Biomedical subjects
Publications and source records attributed to M Hertzman.
A retrospective chart review of psychiatric outpatients selected for a combination of alcohol (or other substance abuse) and mood disorders. A subgroup of patients treated with divalproex sodium diminished their substance abuse during the period of treatment for their disorders. This pilot study suggests that prospective, systematic research on divalproex sodium for dual diagnosis is warranted.
BACKGROUND: This study was designed to compare the efficacy, safety, tolerability profiles, and effects on quality of life of the serotonin selective reuptake inhibitor antidepressant sertraline versus the nonselective tricyclic antidepressant amitriptyline and placebo in patients with major depression. METHOD: Outpatients with DSM-III-R major depression were randomly assigned to double-blind treatment for 8 weeks with sertraline (50-200 mg daily), amitriptyline (50-150 mg daily), or matching placebo. Assessments included the Hamilton Rating Scale for Depression, Montgomery-Asberg Depression Rating Scale, Clinical Global Impressions-Severity of Illness scale, Clinical Global Impressions-Improvement scale, Global Assessment Scale, Profile of Mood States, Beck Depression Inventory, Quality of Life Enjoyment and Satisfaction Questionnaire, and Health-Related Quality of Life battery. RESULTS: All treatment groups demonstrated statistically significant improvement from baseline in depression ratings by Week 1 and thereafter. The antidepressant effects of amitriptyline and sertraline were significantly (p < .05) greater than placebo and did not differ significantly from each other. Sertraline was associated with significantly (p < .05) greater subjective (i.e., patient-rated) improvement in mood than amitriptyline or placebo. Both active drugs were associated with greater improvements than placebo on most quality of life measurements. On several items, sertraline, but not amitriptyline, was superior to placebo. There was a discernible effect of sertraline earlier than amitriptyline on most quality of life scales. Amitriptyline therapy was associated with significantly more treatment-related adverse events, and discontinuations due to treatment-related adverse events, in comparison to both sertraline and placebo therapy. CONCLUSION: Sertraline and amitriptyline each were effective treatments for major depression as assessed by both physician- and patient-rated scales. These results show that sertraline therapy is better tolerated than amitriptyline therapy. Quality of life was also improved by effective antidepressant treatment, with sertraline showing a tendency to produce greater improvements on quality of life measures.
No consensus exists regarding whether early response to an antidepressant strongly predicts a good outcome, what is the criterion for early response, or when to measure it. We hypothesized that early response (> or = 20% decrease in HAM-d21) after any of weeks 1, 2, or 3 of fluoxetine treatment of major depression in geriatric outpatients would predict a favorable outcome by week 6 or an earlier endpoint accurately enough for clinical use. We also hypothesized that the week 1, 2, and 3 percent changes in 21-item Hamilton Rating Scale for Depression (HAM-D21) would predict the percent change at week 6 (or endpoint) accurately enough for clinical use. We enrolled 671 elderly outpatients with unipolar DSM-III-R major depression in a double-blind, placebo-controlled trial of fluoxetine, 20 mg/day. For analysis, fluoxetine-treated patients were randomly divided into a development set (N = 154) for a preliminary test of our criteria and a validation set (N = 181) to validate the development data set's results. Early responders at weeks 1, 2, and 3 were statistically significantly more likely to experience marked improvement or remission than those lacking early response. However, at week 3, this criterion correctly classified only about three-fourths of patients with regard to marked improvement and only about two-thirds with regard to remission. Moreover, about one-third of patients predicted to experience marked improvement and about three-fifths of those predicted to remit did not. The continuous variable, percent change in HAM-D21, did not produce predictive results of any greater clinical utility. We believe that the sensitivity, specificity, false-positive rate, false-negative rate, and kappa of outcome predictions all should be reported in future studies. Without a full set of descriptive statistics, clinicians can be misled by statistically significant results.
BACKGROUND: We report the results from a multicenter, double-blind, randomized, fixed-dose study designed to evaluate the relationship between daily dose and efficacy of adinazolam-SR in patients with panic disorder with agoraphobia. METHOD: Patients (N = 315) were randomized to one of four treatment groups (placebo, N = 83; 30-mg group, N = 79; 60-mg group, N = 81; and 90-mg group, N = 72) and then treated twice daily for 4 weeks. All treatment groups were comparable demographically. Primary efficacy measures included total number of panic attacks, global improvement score using the Clinical Global Impressions (CGI) scale, phobic anxiety dimension of the Symptom Checklist-90 phobic cluster, overall phobia state using the Phobia Scale, and severity of illness on the CGI. RESULTS: The 60- and 90-mg/day adinazolam-SR treatment groups showed superior results when compared with the placebo group at Week 4 while the 30-mg group did not. Treatment with adinazolam-SR was well tolerated, with sedation the only treatment-emergent symptom that occurred more frequently in patients treated with adinazolam-SR than placebo. CONCLUSION: These results suggest that adinazolam-SR at doses of 60-mg/day or greater administered twice daily is a safe and effective treatment in selected patients with panic disorder with agoraphobia.
