Who's your expert? Use of an expert opinion survey to inform development of American Psychiatric Association practice guidelines.

OBJECTIVE: For many clinical questions in psychiatry, high-quality evidence is lacking. Credible practice guidelines for such questions depend on transparent, reproducible, and valid methods for assessing expert opinion. The objective of this study was to develop and demonstrate the feasibility of a method for assessing expert opinion to aid in the development of practice guidelines by the American Psychiatric Association (APA). METHODS: A "snowball" process initially soliciting nominees from three sets of professional leaders was used to identify experts on a guideline topic (psychiatric evaluation). In a Web-based survey, the experts were asked to rate their level of agreement that specific assessments improve specific outcomes when they are included in an initial psychiatric evaluation. The experts were also asked about their own practice patterns with respect to the doing of the assessments. The main outcome measures are the following: number of nominated experts, number of experts who participated in the survey, and number and nature of quantitative and qualitative responses. RESULTS: The snowball process identified 1,738 experts, 784 (45 %) of whom participated in the opinion survey. Participants generally, but not always, agreed or strongly agreed that the assessments asked about would improve specified outcomes. Participants wrote 716 comments explaining why they might not typically include some assessments in an initial evaluation and 1,590 comments concerning other aspects of the topics under consideration. CONCLUSIONS: The snowball process based on initial solicitation of Psychiatry's leaders produced a large expert panel. The Web-based survey systematically assessed the opinions of these experts on the utility of specific psychiatric assessments, providing useful information to substantiate opinion-based practice guidelines on how to conduct a psychiatric evaluation. The considerable engagement of respondents shows promise for using this methodology in developing future APA practice guidelines.

Depression Moderates the Relationship Between Pain and the Nonmedical Use of Opioid Medication Among Adult Outpatients.

BACKGROUND: The nonmedical use of prescription medication among US adults is a growing public health problem. Healthcare providers should proactively address this problem in outpatient encounters. OBJECTIVE: We sought to understand the interactive effects among prescription drugs, pain, and psychiatric symptoms among adult outpatients to build an empirical foundation for comprehensive screening. METHODS: We screened 625 adult neurosurgery and orthopedic patients at a suburban satellite clinic of an urban academic medical center. A convenience sample was screened for psychiatric and substance use disorder symptoms using the American Psychiatric Association's recommended screening protocol. We tested whether psychiatric symptoms moderated the relationship between pain level and nonmedical use of prescription medicine. RESULTS: Patients reported average levels of depression, anxiety, and pain symptoms, within 1 standard deviation of the screeners' normative data. However, patients reported highly elevated levels of nonmedical use of opioids and benzodiazapines compared with national data. Controlling for age, sex, and race, pain level predicted nonprescription use of opioid and benzodiazapine medications. Patients with high levels of depression and pain were more likely to engage in the unprescribed use of opioids. Likewise, patients with reduced levels of depression and pain were protected against the unprescribed use of opioids. CONCLUSIONS: These findings highlight the importance of examining unprescribed medication use even with patients at moderate levels of psychiatric symptoms and pain.

Direct-care staff body mass index in a state mental hospital: staff obesity may impair role modeling for patients.

INTRODUCTION: Direct-care staff at institutions providing long-term care serve as both caretakers and role models for their patients. The authors report a second study showing that major portions of such direct-care staff have significant problems themselves with overweight and obesity. This may be another changeable factor in the complex dynamics governing overweight and obesity among patients with chronic mental illness. METHOD: The authors recorded age, sex, and race, and measured height and weight during a typical 8-h shift among 50 direct-care staff at a long-term care psychiatric institution. Direct-care staff were defined as those members of the nursing staff who spent at least 4 h of their 8-h shift in direct contact with their patients. RESULTS: Of the 50 direct-care staff, 44 were black females. The authors focused on this subgroup in our report. These 44 black female direct-care staff had a mean body mass index (BMI) of 33.8+/-8.3 kg/m(2) and 27 (61.4%) were obese. Six of them (13.6%) were morbidly obese. CONCLUSIONS: Overweight and obesity may be a greater problem for staff providing care for patients with chronic mental illness than for the patients themselves. The authors believe studies are needed to test the hypothesis that staff obesity may impair staff ability to help obese patients lose weight. In our two studies to date, black women functioning as direct-care staff were highly vulnerable to overweight and obesity.

