic disorder may be an overlooked comorbid diagnosis in patients with schizophrenia.

Alcohol dependence and hospitalization in schizophrenia.

Treatment of schizophrenia is often complicated by substance abuse. We report here findings of a retrospective study evaluating readmission rates of patients meeting DSM IV criteria comorbid for schizophrenia and alcohol or drug dependence treated with depot haloperidol or fluphenazine over a 2-year period. During the study period, 14 of the 26 (54%) male veteran patients were admitted to the VAMC, Charleston; 46% of patients met criteria for alcohol, marijuana or cocaine dependence. Patients with alcohol dependence appeared to be at highest risk for hospital admission (p < 0.05). Moreover, patients with alcohol dependence had longer hospital stays (p < 0.05) than patients without alcohol dependence. Marijuana or cocaine dependence was slightly, but not statistically more common among admitted patients. Marijuana or cocaine dependence did not predict length of stay or number of admissions. Alcohol dependence may be an important factor in schizophrenic exacerbation, and may be an important target for treatment.

Psychotic features and illness severity in combat veterans with chronic posttraumatic stress disorder.

BACKGROUND: Psychotic symptoms may be present in up to 40% of patients with combat-related posttraumatic stress disorder (PTSD). In this study, we hypothesized that severity of psychotic symptoms would also reflect severity of PTSD symptoms in patients with well-defined psychotic features. METHODS: Forty-five Vietnam combat veterans with PTSD but without a primary psychotic disorder diagnosis underwent a Structured Clinical Interview for DSM-III-R with Psychotic Screen, and the Clinician Administered PTSD Scale (CAPS). Patients identified as having psychotic features (PTSD-P), (n = 22) also received the Positive and Negative Syndrome Scale (PANSS) and the Hamilton Depression Rating Scale (HDRS). RESULTS: There was a significant positive correlation between the CAPS and PANSS global ratings (p < .001) and the HDRS and PANSS (p < .03) in the PTSD-P patients. Many CAPS and PANSS subscales also demonstrated significant intercorrelations; however, the CAPS-B subscale (reexperiencing) and the PANSS positive symptom scale were not correlated, suggesting that psychotic features may not necessarily be influenced or accounted for by more severe reexperiencing symptoms. Fifteen (68%) of the PTSD-P patients had major depression (MDD). Both CAPS and PANSS ratings were significantly higher in the PTSD-P patients with comorbid MDD. CONCLUSIONS: As postulated, patients with more severe psychosis ratings are likely to have more severe PTSD disease burden if psychotic features are present. This study further documents the occurrence of psychotic features in PTSD that are not necessarily due to a primary psychotic disorder, suggesting that this may be a distinct subtype; however, a significant interaction likely exists between PTSD, depression, and psychotic features.

Repetitive transcranial magnetic stimulation: perspectives for application in the treatment of bipolar and unipolar disorders.

OBJECTIVES: Transcranial magnetic stimulation (TMS) affects the brain by non-invasively stimulating the cerebral cortex and inducing electrical currents in neurons. The powerful magnetic field acts as a vector that passes across the scalp and the skull, and then converts into an electrical energy within the brain. Originally used in neurophysiology, TMS has since been applied in a variety of neuropsychiatric conditions, including mood disorders. Imaging studies in mood-disordered patients have pointed to dysfunctional limbic and prefrontal cortex activity. TMS researchers have thus postulated that dorsolateral prefrontal cortex (DLPFC) stimulation might change brain activity both locally and in paralimbic areas through transynaptic connections, and alter mood. METHODS: We will describe the technology of TMS, its applications to date, and explore its mechanisms of action. RESULTS: Several clinical trials have demonstrated TMS effects on mood in health and disease. There is a growing consensus that TMS has antidepressant effects, although little is known about the role played by a variety of stimulation parameters such as the intensity or frequency of stimulation. One study has found an antimanic effect of right prefrontal TMS. CONCLUSION: TMS is relatively safe; however, much more research is needed before TMS can be integrated into routine clinical practice.

Serotonin reuptake antidepressant effects on sexual function in patients with anxiety disorders.

BACKGROUND: Serotonin reuptake inhibitor (SRI) antidepressants have been associated with sexual dysfunction, though there have been few prospective reports specifically examining this problem. The purpose of this study was to determine if three SRIs affected sexual function in anxiety disorder patients over a 3-month period. METHODS: Thirty-one patients were enrolled in a prospective study of the effect of three SRIs, fluoxetine, sertraline, and paroxetine, on five aspects of sexual function: libido, erection/lubrication, orgasm quality, orgasm delay, and sexual frequency. Measurements were made at baseline and at each month on visual analogue scales. RESULTS: For men and women, orgasm quality was lower and orgasm delay longer at months one, two, and three compared to baseline (p < .01). Erection scores were lower over time, but this change was not statistically significant. Lubrication, libido, and sexual frequency were not appreciably changed over 3 months. A higher rate of anorgasmia was noted in women at months one and two, but this did not achieve significance. CONCLUSIONS: Orgasm appears to be a primary sexual function affected by SRIs.

