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Biomedical subjects

L Portera

Publications and source records attributed to L Portera.

At least 19 recordsLinked to original sources
PubMed2005

Executive functioning in depressed patients with suicidal ideation.

OBJECTIVE: Suicidal thinking has been associated with cognitive rigidity, however, not all depressed patients contemplate suicide. Therefore, we hypothesized that compared with depressed subjects without suicidal ideation, depressed individuals with suicidal ideation would display poorer performance on measures of executive functioning that involve mental flexibility. METHOD: In-patients with a current major depressive episode who had no current suicidal ideation (n=28) were compared with those who had current suicidal ideation (n=5) on measures of executive functioning and two neurocognitive tests that predominantly assess non-frontal regions. RESULTS: Compared with non-suicidal depressed patients, depressed suicidal patients performed significantly worse on several measures of executive functioning after controlling for age, IQ, severity of depression and prior suicide attempts. The two groups performed similarly on tests that predominantly assess non-frontal regions. CONCLUSION: Depressed individuals contemplating suicide have cognitive rigidity, which does not appear to be a global brain dysfunction. Suicidal mental states may result from dysfunctional executive decision-making that is associated with the frontal lobe.

Adult↗
PubMed2001

Maintenance desipramine for dysthymia: a placebo-controlled study.

BACKGROUND: This study examines the efficacy of maintenance pharmacotherapy in dysthymia without concurrent major depression, i.e. 'pure dysthymia'. No published data exist on this topic. METHODS: Responders to a 10-week open trial of desipramine (DMI) whose therapeutic response persisted during a 4-month continuation phase were eligible to begin a 2-year placebo-controlled maintenance phase. We analyzed the subgroup with DSM-III-R pure dysthymia (n=27) that entered maintenance. Time to recurrence during maintenance therapy was compared between the two treatment groups. RESULTS: Six of 13 patients receiving placebo and none of 14 patients receiving ongoing DMI experienced a recurrence. Risk of recurrence was significantly greater for placebo patients. Five of six placebo recurrences occurred within the first 6 months of maintenance. LIMITATIONS: Larger replication studies are needed. CONCLUSION: Desipramine was efficacious as a maintenance treatment in patients with pure dysthymia who responded to 7 months of acute and continuation DMI.

Acute Disease↗
PubMed2001

Psychiatric symptoms, functional impairment, and receptivity toward mental health treatment among obstetrical patients.

OBJECTIVE: To examine psychiatric symptomatology and associated functional impairment among pregnant women; and to examine the obstetrical patient's receptivity to discussion of and intervention regarding emotional distress. METHODS: Fifty-seven patients 16 weeks or less pregnant presenting for routine obstetrical appointments at a faculty practice at a major medical center participated in this study. Each completed a self-administered assessment packet regarding psychopathology, functional impairment and service utilization attitudes. Statistical analyses were performed using chi-square and Mann-Whitney tests. RESULTS: Seventeen subjects (29.8 percent) screened positive for at least one anxiety disorder. Fourteen of those subjects also screened positive for depression. Those with positive screens for either anxiety and/or depression had significantly higher levels of functional impairment. Only five (29.4 percent) of the 17 subjects with positive screens reported having discussed an emotional issue with their Ob/Gyn, although 14 (82.4 percent) said that they would be willing to do so. All subjects (100 percent) reported that they would see a mental health professional if their Ob/Gyn referred them. CONCLUSION: Routine screens for mental disorders in early pregnancy appear to be a useful adjunct in an obstetrical setting. Although most had never discussed their emotional concerns with their Ob/Gyn, a substantial proportion of our study sample reported psychiatric symptomatology and significant levels of functional impairment that had not been recognized by their Ob/Gyn. All of the patients in our study sample reported a willingness to see a mental health professional if their Ob/Gyn referred them. Further studies investigating the benefits of antenatal diagnosis and treatment of psychiatric disorders are warranted.

Adult↗
PubMed2001

The development and evaluation of the brief depression screen in medically ill disability claimants.

