Biomedical subjects

A C Leon

Publications and source records attributed to A C Leon.

At least 91 records · Page 5Linked to original sources

PubMed1996

Evaluation of screens for mental disorders in primary care: methodological issues.

Several brief screens are available to help identify mental disorders in primary care. In choosing among them, an investigator must consider the clinical research setting, the sampling framework, and the strategy used to assess the reliability and validity of the instruments. These issues are considered in the context of the study that revised the Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) for the DSM-IV. The sample size determination strategy used in that study rendered a sample that was large enough to allow for a split-sample approach to data analysis. The screen algorithms were developed on an index sample, and the operating characteristics were cross-validated with data from a separate sample. Standard operating characteristics as well as chance-corrected, or quality operating characteristics were used to evaluate the construct validity of the screens. Criterion-related validity of the screens was evaluated by examining functional impairment. Screens such as these may be valuable clinical and research tools for psychiatric diagnosis in primary care.

Humans↗

PubMed1995

Fatal injuries after cocaine use as a leading cause of death among young adults in New York City.

BACKGROUND: Cocaine intoxication can lead to fatal cardiovascular and cerebrovascular events. In addition, the neurobehavioral effects of cocaine may increase the likelihood that a user will receive violent fatal injuries. Since New York City is a center for the importation and distribution of cocaine, we sought to determine the extent of cocaine use among city residents with fatal injuries. METHODS: Among a total of 14,843 residents of New York City who received fatal injuries from 1990 through 1992, we determined the proportion who used cocaine shortly before their deaths. We also determined the population-based rates of fatal injuries that were known to follow cocaine use and the proportion of all deaths of New York City residents that was represented by these cases for each demographic stratum. For adults 15 to 44 years of age, fatal injury after cocaine use was ranked with other causes of death as though it was a separate cause. RESULTS: Cocaine use, as measured by the detection of the metabolite benzoylecgonine in urine or blood, was found in 26.7 percent of all New York City residents receiving fatal injuries; free cocaine was detected in 18.3 percent. Approximately one third of deaths after cocaine use were the result of drug intoxication, but two thirds involved traumatic injuries resulting from homicides, suicides, traffic accidents, and falls. If fatal injury after cocaine use was considered as a separate cause of death, it would rank among the five leading causes of death among those 15 to 44 years of age in New York City. CONCLUSIONS: Fatal injuries among cocaine users account for a substantial proportion of all deaths among young adults in New York City.

Adolescent↗

PubMed1995

Prevalence of mental disorders in primary care. Implications for screening.

OBJECTIVES: To determine the prevalence of five mental disorders in primary care and to identify patient groups that have a relatively high prevalence of these disorders. DESIGN: Two-stage case identification design that involves administration of a 16-item screening instrument followed by an independent diagnostic assessment. SETTING: Three family practice offices in Rhode Island. SUBJECTS: A total of 937 primary care patients completed the brief screen, 388 of whom completed the independent diagnostic assessment. PREVALENCE ESTIMATION: A Bayesian procedure was used to estimate prevalence of mental disorder from screening and assessment results. Independent assessments were based on the Structured Clinical Interview for DSM-III-R administered by a mental health professional. RESULTS: The prevalence estimates were alcohol abuse or dependence, 3.2%; generalized anxiety disorder, 2.8%; major depressive disorder, 14.1%; obsessive-compulsive disorder, 2.2%; panic disorder, 6.2%; and any of the five disorders, 22.0%. The prevalence of any of the five disorders was higher in patients returning for follow-up visits (27.9%) than in those either presenting with a new illness (21.7%) or seeking a routine physical examination (11.8%). The combined prevalence was also higher in patients with a chronic medical problem (25.8%) than in those without (16.7%). CONCLUSIONS: Patients returning for follow-up care and, to a lesser extent, those with chronic medical problems appear to be at increased risk of having a mental disorder. The practice of selectively screening new patients for mental health problems is questioned. Screening efforts in primary care should include established patients and those with chronic medical illnesses as well as new patients.