Sexual dysfunction induced by serotonin reuptake antidepressants.

Serotonin reuptake inhibitor (SRI) antidepressants have been associated with sexual dysfunction, though there have been few prospective reports specifically examining this problem. The purpose of this study was to determine if three SRIs affected sexual function in patients with an anxiety disorder or major depressive disorder over a 3-month period. Sixty-one patients were evaluated for at least 2 months in a prospective study of the effects of fluoxetine, sertraline, and paroxetine on five aspects of sexual function: libido, erection/lubrication, orgasm quality, orgasm delay, and sexual frequency. Measurements were made at baseline and at each month on visual analog scales. For men and women, orgasm quality was lower and orgasm delay longer at Months 1, 2, and 3 compared with baseline (p < .001). Erection scores were lower over time (p < .02) but this change was less dramatic. Lubrication, libido, and sexual frequency were not appreciably changed over 3 months. Anorgasmia was significantly more common in women than men at Months 1 and 2. Orgasm appears to be a primary sexual function affected by SRIs.

Realigning the values of academic health centers: the role of innovative faculty management.

As a market economy continues to permeate U.S. health care, fiscal accountability imposed by purchasers of medical services will reduce funds for medical education and will heighten the scrutiny of that activity. The authors propose that U.S. academic health centers must respond to these changes in the health care environment by critically examining their culture and values. This process will call for a reorientation of their values to place clinical education at the center of the academic enterprise. The authors challenge the notion that research- and publications-oriented faculty are the best group to train optimally effective clinical practitioners. They argue that although faculty promotion and rank in American medical schools are highly correlated with publications and funded research, there is no body of evidence that shows that fecundity in research or publications is essential for faculty to be excellent medical educators. The authors maintain that the main tool for realigning the fundamental values of academic health centers will be a new form of faculty management by the medical leadership. After outlining the current approach to research, teaching, clinical service, and administration at academic health centers, the authors challenge the traditional view that a faculty member should master all of these four elements, and state that the era of the "quadruple-threat" faculty member is passing. What can emerge is an emphasis on departments' and institutions' becoming "quadruple threats," which can occur only if institutions' leaders become better managers of their individual faculty members' priorities.(ABSTRACT TRUNCATED AT 250 WORDS)

Research on field-based services: models for reform in the delivery of mental health care to populations with complex clinical problems.

OBJECTIVE: Clinical services for psychiatrically impaired populations have only recently been studied with scientifically valid designs to explore innovations in structure, accessibility, and financing. Health systems reform in the United States has provided the impetus for better defining clinically effective and cost-sensitive models for mental health services. This article reviews assertive community treatment, used for adults with severe mental illnesses, and multisystemic therapy, used for adolescents with serious emotional disturbances, as examples of service system innovations that have been studied with controlled clinical trial designs and have demonstrated efficacy in treating difficult and costly clinical populations. METHOD: The authors reviewed the published controlled clinical trials of assertive community treatment and multisystemic therapy, focusing on the clinical and administrative elements that distinguish them from traditional service systems. RESULTS: A qualitative assessment of these two approaches suggests that they share common elements, with important implications for mental health policy. Specifically, the use of an ecological model of behavior applied to mental health patients is critical to both systems. In addition, therapeutic principles emphasizing pragmatic (outcome-oriented) treatment approaches, home-based interventions, and individualized goals are key elements of their success. Most important, both systems embody a therapeutic philosophy demanding therapist accountability, in which personnel are rewarded for clinical outcomes and therapeutic innovation rather than for following a prescribed plan. CONCLUSIONS: As empirically tested approaches, assertive community treatment and multisystemic therapy provide a scientific foundation for continued reform and serve to illustrate critical elements in designing new community treatment initiatives for behavioral as well as medical conditions.

Dexamethasone for the treatment of depression: a randomized, placebo-controlled, double-blind trial.

OBJECTIVE: The authors' goal was to assess dexamethasone for the treatment of depression. METHOD: Thirty-seven outpatients (11 men and 26 women) meeting DSM-III-R criteria for major depressive disorder were randomly assigned to receive either placebo or 4 mg/day of oral dexamethasone for 4 days. Baseline Hamilton depression scale scores were compared with scores obtained 14 days after the first dose of study medication. Data were analyzed by using two-sample t tests, chi-square methods, and Fisher's exact test. RESULTS: Seven (37%) of the 19 patients given dexamethasone but only one (6%) of the 18 patients given placebo responded positively. No adverse events or side effects were reported, and all patients who entered the study completed it. CONCLUSIONS: A brief course of oral dexamethasone (4 days) was significantly more effective than placebo within 14 days for the treatment of depression in a randomized, double-blind study of depressed outpatients.