OBJECTIVE: There is literature demonstrating elevated prevalence of depression in primary care. Yet there remains a need for a brief depression screen designed and evaluated specifically for use among medically ill patients. Our objective was to develop and validate a brief, unobtrusive screen for depression among severely medically ill long-term disability claimants. METHODS: The study sample consisted of 480 long-term disability claimants, less than 55 years of age, with one of the following illnesses: cancer, diabetes, myocardial infarction, rheumatoid arthritis, stroke, or multiple sclerosis. Each subject completed a questionnaire that included 26 potential screening items. A subset of subjects was administered the SCID, which served as the gold standard for the DSM-IV depression and dysthymia diagnoses. RESULTS: The Brief Depression Screen, a three-item screen for major depressive disorder and dysthymia, was developed. About 34 percent of the sample met criteria for major depressive disorder or dysthymia. The Brief Depression Screen detected 75 percent of those subjects in this sample. Furthermore, nearly half of the subjects with positive screen results met criteria for depression or dysthymia. These results are comparable to those of the eight-item Burnam screen, but not as sensitive as the more widely used, twenty item CES-D. CONCLUSION: The Brief Depression Screen was developed and evaluated for use with severely ill long-term disability claimants. In practice, a positive screen for depression is to be followed with a comprehensive diagnostic assessment that could be conducted by a trained clinician. Further research is warranted to determine whether the identification and treatment of depression in disability claimants with non-psychiatric medical illnesses will facilitate return to work, even in the presence of comorbid medical illnesses.

Depressive Disorder↗
PubMed1999

Correlates of suicidal ideation in dysphoric mania.

BACKGROUND: Previous investigations have reported that suicidal ideation and behavior are more prevalent during mixed than pure mania. Uncertainties exist about whether suicidality in mania arises from multiple concurrent depressive symptoms, or rather, as a categorical phenomenon, reflecting dysphoria without necessarily a full major depression. To elucidate the relationship between suicidal ideation and dysphoric mania, we analyzed clinical and demographic features associated with suicidal versus nonsuicidal dysphoric manic inpatients. METHODS: Records were reviewed for 100 DSM-III-R bipolar I manic inpatients at the Payne Whitney Clinic of New York Hospital from 1991-1995. All had > or = 2 concomitant depressive symptoms (other than suicidality). Affective and psychotic symptoms, past suicide attempts, prior illness, and related clinical/demographic variables were assessed by a standardized protocol. RESULTS: Suicidal ideation was significantly more common among dysphoric manics who were caucasian, took antidepressant medications in the week prior to admission, had histories of alcohol abuse/dependence, and made past suicide attempts. Suicidal ideation was evident for nearly half of dysphoric manic patients with < or = 3 depressive symptoms who did not meet DSM criteria for a mixed state. No individual manic or depressive symptoms other than dysphoric mood were more common among suicidal than nonsuicidal patients. LIMITATIONS: Findings from this retrospective study require confirmation using a prospective assessment. Treatments were naturalistic and may have differentially influenced hospital course and illness characteristics. Factors related to suicide attempts (rare in this cohort) or completions (not a focus of this study) may differ from those related only to suicidal ideation. CONCLUSIONS: Caucasian dysphoric manic patients with past suicide attempts and substance abuse may have a significantly elevated risk for suicidality, even when full major depression does not accompany mania. Suicidality is a clinically important consideration in a majority of dysphoric manic patients.

Adult↗
PubMed1999

Predictors of management problems in supported housing: a pilot study.

The study examined predictors of management problems among residents of a supported single room occupancy hotel (SRO) for persons with severe and persistent mental illness (SPMI). Case workers completed questionnaires on the prior six months. We found that medication-compliant residents without drug abuse were rarely disruptive, while those with co-morbid substance abuse were often disruptive. Residents non-compliant with medication also tended to cause management problems whether or not they abused drugs. Supported residences should be staffed and organized to minimize medication non-compliance and substance abuse which are associated with behavioral disruptiveness.

