Awareness of treatment needs and length of stay amongst psychiatric inpatients.

INTRODUCTION: Inpatient psychiatric units experience significant pressure from third party payers to keep length of stay (LOS) to a minimum despite having to treat more severely ill patients. However, there is a paucity of empiric data for guiding treatment decisions that maximize therapeutic outcome while minimizing LOS. We therefore endeavored to begin utilizing a newly created psychometric instrument that assesses patient psychological factors, which we propose will allow for LOS prediction and individualization of therapeutic outcome. MATERIALS AND METHODS: The Goals Questionnaire (GQ), created to determine awareness of treatment needs, was administered to newly admitted patients. Linear regression analyses were conducted to ascertain the relationship between the GQ score and LOS, as well as the effects of confounding factors. RESULTS: A significant and inverse relationship was found between the GQ score and LOS (ß=-4.4; p=0.007) that was dependent upon (i.e., had a significant interaction with) age and substance use disorders. There was minimal confounding from common administrative, legal, and clinical factors. CONCLUSIONS: The GQ may have utility for inpatient treatment teams, providing information that can be used to maximize and individualize therapeutic outcome while minimizing LOS.

A study of polypharmacy with second generation antipsychotics in patients with severe and persistent mental illness.

BACKGROUND: There is a paucity of empirical support for polypharmacy with second generation (atypical) antipsychotics (SGAs), especially in understudied populations. OBJECTIVE: To investigate the frequency, effectiveness, and safety of this practice in patients with severe and persistent mental illness who are chronically hospitalized. METHODS: A chart review was conducted at a state psychiatric hospital in Syracuse, NY. The study subjects (N=26) were chronically hospitalized individuals with DSM-IV diagnoses of schizophrenia or schizoaffective disorder who were initially prescribed at least one SGA and then received at least one other SGA during the study period. Demographic and clinical data were collected. Baseline and 6-month assessments were compared for statistical significance (p<0.05). RESULTS: Of the 117 chronically hospitalized inpatients at the study center, 22.2% (N=26) received treatment regimens involving polypharmacy with SGAs. These patients as a group achieved statistically significant reductions on their scores on the Brief Psychiatric Rating Scale (34.2 +/- 11.0 compared with 25.3 +/- 11.8; p=0.016) and the Clinical Global Impressions-Improvement Scale (5.5 +/- 0.6 compared with. 5.0 +/- 0.8; p=0.016) at 6 months. There was a significant decrease in the use of prn medications (7.6 +/- 19.6 compared with 1.6 +/- 2.6; p<0.04). However, the number of patients receiving anticholinergic medications increased from 5 to 8 (p<0.04). CONCLUSIONS: Polypharmacy with SGAs is quite frequent among chronic inpatients with severe and persistent mental illness despite a limited empirical database supporting its use. The results of our pilot study do not demonstrate the effectiveness and safety of this practice. However, methodological shortcomings may have contributed to our failure to detect a true, positive effect. Controlled studies are needed to accurately determine the risks and benefits of SGA polypharmacy.

Endogenous opiates and the placebo effect: a meta-analytic review.

OBJECTIVE: A meta-analysis was performed to investigate the ability of placebo administration to reduce self-report of pain and to examine whether placebo-induced pain reduction might have physiological and psychological underpinnings. METHOD: Forty-five effect sizes and 1183 participants from 12 studies were meta-analyzed for the effects of placebo and the opioid antagonist, naloxone, on self-report of pain. RESULTS: Analyses showed that placebo administration was associated with a decrease in self-report of pain, and a hidden or blind injection of naloxone reversed placebo-induced analgesia. Furthermore, there were significant between-group differences for type of pain (experimental vs. postoperative/clinical) for placebo studies. CONCLUSIONS: The results support the literature illustrating that the belief and expectation of analgesia induces discrete physiological changes, leading to relief from pain, and this response may be mediated by endogenous opioids. The implications of these findings are discussed in terms of the symbolic aspect of health care and mental health providers' words and context, and their potential impact on the course of illness and well-being.

Sociotropic cognition moderates stress-induced cardiovascular responsiveness in women through effects on total peripheral resistance, but not cardiac output.