Body mass index (BMI) in newly admitted child and adolescent psychiatric inpatients.

INTRODUCTION: Obesity is a major problem among children and adolescents suffering from chronic mental illness. State-of-the-art measures such as body mass index (BMI) and growth-related weight charts are now readily available to clinicians and investigators interested in psychotropic drug-associated weight gain in the pediatric population. However, no reports that utilize such measures in large series of children and adolescents with psychiatric disorders are available. METHODS: The authors employed the Nutstat module of the Centers for Disease Control and Prevention (CDC) Epi Info software to assess BMI in a psychiatry inpatient child and adolescent population in Central Virginia. The authors also developed a scoring system to relate psychotropic administration to BMI. RESULTS: Children and adolescents with chronic mental illness had greater BMI measurements than the general pediatric population. Our scoring system found a relationship between antipsychotic drug administration and increased BMI that almost reached a level of significance (p=0.062). CONCLUSIONS: The present methodology using absolute weight to assess psychotropic drug-associated increase in body weight for children and adolescents is unsatisfactory. The authors offer a new and convenient methodology to correct this problem.

Body image and attitude toward obesity in an historically black university.

INTRODUCTION: The obesity epidemic is a major problem in the United States, particularly among black women. Body image and attitudes toward obesity are important areas to understand and address in any comprehensive approach to this epidemic. METHODS: From an initial evaluation of 200 college students (25 male and 25 female freshmen, sophomores, juniors and seniors each) attending an historically black university, we selected those students who identified themselves as black for data analysis (n = 191). All students underwent height and weight measurement from which body mass index (BMI) was calculated. Each student answered two questions related to nine silhouettes for each sex that progressively moved from extreme thinness to extreme obesity. Also, each student answered 20 questions describing attitudes about obesity. RESULTS: Black college students placed between the 62nd and 72nd percentiles of national BMI data for adolescents. Black female students were more likely than their black male counterparts to be obese. BMI did not vary by sex or grade level. Students of both sexes generally preferred "trim" silhouettes with the caveat that students with BMIs <25 kg/m2 preferred smaller silhouettes than did students with BMIs > or =25 kg/m2. BMI and sex did not favor any particular set of attitudes toward obesity. CONCLUSION: Black male and female college students from an historically black university were largely in the "normal" range of BMI percentiles for sex and age. Our black female students were more likely to be obese than our black male students. Our findings suggest that young black women are tolerant of a variety of body sizes. Based on findings from our Attitudes Toward Obese Persons scale, body size sense of self and sex do not influence attitudes toward obese persons. Further studies are needed.

Application of body mass index principles in a model elementary school: implications for overweight and obese children.

The first model elementary school in Richmond, VA formed the study site for this project. Changes in this model will lay the groundwork for changes throughout the Richmond Public School System. Of the 283 students in grades one through five, 66 students (23.3%) were randomly selected. Of the 66 students, 54 (81.8%) were black. Each student underwent height and weight measurement. Using the Nutstat module of the Centers for Disease Control (CDC) Epi Info software program available at no cost on the Internet, we identified Body Mass Index (BMI), BMI percentile for sex and age, and z-score for each student. Z-score measurements placed the 19 black male children at the 98.08th percentile for BMI (fewer than 2% of U.S. male children were larger). Similarly, the 35 black female children's BMI was at the 95.35th percentile (fewer than 5% of U.S. female children were larger). Based on data in the literature, the typical black male and female elementary child included in our study can expect a significant reduction in life expectancy compared with their nonobese counterparts.