The Long-Term Clinical Outcome of Posttraumatic Stress Disorder With Impaired Coronary Distensibility.

OBJECTIVE: Coronary Distensibility Index (CDI) impairments reflect endothelial-dependent process associated with vulnerable-plaque composition. This study investigated the relation of impaired CDI with posttraumatic stress disorder (PTSD) and their predictive value for major adverse cardiovascular events (MACE). METHODS: This study involved 246 patients (age = 63 [10] years, 12% women) with (n = 50) and without (n = 196) PTSD, who underwent computed tomography angiography to determine coronary artery disease and CDI. Extent of coronary artery disease was defined as normal, nonobstructive (<50% luminal stenosis), and obstructive (>50%). Incidence of MACE, defined as myocardial infarction or cardiovascular death, was documented during a mean follow-up of 50 months. Survival regression was employed to assess the longitudinal association of impaired CDI and PTSD with MACE. RESULTS: A significant inverse correlation between CDI and Clinical Global Impression Severity scale of PTSD symptoms was noted (r = .81, p = .001). CDI was significantly lower in patients with PTSD (3.3 [0.2]) compared with those without PTSD (4.5 [0.3]), a finding that was more robust in women (p < .05). Covariate-adjusted analyses revealed that the relative risk of MACE was higher in patients with PTSD (hazard ratio [HR] = 1.56, 95% CI = 1.34-3.14) and those with impaired CDI (HR = 1.95, 95% CI = 1.27-3.01, per standard deviation lower CDI value). There was also a significant interaction between PTSD and impaired CDI (HR = 3.24, 95% CI = 2.02-5.53). CONCLUSIONS: Impaired CDI is strongly associated with the severity of PTSD symptoms. Both impaired CDI and PTSD were independently associated with an increased risk of MACE during follow-up, and evidence indicated an interaction between these two factors. These findings highlight the important role of CDI in identifying individuals with PTSD at risk for MACE.

EFFICACY AND LONG-TERM CLINICAL OUTCOME OF COMORBID POSTTRAUMATIC STRESS DISORDER AND MAJOR DEPRESSIVE DISORDER AFTER ELECTROCONVULSIVE THERAPY.

BACKGROUND: Many patients fulfill criteria for both posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Electroconvulsive therapy (ECT) is generally acknowledged to be the most-effective treatment for refractory MDD. This study investigated the efficacy of ECT on long-term clinical outcome of comorbid PTSD and MDD. METHODS: This retrospective nested matched case-control study is inclusive of 22,164 subjects [3,485 with comorbid MDD and PTSD (92 with ECT and 3,393 without ECT) and 18,679 without MDD and PTSD]. RESULTS: Using the clinical global impression scale (CGI) to assess efficacy, more-robust improvement of PTSD and MDD symptoms was observed with ECT (90%), compared to antidepressant-treatment alone(50%) (P = 0.001). During the median of 8 years of follow-up, the death-rate was 8% in subjects without PTSD and MDD, 9.7% in PTSD and MDD treated with ECT and 18% in PTSD and MDD without ECT (P < 0.05). The suicide-rate was 2.2 and 5.9% in PTSD and MDD with and without ECT-treatment, respectively (P < 0.05). Survival-analyses revealed that the relative-risk of cardiovascular and all-cause mortality is not significantly different in patients with comorbid MDD and PTSD treated with ECT, compared to a matched-cohort without PTSD and MDD (P > 0.05). The relative risk of suicidality, all-cause, and cardiovascular mortality was reduced 64, 65, and 46% in MDD and PTSD patients treated with ECT, compared to those without ECT (P < 0.05). CONCLUSION: ECT is associated with a significant reduction of symptoms of PTSD and MDD, as well as reduction in risk of suicidality, cardiovascular, and all-cause mortality in MDD and PTSD, an effect more robust than antidepressant-therapy alone.

Traumatic brain injury, coronary atherosclerosis and cardiovascular mortality.

