Jane Salodof MacNeil

SCOTTSDALE, ARIZ. – Early treatment of migraine can contribute to development of medication-overuse headaches in pain-adverse patients, Dr. James R. Couch warned at a symposium sponsored by the American Headache Society.

These patients will take their pills every time they think they might be about to get a migraine, said Dr. Couch, a professor of neurology at the University of Oklahoma Health Sciences Center in Oklahoma City.

“The more they think they are getting a headache and take the medication early, the more likely that this may lead to developing an MOH [medication-overuse headache]-induced chronic daily headache,” he said.

The conundrum for prescribing physicians, as presented by Dr. Couch, is that current and previous studies show patients really do have a better response if they take their medications at the first sign of a migraine. He recommended early treatment for the patient who has an occasional menstrual-induced migraine, but suggested a cautious approach for those with more frequent headaches.

“If a patient is having 10 or more headaches a month, do not get them into the early treatment or be careful about the early treatment,” he said. Instead, make sure these patients know when they are starting a headache as opposed to thinking they might be getting one.

“I think this is one of the main problems,” Dr. Couch said.

He added that patients who “get a buzz” from their medication also could be at greater risk of developing MOH. Some patients will use their headache medication like a dose of alcohol, he warned.

He recommended asking whether the patient feels a lot better immediately after taking a headache remedy. In his experience, some will say that it gives them energy in the afternoon, helping them to finish their work.

The pathophysiology of MOH is not clear, according to Dr. Couch, but genetic predisposition and psychological factors appear to be involved. Depression and bipolar disorder are common in MOH patients, he said. Typically, the MOH patient has an underlying headache, but sometimes social factors drive the medication overuse. “Is there something else going on there?” he urged physicians to explore in these patients.

Chronic daily headaches and MOH are a worldwide problem, according to Dr. Couch. He pointed to studies in the United States, Spain, China, and Ethiopia that show 4%-5% of the population have headaches 15 days or more each month.

In developed countries, he said about 1% of the population develops MOH. These patients account for 20% of the chronic daily headache population and may be increasing in number. In the 25− to 50-year-old age group where MOH is most prevalent, Dr. Couch said it is as common as epilepsy and more common than multiple sclerosis or stroke.

The best treatment is prevention, he said. Know what medications your patients are taking, keep track of refills, and discuss the possibility of MOH as soon as you recognize the patient is at risk, he urged.

SCOTTSDALE, ARIZ. – Early treatment of migraine can contribute to development of medication-overuse headaches in pain-adverse patients, Dr. James R. Couch warned at a symposium sponsored by the American Headache Society.

These patients will take their pills every time they think they might be about to get a migraine, said Dr. Couch, a professor of neurology at the University of Oklahoma Health Sciences Center in Oklahoma City.

“The more they think they are getting a headache and take the medication early, the more likely that this may lead to developing an MOH [medication-overuse headache]-induced chronic daily headache,” he said.

The conundrum for prescribing physicians, as presented by Dr. Couch, is that current and previous studies show patients really do have a better response if they take their medications at the first sign of a migraine. He recommended early treatment for the patient who has an occasional menstrual-induced migraine, but suggested a cautious approach for those with more frequent headaches.

“If a patient is having 10 or more headaches a month, do not get them into the early treatment or be careful about the early treatment,” he said. Instead, make sure these patients know when they are starting a headache as opposed to thinking they might be getting one.

“I think this is one of the main problems,” Dr. Couch said.

He added that patients who “get a buzz” from their medication also could be at greater risk of developing MOH. Some patients will use their headache medication like a dose of alcohol, he warned.

He recommended asking whether the patient feels a lot better immediately after taking a headache remedy. In his experience, some will say that it gives them energy in the afternoon, helping them to finish their work.

The pathophysiology of MOH is not clear, according to Dr. Couch, but genetic predisposition and psychological factors appear to be involved. Depression and bipolar disorder are common in MOH patients, he said. Typically, the MOH patient has an underlying headache, but sometimes social factors drive the medication overuse. “Is there something else going on there?” he urged physicians to explore in these patients.

Chronic daily headaches and MOH are a worldwide problem, according to Dr. Couch. He pointed to studies in the United States, Spain, China, and Ethiopia that show 4%-5% of the population have headaches 15 days or more each month.

In developed countries, he said about 1% of the population develops MOH. These patients account for 20% of the chronic daily headache population and may be increasing in number. In the 25− to 50-year-old age group where MOH is most prevalent, Dr. Couch said it is as common as epilepsy and more common than multiple sclerosis or stroke.

The best treatment is prevention, he said. Know what medications your patients are taking, keep track of refills, and discuss the possibility of MOH as soon as you recognize the patient is at risk, he urged.

SCOTTSDALE, ARIZ. – Early treatment of migraine can contribute to development of medication-overuse headaches in pain-adverse patients, Dr. James R. Couch warned at a symposium sponsored by the American Headache Society.

These patients will take their pills every time they think they might be about to get a migraine, said Dr. Couch, a professor of neurology at the University of Oklahoma Health Sciences Center in Oklahoma City.

“The more they think they are getting a headache and take the medication early, the more likely that this may lead to developing an MOH [medication-overuse headache]-induced chronic daily headache,” he said.

The conundrum for prescribing physicians, as presented by Dr. Couch, is that current and previous studies show patients really do have a better response if they take their medications at the first sign of a migraine. He recommended early treatment for the patient who has an occasional menstrual-induced migraine, but suggested a cautious approach for those with more frequent headaches.

“If a patient is having 10 or more headaches a month, do not get them into the early treatment or be careful about the early treatment,” he said. Instead, make sure these patients know when they are starting a headache as opposed to thinking they might be getting one.

“I think this is one of the main problems,” Dr. Couch said.

He added that patients who “get a buzz” from their medication also could be at greater risk of developing MOH. Some patients will use their headache medication like a dose of alcohol, he warned.

He recommended asking whether the patient feels a lot better immediately after taking a headache remedy. In his experience, some will say that it gives them energy in the afternoon, helping them to finish their work.

The pathophysiology of MOH is not clear, according to Dr. Couch, but genetic predisposition and psychological factors appear to be involved. Depression and bipolar disorder are common in MOH patients, he said. Typically, the MOH patient has an underlying headache, but sometimes social factors drive the medication overuse. “Is there something else going on there?” he urged physicians to explore in these patients.

Chronic daily headaches and MOH are a worldwide problem, according to Dr. Couch. He pointed to studies in the United States, Spain, China, and Ethiopia that show 4%-5% of the population have headaches 15 days or more each month.

In developed countries, he said about 1% of the population develops MOH. These patients account for 20% of the chronic daily headache population and may be increasing in number. In the 25− to 50-year-old age group where MOH is most prevalent, Dr. Couch said it is as common as epilepsy and more common than multiple sclerosis or stroke.

The best treatment is prevention, he said. Know what medications your patients are taking, keep track of refills, and discuss the possibility of MOH as soon as you recognize the patient is at risk, he urged.

TUCSON, ARIZ. – Dementia may be overdiagnosed and delirium overlooked when geriatric patients with vague symptoms are brought to emergency departments, Dr. Lesley Wiesenfeld suggested at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Wiesenfeld reviewed the first 22 patients screened by a small pilot program in which she provided a geriatric psychiatry consultation liaison service to emergency department physicians at Mt. Sinai Hospital in Toronto.

As a result of the consultations, she reported, patients were more likely to be admitted for medical reasons or discharged home. They were less likely to be placed in a psychiatric unit or discharged to long-term care.

“Emergency department doctors were disproportionately assuming cognitive problems in people who had medical and psychiatric problems and delirium,” Dr. Wiesenfeld, a staff psychiatrist and geriatric training program coordinator at the University of Toronto-affiliated hospital, said in a poster-side interview.

Most psychiatric departments offer consultation liaison services after patients are admitted to a hospital, according to Dr. Wiesenfeld.

The pilot program enabled emergency department physicians to seek help in evaluating whether difficult geriatric patients should be admitted.

Dr. Wiesenfeld described the population, which ranged from 66 to 95 years of age, as “quite a mix.” Some were depressed or had mental problems. Many “just seemed different and their family didn't know what to do with them, so they called 911 or brought them in.”

For emergency physicians, just taking a history could be difficult when patients had poor memories and did not know their medications. “They didn't look well, but they didn't look sick enough for admission to the hospital,” Dr. Wiesenfeld said. “[The emergency physicians] were in a kind of limbo about what they should do.”

Behavioral change was the most common reason for referrals to the service, cited by the emergency physicians in eight patients. Other reasons were delirium or dementia (six patients), safe to go home vs. emergency nursing home placement (five), and physical symptoms (three).

The final psychiatric diagnoses reported by Dr. Wiesenfeld were dementia/cognitive disorder (six patients), delirium (five), major mood disorder/episode (four), no disorder (four), and major psychotic disorder (three).

The emergency physicians anticipated that 10 patients would be admitted as psychiatric cases, 7 discharged to long-term care, 4 sent home, and 1 admitted to a medical unit. After the psychogeriatric consultations, the actual disposition was that eight patients went home with a prescription and/or outpatient appointment, seven were admitted for medical reasons, and five were admitted to the psychiatric service.

Only two were sent to long-term care.

Among the case descriptions posted by Dr. Wiesenfeld was a 75-year-old homeless man, presumed psychotic, who was found to have fever and delirium from a urinary tract infection for which he was admitted. Instead of being discharged to a nursing home, a developmentally delayed 66-year-old man was diagnosed with normal pressure hydrocephalus and referred to neurosurgery.

Dr. Wiesenfeld concluded that since the referrals doubled from 7 in the first year to 15 in the second year, this indicates that physicians found value in the service, even though it increased the length of time these patients spent in the emergency department.

Probable next steps, she said, will be more training to help the emergency staff distinguish dementia from delirium and better integration of social workers and psychiatrists into a psychogeriatric team. Also under consideration, she reported, is development of a geriatric crisis clinic.

TUCSON, ARIZ. – Dementia may be overdiagnosed and delirium overlooked when geriatric patients with vague symptoms are brought to emergency departments, Dr. Lesley Wiesenfeld suggested at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Wiesenfeld reviewed the first 22 patients screened by a small pilot program in which she provided a geriatric psychiatry consultation liaison service to emergency department physicians at Mt. Sinai Hospital in Toronto.

As a result of the consultations, she reported, patients were more likely to be admitted for medical reasons or discharged home. They were less likely to be placed in a psychiatric unit or discharged to long-term care.

“Emergency department doctors were disproportionately assuming cognitive problems in people who had medical and psychiatric problems and delirium,” Dr. Wiesenfeld, a staff psychiatrist and geriatric training program coordinator at the University of Toronto-affiliated hospital, said in a poster-side interview.

Most psychiatric departments offer consultation liaison services after patients are admitted to a hospital, according to Dr. Wiesenfeld.

The pilot program enabled emergency department physicians to seek help in evaluating whether difficult geriatric patients should be admitted.

Dr. Wiesenfeld described the population, which ranged from 66 to 95 years of age, as “quite a mix.” Some were depressed or had mental problems. Many “just seemed different and their family didn't know what to do with them, so they called 911 or brought them in.”

For emergency physicians, just taking a history could be difficult when patients had poor memories and did not know their medications. “They didn't look well, but they didn't look sick enough for admission to the hospital,” Dr. Wiesenfeld said. “[The emergency physicians] were in a kind of limbo about what they should do.”

Behavioral change was the most common reason for referrals to the service, cited by the emergency physicians in eight patients. Other reasons were delirium or dementia (six patients), safe to go home vs. emergency nursing home placement (five), and physical symptoms (three).

The final psychiatric diagnoses reported by Dr. Wiesenfeld were dementia/cognitive disorder (six patients), delirium (five), major mood disorder/episode (four), no disorder (four), and major psychotic disorder (three).

The emergency physicians anticipated that 10 patients would be admitted as psychiatric cases, 7 discharged to long-term care, 4 sent home, and 1 admitted to a medical unit. After the psychogeriatric consultations, the actual disposition was that eight patients went home with a prescription and/or outpatient appointment, seven were admitted for medical reasons, and five were admitted to the psychiatric service.

Only two were sent to long-term care.

Among the case descriptions posted by Dr. Wiesenfeld was a 75-year-old homeless man, presumed psychotic, who was found to have fever and delirium from a urinary tract infection for which he was admitted. Instead of being discharged to a nursing home, a developmentally delayed 66-year-old man was diagnosed with normal pressure hydrocephalus and referred to neurosurgery.

Dr. Wiesenfeld concluded that since the referrals doubled from 7 in the first year to 15 in the second year, this indicates that physicians found value in the service, even though it increased the length of time these patients spent in the emergency department.

Probable next steps, she said, will be more training to help the emergency staff distinguish dementia from delirium and better integration of social workers and psychiatrists into a psychogeriatric team. Also under consideration, she reported, is development of a geriatric crisis clinic.

TUCSON, ARIZ. – Dementia may be overdiagnosed and delirium overlooked when geriatric patients with vague symptoms are brought to emergency departments, Dr. Lesley Wiesenfeld suggested at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Wiesenfeld reviewed the first 22 patients screened by a small pilot program in which she provided a geriatric psychiatry consultation liaison service to emergency department physicians at Mt. Sinai Hospital in Toronto.

As a result of the consultations, she reported, patients were more likely to be admitted for medical reasons or discharged home. They were less likely to be placed in a psychiatric unit or discharged to long-term care.

“Emergency department doctors were disproportionately assuming cognitive problems in people who had medical and psychiatric problems and delirium,” Dr. Wiesenfeld, a staff psychiatrist and geriatric training program coordinator at the University of Toronto-affiliated hospital, said in a poster-side interview.

Most psychiatric departments offer consultation liaison services after patients are admitted to a hospital, according to Dr. Wiesenfeld.

The pilot program enabled emergency department physicians to seek help in evaluating whether difficult geriatric patients should be admitted.

Dr. Wiesenfeld described the population, which ranged from 66 to 95 years of age, as “quite a mix.” Some were depressed or had mental problems. Many “just seemed different and their family didn't know what to do with them, so they called 911 or brought them in.”

For emergency physicians, just taking a history could be difficult when patients had poor memories and did not know their medications. “They didn't look well, but they didn't look sick enough for admission to the hospital,” Dr. Wiesenfeld said. “[The emergency physicians] were in a kind of limbo about what they should do.”

Behavioral change was the most common reason for referrals to the service, cited by the emergency physicians in eight patients. Other reasons were delirium or dementia (six patients), safe to go home vs. emergency nursing home placement (five), and physical symptoms (three).

The final psychiatric diagnoses reported by Dr. Wiesenfeld were dementia/cognitive disorder (six patients), delirium (five), major mood disorder/episode (four), no disorder (four), and major psychotic disorder (three).