Adult↗
PubMed1999

Diagnostic errors of primary care screens for depression and panic disorder.

OBJECTIVE: As the health care reimbursement system has changed, brief screens for detecting mental disorders in primary care have been developed. These efforts have faced the formidable task of identifying patients with mental disorders, while at the same time minimizing the number of misclassified cases. Here we consider the balance between sensitivity and positive predictive value. Primary care patients with false positive and false negative results on screens for depression and panic disorder are compared with regard to comorbidity and functional impairment. METHODS: This was a cross-sectional psychometric study. The study sample included 1001 primary care patients from the Department of Internal Medicine at Kaiser Permanente in Oakland, California. The Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) screens and Sheehan Disability Scale were completed by the subjects. The SDDS-PC diagnostic interviews were administered to all subjects. RESULTS: Patients with false positive results on the panic disorder screen did not differ from patients with false negatives results with regard to rates of other psychiatric disorders, functional impairment, or mental health service utilization. In contrast, patients with false negative depression screen results had significantly more psychiatric disorders and functional impairment than those with false positive depression results. CONCLUSIONS: A substantial number of patients with either false positive or false negative screen results met diagnostic criteria for other mental disorders. Given the nominal burden of follow-up assessments for patients with positive screens, these data suggest that erring on the side of sensitivity may have been preferable when algorithms for these screens were selected.

Adolescent↗
PubMed1999

A history of substance abuse complicates remission from acute mania in bipolar disorder.

BACKGROUND: Substance abuse frequently complicates the course of bipolar illness, promotes mixed states, and contributes to poor outcome in mania. Preliminary open trials suggest that anticonvulsant mood stabilizers may enhance remission rates and outcome for bipolar patients with substance abuse. This study compared remission patterns for mixed or pure manic episodes among bipolar inpatients with or without substance abuse histories. METHOD: Hospital records were retrospectively reviewed for 204 DSM-III-R bipolar I inpatients. Clinical features were compared for those with or without substance abuse/dependence histories predating the index manic episode. Time until remission was analyzed by Kaplan-Meier survival analysis. Naturalistic treatment outcome with lithium or anticonvulsant mood stabilizers was compared for those with or without past substance abuse. RESULTS: Past substance abuse was evident in 34% of the bipolar sample and comprised most often alcoholism (82%), followed by cocaine (30%), marijuana (29%), sedative-hypnotic or amphetamine (21%), and opiate (13%) abuse. Substance abuse was more common among men (p < .05) and those with mixed rather than pure mania (p < .05). Remission during hospitalization was less likely among patients with prior substance abuse (p < .05), especially alcohol or marijuana abuse, and among mixed manic patients with past substance abuse (p < .05). Bipolar patients with substance abuse histories who received divalproex or carbamazepine remitted during hospitalization more often than did those who received lithium as the sole mood stabilizer (p < .05). CONCLUSION: These findings support previous reports suggesting that bipolar patients with past substance abuse have poorer naturalistic treatment outcomes, but may show a better response to anticonvulsant mood stabilizers than lithium.

Acute Disease↗
PubMed1998

Ambient temperature and mortality from unintentional cocaine overdose.

