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Biomedical subjects

M D Sullivan

Publications and source records attributed to M D Sullivan.

At least 37 records · Page 2Linked to original sources
PubMed1993

Adjunctive treatment of benzodiazepine discontinuation syndromes: a review.

The variety of pharmacologic and psychotherapeutic approaches to facilitate benzodiazepine discontinuation are reviewed. Strategies to attenuate physiologic withdrawal with clonidine, propranolol and carbamazepine have been inconsistently effective. Strategies to prevent relapse by substituting medications that could later be discontinued more easily (i.e., antidepressants and azapirones) appear more useful but have been less well studied. Psychotherapeutic approaches appear to work, but specific therapeutic components are unclear and non-specific "placebo" effects may play an important role.

Anti-Anxiety Agents↗
PubMed1993

Psychosomatic clinic or pain clinic. Which is more viable?

Outpatient consultation-liaison (C-L) psychiatry has been beset with problems concerning funding and patient acceptance. Though the consultation, liaison, and referral clinic models for outpatient C-L psychiatry each offer advantages, they have not conquered these fundamental problems. This paper introduces the multidisciplinary pain clinic as an alternative means of addressing somatic symptoms and psychiatric disorders in an ambulatory medical population. The multidisciplinary pain clinic offers advantages in terms of reimbursement, patient acceptance, and opportunities for interdisciplinary research. The pain clinic model has disadvantages that include administration by departments other than psychiatry, traditional location in a tertiary care hospital, and limitations to who can be treated. However, it offers a place where both the physiological and psychological aspects of somatic symptoms may be addressed. The pain clinic nurtures the priorities and goals of primary care for a patient population whose complexities may outstrip the resources of a single primary care physician.

Chronic Disease↗
PubMed1993

Placebo controls and epistemic control in orthodox medicine.

American orthodox medicine consolidated its professional authority in the early 20th Century on the basis of its unbiased scientific method. The centerpiece of such a method is a strategy for identifying truly effective new therapies, i.e., the randomized clinical trial (RCT). A crucial component of the RCT in illnesses without established treatment is the placebo control. Placebo effects must be identified and distinguished from pharmacological effects because placebos produce actual but unexplained therapeutic successes. The blinding necessary for a proper placebo-controlled RCT therefore introduces an epistemic bias into orthodox medicine: therapeutic successes that rely upon a direct link between knowing and healing, such as placebo effects, are discarded in favor of therapeutic successes that rely upon an indirect link between knowing and healing, such as pharmacological interventions. Where the capacity to produce therapeutic results once validated the method of clinical medical science, now method validates results. The clinical consequences of this method of testing therapies include a diminished vision of the therapeutic potential of the doctor-patient relationship and of the potential human resources available for healing.

Clinical Medicine↗
PubMed1993

Use of antidepressants in the management of women with chronic pelvic pain.

Despite a lack of formal evidence for the efficacy of antidepressants in the treatment of CPP, several lines of evidence suggest that they may play an increasingly important role in the treatment of this disorder. Although best combined as part of a multimodal treatment package that includes psychotherapy, behavior change, and physical activation, they appear to have promise for at least a subgroup of women with chronic pain. The relative safety of these medications and the high prevalence of major depression in this population of patients make the routine empirical trial of these medications a desirable, cost- and time-effective strategy in the treatment of this disorder.

Antidepressive Agents↗
PubMed1993

Antidepressant treatment of tinnitus patients: report of a randomized clinical trial and clinical prediction of benefit.

Ninety-two middle-aged and elderly patients with disabling tinnitus participated in a double-blind randomized clinical trial comparing nortriptyline (a tricyclic antidepressant) to placebo. The study was stratified for presence (n = 38) or absence (n = 54) of current major depression (by DSM-III criteria). Both active drug and placebo were given for 6 weeks following a dose adjustment phase; the median nightly dose of nortriptyline was 100 mg. The two primary outcome variables were global satisfaction questions: "Has the medication helped you in any way?" and "Has your tinnitus improved?" Sixty-seven percent of nortriptyline patients stated the drug had helped them, versus 40 percent of placebo patients (chi-square = 7.14, p = 0.008). However, tinnitus severity was not significantly affected by nortriptyline (active: 43%; placebo: 30%; chi-square = 1.567, p = N/S). Benefit was more likely to be reported by depressed patients, by patients with insomnia, by women, and by patients without cervical musculoskeletal disease. Nortriptyline is useful in some patients with disabling tinnitus, but has not been shown to directly affect tinnitus sensation. Placebo effects were strongly significant and must be considered important in tinnitus therapy. It is difficult to specify the most appropriate outcome measures for tinnitus therapeutic trials.

Aged↗
PubMed1992

The woman who wanted electroconvulsive therapy and do-not-resuscitate status. Questions of competence on a medical-psychiatry unit.