BACKGROUND: Traumatic-brain-injury (TBI) is a devastating-condition resulting in cerebral edema and ischemia. This study investigates the association of mild-TBI (mTBI) to sub-clinical atherosclerosis and cardiovascular (CV) mortality. METHODS: Five hundred and forty-three veterans without known coronary artery disease or diagnosed mental disorder, who underwent coronary artery calcium (CAC) scanning for clinical indications, were followed for a median of 4-years. Veterans' medical diagnoses and neuropsychiatric health status (mTBI vs non-mTBI) were evaluated using VA electronic medical records. CAC was defined as 0, 1-100, 101-400 and 400+. RESULTS: CAC was higher in mTBI, compared to without-mTBI (p < 0.05). TBI was more prevalent with the-severity of CAC (p < 0.05). Regression-analyses revealed that mTBI is an independent-predictor of CAC (p < 0.01). The CV mortality rate was 25% in mTBI and 10.5% in without-mTBI (p = 0.0001). Multivariable survival regression analyses revealed a significant-association between mTBI and CAC, with increased-risk of CV mortality (p < 0.05). The hazard-ratio of CV mortality was 5.25 in mTBI & CAC > 0, compared to without-mTBI & CAC = 0 (p < 0.05). The risk of CV-mortality was 2.25 for mTBI & CAC = 1-100, 4.93 for mTBI & CAC = 101-400 and 7.06 for mTBI & CAC ≥ 400, compared to matched CAC-categories without-mTBI (p < 0.05). The area under ROC curve to predict CV mortality was 0.64 for mTBI, 0.69 for mTBI & PTSD, 0.85 for mTBI & CAC > 0 and 0.92 for the combination. The prognostication of mTBI to predict CV mortality is superior to the Framingham risk score. Also the combination of mTBI & PTSD provided incremental prognostic values to predict CV mortality (p < 0.05). CONCLUSIONS: mTBI is associated with the severity of sub-clinical coronary atherosclerosis and independently predicts CV mortality.

Does comorbid alcohol and substance abuse affect electroconvulsive therapy outcome in the treatment of mood disorders?

INTRODUCTION: Antidepressant medications remain the principal agents used to treat patients with mood disorders, although 30% to 40% of these patients do not improve. One of the factors associated with poor medication response is alcohol and substance abuse. Persons with mood disorders are at the greatest risk for suicide, and alcoholism is a significant additional risk factor. Electroconvulsive therapy (ECT) is shown to be the most effective treatment for major depression especially when associated with psychosis, catatonia, and suicide intent. However, similar to most antidepressant trials, patients with depression and comorbid alcohol and substance abuse are excluded from ECT efficacy studies. METHOD: Through a retrospective chart review, we compared response to ECT in patients with mood disorder and comorbid alcohol and drug abuse to those with mood disorder only. From 2004 to 2010, 80 patients with mood disorder received ECT. Fifty of these had comorbid alcohol or drug abuse. Using a 10-item psychopathology scale, we compared pre- and post-ECT symptom severity between the 2 groups. Outcome was determined by measuring a decrease in the pre-ECT and post-ECT score using Wilcoxon rank tests, with statistical significance at P = 0.05. RESULTS: There was no difference between the 2 groups in most demographics, ECT medication, or seizure quality. There was no difference in ECT outcome between those with comorbid alcohol abuse and those without based on percent decrease in pre- and post-ECT symptom scores (abuse: mean [SD], 0.89 [0.2] vs nonabuse: mean [SD], 0.93 [0.16]; Wilcoxon, 1332; P = 0.086). When we compared those who met the criteria for alcohol or drug dependence (19 patients) with those with no abuse, there was a trend for the dependence group to not do as well (dependence: mean [SD], 0.83 [0.25] vs nonabuse: mean [SD], 0.93 [0.16]; Wilcoxon, 405; P = 0.053). Those with combined drug and alcohol abuse (18 patients) did have a significantly worse outcome (combined: mean [SD], 0.82 [0.25] vs nonabuse: mean [SD], 0.93 [0.16]; Wilcoxon, 372; P = 0.033). CONCLUSION: Our results indicate that comorbid alcohol and drug abuse may influence the response to ECT in the treatment of mood disorders. Based on our results, patients with comorbid dependence and combined drug and alcohol abuse showed symptom improvement but did not do as well as those with nonabuse.

Quantitative electroencephalographic analysis of bifrontal versus bitemporal electrode placement in a stable maintenance electroconvulsive therapy population.