CONTEXT: Hot weather taxes cardiovascular function and is associated with increased deaths from heart disease. Cocaine can cause hypertension, tachycardia, coronary vasospasm, arrhythmias, and increased core temperature. OBJECTIVE: To determine the association between mortality from cocaine overdose and hot weather. SETTING: New York, NY. DESIGN: Retrospective review of medical examiner cases from 1990 through 1995. SUBJECTS: All fatal unintentional cocaine overdoses from 1990 through 1992 (n = 1382) and all hyperthermia deaths of cocaine users (n = 10) were used to identify a maximum daily temperature threshold above which mortality from cocaine intoxication increased. The study population consisted of all fatal unintentional cocaine overdoses from 1993 through 1995 (n = 2008) and 4 contemporaneous comparison groups that included fatal unintentional opiate overdoses (n = 793), all other fatal unintentional overdoses (n = 85), and a subset of homicides (n = 4638) and fatalities from motor vehicle crashes (n = 815). MAIN OUTCOME MEASURES: The number of overdose deaths and the proportion of homicides and traffic fatalities with a positive cocaine toxicology test result on days with a maximum temperature above or below the temperature threshold. RESULTS: A threshold temperature of 31.1 degrees C (88 degrees F) was identified, above which the mean daily number of fatal cocaine overdoses increased steadily. On days with a maximum daily temperature of 31.1 degrees C (88 degrees F) or higher ("hot days"), the mean daily number of cocaine overdose deaths was 2.34 (SD = 1.68), which was 33% higher than the mean on days with a maximum temperature of less than 31.1 degrees C (88 degrees F) (mean = 1.76 [SD=1.37] (P<.001). In contrast, the mean number of opiate overdose deaths per day was 0.81 (SD = 0.94) on hot days and 0.71 (SD = 0.86) on other days (P=.28). For other drug overdose deaths, the mean number of deaths per day was 0.08 (SD = 0.28) on hot days and 0.08 (SD = 0.28) on other days (P=.69). Among homicides, the proportion with a positive cocaine toxicology test result was 18.9% on hot days and 19.5% on other days (P=.69), and among traffic fatalities, the proportions with positive cocaine toxicology test results were 9.5% on hot days and 10.3% on other days (P=.91). CONCLUSIONS: High ambient temperature is associated with a significant increase in mortality from cocaine overdose. Based on our comparison groups, the increase is not explained by changes in cocaine use among the general population. Although cocaine use is dangerous on all days, it appears to be even more dangerous on hot days.

Accidents, Traffic↗
PubMed1998

Human immunodeficiency virus among trauma patients in New York City.

STUDY OBJECTIVE: To determine the HIV seroprevalence rates in relation to the demographic characteristics of victims, cause of death, and toxicology findings in a sample of victims of violence and accidents who presented to emergency departments before death. METHODS: This descriptive survey of a complete 3-year sample of homicides and accidents was conducted in 5 boroughs of New York City (population 7,322,564). Persons 15 years of age and older injured by intentional violence or accidents (excluding drug overdoses, falls from short heights, and suicides) who presented to hospitals, died, and were sent to the medical examiner were included. Standard methods were used to test plasma and serum samples for HIV and cocaine or its metabolite. Chi2 Tests compared HIV seroprevalence across groups according to demographic characteristics and toxicology findings. Logistic regression analysis was done for those variables found to be significant with chi2 tests. All statistical tests were conducted with 2-tailed alpha levels of .05. RESULTS: Among the 1,242 subjects in the sample, 90 (7.2%) had positive findings. Male patients (8%) had higher rates than female patients (3.4%). HIV rates were highest among patients 35 to 44 years of age (20.8%), followed by the 45- to 54-year age group (9.6%) and 25- to 34-year age group (8.1%). Victims of homicide (8.2%) and accidents other than motor vehicle crashes (10.5%) had higher rates than victims of motor vehicle crashes (4%). Patients with positive results for cocaine (16.3%) were more likely than those with negative result (5.8%) to be HIV positive. There were no statistically significant differences by race, except that no Asians were HIV positive. Logistic regression analysis found that only age and positive cocaine results, not sex and race, were related to increased risk of HIV infection. CONCLUSION: We found the rate of HIV infection among victims of fatal trauma was significant, especially in those with evidence of cocaine use. The HIV infection rate approximates the high end of the range of HIV rates found in studies before 1990. It further emphasizes the need for use of universal precautions in the care of trauma patients.

Accidents↗
PubMed1998

Association of recurrent suicidal ideation with nonremission from acute mixed mania.