A case involving an elderly woman suffering concurrently from serious psychiatric and medical illnesses is presented. Ethical considerations concerning her treatment on a medical-psychiatry unit are discussed with special attention to her requests for both electroconvulsive therapy (ECT) and do-not-resuscitate (DNR) status. The compatibility of simultaneous requests for ECT and DNR is examined on three levels. The effect of depression upon competence to request and refuse treatment is analyzed. This case illustrates a conflict between medical and psychiatric treatment goals and ethical traditions which will become more common as psychiatrists treat older and more medically ill patients.

Activities of Daily Living↗
PubMed1992

Antidepressant treatment of tinnitus patients. Interim report of a randomized clinical trial.

Previous studies have shown that severe tinnitus is associated with current major depression, and that tricyclic antidepressant therapy reduces tinnitus disability, at least compared to brief placebo treatment. We are completing a randomized clinical trial of nortriptyline, stratified by presence or absence of current major depression, in 100 patients with severe chronic tinnitus. Preliminary analysis of global outcome on the first 52 patients reveals that those receiving nortriptyline were more likely to feel that their drug had been helpful (74% vs. 36%, p less than 0.01), but were equally likely to report that their tinnitus was improved (37% vs. 32%, NS). So far, neither audiometric nor self-report measures of tinnitus have demonstrated statistically significant differences between active drug and placebo. Simply administered visual rating scales, if externally-referenced, correlated better with global outcome than did the Iowa Tinnitus Handicap Questionnaire. As expected, nortriptyline was significantly superior to placebo with respect to reductions in the Hamilton Depression Scale, especially in depressed patients. Paradoxically, depressed patients reported more disability and loudness on all scales, but had lower 1 kHz tinnitus intensity matches and dynamic ranges. Our preliminary conclusions are that: 1) nortriptyline reduces depression in patients with severe tinnitus, 2) placebo effects are very important in the treatment of tinnitus, 3) depression may be associated with decreased tolerance for both internal and external sounds, and 4) it is still difficult to specify the appropriate measures of tinnitus loudness and disability for use in therapeutic trials.

Depressive Disorder↗
PubMed1992

The diagnosis of disability. Treating and rating disability in a pain clinic.

Medical diagnosis sanctions illness and directs physicians toward effective treatment. In chronic illness, these two functions of diagnosis can come into conflict. Nowhere is this conflict more striking than in the case of disability ratings for those with chronic pain. An institutional case study examining the relation between a pain clinic and a worker's compensation program is presented and analyzed in terms of two questions: (1) Is it ethical for one physician to both treat pain and rate disability in patients with chronic pain? (2) Is physician rating of disability due to pain scientifically valid? Ethical and conceptual analyses support a negative response to each of these questions. The roots of the ethical and scientific problems concerning disability ratings are identified in society's demand to differentiate medical and nonmedical distress. We propose a system of time-limited compensation for pain as a therapeutically superior alternative to disability ratings.

Attitude of Health Personnel↗
PubMed1991

Chronic pain in primary care. Identification and management of psychosocial factors.

Chronic pain is a problem of great public health importance that is frequently seen in the primary care setting. Pain chronicity shows a strong association with psychosocial factors. Assessment of these factors should be composed of two parts: (1) psychological factors and (2) psychiatric illness. Psychological factors include all those pain-associated alterations in the patient's environment that reinforce illness behavior. Psychiatric illness includes those syndromes that retard recovery from illness or injury, such as depression, anxiety, substance abuse, and dementia. Psychiatric and psychological interventions can be successfully introduced in the context of a comprehensive rehabilitation effort. Usually these interventions can be accomplished by the family physician in concert with a consultant psychiatrist or psychologist. In severely disabled or resistant patients, referral to a multidisciplinary pain clinic will be necessary.

Acute Disease↗
PubMed1990

Reconsidering the wisdom of the body: an epistemological critique of Claude Bernard's concept of the internal environment.

Claude Bernard's concept of the internal environment (milieu intérieur) played a crucial role in the development of experimental physiology and the specific medical therapeutics derived from it. This concept allowed the experimentalist to approach the organism as fully determined yet relatively autonomous with respect to its external environment. However, Bernard's theory of knowledge required that he find organismic functioning as the result of an external necessity. He is therefore unable to explain adequately the origin or operation of organismic autonomy. A more complete conception of biological autonomy must include a theory of knowledge that can accommodate the organism as a source of discrimination and determination. Only in this way will it be possible to see organisms as active as well as reactive, as ordering as well as ordered. This shift in perspective is crucial if medicine is to be able to characterize, for example, susceptibility to disease. A cognitive sense of the organic interior is proposed as an alternative to Bernard's internal environment.

Animals↗
PubMed1990

Depression and chronic medical illness.

Major depression is the most common clinical problem primary care physicians are called upon to diagnose and treat. Depression is associated with high medical care utilization, amplification of somatic symptoms and disability, poor self-care and adherence to medical regimens, and increased morbidity and mortality from medical illness. Despite the high prevalence and the maladaptive effects of major depression on patients' lives, this affective illness is often not accurately diagnosed or effectively treated. Double-blind, placebo-controlled studies have increasingly demonstrated efficacy of the antidepressant agents in primary care patients, patients with chronic pain, and patients with comorbidity--chronic medical illness and major depression.

