Using electronic medical records to enable large-scale studies in psychiatry: treatment resistant depression as a model.

BACKGROUND: Electronic medical records (EMR) provide a unique opportunity for efficient, large-scale clinical investigation in psychiatry. However, such studies will require development of tools to define treatment outcome. METHOD: Natural language processing (NLP) was applied to classify notes from 127 504 patients with a billing diagnosis of major depressive disorder, drawn from out-patient psychiatry practices affiliated with multiple, large New England hospitals. Classifications were compared with results using billing data (ICD-9 codes) alone and to a clinical gold standard based on chart review by a panel of senior clinicians. These cross-sectional classifications were then used to define longitudinal treatment outcomes, which were compared with a clinician-rated gold standard. RESULTS: Models incorporating NLP were superior to those relying on billing data alone for classifying current mood state (area under receiver operating characteristic curve of 0.85-0.88 v. 0.54-0.55). When these cross-sectional visits were integrated to define longitudinal outcomes and incorporate treatment data, 15% of the cohort remitted with a single antidepressant treatment, while 13% were identified as failing to remit despite at least two antidepressant trials. Non-remitting patients were more likely to be non-Caucasian (p<0.001). CONCLUSIONS: The application of bioinformatics tools such as NLP should enable accurate and efficient determination of longitudinal outcomes, enabling existing EMR data to be applied to clinical research, including biomarker investigations. Continued development will be required to better address moderators of outcome such as adherence and co-morbidity.

Low-level sensory processing in obsessive-compulsive disorder: an evoked potential study.

This study used visual and auditory evoked potentials (VEP and AEP) to study low-level sensory processing in a group of 15 unmedicated subjects with obsessive-compulsive disorder (OCD) and 30 age-matched, gender-matched, and handedness-matched normal controls. EPs were recorded to flash (VEP) and binaural click (AEP) stimulation. OCD subjects were found to have significantly shorter latencies on N1 and P2 of the AEP, and no differences were found in the VEP. Results indicate abnormal information processing states in OCD during low-level auditory processing, but not during low-level visual processing. Neural generators of the VEP and AEP are briefly reviewed and results are discussed in relation to current neurobiological models of OCD.

Three patients with concomitant panic attacks and seizure disorder: possible clues to the neurology of anxiety.

The authors present the cases of three patients in whom panic attacks and epilepsy appeared together. These cases illustrate various possible relationships between panic attacks and epilepsy. These relationships include panic attacks representing the aura of a complex partial seizure, panic attacks representing a manifestation of interictal behavior change, and panic attacks and seizure coexisting independently. The authors conclude that exploration of the mechanisms operating in unusual cases like these may provide a vehicle for clarifying the neurobiological basis of anxiety.

Use of magnetic resonance imaging in psychiatry.

The authors report four cases in which magnetic resonance imaging (MRI) provided diagnostic information not apparent by X-ray CAT in clinical investigations of patients with neuropsychiatric disorders. The relative capabilities and contraindications for MRI and CAT are reviewed. The authors suggest that MRI is indicated 1) instead of CAT when there is suspicion of neuropathology that is better visualized by MRI because of its type or location and 2) after CAT when an atypical psychiatric symptom or presentation has not been definitively evaluated by means of CAT.

Obsessive-compulsive disorder: a double-blind, placebo-controlled trial of clomipramine in 27 patients.

Clomipramine was significantly superior to placebo in a 10-week double-blind, placebo-controlled trial in 27 outpatients who met DSM-III-R criteria for obsessive-compulsive disorder.

Triazolam-induced brief episodes of secondary mania in a depressed patient.

Large doses of triazolam repeatedly induced brief episodes of mania in a depressed elderly woman. Features of organic mental disorder (delirium) were not present. Manic excitement was coincident with the duration of action of triazolam. The possible contribution of the triazolo group to changes in affective status is discussed.

Clinical use of topographic brain electrical activity mapping in psychiatry.

The authors report clinically relevant results from topographic brain electrical activity mapping of patients undergoing psychiatric evaluation. Topographic methods are discussed and compared with electroencephalographic (EEG) and evoked potential (EP) techniques. Suggestions are made for using topographic analysis of EEG and EP data in clinical psychiatric practice.

Fluoxetine added to non-MAOI antidepressants converts nonresponders to responders: a preliminary report.

Thirty depressed outpatients poorly responsive to various non-MAOI antidepressants had fluoxetine added to their regimens. Retrospective analysis revealed that 26 (86.7%) of the patients improved. Non-MAOI antidepressant treatment was withdrawn for 12 of the 26 responders; of these, 8 relapsed on fluoxetine treatment alone but recovered when treatment with the discontinued non-MAOI agent was restarted.

