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Biomedical subjects

M Tohen

Publications and source records attributed to M Tohen.

At least 91 records · Page 5Linked to original sources
PubMed1994

Concurrent use of clozapine and valproate in affective and psychotic disorders.

BACKGROUND: This pharmaco-epidemiologic study was undertaken to determine if the combination of clozapine and valproate poses an increased risk of blood dyscrasias, liver function abnormalities, or other side effects and to develop dosing guidelines when the combination is utilized. METHOD: The charts of 55 patients receiving clozapine and valproate concurrently between May 8, 1989, and May 8, 1992, were reviewed to determine the indication for and length of time on each medication, abnormalities in liver function test results, blood cell dyscrasias, seizures, nausea, vomiting, sedation, sialorrhea, and enuresis. In addition, the efficacy of the combination was measured. RESULTS: The combination of clozapine and valproate was efficacious and well tolerated in the majority of patients. Major adverse effects such as blood dyscrasias or seizures were not experienced by the study population. The side effect that led to discontinuation of the combination most frequently was sedation. CONCLUSION: The combination of clozapine and valproate is safe and efficacious.

Adult↗
PubMed1994

Clozapine therapy in refractory affective disorders: polarity predicts response in long-term follow-up.

BACKGROUND: To determine the efficacy and tolerance of long-term clozapine therapy in refractory affective illness. METHOD: Hospital records were reviewed for 193 treatment-resistant patients with a discharge diagnosis of bipolar disorder (N = 52), schizoaffective disorder (N = 81), unipolar depression (N = 14), schizophrenia (N = 40), or other disorders (N = 6) started on clozapine therapy as inpatients at McLean Hospital. An independent "best-estimate" diagnosis, based on DSM-III-R criteria, was established for each patient. Patients were contacted at least 6 months after clozapine initiation for structured follow-up interviews by raters blind to diagnosis. Patients were stratified by diagnosis, and a variety of patient characteristics and outcome measures were compared. RESULTS: Subjects were followed up a mean of 18.7 months after clozapine initiation. Bipolar manic and schizoaffective bipolar subjects had significantly better outcomes than unipolar, bipolar, and schizoaffective depressed patients on a variety of measures. One or more episodes of depression prior to clozapine predicted clozapine discontinuation (p = .01). Affective and schizoaffective subjects had baseline measures of social functioning similar to that of the schizophrenics but had significantly greater improvement in scores at follow-up. CONCLUSION: Clozapine is an efficacious and well-tolerated therapy for refractory affective illness. Manic symptomatology predicts a more favorable response than depression.

Adult↗
PubMed1994

Concomitant use of valproate and carbamazepine in bipolar and schizoaffective disorders.

From pharmacy records, the authors identified 17 consecutive patients who were treated with carbamazepine and valproate simultaneously. Twelve patients were diagnosed with bipolar disorder, manic or mixed types; four patients received a diagnosis of schizoaffective disorder, manic type; and one had major depression and posttraumatic stress disorder. All 12 bipolar patients had a moderate to marked response to the combination drug treatment, whereas all 4 schizoaffective patients failed to respond. Only two patients had minor side effects. The authors conclude that the combination of valproate and carbamazepine is usually well tolerated and that it can be effective in bipolar patients who have previously failed to respond to anticonvulsant monotherapy.

Adult↗
PubMed1993

Outcome after rapid vs gradual discontinuation of lithium treatment in bipolar disorders.

