Computers and psychiatry. Promises to keep.

The potential of computer-based psychiatric information systems is still largely undeveloped. Conceptual, technical, cost, and procedural problems have limited the impact of computers, but there are programs that have been successful or that show promise. While changes in the philosophy of psychiatric computer applications are on-going, a cost-effective, widely available clinical computer system has been developed.

Effect of axis II diagnoses on treatment outcome with clomipramine in 55 patients with obsessive-compulsive disorder.

We used the Structured Interview for DSM-III Personality Disorders to diagnose DSM-III personality disorders systematically in 55 patients with obsessive-compulsive disorder in the active-treatment cell of a controlled trial of clomipramine hydrochloride. Patients with a cluster A personality disorder had significantly higher obsessive-compulsive disorder severity scores at baseline, and the number of personality disorders was strongly related to baseline severity of obsessive-compulsive disorder symptoms. At the conclusion of the 12-week study, we found no significant difference in treatment outcome with clomipramine between those patients with at least one personality disorder and those with no personality disorders. However, the presence of schizotypal, borderline, and avoidant personality disorders, along with total number of personality disorders, did predict poorer treatment outcome. These variables were strongly related to having at least one cluster A personality disorder diagnosis, which was also a strong predictor of poorer outcome. Implications of these findings are discussed.

Medical costs attributed to depression among patients with a history of high medical expenses in a health maintenance organization.

BACKGROUND: While previous studies have compared medical utilization between depressed and nondepressed patients, we conducted a study that focused specifically on patients who had a history of high medical expenditures. METHODS: This study was designed to determine whether a positive screen for depression is predictive of continued high medical expenditures. Medical utilization data were obtained on 50,000 patients enrolled in the DeanCare health maintenance organization for 2 consecutive years. Consistent high utilizers were identified based on the medical utilization costs (paid by the health maintenance organization) for those 2 consecutive years, 1992 and 1993. A depression screen based on the Medical Outcomes Survey was mailed to 786 high utilizers. Their costs were determined for 1994. Regression analyses identified 1994 costs associated with depression, adjusting for age, sex, benefits package, and medical comorbidity. RESULTS: Depressed high utilizers were more likely than nondepressed high utilizers to have higher medical costs in 1994. Among high utilizers, depressed patients' 1994 costs were significantly higher ($5764 vs $4227; P < .001), although expenditures for depressed and nondepressed high utilizers were similar for the previous 2 years. The total medical cost associated with depression in 1994, adjusted for age, sex, benefits package, and medical comorbidity, was $1498 per patient. CONCLUSIONS: In the third year (1994), a positive Medical Outcomes Survey screen for depression in high utilizers was associated with $1498 in higher medical costs. The average actual amount spent on depression treatment accounted for only a small portion of total medical costs for depressed high utilizers in the third year.

Efficacy and tolerability of serotonin transport inhibitors in obsessive-compulsive disorder. A meta-analysis.

BACKGROUND: Questions have been raised regarding the relative efficacy and tolerability of the different serotonin transport inhibitors in the treatment of obsessive-compulsive disorder. We compared the results from four large multicenter placebo-controlled trials of the serotonin transport inhibitors clomipramine hydrochloride (N = 520), fluoxetine hydrochloride (N = 355), fluvoxamine maleate (N = 320), and sertraline hydrochloride (N = 325) for the treatment of obsessive-compulsive disorder. METHODS: Effect size was calculated by subtracting the end-point drug treatment mean change from the end-point placebo mean change and dividing by the end-point pooled change standard deviation. A test for overall differences between effect sizes was conducted, followed by all possible pairwise comparisons. The Yale-Brown Obsessive Compulsive Scale was the primary outcome measure for all four studies. RESULTS: All four agents were significantly more effective than placebo, with clomipramine significantly more effective than the other three treatments, which did not differ in effect size. A significantly greater percentage of patients treated with clomipramine were rated much or very much improved than were patients treated with fluoxetine, fluvoxamine, or sertraline. CONCLUSION: While the results of this meta-analysis support the superiority of clomipramine, head-to-head, double-blind comparisons of these compounds would be the best test of comparative efficacy and tolerability.

The lithium librarian. An international index.

