The management of depression: the implications for managed care--roundtable discussion: Part 1.

Depression affects not only the patient and the provider, but the employer as well. Up to 25% of all women experience major depressive disorder, compared with perhaps as many as 12% of all men. It is highly prevalent in patients with other acute and chronic disease. On October 4, 1999, a panel of managed care medical directors, pharmacy directors, clinicians, researchers, and health economists was convened in San Diego to discuss the optimal treatment of the disorder. This roundtable discussion is presented in three parts. The first portion lays the clinical foundation for the management of this critical disorder.

The management of depression: the implications for managed care--roundtable discussion: Part 3.

From the standpoint of managed care, the rising cost of depression can be addressed in multiple ways. In the final portion of the roundtable discussion, the faculty discuss not only disease management programs for depression, but other initiatives health plans (including at the pharmacy level) are undertaking to address the rising costs associated with depression. They also discuss the effect of mental health coverage "parity" laws, which can be expected to drive costs even higher.

Cerebral blood flow SPECT with Tc-99m exametazine correlates in AIDS dementia complex stages. A preliminary report.

Human immunodeficiency virus (HIV) infection is frequently complicated by a variety of disease processes affecting the central nervous system (CNS). One of them is AIDS dementia complex (ADC), which, in the absence of opportunistic infection, is believed to be caused by HIV itself. ADC is characterized by a constellation of cognitive, motor, and behavioral symptoms that progressively get worse. This study was coined to recruit AIDS patients without any opportunistic CNS infection but with signs of CNS abnormality as evidenced by behavioral and subtle motor changes, then to categorize them into five stages, and finally to perform the cerebral blood flow scan using Ceretec. The aim of this study was to correlate the abnormalities of the brain scan with the different stages of ADC. Five patients were analyzed, with dementias ranging from mild to severe according to Price's classification. After confirming the absence of CNS opportunistic infections and AIDS associated malignancies by CT of the brain, the patients underwent psychiatric evaluation and brain scans. The SPECT scans were very sensitive in showing uptake defects in the brain, even in the early stages of ADC. The blood flow defects were more pronounced in the later stages, while the CT scans remained negative except in patients with the most severe dementia.

Patient dynamics, staff burnout, and consultation-liaison psychiatry.

This paper discusses the valuable role of the consultation-liaison psychiatrist in reducing hospital staff burnout, particularly in working with difficult patients admitted to nonpsychiatric services. Direct patient consultation is a reimbursable service. However, staff-oriented consultation, while not reimbursed by most third-party payers, can be an invaluable means of improving staff-patient relations, reducing liability risk, and alleviating staff stress. The consultation-liaison psychiatrist can be an important element in a hospitalwide, ongoing, comprehensive program to reduce burnout and thereby optimize staff retention and staff effectiveness.

Catatonia and burns.

Two case reports describing symptoms of catatonia associated with thermal injury are reported. The incidence of catatonia in a burn unit was found to be about three times that in a general hospital.

Computer-mediated psychotherapy: toward patient-selection guidelines.

The greatest obstacle currently slowing the progress of research in computer-mediated psychotherapy is the fact that unless the physicians using it truly believe in its effectiveness, even the most sophisticated computer technology will fail. The more complex the tasks, the less likely are people, including mental health professionals, willing to believe that computers can successfully carry them out. Many people fear the psychotherapy experience would be dehumanized by the introduction of computer technology. But the medium must not be confused with the message; the computer is simply an extension of the therapist, permitting one therapist to treat not just a few, but thousands of desperate patients. The current state of computer-mediated psychotherapy is such that this medium appears to be best suited to individual psychotherapy of a brief or focused nature, particularly the cognitive-behavioral therapies. The introduction of computer technology into psychotherapy offers the significant advantages of flexibility, consistency, and economy that would make psychotherapy more effective and more readily available to a much broader patient population than the one presently benefiting from such treatment. The preceding discussion has been an attempt to offer some practical guidelines for patient selection for computer-mediated psychotherapy based upon available investigations. As such, it is nevertheless incomplete and open to future revision. Considerable work remains to be done before definitive recommendations can be made, but it is hoped that these suggestions may prove helpful to clinicians working at the frontier of this new and exciting therapeutic medium.

Psychobiology of the borderline disorders--a heuristic approach.

A psychophysiologic approach to understanding borderline behavior is presented in which psychological and biological explanations complement, rather than exclude, one another. Descriptive-objective diagnoses or a target symptom approach are not sufficient to explain borderline behaviors. Phenomena are described that suggest underlying pathophysiologic processes, although they are usually accorded ego psychological explanations. Their underlying common denominator may be inadequate limbic system "filtering" of irrelevant stimuli. Each patient must be seen as an individual, rather than be fitted to a chosen model. Though the borderline constitutes a unique descriptive category, borderline behaviors result from processes generalizable across a broad range of psychopathology.

Therapeutic usefulness of amitriptyline in spastic colon syndrome.

The therapeutic efficacy of amitriptyline in irritable bowel was studied in a cross-over double-blind trial, employing fourteen patients whose symptoms were rated as Class II or worse on an arbitrarily-defined interval scale and who had not benefited from previous trials of anticholinergics, anticholinergic-sedative combinations, and bulk-forming agents. During the study, patients rated their own symptoms and the interviewer rated their symptoms using the same scale. Average scores for the patients while on drug showed significant improvement compared to pre-test level. No placebo or drug carry-over effects could be demonstrated. Inasmuch as amitriptyline is effective in this context at dosages subtherapeutic with regard to depression, the authors suggest that a central (perhaps anticholinergic) mechanism of action is responsible.