EEG abnormalities in patients with atypical panic attacks.

BACKGROUND: Panic attacks and certain partial seizures have phenomenologic similarities which suggest that they may somehow be related. No evidence of such a relationship, however, was found when the routine EEGs of patients with panic attacks were examined. METHOD: Fifteen subjects with atypical panic attacks who met DSM-III-R criteria for panic disorder agreed to have routine followed by prolonged ambulatory EEG monitoring with sphenoidal electrodes. Fourteen subjects actually underwent monitoring; 1 had a panic attack during premonitoring routine EEG. RESULTS: Focal paroxysmal EEG changes consistent with partial seizure activity occurred during panic attacks in 33% (N = 5) of the 15 subjects; 2 (40%) of the 5 subjects with panic-related EEG changes had normal routine EEGs. Multiple attacks were recorded before panic-related EEG changes were demonstrated in several subjects. CONCLUSION: It may be necessary to monitor the EEG during multiple panic attacks to reveal an association between atypical panic attacks and epileptiform EEG changes.

Wagons ho: forward on the managed care trail.

This paper describes the impact of managed care on an academic medical center department of psychiatry. Like the pioneers before us, academic medical centers have often traveled wilderness paths, training new generations of psychiatrists and providing research about and new understandings of psychiatric illness; under assault from powerful competitive forces, we have all too often circled the wagons in an attempt to survive what we perceive as an onslaught. We describe the ways in which our academic medical center department of psychiatry has responded to managed care forces, in particular, the impact of managed care on residency training, inpatient services, outpatient psychotherapeutic and psychopharmacological care, and faculty morale. We describe how we have worked closely with our medical colleagues, formed new committees, and initiated forays into capitated arrangements. Despite difficult external circumstances, we have been able to survive, regroup, provide leadership, and continue with renewed purpose.

Fluoxetine versus trazodone in depressed geriatric patients.

A total of 27 subjects began active treatment in this double-blind study comparing the efficacy and safety of trazodone and fluoxetine in geriatric depressed patients, but only 13 completed 6 weeks on study medication. Both agents were effective according to weekly and endpoint analyses, and there was no evidence of significant effects on blood pressure, pulse, or weight. Separate analysis of patients who had received an adequate trial of medication indicated a trend toward relatively more fluoxetine-treated patients meeting clinical criteria for resolved depression.

Clonazepam vs. neuroleptics as adjuncts to lithium maintenance.

The majority of patients with bipolar affective disorder will continue to have some recurrences of acute illness despite lithium maintenance. In a significant proportion, the frequency and severity of acute episodes necessitate the administration of adjunctive maintenance medications. Neuroleptic drugs are often used for this purpose, but anticonvulsant drugs (carbamazepine, valproate, clonazepam) are reported to have acute antimanic efficacy and may offer an alternative for some bipolar patients. We report preliminary results of an open, prospective study in which bipolar patients maintained on lithium and a neuroleptic switch to lithium and clonazepam or continue their prior treatment with lithium and neuroleptic.

Sleepwalking.

Sleepwalking is one of the parasomnias, a group of disorders that also includes night terrors, nocturnal enuresis and nightmares. This disorder of arousal is much more common in children than in adults, and it is commonly associated with other parasomnias. Sleepwalking typically occurs during the first three hours of sleep, when sleep stages 3 and 4 (non-rapid-eye-movement sleep) are most prevalent. The episodes usually last 30 seconds to 30 minutes. The differential diagnosis of sleepwalking includes partial complex seizures occurring during sleep, rapid-eye-movement behavior disorder, night terrors, malingering, dissociative phenomena and medication effects. The treatment of sleepwalking in children includes providing a regular sleep-wake schedule, ensuring that the child has sufficient sleep and reassuring the parents. Medications and psychotherapy may be indicated in some adult patients.

Focal paroxysmal EEG changes during atypical panic attacks.

Atypical panic attacks include features such as focal paresthesias or sensory distortions, but attempts to demonstrate a relationship to partial seizures have been unsuccessful. Two patients with atypical panic attacks had attacks during EEG monitoring: one during a routine EEG in the EEG laboratory, the other at home during ambulatory monitoring. Focal paroxysms of sharp wave activity appeared on both patients' EEGs coincident with the spontaneous onset of panic attack symptoms. Both patients remained conscious. The correlation of focal paroxysmal EEG changes with panic attack symptoms suggests that these attacks were produced by partial seizure activity. Further study of the relationship between panic attacks and seizures is indicated.