The emergency physicians anticipated that 10 patients would be admitted as psychiatric cases, 7 discharged to long-term care, 4 sent home, and 1 admitted to a medical unit. After the psychogeriatric consultations, the actual disposition was that eight patients went home with a prescription and/or outpatient appointment, seven were admitted for medical reasons, and five were admitted to the psychiatric service.

Only two were sent to long-term care.

Among the case descriptions posted by Dr. Wiesenfeld was a 75-year-old homeless man, presumed psychotic, who was found to have fever and delirium from a urinary tract infection for which he was admitted. Instead of being discharged to a nursing home, a developmentally delayed 66-year-old man was diagnosed with normal pressure hydrocephalus and referred to neurosurgery.

Dr. Wiesenfeld concluded that since the referrals doubled from 7 in the first year to 15 in the second year, this indicates that physicians found value in the service, even though it increased the length of time these patients spent in the emergency department.

Probable next steps, she said, will be more training to help the emergency staff distinguish dementia from delirium and better integration of social workers and psychiatrists into a psychogeriatric team. Also under consideration, she reported, is development of a geriatric crisis clinic.

TUCSON, ARIZ. — A psychological trait associated with heightened awareness of bodily distress may help to explain why some rheumatoid arthritis patients suffer more from achiness, malaise, and fatigue than do others with similar disease severity, Dr. Ilana M. Braun reported at the annual meeting of the Academy of Psychosomatic Medicine.

The trait, somatic absorption, was closely associated with generalized symptoms of rheumatoid arthritis in 87 patients studied by Dr. Braun, a psychiatrist at Harvard Medical School and Massachusetts General Hospital in Boston. It had no relationship to specific symptoms, such as joint pain, swelling, stiffness, and deformity, or to disease severity.

The magnitude of effect was modest, accounting for just 4% of variability in nonspecific symptoms, but Dr. Braun noted that it was significant statistically—and possibly clinically.

People who score high on measures of absorption have a capacity for deep involvement in sensory events, she said. They have a heightened sense of reality that makes them more sensitive not only to bodily distress, but also to hypnosis and to biofeedback.

“There might be a role for psychiatry in the treatment of rheumatoid arthritis,” she said, questioning whether some patients might respond to these kinds of interventions for nonspecific symptoms.

“It is a personality style that you can target,” Dr. Braun added in an interview. “This is not a disorder. These are perfectly healthy people [mentally]. They just have a certain way of responding to the world.”

While she called for more research into the clinical utility of her finding, Dr. Braun suggested that ultimately it may present rheumatologists with an alternative to increasing medication when patients complain they feel poorly in the absence of specific symptoms. “What I am saying is, for the malaise and the fatigue don't double the dose,” she said. “Send them to the hypnotist.”

The study was supported by a Webb Fellowship from the academy. Dr. Braun enrolled patients from a larger, longitudinal study of rheumatoid arthritis. The largely female population had a median age of 55.5 years. A majority, 85%, had been to college, more than half were employed, and about half were married.

Patients completed the 14-item Rheumatoid Arthritis Symptoms Questionnaire. Dr. Braun and her coinvestigators also used erythrocyte sedimentation rate and a standard 28-joint physical examination by a rheumatologist to measure disease severity. They calculated the total number of medications prescribed for pain and other “disease-modifying agents.”

Assessment of somatic absorption was based on the 29-item Somatic Absorption Scale, a measure derived from the Tellegen Absorption Scale. Dr. Braun said the Somatic Absorption Scale focuses on “absorption as it pertains to somatic or visceral experience.” For example, a subject might be asked whether she could imagine her arm being so heavy she could not move it, or if she notices how her clothes feel against her skin. The Rand Mental Health Inventory was used as well to identify common symptoms that are neither physical nor psychosomatic of prevalent mental disorders.

Dr. Braun reported somatic absorption was significantly more pronounced in younger subjects, people with more severe psychiatric symptoms, African Americans, and Hispanics. Rheumatoid arthritis symptoms with statistically significant ties to somatic absorption were pain in limbs, pain in back, fatigue, generalized aching, and “feeling sick all over.”

In a discussion of the findings, Dr. Stephen J. Ferrando said he found himself looking up the literature on absorption, a personality construct developed in the 1970s to assess which patients might respond to hypnosis and biofeedback.

Dr. Ferrando, a professor of clinical psychiatry and clinical public health at Cornell University in New York, called the findings very interesting and said he looks forward to an analysis of how the subjects fare in the longitudinal study from which the population was drawn.

TUCSON, ARIZ. — A psychological trait associated with heightened awareness of bodily distress may help to explain why some rheumatoid arthritis patients suffer more from achiness, malaise, and fatigue than do others with similar disease severity, Dr. Ilana M. Braun reported at the annual meeting of the Academy of Psychosomatic Medicine.

The trait, somatic absorption, was closely associated with generalized symptoms of rheumatoid arthritis in 87 patients studied by Dr. Braun, a psychiatrist at Harvard Medical School and Massachusetts General Hospital in Boston. It had no relationship to specific symptoms, such as joint pain, swelling, stiffness, and deformity, or to disease severity.

The magnitude of effect was modest, accounting for just 4% of variability in nonspecific symptoms, but Dr. Braun noted that it was significant statistically—and possibly clinically.

People who score high on measures of absorption have a capacity for deep involvement in sensory events, she said. They have a heightened sense of reality that makes them more sensitive not only to bodily distress, but also to hypnosis and to biofeedback.

“There might be a role for psychiatry in the treatment of rheumatoid arthritis,” she said, questioning whether some patients might respond to these kinds of interventions for nonspecific symptoms.

“It is a personality style that you can target,” Dr. Braun added in an interview. “This is not a disorder. These are perfectly healthy people [mentally]. They just have a certain way of responding to the world.”

While she called for more research into the clinical utility of her finding, Dr. Braun suggested that ultimately it may present rheumatologists with an alternative to increasing medication when patients complain they feel poorly in the absence of specific symptoms. “What I am saying is, for the malaise and the fatigue don't double the dose,” she said. “Send them to the hypnotist.”

The study was supported by a Webb Fellowship from the academy. Dr. Braun enrolled patients from a larger, longitudinal study of rheumatoid arthritis. The largely female population had a median age of 55.5 years. A majority, 85%, had been to college, more than half were employed, and about half were married.

Patients completed the 14-item Rheumatoid Arthritis Symptoms Questionnaire. Dr. Braun and her coinvestigators also used erythrocyte sedimentation rate and a standard 28-joint physical examination by a rheumatologist to measure disease severity. They calculated the total number of medications prescribed for pain and other “disease-modifying agents.”

Assessment of somatic absorption was based on the 29-item Somatic Absorption Scale, a measure derived from the Tellegen Absorption Scale. Dr. Braun said the Somatic Absorption Scale focuses on “absorption as it pertains to somatic or visceral experience.” For example, a subject might be asked whether she could imagine her arm being so heavy she could not move it, or if she notices how her clothes feel against her skin. The Rand Mental Health Inventory was used as well to identify common symptoms that are neither physical nor psychosomatic of prevalent mental disorders.

Dr. Braun reported somatic absorption was significantly more pronounced in younger subjects, people with more severe psychiatric symptoms, African Americans, and Hispanics. Rheumatoid arthritis symptoms with statistically significant ties to somatic absorption were pain in limbs, pain in back, fatigue, generalized aching, and “feeling sick all over.”

In a discussion of the findings, Dr. Stephen J. Ferrando said he found himself looking up the literature on absorption, a personality construct developed in the 1970s to assess which patients might respond to hypnosis and biofeedback.

Dr. Ferrando, a professor of clinical psychiatry and clinical public health at Cornell University in New York, called the findings very interesting and said he looks forward to an analysis of how the subjects fare in the longitudinal study from which the population was drawn.

TUCSON, ARIZ. — A psychological trait associated with heightened awareness of bodily distress may help to explain why some rheumatoid arthritis patients suffer more from achiness, malaise, and fatigue than do others with similar disease severity, Dr. Ilana M. Braun reported at the annual meeting of the Academy of Psychosomatic Medicine.

The trait, somatic absorption, was closely associated with generalized symptoms of rheumatoid arthritis in 87 patients studied by Dr. Braun, a psychiatrist at Harvard Medical School and Massachusetts General Hospital in Boston. It had no relationship to specific symptoms, such as joint pain, swelling, stiffness, and deformity, or to disease severity.

The magnitude of effect was modest, accounting for just 4% of variability in nonspecific symptoms, but Dr. Braun noted that it was significant statistically—and possibly clinically.

People who score high on measures of absorption have a capacity for deep involvement in sensory events, she said. They have a heightened sense of reality that makes them more sensitive not only to bodily distress, but also to hypnosis and to biofeedback.

“There might be a role for psychiatry in the treatment of rheumatoid arthritis,” she said, questioning whether some patients might respond to these kinds of interventions for nonspecific symptoms.

“It is a personality style that you can target,” Dr. Braun added in an interview. “This is not a disorder. These are perfectly healthy people [mentally]. They just have a certain way of responding to the world.”

While she called for more research into the clinical utility of her finding, Dr. Braun suggested that ultimately it may present rheumatologists with an alternative to increasing medication when patients complain they feel poorly in the absence of specific symptoms. “What I am saying is, for the malaise and the fatigue don't double the dose,” she said. “Send them to the hypnotist.”

The study was supported by a Webb Fellowship from the academy. Dr. Braun enrolled patients from a larger, longitudinal study of rheumatoid arthritis. The largely female population had a median age of 55.5 years. A majority, 85%, had been to college, more than half were employed, and about half were married.

Patients completed the 14-item Rheumatoid Arthritis Symptoms Questionnaire. Dr. Braun and her coinvestigators also used erythrocyte sedimentation rate and a standard 28-joint physical examination by a rheumatologist to measure disease severity. They calculated the total number of medications prescribed for pain and other “disease-modifying agents.”

Assessment of somatic absorption was based on the 29-item Somatic Absorption Scale, a measure derived from the Tellegen Absorption Scale. Dr. Braun said the Somatic Absorption Scale focuses on “absorption as it pertains to somatic or visceral experience.” For example, a subject might be asked whether she could imagine her arm being so heavy she could not move it, or if she notices how her clothes feel against her skin. The Rand Mental Health Inventory was used as well to identify common symptoms that are neither physical nor psychosomatic of prevalent mental disorders.

Dr. Braun reported somatic absorption was significantly more pronounced in younger subjects, people with more severe psychiatric symptoms, African Americans, and Hispanics. Rheumatoid arthritis symptoms with statistically significant ties to somatic absorption were pain in limbs, pain in back, fatigue, generalized aching, and “feeling sick all over.”

In a discussion of the findings, Dr. Stephen J. Ferrando said he found himself looking up the literature on absorption, a personality construct developed in the 1970s to assess which patients might respond to hypnosis and biofeedback.

Dr. Ferrando, a professor of clinical psychiatry and clinical public health at Cornell University in New York, called the findings very interesting and said he looks forward to an analysis of how the subjects fare in the longitudinal study from which the population was drawn.

TUCSON, ARIZ. — A randomized, multicenter Canadian trial testing interpersonal psychotherapy and citalopram in 284 depressed patients with stable coronary artery disease produced mixed results, investigators reported at the annual meeting of the Academy of Psychosomatic Medicine.

Citalopram (Celexa) was significantly more effective than placebo, reducing Hamilton Depression Rating scale (HAM-D) scores by an additional 3.3 points on average, according to Dr. François Lespérance, principal investigator of the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial.

Adding interpersonal psychotherapy (IPT) to 12 weekly clinical management sessions was a disappointment, however. Short-term therapy turned out to be no more effective in relieving depression than clinical management alone.

The Canadian Institutes of Health Research gave the CREATE trial a $1,342,996 (Canadian) grant. Starting in 2002, the study enrolled patients in Montreal, Kingston, Ottawa, and Toronto. Faced with slow enrollment, it added sites in Halifax and Calgary.

To maximize resources, the investigators randomized patients twice under a 2-by-2 factorial trial design. The participants comprised four cohorts: IPT/clinical management and citalopram (67 patients), IPT/clinical management and placebo (75 patients), clinical management alone and citalopram (75 patients), and clinical management alone and placebo (67 patients).

Consequently, the analyses were based on 142 patients exposed to IPT/clinical management vs. 142 patients exposed to clinical management alone and 142 patients treated with citalopram vs. 142 treated with placebo.

The presentation did not address the combined effect of IPT and citalopram in patients given both therapies.

Dr. Nancy Frasure-Smith, a coinvestigator, said the investigators neither expected nor saw any synergy between IPT and citalopram.

Dr. Frasure-Smith, a professor of psychiatry at McGill University in Montreal and senior research associate at the Montreal Heart Institute, emphasized that the trial used broad inclusion criteria. She cited growing evidence that depression is a risk factor for heart disease, but said little is known about treating depression in coronary disease patients because most depression treatment trials exclude patients with comorbidities.

In addition to having stable coronary artery disease, patients entered the CREATE trial having a current major depressive episode lasting at least 4 weeks based on the Structured Clinical Interview for Depression (SCID) and a baseline score of 19 or more on the 24-item Hamilton Depression Rating scale (HAM-D).

In the medication arms described by Dr. Lespérance, chief of psychiatry at the Centre Hospitalier de l'Université de Montréal, citalopram or placebo was titrated up from 10 mg per day during the first week to 20 mg per day for the next 5 weeks. If a patient's HAM-D score did not fall to 8 or less by week 6, the dose was increased to 40 mg per day for the duration of the study. Dr. Lespérance said the average dose was 33 mg per day by the end of the trial.

The advantage of citalopram over placebo was evident by the sixth week, he said. By the end of the trial, HAM-D scores fell by 14.9 points with citalopram and 11.6 points with placebo. Similar effects were reported on the Beck Depression Inventory and the Inventory for Depressive Symptomatology.

Although side effects typical of selective serotonin reuptake inhibitors (SSRIs) were reported, Dr. Lespérance said cardiovascular side effects were rare and small with no difference between groups. CREATE gave “no evidence that we should be concerned about cardiac safety,” he said. As for evidence that SSRIs might be cardioprotective, he cautioned that the data are inconclusive.

The investigators conducted a biomarker analysis that found treatment with citalopram was associated with enhanced production of nitric oxide. Dr. Louis T. van Zyl, a coinvestigator from Queens University in Kingston (Ont.), said the clinical implications are unclear. He added, however, that increasing nitric oxide might reduce cardiovascular risk.

All of the patients received 15–20 minutes of clinical management each week. During these sessions, therapists reviewed patient progress and side effects, according to Dr. J. Robert Swenson, a coinvestigator from the University of Ottawa Heart Institute.

Weekly IPT sessions were limited to 45 minutes duration and 12 weeks in all, he said. Patients assigned to IPT had to choose one issue to focus upon in short-term therapy, which typically followed clinical management.