Lithium salts are being widely used for treatment and prophylaxis of bipolar affective disorder (manic-depressive psychosis) and are under investigation in more than 30 other illnesses. The relevant literature has grown from 43 articles published between 1949 and 1964 to nearly 4,000 today. A computer-based lithium librarian program has been developed that provides an up-to-date registry of all lithium references, rapid search capability, constant availability, and easy transferability to identical computer systems located on three continents. References provided by the system are more complete, more rapidly available, and less costly than references obtained from other bibliographic services. This specific response to the rapidly expanding lithium literature provides a model for comprehensive aquisition and searching of other specialized subjects areas needed by clinicians and researchers.

Lithium Information Center. One model of a computer-based psychiatric information service.

The Lithium Information Center has been functioning as a specialized psychiatric information service for nearly ten years. Over the years, the center has disseminated information about the medical uses of lithium to psychiatrists and other physicians, to patients, to the family and friends of patients, and to a host of other individuals and organizations including pharmacists, lawyers, nurses, social workers, mental health centers, clinics, and support groups. To encourage the development of similar psychiatric information services, we outline the center's methods of acquiring, organizing, and disseminating lithium information.

Multicenter double-blind comparison of sertraline and desipramine for concurrent obsessive-compulsive and major depressive disorders.

BACKGROUND: Serotonin reuptake inhibitors (SRIs) have demonstrated consistent efficacy in the treatment of obsessive-compulsive disorder (OCD), while agents that are primarily norepinephrine reuptake inhibitors have not. Comparable efficacy has been demonstrated for SRI and non-SRI antidepressants in uncomplicated major depressive disorder (MDD). This multicenter trial is the first comparison of an SRI (sertraline) and a non-SRI antidepressant (desipramine) in the treatment of OCD with concurrent MDD. METHODS: One hundred sixty-six patients diagnosed using structured clinical interviews and recruited from 16 treatment sites were randomly assigned to double-blind treatment with either sertraline (up to 200 mg/d) or desipramine (up to 300 mg/d) over 12 weeks. Measures of severity of OCD and MDD symptoms, as well as adverse effects of the medications, were monitored over the course of the treatment period. RESULTS: Patients assigned to sertraline responded significantly better at end point on measures of OCD and MDD symptoms compared with patients assigned to desipramine. Sertraline was also associated with a significantly greater number of patients who achieved a "robust" improvement in OCD symptoms (> or =40% reduction) compared with desipramine. More patients receiving desipramine than sertraline discontinued treatment because of adverse events. CONCLUSIONS: The SRI sertraline was more effective in reducing MDD and OCD symptoms than the primarily norepinephrine reuptake inhibitor desipramine for patients with concurrent OCD and MDD.

Double-blind parallel comparison of three dosages of sertraline and placebo in outpatients with obsessive-compulsive disorder.

BACKGROUND: Anecdotal evidence suggests patients with obsessive-compulsive disorder (OCD) are treated with selective serotonin uptake inhibitors at dosages significantly higher than those used with depressed patients. The current study examined the efficacy, safety, and optimal dosing strategy of sertraline in patients with OCD. METHODS: Three hundred twenty-four nondepressed outpatients with OCD from 11 sites followed identical protocols using a double-blind parallel design. Following 1 week of single-blind placebo, patients were randomly assigned to 12 weeks of treatment with one of three fixed dosages of sertraline (50, 100, or 200 mg/d) or placebo. RESULTS: Sertraline patients exhibited significantly greater improvement (P < .05) at end point than placebo patients on all three main efficacy measures in the 50-mg/d and 200-mg/d groups and on one measure in the 100-mg/d group. The placebo response was larger in this population of subjects with OCD than in those previously studied. Adverse experiences were common in the sertraline and placebo groups and appeared to be dose-related in the sertraline-treated patients. CONCLUSIONS: Results support the safety and efficacy of daily dosages of 50, 100, and 200 mg of sertraline in the short-term treatment of patients with OCD.

Computer-automated dementia screening using a touch-tone telephone.