Adult↗

PubMed1995

Development and validation of the SDDS-PC screen for multiple mental disorders in primary care.

OBJECTIVE: To develop, validate, and cross-validate a patient-completed screen for multiple mental disorders in primary care. DESIGN: Comparison of a patient self-report screen with an independent diagnostic assessment by mental health professionals using the Structured Clinical Interview for DSM-III-R diagnoses as criterion standard. SETTING: Three Rhode Island family practices and a South Carolina family medicine residency. SUBJECTS: In the initial validation study, 937 patients in Rhode Island were screened; 388 were interviewed. In the cross-validation study, 775 patients were screened in Rhode Island and South Carolina, and 257 were interviewed. SCREEN ITEMS: Sixty-two questions pertaining to nine mental disorders and suicidal ideation. RESULTS: A 16-item screen remained after analysis of item and scale performance. Sensitivity, specificity, and positive predictive value, respectively, were calculated for the following scales: alcohol abuse or dependence (62%, 98%, and 54%), generalized anxiety disorder (90%, 54%, and 5%), major depression (90%, 77%, and 40%), obsessive-compulsive disorder (65%, 73%, and 5%), panic disorder (78%, 80%, and 21%), and suicidal ideation (43%, 91%, and 51%). Replication in a new sample showed attenuated but acceptable operating characteristics for cross-validation. CONCLUSIONS: The Symptom-Driven Diagnostic System for Primary Care screen assesses multiple mental disorders that are common to primary care. It serves as a sensitive, valid, and patient-friendly first step in a new approach to recognizing and managing mental disorders in primary care. Finally, it aids the primary care clinician in selecting an appropriate diagnostic interview module for the disease for which the patient screened positive.

Adult↗

PubMed1995

Brief diagnostic interviews (SDDS-PC) for multiple mental disorders in primary care. A pilot study.

OBJECTIVE: To pilot test the feasibility and validity of new, brief, structured, physician-administered diagnostic interviews for six mental disorders in primary care patients identified from a patient-completed screen. DESIGN: Comparison of the new diagnostic interviews with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, version P (SCID-P), administered independently by a mental health professional. SETTING: Three Rhode Island family practices and a South Carolina family medicine residency. SUBJECTS: Consecutive patients of either sex, aged 18 to 70 years, who were able to read and write English were eligible for screening; 775 patients completed the screen. Of these, 246 screened positive for at least one disorder and received at least one module. Of these, 158 received a SCID-P interview. RESULTS: The diagnostic interviews were found useful by all 16 participating physicians. Eighty-seven percent reported that they diagnosed a new mental problem, and 93% said that the modules clarified suspected symptoms. However, 26% thought the procedure was too time consuming, and 80% believed that reimbursement would be necessary for routine use. Detection of cases using the diagnostic modules was associated with physician intervention and with independent assessment of patient impairment. Over three quarters of the patients (76.4%) who were classified as positive by the physician interview for any of the diagnoses also tested positive on the SCID-P. Two thirds of the patients (62.7%) with at least one of the disorders (according to SCID-P) were classified by the physician interview as having a mental disorder. However, the operating characteristics varied across specific disorders and indicated a need for revisions and testing in larger samples. CONCLUSIONS: These brief physician-administered diagnostic interview modules are part of a screening and diagnostic system (Symptom-Driven Diagnostic System for Primary Care [SDDS-PC], The UpJohn Co, Kalamazoo, Mich) to detect mental disorders in primary care patients. The pilot results help establish their feasibility and validity.

Adult↗

PubMed1995

More reliable outcome measures can reduce sample size requirements.

