Impact of problem alcohol use on patient behavior and caregiver burden in a geriatric assessment clinic.

There has been a growing interest in understanding issues surrounding alcohol use in late life. Information about the relationship of alcohol use to behavioral problems in older persons living in the community is particularly limited. This study used information obtained from an outpatient geriatric assessment clinic to study this relationship and the effects of these behaviors on caregivers. Data on alcohol use, problem behaviors, and caregiver burden were collected prospectively in consecutive patients undergoing geriatric assessment primarily for cognitive problems over a 3-year period. All patients were evaluated by a multidisciplinary team, which included a geriatric psychiatrist. The evaluation screened for current and/or past alcohol use through interviews with the patient and a collateral source. The collateral source also completed the Neuropsychiatric Inventory and the Family Burden Scale. Subjects were classified into 2 groups: those with a current or past alcohol problem and those with no alcohol problem. A total of 349 patients were evaluated, with 17.8% being designated as having a current or past alcohol problem. This subgroup represented 35% of the men and 9% of the women from the study population. Approximately half of the subgroup was actively drinking alcohol. Patients with a history of problem alcohol use, regardless of current use and cognitive status, exhibited more behavioral disturbances including agitation, irritability, and disinhibition. Their caregivers reported significantly higher caregiver distress. Current or past alcohol problem use was frequent in this population of frail, older adults undergoing geriatric assessment. Regardless of current alcohol use, these patients displayed more behavioral disturbances than those without a history of problem drinking, and their caregivers experienced significantly more burden. A history of problem drinking appears to be a significant marker for behavioral disturbances in late life and merits further study.

Differences in the self-reported reasons for adolescent drug use reported at admission vs. reported at discharge.

UNLABELLED: There are several possible reasons for adolescents' alcohol and drug abuse. While genetic, social and cultural factors all play a part in influencing their behavior of using alcohol and drugs, their self-reported reasons may also offer insight into why they use. Adolescents reported using alcohol and drugs to self-medicate their emotional symptoms, due to peer-pressure or their desire to get high. However, it is not known if receiving treatment of their substance use disorders changes these self-perceived and self-reported reasons for use. In this study, we identified self-reported reasons for the adolescents' abusing alcohol/drugs at the time of admission to a drug treatment program and at the time of discharge from this program. METHOD: This is a retrospective chart review of all adolescents admitted to a long-term substance abuse treatment program in one year. A total of 86 charts were reviewed. Demographic information and their self-reported reasons for abusing alcohol and drugs at the time of admission and at the time of discharge were collected. Data was analyzed for significant patterns. RESULTS: There was a significant change in the self-reported reasons for use by adolescents from the time of admission to time of discharge, suggesting that treatment might change their self-rated perception of the reasons for their use. CONCLUSION: This study suggests that alcohol and drug treatment programs can impact the adolescent's self-reported perceptions about why they use alcohol/drugs.

Long-term adjunctive quetiapine may reduce substance use--a preliminary retrospective study.

BACKGROUND: Anxiety disorders often coexist with substance use and complicate treatment by causing non-adherence and relapse. Optimal treatment generally involves the treatment of anxiety along with the treatment of substance abuse. Substance-abuse treatment generally involves individual and group therapy, sobriety maintenance interventions, structured living, and attending self-help groups such as Alcoholics Anonymous. Pharmacotherapy options for treating substance abuse are limited, but atypical antipsychotic medications have reportedly reduced substance abuse when used in patients with alcohol and drug problems. However, there are no reports of long-term benefits of these medications. OBJECTIVE: To assess long-term effects of adjunctive quetiapine on substance abuse in patients treated with quetiapine for severe anxiety symptoms. METHOD: In a previous paper, we reported that adjunctive treatment with quetiapine reduced symptoms of anxiety and cravings for alcohol and drugs when used in patients with anxiety disorders or with anxiety due to alcohol/drug dependence/abuse. In this study, we followed up with these patients one year later to assess their current symptoms, cravings and use of alcohol/drugs, and compared these to results of random breathalyzer and urine drug screening tests conducted as part of routine outpatient treatment of their substance abuse. RESULTS: Six of nine patients continued to take adjunctive quetiapine over the previous 12-month period and reported complete sobriety (substantiated by their random breathalyzer and urine drug screens) and significant reduction in anxiety, depression, and cravings for alcohol and drugs. CONCLUSION: Adjunctive quetiapine used for treatment of anxiety symptoms that may occur as part of different psychiatric disorders in patients with alcohol and drug problems might reduce cravings and substance use.

