EEG coherence and power in the discrimination of psychiatric disorders and medication effects.

Electroencephalogram (EEG) coherence (COH) and power measures were included in a series of stepwise discriminant analyses to determine which variables were most sensitive in the differentiation of four psychiatric inpatient groups and two major classes of psychotropic medication. Eight channels of eyes-closed, bipolar EEG activity were recorded from 74 inpatients (paranoid schizophrenics, dysthymics, major affectives receiving tricyclics, neuroleptics, or no medication, and geriatrics). Discriminant analyses were conducted for theta, alpha, and fast beta frequency bands for power variables, COH variables, and the resultant significant power and COH discriminating variables. Without exception, COH measures, usually in the alpha band, were more sensitive than power measures in differentiating the various groups. Results suggested that COH decreases with age, is greatest in paranoid schizophrenics, decreases with neuroleptic medication, and increases with tricyclic antidepressants. Group differences were interpreted in accordance with an arousal model for COH.

Shifts in diagnostic frequencies of schizophrenia and major affective disorders at six North American psychiatric hospitals, 1972-1988.

OBJECTIVE: This study tested the impression that there have been significant shifts in the relative diagnostic frequencies of schizophrenia and major affective disorders. METHOD: Data on discharge diagnoses from 1972 to 1988 were gathered from six North American psychiatric teaching hospitals (data from one extended through 1991), and rates for schizophrenia and major mood disorders were evaluated. RESULTS: Total annual discharges increased by 6.6% during the study period. Large reciprocal shifts in the frequencies of diagnoses of schizophrenia and major affective disorders were found; schizoaffective disorder was a minor diagnosis. Beginning in the early 1970s, a gradual increase in the frequency of diagnoses of major affective disorders at all sites was accompanied by a corresponding decrease in diagnoses of schizophrenia at five of the six centers. Schizophrenia diagnoses decreased from a peak of 27% in 1976 to 9% in 1989 (a threefold decrease), and diagnoses of major affective disorders rose from a low of 10% in 1972 to 44% in 1990 (a fourfold increase). CONCLUSIONS: Several forces may have influenced these changes. 1) DSM-III narrowed the definition of schizophrenia and broadened the category of major affective disorders. 2) Treatment-oriented diagnostic bias associated with the availability of lithium and other mood-altering agents may have encouraged consideration of affective disorders. 3) Economic and social forces, including better third-party reimbursement rates, may have favored affective diagnoses. 4) True increases in the incidence of affective disorders may have occurred. 5) Although a real decrease in new cases of schizophrenia may have occurred, this effect was probably minor and dominated by a larger shift of such diagnoses to affective categories.

Multiple-monitored electroconvulsive therapy: safety and efficacy in elderly depressed patients.

Forty-four patients with severe endogenous depression, all of whom had been administered multiple-monitored electroconvulsive therapy (MMECT), were studied by retrospective chart review. The subjects were divided into two groups, the elderly and the nonelderly, and compared for number of anesthesia inductions (treatment sessions), total number of seizures, total seizure time, and therapeutic outcome. One myocardial infarction occurred in an elderly man, and a confusional state developed whenever MMECT was administered simultaneously with lithium. The conclusions from this project are that MMECT is as safe and efficacious for the elderly as for the nonelderly and that the elderly tolerate many seizures as well as do the nonelderly. While other variables were similar between groups, the overall number of anesthesia inductions in both groups was less than is expected with conventional electroconvulsive therapy.

Functional impairment in depressed inpatients.

The Sickness Impact Profile (SIP) was administered to 95 patients with major depression. The SIP includes 12 subscales, each representing a specific area of sickness-related dysfunction. To relate these measures to psychiatric symptoms, patients also completed a measure of depression severity. Consistent with earlier findings, there were high levels of functional impairment. Impairment was correlated with symptoms but, as noted elsewhere, functional status does not always parallel symptom severity. The SIP, widely used with medical disorders but, to our knowledge, underutilized to assess psychiatric patients, may provide more precise assessment of the impact of psychiatric disorders on the individual's daily life.

OVERSEER: a prototype expert system for monitoring drug treatment in the psychiatric clinic.

This paper describes the development of OVERSEER: a prototype knowledge-based system that monitors the drug treatment of psychiatric patients in real time. Using treatment protocols developed by the expert clinician, OVERSEER monitors the drug treatment process and issues alerts when standard clinical practices are not followed or when laboratory results are abnormal. Written in Prolog, OVERSEER is designed to interface directly with the hospital's database, and, thereby, utilizes all available pharmacy and laboratory data. Moreover, unlike the interactive expert systems developed for the psychiatric clinic, OVERSEER does not require extensive data entry by the clinician. Consequently, the chief benefit of OVERSEER's monitoring approach is the unobtrusive manner in which it evaluates psychopharmacological treatment and provides information regarding patient management to the hospital.

EEG coherence and power changes during a continuous movement task.

EEG coherence (COH) is a mathematically derived measure of the time- and frequency-related similarities between a pair of EEG channels. In this report, COH was measured during an externally verified motor task in which the areas of cortical involvement are known, with special consideration given to procedural and artifactual issues. Fourteen right-handed women (ages 18-39, means = 26.7 years) were instructed to alternate continuously between fist-clenching and finger extension of the right hand, left hand, both hands, or neither hand (rest condition) in a counter-balanced sequence (4 one-minute trials for each condition; 16 total minutes). One minute each of intentional eye-movement (EOG) and intentional facial muscle tension (EMG) was recorded for artifact assessment. Eight channels of eyes-closed EEG were recorded from Fp1, Fp2, F3, F4, C3, C4, P3 and P4, each referenced to the ipsilateral earlobe. FFT spectral power analyses were conducted on 8 EEG channels and COH analyses (percentage of seconds/minute in which COH greater than or equal to 0.80) were performed on 16 pairs of leads: 4 interhemispheric, 6 intrahemispheric (left) and 6 intrahemispheric (right). COH measures increased during hand movement conditions, especially in the 9-12 Hz range, and were most apparent from prefrontal, premotor and motor areas. Parietal sources were essentially unchanged. Power measures were unchanged for virtually all leads and conditions. Increases in COH were not due to EOG or EMG artifact contamination. Evidence for lateralized increases was equivocal; significant bilateral increases were observed more often regardless of the hand clenched. Implications and suggested areas for future research are discussed.