OBJECTIVE: Withdrawal of bipolar mood disorder (BP-I) patients from prolonged, stable lithium maintenance has a high risk of early recurrence, particularly of mania. We thus compared risks of stopping lithium rapidly vs gradually. DESIGN: Outpatients undergoing clinically determined discontinuation of lithium treatment at different rates were followed up prospectively to 5 years. Risks and timing of new episodes were analyzed. PATIENTS: Subjects (N = 64) with a DSM-III-R BP disorder, previously stable on lithium monotherapy for 18 to 120 months (mean, 3.6 years) were followed up clinically after discontinuing lithium (elected in prolonged wellbeing in 67%). None was unavailable for follow-up, and subtyping (BP-I or BP-II) remained stable. RESULTS: Within 5 years, 75% had a recurrent episode; BP-I patients were 1.5-times less likely than BP-II to remain in remission. Polarity of first-recurrent and onset episodes was 80.8% concordant. Overall risk of a new episode of mania was significantly greater after rapid (< 2) than gradual (2 to 4 weeks discontinuation (5-year hazard ratio = 2.8); the difference in risk of depression was even greater hazard ratio = 5.4). Recurrence rate was more elevated within months of rapid discontinuation (12-month hazard ratio = 5.4). Recurrence rate was more elevated within months of rapid discontinuation (12-month hazard ratio = 4.3) than at later times (2 to 5 years), when courses of "survival" over time were nearly parallel in both discontinuation groups. CONCLUSIONS: Risk of early recurrence of BP disorder following discontinuation of lithium maintenance is elevated, but may be both predictable (timing and polarity) and modifiable by gradual discontinuation.

Adult↗
PubMed1993

The Tridimensional Personality Questionnaire as a predictor of six-month outcome in first episode mania.

The authors administered the Tridimensional Personality Questionnaire (TPQ) near hospital discharge to 27 patients with first episode mania. All patients met DSM-III-R criteria for bipolar disorder, manic type, as assessed by the Structured Clinical Interview for DSM-III-R. Associations of TPQ scores with operationalized outcome variables were analyzed. Outcome variables included syndromic recovery at discharge and at 6 months, syndromic recurrence, and functional recovery. Patients who failed to achieve functional recovery by 6 months had significantly higher Novelty-Seeking dimensional scores at the time of hospital discharge. This association between TPQ scores and short-term outcome suggests that elevated Novelty-Seeking scores may reflect either personality characteristics that impair functional recovery or subclinical manic symptomatology that is not reflected in other symptom measures. The TPQ may provide useful prognostic measures in patients with new onset mania.

Adult↗
PubMed1993

Shifts in diagnostic frequencies of schizophrenia and major affective disorders at six North American psychiatric hospitals, 1972-1988.

OBJECTIVE: This study tested the impression that there have been significant shifts in the relative diagnostic frequencies of schizophrenia and major affective disorders. METHOD: Data on discharge diagnoses from 1972 to 1988 were gathered from six North American psychiatric teaching hospitals (data from one extended through 1991), and rates for schizophrenia and major mood disorders were evaluated. RESULTS: Total annual discharges increased by 6.6% during the study period. Large reciprocal shifts in the frequencies of diagnoses of schizophrenia and major affective disorders were found; schizoaffective disorder was a minor diagnosis. Beginning in the early 1970s, a gradual increase in the frequency of diagnoses of major affective disorders at all sites was accompanied by a corresponding decrease in diagnoses of schizophrenia at five of the six centers. Schizophrenia diagnoses decreased from a peak of 27% in 1976 to 9% in 1989 (a threefold decrease), and diagnoses of major affective disorders rose from a low of 10% in 1972 to 44% in 1990 (a fourfold increase). CONCLUSIONS: Several forces may have influenced these changes. 1) DSM-III narrowed the definition of schizophrenia and broadened the category of major affective disorders. 2) Treatment-oriented diagnostic bias associated with the availability of lithium and other mood-altering agents may have encouraged consideration of affective disorders. 3) Economic and social forces, including better third-party reimbursement rates, may have favored affective diagnoses. 4) True increases in the incidence of affective disorders may have occurred. 5) Although a real decrease in new cases of schizophrenia may have occurred, this effect was probably minor and dominated by a larger shift of such diagnoses to affective categories.

Canada↗
PubMed1993

Comorbidity in psychosis at first hospitalization.