Aripiprazole possibly worsens psychosis.

Aripirazole is a novel antipsychotic that functions as a partial agonist at the dopamine D2 receptor and, thus, might theoretically worsen psychosis. We report a series of four clinical cases of exacerbation of psychosis related to initiation of aripiprazole therapy. Cases 1 and 2 demonstrated the worsening of psychosis following initiation of aripiprazole (15-30 mg daily) while tapering off the previous atypical antipsychotic. Cases 3 and 4 demonstrated worsening of psychosis following the addition of aripiprazole (15-30 mg daily) to an atypical antipsychotic. In two out of the four cases, discontinuation of arpiprazole resulted in improvement of psychotic symptoms. Although the cases presented are suggestive of a relationship between initiation of aripiprazole therapy and worsening of psychosis, further research is needed to clarify any potential association.

Diagnosis and treatment of alcohol dependence in older alcoholics.

Treatment of alcohol dependence among older alcoholic patients should be multidimensional to address as many potential relapse factors as possible. As the literature suggests, alcohol-related disorders often are under diagnosed and under treated. More efforts are needed to identify and improve diagnosis of these disorders in older alcoholic patients. For better outcomes, age-specific programs should be implemented. Furthermore, when treating elderly patients, basic therapeutic principles like respect for privacy and a respectful attitude should be adopted. Adequate medical, pharmacologic, and psychiatric treatment should be provided when appropriate. Medication to reduce cravings should be considered in patients without contraindications to its use. Participation in individual, group, and family therapy and attendance at self-help group meetings such as AA should be encouraged (Table 8). Despite the lack of empiric testing to validate these recommendations in an elderly population, clinical experience suggests that adherence to these recommendations will benefit elderly patients just as it has the general adult population. Research is necessary to explore the benefits of alcohol treatments in elderly patients. Until then, adherence to these recommendations should be the best available approach.

Countering countertransference: a forensic trainee's dilemma.

Forensic psychiatry involves an adaptation to a role that is very different from the psychiatrist's previous clinical experiences. To render an unbiased forensic opinion, psychiatrists have to rise above their countertransference feelings. This takes years of practice and experience. The following is an account of a forensic trainee who faced several countertransference problems as he evaluated a patient charged with attempted murder. The case report is interspersed with a review of the relevant literature.

Countering countertransference, II: beyond evaluation to cross-examination.

Countertransference is a clinical term introduced by Freud in 1909. For years, despite mounting criticism, forensic psychiatrists borrowed this clinical concept to explain their emotional experiences and responses to examinees' emotions and behavior. The authors describe the impact of examinee and nonexaminee factors during evaluations and beyond, including during trial and while providing forensic testimony. The suggestion is made that using the term countertransference in forensic psychiatry can be problematic. The authors delineate the complexities of the term as related to forensic psychiatry and consider modified terms to provide a better explanation of these concepts in forensic contexts.

Are medical students assigning proper global assessment of functioning scores?

OBJECTIVE: This article seeks to determine whether medical students can estimate the appropriate score for the Global Assessment of Functioning (GAF) compared with psychiatry residents and staff psychiatrists. The authors hypothesized that medical students' estimations of GAF scores for patients in clinical vignettes would differ from those assessed by the psychiatry residents and staff psychiatrists. METHOD: The authors designed a cross-sectional confidential survey of medical students, psychiatry residents, and staff psychiatrists. Consenting participants were asked to provide demographic information and then complete the accompanying questionnaire after reading two vignettes. One of the vignettes described a depressed patient and the other a psychotic patient. The subjects were asked to estimate the GAF scores for the patients in both vignettes. Then the subjects were given the GAF scoring guide to review and were asked to re-assess their initial GAF scores for the patients in the vignettes. RESULTS: Medical students assigned much higher GAF scores for the patient in the vignette with less severe symptoms than the psychiatry residents and staff psychiatrists. The GAF scores of all three groups for the patient in the vignette with more severe symptoms were comparable. CONCLUSIONS: The ability of medical students to assign proper GAF scores needs to be studied further. Our study suggests that current 1-month rotations in psychiatry, without specific training on assigning GAF scores, may not provide medical students with enough information to assess GAF scores accurately. This might need to be addressed in psychiatry clerkships.