Antidepressive Agents↗
PubMed1989

Immunophenotypic analysis of colorectal carcinomas with monoclonal antibodies 47D10 and anti-carcinoembryonic antigen.

A series of 80 colorectal adenocarcinomas were analyzed immunohistochemically for the antigen recognized by a new monoclonal antibody (MCA) 47D10. These antigens are part of a complex family of substances similar to, yet distinct from carcinoembryonic antigen (CEA), and are termed nonspecific cross-reacting antigens (NCA). Formalin-fixed paraffin-embedded sections of colorectal adenocarcinomas were evaluated for the expression of these antigens and compared to the expression of CEA. Our study shows that 83.8% of the cases were positively stained for NCA while 91.3% were positive for CEA. Both antigens were coexpressed in 80% of the cases. No correlation was found between MCA 47D10 immunoreactivity and tumor grade, stage, size or location within the colon. In 25 cases, the benign colonic mucosa adjacent to the carcinoma stained positively with MCA 47D10. Normal colon does not express NCA as recognized by MCA 47D10, except in rare cells. Forty-eight of these cases had serum available for study. Both NCA and CEA were determined in these serum samples. Forty-two of these sera demonstrated elevated CEA levels, whereas only 8 showed increased levels of the 47D10 antigen(s). These findings suggest that the gene product(s) recognized by MCA 47D10 can be independently expressed or, more commonly, coexpressed with CEA in these tissues.

Adult↗
PubMed1989

Treatment of depressed tinnitus patients with nortriptyline.

Patients disabled by tinnitus show a high prevalence of major depression. Furthermore, tinnitus produces patterns of disability similar to those produced by major depression. To explore further this link between tinnitus and depression, and to investigate the efficacy of treating depression in the treatment of tinnitus, a single-blind, placebo-washout, nonrandomized pilot study of the tricyclic antidepressant nortriptyline (hydrochloride) was undertaken in disabled tinnitus patients who also met diagnostic criteria for major depression. Nineteen patients began the study, two responded to placebo, and two dropped out prior to completion. Fourteen considered their tinnitus improved, and 12 chose to continue taking nortriptyline after the study. Depression severity decreased, on the average, by 65% (p less than .0001). Tinnitus loudness measured by audiometric matching decreased by a mean of 10 dB or 50% (p less than .02). Self-reports of tinnitus loudness and severity, somatic and psychologic symptoms, and psychosocial dysfunction all showed significant improvement with treatment. These results suggest that what initially appears to be an irreversible otologic disability in these patients may be in large part a reversible psychiatric disability.

Adolescent↗
PubMed1988

Disabling tinnitus. Association with affective disorder.

Forty consecutive patients with disabling tinnitus were interviewed using a structured psychiatric interview and were asked to complete the Hopkins Symptom Checklist (SCL-90), the Chronic Illness Problem Inventory, and the Revised Ways of Coping Checklist. They were compared to a control group of 14 patients attending the same otolaryngologic clinic with a complaint of hearing loss. The tinnitus patients had a significantly greater lifetime prevalence of major depression (78% vs 21%) than controls and a significantly higher prevalence of current major depression (60% vs 7%). The currently depressed tinnitus patients had significantly higher scores on all subscales of the SCL-90 compared to the nondepressed tinnitus group and to the controls. The number of psychological problems as measured by the Chronic Illness Problem Inventory was significantly greater in the tinnitus group than in controls. This difference in psychosocial disability was due to the high psychologic and social impairment in the depressed tinnitus group, as there were no significant differences in psychosocial problems between the nondepressed tinnitus group and the controls. These results demonstrate that tinnitus disability is strongly associated with major depression and suggest that treatment of the concurrent affective illness may reduce disability due to tinnitus.

Depressive Disorder↗
PubMed1979

Müllerian duct regression in the embryo correlated with cytotoxic activity against human ovarian cancer.

A significant cytotoxicity index was obtained when human ovarian cancer cells in a microcytotoxicity assay were exposed during the S (DNA-synthesizing) phase of the cell cycle to purified fractions of testis exhibiting high Müllerian inhibiting substance bioactivity. The same effect was not observed when these fractions were tested against human glioblastoma or fibroblast lines. Most human ovarian cancers are said to resemble Müllerian tissues histologically. Müllerian inhibiting substance may thus deserve further study as a potential chemotherapeutic agent.

Animals↗
PubMed1979

Wives' evaluation of problems related to laryngectomy.

Previous questionnaire studies of problems after laryngectomy have been directed toward the patients. In this study, 45 wives of laryngectomees were surveyed regarding their prior understanding of laryngeal surgery. The wives were also asked questions pertaining to health and physical care, and financial and social problems encountered after the operation. The survey results indicate a need for improved family counseling both before and after surgery.

Adult↗