Decision Regret among Patients with Early-stage Lung Cancer Undergoing Radiation Therapy or Surgical Resection.

AIMS: Clinical equipoise exists regarding early-stage lung cancer treatment among patients as trials comparing stereotactic body radiation therapy (SBRT) and surgical resection are unavailable. Given the potential differences in treatment effectiveness and side-effects, we sought to determine the associations between treatment type, decision regret and depression. MATERIALS AND METHODS: A multicentre, prospective study of patients with stage IA-IIA non-small cell lung cancer (NSCLC) with planned treatment with SBRT or surgical resection was conducted. Decision regret and depression were measured using the Decision Regret Scale (DRS) and Patient Health Questionnaire-4 (PHQ-4) at 3, 6 and 12 months post-treatment, respectively. Mixed linear regression modelling examined associations between treatment and decision regret adjusting for patient sociodemographics. RESULTS: Among 211 study participants with early-stage lung cancer, 128 (61%) patients received SBRT and 83 (39%) received surgical resection. The mean age was 73 years (standard deviation = 8); 57% were female; 79% were White non-Hispanic. In the entire cohort at 3 months post-treatment, 72 (34%) and 57 (27%) patients had mild and severe decision regret, respectively. Among patients who received SBRT or surgery, 71% and 46% of patients experienced at least mild decision regret at 3 months, respectively. DRS scores increased at 6 months and decreased slightly at 12 months of follow-up in both groups. Higher DRS scores were associated with SBRT treatment (adjusted mean difference = 4.18, 95% confidence interval 0.82 to 7.54) and depression (adjusted mean difference = 3.49, 95% confidence interval 0.52 to 6.47). Neither patient satisfaction with their provider nor decision-making role concordance was associated with DRS scores. CONCLUSIONS: Most early-stage lung cancer patients experienced at least mild decision regret, which was associated with SBRT treatment and depression symptoms. Findings suggest patients with early-stage lung cancer may not be receiving optimal treatment decision-making support. Therefore, opportunities for improved patient-clinician communication probably exist.

A clinical tool for rating response to civil commitment for substance abuse treatment.

OBJECTIVE: The objectives of this study were to develop a measure to assess patients' response to civil commitment, to test this measure on two groups of dually diagnosed patients (medically ill alcoholics and patients with dual mental and substance use disorders), and to identify patient characteristics associated with a positive response to commitment. METHODS: The outcome of 38 male veterans civilly committed to inpatient substance abuse treatment for an average of six months was rated by their treating clinicians. Raters used the Commitment Response Form (CRF), a scale anchored to behavioral descriptions that was developed for the study and that measures outcome in five areas: patients' attitude toward recovery, substance use, medical condition, engagement in substance abuse treatment, and independence of functioning. Each patient's medical records were reviewed by two clinical staff members who made independent retrospective ratings and a joint rating using the CRF. They also made independent and joint dichotomous ratings of whether the patient was a positive responder or a nonresponder to civil commitment. RESULTS: The CRF showed superior reliability when compared with the dichotomous rating of outcome. The scale demonstrated reasonable psychometric properties. Mean scale scores did not differ significantly by patient group; slightly more than half were rated as having a good to excellent overall response. Better outcome was associated with longer periods of previous abstinence from alcohol and a higher level of education. CONCLUSIONS: Use of a scale anchored to behavioral descriptions improved reliability of outcome determinations by clinical staff. Civil commitment resulted in good to excellent outcome in many but not all committed patients.

Prevalence of ADHD and comorbid disorders among elementary school children screened for disruptive behavior.

In the context of a school-based prevention of conduct disorder program, 7,231 first- through fourth-grade children were screened for cross-setting disruptive behavior. Frequencies of DSM-III-R psychiatric disorders and patterns of comorbidity were assessed. We also examined the association of psychiatric diagnosis with child and parent characteristics to determine differential risk based on diagnostic subgroups. Attention deficit hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) were the most frequent diagnoses. Mood and anxiety disorders were infrequent as single diagnoses. Patterns of comorbidity demonstrated that both externalizing and internalizing disorders commonly cooccurred with ADHD. More severe degrees of psychopathology and psychosocial risk accrued to the subgroup of youths with ADHD plus a comorbid externalizing disorder.

The use of alcohol home delivery services by male problem drinkers: a preliminary report.