In the design of a clinical trial, considerations of statistical power primarily involve the evaluation of prospective sample sizes. Another strategy for increasing statistical power that is rarely used focuses on the selection of the outcome measure. When an outcome measure is selected, its reliability and validity must be carefully evaluated. Here the relationship between reliability and statistical power is explored empirically. We show that as the number of related items in an outcome scale increases, the internal consistency reliability of the scale also increases. As a consequence, the within-group variability decreases and, in turn, the between-group effect size increases and sample size requirements decrease. As a result, sample size requirements can be reduced and research costs decreased. We recommend careful consideration of the psychometric properties of outcome measures prior to sample size determination in any statistical power analyses.

Alprazolam↗

PubMed1995

An empirical study of defense mechanisms in panic disorder.

Psychodynamic factors have rarely been systematically studied in panic disorder, despite indications that these factors may be important in the understanding and treatment of panic. This is a report of a study using the Defense Mechanism Rating Scale to test the hypothesis that patients with panic disorder utilize particular defense mechanisms: reaction formation, undoing, and displacement. The use of defense mechanisms in 22 patients with primary panic disorder was compared with that of 22 patients with primary dysthymic disorder, based on Defense Mechanism Rating Scale ratings of psychodynamic interviews of these patients. Panic subjects scored significantly higher than dysthymics on the defenses of reaction formation and undoing, but not on the defense of displacement. The defense mechanisms found are consistent with a proposed psychodynamic formulation for panic disorder that emphasizes the panic patient's difficulty in tolerating angry feelings toward significant others. Knowledge of these defense mechanisms can be useful for various treatment approaches in panic disorder.

Adult↗

PubMed1995

Use of prescription psychotropic drugs among suicide victims in New York City.

OBJECTIVE: The authors examined the rate of prescription psychotropic drug use among suicide victims at the time of their death. METHOD: From a total of 1,970 suicides that occurred in New York City from 1990 to 1992, 1,635 cases that had a complete toxicologic analysis and an injury-death interval of 48 hours or less were assessed at autopsy for the presence of commonly prescribed antidepressants and neuroleptics. RESULTS: Prescription psychotropic medications were detected in only 16.4% (N = 268) of the suicide victims studied. Demographic factors associated with use of these drugs included female gender and white race. Poisoning accounted for 17.9% (N = 293) of all suicides studied, but antidepressants or neuroleptics were detected in less than half of these victims. Among all suicide victims in whom an antidepressant or neuroleptic was detected, almost half had used lethal methods other than poisoning. CONCLUSIONS: In this study, most individuals who committed suicide in New York City were not taking prescription psychotropic medications at the time of their death and either were not receiving pharmacotherapy or were noncompliant.

Adult↗

PubMed1995

Long-term stability of polarity distinctions in the affective disorders.

OBJECTIVE: This analysis aimed to quantify the long-term stability of distinctions between nonbipolar, bipolar II, and bipolar I affective disorders and to determine the predictors of shifts in patients' diagnoses among these categories. METHOD: Probands entered the study as they sought treatment for manic, major depressive, or schizoaffective disorder diagnosed according to the Research Diagnostic Criteria. After thorough baseline evaluations, 605 patients with nonbipolar major depressive disorder or schizoaffective disorder, depressed type; 96 with bipolar II disorder; and 231 with bipolar I disorder or schizoaffective disorder, manic type, began the follow-up study. Direct interviews took place at 6-month intervals for the first 5 years and annually thereafter. RESULTS: Only 20 (5.2%) of the 381 initially nonbipolar probands who completed 10 years of follow-up developed mania during that time, and only 19 (5.0%) developed hypomania. A slightly higher proportion of the 67 who began with bipolar II disorder developed mania during the 10 years. Although 101 (66.4%) of the 152 bipolar I or schizoaffective manic probands developed subsequent manic episodes, only 11 (7.2%) developed hypomanic episodes and no mania. Young age at intake and at onset and chronicity of the index episode predicted shifts from nonbipolar to bipolar II disorder. Psychosis and a family history of mania predicted shifts from nonbipolar to bipolar I disorder. CONCLUSIONS: The high stability of baseline distinctions between nonbipolar, bipolar II, and bipolar I disorders, in combination with previously described family study data, strongly supports the separation of these disorders for both clinical and research purposes.