BACKGROUND: This study investigated the sensitivity and specificity of a computer-automated telephone system to evaluate cognitive impairment in elderly callers to identify signs of early dementia. METHODS: The Clinical Dementia Rating Scale was used to assess 155 subjects aged 56 to 93 years (n = 74, 27, 42, and 12, with a Clinical Dementia Rating Scale score of 0, 0.5, 1, and 2, respectively). These subjects performed a battery of tests administered by an interactive voice response system using standard Touch-Tone telephones. Seventy-four collateral informants also completed an interactive voice response version of the Symptoms of Dementia Screener. RESULTS: Sixteen cognitively impaired subjects were unable to complete the telephone call. Performances on 6 of 8 tasks were significantly influenced by Clinical Dementia Rating Scale status. The mean (SD) call length was 12 minutes 27 seconds (2 minutes 32 seconds). A subsample (n = 116) was analyzed using machine-learning methods, producing a scoring algorithm that combined performances across 4 tasks. Results indicated a potential sensitivity of 82.0% and specificity of 85.5%. The scoring model generalized to a validation subsample (n = 39), producing 85.0% sensitivity and 78.9% specificity. The kappa agreement between predicted and actual group membership was 0.64 (P<.001). Of the 16 subjects unable to complete the call, 11 provided sufficient information to permit us to classify them as impaired. Standard scoring of the interactive voice response-administered Symptoms of Dementia Screener (completed by informants) produced a screening sensitivity of 63.5% and 100% specificity. A lower criterion found a 90.4% sensitivity, without lowering specificity. CONCLUSIONS: Computer-automated telephone screening for early dementia using either informant or direct assessment is feasible. Such systems could provide wide-scale, cost-effective screening, education, and referral services to patients and caregivers.

Some hazards of lithium use.

The increasingly widespread use of lithium has benefited many, but the therapeutic potential of the drug will not be realized if it is used in a way that is haphazard or inattentive or adheres too rigidly to written guidelines. The authors present clinical vignettes that are representative rather than comprehensive examples of misadventures which can occur during the course of lithium therapy. They hope to stimulate a more knowledgeable, flexible, open-minded, and individualized approach to the use of this drug.

Routine on-line psychiatric diagnosis by computer.

With the advent of effective psychiatric treatments, greater accuracy in psychiatric diagnosis has become a vital concern for psychiatric training, research, and patient care. The authors have adapted current computer diagnostic procedures in order to obtain highly accurate diagnosis while simplifying and shortening the process of information input and diagnostic output. Their program requires a minimum of the clinician's time and provides feedback during the diagnostic process when the clinician requires it. The authors believe that routine use of this computer diagnostic program will improve psychiatric training, research, and patient care.

Computer-administered cognitive-behavioral therapy for depression.

The authors evaluated a six-session interactive computer cognitive-behavioral treatment program given to volunteer patients who met Research Diagnostic Criteria (RDC) for major or minor depressive disorder. Patients were randomly assigned to computer-administered cognitive-behavioral treatment, to therapist-administered cognitive-behavioral treatment, or to a waiting-list control condition. After treatment and at 2-month follow-up, both treatment groups had improved significantly more than control subjects in their scores on the Beck Depression Inventory, SCL-90-R depression and global scales, Hamilton Rating Scale for Depression, and Automatic Thoughts Questionnaire. The treatment groups did not differ from each other at either time.

Fluvoxamine treatment of obsessive-compulsive disorder.

Sixteen outpatients who met DSM-III criteria for obsessive-compulsive disorder completed a 20-week double-blind, crossover trial with fluvoxamine and placebo. Thirteen (81%) improved with fluvoxamine, while three (19%) improved with placebo. Fluvoxamine treatment was associated with significant improvement on measures of obsessive-compulsive symptoms, anxiety, and depression. Depressed subjects' improvement on obsessive-compulsive measures correlated with improvement in symptoms of depression. Nondepressed subjects also showed improvement on measures of obsessive-compulsive symptoms. In this trial, fluvoxamine was an effective and safe treatment for obsessive-compulsive disorder.

The Lithium Index: an innovative approach to consultation by computer.

The Lithium Index, a computer consultation program, was developed at the Lithium Information Center to quickly provide up-to-date information about lithium and its side effects. Information is contained in brief summaries that are compiled from the literature, organized by clinical topic, and written and retrieved by means of an interactive computer program. Computer-stored texts are easily updated to incorporate new information. The authors present an example that deals with the use of lithium during pregnancy, the most frequently requested topic.

A comparison of the Diagnostic Interview Schedule and clinical diagnosis.

The Diagnostic Interview Schedule (DIS) was administered to 220 psychiatric patients by lay interviewers. Kappas for agreement between DIS and chart diagnoses ranged from .39 to -.03 and averaged .14 for 13 diagnostic categories. Agreement was best for affective, obsessive-compulsive, and schizophrenic disorders and was poorest for phobias where patients overemphasized fears. The authors suggest that clinician evaluation of information collected by the DIS is important, especially in diagnosing individual cases.

Sertraline for social phobia: a double-blind, placebo-controlled crossover study.