Dr. Swenson said patients who received clinical management without IPT did slightly better halfway through the trial. No significant difference was found at 12 weeks, as he reported about half the patients in both groups responded to treatment, and a third went into remission.

Therapists who were experienced in IPT or specially trained for the trial delivered both the clinical management and IPT sessions.

This use of the IPT therapists for clinical management generated extensive discussion at the meeting. Despite assurances by the investigators that the clinical management sessions were closely monitored, some audience members questioned whether the clinical management-alone arm received more therapy than a nurse practitioner would deliver as usual care to similar patients who were outside of the trial.

ELSEVIER GLOBAL MEDICAL NEWS

Does Treatment Reduce Deaths?

CREATE was the third large clinical trial to investigate treatment of major depressive disorder in heart disease patients.

In the Sertraline Antidepressant Heart Attack Randomized Trial (SADHART), investigators did not find the selective serotonin reuptake inhibitor sertraline (Zoloft) to be significantly better than placebo in reducing depressive symptoms for the population overall, but it was safe and more effective for recurrent depression in patients with a recent myocardial infarction or unstable angina (JAMA 2002;288:701–9).

In the Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial, investigators compared 6 months of cognitive-behavioral therapy supplemented as needed with sertraline with usual care in 2,481 patients who were depressed when enrolled 1 month after an acute myocardial infarction. Changes on the Hamilton Depression Scale were statistically significant, but therapy had no impact on the primary outcomes of the study: death or recurrent myocardial infarction (JAMA 2003;289:3106–16).

The direct effect that lowering cholesterol or relieving depression has on heart disease may never be known, said Dr. Nancy Frasure-Smith, a CREATE investigator, in a plenary lecture before release of the CREATE results at the Academy of Psychosomatic Medicine meeting. Statins and antidepressants have pleiotropic effects, she said; they can affect multiple systems or metabolic processes. With respect to antidepressants, she cited human and animal studies showing impacts on platelet activation, endothelial function, C-reactive protein levels, and inflammation.

“If any of these treatments improves prognosis in coronary artery disease patients, we'll know [it] should be widely used because it helps improve survival,” she said. “But because of the pleiotropic effects of most available depressant treatments, we will not know what the impact is because of a change in depression itself.” Depression should be treated in its own right, she advised, reminding cardiologists about “the compliance issue:” Depressed patients are less likely to adhere to treatment of their coronary artery disease.

TUCSON, ARIZ. — A randomized, multicenter Canadian trial testing interpersonal psychotherapy and citalopram in 284 depressed patients with stable coronary artery disease produced mixed results, investigators reported at the annual meeting of the Academy of Psychosomatic Medicine.

Citalopram (Celexa) was significantly more effective than placebo, reducing Hamilton Depression Rating scale (HAM-D) scores by an additional 3.3 points on average, according to Dr. François Lespérance, principal investigator of the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial.

Adding interpersonal psychotherapy (IPT) to 12 weekly clinical management sessions was a disappointment, however. Short-term therapy turned out to be no more effective in relieving depression than clinical management alone.

The Canadian Institutes of Health Research gave the CREATE trial a $1,342,996 (Canadian) grant. Starting in 2002, the study enrolled patients in Montreal, Kingston, Ottawa, and Toronto. Faced with slow enrollment, it added sites in Halifax and Calgary.

To maximize resources, the investigators randomized patients twice under a 2-by-2 factorial trial design. The participants comprised four cohorts: IPT/clinical management and citalopram (67 patients), IPT/clinical management and placebo (75 patients), clinical management alone and citalopram (75 patients), and clinical management alone and placebo (67 patients).

Consequently, the analyses were based on 142 patients exposed to IPT/clinical management vs. 142 patients exposed to clinical management alone and 142 patients treated with citalopram vs. 142 treated with placebo.

The presentation did not address the combined effect of IPT and citalopram in patients given both therapies.

Dr. Nancy Frasure-Smith, a coinvestigator, said the investigators neither expected nor saw any synergy between IPT and citalopram.

Dr. Frasure-Smith, a professor of psychiatry at McGill University in Montreal and senior research associate at the Montreal Heart Institute, emphasized that the trial used broad inclusion criteria. She cited growing evidence that depression is a risk factor for heart disease, but said little is known about treating depression in coronary disease patients because most depression treatment trials exclude patients with comorbidities.

In addition to having stable coronary artery disease, patients entered the CREATE trial having a current major depressive episode lasting at least 4 weeks based on the Structured Clinical Interview for Depression (SCID) and a baseline score of 19 or more on the 24-item Hamilton Depression Rating scale (HAM-D).

In the medication arms described by Dr. Lespérance, chief of psychiatry at the Centre Hospitalier de l'Université de Montréal, citalopram or placebo was titrated up from 10 mg per day during the first week to 20 mg per day for the next 5 weeks. If a patient's HAM-D score did not fall to 8 or less by week 6, the dose was increased to 40 mg per day for the duration of the study. Dr. Lespérance said the average dose was 33 mg per day by the end of the trial.

The advantage of citalopram over placebo was evident by the sixth week, he said. By the end of the trial, HAM-D scores fell by 14.9 points with citalopram and 11.6 points with placebo. Similar effects were reported on the Beck Depression Inventory and the Inventory for Depressive Symptomatology.

Although side effects typical of selective serotonin reuptake inhibitors (SSRIs) were reported, Dr. Lespérance said cardiovascular side effects were rare and small with no difference between groups. CREATE gave “no evidence that we should be concerned about cardiac safety,” he said. As for evidence that SSRIs might be cardioprotective, he cautioned that the data are inconclusive.

The investigators conducted a biomarker analysis that found treatment with citalopram was associated with enhanced production of nitric oxide. Dr. Louis T. van Zyl, a coinvestigator from Queens University in Kingston (Ont.), said the clinical implications are unclear. He added, however, that increasing nitric oxide might reduce cardiovascular risk.

All of the patients received 15–20 minutes of clinical management each week. During these sessions, therapists reviewed patient progress and side effects, according to Dr. J. Robert Swenson, a coinvestigator from the University of Ottawa Heart Institute.

Weekly IPT sessions were limited to 45 minutes duration and 12 weeks in all, he said. Patients assigned to IPT had to choose one issue to focus upon in short-term therapy, which typically followed clinical management.

Dr. Swenson said patients who received clinical management without IPT did slightly better halfway through the trial. No significant difference was found at 12 weeks, as he reported about half the patients in both groups responded to treatment, and a third went into remission.

Therapists who were experienced in IPT or specially trained for the trial delivered both the clinical management and IPT sessions.

This use of the IPT therapists for clinical management generated extensive discussion at the meeting. Despite assurances by the investigators that the clinical management sessions were closely monitored, some audience members questioned whether the clinical management-alone arm received more therapy than a nurse practitioner would deliver as usual care to similar patients who were outside of the trial.

ELSEVIER GLOBAL MEDICAL NEWS

Does Treatment Reduce Deaths?

CREATE was the third large clinical trial to investigate treatment of major depressive disorder in heart disease patients.

In the Sertraline Antidepressant Heart Attack Randomized Trial (SADHART), investigators did not find the selective serotonin reuptake inhibitor sertraline (Zoloft) to be significantly better than placebo in reducing depressive symptoms for the population overall, but it was safe and more effective for recurrent depression in patients with a recent myocardial infarction or unstable angina (JAMA 2002;288:701–9).

In the Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial, investigators compared 6 months of cognitive-behavioral therapy supplemented as needed with sertraline with usual care in 2,481 patients who were depressed when enrolled 1 month after an acute myocardial infarction. Changes on the Hamilton Depression Scale were statistically significant, but therapy had no impact on the primary outcomes of the study: death or recurrent myocardial infarction (JAMA 2003;289:3106–16).

The direct effect that lowering cholesterol or relieving depression has on heart disease may never be known, said Dr. Nancy Frasure-Smith, a CREATE investigator, in a plenary lecture before release of the CREATE results at the Academy of Psychosomatic Medicine meeting. Statins and antidepressants have pleiotropic effects, she said; they can affect multiple systems or metabolic processes. With respect to antidepressants, she cited human and animal studies showing impacts on platelet activation, endothelial function, C-reactive protein levels, and inflammation.

“If any of these treatments improves prognosis in coronary artery disease patients, we'll know [it] should be widely used because it helps improve survival,” she said. “But because of the pleiotropic effects of most available depressant treatments, we will not know what the impact is because of a change in depression itself.” Depression should be treated in its own right, she advised, reminding cardiologists about “the compliance issue:” Depressed patients are less likely to adhere to treatment of their coronary artery disease.

TUCSON, ARIZ. — A randomized, multicenter Canadian trial testing interpersonal psychotherapy and citalopram in 284 depressed patients with stable coronary artery disease produced mixed results, investigators reported at the annual meeting of the Academy of Psychosomatic Medicine.

Citalopram (Celexa) was significantly more effective than placebo, reducing Hamilton Depression Rating scale (HAM-D) scores by an additional 3.3 points on average, according to Dr. François Lespérance, principal investigator of the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial.

Adding interpersonal psychotherapy (IPT) to 12 weekly clinical management sessions was a disappointment, however. Short-term therapy turned out to be no more effective in relieving depression than clinical management alone.

The Canadian Institutes of Health Research gave the CREATE trial a $1,342,996 (Canadian) grant. Starting in 2002, the study enrolled patients in Montreal, Kingston, Ottawa, and Toronto. Faced with slow enrollment, it added sites in Halifax and Calgary.

To maximize resources, the investigators randomized patients twice under a 2-by-2 factorial trial design. The participants comprised four cohorts: IPT/clinical management and citalopram (67 patients), IPT/clinical management and placebo (75 patients), clinical management alone and citalopram (75 patients), and clinical management alone and placebo (67 patients).

Consequently, the analyses were based on 142 patients exposed to IPT/clinical management vs. 142 patients exposed to clinical management alone and 142 patients treated with citalopram vs. 142 treated with placebo.

The presentation did not address the combined effect of IPT and citalopram in patients given both therapies.

Dr. Nancy Frasure-Smith, a coinvestigator, said the investigators neither expected nor saw any synergy between IPT and citalopram.

Dr. Frasure-Smith, a professor of psychiatry at McGill University in Montreal and senior research associate at the Montreal Heart Institute, emphasized that the trial used broad inclusion criteria. She cited growing evidence that depression is a risk factor for heart disease, but said little is known about treating depression in coronary disease patients because most depression treatment trials exclude patients with comorbidities.

In addition to having stable coronary artery disease, patients entered the CREATE trial having a current major depressive episode lasting at least 4 weeks based on the Structured Clinical Interview for Depression (SCID) and a baseline score of 19 or more on the 24-item Hamilton Depression Rating scale (HAM-D).

In the medication arms described by Dr. Lespérance, chief of psychiatry at the Centre Hospitalier de l'Université de Montréal, citalopram or placebo was titrated up from 10 mg per day during the first week to 20 mg per day for the next 5 weeks. If a patient's HAM-D score did not fall to 8 or less by week 6, the dose was increased to 40 mg per day for the duration of the study. Dr. Lespérance said the average dose was 33 mg per day by the end of the trial.

The advantage of citalopram over placebo was evident by the sixth week, he said. By the end of the trial, HAM-D scores fell by 14.9 points with citalopram and 11.6 points with placebo. Similar effects were reported on the Beck Depression Inventory and the Inventory for Depressive Symptomatology.

Although side effects typical of selective serotonin reuptake inhibitors (SSRIs) were reported, Dr. Lespérance said cardiovascular side effects were rare and small with no difference between groups. CREATE gave “no evidence that we should be concerned about cardiac safety,” he said. As for evidence that SSRIs might be cardioprotective, he cautioned that the data are inconclusive.

The investigators conducted a biomarker analysis that found treatment with citalopram was associated with enhanced production of nitric oxide. Dr. Louis T. van Zyl, a coinvestigator from Queens University in Kingston (Ont.), said the clinical implications are unclear. He added, however, that increasing nitric oxide might reduce cardiovascular risk.

All of the patients received 15–20 minutes of clinical management each week. During these sessions, therapists reviewed patient progress and side effects, according to Dr. J. Robert Swenson, a coinvestigator from the University of Ottawa Heart Institute.

Weekly IPT sessions were limited to 45 minutes duration and 12 weeks in all, he said. Patients assigned to IPT had to choose one issue to focus upon in short-term therapy, which typically followed clinical management.

Dr. Swenson said patients who received clinical management without IPT did slightly better halfway through the trial. No significant difference was found at 12 weeks, as he reported about half the patients in both groups responded to treatment, and a third went into remission.

Therapists who were experienced in IPT or specially trained for the trial delivered both the clinical management and IPT sessions.

This use of the IPT therapists for clinical management generated extensive discussion at the meeting. Despite assurances by the investigators that the clinical management sessions were closely monitored, some audience members questioned whether the clinical management-alone arm received more therapy than a nurse practitioner would deliver as usual care to similar patients who were outside of the trial.

ELSEVIER GLOBAL MEDICAL NEWS

Does Treatment Reduce Deaths?

CREATE was the third large clinical trial to investigate treatment of major depressive disorder in heart disease patients.

In the Sertraline Antidepressant Heart Attack Randomized Trial (SADHART), investigators did not find the selective serotonin reuptake inhibitor sertraline (Zoloft) to be significantly better than placebo in reducing depressive symptoms for the population overall, but it was safe and more effective for recurrent depression in patients with a recent myocardial infarction or unstable angina (JAMA 2002;288:701–9).

In the Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial, investigators compared 6 months of cognitive-behavioral therapy supplemented as needed with sertraline with usual care in 2,481 patients who were depressed when enrolled 1 month after an acute myocardial infarction. Changes on the Hamilton Depression Scale were statistically significant, but therapy had no impact on the primary outcomes of the study: death or recurrent myocardial infarction (JAMA 2003;289:3106–16).

The direct effect that lowering cholesterol or relieving depression has on heart disease may never be known, said Dr. Nancy Frasure-Smith, a CREATE investigator, in a plenary lecture before release of the CREATE results at the Academy of Psychosomatic Medicine meeting. Statins and antidepressants have pleiotropic effects, she said; they can affect multiple systems or metabolic processes. With respect to antidepressants, she cited human and animal studies showing impacts on platelet activation, endothelial function, C-reactive protein levels, and inflammation.

“If any of these treatments improves prognosis in coronary artery disease patients, we'll know [it] should be widely used because it helps improve survival,” she said. “But because of the pleiotropic effects of most available depressant treatments, we will not know what the impact is because of a change in depression itself.” Depression should be treated in its own right, she advised, reminding cardiologists about “the compliance issue:” Depressed patients are less likely to adhere to treatment of their coronary artery disease.

