Wagons ho: forward on the managed care trail.

This paper describes the impact of managed care on an academic medical center department of psychiatry. Like the pioneers before us, academic medical centers have often traveled wilderness paths, training new generations of psychiatrists and providing research about and new understandings of psychiatric illness; under assault from powerful competitive forces, we have all too often circled the wagons in an attempt to survive what we perceive as an onslaught. We describe the ways in which our academic medical center department of psychiatry has responded to managed care forces, in particular, the impact of managed care on residency training, inpatient services, outpatient psychotherapeutic and psychopharmacological care, and faculty morale. We describe how we have worked closely with our medical colleagues, formed new committees, and initiated forays into capitated arrangements. Despite difficult external circumstances, we have been able to survive, regroup, provide leadership, and continue with renewed purpose.

Portal venous gas as a complication of ERCP and endoscopic sphincterotomy.

We report a patient in whom portal venous gas occurred as a complication of endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy, presumably because of bleeding at the papilla that allowed gas to enter the duodenal wall and portal venous system. To our knowledge, four similar cases have been reported previously. Although these patients have had a benign clinical course with rapid resolution of the gas, they should be observed carefully for signs of duodenal bleeding or perforation.

Double-blind, placebo-controlled comparison of clonazepam and alprazolam for panic disorder.

To test the reported antipanic efficacy of clonazepam, the authors randomized 72 subjects with panic disorder to 6 weeks of treatment with either alprazolam, clonazepam, or placebo. Endpoint analysis demonstrated a significant beneficial effect of both active treatments, but not placebo treatment, on the frequency of panic attacks, overall phobia ratings, and the extent of disability. Comparison of the two active treatments revealed no significant differences and no consistent tendency for one agent to be favored over another, although power to detect small differences was limited. Sedation and ataxia were the most common side effects reported, but these effects were mild and transient and did not interfere with treatment outcome. The results of this double-blind, placebo-controlled trial are consistent with previous reports of clonazepam's antipanic efficacy.

Fluoxetine-induced sexual dysfunction.

Of the first 60 patients treated at our clinic with the antidepressant fluoxetine, 5 (8.3%) developed treatment-emergent sexual dysfunction (anorgasmia and/or delayed orgasm). Three of those 5 patients had a history of treatment-emergent sexual dysfunction while receiving other antidepressant agents. Clinicians should be aware of this side effect of fluoxetine.

Diabetes and hypertension. Blood pressure in clinical diabetic patients and a control population.

Blood pressure was recorded in a group of 514 randomly selected Swiss diabetic patients (267 men and 247 women; 164 early-onset and 350 late-onset diabetics) aged from 35 to 54 years. These patients were compared with a control group from a population survey in Switzerland (877 men and 850 women). Mean systolic pressure (+/- SD) in the diabetic population was 139.3 +/- 21 mm Hg as compared with 125.5 +/- 17 mm Hg among controls. Mean diastolic pressure was 85.4 +/- 12 mm Hg in diabetic subjects as compared with 79.1 +/- 12 mm Hg in controls. The difference was reduced by about 25% after adjustment for body mass, age, and sex; 30.7% of diabetic subjects as compared with 8.2% among controls were hypertensive. Sixty-two percent of the hypertensive diabetic patients and 45% of the hypertensive controls were receiving antihypertensive treatment. In a multivariate analysis, presence of proteinuria and larger body mass had an important influence on systolic and diastolic blood pressures and the risk of hypertension. Diabetes duration had a significant influence only on systolic blood pressure. Efforts are needed in the clinical and research field to limit and clarify the harmful effects of elevated blood pressure in diabetes.

Behavioral inhibition in children of parents with panic disorder and agoraphobia. A controlled study.

To investigate the role of "behavioral inhibition to the unfamiliar" as an early temperamental characteristic of children at risk for adult panic disorder and agoraphobia (PDAG), we compared children of parents with PDAG with those from psychiatric comparison groups. Fifty-six children aged 2 to 7 years, matched for age, socioeconomic status, ethnic background, and ordinal position, were blindly evaluated at the Harvard Infant Study laboratory, Cambridge, Mass. The rates of behavioral inhibition in children of probands with PDAG, with or without comorbid major depressive disorder (MDD), were significantly higher than for our comparison group without PDAG. Further, the data suggest a progression of increasing rates of inhibition from the comparison group without MDD (15.4%), to MDD (50.0%), and to comorbid PDAG and MDD (70%) and PDAG (84.6%). In contrast, the rate of behavioral inhibition in children of probands with MDD did not meaningfully differ from the comparison group without MDD. Behavioral inhibition to the unfamiliar, as defined and measured in the previous work of the Harvard Infant Study program, is highly prevalent in the offspring of adults in treatment for PDAG. These children appear to be at risk for distress and disability in childhood and also perhaps for development of psychiatric disorder in later childhood and aulthood.

Rebound anxiety in panic disorder patients treated with shorter-acting benzodiazepines.

