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High medication burden persists in bipolar disorder
Almost one-third of patients with bipolar I disorder were taking at least four psychotropic medications when admitted to a psychiatric hospital, researchers reported in the April issue of Psychiatry Research.
The findings "reflect the enormous challenge of symptom management" in bipolar I disorder and the "fine line between help and harm that clinicians face" because monotherapies for [bipolar disorder] often are ineffective, said Dr. Lauren M. Weinstock and her associates at Brown University and Butler Hospital in Providence, R.I.
Using a computer algorithm, the investigators reviewed the charts of 218 adults with bipolar I disorder presenting for admission to a single psychiatric hospital. Patients averaged 42 years in age (range, 18-77), and 58% were female (Psychiatry Res. 2014;216:24-30).
In all, 82 patients (32%) were taking at least four psychotropic medications on admission. Taking this many medications was significantly associated with comorbid anxiety disorder (P less than .001), depression on admission (P = .002), a past suicide attempt (P = .010), and female gender (P = .025). Women were more likely than men to be prescribed benzodiazepines (P = .008), antidepressants (P = .012), and stimulants (P = .052), even after depressed mood was controlled for.
The results highlight concerns about an "increased risk of adverse side effects, drug interactions, medication error, and poor treatment adherence," and the complex polypharmacy’s "high cost burden to both patients and the health care system," said Dr. Weinstock and her associates. They emphasized the need for more research on outpatient prescribing for bipolar disorder patients and "the potential risks, especially for women, of iatrogenic complications without evidence of potential benefits."
The researchers did not use supplementary methods to confirm chart data and could not distinguish between long-standing treatment patterns or recent changes to medications. Because 94% of patients were white and most had health insurance, the findings could not be generalized to other patient populations.
A grant from the National Institute of Mental Health funded manuscript preparation. The authors did not disclose conflicts of interest.
Almost one-third of patients with bipolar I disorder were taking at least four psychotropic medications when admitted to a psychiatric hospital, researchers reported in the April issue of Psychiatry Research.
The findings "reflect the enormous challenge of symptom management" in bipolar I disorder and the "fine line between help and harm that clinicians face" because monotherapies for [bipolar disorder] often are ineffective, said Dr. Lauren M. Weinstock and her associates at Brown University and Butler Hospital in Providence, R.I.
Using a computer algorithm, the investigators reviewed the charts of 218 adults with bipolar I disorder presenting for admission to a single psychiatric hospital. Patients averaged 42 years in age (range, 18-77), and 58% were female (Psychiatry Res. 2014;216:24-30).
In all, 82 patients (32%) were taking at least four psychotropic medications on admission. Taking this many medications was significantly associated with comorbid anxiety disorder (P less than .001), depression on admission (P = .002), a past suicide attempt (P = .010), and female gender (P = .025). Women were more likely than men to be prescribed benzodiazepines (P = .008), antidepressants (P = .012), and stimulants (P = .052), even after depressed mood was controlled for.
The results highlight concerns about an "increased risk of adverse side effects, drug interactions, medication error, and poor treatment adherence," and the complex polypharmacy’s "high cost burden to both patients and the health care system," said Dr. Weinstock and her associates. They emphasized the need for more research on outpatient prescribing for bipolar disorder patients and "the potential risks, especially for women, of iatrogenic complications without evidence of potential benefits."
The researchers did not use supplementary methods to confirm chart data and could not distinguish between long-standing treatment patterns or recent changes to medications. Because 94% of patients were white and most had health insurance, the findings could not be generalized to other patient populations.
A grant from the National Institute of Mental Health funded manuscript preparation. The authors did not disclose conflicts of interest.
Almost one-third of patients with bipolar I disorder were taking at least four psychotropic medications when admitted to a psychiatric hospital, researchers reported in the April issue of Psychiatry Research.
The findings "reflect the enormous challenge of symptom management" in bipolar I disorder and the "fine line between help and harm that clinicians face" because monotherapies for [bipolar disorder] often are ineffective, said Dr. Lauren M. Weinstock and her associates at Brown University and Butler Hospital in Providence, R.I.
Using a computer algorithm, the investigators reviewed the charts of 218 adults with bipolar I disorder presenting for admission to a single psychiatric hospital. Patients averaged 42 years in age (range, 18-77), and 58% were female (Psychiatry Res. 2014;216:24-30).
In all, 82 patients (32%) were taking at least four psychotropic medications on admission. Taking this many medications was significantly associated with comorbid anxiety disorder (P less than .001), depression on admission (P = .002), a past suicide attempt (P = .010), and female gender (P = .025). Women were more likely than men to be prescribed benzodiazepines (P = .008), antidepressants (P = .012), and stimulants (P = .052), even after depressed mood was controlled for.
The results highlight concerns about an "increased risk of adverse side effects, drug interactions, medication error, and poor treatment adherence," and the complex polypharmacy’s "high cost burden to both patients and the health care system," said Dr. Weinstock and her associates. They emphasized the need for more research on outpatient prescribing for bipolar disorder patients and "the potential risks, especially for women, of iatrogenic complications without evidence of potential benefits."
The researchers did not use supplementary methods to confirm chart data and could not distinguish between long-standing treatment patterns or recent changes to medications. Because 94% of patients were white and most had health insurance, the findings could not be generalized to other patient populations.
A grant from the National Institute of Mental Health funded manuscript preparation. The authors did not disclose conflicts of interest.
FROM PSYCHIATRY RESEARCH
Major finding: Eight-two patients (32%) were taking at least four psychotropic medications. Taking this many medications was significantly associated with comorbid anxiety disorder (P less than .001), depression on admission (P = .002), a past suicide attempt (P = .010), and female gender (P = .025).
Data source: A retrospective chart study of 218 patients with bipolar I disorder who were presenting for psychiatric hospital admission.
Disclosures: A grant from the National Institute of Mental Health funded manuscript preparation. The authors did not disclose conflicts of interest.
Deaf and self-signing
CASE Self Signing
Mrs. H, a 47-year-old, deaf, African American woman, is brought into the emergency room because she is becoming increasingly withdrawn and is signing to herself. She was hospitalized more than 10 years ago after developing psychotic symptoms and received a diagnosis of psychotic disorder, not otherwise specified. She was treated with olanzapine, 10 mg/d, and valproic acid, 1,000 mg/d, but she has not seen a psychiatrist or taken any psychotropics in 8 years. Upon admission to the inpatient psychiatric unit, Mrs. H reports, through an American Sign Language (ASL) interpreter, that she has had “problems with her parents” and with “being fair” and that she is 18 months pregnant. Urine pregnancy test is negative. Mrs. H also reports that her mother is pregnant. She indicates that it is difficult for her to describe what she is trying to say and that it is difficult to be deaf.
She endorses “very strong” racing thoughts, which she first states have been present for 15 years, then reports it has been 20 months. She endorses high-energy levels, feeling like there is “work to do,” and poor sleep. However, when asked, she indicates that she sleeps for 15 hours a day.
Which is critical when conducting a psychiatric assessment for a deaf patient?
a) rely only on the ASL interpreter
b) inquire about the patient’s communication preferences
c) use written language to communicate instead of speech
d) use a family member as interpreter
The authors’ observations
Mental health assessment of a deaf a patient involves a unique set of challenges and requires a specialized skill set for mental health practitioners—a skill set that is not routinely covered in psychiatric training programs.
a We use the term “deaf” to describe patients who have severe hearing loss. Other terms, such as “hearing impaired,” might be considered pejorative in the Deaf community. The term “Deaf” (capitalized) refers to Deaf culture and community, which deaf patients may or may not identify with.
Deafness history
It is important to assess the cause of deafness,1,2 if known, and its age of onset (Table 1). A person is considered to be prelingually deaf if hearing loss was diagnosed before age 3.2 Clinicians should establish the patient’s communication preferences (use of assistive devices or interpreters or preference for lip reading), home communication dynamic,2 and language fluency level.1-3 Ask the patient if she attended a specialized school for the deaf and, if so, if there was an emphasis on oral communication or signing.2
HISTORY Conflicting reports
Mrs. H reports that she has been deaf since age 9, and that she learned sign language in India, where she became the “star king.” Mrs. H states that she then moved to the United States where she went to a school for the deaf. When asked if her family is able to communicate with her in sign language, she nods and indicates that they speak to her in “African and Indian.”
Mrs. H’s husband, who is hearing, says that Mrs. H is congenitally deaf, and was raised in the Midwestern United States where she attended a specialized school for the deaf. Mr. H and his 2 adult sons are hearing but communicate with Mrs. H in basic ASL. He states that Mrs. H sometimes uses signs that he and his sons cannot interpret. In addition to increased self-preoccupation and self-signing, Mrs. H has become more impulsive.
What are limitations of the mental status examination when evaluating a deaf patient?
a) facial expressions have a specific linguistic function in ASL
b) there is no differentiation in the mental status exam of deaf patients from that of hearing patients
c) the Mini-Mental State Examination (MMSE) is a validated tool to assess cognition in deaf patients
d) the clinician should not rely on the interpreter to assist with the mental status examination
The authors’ observation
Performing a mental status examination of a deaf patient without recognizing some of the challenges inherent to this task can lead to misleading findings. For example, signing and gesturing can give the clinician an impression of psychomotor agitation.2 What appears to be socially withdrawn behavior might be a reaction to the patient’s inability to communicate with others.2,3 Social skills may be affected by language deprivation, if present.3 In ASL, facial expressions have specific linguistic functions in addition to representing emotions,2 and can affect the meaning of the sign used. An exaggerated or intense facial expression with the sign “quiet,” for example, usually means “very quiet.”4 In assessing cognition, the MMSE is not available in ASL and has not been validated in deaf patients.5 Also, deaf people have reduced access to information, and a lack of knowledge does not necessarily correlate with low IQ.2
The interpreter’s role
An ASL interpreter can aid in assessing a deaf patient’s communication skills. The interpreter can help with a thorough language evaluation1,6 and provide information about socio-cultural norms in the Deaf community.7 Using an ASL interpreter with special training in mental health1,3,6,7 is important to accurately diagnose thought disorders in deaf patients.1
EVALUATION Mental status exam
Mrs. H is poorly groomed and is wearing a pink housecoat, with her hair in disarray. She seems to be distracted by something next to the interpreter, because her eyes keep roving in this direction. She has moderate psychomotor agitation, based on the rapidity of her signing and gesturing. Mrs. H makes indecipherable vocalizations while signing, often loud and with an urgent quality. Her affect is elevated and expansive. She is not oriented to place or time and when asked where she is, signs, “many times, every day, 6-9-9, 2-5, more trouble…”
The ASL interpreter notes that Mrs. H signs so quickly that only about one-half of her signs are interpretable. Mrs. H’s grammar is not always correct and that her syntax is, at times, inappropriate. Mrs. H’s letters are difficult to interpret because she often starts and concludes a word with a clear sign, but the intervening letters are rapid and uninterpretable. She also uses several non-alphabet signs that cannot be interpreted (approximately 10% to 15% of signs) and repeats signs without clear context, such as “nothing off.” Mrs. H can pause to clarify for the interpreter at the beginning of the interview but is not able to do so by the end of the interview.
How does assessment of psychosis differ when evaluating deaf patients?
a) language dysfluency must be carefully differentiated from a thought disorder
b) signing to oneself does not necessarily indicate a response to internal stimuli
c) norms in Deaf culture might be misconstrued as delusions
d) all of the above
The authors’ observations
The prevalence of psychotic disorders among deaf patients is unknown.8 Although older studies have reported an increased prevalence of psychotic disorders among deaf patients, these studies suffer from methodological problems.1 Other studies are at odds with each other, variably reporting a greater,9 equivalent,10 and lesser incidence of psychotic disorders in deaf psychiatric inpatients.11 Deaf patients with psychotic disorders experience delusions, hallucinations, and thought disorders,1,3 and assessing for these symptoms in deaf patients can present a diagnostic challenge (Table 2).
Delusions are thought to present similarly in deaf patients with psychotic disorders compared with hearing patients.1,3 Paranoia may be increased in patients who are postlingually deaf, but has not been associated with prelingual deafness. Deficits in theory of mind related to hearing impairment have been thought to contribute to delusions in deaf patients.1,12
Many deaf patients distrust health care systems and providers,2,3,13 which may be misinterpreted as paranoia. Poor communication between deaf patients and clinicians and poor health literacy among deaf patients contribute to feelings of mistrust. Deaf patients often report experiencing prejudice within the health care system, and think that providers lack sufficient knowledge of deafness.13 Care must be taken to ensure that Deaf cultural norms are not misinterpreted as delusions.