TUCSON, ARIZ. — Apathy is not recognized as a psychiatric disorder, but treating it may improve glycemic control in patients with type 2 diabetes, according to a poster presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Prasad R. Padala reported that apathy was highly prevalent in a cross-sectional study of 70 patients with diabetes mellitus who were recruited from various clinics at the Omaha division of the VA (Veterans Affairs) Nebraska Western Iowa Health Care System. Of these, 44 patients (63%) had clinically significant apathy, as defined by a score above 30 on the Apathy Evaluation Scale (AES).

Poor glycemic control was common, too, as 47 patients (67%) had HbA_1c values of 7% or more, reported Dr. Padala of the department of psychiatry at the University of Nebraska Medical Center, Omaha.

And patients who met clinical criteria for apathy were more likely to have poor glycemic control than were those who did not.

Investigators found 34 (77%) of the 44 patients who met criteria for clinically significant apathy also met the criterion for poor glycemic control. In comparison, just half of 26 patients who did not meet the clinical definition of apathy were failing to control their glucose levels. The difference was statistically significant.

Conversely, the 23 patients with good glycemic control also were less likely to have clinically significant apathy: Just 10 of them (43%) scored high on the apathy scale. The patients studied were 91% male with a mean age of 57.3 years and a mean HbA_1c of 7.9%.

“Apathy syndrome is a lack of motivation—a lack of drive—that typically is not explained by just depression or cognitive decline or delirium,” Dr. Padala said in an interview. “And this has significant impact on the outcomes of chronic illness.”

Apathy is not a disorder according to the DSM-IV, he added, but psychiatrists are debating whether it should be defined as one in the next edition.

“What we feel is, apathy transcends diagnosis. This could be a dimension of psychiatry that goes through different clinical diagnoses,” Dr. Padala said, noting that apathy has been found in patients with bipolar and anxiety disorders, and also is common in chronic medical conditions such as parkinsonism.

Available treatments include methylphenidate, modafinil (Provigil), and a form of group therapy called medical crisis counseling, according to Dr. Padala. He said he works with an endocrinologist who has learned how to screen patients with poor glycemic control for apathy and has started to treat them with methylphenidate.

For easy screening in endocrinology practices, Dr. Padala recommended asking the following four questions on apathy from the Neuropsychiatric Inventory (Neurology 1994;44:2308–14):

▸ Has the patient lost interest in the world around him/her?

▸ Has he/she lost interest in doing things, or lack motivation for starting new activities?

▸ Is he/she more difficult to engage in conversation or in doing chores?

▸ Is the patient apathetic or indifferent?

“You have to ask [about apathy]. If you don't ask, people are not going to tell,” Dr. Padala said.

TUCSON, ARIZ. — Apathy is not recognized as a psychiatric disorder, but treating it may improve glycemic control in patients with type 2 diabetes, according to a poster presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Prasad R. Padala reported that apathy was highly prevalent in a cross-sectional study of 70 patients with diabetes mellitus who were recruited from various clinics at the Omaha division of the VA (Veterans Affairs) Nebraska Western Iowa Health Care System. Of these, 44 patients (63%) had clinically significant apathy, as defined by a score above 30 on the Apathy Evaluation Scale (AES).

Poor glycemic control was common, too, as 47 patients (67%) had HbA_1c values of 7% or more, reported Dr. Padala of the department of psychiatry at the University of Nebraska Medical Center, Omaha.

And patients who met clinical criteria for apathy were more likely to have poor glycemic control than were those who did not.

Investigators found 34 (77%) of the 44 patients who met criteria for clinically significant apathy also met the criterion for poor glycemic control. In comparison, just half of 26 patients who did not meet the clinical definition of apathy were failing to control their glucose levels. The difference was statistically significant.

Conversely, the 23 patients with good glycemic control also were less likely to have clinically significant apathy: Just 10 of them (43%) scored high on the apathy scale. The patients studied were 91% male with a mean age of 57.3 years and a mean HbA_1c of 7.9%.

“Apathy syndrome is a lack of motivation—a lack of drive—that typically is not explained by just depression or cognitive decline or delirium,” Dr. Padala said in an interview. “And this has significant impact on the outcomes of chronic illness.”

Apathy is not a disorder according to the DSM-IV, he added, but psychiatrists are debating whether it should be defined as one in the next edition.

“What we feel is, apathy transcends diagnosis. This could be a dimension of psychiatry that goes through different clinical diagnoses,” Dr. Padala said, noting that apathy has been found in patients with bipolar and anxiety disorders, and also is common in chronic medical conditions such as parkinsonism.

Available treatments include methylphenidate, modafinil (Provigil), and a form of group therapy called medical crisis counseling, according to Dr. Padala. He said he works with an endocrinologist who has learned how to screen patients with poor glycemic control for apathy and has started to treat them with methylphenidate.

For easy screening in endocrinology practices, Dr. Padala recommended asking the following four questions on apathy from the Neuropsychiatric Inventory (Neurology 1994;44:2308–14):

▸ Has the patient lost interest in the world around him/her?

▸ Has he/she lost interest in doing things, or lack motivation for starting new activities?

▸ Is he/she more difficult to engage in conversation or in doing chores?

▸ Is the patient apathetic or indifferent?

“You have to ask [about apathy]. If you don't ask, people are not going to tell,” Dr. Padala said.

TUCSON, ARIZ. — Apathy is not recognized as a psychiatric disorder, but treating it may improve glycemic control in patients with type 2 diabetes, according to a poster presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Prasad R. Padala reported that apathy was highly prevalent in a cross-sectional study of 70 patients with diabetes mellitus who were recruited from various clinics at the Omaha division of the VA (Veterans Affairs) Nebraska Western Iowa Health Care System. Of these, 44 patients (63%) had clinically significant apathy, as defined by a score above 30 on the Apathy Evaluation Scale (AES).

Poor glycemic control was common, too, as 47 patients (67%) had HbA_1c values of 7% or more, reported Dr. Padala of the department of psychiatry at the University of Nebraska Medical Center, Omaha.

And patients who met clinical criteria for apathy were more likely to have poor glycemic control than were those who did not.

Investigators found 34 (77%) of the 44 patients who met criteria for clinically significant apathy also met the criterion for poor glycemic control. In comparison, just half of 26 patients who did not meet the clinical definition of apathy were failing to control their glucose levels. The difference was statistically significant.

Conversely, the 23 patients with good glycemic control also were less likely to have clinically significant apathy: Just 10 of them (43%) scored high on the apathy scale. The patients studied were 91% male with a mean age of 57.3 years and a mean HbA_1c of 7.9%.

“Apathy syndrome is a lack of motivation—a lack of drive—that typically is not explained by just depression or cognitive decline or delirium,” Dr. Padala said in an interview. “And this has significant impact on the outcomes of chronic illness.”

Apathy is not a disorder according to the DSM-IV, he added, but psychiatrists are debating whether it should be defined as one in the next edition.

“What we feel is, apathy transcends diagnosis. This could be a dimension of psychiatry that goes through different clinical diagnoses,” Dr. Padala said, noting that apathy has been found in patients with bipolar and anxiety disorders, and also is common in chronic medical conditions such as parkinsonism.

Available treatments include methylphenidate, modafinil (Provigil), and a form of group therapy called medical crisis counseling, according to Dr. Padala. He said he works with an endocrinologist who has learned how to screen patients with poor glycemic control for apathy and has started to treat them with methylphenidate.

For easy screening in endocrinology practices, Dr. Padala recommended asking the following four questions on apathy from the Neuropsychiatric Inventory (Neurology 1994;44:2308–14):

▸ Has the patient lost interest in the world around him/her?

▸ Has he/she lost interest in doing things, or lack motivation for starting new activities?

▸ Is he/she more difficult to engage in conversation or in doing chores?

▸ Is the patient apathetic or indifferent?

“You have to ask [about apathy]. If you don't ask, people are not going to tell,” Dr. Padala said.

TUCSON, ARIZ. – As of this month, the Joint Commission on Accreditation of Healthcare Organizations has made the identification of patients who are at risk for suicide one of its patient safety goals for behavioral health care.

Yet little is known about hospital-based suicide and how to prevent it, according to speakers at a workshop on inpatient suicide at the annual meeting of the Academy of Psychosomatic Medicine.

“So far, there is no guidance whatsoever on how to do that, who should do that, what instruments you should use, and how frequently you should assess people,” Dr. Donald L. Rosenstein said of the new patient safety goal.

Despite its being rare, inpatient suicide is the most common sentinel event reported to JCAHO, according to Dr. Rosenstein, clinical director of the National Institute of Mental Health in Bethesda, Md. He said JCAHO is informed of about 50 inpatient suicides each year, most of them occurring on psychiatric units or within 72 hours of discharge.

The new JCAHO mandate applies to psychiatric hospitals and to patients who are being treated for emotional or behavioral disorders in general hospitals. Suicides also occur on medical and surgical wards–albeit less frequently–and speakers focused on all patients for whom consultation-liaison psychiatrists may be called to assess suicide risk.

Most standard risk assessments do not predict inpatient suicides, according to Dr. J. Michael Bostwick. These are often acute events brought on by anxiety, pain, and delirium, said Dr. Bostwick, a psychiatrist at the Mayo Medical School in Rochester, Minn. Accordingly, the reduction of these risk factors can be more important than psychiatric interventions when an inpatient is at risk.

“The key is, suicidality is not really the point. The agitation and anxiety [are],” he said.

Dr. Bostwick cited seminal work by Dr. Jan A. Fawcett, a psychiatrist at the University of New Mexico, Albuquerque, who found that many–but not all–inpatient suicides do not exhibit chronic risk factors, such as hopelessness, suicide ideation, and prior attempts. Suicidal inpatients are more likely to present with acute risk factors, such as psychic anxiety or panic; severe anhedonia; and recent alcohol abuse, according to research by Dr. Fawcett and his colleagues in the 1980s. More recently, Dr. Fawcett reported that 79% of inpatient suicides followed severe anxiety and agitation (J. Clin. Psychiatry. 2003;64:14–9).

Although a medical illness, such as cancer, is a risk factor for suicide, Dr. Bostwick said it is not a useful predictor because most seriously ill patients are not suicidal.

Several reports cited by Dr. Bostwick found that older male patients are more likely to commit suicide. In a Finnish study that compared 26 general hospital suicides to 1,397 suicides outside of hospitals, the hospital patients were significantly older (mean age 58.7 vs. 44.3 years); they were also more likely to use a violent method (96% vs. 62%) or to jump (35% vs. 2%), to have a major depression (62% vs. 30%), and to be delirious (12% vs. 1%).

Conversely, the hospital patients who committed suicide were significantly less likely to depend on alcohol (12% vs. 33%), to have an Axis II disorder (8% vs. 31%), or to present with a borderline personality disorder (0% vs. 14%) (Gen. Hosp. Psychiatry 2002;24:412–6).

“Jumping is a big deal,” Dr. Bostwick said. Although many hospitals have been redesigned to eliminate opportunities for suicidal patients to jump from high places or throw themselves down stairs, he said, such events still happen.

Dr. Bostwick concluded with an unpublished review of 25 cases evaluated as suicide risks at the Mayo Clinic. The patients came from a wide range of medical and surgical units. Of these, 12 had simply said the “S word” (suicide); 5 had been drunk, 4 had engaged in self-injurious behavior, 2 were delirious, and 2 were end-of-life patients.

Consultation-liaison psychiatrists must recognize the limits of their own ability both to predict suicide and to protect patients who are suicidal, said Dr. James L. Levenson. Among the factors he cited for consideration were countertransference by psychiatrists and nonpsychiatric staff; the complexity of depression and decision making; and the legal and medical implications when a patient with an advanced or terminal illness wants to stop treatment.

Assessment can be difficult even when patients are severely depressed, openly suicidal, and/or have already attempted suicide, advised Dr. Levenson, chairman of consultation-liaison psychiatry at Virginia Commonwealth University Medical Center, Richmond.

For example, one patient may be hospitalized after a near-lethal attempt that was not meant to be lethal, such as an unintended overdose of an over-the-counter painkiller. Another person in less serious condition might have expected an overdose of a prescription drug, such as Valium, to be deadly.

“It is important to look not just at what the person took, but what the person was thinking to do,” Dr. Levenson said.

He recommended considering one-to-one care for suicidal patients and assessing environmental safety, which refers not only to exits and stairwells, but also to “all kinds of dangerous things coming in and out of the room.” Before moving patients to psychiatric units, he said, psychiatrists should do their own “medical clearance” to be sure patients are medically stable.

Finally, he said that a suicidal patient who is being discharged should always be asked, “Do you have a gun at home?”

A Lexicon for Suicidality

Consultation-liaison psychiatrists need more than one word for suicidality, according to Dr. James L. Levenson, who offered a brief lexicon at the meeting.

Dr. Levenson defined the following terms in a talk on the varieties of suicidality that are encountered in the general hospital. All are difficult situations, he warned, “and they require judgment calls at the end of the day.”

▸ Occult suicidality. (This is also referred to as the “shot-in-the-dark” patient.) Dr. Levenson described a 74-year-old, widowed, white man who was weak, losing weight, and suffering from nausea. The man was diagnosed with “failure to thrive.” Nonmedical staff should be educated in how and when to ask patients about suicide, said Dr. Levenson.

▸ Suicide in perpetuity. The patient has made one attempt after another, and psychiatric hospitalizations did not help. The medical/surgical staff wants the patient transferred to the psychiatric service, but Dr. Levenson wonders whether that would make the patient worse.

▸ “Boy who cried wolf.” Dr. Levenson told of a chronically ill woman who had threatened suicide for years, and then jumped off a roof while hospitalized for transverse myelitis. “Why was this threat different from all other threats?” he asked, warning against becoming inured.

▸ Pseudosuicidality. The patient who threatens suicide is about to be discharged and/or be cut off from opiates. Is the patient trying to manipulate hospital staff? Again, Dr. Levenson emphasized the need to document the reason for not taking a threat seriously.

▸ Suicidality in the future conditional tense. The patient “reserves the right to kill myself someday.” Don't overreact, advised Dr. Levenson. “Explore what this means to the patient.”

▸ Suicidal figures of speech. The patient says he feels like jumping out the window. He means it as a figure of speech, but family members and staff take him seriously. Dr. Levenson said to be sure to thank everyone for calling. Otherwise, nurses will think they wasted the psychiatric staff's time, and may not call the next time when a patient really means it.

▸ Unintentional suicidality. The patient is delirious and tries to jump out a window or poke himself with needles. “Delirious patients who are suicidal are impossible to predict. Nonpsychiatric personnel need to know the delirious patient is the one you need to be most concerned about,” said Dr. Levenson.

▸ Quasisuicidality. The patient wishes to end dialysis. Does the patient want to die, or is his quality of life too poor? Recognize that this is not a simple decision to make, and that the assessment of the patient's capacity is not simple either.