OBJECTIVE: The authors' goal was to examine suicidality in relation to acute symptom remission in inpatients with mixed and pure bipolar disorder. METHOD: Using chart review of 184 adult inpatients with bipolar I disorder, the authors assessed patients' past and current suicidality, other psychopathology, treatment, and remission. RESULTS: Past, current, and recurrent suicidality were significantly more common among patients with mixed mania than among those with pure mania. The probability of remission declined by 49% for every suicide attempt made before the index manic episode. Mixed mania, multiple previous hospitalizations, and previous suicide attempts were significantly associated with current suicidality. CONCLUSIONS: Suicidality is linked with mixed manic states and may be a clinical marker for recurrent dysphoric mania. Multiple suicide attempts are associated with nonremission from mixed manic episodes.

Acute Disease↗
PubMed1998

Aborted suicide attempts: a new classification of suicidal behavior.

OBJECTIVE: With the goal of ultimately finding early suicide predictors, the authors undertook a study of aborted suicide attempts. They defined such an attempt as an event in which an individual comes close to attempting suicide but does not complete the act and thus sustains no injury. METHODS: The authors interviewed a random sample of 135 adult psychiatric inpatients concerning their past suicidal behavior. Using standardized scales, they assessed suicidal intent for aborted suicide attempts and actual suicide attempts, as well as degree of injury for actual attempts. RESULTS: Over half of the 135 subjects reported making at least one aborted suicide attempt. Aside from younger age, no demographic characteristics were associated with aborted attempts. Aborted attempts were reported more often in subjects with a diagnosis of borderline personality disorder than in subjects with other diagnoses. Intent scores for aborted attempts were comparable to those for actual suicide attempts. Subjects who had made an aborted attempt were nearly twice as likely to have made an actual suicide attempt as subjects with no aborted attempts. Among subjects with both aborted and actual attempts, the first aborted attempt preceded the first actual attempt approximately half the time. CONCLUSIONS: Aborted suicide attempts were reported commonly by psychiatric inpatients, had a similar level of intent as actual attempts, and were highly associated with actual attempts. Thus, clinicians should specifically ask patients about aborted attempts as a part of the suicide history. Further study is needed to examine the association between aborted suicide attempts and suicide.

Adult↗
PubMed1998

Rapid titration of mood stabilizers predicts remission from mixed or pure mania in bipolar patients.

BACKGROUND: Recent investigations have suggested that the antimanic agents divalproex sodium and carbamazepine may each hasten hospital discharge and be especially beneficial in treating mixed-state mania. This study retrospectively compared the time to remission for pure versus mixed manic bipolar inpatients who were taking lithium, divalproex, or carbamazepine, or their combination, under naturalistic conditions. METHOD: Records were reviewed for 120 bipolar inpatients from 1991 to 1995. Research DSM-III-R diagnoses of pure or mixed mania were assigned along standardized guidelines. Data were obtained on daily symptoms, medication doses, and blood levels. Weekly improvement was evaluated by Kaplan-Meier survival analysis of Clinical Global Impressions scale scores. Variables associated with "remission" versus "nonremission" were examined by logistic regression. RESULTS: Mixed mania (N = 70) was more common than pure mania (N = 50). No significant differences were observed in the time to remission for mixed or pure manic bipolar patients who took lithium compared with those who took divalproex or carbamazepine. In patients who remained symptomatic with lithium as a single-agent mood stabilizer despite therapeutic serum lithium levels, the addition of a second mood stabilizer led to rapid symptom improvement. Among all medication subgroups, the speed with which patients achieved therapeutic blood levels of any of these agents significantly affected the time to remission. CONCLUSION: Mixed manic bipolar patients taking lithium, divalproex, or carbamazepine under naturalistic conditions remit at comparable rates. Those failing to respond to single-agent mood stabilizers often receive combinations of mood stabilizers. However, delays in optimizing a medication regimen may attenuate short-term outcome, regardless of the mood stabilizer selected. Rapid achievement of therapeutic blood levels of any antimanic agent appears to be strongly related to swift symptom remission.

Adult↗
PubMed1998

A strategy to evaluate a covariate by group interaction in an analysis of covariance.