Rebound--the relative worsening of symptoms on discontinuation of treatment as compared to baseline symptoms--is distinguished from withdrawal. Case reports and a clinical study are presented to illustrate the management of patients with panic disorder who are taking short- and intermediate-acting benzodiazepines and are experiencing rebound anxiety. The authors present the results of switching over to clonazepam 48 patients with panic disorder who were experiencing rebound effects with alprazolam. Eighty-two percent (39) of the patients rated clonazepam as being "better" than alprazolam due to decreased dosing frequency and lack of interdose anxiety. The authors conclude that clonazepam can be a useful alternative to alprazolam and other short-acting benzodiazepines in the treatment of anxiety disorders. Clonazepam offers the advantage of antipanic efficacy without the relative side effect problems seen with tricyclic antidepressants and monoamine oxidase inhibitors.

Clonazepam versus alprazolam in the treatment of panic disorder: interim analysis of data from a prospective, double-blind, placebo-controlled trial.

The authors present interim results of a prospective, random assignment, double-blind, placebo-controlled trial conducted to determine whether clonazepam is as effective as alprazolam in reducing the frequency of panic attacks and whether both agents are superior to placebo. Analysis on 44 of 60 randomized subjects showed no statistically significant differences between the clonazepam and alprazolam groups on the following clinically meaningful outcome measures: total number of panic attacks and percent of time subjects experienced anticipatory anxiety, extent of phobic avoidance, and fear. Statistically significant differences did exist among the drug and placebo groups on these measures. The authors conclude that this interim analysis of the data supports the inclusion of clonazepam in the treatment of panic disorder.

The alprazolam to clonazepam switch for the treatment of panic disorder.

Forty-eight consecutive patients treated for panic disorder with alprazolam, but with presumed interdose anxiety symptoms, were switched to clonazepam. Forty-one patients made the "switch" according to a protocol, and 82% rated clonazepam "better" because of decreased frequency of administration and lack of interdose anxiety. Both medications seemed effective for panic disorder at comparable doses, and the authors describe how to switch from alprazolam to clonazepam when interdose anxiety is a concern.

[Vascular diseases in 534 Swiss diabetics within the scope of a multinational study]. / Vaskuläre Erkrankungen bei 534 Schweizer Diabetikern im Rahmen einer multinationalen Studie.

In Switzerland 278 diabetic men and 256 women in the age group 35 to 54 were examined for the presence of angiopathic lesions, according to a standardized protocol of a multinational study comprising 6,695 diabetics from 14 countries. The diabetics were distributed according to sex, age, and duration of the disease into groups of equal size. Macro-angiopathy, as the sum of coronary heart disease, stroke, and vascular disease of the legs was found in 28% of men and in 29% of women in the Swiss group. The prevalence of myocardial infarction alone was 6.8% in men and 5.5% in women. These rates did not differ from those found in the other national groups. Micro-angiopathy was found in the form of retinopathy in 35% and as nephropathy in 32% of the Swiss diabetics. These rates were not different from those of all groups. Severe retinopathy was found more frequently in Swiss diabetics than in the whole study. Micro-angiopathy was strongly related to duration, hypertension, and type of treatment in all centres. Japanese diabetics showed a higher frequency of micro-angiopathy, although macrovascular disease was found at a low rate. Systolic blood pressure (BP) in the Swiss diabetics did not differ from the results of the whole group. In 14% of the Swiss diabetic men and in 18% of the women, systolic BP was over 160 mmHg. These rates were remarkably higher than in an age- and sex-matched sample of a randomly selected sample of a Swiss population (3.2% in men, 2.4% in women). Cholesterol was high in the Swiss diabetic groups, whereas body mass index was in the intermediate range. Of the Swiss diabetic men 38% smoked regularly. The frequency of coronary heart disease in Swiss men and women was similar. This is different from the lower rate usually found in non-diabetic women. Age, and not duration of the disease was the most important factor relating to macro-angiopathy. The different rates of macro- and microvascular complications in various populations, selected according to the same protocol, suggests that the risk factors for macrovascular disease differ from those of microvascular complications. Race, nutrition, treatment, exercise, and hypertension may further influence the prevalence of angiopathy in diabetics of same sex, age, and duration of the disease.

Differences in cardiovascular morbidity and mortality between previously known and newly diagnosed adult diabetics.

498 diabetics were discovered in a survey of ischaemic heart disease in 10,059 men aged 40 years and over in Israel. -The diabetics were divided into previously known and newly diagnosed. -During a 5 year follow-up period, the incidence rates of fatal and non-fatal myocardial infarction and the incidence of intermittent claudication were considerably greater in both groups of diabetics than in non-diabetics. The frequency of hypertension and left ventricular hypertrophy was about the same in both groups, and in non-diabetics. -However, the pattern of increased morbidity for angina pectoris and the increased rate of sudden death is seen only in the previously diagnosed diabetics. Different pathological mechanisms might be responsible for angina pectoris and sudden death, as compared to myocardial infarction and these might be related in diabetics to the duration and severity of the disease.