▸ De facto suicidality. The patient is a nonstop drinker or an asthmatic who continues to smoke. Dr. Levenson said psychiatrists need to accept their limits when attempting to treat such patients, but also to guard against nihilism.

▸ Medical Russian roulette. The patient will not permit replacement of the battery in her pacemaker. Don't underreact or overreact, advised Dr. Levenson. “Explore what this means to the patient.”

TUCSON, ARIZ. – As of this month, the Joint Commission on Accreditation of Healthcare Organizations has made the identification of patients who are at risk for suicide one of its patient safety goals for behavioral health care.

Yet little is known about hospital-based suicide and how to prevent it, according to speakers at a workshop on inpatient suicide at the annual meeting of the Academy of Psychosomatic Medicine.

“So far, there is no guidance whatsoever on how to do that, who should do that, what instruments you should use, and how frequently you should assess people,” Dr. Donald L. Rosenstein said of the new patient safety goal.

Despite its being rare, inpatient suicide is the most common sentinel event reported to JCAHO, according to Dr. Rosenstein, clinical director of the National Institute of Mental Health in Bethesda, Md. He said JCAHO is informed of about 50 inpatient suicides each year, most of them occurring on psychiatric units or within 72 hours of discharge.

The new JCAHO mandate applies to psychiatric hospitals and to patients who are being treated for emotional or behavioral disorders in general hospitals. Suicides also occur on medical and surgical wards–albeit less frequently–and speakers focused on all patients for whom consultation-liaison psychiatrists may be called to assess suicide risk.

Most standard risk assessments do not predict inpatient suicides, according to Dr. J. Michael Bostwick. These are often acute events brought on by anxiety, pain, and delirium, said Dr. Bostwick, a psychiatrist at the Mayo Medical School in Rochester, Minn. Accordingly, the reduction of these risk factors can be more important than psychiatric interventions when an inpatient is at risk.

“The key is, suicidality is not really the point. The agitation and anxiety [are],” he said.

Dr. Bostwick cited seminal work by Dr. Jan A. Fawcett, a psychiatrist at the University of New Mexico, Albuquerque, who found that many–but not all–inpatient suicides do not exhibit chronic risk factors, such as hopelessness, suicide ideation, and prior attempts. Suicidal inpatients are more likely to present with acute risk factors, such as psychic anxiety or panic; severe anhedonia; and recent alcohol abuse, according to research by Dr. Fawcett and his colleagues in the 1980s. More recently, Dr. Fawcett reported that 79% of inpatient suicides followed severe anxiety and agitation (J. Clin. Psychiatry. 2003;64:14–9).

Although a medical illness, such as cancer, is a risk factor for suicide, Dr. Bostwick said it is not a useful predictor because most seriously ill patients are not suicidal.

Several reports cited by Dr. Bostwick found that older male patients are more likely to commit suicide. In a Finnish study that compared 26 general hospital suicides to 1,397 suicides outside of hospitals, the hospital patients were significantly older (mean age 58.7 vs. 44.3 years); they were also more likely to use a violent method (96% vs. 62%) or to jump (35% vs. 2%), to have a major depression (62% vs. 30%), and to be delirious (12% vs. 1%).

Conversely, the hospital patients who committed suicide were significantly less likely to depend on alcohol (12% vs. 33%), to have an Axis II disorder (8% vs. 31%), or to present with a borderline personality disorder (0% vs. 14%) (Gen. Hosp. Psychiatry 2002;24:412–6).

“Jumping is a big deal,” Dr. Bostwick said. Although many hospitals have been redesigned to eliminate opportunities for suicidal patients to jump from high places or throw themselves down stairs, he said, such events still happen.

Dr. Bostwick concluded with an unpublished review of 25 cases evaluated as suicide risks at the Mayo Clinic. The patients came from a wide range of medical and surgical units. Of these, 12 had simply said the “S word” (suicide); 5 had been drunk, 4 had engaged in self-injurious behavior, 2 were delirious, and 2 were end-of-life patients.

Consultation-liaison psychiatrists must recognize the limits of their own ability both to predict suicide and to protect patients who are suicidal, said Dr. James L. Levenson. Among the factors he cited for consideration were countertransference by psychiatrists and nonpsychiatric staff; the complexity of depression and decision making; and the legal and medical implications when a patient with an advanced or terminal illness wants to stop treatment.

Assessment can be difficult even when patients are severely depressed, openly suicidal, and/or have already attempted suicide, advised Dr. Levenson, chairman of consultation-liaison psychiatry at Virginia Commonwealth University Medical Center, Richmond.

For example, one patient may be hospitalized after a near-lethal attempt that was not meant to be lethal, such as an unintended overdose of an over-the-counter painkiller. Another person in less serious condition might have expected an overdose of a prescription drug, such as Valium, to be deadly.

“It is important to look not just at what the person took, but what the person was thinking to do,” Dr. Levenson said.

He recommended considering one-to-one care for suicidal patients and assessing environmental safety, which refers not only to exits and stairwells, but also to “all kinds of dangerous things coming in and out of the room.” Before moving patients to psychiatric units, he said, psychiatrists should do their own “medical clearance” to be sure patients are medically stable.

Finally, he said that a suicidal patient who is being discharged should always be asked, “Do you have a gun at home?”

A Lexicon for Suicidality

Consultation-liaison psychiatrists need more than one word for suicidality, according to Dr. James L. Levenson, who offered a brief lexicon at the meeting.

Dr. Levenson defined the following terms in a talk on the varieties of suicidality that are encountered in the general hospital. All are difficult situations, he warned, “and they require judgment calls at the end of the day.”

▸ Occult suicidality. (This is also referred to as the “shot-in-the-dark” patient.) Dr. Levenson described a 74-year-old, widowed, white man who was weak, losing weight, and suffering from nausea. The man was diagnosed with “failure to thrive.” Nonmedical staff should be educated in how and when to ask patients about suicide, said Dr. Levenson.

▸ Suicide in perpetuity. The patient has made one attempt after another, and psychiatric hospitalizations did not help. The medical/surgical staff wants the patient transferred to the psychiatric service, but Dr. Levenson wonders whether that would make the patient worse.

▸ “Boy who cried wolf.” Dr. Levenson told of a chronically ill woman who had threatened suicide for years, and then jumped off a roof while hospitalized for transverse myelitis. “Why was this threat different from all other threats?” he asked, warning against becoming inured.

▸ Pseudosuicidality. The patient who threatens suicide is about to be discharged and/or be cut off from opiates. Is the patient trying to manipulate hospital staff? Again, Dr. Levenson emphasized the need to document the reason for not taking a threat seriously.

▸ Suicidality in the future conditional tense. The patient “reserves the right to kill myself someday.” Don't overreact, advised Dr. Levenson. “Explore what this means to the patient.”

▸ Suicidal figures of speech. The patient says he feels like jumping out the window. He means it as a figure of speech, but family members and staff take him seriously. Dr. Levenson said to be sure to thank everyone for calling. Otherwise, nurses will think they wasted the psychiatric staff's time, and may not call the next time when a patient really means it.

▸ Unintentional suicidality. The patient is delirious and tries to jump out a window or poke himself with needles. “Delirious patients who are suicidal are impossible to predict. Nonpsychiatric personnel need to know the delirious patient is the one you need to be most concerned about,” said Dr. Levenson.

▸ Quasisuicidality. The patient wishes to end dialysis. Does the patient want to die, or is his quality of life too poor? Recognize that this is not a simple decision to make, and that the assessment of the patient's capacity is not simple either.

▸ De facto suicidality. The patient is a nonstop drinker or an asthmatic who continues to smoke. Dr. Levenson said psychiatrists need to accept their limits when attempting to treat such patients, but also to guard against nihilism.

▸ Medical Russian roulette. The patient will not permit replacement of the battery in her pacemaker. Don't underreact or overreact, advised Dr. Levenson. “Explore what this means to the patient.”

TUCSON, ARIZ. – As of this month, the Joint Commission on Accreditation of Healthcare Organizations has made the identification of patients who are at risk for suicide one of its patient safety goals for behavioral health care.

Yet little is known about hospital-based suicide and how to prevent it, according to speakers at a workshop on inpatient suicide at the annual meeting of the Academy of Psychosomatic Medicine.

“So far, there is no guidance whatsoever on how to do that, who should do that, what instruments you should use, and how frequently you should assess people,” Dr. Donald L. Rosenstein said of the new patient safety goal.

Despite its being rare, inpatient suicide is the most common sentinel event reported to JCAHO, according to Dr. Rosenstein, clinical director of the National Institute of Mental Health in Bethesda, Md. He said JCAHO is informed of about 50 inpatient suicides each year, most of them occurring on psychiatric units or within 72 hours of discharge.

The new JCAHO mandate applies to psychiatric hospitals and to patients who are being treated for emotional or behavioral disorders in general hospitals. Suicides also occur on medical and surgical wards–albeit less frequently–and speakers focused on all patients for whom consultation-liaison psychiatrists may be called to assess suicide risk.

Most standard risk assessments do not predict inpatient suicides, according to Dr. J. Michael Bostwick. These are often acute events brought on by anxiety, pain, and delirium, said Dr. Bostwick, a psychiatrist at the Mayo Medical School in Rochester, Minn. Accordingly, the reduction of these risk factors can be more important than psychiatric interventions when an inpatient is at risk.

“The key is, suicidality is not really the point. The agitation and anxiety [are],” he said.

Dr. Bostwick cited seminal work by Dr. Jan A. Fawcett, a psychiatrist at the University of New Mexico, Albuquerque, who found that many–but not all–inpatient suicides do not exhibit chronic risk factors, such as hopelessness, suicide ideation, and prior attempts. Suicidal inpatients are more likely to present with acute risk factors, such as psychic anxiety or panic; severe anhedonia; and recent alcohol abuse, according to research by Dr. Fawcett and his colleagues in the 1980s. More recently, Dr. Fawcett reported that 79% of inpatient suicides followed severe anxiety and agitation (J. Clin. Psychiatry. 2003;64:14–9).

Although a medical illness, such as cancer, is a risk factor for suicide, Dr. Bostwick said it is not a useful predictor because most seriously ill patients are not suicidal.

Several reports cited by Dr. Bostwick found that older male patients are more likely to commit suicide. In a Finnish study that compared 26 general hospital suicides to 1,397 suicides outside of hospitals, the hospital patients were significantly older (mean age 58.7 vs. 44.3 years); they were also more likely to use a violent method (96% vs. 62%) or to jump (35% vs. 2%), to have a major depression (62% vs. 30%), and to be delirious (12% vs. 1%).

Conversely, the hospital patients who committed suicide were significantly less likely to depend on alcohol (12% vs. 33%), to have an Axis II disorder (8% vs. 31%), or to present with a borderline personality disorder (0% vs. 14%) (Gen. Hosp. Psychiatry 2002;24:412–6).

“Jumping is a big deal,” Dr. Bostwick said. Although many hospitals have been redesigned to eliminate opportunities for suicidal patients to jump from high places or throw themselves down stairs, he said, such events still happen.

Dr. Bostwick concluded with an unpublished review of 25 cases evaluated as suicide risks at the Mayo Clinic. The patients came from a wide range of medical and surgical units. Of these, 12 had simply said the “S word” (suicide); 5 had been drunk, 4 had engaged in self-injurious behavior, 2 were delirious, and 2 were end-of-life patients.

Consultation-liaison psychiatrists must recognize the limits of their own ability both to predict suicide and to protect patients who are suicidal, said Dr. James L. Levenson. Among the factors he cited for consideration were countertransference by psychiatrists and nonpsychiatric staff; the complexity of depression and decision making; and the legal and medical implications when a patient with an advanced or terminal illness wants to stop treatment.

Assessment can be difficult even when patients are severely depressed, openly suicidal, and/or have already attempted suicide, advised Dr. Levenson, chairman of consultation-liaison psychiatry at Virginia Commonwealth University Medical Center, Richmond.

For example, one patient may be hospitalized after a near-lethal attempt that was not meant to be lethal, such as an unintended overdose of an over-the-counter painkiller. Another person in less serious condition might have expected an overdose of a prescription drug, such as Valium, to be deadly.

“It is important to look not just at what the person took, but what the person was thinking to do,” Dr. Levenson said.

He recommended considering one-to-one care for suicidal patients and assessing environmental safety, which refers not only to exits and stairwells, but also to “all kinds of dangerous things coming in and out of the room.” Before moving patients to psychiatric units, he said, psychiatrists should do their own “medical clearance” to be sure patients are medically stable.

Finally, he said that a suicidal patient who is being discharged should always be asked, “Do you have a gun at home?”

A Lexicon for Suicidality

Consultation-liaison psychiatrists need more than one word for suicidality, according to Dr. James L. Levenson, who offered a brief lexicon at the meeting.

Dr. Levenson defined the following terms in a talk on the varieties of suicidality that are encountered in the general hospital. All are difficult situations, he warned, “and they require judgment calls at the end of the day.”

▸ Occult suicidality. (This is also referred to as the “shot-in-the-dark” patient.) Dr. Levenson described a 74-year-old, widowed, white man who was weak, losing weight, and suffering from nausea. The man was diagnosed with “failure to thrive.” Nonmedical staff should be educated in how and when to ask patients about suicide, said Dr. Levenson.

▸ Suicide in perpetuity. The patient has made one attempt after another, and psychiatric hospitalizations did not help. The medical/surgical staff wants the patient transferred to the psychiatric service, but Dr. Levenson wonders whether that would make the patient worse.

▸ “Boy who cried wolf.” Dr. Levenson told of a chronically ill woman who had threatened suicide for years, and then jumped off a roof while hospitalized for transverse myelitis. “Why was this threat different from all other threats?” he asked, warning against becoming inured.

▸ Pseudosuicidality. The patient who threatens suicide is about to be discharged and/or be cut off from opiates. Is the patient trying to manipulate hospital staff? Again, Dr. Levenson emphasized the need to document the reason for not taking a threat seriously.

▸ Suicidality in the future conditional tense. The patient “reserves the right to kill myself someday.” Don't overreact, advised Dr. Levenson. “Explore what this means to the patient.”

▸ Suicidal figures of speech. The patient says he feels like jumping out the window. He means it as a figure of speech, but family members and staff take him seriously. Dr. Levenson said to be sure to thank everyone for calling. Otherwise, nurses will think they wasted the psychiatric staff's time, and may not call the next time when a patient really means it.

▸ Unintentional suicidality. The patient is delirious and tries to jump out a window or poke himself with needles. “Delirious patients who are suicidal are impossible to predict. Nonpsychiatric personnel need to know the delirious patient is the one you need to be most concerned about,” said Dr. Levenson.

▸ Quasisuicidality. The patient wishes to end dialysis. Does the patient want to die, or is his quality of life too poor? Recognize that this is not a simple decision to make, and that the assessment of the patient's capacity is not simple either.