Analysis of covariance (ANCOVA) is commonly used in psychiatric research to statistically adjust for illness severity when making group comparisons. A fundamental assumption of the procedure is that the groups' differences in outcome are constant across all levels of baseline severity. This is the classic assumption of equal linear slopes. The plausibility of this assumption is rarely reported in manuscripts that use an ANCOVA. A statistical model is discussed that can be used to test the assumption, and if the assumption is not fulfilled, the model can incorporate a covariate by group interaction. An application of this model, the multiple linear regression approach to analysis of covariance, is provided using data from a large clinical trial for patients with panic disorder. The authors recommend that manuscripts reporting results from an ANCOVA also report the results of the test of the covariate by group interaction and account for the interaction when the slopes are heterogeneous.

Alprazolam↗
PubMed1997

Service utilization and expenditures for the treatment of panic disorder.

The outpatient service utilization and estimated expenditures for the treatment of panic disorder for patients prior to their enrollment in a large clinical trial were examined. Data were drawn from the Cross-National Collaborative Panic Study. The sample consists of 391 patients who met DSM-III criteria for panic disorder and were enrolled at one of the US sites of the trial. The rate and frequency of outpatient mental health visits to primary care and specially mental health providers for the current episode of panic disorder are examined. Estimates of direct expenditures for these services are presented (in 1993 US dollars). Over 70% of the patients used primary care for mental health services whereas about 47% of the patients used specialty mental health services. Nearly half of the patients (46.8%) saw a nonpsychiatrist medical specialist, most often a cardiologist (20.6%). Among all patients, those with more frequent panic attacks were more likely to use some form of outpatient mental health services for panic disorder. Among users of any services, those with more severe impairment were more likely to use specialized mental health services. The mean estimated expenditure for the panic episode was $3339, about half of which was accounted for by specialty mental health expenditures. Among users, the median estimated expenditures was $518 for primary care physicians and $2122 for specialty mental health services. In conclusion, the service utilization in this sample of patients with panic disorder is highly varied. Both the primary care and specialty mental health sectors play prominent roles in the community treatment of panic disorder.

Adult↗
PubMed1997

The prevalence of aborted suicide attempts among psychiatric in-patients.

We report the prevalence of aborted suicide attempts in which the essential characteristics are (i) intent to kill oneself (ii) a change of mind before making an actual suicide attempt and (iii) the absence of physical injury. The lifetime history of aborted suicide attempts was assessed by semi-structured interview of 733 patients, aged 18-59 years, who were consecutively admitted to a psychiatric hospital. In the study group, 46% of subjects had made a suicide attempt and 29% had made at least one aborted attempt during their lifetime. Subjects who had made aborted attempts were more likely to have made actual attempts. Approximately 11% of the subjects in the study group had a history of aborted attempts of potential high lethality, such as going to a height in order to jump, or holding a gun to the head. There were no major demographic differences between those with and without a history of aborted attempts. However, among those with no prior history of actual attempts, subjects with depression and a family history of suicide were more than twice as likely as those without such a history to have made an aborted attempt. Aborted suicide attempts are a common suicidal behaviour among psychiatric in-patients. Whether they predict actual attempts or suicide warrants prospective investigation.

Adolescent↗
PubMed1997

Lower risk of suicide during pregnancy.

OBJECTIVE: The authors determined the risk of suicide during pregnancy. METHOD: The autopsy reports of all female residents of New York City, 10-44 years old, who committed suicide from 1990 to 1993 were assessed for pregnancy. These data were compared with age-adjusted and race-adjusted standardized mortality ratios for women, which were calculated by using population data from the 1990 U.S. Census as well as data obtained from the New York City Health Department on the number of live births, spontaneous abortions, and induced abortions. RESULTS: The standardized mortality ratio for suicide during pregnancy was 0.33; that is, the number of suicides of pregnant women was only one-third of that expected. CONCLUSIONS: Despite the mood swings and stresses associated with pregnancy and impending childbirth, pregnant women have a significantly lower risk of suicide than women of childbearing age who are not pregnant.

Adult↗