Hallucinations. How deaf patients experience hallucinations, especially in prelingual deafness, likely is different from hallucinatory experiences of hearing patients.1,14 Deaf people with psychosis have described ”ideas coming into one’s head” and an almost “telepathic” process of “knowing.”14 Deaf patients with schizophrenia are more likely to report visual elements to their hallucinations; however, these may be subvisual precepts rather than true visual hallucinations.1,15 For example, hallucination might include the perception of being signed to.1
Deaf patients’ experience of auditory hallucinations is thought to be closely related to past auditory experiences. It is unlikely that prelingually deaf patients experience true auditory hallucinations.1,14 An endorsement of hearing a “voice” in ASL does not necessarily translate to an audiological experience.15 If profoundly prelingually deaf patients endorse hearing voices, generally they cannot assign acoustic properties (pitch, tone, volume, accent, etc.).1,14,15 It may not be necessary to fully comprehend the precise modality of how hallucinations are experienced by deaf patients to provide therapy.14
Self-signing, or signing to oneself, does not necessarily indicate that a deaf person is responding to a hallucinatory experience. Non-verbal patients may gesture to themselves without clear evidence of psychosis. When considering whether a patient is experiencing hallucinations, it is important to look for other evidence of psychosis.3
Possible approaches to evaluating hallucinations in deaf patients include asking,, “is someone signing in your head?” or “Is someone who is not in the room trying to communicate with you?”
Thought disorders in deaf psychiatric inpatients are difficult to diagnose, in part because of a high rate of language dysfluency in deaf patients; in samples of psychiatric inpatients, 75% are not fluent in ASL, 66% are not fluent in any language).1,3,11 Commonly, language dysfluency is related to language deprivation because of late or inadequate exposure to ASL, although it may be related to neurologic damage or aphasia.1,3,6,16 Deaf patients can have additional disabilities, including learning disabilities, that might contribute to language dysfluency.2 Language dysfluency can be misattributed to a psychotic process1-3,7 (Table 3).1
Language dysfluency and thought disorders can be difficult to differentiate and may be comorbid. Loose associations and flight of ideas can be hard to assess in patients with language dysfluency. In general, increasing looseness of association between concepts corresponds to an increasing likelihood that a patient has true loose associations rather than language dysfluency alone.3 Deaf patients with schizophrenia can be identified by the presence of associated symptoms of psychosis, especially if delusions are present.1,3
EVALUATION Psychotic symptoms
Mrs. H’s thought process appears disorganized and illogical, with flight of ideas. She might have an underlying language dysfluency. It is likely that Mrs. H is using neologisms to communicate because of her family’s lack of familiarity with some of her signs. She also demonstrates perseveration, with use of certain signs repeatedly without clear context (ie, “nothing off”).
Her thought content includes racial themes—she mentions Russia, Germany, and Vietnam without clear context—and delusions of being the “star king” and of being pregnant. She endorses paranoid feelings that people on the inpatient unit are trying to hurt her, although it isn’t clear whether this represents a true paranoid delusion because of the hectic climate of the unit, and she did not show unnecessarily defensive or guarded behaviors.
She is seen signing to herself in the dayroom and endorses feeling as though someone who is not in the room—described as an Indian teacher (and sometimes as a boss or principal) known as “Mr. Smith” or “Mr. Donald”—is trying to communicate with her. She describes this person as being male and female. She mentions that sometimes she sees an Indian man and another man fighting. It is likely that Mrs. H is experiencing hallucinations from decompensated psychosis, because of the constellation and trajectory of her symptoms. Her nonverbal behavior—her eyes rove around the room during interviews—also supports this conclusion.
Because of evidence of mood and psychotic symptoms, and with a collateral history that suggests significant baseline disorganization, Mrs. H receives a diagnosis of schizoaffective disorder, bipolar type. She is restarted on olanzapine, 10 mg/d, and valproic acid, 1,000 mg/d.
Mrs. H’s psychomotor acceleration and affective elevation gradually improve with pharmacotherapy. After a 2-week hospitalization, despite ongoing disorganization and self-signing, Mrs. H’s husband says that he feels she is improved enough to return home, with plans to continue to take her medications and to reestablish outpatient follow-up.
Bottom Line
Psychiatric assessment of deaf patients presents distinctive challenges related to cultural and language barriers—making it important to engage an ASL interpreter with training in mental health during assessment of a deaf patient. Clinicians must become familiar with these challenges to provide effective care for mentally ill deaf patients.
Related Resources
• Landsberger SA, Diaz DR. Communicating with deaf patients: 10 tips to deliver appropriate care. Current Psychiatry. 2010;9(6):36-37.
• Deaf Wellness Center. University of Rochester School of Medicine. www.urmc.rochester.edu/deaf-wellness-center.
• Gallaudet University Mental Health Center. www.gallaudet.edu/
mental_health_center.html.
Drug Brand Names
Olanzapine • Zyprexa
Valproic acid • Depakote
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Landsberger SA, Diaz DR. Identifying and assessing psychosis in deaf psychiatric patients. Curr Psychiatry Rep. 2011;13(3):198-202.
2. Fellinger J, Holzinger D, Pollard R. Mental health of deaf people. Lancet. 2012;379(9820):1037-1044.
3. Glickman N. Do you hear voices? Problems in assessment of mental status in deaf persons with severe language deprivation. J Deaf Stud Deaf Educ. 2007;12(2):127-147.
4. Vicars W. ASL University. Facial expressions. http://www.lifeprint.com/asl101/pages-layout/facialexpressions.htm. Accessed April 2, 2013.
5. Dean PM, Feldman DM, Morere D, et al. Clinical evaluation of the mini-mental state exam with culturally deaf senior citizens. Arch Clin Neuropsychol. 2009;24(8):753-760.
6. Crump C, Glickman N. Mental health interpreting with language dysfluent deaf clients. Journal of Interpretation. 2011;21(1):21-36.
7. Leigh IW, Pollard RQ Jr. Mental health and deaf adults. In: Marschark M, Spencer PE, eds. Oxford handbook of deaf studies, language, and education. Vol 1. New York, NY: Oxford University Press. 2011:214-226.
8. Øhre B, von Tezchner S, Falkum E. Deaf adults and mental health: A review of recent research on the prevalence and distribution of psychiatric symptoms and disorders in the prelingually deaf adult population. International Journal on Mental Health and Deafness. 2011;1(1):3-22.
9. Appleford J. Clinical activity within a specialist mental health service for deaf people: comparison with a general psychiatric service. Psychiatric Bulletin. 2003;27(10): 375-377.
10. Landsberger SA, Diaz DR. Inpatient psychiatric treatment of deaf adults: demographic and diagnostic comparisons with hearing inpatients. Psychiatr Serv. 2010;61(2):196-199.
11. Black PA, Glickman NS. Demographics, psychiatric diagnoses, and other characteristics of North American deaf and hard-of-hearing inpatients. J Deaf Stud Deaf Educ. 2006; 11(3):303-321.
12. Thewissen V, Myin-Germeys I, Bentall R, et al. Hearing impairment and psychosis revisited. Schizophr Res. 2005; 76(1):99-103.
13. Steinberg AG, Barnett S, Meador HE, et al. Health care system accessibility. Experiences and perceptions of deaf people. J Gen Inter Med. 2006;21(3):260-266.
14. Paijmans R, Cromwell J, Austen S. Do profoundly prelingually deaf patients with psychosis really hear voices? Am Ann Deaf. 2006;151(1):42-48.
15. Atkinson JR. The perceptual characteristics of voice-hallucinations in deaf people: insights into the nature of subvocal thought and sensory feedback loops. Schizophr Bull. 2006;32(4):701-708.
16. Trumbetta SL, Bonvillian JD, Siedlecki T, et al. Language-related symptoms in persons with schizophrenia and how deaf persons may manifest these symptoms. Sign Language Studies. 2001;1(3):228-253.
CASE Self Signing
Mrs. H, a 47-year-old, deaf, African American woman, is brought into the emergency room because she is becoming increasingly withdrawn and is signing to herself. She was hospitalized more than 10 years ago after developing psychotic symptoms and received a diagnosis of psychotic disorder, not otherwise specified. She was treated with olanzapine, 10 mg/d, and valproic acid, 1,000 mg/d, but she has not seen a psychiatrist or taken any psychotropics in 8 years. Upon admission to the inpatient psychiatric unit, Mrs. H reports, through an American Sign Language (ASL) interpreter, that she has had “problems with her parents” and with “being fair” and that she is 18 months pregnant. Urine pregnancy test is negative. Mrs. H also reports that her mother is pregnant. She indicates that it is difficult for her to describe what she is trying to say and that it is difficult to be deaf.
She endorses “very strong” racing thoughts, which she first states have been present for 15 years, then reports it has been 20 months. She endorses high-energy levels, feeling like there is “work to do,” and poor sleep. However, when asked, she indicates that she sleeps for 15 hours a day.
Which is critical when conducting a psychiatric assessment for a deaf patient?
a) rely only on the ASL interpreter
b) inquire about the patient’s communication preferences
c) use written language to communicate instead of speech
d) use a family member as interpreter
The authors’ observations
Mental health assessment of a deaf a patient involves a unique set of challenges and requires a specialized skill set for mental health practitioners—a skill set that is not routinely covered in psychiatric training programs.
a We use the term “deaf” to describe patients who have severe hearing loss. Other terms, such as “hearing impaired,” might be considered pejorative in the Deaf community. The term “Deaf” (capitalized) refers to Deaf culture and community, which deaf patients may or may not identify with.
Deafness history
It is important to assess the cause of deafness,1,2 if known, and its age of onset (Table 1). A person is considered to be prelingually deaf if hearing loss was diagnosed before age 3.2 Clinicians should establish the patient’s communication preferences (use of assistive devices or interpreters or preference for lip reading), home communication dynamic,2 and language fluency level.1-3 Ask the patient if she attended a specialized school for the deaf and, if so, if there was an emphasis on oral communication or signing.2
HISTORY Conflicting reports
Mrs. H reports that she has been deaf since age 9, and that she learned sign language in India, where she became the “star king.” Mrs. H states that she then moved to the United States where she went to a school for the deaf. When asked if her family is able to communicate with her in sign language, she nods and indicates that they speak to her in “African and Indian.”
Mrs. H’s husband, who is hearing, says that Mrs. H is congenitally deaf, and was raised in the Midwestern United States where she attended a specialized school for the deaf. Mr. H and his 2 adult sons are hearing but communicate with Mrs. H in basic ASL. He states that Mrs. H sometimes uses signs that he and his sons cannot interpret. In addition to increased self-preoccupation and self-signing, Mrs. H has become more impulsive.
What are limitations of the mental status examination when evaluating a deaf patient?
a) facial expressions have a specific linguistic function in ASL
b) there is no differentiation in the mental status exam of deaf patients from that of hearing patients
c) the Mini-Mental State Examination (MMSE) is a validated tool to assess cognition in deaf patients
d) the clinician should not rely on the interpreter to assist with the mental status examination
The authors’ observation
Performing a mental status examination of a deaf patient without recognizing some of the challenges inherent to this task can lead to misleading findings. For example, signing and gesturing can give the clinician an impression of psychomotor agitation.2 What appears to be socially withdrawn behavior might be a reaction to the patient’s inability to communicate with others.2,3 Social skills may be affected by language deprivation, if present.3 In ASL, facial expressions have specific linguistic functions in addition to representing emotions,2 and can affect the meaning of the sign used. An exaggerated or intense facial expression with the sign “quiet,” for example, usually means “very quiet.”4 In assessing cognition, the MMSE is not available in ASL and has not been validated in deaf patients.5 Also, deaf people have reduced access to information, and a lack of knowledge does not necessarily correlate with low IQ.2
The interpreter’s role
An ASL interpreter can aid in assessing a deaf patient’s communication skills. The interpreter can help with a thorough language evaluation1,6 and provide information about socio-cultural norms in the Deaf community.7 Using an ASL interpreter with special training in mental health1,3,6,7 is important to accurately diagnose thought disorders in deaf patients.1
EVALUATION Mental status exam
Mrs. H is poorly groomed and is wearing a pink housecoat, with her hair in disarray. She seems to be distracted by something next to the interpreter, because her eyes keep roving in this direction. She has moderate psychomotor agitation, based on the rapidity of her signing and gesturing. Mrs. H makes indecipherable vocalizations while signing, often loud and with an urgent quality. Her affect is elevated and expansive. She is not oriented to place or time and when asked where she is, signs, “many times, every day, 6-9-9, 2-5, more trouble…”
The ASL interpreter notes that Mrs. H signs so quickly that only about one-half of her signs are interpretable. Mrs. H’s grammar is not always correct and that her syntax is, at times, inappropriate. Mrs. H’s letters are difficult to interpret because she often starts and concludes a word with a clear sign, but the intervening letters are rapid and uninterpretable. She also uses several non-alphabet signs that cannot be interpreted (approximately 10% to 15% of signs) and repeats signs without clear context, such as “nothing off.” Mrs. H can pause to clarify for the interpreter at the beginning of the interview but is not able to do so by the end of the interview.