Adult↗

PubMed1995

Low serum cholesterol level and attempted suicide.

OBJECTIVE: Several studies suggest that a low cholesterol concentration is associated with a greater than normal risk of mortality from suicide. The authors sought to determine whether a low cholesterol level is associated with a history of serious suicide attempts among psychiatric inpatients. METHOD: Lifetime history of attempted suicide of 650 patients, aged 18-59 years, consecutively admitted to a psychiatric hospital was assessed by semistructured interview. The seriousness of an attempt was rated on the basis of the resulting medical injury. Serum cholesterol levels, obtained from the admission biochemical profiles, were divided into quartiles. RESULTS: Compared to men with low cholesterol levels (defined as less than or equal to the 25th percentile), men with cholesterol levels above the 25th percentile were less likely to have ever made a serious suicide attempt when age, weight, race, socioeconomic status, alcohol use, and depression were controlled for. There was no association between cholesterol level and attempted suicide in women. CONCLUSIONS: Male psychiatric patients with low cholesterol levels were twice as likely to have ever made a medically serious suicide attempt than men with cholesterol levels above the 25th percentile. Low cholesterol concentration should be further investigated as a potential biological marker of suicide risk.

Adolescent↗

PubMed1995

Pattern of placebo response in panic disorder.

This study characterizes the pattern of placebo response in depressed panic disorder patients who participated in a randomized clinical trial. We compared placebo-treated subjects whose panic attacks remitted, with those whose attacks did not remit, and with remitting and nonremitting subjects treated with active medication. Seventy-one subjects who met criteria for panic disorder and for a concurrent depressive diagnosis (major depression, dysthymia, or depressive disorder not otherwise specified [NOS]) were treated with either imipramine (n = 36) or alprazolam (n = 35), and 28 patients were treated with placebo. Sixteen placebo-treated and 40 medication-treated patients were panic free at Week 8. Placebo panic remitters were significantly more ill than active-medication remitters on all measures. In contrast, subjects who achieved panic remission on placebo showed no difference on other clinical measures from active medication nonremitters, and little difference from placebo nonremitters. Results support the need for assessment of all core panic disorder symptoms in determining treatment efficacy and in considerations of response and remission.

Alprazolam↗

PubMed1995

The SDDS-PC: a diagnostic aid for multiple mental disorders in primary care.

The Symptom Driven Diagnostic System for Primary Care (SDDS-PC) is a new computerized clinical procedure to assist primary care physicians in diagnosing mental disorders during the course of routine practice. It has three components: (1) a 5-minute patient-administered 16-item screening questionnaire, (2) six 5-minute physician-administered diagnostic interview modules based on DSM-III-R criteria, and (3) a longitudinal tracking form. The SDDS-PC covers five disorders (major depression, panic disorder, alcohol abuse or dependence, generalized anxiety disorder, and obsessive compulsive disorder) as well as suicidal ideation. Patients who screen positive for a disorder receive the corresponding diagnostic interview module. Patients who meet mental disorder criteria on the diagnostic interview module are then followed with the longitudinal tracking form. Minor or subsyndromal conditions are also addressed at the physician's discretion. This article describes the development of SDDS-PC and summarizes results from two studies which involved comparisons between the SDDS-PC and independently administered full-length structured diagnostic interviews.

Depression↗

PubMed1995

Psychological management by family physicians.