Although cardiovascular disease (CVD) remains the leading cause of mortality in women, few studies have examined the role of psychosocial factors in its development. This study examined the moderating effects of sociotropic cognition (SC), a need for social acceptance and approval, on psychosocial stress-induced cardiovascular responsiveness (CVR) and affect reactivity in women. Sixty-eight normotensive, college-aged females were randomly assigned to a low or high social threat condition. Measures of systolic, diastolic and mean arterial blood pressures (SBP, DBP and MAP, respectively), heart rate (HR), cardiac output (CO), total peripheral resistance (TPR) and negative affect were collected during rest, and under conditions of high vs. low interpersonal threat. A two-step hierarchical regression analysis was performed to predict all response variables (BPs, HR, CO, TPR and affect). Increases in SBP, DBP, MAP, TPR and negative affect were greater in the high threat than low threat condition. Changes in SBP, MAP and TPR positively covaried with SC under conditions of high interpersonal threat, but showed no significant covariation in the low threat condition. The data suggest that an excessive need for social acceptance may contribute to rises in BP through an increase in TPR, but not CO under conditions of high social threat.

Stress, glucocorticoids, and memory: a meta-analytic review.

Although a strong psychoneuroendocrine linkage exists between stress, glucocorticoids and memory, the relationship is not always straightforward. Eighty-eight effect sizes and 1642 participants from 28 studies were meta-analyzed for the effects of stress on memory performance and glucocorticoid activation. Analyses showed that stress was associated with glucocorticoid activation and declarative memory decline. In animal studies, predator stress affected memory performance more than physical stress. In human studies, males showed higher cortisol levels than females in response to stress. Further, the correlation between cortisol levels and memory deficits was stronger in studies using laboratory stressors than those examining long term effects of chronic exposure to rising basal levels of glucocorticoids and chronic life stressors. It was concluded that, although the relationship between stress, glucocorticoids, and memory loss was empirically supported, there were other factors, such as stress condition and gender, as well as individual differences within groups, that influenced the association between these variables, and warrant further examination.

Gabapentin's effect on agitation in severely and persistently mentally ill patients.

OBJECTIVE: To study the effects of adjunctive gabapentin on agitation in severely and persistently mentally ill (SPMI) inpatients. METHOD: Eleven chronic SPMI inpatients on stable psychotropic medication regimens were evaluated before and after the initiation of adjunctive gabapentin for six months. The following psychometric tests were used: Brief Psychiatric Rating Scale (BPRS), Corrigan Agitated Behavior Scale (CABS), and Clinical Global Impression (CGI)-Severity. Data collection was accomplished via retrospective chart review. An internal reliability check indicated that a chart review BPRS is significantly predictive of one performed face-to-face. RESULTS: Statistically significant reductions were found at six months for each assessment instrument (p < 0.05, two-tailed). BPRS scores were reduced from 40.6 to 33.2, CABS from 34.4 to 25.0, and CGI-Severity from 5.9 to 5.3. The bulk of the BPRS reduction was accounted for by several subscores exclusive of those assessing affective/anxious symptomatology. Adverse effects were minimal. Two patients were discharged 12 and 17 months after implementation of gabapentin. CONCLUSIONS: Adjunctive gabapentin appears to be associated with a reduction in agitation in chronically hospitalized SPMI patients. Controlled, prospective trials are needed before any definitive conclusion can be drawn regarding the role of gabapentin in the treatment of this group of patients.

Trait anger, anger expression, and ambulatory blood pressure: a meta-analytic review.

A meta-analysis of 15 studies was conducted to investigate the relationship between trait anger and ambulatory blood pressure. Overall, the experience of anger was significantly and positively associated with systolic blood pressure (r+ = 0.049), but not reliably associated with diastolic blood pressure (r+ = 0.028). After removing an outlier, the expression of anger was found to have a reliable inverse relationship with diastolic blood pressure (r+ = -0.072). No reliable relationship between expression of anger and systolic blood pressure (r+ = -0.041) was found. These results continue to support the modest role of self-reported trait anger and anger expression in blood pressure levels. Several suggestions for future research are discussed, including increasing the focus on the complexity and synergism of these effects.