Possible carbamazepine toxicity with terbinafine.

OBJECTIVE: To report a case of carbamazepine and terbinafine interaction resulting in an elevated level of carbamazepine and associated symptoms of toxicity. CASE SUMMARY: A 50-year-old Caucasian man developed an elevated carbamazapine level after starting terbinafine, which caused symptoms of toxicity with gait ataxia, dizziness and falls. DISCUSSION: This is a first report of a drug-drug interaction between carbamazapine and terbinafine. Although the mechanism for this interaction is not fully known, it is suspected that terbinafine decreased the metabolism of carbamazapine and led to increased levels that continued even days after the carbamazapine had been stopped. The Naranjo Scale suggests that this was a probable interaction (score 6). CONCLUSIONS: While several drug-drug interactions have been reported with carbamazapine, there are no previous reports of its interaction with terbinafine. Prescribers should exercise caution when prescribing these medications together.

To commit or not to commit: the psychiatry resident as a variable in involuntary commitment decisions.

OBJECTIVE: To study whether psychiatry residents' personal variables (such as age, gender, level of training, previous experience with patient suicide, or lawsuits) and their temperamental predispositions have an impact on their decisions to seek involuntary commitment. METHOD: In a prospective pilot study, all psychiatry residents in Massachusetts were surveyed using a questionnaire that assessed their risk-taking behavior and clinical vignettes of patients with risk of harm to self or others. Data were analyzed using chi-squares and t tests. RESULTS: Level of training and the residents' risk-taking behavior may be linked to their likelihood to seek involuntary commitment. CONCLUSIONS: Psychiatric residency training should address nonpatient variables that might inappropriately influence the residents' decisions to seek involuntary commitment.

Use of alcoholic beverages in VA medical centers.

BACKGROUND: Benzodiazepines are the first-line choice for the treatment of alcohol withdrawal syndrome. However, several hospitals continue to provide alcoholic beverages through their formulary for the treatment of alcohol withdrawal. While there are data on the prevalence of this practice in academic medical centers, there are no data on the availability of alcoholic beverages at the formularies of the hospitals operated by the department of Veteran's Affairs. METHODS: In this study, we surveyed the Pharmacy managers at 112 Veterans' Affairs Medical Centers (VAMCs) to ascertain the availability of alcohol on the VAMC formularies, and presence or lack of a policy on the use of alcoholic beverages in their VA Medical Center. RESULTS: Of the pharmacy directors contacted, 81 responded. 8 did not allow their use, while 20 allowed their use. There was a lack of a consistent policy across the VA medical centers on availability and use of alcoholic beverages for the treatment of alcohol withdrawal syndrome. CONCLUSION: There is lack of uniform policy on the availability of alcoholic beverages across the VAMCs, which may create potential problems with difference in the standards of care.

New ACGME work-hour guidelines and their impact on current residency training practices.

OBJECTIVE: Accreditation Council for Graduate Medical Education (ACGME) has introduced new work-hour guidelines for residents in ACGME accredited programs that were implemented in July 2003. The new ACGME policies impact several practices in various psychiatry residency programs across the U.S., even though psychiatry has not been at the forefront of the debate regarding work hours. METHODS: The authors surveyed all psychiatry residency programs in the U.S. and identified several current practices that may infringe on the new ACGME work-hour guidelines. CONCLUSION: Further interpretation of the new guidelines is needed.

Olanzapine-induced hyperventilation: case report.