Alcohol home delivery services (AHDS) provide convenient and confidential access to alcohol, yet little is known about their use. The purpose of this report is to present preliminary data describing the use of AHDS by problem drinkers. We surveyed 174 males regarding social and demographic characteristics, alcohol use history, and use of AHDS. Use of AHDS was most common among problem drinkers. When statistically controlling for the effects of demographic and social characteristics, regular drinkers without a history of alcohol problems were significantly less likely to have had alcohol delivered than problem drinkers, p = .0036. Contrary to expectation, medically ill alcoholics with advanced and disabling medical complications of heavy drinking were not more likely than other problem drinkers to have alcohol delivered. Living in an urban area and not having a vehicle available were associated with the use of AHDS. The public health and safety considerations of alcohol availability via home delivery are discussed.

Survival analysis of response to group psychotherapy in bulimia nervosa.

A reanalysis of treatment response and relapse was performed using survival analysis in a 12-week clinical trial of cognitive behavioral group psychotherapy for the treatment of bulimia nervosa. One hundred forty-three (143) bulimic women with high incidence of binge eating, self-induced vomiting, and/or laxative abuse were randomly assigned to one of four possible treatment conditions that consisted of a combination of two factors: (1) emphasis on abstinence (high and low), and (2) treatment intensity (high and low). "Initial" and "maintained" response to treatment based on "total" and "near" abstinence criteria were determined using self-reported binge eating, vomiting, and laxative use data. Results suggest that an emphasis on abstinence appears important in achieving initial abstinence, whereas intensity of treatment may be important in maintaining abstinence.

The effect of carbamazepine on the white blood cell count in cocaine abusers.

Various medication therapies have been attempted to assist in detoxification and abstinence maintenance among cocaine users. The safety of these medications in this unique population has not been documented. Carbamazepine, an anticonvulsant being used with this population, is known to cause leukopenia and agranulocytosis in seizure patients. Analysis of data involving two different populations of cocaine users treated with carbamazepine revealed no statistically or clinically significant changes in total white blood cell count, or in any component white cell, using endpoint analysis, lowpoint analysis, or regression analysis. These results should be reassuring to the addiction medicine clinician.

1990-1991 survey of pharmacotherapies used in the treatment of cocaine abuse.

In order to assess the usefulness of pharmacotherapeutic agents in cocaine treatment, all 3,631 physician members of the American Society of Addiction Medicine (ASAM) were surveyed. Five hundred and two physicians indicated use of pharmacotherapies, involving treatment experiences with approximately 79,760 patients for cocaine detoxification, and with 37,166 patients for cocaine abstinence maintenance. For both detoxification and abstinence maintenance, the four most commonly prescribed medications were amantadine, bromocriptine, desipramine, and l-tryptophan. As expected, these four medications were also the preferred treatment by a majority of physicians expressing any preference. Some relatively new medications are also being tried for the treatment of cocaine abuse, specifically carbamazepine, fluoxetine, and Tropamine.

The convergent validity of the Drug Impairment Rating Scale for Cocaine.

The Halikas-Crosby Drug Impairment Rating Scale for Cocaine (HAL DIRS-C) is designed to measure improvement in drug treatment through interval assessment of impact of cocaine use on daily functioning, relationships with other people, other alcohol and drug use, cocaine withdrawal symptoms, adverse effects associated with cocaine use, and personal outlook over the previous week. The scale is a 25-item clinical rating scale administered in the context of a semistructured interview (modeled after and similar to the Hamilton Rating Scale for Depression). The HAL DIRS-C was administered weekly to 147 subjects participating in a 12-week, double-blind medication trial with a psychosocial treatment component. Without breaking the pharmacologic blind, the HAL DIRS-C score was found to be significantly related to study retention, ongoing psychosocial treatment participation, urinalysis results, and other measures of outcome. The results support the validity of the HAL DIRS-C as a standardized measure of improvement or outcome in clinical research involving the treatment of cocaine abuse.

Daily monitored cardiovascular effects of carbamazepine in chronic crack cocaine users.

During a 20-day, double-blind, placebo-controlled, fixed-dose outpatient trial of carbamazepine (either 200 mg or 400 mg) for potential anticocaine treatment effects in volunteers who were unmotivated for treatment and who lacked any external coercion for cocaine abstinence, we monitored cardiovascular effects in 30 subjects on a daily basis. All individual cardiovascular measures obtained were within clinically normal limits. Corrected QT interval under carbamazepine was shorter than under placebo condition, although both were in the normal range. Systolic pressure was elevated by 2.1 mm Hg. No differences in pulse rate were found. With carbamazepine and concurrent ad lib cocaine use, heart rate was significantly, although not clinically, elevated (mean increase = 2.3 beats/minute). The analysis of these approximately 600 observations indicates that carbamazepine in cocaine users, alone and in combination with ad lib street crack use, causes no clinically significant cardiovascular effects.