How does assessment of psychosis differ when evaluating deaf patients?
a) language dysfluency must be carefully differentiated from a thought disorder
b) signing to oneself does not necessarily indicate a response to internal stimuli
c) norms in Deaf culture might be misconstrued as delusions
d) all of the above
The authors’ observations
The prevalence of psychotic disorders among deaf patients is unknown.8 Although older studies have reported an increased prevalence of psychotic disorders among deaf patients, these studies suffer from methodological problems.1 Other studies are at odds with each other, variably reporting a greater,9 equivalent,10 and lesser incidence of psychotic disorders in deaf psychiatric inpatients.11 Deaf patients with psychotic disorders experience delusions, hallucinations, and thought disorders,1,3 and assessing for these symptoms in deaf patients can present a diagnostic challenge (Table 2).
Delusions are thought to present similarly in deaf patients with psychotic disorders compared with hearing patients.1,3 Paranoia may be increased in patients who are postlingually deaf, but has not been associated with prelingual deafness. Deficits in theory of mind related to hearing impairment have been thought to contribute to delusions in deaf patients.1,12
Many deaf patients distrust health care systems and providers,2,3,13 which may be misinterpreted as paranoia. Poor communication between deaf patients and clinicians and poor health literacy among deaf patients contribute to feelings of mistrust. Deaf patients often report experiencing prejudice within the health care system, and think that providers lack sufficient knowledge of deafness.13 Care must be taken to ensure that Deaf cultural norms are not misinterpreted as delusions.
Hallucinations. How deaf patients experience hallucinations, especially in prelingual deafness, likely is different from hallucinatory experiences of hearing patients.1,14 Deaf people with psychosis have described ”ideas coming into one’s head” and an almost “telepathic” process of “knowing.”14 Deaf patients with schizophrenia are more likely to report visual elements to their hallucinations; however, these may be subvisual precepts rather than true visual hallucinations.1,15 For example, hallucination might include the perception of being signed to.1
Deaf patients’ experience of auditory hallucinations is thought to be closely related to past auditory experiences. It is unlikely that prelingually deaf patients experience true auditory hallucinations.1,14 An endorsement of hearing a “voice” in ASL does not necessarily translate to an audiological experience.15 If profoundly prelingually deaf patients endorse hearing voices, generally they cannot assign acoustic properties (pitch, tone, volume, accent, etc.).1,14,15 It may not be necessary to fully comprehend the precise modality of how hallucinations are experienced by deaf patients to provide therapy.14
Self-signing, or signing to oneself, does not necessarily indicate that a deaf person is responding to a hallucinatory experience. Non-verbal patients may gesture to themselves without clear evidence of psychosis. When considering whether a patient is experiencing hallucinations, it is important to look for other evidence of psychosis.3
Possible approaches to evaluating hallucinations in deaf patients include asking,, “is someone signing in your head?” or “Is someone who is not in the room trying to communicate with you?”
Thought disorders in deaf psychiatric inpatients are difficult to diagnose, in part because of a high rate of language dysfluency in deaf patients; in samples of psychiatric inpatients, 75% are not fluent in ASL, 66% are not fluent in any language).1,3,11 Commonly, language dysfluency is related to language deprivation because of late or inadequate exposure to ASL, although it may be related to neurologic damage or aphasia.1,3,6,16 Deaf patients can have additional disabilities, including learning disabilities, that might contribute to language dysfluency.2 Language dysfluency can be misattributed to a psychotic process1-3,7 (Table 3).1
Language dysfluency and thought disorders can be difficult to differentiate and may be comorbid. Loose associations and flight of ideas can be hard to assess in patients with language dysfluency. In general, increasing looseness of association between concepts corresponds to an increasing likelihood that a patient has true loose associations rather than language dysfluency alone.3 Deaf patients with schizophrenia can be identified by the presence of associated symptoms of psychosis, especially if delusions are present.1,3
EVALUATION Psychotic symptoms
Mrs. H’s thought process appears disorganized and illogical, with flight of ideas. She might have an underlying language dysfluency. It is likely that Mrs. H is using neologisms to communicate because of her family’s lack of familiarity with some of her signs. She also demonstrates perseveration, with use of certain signs repeatedly without clear context (ie, “nothing off”).
Her thought content includes racial themes—she mentions Russia, Germany, and Vietnam without clear context—and delusions of being the “star king” and of being pregnant. She endorses paranoid feelings that people on the inpatient unit are trying to hurt her, although it isn’t clear whether this represents a true paranoid delusion because of the hectic climate of the unit, and she did not show unnecessarily defensive or guarded behaviors.
She is seen signing to herself in the dayroom and endorses feeling as though someone who is not in the room—described as an Indian teacher (and sometimes as a boss or principal) known as “Mr. Smith” or “Mr. Donald”—is trying to communicate with her. She describes this person as being male and female. She mentions that sometimes she sees an Indian man and another man fighting. It is likely that Mrs. H is experiencing hallucinations from decompensated psychosis, because of the constellation and trajectory of her symptoms. Her nonverbal behavior—her eyes rove around the room during interviews—also supports this conclusion.
Because of evidence of mood and psychotic symptoms, and with a collateral history that suggests significant baseline disorganization, Mrs. H receives a diagnosis of schizoaffective disorder, bipolar type. She is restarted on olanzapine, 10 mg/d, and valproic acid, 1,000 mg/d.
Mrs. H’s psychomotor acceleration and affective elevation gradually improve with pharmacotherapy. After a 2-week hospitalization, despite ongoing disorganization and self-signing, Mrs. H’s husband says that he feels she is improved enough to return home, with plans to continue to take her medications and to reestablish outpatient follow-up.
Bottom Line
Psychiatric assessment of deaf patients presents distinctive challenges related to cultural and language barriers—making it important to engage an ASL interpreter with training in mental health during assessment of a deaf patient. Clinicians must become familiar with these challenges to provide effective care for mentally ill deaf patients.
Related Resources
• Landsberger SA, Diaz DR. Communicating with deaf patients: 10 tips to deliver appropriate care. Current Psychiatry. 2010;9(6):36-37.
• Deaf Wellness Center. University of Rochester School of Medicine. www.urmc.rochester.edu/deaf-wellness-center.
• Gallaudet University Mental Health Center. www.gallaudet.edu/
mental_health_center.html.
Drug Brand Names
Olanzapine • Zyprexa
Valproic acid • Depakote
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
CASE Self Signing
Mrs. H, a 47-year-old, deaf, African American woman, is brought into the emergency room because she is becoming increasingly withdrawn and is signing to herself. She was hospitalized more than 10 years ago after developing psychotic symptoms and received a diagnosis of psychotic disorder, not otherwise specified. She was treated with olanzapine, 10 mg/d, and valproic acid, 1,000 mg/d, but she has not seen a psychiatrist or taken any psychotropics in 8 years. Upon admission to the inpatient psychiatric unit, Mrs. H reports, through an American Sign Language (ASL) interpreter, that she has had “problems with her parents” and with “being fair” and that she is 18 months pregnant. Urine pregnancy test is negative. Mrs. H also reports that her mother is pregnant. She indicates that it is difficult for her to describe what she is trying to say and that it is difficult to be deaf.
She endorses “very strong” racing thoughts, which she first states have been present for 15 years, then reports it has been 20 months. She endorses high-energy levels, feeling like there is “work to do,” and poor sleep. However, when asked, she indicates that she sleeps for 15 hours a day.
Which is critical when conducting a psychiatric assessment for a deaf patient?
a) rely only on the ASL interpreter
b) inquire about the patient’s communication preferences
c) use written language to communicate instead of speech
d) use a family member as interpreter
The authors’ observations
Mental health assessment of a deaf a patient involves a unique set of challenges and requires a specialized skill set for mental health practitioners—a skill set that is not routinely covered in psychiatric training programs.
a We use the term “deaf” to describe patients who have severe hearing loss. Other terms, such as “hearing impaired,” might be considered pejorative in the Deaf community. The term “Deaf” (capitalized) refers to Deaf culture and community, which deaf patients may or may not identify with.
Deafness history
It is important to assess the cause of deafness,1,2 if known, and its age of onset (Table 1). A person is considered to be prelingually deaf if hearing loss was diagnosed before age 3.2 Clinicians should establish the patient’s communication preferences (use of assistive devices or interpreters or preference for lip reading), home communication dynamic,2 and language fluency level.1-3 Ask the patient if she attended a specialized school for the deaf and, if so, if there was an emphasis on oral communication or signing.2
HISTORY Conflicting reports
Mrs. H reports that she has been deaf since age 9, and that she learned sign language in India, where she became the “star king.” Mrs. H states that she then moved to the United States where she went to a school for the deaf. When asked if her family is able to communicate with her in sign language, she nods and indicates that they speak to her in “African and Indian.”
Mrs. H’s husband, who is hearing, says that Mrs. H is congenitally deaf, and was raised in the Midwestern United States where she attended a specialized school for the deaf. Mr. H and his 2 adult sons are hearing but communicate with Mrs. H in basic ASL. He states that Mrs. H sometimes uses signs that he and his sons cannot interpret. In addition to increased self-preoccupation and self-signing, Mrs. H has become more impulsive.
What are limitations of the mental status examination when evaluating a deaf patient?
a) facial expressions have a specific linguistic function in ASL
b) there is no differentiation in the mental status exam of deaf patients from that of hearing patients
c) the Mini-Mental State Examination (MMSE) is a validated tool to assess cognition in deaf patients
d) the clinician should not rely on the interpreter to assist with the mental status examination
The authors’ observation
Performing a mental status examination of a deaf patient without recognizing some of the challenges inherent to this task can lead to misleading findings. For example, signing and gesturing can give the clinician an impression of psychomotor agitation.2 What appears to be socially withdrawn behavior might be a reaction to the patient’s inability to communicate with others.2,3 Social skills may be affected by language deprivation, if present.3 In ASL, facial expressions have specific linguistic functions in addition to representing emotions,2 and can affect the meaning of the sign used. An exaggerated or intense facial expression with the sign “quiet,” for example, usually means “very quiet.”4 In assessing cognition, the MMSE is not available in ASL and has not been validated in deaf patients.5 Also, deaf people have reduced access to information, and a lack of knowledge does not necessarily correlate with low IQ.2
The interpreter’s role
An ASL interpreter can aid in assessing a deaf patient’s communication skills. The interpreter can help with a thorough language evaluation1,6 and provide information about socio-cultural norms in the Deaf community.7 Using an ASL interpreter with special training in mental health1,3,6,7 is important to accurately diagnose thought disorders in deaf patients.1
EVALUATION Mental status exam
Mrs. H is poorly groomed and is wearing a pink housecoat, with her hair in disarray. She seems to be distracted by something next to the interpreter, because her eyes keep roving in this direction. She has moderate psychomotor agitation, based on the rapidity of her signing and gesturing. Mrs. H makes indecipherable vocalizations while signing, often loud and with an urgent quality. Her affect is elevated and expansive. She is not oriented to place or time and when asked where she is, signs, “many times, every day, 6-9-9, 2-5, more trouble…”
The ASL interpreter notes that Mrs. H signs so quickly that only about one-half of her signs are interpretable. Mrs. H’s grammar is not always correct and that her syntax is, at times, inappropriate. Mrs. H’s letters are difficult to interpret because she often starts and concludes a word with a clear sign, but the intervening letters are rapid and uninterpretable. She also uses several non-alphabet signs that cannot be interpreted (approximately 10% to 15% of signs) and repeats signs without clear context, such as “nothing off.” Mrs. H can pause to clarify for the interpreter at the beginning of the interview but is not able to do so by the end of the interview.