Although olanzapine therapy has been associated with fewer extrapyramidal side effects than the traditional antipsychotic medications, reported side effects include dystonia, tardive dyskinesia, hypotension, diabetes mellitus, seizures and neuroleptic malignant syndrome. There are no previous published reports of hyperventilation associated with olanzapine therapy, but we present the case of a male patient who developed dyspnea and hyperventilation while taking olanzapine.

Potential benefits of quetiapine in the treatment of substance dependence disorders.

OBJECTIVE: Some antipsychotic medications prescribed for the treatment of psychoses, mood disorders or post-traumatic stress disorder in patients with coexisting substance dependence disorders (SDD) have reduced substance dependence. We studied the potential benefits of quetiapine in the treatment of SDD. METHODS: We conducted a retrospective chart review of data for 9 patients who were admitted to a 28-day residential rehabilitation program designed for individuals with SDD during a 3-month period from January 2003 through March 2003 and treated with quetiapine for nonpsychotic anxiety. These patients also met the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria for alcohol, cocaine and/or methamphetamine dependence and substance-induced anxiety disorder. The patients were assessed using the Hamilton-D Rating Scale for Depression (Ham-D), a 10-point Likert scale to measure alcohol or drug cravings, and random Breathalyzer and urine drug screens. RESULTS: Quetiapine was generally well tolerated. Only 1 of the 9 patients stopped taking the medication because of increased anxiety. Other patients reported improvement in sleep and anxiety. The mean decrease in Ham-D score at discharge for the responders was 18.5 (p < 0.005). The biggest decreases on the Ham-D occurred on the subscales of insomnia, agitation, somatic anxiety, psychologic anxiety, hypochondriasis and obsessional symptoms. The mean decrease in the Likert 10-point craving scale was 5.9 for the responders (p < 0.005). These patients' periodic Breathalyzer and urine test results suggested that they remained abstinent from alcohol and other drug use. CONCLUSION: Quetiapine was beneficial in the treatment of SDD in patients with nonpsychotic anxiety.

Addiction training scale: pilot study of a self-report evaluation tool for psychiatry residents.

OBJECTIVE: Alcohol and drug dependence disorders have become common public health hazards. Psychiatrists encounter these problems in a major portion of their patients. However, recent data suggest that their training does not provide them the confidence to treat these disorders. Current methods of evaluating residents fail to adequately ascertain the lack of confidence in substance abuse training. Here, we present the Addiction Training Scale (ATS) that we developed to help trainers identify deficits in residents' substance abuse training. METHOD: We developed the ATS and conducted a pilot study with the psychiatry residents at the Creighton University Department of Psychiatry, to test the validity of the ATS as a self-report evaluation tool to measure the level of psychiatry residents' preparedness in treating substance abuse disorders. RESULTS: Our results suggest that the ATS is related to the confidence and preparedness that residents express in their ability to treat substance abuse problems. CONCLUSION: The ATS may be beneficial in assessing psychiatry residents' substance abuse training and identifying deficits, which may be addressed during training.

Inert medication ingredients causing nonadherence due to religious beliefs.

OBJECTIVE: To report 4 cases of medication nonadherence due to presence of inert ingredients forbidden by the patients' religion. CASE SUMMARIES: We describe 4 cases in which religious concerns about prescribed medications' inert components led to discontinuation of these medications. These inert components are gelatin and stearic acid, which might be derived from pork or beef products. In these 4 cases, patients of Muslim, Orthodox Christian, and Seventh Day Adventist faiths, who consider it against their religion to consume pork products, stopped their medications on discovering this possibility. This led to relapse of their illnesses. DISCUSSION: These cases demonstrate that, for some patients, inert medication components that are forbidden by their religion may lead to discontinuation of medications. This could lead to relapse of symptoms and might even lead to hospitalization. Therefore, it is important for prescribers to inform patients of this possibility when treating patients whose religious background might conflict with these inert medication components. CONCLUSIONS: Patients with religion prohibitions against consumption of pork and/or beef products might stop their medications when prescribed those with pork- and beef-derived gelatin and/or stearic acid. Prescribers should discuss this possibility with their patients, perhaps as part of informed consent.