▸ De facto suicidality. The patient is a nonstop drinker or an asthmatic who continues to smoke. Dr. Levenson said psychiatrists need to accept their limits when attempting to treat such patients, but also to guard against nihilism.

▸ Medical Russian roulette. The patient will not permit replacement of the battery in her pacemaker. Don't underreact or overreact, advised Dr. Levenson. “Explore what this means to the patient.”

PARIS – Pooled data from two clinical trials of eszopiclone suggest that elderly insomniacs have more difficulty staying asleep than falling asleep, Judy Caron, Ph.D., reported at the annual congress of the European College of Neuropsychopharmacology.

Before treatment, time to sleep onset was similar across patients aged 18–85, according to Dr. Caron, vice president of product development at Sepracor Inc. in Marlborough, Mass. People 60 years of age and older were awake roughly a third more of the time, however, compared with younger patients. Dr. Caron documented this difference using data on wake time after sleep onset.

In both age groups, measures of sleep onset and sleep maintenance improved significantly with eszopiclone (Lunesta), a sedative hypnotic approved by the U.S. Food and Drug Administration in April 2005 for long-term treatment of insomnia.

“Sleep maintenance really is the major sleep disruption that occurs in the elderly,” Dr. Caron said.

Her presentation drew upon a database of 1,616 insomniacs who participated in two 6-month-long, placebo-controlled trials of eszopiclone. The trials enrolled 1,441 patients aged 18–59 and 175 older patients. Most in both age groups were on the active drug.

Pooled analyses of these studies found daytime alertness, ability to function, and sense of physical well-being to be comparable in both age groups, with similar improvements when treated with eszopiclone. She did not present the data, but Dr. Caron said elderly patients were found to nap less when their insomnia was treated.

She reported adverse events were slightly higher in the elderly on eszopiclone, however, occurring in 90% of older patients vs. 77% of those under the age of 60. Dr. Caron attributed the higher adverse event rate in the elderly primarily to central nervous system events. These occurred in 37% of older patients, compared with 27% of those under the age of 60.

“What is remarkable is there is no difference in terms of accidental injury in the older age group,” she added. About 7% of the elderly and 6% of the younger patients had accidental injuries during the trials.

Insomnia increases with age, Dr. Caron said. The prevalence of insomnia rises from 10% of young adults to 20%–30% in middle age to 33%–55% in those above the age of 65. It is comorbid in 85%–90% of cases, she said.

Worldwide, she estimated that 40% of people suffer from insomnia. Yet, she said, only one in eight patients seek treatment, and physicians rarely ask whether patients are getting enough sleep.

Older patients, who have a significant problem in terms of sleep, especially are undertreated, Dr. Caron said.

Worldwide, 40% of people suffer from insomnia, but only one in eight patients seek treatment. DR. CARON

PARIS – Pooled data from two clinical trials of eszopiclone suggest that elderly insomniacs have more difficulty staying asleep than falling asleep, Judy Caron, Ph.D., reported at the annual congress of the European College of Neuropsychopharmacology.

Before treatment, time to sleep onset was similar across patients aged 18–85, according to Dr. Caron, vice president of product development at Sepracor Inc. in Marlborough, Mass. People 60 years of age and older were awake roughly a third more of the time, however, compared with younger patients. Dr. Caron documented this difference using data on wake time after sleep onset.

In both age groups, measures of sleep onset and sleep maintenance improved significantly with eszopiclone (Lunesta), a sedative hypnotic approved by the U.S. Food and Drug Administration in April 2005 for long-term treatment of insomnia.

“Sleep maintenance really is the major sleep disruption that occurs in the elderly,” Dr. Caron said.

Her presentation drew upon a database of 1,616 insomniacs who participated in two 6-month-long, placebo-controlled trials of eszopiclone. The trials enrolled 1,441 patients aged 18–59 and 175 older patients. Most in both age groups were on the active drug.

Pooled analyses of these studies found daytime alertness, ability to function, and sense of physical well-being to be comparable in both age groups, with similar improvements when treated with eszopiclone. She did not present the data, but Dr. Caron said elderly patients were found to nap less when their insomnia was treated.

She reported adverse events were slightly higher in the elderly on eszopiclone, however, occurring in 90% of older patients vs. 77% of those under the age of 60. Dr. Caron attributed the higher adverse event rate in the elderly primarily to central nervous system events. These occurred in 37% of older patients, compared with 27% of those under the age of 60.

“What is remarkable is there is no difference in terms of accidental injury in the older age group,” she added. About 7% of the elderly and 6% of the younger patients had accidental injuries during the trials.

Insomnia increases with age, Dr. Caron said. The prevalence of insomnia rises from 10% of young adults to 20%–30% in middle age to 33%–55% in those above the age of 65. It is comorbid in 85%–90% of cases, she said.

Worldwide, she estimated that 40% of people suffer from insomnia. Yet, she said, only one in eight patients seek treatment, and physicians rarely ask whether patients are getting enough sleep.

Older patients, who have a significant problem in terms of sleep, especially are undertreated, Dr. Caron said.

Worldwide, 40% of people suffer from insomnia, but only one in eight patients seek treatment. DR. CARON

PARIS – Pooled data from two clinical trials of eszopiclone suggest that elderly insomniacs have more difficulty staying asleep than falling asleep, Judy Caron, Ph.D., reported at the annual congress of the European College of Neuropsychopharmacology.

Before treatment, time to sleep onset was similar across patients aged 18–85, according to Dr. Caron, vice president of product development at Sepracor Inc. in Marlborough, Mass. People 60 years of age and older were awake roughly a third more of the time, however, compared with younger patients. Dr. Caron documented this difference using data on wake time after sleep onset.

In both age groups, measures of sleep onset and sleep maintenance improved significantly with eszopiclone (Lunesta), a sedative hypnotic approved by the U.S. Food and Drug Administration in April 2005 for long-term treatment of insomnia.

“Sleep maintenance really is the major sleep disruption that occurs in the elderly,” Dr. Caron said.

Her presentation drew upon a database of 1,616 insomniacs who participated in two 6-month-long, placebo-controlled trials of eszopiclone. The trials enrolled 1,441 patients aged 18–59 and 175 older patients. Most in both age groups were on the active drug.

Pooled analyses of these studies found daytime alertness, ability to function, and sense of physical well-being to be comparable in both age groups, with similar improvements when treated with eszopiclone. She did not present the data, but Dr. Caron said elderly patients were found to nap less when their insomnia was treated.

She reported adverse events were slightly higher in the elderly on eszopiclone, however, occurring in 90% of older patients vs. 77% of those under the age of 60. Dr. Caron attributed the higher adverse event rate in the elderly primarily to central nervous system events. These occurred in 37% of older patients, compared with 27% of those under the age of 60.

“What is remarkable is there is no difference in terms of accidental injury in the older age group,” she added. About 7% of the elderly and 6% of the younger patients had accidental injuries during the trials.

Insomnia increases with age, Dr. Caron said. The prevalence of insomnia rises from 10% of young adults to 20%–30% in middle age to 33%–55% in those above the age of 65. It is comorbid in 85%–90% of cases, she said.

Worldwide, she estimated that 40% of people suffer from insomnia. Yet, she said, only one in eight patients seek treatment, and physicians rarely ask whether patients are getting enough sleep.

Older patients, who have a significant problem in terms of sleep, especially are undertreated, Dr. Caron said.

Worldwide, 40% of people suffer from insomnia, but only one in eight patients seek treatment. DR. CARON

Dr. Amanda A. Beck and her colleagues were puzzled by some of their patients at the University of New Mexico's Sleep Disorders Center in Albuquerque. The patients took methadone, but they did not have histories of drug abuse. They were middle-class baby boomers under treatment for chronic pain, and their nighttime breathing problems were severe.

They needed a variable positive airway pressure device, the VPAP Adapt, recently approved for the treatment of central sleep apnea, mixed sleep apnea, and periodic breathing. “We are getting this very complicated sleep-disordered breathing, which used not to be in our lexicon,” Dr. Beck, director of adult services, said at a university-sponsored psychiatric symposium, where she described her center's experience as a red flag for methadone prescribers.

Concern about accidental deaths from methadone use is long-standing. Reports linking methadone to sleep-disordered breathing are a recent and, as yet, poorly understood phenomenon. Dr. Beck said her group and other sleep centers are documenting cases of sleep-disordered breathing in methadone patients, now estimated at one per week in her clinic.

The Food and Drug Administration has responded to concern over methadone related deaths and complications with an advisory. (See related story, p. 2.)

Several studies of the complication have been published, but most accounts are anecdotal. Some reports focus on patients on methadone maintenance, while others address the growing number of people taking opioids for chronic pain. (See box.)

Emerging Evidence

In 2003, physicians at the Intermountain Sleep Disorders Center in Salt Lake City described ataxic breathing, central apnea, sustained hypoxemia, and other abnormalities in three patients on long-term opioid therapy for pain (Chest 2003;123:632–9).

That article spurred Dr. Lynn R. Webster to order sleep studies on patients prescribed opioid therapies at the Lifetree Pain Clinic in Salt Lake City. Dr. Webster, medical director of the clinic and its affiliated research center, presented polysomnography data on 152 patients at the American Academy of Pain meeting in February 2006.

Three-fourths of the patients had an abnormal apnea-hypopnea index, including 42% with obstructive sleep apnea, 12% with central sleep apnea, and 21% with mixed obstructive and central sleep apnea. One-third of the patients had been prescribed methadone and long-acting opioids; 4% took only methadone, according to the abstract.

In another study that Dr. Webster presented at the same meeting, he compared polysomnography data on 73 opioid-naive primary care patients who had been referred for sleep studies with data on 139 asymptomatic chronic pain patients taking opioids. In both groups, 36% of the patients had severe sleep apnea.

Obstructive sleep apnea was more common in the primary care patients at 89%, vs. 77% of cases in the pain group. Central sleep apnea, a more severe condition, occurred more in the pain patients: 32%, vs. 6% of the primary care cases.

As a result of his ongoing research, Dr. Webster has become a campaigner for more conservative use of methadone. “No one was aware this was a problem. Most pain practices would not ordinarily order sleep studies,” he said in an interview with this newspaper.

Dr. Webster emphasized that he is not opposed to methadone use for pain management. “But patients and physicians need to understand it is not like other opioids.”

Recent reports have also associated methadone with poor sleep quality in addiction patients at maintenance programs.

A U.S. study reported that 84% of 225 patients were “poor” sleepers with Pittsburgh Sleep Quality Index scores of 6 or higher (J. Subst. Abuse Treat. 2004;26:175–80).

Israeli researchers found that 75% of 102 patients were poor sleepers (Drug Alcohol Depend. 2006;82:103–10).

Searching for Mechanisms

Looking for sleep-disordered breathing (SDB), an Australian group reported that 30% of 50 stable methadone maintenance patients had central sleep apnea.

Blood methadone level was significantly associated with severity but was only a minor contributing factor, explaining just 12% of the variability. The authors speculated that central sleep apnea in the population “may be multifactorial in nature and related to abnormalities of the central controller and central and peripheral metabolic control mechanisms” (Chest 2005;128:1348–56).

Abnormalities in both waking hypoxic and hypercapnic ventilatory responses in the methadone patients would lead to this instability, Dr. Harry Teichtahl, who is director of respiratory and sleep disorders medicine at Western Health in Victoria, said in an interview.

Instability in carbon dioxide ventilatory responses may be involved in SDB in asymptomatic patients, continued Dr. Teichtahl, of the University of Melbourne.

His study showed a high prevalence of central sleep apnea, he said, but the patients had no more obstructive sleep apnea than a normal control group did.

Risky Business

Last July, researchers from the CDC reported that increases in prescriptions for opioid analgesics paralleled and may have contributed to an annual 18% increase in unintentional drug-poisoning deaths from 1990 to 2002.

From 1999 to 2002, the number of death certificates listing methadone poisoning rose by 213%, according to Dr. Leonard Jduring this period, while sales through narcotics treatment programs rose only 43% (Pharmacoepidemiol. Drug Saf. 2006;15:618–27).

'We are getting this very complicated sleep-disordered breathing, which used not to be in our lexicon.' DR. BECK

Methadone Prescribing on the Rise

Not without irony, Dr. Webster said physicians turned to methadone for treatment of pain in part because they believed it was safer than other opioids and less likely to bring regulatory sanctions. When OxyContin abuse became a public policy issue, they saw methadone as a drug with little street value or abuse potential.

“Physicians think it is safe because it has been used for addiction so many years,” he said.

Health insurers also appear to have played a role. Methadone is the cheapest opioid by far. One estimate puts the monthly cost to pharmacists as $8 for an oral dose of 5 mg taken three times a day, based on wholesale prices. In comparison, chronic pain therapy with generic sustained-release morphine would cost $101.50; MS Contin, $113.50; OxyContin, $176.50; and Duragesic, $154 (Am. Fam. Physician 2005; 71:1353–8).

Confronted with such steep price differences, some health plans reportedly have made methadone their drug of choice when an opioid is prescribed for pain. In many cases, Dr. Beck said, that is why methadone is being prescribed to older pain patients with comorbidities and other medications that can interact with methadone.

“It is really irresponsible of insurers and HMOs, of anyone who sets up a formulary that [designates] the most dangerous in its entire category as the first-line agent to be used. I think that is unconscionable,” she said.

Formularies also are responsible for an increase in methadone prescribing by primary care physicians who are not familiar with its unique characteristics, according to Dr. Howard A. Heit, a chronic pain specialist certified in addiction medicine who practices in Fairfax, Va. “Are we forcing doctors to use a medication that they don't have the knowledge to use, which could be fraught with major complications, which will cost more in the long run?” he asked during an interview.

Dr. Heit served on a U.S. Substance Abuse and Mental Services Administration panel that reported in 2004 on nationwide increases in methadone-related deaths. The panel cited as a likely factor a fivefold increase from 1998 to 2002 in the volume of methadone distributed through pharmacies. The risk of apnea was not considered because it was not an issue at that time, he said.

Dr. Amanda A. Beck and her colleagues were puzzled by some of their patients at the University of New Mexico's Sleep Disorders Center in Albuquerque. The patients took methadone, but they did not have histories of drug abuse. They were middle-class baby boomers under treatment for chronic pain, and their nighttime breathing problems were severe.

They needed a variable positive airway pressure device, the VPAP Adapt, recently approved for the treatment of central sleep apnea, mixed sleep apnea, and periodic breathing. “We are getting this very complicated sleep-disordered breathing, which used not to be in our lexicon,” Dr. Beck, director of adult services, said at a university-sponsored psychiatric symposium, where she described her center's experience as a red flag for methadone prescribers.

Concern about accidental deaths from methadone use is long-standing. Reports linking methadone to sleep-disordered breathing are a recent and, as yet, poorly understood phenomenon. Dr. Beck said her group and other sleep centers are documenting cases of sleep-disordered breathing in methadone patients, now estimated at one per week in her clinic.