OBJECTIVE: Electrode placement in electroconvulsive therapy (ECT) is one of the many variables that can influence clinical outcome. Quantitative electroencephalographic (EEG) measures of the ECT-induced seizure have been studied in an attempt to determine differences in various electrode placements. The objective of this study was to evaluate the differences in the EEG between bifrontal (BF) and bitemporal (BT) placement. METHOD: Seventeen patients of maintenance ECT (10 males and 7 females) who received both BT and BF ECTs for a 12-month period starting January 2007 were identified through chart review. Patients were included if their medications, dosages and ECT parameters, and clinical condition remained stable during the study period. Each patient received both BF (n = 124) and BT (n = 112) placements. RESULTS: We found no significant differences in EEG measures between the 2 placements. We demonstrated that the qualitative EEG measures in both BT and BF electrode placements are similar. CONCLUSIONS: Our findings support that BF electrode placement produces similar quality seizures when compared with BT placement and may be a viable alternative placement to BT.

Clinical outcome of maintenance electroconvulsive therapy in comorbid Posttraumatic Stress Disorder and major depressive disorder.

BACKGROUND: Post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) are prevalent and frequently comorbid. Approximately 42-48% of patients with PTSD also meet diagnostic criteria for MDD. Maintenance electroconvulsive therapy (mECT) has been found to be efficacious for the prevention of recurrence of MDD. This study investigated the efficacy of mECT in the treatment of MDD with and without comorbid syndromal PTSD. METHODS: This retrospective study includes 36 patients, 26 with MDD and 10 with comorbid MDD & PTSD receiving monthly mECT for a mean of 1.5 years. The mean age was 52 ±â€¯14 years and 25% were female. The change in PTSD and MDD symptoms in response to mECT was assessed using Clinical Global Impression - Severity Scale (CGI-S). Heart rate variability (HRV), 12-month hospitalization rate, suicide rate and all-cause mortality in response to mECT were assessed and compared between groups using repeated generalized linear regression (GLM) analysis. RESULTS: At mECT baseline, there were no statistically significant differences in CGI-S scores, HRV between patients with MDD alone and those with comorbid MDD and PTSD (P > 0.05). After 12-months of mECT, a significant increase in HRV (mean difference: 10.9 95%CI 4.8-20.3, p = 0.001) and decrease in CGI-S overall (mean difference: 3.5, 95% CI 3.3-3.6, p = 0.001)], PTSD (mean difference: 3.4, 95% CI 3.2-3.6, p = 0.001)], and MDD (mean difference: 3.8, 95% CI 3.5-3.9, p = 0.001)] symptoms in both groups were noted (p < 0.05). No psychiatric hospitalization or suicide occurred in any of the patients. CONCLUSIONS: Maintenance ECT is associated with improved HRV, reduction of both major depression and PTSD symptoms, and a favorable clinical outcome.

Models, metaphors and psychopathology: commentary on Javanbakht's "bugs and bowls".

The theory of bugs and bowls," as outlined by Javanbakht (2005), is, in essence a psychobiological metaphor for understanding psychotic processes. It attempts to bridge psychological and biological explanations for psychotic phenomena by using the metaphor of "bugs and bowls." In this metaphor, the bowl represents the organism's capacity to contain its own inner experience. The bowl is described psychologically, in analytic terms, vis-à-vis traditional ego function and its action of repression. Interestingly, the superego is left out in this discussion. Inner experience, in this regard, corresponds to the wishes and fears of the unconscious. Repressed pathological memories are included in this explanation as well. On the biological side, neuroanatomic, neurochemical, and cortical-subcortical circuits and neural networks are reviewed and folded into the metaphor. The author cites a variety of different literatures to beef up his proposal that "bugs and bowls" is a utilitarian model for the modern clinician. Although we are quite fond of the analogy, there are a few things about it that "bug" us.

The impact of VA and Navy Hospital Collaboration on medical school education.

OBJECTIVE: The U.S. Department of Veterans Affairs (VA) is the largest single provider of medical education in the United States and is often the preferred training site for medical students and residents. However, changing priorities of patients and the marketplace are forcing medical schools and the VA to consider new ways of practicing medicine and relating to each other. This article reviews the value of that relationship. METHODS: The authors describe a VA and Department of Defense sharing agreement and the development of a federal medical center as well as the involvement of a local medical college and the impact on education. RESULTS: The federal medical center will provide more clinical services to veterans, active duty service members, and their beneficiaries. Trainees see a variety of young adults of both genders and are exposed to behaviors and pathology not commonly seen in typical general adult inpatient VA psychiatric units. CONCLUSION: The federal facility will provide accessible, high quality health care for active duty and veteran patients. It benefits trainees by enriching their training experience and allowing students and residents to receive a comprehensive clinical experience by caring for diversified patients with a wide range of pathology.