How does assessment of psychosis differ when evaluating deaf patients?
a) language dysfluency must be carefully differentiated from a thought disorder
b) signing to oneself does not necessarily indicate a response to internal stimuli
c) norms in Deaf culture might be misconstrued as delusions
d) all of the above
The authors’ observations
The prevalence of psychotic disorders among deaf patients is unknown.8 Although older studies have reported an increased prevalence of psychotic disorders among deaf patients, these studies suffer from methodological problems.1 Other studies are at odds with each other, variably reporting a greater,9 equivalent,10 and lesser incidence of psychotic disorders in deaf psychiatric inpatients.11 Deaf patients with psychotic disorders experience delusions, hallucinations, and thought disorders,1,3 and assessing for these symptoms in deaf patients can present a diagnostic challenge (Table 2).
Delusions are thought to present similarly in deaf patients with psychotic disorders compared with hearing patients.1,3 Paranoia may be increased in patients who are postlingually deaf, but has not been associated with prelingual deafness. Deficits in theory of mind related to hearing impairment have been thought to contribute to delusions in deaf patients.1,12
Many deaf patients distrust health care systems and providers,2,3,13 which may be misinterpreted as paranoia. Poor communication between deaf patients and clinicians and poor health literacy among deaf patients contribute to feelings of mistrust. Deaf patients often report experiencing prejudice within the health care system, and think that providers lack sufficient knowledge of deafness.13 Care must be taken to ensure that Deaf cultural norms are not misinterpreted as delusions.
Hallucinations. How deaf patients experience hallucinations, especially in prelingual deafness, likely is different from hallucinatory experiences of hearing patients.1,14 Deaf people with psychosis have described ”ideas coming into one’s head” and an almost “telepathic” process of “knowing.”14 Deaf patients with schizophrenia are more likely to report visual elements to their hallucinations; however, these may be subvisual precepts rather than true visual hallucinations.1,15 For example, hallucination might include the perception of being signed to.1
Deaf patients’ experience of auditory hallucinations is thought to be closely related to past auditory experiences. It is unlikely that prelingually deaf patients experience true auditory hallucinations.1,14 An endorsement of hearing a “voice” in ASL does not necessarily translate to an audiological experience.15 If profoundly prelingually deaf patients endorse hearing voices, generally they cannot assign acoustic properties (pitch, tone, volume, accent, etc.).1,14,15 It may not be necessary to fully comprehend the precise modality of how hallucinations are experienced by deaf patients to provide therapy.14
Self-signing, or signing to oneself, does not necessarily indicate that a deaf person is responding to a hallucinatory experience. Non-verbal patients may gesture to themselves without clear evidence of psychosis. When considering whether a patient is experiencing hallucinations, it is important to look for other evidence of psychosis.3
Possible approaches to evaluating hallucinations in deaf patients include asking,, “is someone signing in your head?” or “Is someone who is not in the room trying to communicate with you?”
Thought disorders in deaf psychiatric inpatients are difficult to diagnose, in part because of a high rate of language dysfluency in deaf patients; in samples of psychiatric inpatients, 75% are not fluent in ASL, 66% are not fluent in any language).1,3,11 Commonly, language dysfluency is related to language deprivation because of late or inadequate exposure to ASL, although it may be related to neurologic damage or aphasia.1,3,6,16 Deaf patients can have additional disabilities, including learning disabilities, that might contribute to language dysfluency.2 Language dysfluency can be misattributed to a psychotic process1-3,7 (Table 3).1
Language dysfluency and thought disorders can be difficult to differentiate and may be comorbid. Loose associations and flight of ideas can be hard to assess in patients with language dysfluency. In general, increasing looseness of association between concepts corresponds to an increasing likelihood that a patient has true loose associations rather than language dysfluency alone.3 Deaf patients with schizophrenia can be identified by the presence of associated symptoms of psychosis, especially if delusions are present.1,3
EVALUATION Psychotic symptoms
Mrs. H’s thought process appears disorganized and illogical, with flight of ideas. She might have an underlying language dysfluency. It is likely that Mrs. H is using neologisms to communicate because of her family’s lack of familiarity with some of her signs. She also demonstrates perseveration, with use of certain signs repeatedly without clear context (ie, “nothing off”).
Her thought content includes racial themes—she mentions Russia, Germany, and Vietnam without clear context—and delusions of being the “star king” and of being pregnant. She endorses paranoid feelings that people on the inpatient unit are trying to hurt her, although it isn’t clear whether this represents a true paranoid delusion because of the hectic climate of the unit, and she did not show unnecessarily defensive or guarded behaviors.
She is seen signing to herself in the dayroom and endorses feeling as though someone who is not in the room—described as an Indian teacher (and sometimes as a boss or principal) known as “Mr. Smith” or “Mr. Donald”—is trying to communicate with her. She describes this person as being male and female. She mentions that sometimes she sees an Indian man and another man fighting. It is likely that Mrs. H is experiencing hallucinations from decompensated psychosis, because of the constellation and trajectory of her symptoms. Her nonverbal behavior—her eyes rove around the room during interviews—also supports this conclusion.
Because of evidence of mood and psychotic symptoms, and with a collateral history that suggests significant baseline disorganization, Mrs. H receives a diagnosis of schizoaffective disorder, bipolar type. She is restarted on olanzapine, 10 mg/d, and valproic acid, 1,000 mg/d.
Mrs. H’s psychomotor acceleration and affective elevation gradually improve with pharmacotherapy. After a 2-week hospitalization, despite ongoing disorganization and self-signing, Mrs. H’s husband says that he feels she is improved enough to return home, with plans to continue to take her medications and to reestablish outpatient follow-up.
Bottom Line
Psychiatric assessment of deaf patients presents distinctive challenges related to cultural and language barriers—making it important to engage an ASL interpreter with training in mental health during assessment of a deaf patient. Clinicians must become familiar with these challenges to provide effective care for mentally ill deaf patients.
Related Resources
• Landsberger SA, Diaz DR. Communicating with deaf patients: 10 tips to deliver appropriate care. Current Psychiatry. 2010;9(6):36-37.
• Deaf Wellness Center. University of Rochester School of Medicine. www.urmc.rochester.edu/deaf-wellness-center.
• Gallaudet University Mental Health Center. www.gallaudet.edu/
mental_health_center.html.
Drug Brand Names
Olanzapine • Zyprexa
Valproic acid • Depakote
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Landsberger SA, Diaz DR. Identifying and assessing psychosis in deaf psychiatric patients. Curr Psychiatry Rep. 2011;13(3):198-202.
2. Fellinger J, Holzinger D, Pollard R. Mental health of deaf people. Lancet. 2012;379(9820):1037-1044.
3. Glickman N. Do you hear voices? Problems in assessment of mental status in deaf persons with severe language deprivation. J Deaf Stud Deaf Educ. 2007;12(2):127-147.
4. Vicars W. ASL University. Facial expressions. http://www.lifeprint.com/asl101/pages-layout/facialexpressions.htm. Accessed April 2, 2013.
5. Dean PM, Feldman DM, Morere D, et al. Clinical evaluation of the mini-mental state exam with culturally deaf senior citizens. Arch Clin Neuropsychol. 2009;24(8):753-760.
6. Crump C, Glickman N. Mental health interpreting with language dysfluent deaf clients. Journal of Interpretation. 2011;21(1):21-36.
7. Leigh IW, Pollard RQ Jr. Mental health and deaf adults. In: Marschark M, Spencer PE, eds. Oxford handbook of deaf studies, language, and education. Vol 1. New York, NY: Oxford University Press. 2011:214-226.
8. Øhre B, von Tezchner S, Falkum E. Deaf adults and mental health: A review of recent research on the prevalence and distribution of psychiatric symptoms and disorders in the prelingually deaf adult population. International Journal on Mental Health and Deafness. 2011;1(1):3-22.
9. Appleford J. Clinical activity within a specialist mental health service for deaf people: comparison with a general psychiatric service. Psychiatric Bulletin. 2003;27(10): 375-377.
10. Landsberger SA, Diaz DR. Inpatient psychiatric treatment of deaf adults: demographic and diagnostic comparisons with hearing inpatients. Psychiatr Serv. 2010;61(2):196-199.
11. Black PA, Glickman NS. Demographics, psychiatric diagnoses, and other characteristics of North American deaf and hard-of-hearing inpatients. J Deaf Stud Deaf Educ. 2006; 11(3):303-321.
12. Thewissen V, Myin-Germeys I, Bentall R, et al. Hearing impairment and psychosis revisited. Schizophr Res. 2005; 76(1):99-103.
13. Steinberg AG, Barnett S, Meador HE, et al. Health care system accessibility. Experiences and perceptions of deaf people. J Gen Inter Med. 2006;21(3):260-266.
14. Paijmans R, Cromwell J, Austen S. Do profoundly prelingually deaf patients with psychosis really hear voices? Am Ann Deaf. 2006;151(1):42-48.
15. Atkinson JR. The perceptual characteristics of voice-hallucinations in deaf people: insights into the nature of subvocal thought and sensory feedback loops. Schizophr Bull. 2006;32(4):701-708.
16. Trumbetta SL, Bonvillian JD, Siedlecki T, et al. Language-related symptoms in persons with schizophrenia and how deaf persons may manifest these symptoms. Sign Language Studies. 2001;1(3):228-253.
1. Landsberger SA, Diaz DR. Identifying and assessing psychosis in deaf psychiatric patients. Curr Psychiatry Rep. 2011;13(3):198-202.
2. Fellinger J, Holzinger D, Pollard R. Mental health of deaf people. Lancet. 2012;379(9820):1037-1044.
3. Glickman N. Do you hear voices? Problems in assessment of mental status in deaf persons with severe language deprivation. J Deaf Stud Deaf Educ. 2007;12(2):127-147.
4. Vicars W. ASL University. Facial expressions. http://www.lifeprint.com/asl101/pages-layout/facialexpressions.htm. Accessed April 2, 2013.
5. Dean PM, Feldman DM, Morere D, et al. Clinical evaluation of the mini-mental state exam with culturally deaf senior citizens. Arch Clin Neuropsychol. 2009;24(8):753-760.
6. Crump C, Glickman N. Mental health interpreting with language dysfluent deaf clients. Journal of Interpretation. 2011;21(1):21-36.
7. Leigh IW, Pollard RQ Jr. Mental health and deaf adults. In: Marschark M, Spencer PE, eds. Oxford handbook of deaf studies, language, and education. Vol 1. New York, NY: Oxford University Press. 2011:214-226.
8. Øhre B, von Tezchner S, Falkum E. Deaf adults and mental health: A review of recent research on the prevalence and distribution of psychiatric symptoms and disorders in the prelingually deaf adult population. International Journal on Mental Health and Deafness. 2011;1(1):3-22.
9. Appleford J. Clinical activity within a specialist mental health service for deaf people: comparison with a general psychiatric service. Psychiatric Bulletin. 2003;27(10): 375-377.
10. Landsberger SA, Diaz DR. Inpatient psychiatric treatment of deaf adults: demographic and diagnostic comparisons with hearing inpatients. Psychiatr Serv. 2010;61(2):196-199.
11. Black PA, Glickman NS. Demographics, psychiatric diagnoses, and other characteristics of North American deaf and hard-of-hearing inpatients. J Deaf Stud Deaf Educ. 2006; 11(3):303-321.
12. Thewissen V, Myin-Germeys I, Bentall R, et al. Hearing impairment and psychosis revisited. Schizophr Res. 2005; 76(1):99-103.
13. Steinberg AG, Barnett S, Meador HE, et al. Health care system accessibility. Experiences and perceptions of deaf people. J Gen Inter Med. 2006;21(3):260-266.
14. Paijmans R, Cromwell J, Austen S. Do profoundly prelingually deaf patients with psychosis really hear voices? Am Ann Deaf. 2006;151(1):42-48.
15. Atkinson JR. The perceptual characteristics of voice-hallucinations in deaf people: insights into the nature of subvocal thought and sensory feedback loops. Schizophr Bull. 2006;32(4):701-708.
16. Trumbetta SL, Bonvillian JD, Siedlecki T, et al. Language-related symptoms in persons with schizophrenia and how deaf persons may manifest these symptoms. Sign Language Studies. 2001;1(3):228-253.
Hoarding: Not just a symptom of OCD
ORLANDO – Compulsive hoarding traditionally has been considered virtually synonymous with obsessive-compulsive disorder, but its reach actually extends far beyond.