OBJECTIVE: The authors examined the efficacy of sertraline in the treatment of social phobia. METHOD: In a double-blind crossover study, 12 outpatients were randomly assigned to 10 weeks of sertraline (50-200 mg/day, flexible dosing) and 10 weeks of placebo. RESULTS: A statistically significant improvement in scores on the Liebowitz Social Anxiety Scale was found with sertraline but not with placebo. There was no significant difference between scores obtained with computer- and clinician-administered versions of the Liebowitz Social Anxiety Scale, and the majority of patients preferred to be interviewed by the computer. CONCLUSIONS: Sertraline seems a safe and effective treatment for social phobia, and computer administration may be a preferable mode of assessment with socially phobic patients.

Effect of strenuous exercise on serum lithium level in man.

The authors examined the effect of strenuous exercise on the serum lithium levels of four healthy, conditioned athletes who were stabilized on lithium carbonate for 7 days and who ran a 20-km race under hot, humid conditions. The subjects became substantially dehydrated during the race, and their serum lithium levels decreased, suggesting that sweat lithium loss may be substantial. (The sweat-to-serum ratio for lithium exceeded that for sodium by a factor of 4.) The authors conclude that contrary to widely held belief, heavy sweating may not increase the risk of lithium intoxication.

Impact of generalized social anxiety disorder in managed care.

OBJECTIVE: The authors determined the costs associated with generalized social anxiety disorder in a managed care setting. METHOD: A three-phase mail and telephone survey was conducted from July to October 1998 in two outpatient clinics of a large health maintenance organization (HMO). The survey assessed direct costs, indirect costs, health-related quality of life, and clinical severity associated with generalized social anxiety disorder, both alone and with comorbid psychopathology. RESULTS: The weighted prevalence rate of current generalized social anxiety disorder was 8.2%. In the past year, only 0.5% of subjects with generalized social anxiety disorder had been accurately diagnosed. Yet 44.1% had a mental health specialty visit or had been prescribed an antidepressant, and psychiatric comorbidity was found in 43.6%. Noncomorbid generalized social anxiety disorder was associated with significantly lower health-related quality of life, work productivity, and earnings and greater utilization of health services; generalized social anxiety disorder with comorbid psychopathology was even more disabling. Suicide was attempted by 21.9% of subjects with noncomorbid generalized social anxiety disorder. Persons with average-severity generalized social anxiety disorder had probabilities of graduating from college that were 10 percentage points lower, earned wages that were 10% lower, and had probabilities of holding a technical, professional, or managerial job that were 14 percentage points lower than the comparison group. CONCLUSIONS: In a community cohort of HMO members, generalized social anxiety disorder was rarely diagnosed or treated despite being highly prevalent and associated with significant direct and indirect costs, comorbid depression, and impairment.

Treating the anxiety: therapeutic options in obsessive compulsive disorder.

Obsessive compulsive disorder (OCD) is far more prevalent and frequently more severe than recognized previously. Behavior therapy with exposure and response-prevention has proven effective treatment, as have potent serotonin uptake inhibitors, especially clomipramine, despite a high relapse rate after drug discontinuation. These therapies are complementary and a combination of the two approaches shows great promise in the treatment of OCD.

Treatment of obsessive compulsive disorder: psychotherapies, drugs, and other somatic treatment.

Ninety percent of obsessive compulsive patients can be helped by treatment with behavior therapy and drug treatment, used sequentially or concurrently. The effectiveness of these treatments has been demonstrated in controlled clinical trials and is superior to electroconvulsive therapy and dynamic or cognitive psychotherapies for this disorder. Potent serotonin uptake inhibiting drugs, from the class of heterocyclic antidepressants, are the most effective antiobsessional medications currently available. Although these drugs usually do not induce complete remission, they can reduce obsessive compulsive symptoms by 30% to 42%. Behavior therapy combines exposure and response prevention, which the patient first learns with the therapist and then practices independently. With behavior therapy, patients confront the triggers for their anxiety and then delay, diminish, or discontinue their rituals. Reduction in symptoms with behavior therapy averages 50% or greater. Behavior therapy is usually not effective in patients who are substantially depressed, are delusional, fail to comply, or undermine therapy with covert rituals or avoidance techniques. The rare patient with very severe obsessive compulsive disorder who does not respond to behavior or drug therapy may be a candidate for psychosurgery. Modern psychosurgical procedures are quite safe and can improve symptoms in the majority of otherwise unresponsive patients.