Isolated inability to write cursively after transient ischemic attack (TIA).

OBJECTIVE: To examine the different aspects of language and its representation in the brain. BACKGROUND: Apractic agraphia, a form of mechanical agraphia, is produced by lesions in the left superior parietal lobe. However, little is known about the dissociation between allographic level representations for cursive writing and printing. METHOD: A 78-year-old right-handed patient with a history of transient ischemic attack was evaluated by interview, neurologic and neuropsychiatric examination, neuropsychologic testing, speech and language evaluation, and functional neuroimaging (single photon emission computed tomography). RESULTS: The patient exhibited a disorder strictly limited to cursive writing resulting from ischemic damage to parietal and occipital lobes bilateral. CONCLUSIONS: These findings support the assertion that printing and cursive writing are represented differentially and an isolated deficit in any of them can be the only presentation of disorder of language organization, secondary to brain damage in left superior parietal area.

Women chairs in psychiatry: a collective reflection.

OBJECTIVE: This article describes the experiences of women chairs in psychiatry. METHOD: All women chairs in psychiatry were contacted by the author to share their personal experiences as chair. Seven out of 10 chairs accepted the invitation. A similar invitation was extended to a few female and male academics. CONCLUSIONS: Women in chair positions come from smaller schools and departments, have clinical and educational backgrounds, have fewer grants than their male counterparts, and are more likely to be recruited from within. Most of the women did not aspire to be chair, but after an initial adjustment period, they felt their job to be less stressful. Mentors played a role in the careers of some, but not all women chairs.

Electroconvulsive therapy as an alternative treatment for obese patients with mood disorders.

With the increased use of atypical antipsychotic medication in the treatment of mood disorders, patients are increasingly experiencing side effects, such as obesity, insulin resistance, and the metabolic syndrome, which, in turn, increases the risk of developing cardiovascular disease, type 2 diabetes, and hypertension. Maintenance electroconvulsive therapy (MECT) can be used as a prophylaxis for the recurrence of mood episodes for treatment-resistant patients. There are no reports of metabolic syndromes associated with ECT. We reviewed the charts of 10 patients who have received MECT at our institution over the last 10-year period. Five of 10 patients were obese pre-ECT, all of whom had a significant weight loss after ECT. Patients whose weights were normal pre-ECT, did not experience weight loss. Our finding suggests that ECT is a viable alternative for overweight patients with mood disorders who do not respond to mood stabilizers or cannot tolerate side effects.

Do the personalities of international and U.S. medical graduates in psychiatry differ? A preliminary study.

OBJECTIVE: To compare personality traits of psychiatry residents with various characteristics. METHOD: The authors administered Cloninger's personality inventory to residents at two schools. RESULTS: There were no trait differences between international medical graduates (IMGs) and U.S. medical graduates (USMGs) or those for whom psychiatry was a first or second choice. CONCLUSION: Perceived differences between IMG and USMG psychiatry residents appear unrelated to personality.

Psychopathology in neuropsychiatry: DSM and beyond.

The case reports described in this article indicate that current neuropsychiatric practice is strongly limited by reliance on the Diagnostic and Statistical Manual of Mental Disorders (DSM). Knowledge of new psychopathology that will enable the neuropsychiatrists and neuroscientists identify specific areas of brain dysfunction is essential to modern practice of neuropsychiatry. Today, less than 20% of neuropsychiatry and neuroscience programs teach such psychopathology.The development of brain imaging and metabolic measurement technologies; the continuous and rapid introduction of many new pharmaceutical agents into clinical care; and the various, detailed editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) have all shaped modern psychiatric training and thus future psychiatric practice. This "shaping" is observed most often in the teaching of psychopathology and of mental status examinations, both currently focusing on how to recognize and elicit the clinical features needed to apply the criteria set by the DSM. Once DSM criteria are met, a best-choice treatment plan based on DSM diagnosis is selected from an array of pharmacotherapy algorithms. It is assumed that the known reliability of the DSM system maximizes the likelihood that these diagnostic decisions are valid and treatment choices are therefore appropriate. Descriptive psychopathology that goes beyond the DSM is primarily relegated to historical consideration and rarely pertains to issues regarding patient care.