Indeed, hoarding turns out to be is highly prevalent across a broad span of psychiatric disorders, including bipolar disorder.
In a random sample of 165 psychiatric inpatients with a variety of diagnoses who were screened using the Hoarding Rating Scale, 70 (42%) showed evidence of clinically significant compulsive hoarding, Dr. Nidhi Goel reported at the annual meeting of the American Association for Geriatric Psychiatry.
Clinically significant hoarding as defined by a score of 14 or more was present in half of patients hospitalized with bipolar disorder, 41% of those with substance use disorders, close to 40% of those diagnosed with schizophrenia or schizoaffective disorder, more than one-third of patients hospitalized for major depression, and 28% with other psychotic spectrum disorders, noted Dr. Goel, director of inpatient psychiatric services at Maimonides Medical Center in Brooklyn, N.Y.
The clinical implication is clear, she added: Hoarding disorder – newly upgraded to a full-blown diagnostic category in the DSM-5 – needs to be brought up onto more psychiatrists’ radars.
"Patients come in with depression, substance use problems, and all sorts of Axis I diagnoses where we just forget to assess the hoarding problem. Then when they’re ready to be discharged, a family member mentions, ‘We cannot even get into their apartment because of all the stuff that has piled up.’ This disorder negatively [affects] our patients’ quality of life quite a lot," Dr. Goel continued.
"My thinking is that if hoarding is so common in all of these disorders, could treating hoarding prevent some of these other disorders? We don’t know. It hasn’t been studied," Dr. Goel said in an interview.
In the DSM-5, hoarding disorder is for the first time categorized as a distinct entity. It is listed under the chapter heading Obsessive-Compulsive and Related Disorders. Before the DSM-5, there was no "hoarding disorder." Rather, hoarding was merely considered a symptom of OCD. And OCD was included in the chapter on anxiety disorders. Now OCD and Related Disorders have their own chapter and are no longer considered anxiety disorders.
The DSM-5 fact sheet on hoarding disorder states, "Creating a unique diagnosis in DSM-5 will increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatments for hoarding disorder. This is particularly important, as studies show that the prevalence of hoarding disorder is estimated at approximately 2%-5% of the population. These behaviors can often be quite severe and even threatening."
Hoarding disorder and its attendant clutter also create a significant public health problem, according to Dr. Goel, who noted that hoarding-related complaints to urban public health departments occur at a rate of 26/100,000 population per 5 years.
One of the features of the DSM-5 diagnostic category of hoarding disorder Dr. Goel considers a big step forward is the inclusion of specifiers regarding insight and delusional beliefs. Patients with hoarding disorder can be categorized as having good or fair insight, poor insight, or absent insight with delusional beliefs.
"Let’s say, for example, that a patient comes in who has been diagnosed with schizophrenia just because there is some delusional component attached. I’m now thinking maybe this patient may not have schizophrenia. Maybe it’s just hoarding disorder with delusions, or delusional disorder [not otherwise specified]," she said.
The Hoarding Rating Scale assesses difficulty in using living spaces because of clutter, the inability to get rid of possessions, the excessive acquisition of objects, and hoarding behavior–related functional impairment and emotional distress.
Dr. Goel reported having no financial conflicts with regard to this study.
ORLANDO – Compulsive hoarding traditionally has been considered virtually synonymous with obsessive-compulsive disorder, but its reach actually extends far beyond.
Indeed, hoarding turns out to be is highly prevalent across a broad span of psychiatric disorders, including bipolar disorder.
In a random sample of 165 psychiatric inpatients with a variety of diagnoses who were screened using the Hoarding Rating Scale, 70 (42%) showed evidence of clinically significant compulsive hoarding, Dr. Nidhi Goel reported at the annual meeting of the American Association for Geriatric Psychiatry.
Clinically significant hoarding as defined by a score of 14 or more was present in half of patients hospitalized with bipolar disorder, 41% of those with substance use disorders, close to 40% of those diagnosed with schizophrenia or schizoaffective disorder, more than one-third of patients hospitalized for major depression, and 28% with other psychotic spectrum disorders, noted Dr. Goel, director of inpatient psychiatric services at Maimonides Medical Center in Brooklyn, N.Y.
The clinical implication is clear, she added: Hoarding disorder – newly upgraded to a full-blown diagnostic category in the DSM-5 – needs to be brought up onto more psychiatrists’ radars.
"Patients come in with depression, substance use problems, and all sorts of Axis I diagnoses where we just forget to assess the hoarding problem. Then when they’re ready to be discharged, a family member mentions, ‘We cannot even get into their apartment because of all the stuff that has piled up.’ This disorder negatively [affects] our patients’ quality of life quite a lot," Dr. Goel continued.
"My thinking is that if hoarding is so common in all of these disorders, could treating hoarding prevent some of these other disorders? We don’t know. It hasn’t been studied," Dr. Goel said in an interview.
In the DSM-5, hoarding disorder is for the first time categorized as a distinct entity. It is listed under the chapter heading Obsessive-Compulsive and Related Disorders. Before the DSM-5, there was no "hoarding disorder." Rather, hoarding was merely considered a symptom of OCD. And OCD was included in the chapter on anxiety disorders. Now OCD and Related Disorders have their own chapter and are no longer considered anxiety disorders.
The DSM-5 fact sheet on hoarding disorder states, "Creating a unique diagnosis in DSM-5 will increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatments for hoarding disorder. This is particularly important, as studies show that the prevalence of hoarding disorder is estimated at approximately 2%-5% of the population. These behaviors can often be quite severe and even threatening."
Hoarding disorder and its attendant clutter also create a significant public health problem, according to Dr. Goel, who noted that hoarding-related complaints to urban public health departments occur at a rate of 26/100,000 population per 5 years.
One of the features of the DSM-5 diagnostic category of hoarding disorder Dr. Goel considers a big step forward is the inclusion of specifiers regarding insight and delusional beliefs. Patients with hoarding disorder can be categorized as having good or fair insight, poor insight, or absent insight with delusional beliefs.
"Let’s say, for example, that a patient comes in who has been diagnosed with schizophrenia just because there is some delusional component attached. I’m now thinking maybe this patient may not have schizophrenia. Maybe it’s just hoarding disorder with delusions, or delusional disorder [not otherwise specified]," she said.
The Hoarding Rating Scale assesses difficulty in using living spaces because of clutter, the inability to get rid of possessions, the excessive acquisition of objects, and hoarding behavior–related functional impairment and emotional distress.
Dr. Goel reported having no financial conflicts with regard to this study.
ORLANDO – Compulsive hoarding traditionally has been considered virtually synonymous with obsessive-compulsive disorder, but its reach actually extends far beyond.
Indeed, hoarding turns out to be is highly prevalent across a broad span of psychiatric disorders, including bipolar disorder.
In a random sample of 165 psychiatric inpatients with a variety of diagnoses who were screened using the Hoarding Rating Scale, 70 (42%) showed evidence of clinically significant compulsive hoarding, Dr. Nidhi Goel reported at the annual meeting of the American Association for Geriatric Psychiatry.
Clinically significant hoarding as defined by a score of 14 or more was present in half of patients hospitalized with bipolar disorder, 41% of those with substance use disorders, close to 40% of those diagnosed with schizophrenia or schizoaffective disorder, more than one-third of patients hospitalized for major depression, and 28% with other psychotic spectrum disorders, noted Dr. Goel, director of inpatient psychiatric services at Maimonides Medical Center in Brooklyn, N.Y.
The clinical implication is clear, she added: Hoarding disorder – newly upgraded to a full-blown diagnostic category in the DSM-5 – needs to be brought up onto more psychiatrists’ radars.
"Patients come in with depression, substance use problems, and all sorts of Axis I diagnoses where we just forget to assess the hoarding problem. Then when they’re ready to be discharged, a family member mentions, ‘We cannot even get into their apartment because of all the stuff that has piled up.’ This disorder negatively [affects] our patients’ quality of life quite a lot," Dr. Goel continued.
"My thinking is that if hoarding is so common in all of these disorders, could treating hoarding prevent some of these other disorders? We don’t know. It hasn’t been studied," Dr. Goel said in an interview.
In the DSM-5, hoarding disorder is for the first time categorized as a distinct entity. It is listed under the chapter heading Obsessive-Compulsive and Related Disorders. Before the DSM-5, there was no "hoarding disorder." Rather, hoarding was merely considered a symptom of OCD. And OCD was included in the chapter on anxiety disorders. Now OCD and Related Disorders have their own chapter and are no longer considered anxiety disorders.
The DSM-5 fact sheet on hoarding disorder states, "Creating a unique diagnosis in DSM-5 will increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatments for hoarding disorder. This is particularly important, as studies show that the prevalence of hoarding disorder is estimated at approximately 2%-5% of the population. These behaviors can often be quite severe and even threatening."
Hoarding disorder and its attendant clutter also create a significant public health problem, according to Dr. Goel, who noted that hoarding-related complaints to urban public health departments occur at a rate of 26/100,000 population per 5 years.
One of the features of the DSM-5 diagnostic category of hoarding disorder Dr. Goel considers a big step forward is the inclusion of specifiers regarding insight and delusional beliefs. Patients with hoarding disorder can be categorized as having good or fair insight, poor insight, or absent insight with delusional beliefs.
"Let’s say, for example, that a patient comes in who has been diagnosed with schizophrenia just because there is some delusional component attached. I’m now thinking maybe this patient may not have schizophrenia. Maybe it’s just hoarding disorder with delusions, or delusional disorder [not otherwise specified]," she said.
The Hoarding Rating Scale assesses difficulty in using living spaces because of clutter, the inability to get rid of possessions, the excessive acquisition of objects, and hoarding behavior–related functional impairment and emotional distress.
Dr. Goel reported having no financial conflicts with regard to this study.
AT THE AAGP ANNUAL MEETING
Major finding: Seventy of 165 adult psychiatric inpatients screened for compulsive hoarding displayed evidence of a clinically significant hoarding problem. Hoarding was highly prevalent among patients hospitalized for depression, schizophrenia, bipolar disorder, substance use, and a variety of diagnoses other than obsessive-compulsive disorder.
Data source: This was a cross-sectional study in which inpatients with a broad array of psychiatric diagnoses were screened for compulsive hoarding using the Hoarding Rating Scale.
Disclosures: The study presenter reported having no financial conflicts of interest.
Treatment decisions complex for pregnant, postpartum women with bipolar disorder
The clinical features of perinatal women with bipolar disorder are much more severe than those of women seeking care for other psychiatric conditions, including greater history of suicidal behavior and substance abuse, and more difficulties during childbirth and while breastfeeding, a retrospective study of 334 pregnant and postpartum women suggests.
Cynthia L. Battle, Ph.D., of Butler Hospital in Providence, R.I., and her colleagues reviewed the clinical records of the women, who sought treatment at a specialized partial hospitalization program that serves patients during pregnancy and the first postpartum year. Their ages ranged from 15 to 43 years, and they came from a range of ethnic backgrounds. Less than half of the women in the sample were either married or had partners (J. Affect. Disord. 2014;158:97-100). Two-thirds were postpartum, and one-third of them were pregnant.
The investigators asked the patients to complete the Edinburgh Postnatal Depression Scale and the facility’s Day Hospital Screener for self-reporting of psychiatric disorders, including bipolar disorder.
About 10% of women had a bipolar disorder diagnosis, including 19 with bipolar I disorder, 10 with bipolar II disorder, and 5 with bipolar not otherwise specified. Twenty-six percent reported bipolar disorder symptoms of elation, and 76% reported symptoms of irritability lasting 4 or more days within the previous month.
"Pregnant and postpartum women with [bipolar disorder] reported more extensive mental health histories, including prior use of pharmacotherapy and psychotherapy, as well as higher rates of prior substance abuse," the authors noted. Women with bipolar disorder were significantly more likely than those with other Axis I disorders to report prior suicidal behavior and attempts. A higher proportion of expectant mothers with bipolar disorder took psychotropics than did pregnant women with other disorders. Among postpartum women, mothers with bipolar disorder were more likely to report delivery complications and difficulties breastfeeding their babies.
Although analyses were limited to data recorded in the charts, the current findings "shed light on the clinical and demographic features associated with perinatal bipolar disorder," including a high level of functional impairment experienced by these women, the authors wrote. The high level of self-reported symptoms of elation and irritability "underscore the importance of consistently assessing for mania and hypomania during pregnancy and postpartum."