Ten patients, who underwent computerized tomography (CT) study during evaluation for first episode schizophreniform psychosis were restudied an average of 7 years later. Of the 10 patients, 7 were found to carry a diagnosis of schizophrenia at follow-up. In this subgroup, there was no significant change in the mean ventricular brain ratio measure of cerebral ventricular size between the index and follow-up scans. These findings are consistent with the hypothesis that ventricular enlargement is present at the onset of schizophrenia and does not progress with duration of illness or treatment.
OBJECTIVE: About 20 percent of patients receiving long-term treatment with neuroleptic medications develop tardive dyskinesia. A 1988 review of treatment studies for the disorder found that 40 percent of patients showed at least 50 percent improvement in symptoms. This paper reviews studies published since 1984, including those not reviewed in 1988, to learn whether new or improved treatments for the disorder have been developed. METHODS: Twenty-five open, blind, or double-blind studies (with a minimum of five patients) published between 1984 and May 1992 were examined. The studies involved neuroleptics, including clozapine, dopaminergic and dopamine-depleting agents, GABAergic drugs, vitamin E, calcium channel blockers, and adrenergic drugs. RESULTS AND CONCLUSIONS: Overall, only 26 percent of patients who participated in the studies reviewed had a 50 percent or greater reduction in symptoms. The authors conclude that treatment of tardive dyskinesia remains a highly individual process and recommend that future studies be more carefully designed.
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We developed a two-step assay of phencyclidine (PCP), in which 2.5 mL of serum is adsorbed onto a disposable solid-phase extraction column and the eluted drug is determined by gas chromatography with nitrogen-phosphorus detection. Methapyriline is the internal standard. The detection limit of this technique is 0.5 microgram/L and the linear range exceeds 200 micrograms/L. Precision (CV) ranges from 30 to 10% with increasing concentration. No interferences were encountered in more than 400 clinical samples. The assay permits serial observation of low concentrations of the drug in serum for pharmacokinetic study and for quantitative clinical correlation with the Brief Psychiatric Rating Scale.
Quality assessment of mental health care is distinguished by it defensive character. The field has been sensitive to the criticisms of outside agencies and groups to the point of studying the quality of care it provides far more than other health providers have done. The result has been productive leadership in matters of practical evaluation. The author details the impact of PSRO, the JCAH, DRGS, and other formal review mechanisms upon the quality assessment process. He catalogs a shift in emphasis to take into account organizational dynamics and concludes that the JCAH seems to be propelling alcohol, drug, and mental health treatment programs into creative new directions.
Studies of patients signing out against medical advice (AMA) from a psychiatric service have been retrospective and inconsistent or contradictory in their findings. The authors report findings from a prospective study in which data from a brief structured interview of patients at the time of admission were used to predict subsequent AMA behavior. They achieved 80% accuracy. Critical variables centered around the nature of the "treatment contract" as perceived by the patient: AMA patients never intended to stay in the hospital for more than a few days.
There have been important expansions in knowledge about alcohol recently. In this chapter a number of advances pertinent to the family practitioner are summarized. However, technology is not our focus. We are talking first about troubled people. The applications of research may help such people in practice. However, our main concern is for the patients and their families as a primary care practitioner rightly should be. Therefore, scientific study results are interspersed among the sections on a variety of clinical concerns. Alcohol abuse and alcoholism are family affairs. Families are complex interactive systems that serve to maintain themselves and their members. Under certain conditions the powerful forces at work within a family can promote the use of alcohol as an effort to solve problems. This chapter has discussed some methods which may be used to change them. Alcohol also presents a number of specialized problems that may occur in family practice. We include recent modifications in the treatment of withdrawal. Another syndrome increasingly observed is that of the effects of alcohol on the human fetus. The interesting but less usual manifestations of alcoholism are also noted in passing.
To obtain an operational description of the therapeutic community, the authors reviewed recent literature and composed a 40-item questionnaire describing aspects of the therapeutic community. The questionnaire was mailed to authors of recently published articles or books on the subject, 27 of whom responded with ratings of the degree to which each item was characteristic of a therapeutic community. The validated questionnaire was then completed by 22 staff members on four psychiatric wards of a university-affiliated municipal hospital, who rated the items in terms of real and ideal conditions on the ward. Comparisons of the real and ideal ratings are discussed.
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Indicators of the effectiveness of mental hospitals currently in use have severe limitations. Admissions, discharges, and occupancy rates are affected by multiple factors and determined largely be institutional policies. A rapidly calculable measure of responsiveness to patient requests for hospital admission is described. The synchrony ratio (psi) requires only that the number of emergency room visits and admissions by known accurately. If hospitals override patient needs, this is reflected in declining psi values. The utility of the synchrony ratio has been tested in a comparison of a general hospital psychiatric service and community mental health center inpatient wards.
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