BACKGROUND: It is frequently assumed that primary care physicians seldom provide psychological interventions to their patients with mental health problems. This study examines self-reports of psychological interventions by family physicians. METHODS: Primary care patients (N = 937) completed a mental health screening form immediately prior to their medical visit. Results were withheld from their seven respective physicians. Following the visit, the physicians were asked to classify the range of psychological interventions they used to manage their patients' emotional problems during the visit. A structured psychiatric diagnostic interview was subsequently administered to a subgroup of the patients (n = 388). RESULTS: At least one psychological intervention was provided to nearly one fourth (24.1%) of the patients. The interventions included listening to the patient's emotional problems (22.4%), providing advice (19.0%), discussing the patient's mental disorder diagnosis (11.4%), and providing individual counseling (8.4%) or family counseling (0.6%). Two thirds (66.7%) of the patients who reported that their emotional health was poor received at least one of these psychological interventions. In a multivariate model, the likelihood of receiving a psychological intervention was higher for patients who were separated or divorced; those between 45 and 59 years of age; those with less than a college education; those who received disability payments; those who reported poor emotional health; and those who had a positive screening result for panic disorder, major depressive disorder, or obsessive-compulsive disorder. CONCLUSIONS: Primary care physicians may be far more extensively involved in providing psychological interventions than is commonly assumed.

Adolescent↗

PubMed1995

Cocaine, opiates, and ethanol in homicides in New York City: 1990 and 1991.

Studies using medical examiner cases are useful in monitoring drug use in special populations. This study assesses the presence of cocaine and its metabolite, benzoylecgonine (BE), opiates and ethanol in all homicide victims who were injured and who survived two hours or less after injury in 1990 and 1991 in New York City. There were 2824 homicides in the study period and cocaine and/or BE were found in 884 (31.3%) of cases. In over half of the cases positive for cocaine/BE, ethanol or opiates were found. African-Americans and Latinos were much more likely than whites or Asians to be positive for cocaine/BE. There were no differences between men and women in regard to being positive for cocaine/BE. Cocaine/BE was most frequently identified among victims 25 to 44 years of age. Males were more likely to be positive for ethanol. There were no differences among age groups or ethnic groups in regard to ethanol except for a very low ethanol incidence among Asians. Victims positive for cocaine/BE were more likely to be killed with firearms in open places. The percentage of victims positive for cocaine/BE remains approximately that found by other studies in the late 1980s, however, the percentage of opiate-positive homicides seems to be increasing. Opiates usually were found with cocaine/BE. Two-thirds of the cocaine and/or BE positive cases had cocaine present, thus they were under the influence of the drug at the time they were injured. The authors discuss how the use of cocaine, ethanol and opiates may be related to one's becoming a homicide victim.

Adolescent↗

PubMed1995

The social costs of anxiety disorders.

BACKGROUND: The social costs of anxiety disorders, which afflict a substantial proportion of the general population in the United States, are considered. METHOD: Data from the National Institute of Mental Health (NIMH) Epidemiological Catchment Area Program were analysed. RESULTS: Over 6% of men and 13% of women in the sample of 18,571 had suffered from a DSM-III anxiety disorder in the past six months. Nearly 30% of those with panic disorder had used the general medical system for emotional, alcohol or drug-related problems in the six months prior to the interview. Those with anxiety disorders were also more likely to seek help from emergency rooms and from the specialised mental health system. Men with panic disorder, phobias or obsessive-compulsive disorder in the previous six months are more likely to be chronically unemployed and to receive disability or welfare. DISCUSSION: Once correctly diagnosed there are safe and effective psychopharmacologic and behavioural treatments for the anxiety disorders. Nevertheless the burden of anxiety disorders extends beyond the direct costs of treatment to the indirect costs of impaired social functioning.

Adolescent↗

PubMed1994

Homicide in New York City. Cocaine use and firearms.