While bipolar disorder guidelines recommend maintenance pharmacotherapy and adjunctive psychotherapy, the authors say, "tailored psychosocial interventions have not yet been developed for this population. ... Patient-centered decision support and development of tailored adjunctive psychotherapies for perinatal [bipolar disorder] may play a key role in helping women with [bipolar disorder] remain engaged in treatment during pregnancy and postpartum."
Dr. Battle and her colleagues noted several limitations of the study. For example, because the methodology used was retrospective, their analyses were limited to data that had been recorded in the charts.
This study was unfunded; one author was supported in part through a National Institutes of Health mentored career development award. The authors reported no relevant financial conflicts of interest.
The clinical features of perinatal women with bipolar disorder are much more severe than those of women seeking care for other psychiatric conditions, including greater history of suicidal behavior and substance abuse, and more difficulties during childbirth and while breastfeeding, a retrospective study of 334 pregnant and postpartum women suggests.
Cynthia L. Battle, Ph.D., of Butler Hospital in Providence, R.I., and her colleagues reviewed the clinical records of the women, who sought treatment at a specialized partial hospitalization program that serves patients during pregnancy and the first postpartum year. Their ages ranged from 15 to 43 years, and they came from a range of ethnic backgrounds. Less than half of the women in the sample were either married or had partners (J. Affect. Disord. 2014;158:97-100). Two-thirds were postpartum, and one-third of them were pregnant.
The investigators asked the patients to complete the Edinburgh Postnatal Depression Scale and the facility’s Day Hospital Screener for self-reporting of psychiatric disorders, including bipolar disorder.
About 10% of women had a bipolar disorder diagnosis, including 19 with bipolar I disorder, 10 with bipolar II disorder, and 5 with bipolar not otherwise specified. Twenty-six percent reported bipolar disorder symptoms of elation, and 76% reported symptoms of irritability lasting 4 or more days within the previous month.
"Pregnant and postpartum women with [bipolar disorder] reported more extensive mental health histories, including prior use of pharmacotherapy and psychotherapy, as well as higher rates of prior substance abuse," the authors noted. Women with bipolar disorder were significantly more likely than those with other Axis I disorders to report prior suicidal behavior and attempts. A higher proportion of expectant mothers with bipolar disorder took psychotropics than did pregnant women with other disorders. Among postpartum women, mothers with bipolar disorder were more likely to report delivery complications and difficulties breastfeeding their babies.
Although analyses were limited to data recorded in the charts, the current findings "shed light on the clinical and demographic features associated with perinatal bipolar disorder," including a high level of functional impairment experienced by these women, the authors wrote. The high level of self-reported symptoms of elation and irritability "underscore the importance of consistently assessing for mania and hypomania during pregnancy and postpartum."
While bipolar disorder guidelines recommend maintenance pharmacotherapy and adjunctive psychotherapy, the authors say, "tailored psychosocial interventions have not yet been developed for this population. ... Patient-centered decision support and development of tailored adjunctive psychotherapies for perinatal [bipolar disorder] may play a key role in helping women with [bipolar disorder] remain engaged in treatment during pregnancy and postpartum."
Dr. Battle and her colleagues noted several limitations of the study. For example, because the methodology used was retrospective, their analyses were limited to data that had been recorded in the charts.
This study was unfunded; one author was supported in part through a National Institutes of Health mentored career development award. The authors reported no relevant financial conflicts of interest.
The clinical features of perinatal women with bipolar disorder are much more severe than those of women seeking care for other psychiatric conditions, including greater history of suicidal behavior and substance abuse, and more difficulties during childbirth and while breastfeeding, a retrospective study of 334 pregnant and postpartum women suggests.
Cynthia L. Battle, Ph.D., of Butler Hospital in Providence, R.I., and her colleagues reviewed the clinical records of the women, who sought treatment at a specialized partial hospitalization program that serves patients during pregnancy and the first postpartum year. Their ages ranged from 15 to 43 years, and they came from a range of ethnic backgrounds. Less than half of the women in the sample were either married or had partners (J. Affect. Disord. 2014;158:97-100). Two-thirds were postpartum, and one-third of them were pregnant.
The investigators asked the patients to complete the Edinburgh Postnatal Depression Scale and the facility’s Day Hospital Screener for self-reporting of psychiatric disorders, including bipolar disorder.
About 10% of women had a bipolar disorder diagnosis, including 19 with bipolar I disorder, 10 with bipolar II disorder, and 5 with bipolar not otherwise specified. Twenty-six percent reported bipolar disorder symptoms of elation, and 76% reported symptoms of irritability lasting 4 or more days within the previous month.
"Pregnant and postpartum women with [bipolar disorder] reported more extensive mental health histories, including prior use of pharmacotherapy and psychotherapy, as well as higher rates of prior substance abuse," the authors noted. Women with bipolar disorder were significantly more likely than those with other Axis I disorders to report prior suicidal behavior and attempts. A higher proportion of expectant mothers with bipolar disorder took psychotropics than did pregnant women with other disorders. Among postpartum women, mothers with bipolar disorder were more likely to report delivery complications and difficulties breastfeeding their babies.
Although analyses were limited to data recorded in the charts, the current findings "shed light on the clinical and demographic features associated with perinatal bipolar disorder," including a high level of functional impairment experienced by these women, the authors wrote. The high level of self-reported symptoms of elation and irritability "underscore the importance of consistently assessing for mania and hypomania during pregnancy and postpartum."
While bipolar disorder guidelines recommend maintenance pharmacotherapy and adjunctive psychotherapy, the authors say, "tailored psychosocial interventions have not yet been developed for this population. ... Patient-centered decision support and development of tailored adjunctive psychotherapies for perinatal [bipolar disorder] may play a key role in helping women with [bipolar disorder] remain engaged in treatment during pregnancy and postpartum."
Dr. Battle and her colleagues noted several limitations of the study. For example, because the methodology used was retrospective, their analyses were limited to data that had been recorded in the charts.
This study was unfunded; one author was supported in part through a National Institutes of Health mentored career development award. The authors reported no relevant financial conflicts of interest.
FROM JOURNAL OF AFFECTIVE DISORDERS
Major finding: Perinatal women with bipolar disorder have a greater history of suicidal behavior and substance abuse, and report more difficulties during delivery and while breastfeeding, than do women with other psychiatric disorders.
Data source: A chart review of 334 women who sought treatment at a specialized partial hospitalization program serving perinatal women with psychiatric conditions. A third of the women were pregnant; two-thirds were postpartum.
Disclosures: This study was unfunded; one author was supported in part through a National Institutes of Health mentored career development award. The authors reported no relevant financial conflicts of interest.
Personal health records help mentally ill patients with comorbidities access medical services
Personal health records can help people with serious mental illnesses and comorbid medical conditions improve the quality of their medical care, according to a randomized trial of 170 patients.
Patients with serious mental illnesses and at least one comorbid medical condition were recruited from a community mental health center by Dr. Benjamin G. Druss, professor and Rosalynn Carter Chair in Mental Health at Emory University in Atlanta, and his colleagues. The mean age of the patients was 49; most (83.5%) were African American and had a mean annual income of less than $7,000. Nearly half had major depression and 28% had schizophrenia. Other patients had schizoaffective disorder, bipolar disorder, or posttraumatic stress disorder. Overall, patients had an average 2.3 comorbid chronic medical diagnoses such as diabetes, hyperlipidemia, and hypertension.
The investigators assigned half of the patients to use of a personal health record (PHR) for a 1-year period and helped patients set them up; the other half did not use PHRs (Am. J. Psychiatry 2014;171:360-8).
Dr. Druss and his colleagues adapted an available PHR system for participants by rewriting elements to a sixth-grade reading level, adding a section on mental health and health goals, adding a mental health advanced directive section listing patient preferences for mental health care, and providing a list of resources such as local grocery stores and health providers in patients’ neighborhoods. They gave participants computer training and set up a computer workstation at the mental health clinic.
Overall, those in the PHR group accessed their PHRs an average of 42 times over the course of the year. The proportion of eligible preventive services received "increased in the PHR group from 24% at baseline to 40% at the 12-month follow-up, compared with a decline in the usual care group from 25% to 18% (P less than .001)." The PHR group had "significantly greater improvements in rates of physical examination (P less than .001), screening (P = .02), vaccination (P less than .001), and education (P less than .001)."
Among 118 patients with cardiometabolic conditions, the proportion of cardiometabolic services received "improved by 2 percentage points in the personal health record group but declined by 11 percentage points in the usual care group, resulting in a significant difference in change between the two groups (P = .003)."
"Having a personal health record resulted in significantly improved quality of medical care and increased use of medical services among patients," Dr. Druss and his colleagues wrote. "Personal health records could provide a relatively low-cost, scalable strategy for improving medical care for patients with comorbid medical and serious mental illnesses."
The limitations cited by Dr. Druss and his colleagues included the study’s focus on patients in one urban community health center. "Further work is needed to establish generalizability to other mental health settings," they wrote. Also, the study focused on those patients who had a regular mental health care provider, which suggests that access issues would need to be addressed for those without a regular source of care before this kind of approach could be broadly implemented.
The study was supported by the Agency for Healthcare Research and Quality. The authors reported no relevant financial conflicts of interest.
Personal health records can help people with serious mental illnesses and comorbid medical conditions improve the quality of their medical care, according to a randomized trial of 170 patients.
Patients with serious mental illnesses and at least one comorbid medical condition were recruited from a community mental health center by Dr. Benjamin G. Druss, professor and Rosalynn Carter Chair in Mental Health at Emory University in Atlanta, and his colleagues. The mean age of the patients was 49; most (83.5%) were African American and had a mean annual income of less than $7,000. Nearly half had major depression and 28% had schizophrenia. Other patients had schizoaffective disorder, bipolar disorder, or posttraumatic stress disorder. Overall, patients had an average 2.3 comorbid chronic medical diagnoses such as diabetes, hyperlipidemia, and hypertension.
The investigators assigned half of the patients to use of a personal health record (PHR) for a 1-year period and helped patients set them up; the other half did not use PHRs (Am. J. Psychiatry 2014;171:360-8).
Dr. Druss and his colleagues adapted an available PHR system for participants by rewriting elements to a sixth-grade reading level, adding a section on mental health and health goals, adding a mental health advanced directive section listing patient preferences for mental health care, and providing a list of resources such as local grocery stores and health providers in patients’ neighborhoods. They gave participants computer training and set up a computer workstation at the mental health clinic.
Overall, those in the PHR group accessed their PHRs an average of 42 times over the course of the year. The proportion of eligible preventive services received "increased in the PHR group from 24% at baseline to 40% at the 12-month follow-up, compared with a decline in the usual care group from 25% to 18% (P less than .001)." The PHR group had "significantly greater improvements in rates of physical examination (P less than .001), screening (P = .02), vaccination (P less than .001), and education (P less than .001)."
Among 118 patients with cardiometabolic conditions, the proportion of cardiometabolic services received "improved by 2 percentage points in the personal health record group but declined by 11 percentage points in the usual care group, resulting in a significant difference in change between the two groups (P = .003)."
"Having a personal health record resulted in significantly improved quality of medical care and increased use of medical services among patients," Dr. Druss and his colleagues wrote. "Personal health records could provide a relatively low-cost, scalable strategy for improving medical care for patients with comorbid medical and serious mental illnesses."
The limitations cited by Dr. Druss and his colleagues included the study’s focus on patients in one urban community health center. "Further work is needed to establish generalizability to other mental health settings," they wrote. Also, the study focused on those patients who had a regular mental health care provider, which suggests that access issues would need to be addressed for those without a regular source of care before this kind of approach could be broadly implemented.
The study was supported by the Agency for Healthcare Research and Quality. The authors reported no relevant financial conflicts of interest.
Personal health records can help people with serious mental illnesses and comorbid medical conditions improve the quality of their medical care, according to a randomized trial of 170 patients.
Patients with serious mental illnesses and at least one comorbid medical condition were recruited from a community mental health center by Dr. Benjamin G. Druss, professor and Rosalynn Carter Chair in Mental Health at Emory University in Atlanta, and his colleagues. The mean age of the patients was 49; most (83.5%) were African American and had a mean annual income of less than $7,000. Nearly half had major depression and 28% had schizophrenia. Other patients had schizoaffective disorder, bipolar disorder, or posttraumatic stress disorder. Overall, patients had an average 2.3 comorbid chronic medical diagnoses such as diabetes, hyperlipidemia, and hypertension.