OBJECTIVE: The authors sought to determine the prevalence and effects of medical and psychiatric comorbidity on initial outcome in a group of patients experiencing a first episode of psychosis. METHOD: Patients with a first episode of psychosis who were consecutively admitted to a hospital (N = 102) were examined for the presence of psychiatric and medical disorders. Patients were given psychiatric diagnoses with the use of the Structured Clinical Interview for DSM-III-R and were rated weekly on symptom rating scales. Outcome variables at discharge were final symptom rating scale scores, length of hospitalization, and recovery on the basis of operationalized criteria. RESULTS: Comorbid diagnoses were present in 52.0% (N = 53) of the patients, and 37.7% (N = 20) had multiple comorbid diagnoses. The most common comorbid diagnosis was substance abuse. Patients with affected psychoses were significantly more likely than those with nonaffective psychoses to have a comorbid substance abuse diagnosis. Patients with psychiatric comorbidity had poorer initial outcomes, while those with medical comorbidity had fewer symptoms at discharge. CONCLUSIONS: Comorbidity is common and may be a useful predictor of the outcome of a first episode of psychosis.

Adult↗
PubMed1993

High risk of eosinophilia in women treated with clozapine.

BACKGROUND: Eosinophilia associated with clozapine treatment has been reported in some studies and limited case reports. Because little is known regarding incidence, course, and relevance of this finding, clozapine therapy has been terminated prematurely in some patients with elevated eosinophil counts. METHOD: Records were reviewed on 118 consecutively hospitalized, acutely psychotic patients treated over a 1-year period with clozapine for at least 3 weeks. Demographic data were obtained on those patients, and white blood cell counts were analyzed. We reviewed the data for predisposing factors, associated medical findings, or clinical sequelae, and performed a two-sided Fisher's exact test to determine if sex or diagnosis was associated with a higher risk of developing eosinophilia. The literature pertaining to this blood dyscrasia and its relationship to clozapine was reviewed. RESULTS: In our population, the cumulative incidence of eosinophilia among women was 23% (13/57), a statistically significant higher risk (p < .01) than that in men (7% [4/61]). In all cases, the eosinophilia was noted between Weeks 3 and 5 of treatment and resolved without medical or psychiatric complications. CONCLUSION: Eosinophilia should be added to the list of commonly observed side effects of clozapine treatment. Women appear to be at significant risk. Eosinophilia usually occurs early in therapy, spontaneously resolves, and is not associated with any known complications. An otherwise healthy person with this blood dyscrasia may continue with treatment but should be monitored closely. Further investigation into this finding may provide insight into the mechanism of neutropenia and other adverse reactions to clozapine.

Acute Disease↗
PubMed1992

Possible affective-state dependence of the Tridimensional Personality Questionnaire in first-episode psychosis.

The authors administered the Tridimensional Personality Questionnaire (TPQ) to 61 patients with first-episode psychosis. Subjects were classified into affective states according to DSM-III-R diagnoses. TPQ scores were compared among these states and correlated with two affective symptom subscales: "mania" and "depression." Manic subjects demonstrated little variation from normative TPQ scores. Compared with findings in manic subjects, the dimensional score for Harm Avoidance was elevated in all affective groups, "worry and pessimism" was elevated in mixed-state subjects, "shyness with strangers" was elevated in depressed and nonaffective subjects, and "attachment" was lower in depressed and nonaffective subjects. The Harm Avoidance dimensional score and two subdimensional scores were positively correlated with the "depression" subscale. The Harm Avoidance dimensional and subdimensional scores showed possible affective-state dependence that may limit the utility of this instrument as a personality measure in first-episode psychosis.

Adolescent↗
PubMed1992

The McLean First-Episode Psychosis Project: six-month recovery and recurrence outcome.

The McLean First-Episode Psychosis project began in 1989. The authors describe the study design, diagnostic distribution, and recovery and relapse data on the first 102 recruited subjects. Fifty-nine percent of the subjects had a diagnosis of bipolar disorder, 15 percent psychotic depression, 10 percent schizophrenic spectrum, 9 percent delusional disorder, and 8 percent other psychotic disorders. By 6 months, 80 percent recovered syndromically but only 55 percent recovered functionally, and only 50 percent recovered both functionally and syndromically. Non-white and male patients were more likely to have a recurrence. Men were less likely and bipolar patients were more likely to recover functionally. Patients with nonaffective psychosis had longer hospitalizations and lower rates of functional recovery 6 months after discharge.