OBJECTIVE: To determine differences between racial/ethnic groups in overall rates of death by homicide, proportion of firearm homicides, and the use of cocaine prior to death. DESIGN: Descriptive epidemiologic survey of a complete 2-year sample of homicides. SETTING: New York City, NY (population 7,322,564). SUBJECTS: All residents (N = 4298) of New York City who were victims of homicide during 1990 and 1991. MAIN OUTCOME MEASURES: Using medical examiner data, age- and gender-specific rates of homicide were calculated for African Americans, Latinos, and whites. Separate logistic regression analyses were conducted to examine the association between demographic variables and both recent cocaine use and firearm-related homicides. RESULTS: Young African-American and Latino men were more likely to be victims of homicide than all other demographic groups. Approximately three fourths of all homicides involved firearms. In the subset of homicide victims dying within 48 hours (n = 3890), 31.0% were positive for cocaine metabolites. African Americans (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.2 to 2.1), Latinos (OR, 1.4; 95% CI, 1.1 to 1.9), and victims 25 through 34 years of age (OR, 2.9; 95% CI, 2.5 to 3.5) and 35 through 44 years of age (OR, 2.7; 95% CI, 2.2 to 3.4) were more likely to be positive for cocaine metabolites than other groups. Young males and females were equally likely to have used cocaine before death. Victims 15 through 24 years of age were more likely than other age groups to be killed by a firearm. African Americans (OR, 1.7; 95% CI, 1.3 to 2.3), Latinos (OR, 1.5; 95% CI, 1.2 to 2.0), and Asians (OR, 2.2; 95% CI, 1.4 to 3.6) were more likely than whites to be killed by a firearm. Men (OR, 4.8; 95% CI, 4.0 to 5.9) were more likely than women to be killed by a firearm. There was no association between having used cocaine before death and being killed by a firearm. CONCLUSIONS: The high rates of death by homicide among young African Americans and Latinos may be due to the increased involvement with both cocaine use and firearms. New efforts must be made to decrease cocaine use and firearm availability.

Adolescent↗

PubMed1994

Cognitive behavioral treatment compared with nonprescriptive treatment of panic disorder.

BACKGROUND: The efficacy of cognitive behavioral treatment for panic disorder has been established in controlled studies. However, little is known about the efficacy of other psychological treatments. We report the results of a study comparing cognitive behavioral treatment with a focused nonprescriptive treatment for panic. METHODS: Three sessions of panic-related information were provided in each treatment, followed by 12 sessions of either nonprescriptive, reflective listening (non-prescriptive treatment) or a treatment package that included breathing retraining, muscle relaxation, cognitive reframing, and exposure to interoceptive and agoraphobic stimuli (cognitive behavioral treatment). RESULTS: Posttreatment and 6-month follow-up assessments revealed a good response to both treatments. We observed a high rate of panic remission and significant improvement in associated symptoms in subjects in each treatment group. CONCLUSION: These findings raise questions about the specificity of cognitive behavioral treatment.

Adult↗

PubMed1994

The time course of nonchronic major depressive disorder. Uniformity across episodes and samples. National Institute of Mental Health Collaborative Program on the Psychobiology of Depression--Clinical Studies.

BACKGROUND: Most natural history studies of affective disorders have emphasized the prediction of eventual recovery. Little is known of changes over time in the immediate probability of recovery. METHODS: To identify regularities in the timing of recovery from nonbipolar major depressive disorders, we considered only episodes that began during follow-up to increase the accuracy with which onsets were timed and to limit the study sample to individuals who had a demonstrably episodic course. Five participating centers conducted baseline assessments and followed probands (N = 605) and nonclinical subjects (relatives, controls, and spouses, N = 826) up for 6 years. During that time, 359 probands had at least one prospectively observed episode, and 181 had two episodes; corresponding numbers for the nonclinical subjects were 216 and 78, respectively. Our analyses considered the distribution of episode lengths across ascertainment source (probands vs nonclinical subjects), center, and episode number (first vs second prospectively observed episode). RESULTS: Distribution was remarkably uniform. Regardless of ascertainment source, center, or episode number, recovery occurred within 3 months in 40% of episodes, within 6 months in 60%, and within 1 year in 80%; 20% had more protracted courses. CONCLUSIONS: Once triggered, the immediate likelihood of recovery changes over time in a predictable fashion. This has practical implications for the study of antidepressant efficacy and theoretical implications for factors involved in affective dysregulation.

Adolescent↗