The investigators assigned half of the patients to use of a personal health record (PHR) for a 1-year period and helped patients set them up; the other half did not use PHRs (Am. J. Psychiatry 2014;171:360-8).
Dr. Druss and his colleagues adapted an available PHR system for participants by rewriting elements to a sixth-grade reading level, adding a section on mental health and health goals, adding a mental health advanced directive section listing patient preferences for mental health care, and providing a list of resources such as local grocery stores and health providers in patients’ neighborhoods. They gave participants computer training and set up a computer workstation at the mental health clinic.
Overall, those in the PHR group accessed their PHRs an average of 42 times over the course of the year. The proportion of eligible preventive services received "increased in the PHR group from 24% at baseline to 40% at the 12-month follow-up, compared with a decline in the usual care group from 25% to 18% (P less than .001)." The PHR group had "significantly greater improvements in rates of physical examination (P less than .001), screening (P = .02), vaccination (P less than .001), and education (P less than .001)."
Among 118 patients with cardiometabolic conditions, the proportion of cardiometabolic services received "improved by 2 percentage points in the personal health record group but declined by 11 percentage points in the usual care group, resulting in a significant difference in change between the two groups (P = .003)."
"Having a personal health record resulted in significantly improved quality of medical care and increased use of medical services among patients," Dr. Druss and his colleagues wrote. "Personal health records could provide a relatively low-cost, scalable strategy for improving medical care for patients with comorbid medical and serious mental illnesses."
The limitations cited by Dr. Druss and his colleagues included the study’s focus on patients in one urban community health center. "Further work is needed to establish generalizability to other mental health settings," they wrote. Also, the study focused on those patients who had a regular mental health care provider, which suggests that access issues would need to be addressed for those without a regular source of care before this kind of approach could be broadly implemented.
The study was supported by the Agency for Healthcare Research and Quality. The authors reported no relevant financial conflicts of interest.
FROM THE AMERICAN JOURNAL OF PSYCHIATRY
Major finding: The proportion of eligible preventive services received increased in the PHR group from 24% at baseline to 40% at the 12-month follow-up, compared with a decline in the usual care group from 25% to 18% (P less than .001). The PHR group had significantly greater improvements in rates of physical examination (P less than .001), screening (P = .02), vaccination (P less than .001), and education (P less than .001)."
Data source: A randomized trial of 170 people with a serious mental disorder and at least one comorbid condition treated at a community mental health center.
Disclosures: The study was supported by the Agency for Healthcare Research and Quality. The authors reported no conflicts of interest.
Combination therapy brought lasting benefits in bipolar disorder
Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.
"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.
The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).
In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).
Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.
The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.
Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.
Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).
It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."
Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.
Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.
"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.
The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).
In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).
Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.
The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.
Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.
Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).
It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."
Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.
Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.
"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.
The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).
In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).
Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.
The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.
Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.
Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).
It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."
Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.
FROM EUROPEAN PSYCHIATRY
Major findings: Mania symptoms remained unchanged (P = .093) among patients in the experimental group and increased significantly among those in the control group (P = .003).
Data source: The results are based in an analysis of outpatients diagnosed with refractory bipolar disorder who were being treated at the Center for Mental Health of Las Palmas in Spain between 2005 and 2006.
Disclosures: Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.
AIM subscale scores measure affective intensity in bipolar I, II
Affect Intensity Measure subscale scores can be used to help understand the complexity of emotions experienced by patients with bipolar disorder I and II, a study of 310 outpatients suggests.
Furthermore, four factors – positive affectivity, "unpeacefulness" (lack of serenity), negative reactivity, and negative intensity – allow clinicians to "explore more subtle components characterizing various aspects of emotional response" among patients with both types of bipolar, Flavie Mathieu, Ph.D., Dr. Bruno Etain, and their colleagues reported (J. Affect. Disord. 2014;157:8-13).
The Affect Intensity Measure (AIM) is a 40-item questionnaire designed to measure the extent to which patients experience emotion.
For the study, Dr. Mathieu, Dr. Etain, and their colleagues recruited patients at four university-affiliated psychiatric departments in France. All of the patients included in the study were aged 18 years or older (mean age, 42.4 years). In all, 233 of the patients met the DSM-IV criteria for bipolar disorder I, 65 met the criteria for bipolar II, and 12 for bipolar not otherwise specified, wrote Dr. Mathieu of Université Paris Diderot, Dr. Etain of Hôpital Albert Chenevier, Créteil, France, and their colleagues.
The team developed a French translation of the AIM and got it "backtranslated" by an independent translator. The patients were asked to describe their affect during euthymic periods rather than during either manic or depressive episodes. Euthymic states were confirmed based on the patients’ scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Mania Rating Scale.
No statistically significant association was found between the patients’ total AIM scores and the clinical characteristics of bipolar disorder. However, when the investigators looked at the four factors, they found significant associations between the AIM subscale scores and bipolar disorder characteristics. For example, the unpeacefulness subscale score was associated with the onset of psychotic symptoms (P = .0006) and substance misuse (P = .008). The negative intensity subscale score was associated with social phobia (P = .0005).
The investigators cited several limitations. For example, they found no correlation between the patients’ total AIM scores and MADRS scores, which suggests that "AIM total score is not necessarily influenced by depression."
Despite these limitations, the investigators said their findings "suggest that assessment of affective intensity using this self-report scale may be useful in clinical settings but also as a means of further characterizing [bipolar disorder] phenotypes in future research."
The research was funded by INSERM, Assistance Publique des Hôpitaux de Paris, Agence National pour la Recherche, and the Fondation FondaMental. The authors reported no financial conflicts.
 |
| Dr. Igor I. Galynker |
Without comparison groups, however, one cannot conclude that the AIM structure is specific to BD; it could be the same across all diagnoses. Thus, before any practical use is possible, further research should optimize and validate the AIM subscales, both in BD and in other diagnoses.
Dr. Igor I. Galynker is director of the Family Center for Bipolar and associate chairman, department of psychiatry and behavioral sciences, Beth Israel Medical Center, New York.
|
| Dr. Igor I. Galynker |
Without comparison groups, however, one cannot conclude that the AIM structure is specific to BD; it could be the same across all diagnoses. Thus, before any practical use is possible, further research should optimize and validate the AIM subscales, both in BD and in other diagnoses.
Dr. Igor I. Galynker is director of the Family Center for Bipolar and associate chairman, department of psychiatry and behavioral sciences, Beth Israel Medical Center, New York.
|
| Dr. Igor I. Galynker |
Without comparison groups, however, one cannot conclude that the AIM structure is specific to BD; it could be the same across all diagnoses. Thus, before any practical use is possible, further research should optimize and validate the AIM subscales, both in BD and in other diagnoses.
Dr. Igor I. Galynker is director of the Family Center for Bipolar and associate chairman, department of psychiatry and behavioral sciences, Beth Israel Medical Center, New York.
Affect Intensity Measure subscale scores can be used to help understand the complexity of emotions experienced by patients with bipolar disorder I and II, a study of 310 outpatients suggests.
Furthermore, four factors – positive affectivity, "unpeacefulness" (lack of serenity), negative reactivity, and negative intensity – allow clinicians to "explore more subtle components characterizing various aspects of emotional response" among patients with both types of bipolar, Flavie Mathieu, Ph.D., Dr. Bruno Etain, and their colleagues reported (J. Affect. Disord. 2014;157:8-13).
The Affect Intensity Measure (AIM) is a 40-item questionnaire designed to measure the extent to which patients experience emotion.
For the study, Dr. Mathieu, Dr. Etain, and their colleagues recruited patients at four university-affiliated psychiatric departments in France. All of the patients included in the study were aged 18 years or older (mean age, 42.4 years). In all, 233 of the patients met the DSM-IV criteria for bipolar disorder I, 65 met the criteria for bipolar II, and 12 for bipolar not otherwise specified, wrote Dr. Mathieu of Université Paris Diderot, Dr. Etain of Hôpital Albert Chenevier, Créteil, France, and their colleagues.
The team developed a French translation of the AIM and got it "backtranslated" by an independent translator. The patients were asked to describe their affect during euthymic periods rather than during either manic or depressive episodes. Euthymic states were confirmed based on the patients’ scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Mania Rating Scale.
No statistically significant association was found between the patients’ total AIM scores and the clinical characteristics of bipolar disorder. However, when the investigators looked at the four factors, they found significant associations between the AIM subscale scores and bipolar disorder characteristics. For example, the unpeacefulness subscale score was associated with the onset of psychotic symptoms (P = .0006) and substance misuse (P = .008). The negative intensity subscale score was associated with social phobia (P = .0005).
The investigators cited several limitations. For example, they found no correlation between the patients’ total AIM scores and MADRS scores, which suggests that "AIM total score is not necessarily influenced by depression."
Despite these limitations, the investigators said their findings "suggest that assessment of affective intensity using this self-report scale may be useful in clinical settings but also as a means of further characterizing [bipolar disorder] phenotypes in future research."
The research was funded by INSERM, Assistance Publique des Hôpitaux de Paris, Agence National pour la Recherche, and the Fondation FondaMental. The authors reported no financial conflicts.
Affect Intensity Measure subscale scores can be used to help understand the complexity of emotions experienced by patients with bipolar disorder I and II, a study of 310 outpatients suggests.
Furthermore, four factors – positive affectivity, "unpeacefulness" (lack of serenity), negative reactivity, and negative intensity – allow clinicians to "explore more subtle components characterizing various aspects of emotional response" among patients with both types of bipolar, Flavie Mathieu, Ph.D., Dr. Bruno Etain, and their colleagues reported (J. Affect. Disord. 2014;157:8-13).
The Affect Intensity Measure (AIM) is a 40-item questionnaire designed to measure the extent to which patients experience emotion.
For the study, Dr. Mathieu, Dr. Etain, and their colleagues recruited patients at four university-affiliated psychiatric departments in France. All of the patients included in the study were aged 18 years or older (mean age, 42.4 years). In all, 233 of the patients met the DSM-IV criteria for bipolar disorder I, 65 met the criteria for bipolar II, and 12 for bipolar not otherwise specified, wrote Dr. Mathieu of Université Paris Diderot, Dr. Etain of Hôpital Albert Chenevier, Créteil, France, and their colleagues.
The team developed a French translation of the AIM and got it "backtranslated" by an independent translator. The patients were asked to describe their affect during euthymic periods rather than during either manic or depressive episodes. Euthymic states were confirmed based on the patients’ scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Mania Rating Scale.
No statistically significant association was found between the patients’ total AIM scores and the clinical characteristics of bipolar disorder. However, when the investigators looked at the four factors, they found significant associations between the AIM subscale scores and bipolar disorder characteristics. For example, the unpeacefulness subscale score was associated with the onset of psychotic symptoms (P = .0006) and substance misuse (P = .008). The negative intensity subscale score was associated with social phobia (P = .0005).
The investigators cited several limitations. For example, they found no correlation between the patients’ total AIM scores and MADRS scores, which suggests that "AIM total score is not necessarily influenced by depression."
Despite these limitations, the investigators said their findings "suggest that assessment of affective intensity using this self-report scale may be useful in clinical settings but also as a means of further characterizing [bipolar disorder] phenotypes in future research."
The research was funded by INSERM, Assistance Publique des Hôpitaux de Paris, Agence National pour la Recherche, and the Fondation FondaMental. The authors reported no financial conflicts.
FROM THE JOURNAL OF AFFECTIVE DISORDERS
Major finding: The unpeacefulness subscale score on the Affect Intensity Measure was associated with the onset of psychotic symptoms (P = .0006) and substance misuse (P = .008). The negative intensity subscale score was associated with social phobia (P = .0005).
Data source: An analysis of data on 310 inpatients with bipolar I, bipolar II, or bipolar NOS at four university-affiliated hospitals in France.
Disclosures: The research was funded by INSERM, Assistance Publique des Hôpitaux de Paris, Agence National pour la Recherche, and the Fondation FondaMental. The authors reported no financial conflicts.
Group issues recommendations for genetic susceptibility testing for carbamazepine skin reactions
Genetic testing for alleles that affect histocompatibility should be the rule for patients who initiate the drug carbamazepine, according to new recommendations issued by the Canadian Pharmacogenomics Network for Drug Safety.