The Food and Drug Administration has responded to concern over methadone related deaths and complications with an advisory. (See related story, p. 2.)

Several studies of the complication have been published, but most accounts are anecdotal. Some reports focus on patients on methadone maintenance, while others address the growing number of people taking opioids for chronic pain. (See box.)

Emerging Evidence

In 2003, physicians at the Intermountain Sleep Disorders Center in Salt Lake City described ataxic breathing, central apnea, sustained hypoxemia, and other abnormalities in three patients on long-term opioid therapy for pain (Chest 2003;123:632–9).

That article spurred Dr. Lynn R. Webster to order sleep studies on patients prescribed opioid therapies at the Lifetree Pain Clinic in Salt Lake City. Dr. Webster, medical director of the clinic and its affiliated research center, presented polysomnography data on 152 patients at the American Academy of Pain meeting in February 2006.

Three-fourths of the patients had an abnormal apnea-hypopnea index, including 42% with obstructive sleep apnea, 12% with central sleep apnea, and 21% with mixed obstructive and central sleep apnea. One-third of the patients had been prescribed methadone and long-acting opioids; 4% took only methadone, according to the abstract.

In another study that Dr. Webster presented at the same meeting, he compared polysomnography data on 73 opioid-naive primary care patients who had been referred for sleep studies with data on 139 asymptomatic chronic pain patients taking opioids. In both groups, 36% of the patients had severe sleep apnea.

Obstructive sleep apnea was more common in the primary care patients at 89%, vs. 77% of cases in the pain group. Central sleep apnea, a more severe condition, occurred more in the pain patients: 32%, vs. 6% of the primary care cases.

As a result of his ongoing research, Dr. Webster has become a campaigner for more conservative use of methadone. “No one was aware this was a problem. Most pain practices would not ordinarily order sleep studies,” he said in an interview with this newspaper.

Dr. Webster emphasized that he is not opposed to methadone use for pain management. “But patients and physicians need to understand it is not like other opioids.”

Recent reports have also associated methadone with poor sleep quality in addiction patients at maintenance programs.

A U.S. study reported that 84% of 225 patients were “poor” sleepers with Pittsburgh Sleep Quality Index scores of 6 or higher (J. Subst. Abuse Treat. 2004;26:175–80).

Israeli researchers found that 75% of 102 patients were poor sleepers (Drug Alcohol Depend. 2006;82:103–10).

Searching for Mechanisms

Looking for sleep-disordered breathing (SDB), an Australian group reported that 30% of 50 stable methadone maintenance patients had central sleep apnea.

Blood methadone level was significantly associated with severity but was only a minor contributing factor, explaining just 12% of the variability. The authors speculated that central sleep apnea in the population “may be multifactorial in nature and related to abnormalities of the central controller and central and peripheral metabolic control mechanisms” (Chest 2005;128:1348–56).

Abnormalities in both waking hypoxic and hypercapnic ventilatory responses in the methadone patients would lead to this instability, Dr. Harry Teichtahl, who is director of respiratory and sleep disorders medicine at Western Health in Victoria, said in an interview.

Instability in carbon dioxide ventilatory responses may be involved in SDB in asymptomatic patients, continued Dr. Teichtahl, of the University of Melbourne.

His study showed a high prevalence of central sleep apnea, he said, but the patients had no more obstructive sleep apnea than a normal control group did.

Risky Business

Last July, researchers from the CDC reported that increases in prescriptions for opioid analgesics paralleled and may have contributed to an annual 18% increase in unintentional drug-poisoning deaths from 1990 to 2002.

From 1999 to 2002, the number of death certificates listing methadone poisoning rose by 213%, according to Dr. Leonard Jduring this period, while sales through narcotics treatment programs rose only 43% (Pharmacoepidemiol. Drug Saf. 2006;15:618–27).

'We are getting this very complicated sleep-disordered breathing, which used not to be in our lexicon.' DR. BECK

Methadone Prescribing on the Rise

Not without irony, Dr. Webster said physicians turned to methadone for treatment of pain in part because they believed it was safer than other opioids and less likely to bring regulatory sanctions. When OxyContin abuse became a public policy issue, they saw methadone as a drug with little street value or abuse potential.

“Physicians think it is safe because it has been used for addiction so many years,” he said.

Health insurers also appear to have played a role. Methadone is the cheapest opioid by far. One estimate puts the monthly cost to pharmacists as $8 for an oral dose of 5 mg taken three times a day, based on wholesale prices. In comparison, chronic pain therapy with generic sustained-release morphine would cost $101.50; MS Contin, $113.50; OxyContin, $176.50; and Duragesic, $154 (Am. Fam. Physician 2005; 71:1353–8).

Confronted with such steep price differences, some health plans reportedly have made methadone their drug of choice when an opioid is prescribed for pain. In many cases, Dr. Beck said, that is why methadone is being prescribed to older pain patients with comorbidities and other medications that can interact with methadone.

“It is really irresponsible of insurers and HMOs, of anyone who sets up a formulary that [designates] the most dangerous in its entire category as the first-line agent to be used. I think that is unconscionable,” she said.

Formularies also are responsible for an increase in methadone prescribing by primary care physicians who are not familiar with its unique characteristics, according to Dr. Howard A. Heit, a chronic pain specialist certified in addiction medicine who practices in Fairfax, Va. “Are we forcing doctors to use a medication that they don't have the knowledge to use, which could be fraught with major complications, which will cost more in the long run?” he asked during an interview.

Dr. Heit served on a U.S. Substance Abuse and Mental Services Administration panel that reported in 2004 on nationwide increases in methadone-related deaths. The panel cited as a likely factor a fivefold increase from 1998 to 2002 in the volume of methadone distributed through pharmacies. The risk of apnea was not considered because it was not an issue at that time, he said.

Dr. Amanda A. Beck and her colleagues were puzzled by some of their patients at the University of New Mexico's Sleep Disorders Center in Albuquerque. The patients took methadone, but they did not have histories of drug abuse. They were middle-class baby boomers under treatment for chronic pain, and their nighttime breathing problems were severe.

They needed a variable positive airway pressure device, the VPAP Adapt, recently approved for the treatment of central sleep apnea, mixed sleep apnea, and periodic breathing. “We are getting this very complicated sleep-disordered breathing, which used not to be in our lexicon,” Dr. Beck, director of adult services, said at a university-sponsored psychiatric symposium, where she described her center's experience as a red flag for methadone prescribers.

Concern about accidental deaths from methadone use is long-standing. Reports linking methadone to sleep-disordered breathing are a recent and, as yet, poorly understood phenomenon. Dr. Beck said her group and other sleep centers are documenting cases of sleep-disordered breathing in methadone patients, now estimated at one per week in her clinic.

The Food and Drug Administration has responded to concern over methadone related deaths and complications with an advisory. (See related story, p. 2.)

Several studies of the complication have been published, but most accounts are anecdotal. Some reports focus on patients on methadone maintenance, while others address the growing number of people taking opioids for chronic pain. (See box.)

Emerging Evidence

In 2003, physicians at the Intermountain Sleep Disorders Center in Salt Lake City described ataxic breathing, central apnea, sustained hypoxemia, and other abnormalities in three patients on long-term opioid therapy for pain (Chest 2003;123:632–9).

That article spurred Dr. Lynn R. Webster to order sleep studies on patients prescribed opioid therapies at the Lifetree Pain Clinic in Salt Lake City. Dr. Webster, medical director of the clinic and its affiliated research center, presented polysomnography data on 152 patients at the American Academy of Pain meeting in February 2006.

Three-fourths of the patients had an abnormal apnea-hypopnea index, including 42% with obstructive sleep apnea, 12% with central sleep apnea, and 21% with mixed obstructive and central sleep apnea. One-third of the patients had been prescribed methadone and long-acting opioids; 4% took only methadone, according to the abstract.

In another study that Dr. Webster presented at the same meeting, he compared polysomnography data on 73 opioid-naive primary care patients who had been referred for sleep studies with data on 139 asymptomatic chronic pain patients taking opioids. In both groups, 36% of the patients had severe sleep apnea.

Obstructive sleep apnea was more common in the primary care patients at 89%, vs. 77% of cases in the pain group. Central sleep apnea, a more severe condition, occurred more in the pain patients: 32%, vs. 6% of the primary care cases.

As a result of his ongoing research, Dr. Webster has become a campaigner for more conservative use of methadone. “No one was aware this was a problem. Most pain practices would not ordinarily order sleep studies,” he said in an interview with this newspaper.

Dr. Webster emphasized that he is not opposed to methadone use for pain management. “But patients and physicians need to understand it is not like other opioids.”

Recent reports have also associated methadone with poor sleep quality in addiction patients at maintenance programs.

A U.S. study reported that 84% of 225 patients were “poor” sleepers with Pittsburgh Sleep Quality Index scores of 6 or higher (J. Subst. Abuse Treat. 2004;26:175–80).

Israeli researchers found that 75% of 102 patients were poor sleepers (Drug Alcohol Depend. 2006;82:103–10).

Searching for Mechanisms

Looking for sleep-disordered breathing (SDB), an Australian group reported that 30% of 50 stable methadone maintenance patients had central sleep apnea.

Blood methadone level was significantly associated with severity but was only a minor contributing factor, explaining just 12% of the variability. The authors speculated that central sleep apnea in the population “may be multifactorial in nature and related to abnormalities of the central controller and central and peripheral metabolic control mechanisms” (Chest 2005;128:1348–56).

Abnormalities in both waking hypoxic and hypercapnic ventilatory responses in the methadone patients would lead to this instability, Dr. Harry Teichtahl, who is director of respiratory and sleep disorders medicine at Western Health in Victoria, said in an interview.

Instability in carbon dioxide ventilatory responses may be involved in SDB in asymptomatic patients, continued Dr. Teichtahl, of the University of Melbourne.

His study showed a high prevalence of central sleep apnea, he said, but the patients had no more obstructive sleep apnea than a normal control group did.

Risky Business

Last July, researchers from the CDC reported that increases in prescriptions for opioid analgesics paralleled and may have contributed to an annual 18% increase in unintentional drug-poisoning deaths from 1990 to 2002.

From 1999 to 2002, the number of death certificates listing methadone poisoning rose by 213%, according to Dr. Leonard Jduring this period, while sales through narcotics treatment programs rose only 43% (Pharmacoepidemiol. Drug Saf. 2006;15:618–27).

'We are getting this very complicated sleep-disordered breathing, which used not to be in our lexicon.' DR. BECK

Methadone Prescribing on the Rise

Not without irony, Dr. Webster said physicians turned to methadone for treatment of pain in part because they believed it was safer than other opioids and less likely to bring regulatory sanctions. When OxyContin abuse became a public policy issue, they saw methadone as a drug with little street value or abuse potential.

“Physicians think it is safe because it has been used for addiction so many years,” he said.

Health insurers also appear to have played a role. Methadone is the cheapest opioid by far. One estimate puts the monthly cost to pharmacists as $8 for an oral dose of 5 mg taken three times a day, based on wholesale prices. In comparison, chronic pain therapy with generic sustained-release morphine would cost $101.50; MS Contin, $113.50; OxyContin, $176.50; and Duragesic, $154 (Am. Fam. Physician 2005; 71:1353–8).

Confronted with such steep price differences, some health plans reportedly have made methadone their drug of choice when an opioid is prescribed for pain. In many cases, Dr. Beck said, that is why methadone is being prescribed to older pain patients with comorbidities and other medications that can interact with methadone.

“It is really irresponsible of insurers and HMOs, of anyone who sets up a formulary that [designates] the most dangerous in its entire category as the first-line agent to be used. I think that is unconscionable,” she said.

Formularies also are responsible for an increase in methadone prescribing by primary care physicians who are not familiar with its unique characteristics, according to Dr. Howard A. Heit, a chronic pain specialist certified in addiction medicine who practices in Fairfax, Va. “Are we forcing doctors to use a medication that they don't have the knowledge to use, which could be fraught with major complications, which will cost more in the long run?” he asked during an interview.

Dr. Heit served on a U.S. Substance Abuse and Mental Services Administration panel that reported in 2004 on nationwide increases in methadone-related deaths. The panel cited as a likely factor a fivefold increase from 1998 to 2002 in the volume of methadone distributed through pharmacies. The risk of apnea was not considered because it was not an issue at that time, he said.

SCOTTSDALE, ARIZ. – Withdrawing patients from overused headache medications is long, hard work for them, but it can be accomplished with strong physician support, Dr. Todd D. Rozen told clinicians at a symposium sponsored by the American Headache Society.

Dr. Rozen, a neurologist at the Michigan Head-Pain and Neurological Institute in Ann Arbor, Mich., outlined a cornucopia of maneuvers ranging from medication switches to acupuncture and biofeedback that can be used to accomplish withdrawal.

Getting patients to adopt realistic expectations is crucial to successful withdrawal, he said. Chronic daily headache patients must understand at the outset that the brain has to be reset and takes time to heal after long-time overuse of medications. Eventually they may have fewer headaches, he said, but they will not be headache-free after withdrawal.

“The goal is to get away from daily headache,” he said. “I tell my patients, having migraine is normal … but daily pain is never normal.”

Whether you decide that inpatient treatment is necessary or that outpatient treatment is possible, quickly discontinue the overused medication, because tapering it does not work, Dr. Rozen advised.

Patients who overuse an over-the-counter remedy can usually withdraw with outpatient therapy, he said. Some patients can even stop “cold turkey.” In most cases, however, he recommended switching them to a longer-acting nonsteroidal anti-inflammatory drug such as naproxen sodium or indomethacin for 5–7 days per week and then tapering it down to 3–4 days per week.

Meanwhile, prepare the patient to deal with pain, he advised. “You have to have a treatment strategy for mild pain, moderate pain, [and] severe pain.”

Mild pain is the hardest to treat in some respects because the strategy is to pursue alternative therapies rather than medication, he said. These alternatives could include hydration, relaxation techniques, biofeedback, and aerobic exercise, but not medication.

“If they can get over this step, they are going to get better,” he said. “If they can't, they will not.”

For moderate pain, Dr. Rozen suggested indomethacin or naproxen sodium with or without a dopamine receptor antagonist. Start at 3–4 days per week, tapering down to 2 days per week. If the patient has nausea, add an antiemetic.

For severe pain, the medication choice can vary, but rescue therapy should be limited to two times per week. “You need rescue medication,” he said. “It is helpful if patients are sedated. They have had this headache all day long. It helps if they sleep well.”

Outpatient therapy usually works for patients who have overused triptans, but some need inpatient therapy. Triptan withdrawal is relatively fast and some patients can simply stop their medications, he explained. But triptan withdrawal also can mimic opioid withdrawal with associated nausea, diarrhea, and abdominal pain. Inpatients can be switched to intravenous DHE (dihydroergotamine mesylate) and outpatients can be given Migranal NS. A steroid taper is another option, but a longer-acting triptan is rarely the best option.