Measurement of depression and anxiety for hospitalized depressed patients.

Standard scales for measuring anxiety and depression did not distinguish between these two psychological constructs in a sample of 295 inpatients with major depressive disorder. Items from these scales were used to form new measures, based on the results of a factor analysis. The new depression and anxiety subscales were internally consistent and only moderately correlated with one another, compared with the standard measures, which were highly correlated. When the factorial procedure was repeated with a subsample of patients with only mild to moderate symptoms, there was no discrimination between depression and anxiety. This finding suggests that when measured in a sample with a restricted range of symptom severity, anxiety and depression have poor discriminant validity.

Functional capabilities of depressed patients one year after hospitalization.

During hospitalization and at one-year follow-up, 48 patients with a diagnosis of major depression completed the Inventory to Diagnose Depression and the Sickness Impact Profile (SIP). Overall change scores revealed statistically significant and clinically important improvements in depression and functioning. SIP subscale scores showed no deficits in some functions (communication and bodily care) at baseline, restoration of functioning in other activities at one-year follow-up, and continuing dysfunctions in emotionality, alertness, recreation, socialization, and work. The SIP appears useful for measuring disability and patterns of recovery in depressed patients.

Herbal medicines with psychiatric indications: a review for practitioners.

The use of herbal medicines remains controversial despite their wide use by consumers. By U.S. standards few of these products have been sufficiently evaluated in scientific studies to determine with certainty their efficacy and safety. The authors review the herbal medicines with reputed psychiatric indications and discuss the potential adverse events with which physicians should be familiar. Whatever their potential benefits, some of these herbal products have potentially serious side effects, and many can interact with prescription medications. Patients frequently do not tell their physicians about their use of alternative medicines, and practitioners must ask specifically about products patients may be taking for health promotion and disease prevention as well as for the treatment of the presenting complaint.

Suicidal behaviors among Connecticut youth.

In the United States, youth (15-24 years) suicide rates increased 191% between 1950 and 1986. This paper presents data regarding suicidal ideation and attempts, suicide-related hospitalizations, and completed suicides among Connecticut youth, comparing them with data from other states and the United States. Girls have higher rates of attempts and hospitalization, boys of completed suicide. Firearms are the suicidal method of choice for both sexes. Nonmetropolitan areas had higher rates than metropolitan. Reported suicidal ideation among students ranged from 10% to as high as 66%, while attempts range from 3% to 15%. The authors stress that caution is necessary when comparing rates, pointing to the need for standardized data collection and analysis. Reported rates of suicidal behavior are lower among Connecticut youth compared to their counterparts in other states, but suicide is increasing among young males in Connecticut and remains a major issue for health care providers.

Physician compliance with practice guidelines.

BACKGROUND: Physician adherence to established practice standards has become an important national issue. Despite the proliferation of formal standards of practice, there is little evidence that the mere availability of guidelines results in changes in physician practices. This paper presents the results of a study of the effectiveness of a computerized monitoring and notification system in increasing physician compliance with treatment guidelines. METHODS: This study prospectively compared medical staff practices in two one-year periods utilizing a computer system which tabulated noncompliance and provided reminders. RESULTS: Overall, there was a statistically-significant decrease in the number of alerts issued in year two compared to year one; alerts were issued on 15% vs 29% of all patients (P < .001). The average number of alerts per patient decreased to .20 from .41. CONCLUSIONS: The study results indicate that a clinical decision support system such as that described can improve adherence to treatment guidelines.

Assessing outcomes: identifying psychiatric patients with severe and persistent illness.

BACKGROUND: Identification of psychiatric patients with severe and persisting impairments can facilitate treatment, aid in program planning, and provide data for cost-of-care projections. METHODS: In this prospective study of patient outcomes, 1,679 inpatients were classified on admission using a functional status measure developed by the authors. Consenting subjects were reassessed at discharge and at 3, 6, and 12 months postdischarge to determine what proportion of patients classified as low functioning on admission remained so at follow-up. RESULTS: Patients classified as low functioning on admission represented 23.4% of the sample; the proportion that remained low functioning at the follow-ups ranged from 56.1% to 65.2%. Compared to the high functioning group, three times more low functioning patients were rehospitalized within 12 months of discharge (9.4% vs 32%). CONCLUSIONS: Patients with increased risk of persisting disability can be identified on admission using commonly available clinical measures. Of patients with low functioning on admission, more than half will have long-term impairment.

Psychiatric education and the future of psychoanalysis.

Given all that is invested in psychoanalytic training and practice, it is understandable that psychoanalysts wish to view the future as promising. Those who have contributed to the development of The Academy can be proud of their past and present efforts, and undoubtedly hope that these contributions will be lasting. However, to ensure the future of The Academy, we must invest in education. Whatever the location of the psychoanalytic institute, the location of medical training will always be in the universities. As psychoanalysts, we must remain visible to the medical student; we must participate actively in the training of the psychiatric resident. We must be able to demonstrate the relevance of psychoanalysis. Exactly what lies ahead is uncertain, but without a commitment to education there will be no future. Because of its history, The Academy has a special opportunity to ensure the future of psychoanalytic contributions to psychiatry.