Two variants are associated with the severe, sometimes deadly, skin reactions that carbamazepine can bring on, usually within the first 3 months of therapy. One (HLA-B*15-02) is a particularly high-risk allele that is not uncommon in patients of Chinese, Thai, Malaysian, and Indian descent. It’s strongly associated with Stevens-Johnson syndrome and toxic epidermal necrolysis in those taking carbamazepine.
HLA-A*31:01 has been found among white, Japanese, Korean, and Chinese patients; in fact, it is somewhat common in most ethnic groups and people of mixed descent. This allele is associated with Stevens-Johnson, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis, as well as some of the less-severe skin reactions, said Dr. Ursula Amstutz of the University of British Columbia, Vancouver, and her colleagues in the Network’s clinical recommendation group (Epilepsia 2014 March 5 [doi:10.1111/epi.12564]).
Genetic testing for the variants should be carried out before initiating treatment or within the first 3 months of treatment. But patients who have not had a reaction after at least 3 months’ treatment don’t need to be screened, advised the group, which used a systematic review of the literature to develop an expert consensus on the recommendations.
The group’s other recommendations include:
• Testing for HLA-B*15-02 should be done in all patients of the susceptible ethnic groups before treatment begins. It’s optional in groups where it is uncommon, but all drug-naïve patients should probably undergo the test.
• All patients, regardless of ethnicity, should undergo testing for HLA-A*31:01.
• Genetic testing should be done in patients who have previously experienced a skin reaction while taking carbamazepine, regardless of how long they have taken it.
• Negative tests don’t entirely rule out the possibility of a reaction, so patients, families, and physicians should still be alert for any early signs that one could develop.
One author was been a paid consultant for Novartis in legal cases relevant to carbamazepine-induced hypersensitivity. The others reported no relevant financial conflicts.
On Twitter @alz_gal
Genetic testing for alleles that affect histocompatibility should be the rule for patients who initiate the drug carbamazepine, according to new recommendations issued by the Canadian Pharmacogenomics Network for Drug Safety.
Two variants are associated with the severe, sometimes deadly, skin reactions that carbamazepine can bring on, usually within the first 3 months of therapy. One (HLA-B*15-02) is a particularly high-risk allele that is not uncommon in patients of Chinese, Thai, Malaysian, and Indian descent. It’s strongly associated with Stevens-Johnson syndrome and toxic epidermal necrolysis in those taking carbamazepine.
HLA-A*31:01 has been found among white, Japanese, Korean, and Chinese patients; in fact, it is somewhat common in most ethnic groups and people of mixed descent. This allele is associated with Stevens-Johnson, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis, as well as some of the less-severe skin reactions, said Dr. Ursula Amstutz of the University of British Columbia, Vancouver, and her colleagues in the Network’s clinical recommendation group (Epilepsia 2014 March 5 [doi:10.1111/epi.12564]).
Genetic testing for the variants should be carried out before initiating treatment or within the first 3 months of treatment. But patients who have not had a reaction after at least 3 months’ treatment don’t need to be screened, advised the group, which used a systematic review of the literature to develop an expert consensus on the recommendations.
The group’s other recommendations include:
• Testing for HLA-B*15-02 should be done in all patients of the susceptible ethnic groups before treatment begins. It’s optional in groups where it is uncommon, but all drug-naïve patients should probably undergo the test.
• All patients, regardless of ethnicity, should undergo testing for HLA-A*31:01.
• Genetic testing should be done in patients who have previously experienced a skin reaction while taking carbamazepine, regardless of how long they have taken it.
• Negative tests don’t entirely rule out the possibility of a reaction, so patients, families, and physicians should still be alert for any early signs that one could develop.
One author was been a paid consultant for Novartis in legal cases relevant to carbamazepine-induced hypersensitivity. The others reported no relevant financial conflicts.
On Twitter @alz_gal
Genetic testing for alleles that affect histocompatibility should be the rule for patients who initiate the drug carbamazepine, according to new recommendations issued by the Canadian Pharmacogenomics Network for Drug Safety.
Two variants are associated with the severe, sometimes deadly, skin reactions that carbamazepine can bring on, usually within the first 3 months of therapy. One (HLA-B*15-02) is a particularly high-risk allele that is not uncommon in patients of Chinese, Thai, Malaysian, and Indian descent. It’s strongly associated with Stevens-Johnson syndrome and toxic epidermal necrolysis in those taking carbamazepine.
HLA-A*31:01 has been found among white, Japanese, Korean, and Chinese patients; in fact, it is somewhat common in most ethnic groups and people of mixed descent. This allele is associated with Stevens-Johnson, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis, as well as some of the less-severe skin reactions, said Dr. Ursula Amstutz of the University of British Columbia, Vancouver, and her colleagues in the Network’s clinical recommendation group (Epilepsia 2014 March 5 [doi:10.1111/epi.12564]).
Genetic testing for the variants should be carried out before initiating treatment or within the first 3 months of treatment. But patients who have not had a reaction after at least 3 months’ treatment don’t need to be screened, advised the group, which used a systematic review of the literature to develop an expert consensus on the recommendations.
The group’s other recommendations include:
• Testing for HLA-B*15-02 should be done in all patients of the susceptible ethnic groups before treatment begins. It’s optional in groups where it is uncommon, but all drug-naïve patients should probably undergo the test.
• All patients, regardless of ethnicity, should undergo testing for HLA-A*31:01.
• Genetic testing should be done in patients who have previously experienced a skin reaction while taking carbamazepine, regardless of how long they have taken it.
• Negative tests don’t entirely rule out the possibility of a reaction, so patients, families, and physicians should still be alert for any early signs that one could develop.
One author was been a paid consultant for Novartis in legal cases relevant to carbamazepine-induced hypersensitivity. The others reported no relevant financial conflicts.
On Twitter @alz_gal
FROM EPILEPSIA
Pharmacist discovery spurs recall of extended-release venlafaxine
Different lots of brand-name and generic versions of extended-release venlafaxine are being recalled because of a report that one bottle contained a capsule of the antiarrhythmic drug dofetilide, according to the Food and Drug Administration.
A statement posted March 7 on the agency’s MedWatch site said that Pfizer has issued a voluntary recall of one lot of 30-count venlafaxine 150-mg extended-release capsules (marketed as Effexor XR), one lot of 90-count Effexor XR 150-mg capsules, and one lot of 90-count Greenstone LLC brand of venlafaxine 150-mg extended release capsules.
The recall was spurred by a pharmacist’s report that a 0.25-mg capsule of dofetilide (Tikosyn) was found in a bottle of Effexor XR.
"The use of Tikosyn by an Effexor XR/Venlafaxine HCl patient, where the contraindications and drug-drug interactions with Tikosyn have not been considered by the prescribing physician, could cause serious adverse health consequences that could be fatal," the notice said.
Tikosyn, also manufactured by Pfizer, is a class III antiarrhythmic drug that is approved for treating atrial fibrillation/atrial flutter. The drug’s label includes a black box warning that recommends patients start treatment in a facility where they can be closely monitored, to minimize the risk of a dofetilide-induced arrhythmia. There is also a Risk Evaluation and Mitigation Strategy (REMS) in place that addresses this risk. The affected venlafaxine XR products are Pfizer lot numbers V130142 and V130140, which both expire in October 2015; and Greenstone lot number V130014, which expires in August 2015. Patients who have the affected product are being advised to call their physicians and/or return the product to their pharmacies. The FDA advises patients with questions to call Stericycle at 888-345-0481 (Mon.-Fri., 8 a.m. to 5 p.m., Eastern time); or Pfizer, at 800-438-1985 (Mon.-Thur., 9 a.m. to 8 p.m., Eastern time or Fri., 9 a.m. to 5 p.m., Eastern time).
Adverse events associated with the use of these products should be reported to MedWatch at or 800-332-1088.
Different lots of brand-name and generic versions of extended-release venlafaxine are being recalled because of a report that one bottle contained a capsule of the antiarrhythmic drug dofetilide, according to the Food and Drug Administration.
A statement posted March 7 on the agency’s MedWatch site said that Pfizer has issued a voluntary recall of one lot of 30-count venlafaxine 150-mg extended-release capsules (marketed as Effexor XR), one lot of 90-count Effexor XR 150-mg capsules, and one lot of 90-count Greenstone LLC brand of venlafaxine 150-mg extended release capsules.
The recall was spurred by a pharmacist’s report that a 0.25-mg capsule of dofetilide (Tikosyn) was found in a bottle of Effexor XR.
"The use of Tikosyn by an Effexor XR/Venlafaxine HCl patient, where the contraindications and drug-drug interactions with Tikosyn have not been considered by the prescribing physician, could cause serious adverse health consequences that could be fatal," the notice said.
Tikosyn, also manufactured by Pfizer, is a class III antiarrhythmic drug that is approved for treating atrial fibrillation/atrial flutter. The drug’s label includes a black box warning that recommends patients start treatment in a facility where they can be closely monitored, to minimize the risk of a dofetilide-induced arrhythmia. There is also a Risk Evaluation and Mitigation Strategy (REMS) in place that addresses this risk. The affected venlafaxine XR products are Pfizer lot numbers V130142 and V130140, which both expire in October 2015; and Greenstone lot number V130014, which expires in August 2015. Patients who have the affected product are being advised to call their physicians and/or return the product to their pharmacies. The FDA advises patients with questions to call Stericycle at 888-345-0481 (Mon.-Fri., 8 a.m. to 5 p.m., Eastern time); or Pfizer, at 800-438-1985 (Mon.-Thur., 9 a.m. to 8 p.m., Eastern time or Fri., 9 a.m. to 5 p.m., Eastern time).
Adverse events associated with the use of these products should be reported to MedWatch at or 800-332-1088.
Different lots of brand-name and generic versions of extended-release venlafaxine are being recalled because of a report that one bottle contained a capsule of the antiarrhythmic drug dofetilide, according to the Food and Drug Administration.
A statement posted March 7 on the agency’s MedWatch site said that Pfizer has issued a voluntary recall of one lot of 30-count venlafaxine 150-mg extended-release capsules (marketed as Effexor XR), one lot of 90-count Effexor XR 150-mg capsules, and one lot of 90-count Greenstone LLC brand of venlafaxine 150-mg extended release capsules.
The recall was spurred by a pharmacist’s report that a 0.25-mg capsule of dofetilide (Tikosyn) was found in a bottle of Effexor XR.
"The use of Tikosyn by an Effexor XR/Venlafaxine HCl patient, where the contraindications and drug-drug interactions with Tikosyn have not been considered by the prescribing physician, could cause serious adverse health consequences that could be fatal," the notice said.
Tikosyn, also manufactured by Pfizer, is a class III antiarrhythmic drug that is approved for treating atrial fibrillation/atrial flutter. The drug’s label includes a black box warning that recommends patients start treatment in a facility where they can be closely monitored, to minimize the risk of a dofetilide-induced arrhythmia. There is also a Risk Evaluation and Mitigation Strategy (REMS) in place that addresses this risk. The affected venlafaxine XR products are Pfizer lot numbers V130142 and V130140, which both expire in October 2015; and Greenstone lot number V130014, which expires in August 2015. Patients who have the affected product are being advised to call their physicians and/or return the product to their pharmacies. The FDA advises patients with questions to call Stericycle at 888-345-0481 (Mon.-Fri., 8 a.m. to 5 p.m., Eastern time); or Pfizer, at 800-438-1985 (Mon.-Thur., 9 a.m. to 8 p.m., Eastern time or Fri., 9 a.m. to 5 p.m., Eastern time).
Adverse events associated with the use of these products should be reported to MedWatch at or 800-332-1088.
High-yield techniques in brief CBT sessions can promote adherence
SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.
Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.
"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.
It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.
Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.
Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.
In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.
Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.
And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.
Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.
Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.
Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.
She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.
Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.
"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.
Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.
An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.
Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.
These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.
As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.
Cognitions that can interfere with adherence include:
• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.
• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.
• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.
• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.
Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.
Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).
SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.
Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.
"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.
It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.
Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.
Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.
In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.
Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.
And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.
Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.
Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.
Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.
She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.
Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.
"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.
Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.
An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.
Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.
These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.
As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.
Cognitions that can interfere with adherence include:
• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.
• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.
• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.
• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.
Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.
Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).
SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.
Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.
"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.
It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.
Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.
Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.
In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.
Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.
And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.
Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.
Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.
Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.
She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.
Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.
"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.
Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.
An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.
Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.
These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.
As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.
Cognitions that can interfere with adherence include:
• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.
• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.
• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.
• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.
Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.
Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).
AT THE AMERICAN COLLEGE OF PSYCHIATRISTS MEETING