“Get them away from triptans. Switch them to something different,” Dr. Rozen said, adding that overusers of triptans also benefit from the mild-moderate-severe approach to headache pain during withdrawal.

When weaning patients from butalbital, the first step is to determine their butalbital level, he continued. If it is above 10 mcg/mL, the patient is at risk of withdrawal seizures and needs to be weaned off the drug as an inpatient.

For patients with very low butalbital levels, he suggested outpatient care and prevention of withdrawal symptoms with clonazepam. Don't try to taper patients from butalbital because they are using it to treat anxiety and will not stop. Phenobarbital is another option, he added, but be prepared to vary the dose.

Patients who are abusing opioids almost always have to be hospitalized. “I tell them I will be there every step of the way, as long as [they] show the effort and do the hard work,” Dr. Rozen said. “They have to know that.”

SCOTTSDALE, ARIZ. – Withdrawing patients from overused headache medications is long, hard work for them, but it can be accomplished with strong physician support, Dr. Todd D. Rozen told clinicians at a symposium sponsored by the American Headache Society.

Dr. Rozen, a neurologist at the Michigan Head-Pain and Neurological Institute in Ann Arbor, Mich., outlined a cornucopia of maneuvers ranging from medication switches to acupuncture and biofeedback that can be used to accomplish withdrawal.

Getting patients to adopt realistic expectations is crucial to successful withdrawal, he said. Chronic daily headache patients must understand at the outset that the brain has to be reset and takes time to heal after long-time overuse of medications. Eventually they may have fewer headaches, he said, but they will not be headache-free after withdrawal.

“The goal is to get away from daily headache,” he said. “I tell my patients, having migraine is normal … but daily pain is never normal.”

Whether you decide that inpatient treatment is necessary or that outpatient treatment is possible, quickly discontinue the overused medication, because tapering it does not work, Dr. Rozen advised.

Patients who overuse an over-the-counter remedy can usually withdraw with outpatient therapy, he said. Some patients can even stop “cold turkey.” In most cases, however, he recommended switching them to a longer-acting nonsteroidal anti-inflammatory drug such as naproxen sodium or indomethacin for 5–7 days per week and then tapering it down to 3–4 days per week.

Meanwhile, prepare the patient to deal with pain, he advised. “You have to have a treatment strategy for mild pain, moderate pain, [and] severe pain.”

Mild pain is the hardest to treat in some respects because the strategy is to pursue alternative therapies rather than medication, he said. These alternatives could include hydration, relaxation techniques, biofeedback, and aerobic exercise, but not medication.

“If they can get over this step, they are going to get better,” he said. “If they can't, they will not.”

For moderate pain, Dr. Rozen suggested indomethacin or naproxen sodium with or without a dopamine receptor antagonist. Start at 3–4 days per week, tapering down to 2 days per week. If the patient has nausea, add an antiemetic.

For severe pain, the medication choice can vary, but rescue therapy should be limited to two times per week. “You need rescue medication,” he said. “It is helpful if patients are sedated. They have had this headache all day long. It helps if they sleep well.”

Outpatient therapy usually works for patients who have overused triptans, but some need inpatient therapy. Triptan withdrawal is relatively fast and some patients can simply stop their medications, he explained. But triptan withdrawal also can mimic opioid withdrawal with associated nausea, diarrhea, and abdominal pain. Inpatients can be switched to intravenous DHE (dihydroergotamine mesylate) and outpatients can be given Migranal NS. A steroid taper is another option, but a longer-acting triptan is rarely the best option.

“Get them away from triptans. Switch them to something different,” Dr. Rozen said, adding that overusers of triptans also benefit from the mild-moderate-severe approach to headache pain during withdrawal.

When weaning patients from butalbital, the first step is to determine their butalbital level, he continued. If it is above 10 mcg/mL, the patient is at risk of withdrawal seizures and needs to be weaned off the drug as an inpatient.

For patients with very low butalbital levels, he suggested outpatient care and prevention of withdrawal symptoms with clonazepam. Don't try to taper patients from butalbital because they are using it to treat anxiety and will not stop. Phenobarbital is another option, he added, but be prepared to vary the dose.

Patients who are abusing opioids almost always have to be hospitalized. “I tell them I will be there every step of the way, as long as [they] show the effort and do the hard work,” Dr. Rozen said. “They have to know that.”

SCOTTSDALE, ARIZ. – Withdrawing patients from overused headache medications is long, hard work for them, but it can be accomplished with strong physician support, Dr. Todd D. Rozen told clinicians at a symposium sponsored by the American Headache Society.

Dr. Rozen, a neurologist at the Michigan Head-Pain and Neurological Institute in Ann Arbor, Mich., outlined a cornucopia of maneuvers ranging from medication switches to acupuncture and biofeedback that can be used to accomplish withdrawal.

Getting patients to adopt realistic expectations is crucial to successful withdrawal, he said. Chronic daily headache patients must understand at the outset that the brain has to be reset and takes time to heal after long-time overuse of medications. Eventually they may have fewer headaches, he said, but they will not be headache-free after withdrawal.

“The goal is to get away from daily headache,” he said. “I tell my patients, having migraine is normal … but daily pain is never normal.”

Whether you decide that inpatient treatment is necessary or that outpatient treatment is possible, quickly discontinue the overused medication, because tapering it does not work, Dr. Rozen advised.

Patients who overuse an over-the-counter remedy can usually withdraw with outpatient therapy, he said. Some patients can even stop “cold turkey.” In most cases, however, he recommended switching them to a longer-acting nonsteroidal anti-inflammatory drug such as naproxen sodium or indomethacin for 5–7 days per week and then tapering it down to 3–4 days per week.

Meanwhile, prepare the patient to deal with pain, he advised. “You have to have a treatment strategy for mild pain, moderate pain, [and] severe pain.”

Mild pain is the hardest to treat in some respects because the strategy is to pursue alternative therapies rather than medication, he said. These alternatives could include hydration, relaxation techniques, biofeedback, and aerobic exercise, but not medication.

“If they can get over this step, they are going to get better,” he said. “If they can't, they will not.”

For moderate pain, Dr. Rozen suggested indomethacin or naproxen sodium with or without a dopamine receptor antagonist. Start at 3–4 days per week, tapering down to 2 days per week. If the patient has nausea, add an antiemetic.

For severe pain, the medication choice can vary, but rescue therapy should be limited to two times per week. “You need rescue medication,” he said. “It is helpful if patients are sedated. They have had this headache all day long. It helps if they sleep well.”

Outpatient therapy usually works for patients who have overused triptans, but some need inpatient therapy. Triptan withdrawal is relatively fast and some patients can simply stop their medications, he explained. But triptan withdrawal also can mimic opioid withdrawal with associated nausea, diarrhea, and abdominal pain. Inpatients can be switched to intravenous DHE (dihydroergotamine mesylate) and outpatients can be given Migranal NS. A steroid taper is another option, but a longer-acting triptan is rarely the best option.

“Get them away from triptans. Switch them to something different,” Dr. Rozen said, adding that overusers of triptans also benefit from the mild-moderate-severe approach to headache pain during withdrawal.

When weaning patients from butalbital, the first step is to determine their butalbital level, he continued. If it is above 10 mcg/mL, the patient is at risk of withdrawal seizures and needs to be weaned off the drug as an inpatient.

For patients with very low butalbital levels, he suggested outpatient care and prevention of withdrawal symptoms with clonazepam. Don't try to taper patients from butalbital because they are using it to treat anxiety and will not stop. Phenobarbital is another option, he added, but be prepared to vary the dose.

Patients who are abusing opioids almost always have to be hospitalized. “I tell them I will be there every step of the way, as long as [they] show the effort and do the hard work,” Dr. Rozen said. “They have to know that.”

STOCKHOLM — Researchers were surprised to find striking gender differences in 30-day mortality when they analyzed 30,036 cardiac procedures in the European Association for Cardio-Thoracic Surgery's Congenital Database.

Neonatal girls were significantly more likely to die than were boys in the same age group, Dr. Matthias Siepe reported at a meeting of the association. Female mortality was 14% (319 deaths reported from 2,280 procedures) and male mortality was 12% (407 deaths out of 3,377 procedures).

When children were older than 1 year, however, the advantage was reversed. Boys had higher mortality, 2.3% (182 deaths out of 7,840 procedures), compared with girls, 1.8% (123 deaths out of 6,977 procedures).

Dr. Siepe, a resident in cardiovascular surgery at the University Hospital in Freiburg, Germany, said the investigators could offer no explanation for the change, but had started a multivariate analysis to search for underlying reasons.

“We asked, are females more prone to diagnoses that might be lethal? But … that is not the case,” he said at the meeting, which was held with the European Society of Thoracic Surgeons.

In an attempt to localize the effect, the investigators performed an analysis of the top 10 procedures. This turned up only one surgery, correction of coarctation, that was associated with a gender difference. Mortality was 3.5% in girls, compared with 1.6% in boys.

Among neonates, despite the higher death rate in girls, boys had more hypoplastic left heart syndrome, which contributed significantly to mortality in this age group.

Dr. Siepe said the investigators did not find a significant global difference between girls and boys overall. The girls had a 30-day mortality of 4.8% (659 deaths out of 13,780 procedures). For the boys, it was 5.1% (837 deaths out of 16,256 procedures).

Poland was the only country in which the investigators reported an overall gender difference. Boys had higher mortality, 4.4%, than girls, 2.7%, according to the report.

Asked whether smaller weight at birth could account for higher mortality in neonatal girls, compared with neonatal boys, Dr. Siepe said correcting for weight reduced the gap but did not eliminate it.

In an interview after the talk, he described the difference in neonatal mortality as “even more astonishing” when compared with mortality in infants who are premature but healthy. “In prenatal births in intensive care units, ordinarily premature girls are stronger when they are born,” he said.

While the results are intriguing, he said the differences are small and have no practical meaning unless the researchers can determine the underlying causes. “But if we go into more detail and find mechanisms why female neonates are more prone to die, we may be able to treat these mechanisms and make our therapy better,” he said.

STOCKHOLM — Researchers were surprised to find striking gender differences in 30-day mortality when they analyzed 30,036 cardiac procedures in the European Association for Cardio-Thoracic Surgery's Congenital Database.

Neonatal girls were significantly more likely to die than were boys in the same age group, Dr. Matthias Siepe reported at a meeting of the association. Female mortality was 14% (319 deaths reported from 2,280 procedures) and male mortality was 12% (407 deaths out of 3,377 procedures).

When children were older than 1 year, however, the advantage was reversed. Boys had higher mortality, 2.3% (182 deaths out of 7,840 procedures), compared with girls, 1.8% (123 deaths out of 6,977 procedures).

Dr. Siepe, a resident in cardiovascular surgery at the University Hospital in Freiburg, Germany, said the investigators could offer no explanation for the change, but had started a multivariate analysis to search for underlying reasons.

“We asked, are females more prone to diagnoses that might be lethal? But … that is not the case,” he said at the meeting, which was held with the European Society of Thoracic Surgeons.

In an attempt to localize the effect, the investigators performed an analysis of the top 10 procedures. This turned up only one surgery, correction of coarctation, that was associated with a gender difference. Mortality was 3.5% in girls, compared with 1.6% in boys.

Among neonates, despite the higher death rate in girls, boys had more hypoplastic left heart syndrome, which contributed significantly to mortality in this age group.

Dr. Siepe said the investigators did not find a significant global difference between girls and boys overall. The girls had a 30-day mortality of 4.8% (659 deaths out of 13,780 procedures). For the boys, it was 5.1% (837 deaths out of 16,256 procedures).

Poland was the only country in which the investigators reported an overall gender difference. Boys had higher mortality, 4.4%, than girls, 2.7%, according to the report.

Asked whether smaller weight at birth could account for higher mortality in neonatal girls, compared with neonatal boys, Dr. Siepe said correcting for weight reduced the gap but did not eliminate it.

In an interview after the talk, he described the difference in neonatal mortality as “even more astonishing” when compared with mortality in infants who are premature but healthy. “In prenatal births in intensive care units, ordinarily premature girls are stronger when they are born,” he said.

While the results are intriguing, he said the differences are small and have no practical meaning unless the researchers can determine the underlying causes. “But if we go into more detail and find mechanisms why female neonates are more prone to die, we may be able to treat these mechanisms and make our therapy better,” he said.

STOCKHOLM — Researchers were surprised to find striking gender differences in 30-day mortality when they analyzed 30,036 cardiac procedures in the European Association for Cardio-Thoracic Surgery's Congenital Database.

Neonatal girls were significantly more likely to die than were boys in the same age group, Dr. Matthias Siepe reported at a meeting of the association. Female mortality was 14% (319 deaths reported from 2,280 procedures) and male mortality was 12% (407 deaths out of 3,377 procedures).

When children were older than 1 year, however, the advantage was reversed. Boys had higher mortality, 2.3% (182 deaths out of 7,840 procedures), compared with girls, 1.8% (123 deaths out of 6,977 procedures).

Dr. Siepe, a resident in cardiovascular surgery at the University Hospital in Freiburg, Germany, said the investigators could offer no explanation for the change, but had started a multivariate analysis to search for underlying reasons.

“We asked, are females more prone to diagnoses that might be lethal? But … that is not the case,” he said at the meeting, which was held with the European Society of Thoracic Surgeons.

In an attempt to localize the effect, the investigators performed an analysis of the top 10 procedures. This turned up only one surgery, correction of coarctation, that was associated with a gender difference. Mortality was 3.5% in girls, compared with 1.6% in boys.

Among neonates, despite the higher death rate in girls, boys had more hypoplastic left heart syndrome, which contributed significantly to mortality in this age group.

Dr. Siepe said the investigators did not find a significant global difference between girls and boys overall. The girls had a 30-day mortality of 4.8% (659 deaths out of 13,780 procedures). For the boys, it was 5.1% (837 deaths out of 16,256 procedures).

Poland was the only country in which the investigators reported an overall gender difference. Boys had higher mortality, 4.4%, than girls, 2.7%, according to the report.

Asked whether smaller weight at birth could account for higher mortality in neonatal girls, compared with neonatal boys, Dr. Siepe said correcting for weight reduced the gap but did not eliminate it.

In an interview after the talk, he described the difference in neonatal mortality as “even more astonishing” when compared with mortality in infants who are premature but healthy. “In prenatal births in intensive care units, ordinarily premature girls are stronger when they are born,” he said.

While the results are intriguing, he said the differences are small and have no practical meaning unless the researchers can determine the underlying causes. “But if we go into more detail and find mechanisms why female neonates are more prone to die, we may be able to treat these mechanisms and make our therapy better,” he said.