Continuation and maintenance ECT in treatment-resistant bipolar disorder.

Continuation and maintenance electroconvulsive therapy (c/mECT) is a treatment alternative for the long-term management of mood and psychotic disorders, especially in chronic, recurring, medication-resistant illnesses and in patients who are medication-intolerant, are non-compliant, and have a high risk of suicide with medications. A MEDLINE search was performed with maintenance electroconvulsive therapy (ECT), continuation ECT, and prophylactic ECT as keywords. The relevant literature was obtained and reviewed. Despite methodologic flaws, the overwhelming majority of the studies report the effectiveness of c/mECT in bipolar mood disorder. We also reviewed the charts of 13 patients with mood disorder receiving maintenance ECT in the ECT service of a Veterans Administration medical center. Despite good results, c/mECT is underused in the treatment of bipolar mood disorder. More research with better study design is needed to define the predictors of response to c/mECT and to develop c/mECT treatment protocols for treatment-resistant bipolar patients.

Teaching the APA Practice Guidelines to psychiatry residents: a novel strategy.

In anticipation that the APA Practice Guidelines will find broad acceptance in clinical practice, the authors introduced the guidelines into their psychiatry residency curriculum. Small resident teams were used to cross-teach the essential material to each other. Thirty-seven residents participated in an 18-month trainee-led teaching program. Nine resident teams were constructed, one for each of the Practice Guidelines available at the time. Every other Friday, the residents from one guideline team presented it to the other residents at site lunchtime meetings. A pre- and post-study examination, assessing knowledge of the content of the guidelines, was administered to 27 residents. Each resident showed statistically significant increases in scores on the post-study test. A follow-up survey of resident attitudes about this teaching strategy revealed that it facilitated the learning process. Resident-led, small-group teaching may be an effective way to incorporate the APA Practice Guidelines into psychiatry curricula.

Relationship between specialty choice and medical student temperament and character assessed with Cloninger Inventory.

BACKGROUND: Multiple variables affect medical specialty choice, including temperament, sociodemographic factors, and personal experiences. Many studies address specific variables for specific specialties, but few assess the relative impact of each factor. PURPOSE: To identify the relative influence of temperament in choosing a specialty. METHODS: A sociodemographic and personal experiences questionnaire and a 240-question temperament and character inventory was distributed to 682 medical students. Their scores for 6 medical specialties were examined using analyses of variance, multivariate analyses of variance, and discriminant analysis. RESULTS: Students choosing surgery, emergency medicine, and obstetrics and gynecology were higher on novelty seeking than other students. Future surgeons were lower in harm avoidance and reward dependence (RD) than the others. Students choosing primary care specialties, emergency medicine, and obstetrics and gynecology were all high on RD; with pediatrics being highest. Students differed from college students, the women differed from the men, and the Asian Americans differed from the other groups. CONCLUSION: The implications of these findings are discussed for career counseling and future research.

Factors affecting medical student career choice of psychiatry from 1999 to 2001.

OBJECTIVE: The proportion of students matching into psychiatry (PMP) at each medical school results from a complex interplay between extrinsic (e.g., national trends, geographic region) and intrinsic factors (e.g., the quality of psychiatric education). The goal of the study was to learn the extent to which regional and local extrinsic factors (and one intrinsic factor) influenced PMP at medical schools in the U.S. from 1999 to 2001. METHODS: The authors obtained data about these factors from deans of student affairs, the National Resident Matching Program (NRMP), American Medical Association (AMA), Association of American Medical Colleges (AAMC), American Psychiatric Association (APA), and Harvard University's HealthSystem Consortium. RESULTS: The best predictor of a school's PMP is the PMP of the prior year for that particular school. Local and regional extrinsic factors were not significantly associated with PMP. There was a modest inverse correlation between PMP and the proportion of international medical graduates (IMGs) in psychiatry residency. CONCLUSIONS: The authors infer that intrinsic factors are most important for recruitment, and they make recommendations for addressing these factors.