Adolescent↗
PubMed1992

Prediction of outcome in mania by mood-congruent or mood-incongruent psychotic features.

OBJECTIVE: The aim of this study was to determine the significance of mood congruence of psychotic features in mania as a predictor of outcome. METHOD: Fifty-four patients with bipolar disorder were followed prospectively for 4 years after recovery from an episode of mania with psychotic features. Assessments of residential and occupational status, interepisode symptoms, and episode recurrences were made at 6 and 48 months after recovery. Categorical outcomes were evaluated by logistic regression and recurrence risk with survival analysis. RESULTS: Mood-incongruent psychotic features during the index manic episode predicted a shorter time in remission at 4 years (hazard ratio = 2.6), and Schneiderian first-rank symptoms predicted poor residential status at 4 years (odds ratio = 20.1). CONCLUSIONS: Differentiation of mood congruence of psychotic features in mania evidently has prognostic validity and, therefore, has utility as a nosological characteristic.

Adult↗
PubMed1992

Mania compared with unipolar depression in old age.

OBJECTIVE: The goal of this study was to clarify the meaning and importance of mania in old age. METHOD: The authors conducted a retrospective study of 50 elderly patients consecutively admitted to a private mental hospital with an index episode of mania. As a comparison group, they used 50 age- and sex-matched patients with unipolar depression. They reviewed the charts of the 100 patients for family history, clinical course, and neurological disorders. Outcome was determined by contacting patients, families, physicians, institutional settings, and vital statistics records. Survival analysis compared mortality rates. RESULTS: The manic patients had a greater familial predisposition to affective disorder and were younger at first psychiatric hospitalization. For the 20 manic patients whose first affective episode was depression, an average of 15 years elapsed before mania became manifest. Eighteen of the manic patients, compared with only four of the depressed patients, had neurological disorders. The manic patients had a significantly higher mortality rate than the depressed patients; by the end of the follow-up, 25 of the manic patients, compared with 10 of the depressed patients, had died. CONCLUSIONS: Mania appears to have a poorer prognosis and to be a more severe form of affective illness than unipolar depression. The 18 manic patients with neurological disorders seemed to have "secondary mania." Subtle cerebral changes due to aging may have been responsible for the conversion to mania in the 20 patients who experienced a long latency from first depression to onset of mania. The low frequency of early-onset mania in this study group highlights the need to differentiate early- from late-onset mania.

Adult↗
PubMed1992

Comorbidity in mania at first hospitalization.

Comorbidity was studied in 41 manic and mixed-state bipolar patients at first hospitalization. The lifetime prevalence of comorbidity was high; 21 subjects (51.2%) had at least one other psychiatric diagnosis (N = 16, 39.0%) or medical disorder (N = 9, 22.0%). Nine subjects had multiple comorbid diagnoses. Women were 2.7 times more likely to have a comorbid diagnosis. The presence of comorbidity was not associated with differences in outcome measures.

Adult↗
PubMed1992

Increasing frequency of the diagnosis of obsessive-compulsive disorder.

OBJECTIVE: This study attempted to document a hypothesized increase in the frequency of the diagnosis of obsessive-compulsive disorder at a large psychiatric teaching hospital and to investigate correlates of this trend. METHOD: The annual rates of psychiatric discharge diagnoses at the hospital from 1969 to 1990 were reviewed, and the frequency of the diagnosis of obsessive-compulsive disorder was compared with that of paranoid disorders. Correlations were also done on these diagnostic rates and the rates of reports in the literature in the same years on each of these types of disorders and their treatment. RESULTS: The frequency of the diagnosis of obsessive-compulsive disorder, but not paranoid disorders, increased markedly during the 1980s. This increase was associated strongly and selectively with increases in publications about that disorder, particularly reports on drug and behavior therapy. CONCLUSIONS: There has been a large recent increase in the rate of diagnosis of obsessive-compulsive disorder, evidently associated with advances in the study and treatment of the disorder. The observations suggest the influence of a treatment-oriented diagnostic bias in which clinicians may more readily consider and diagnose a condition for which an innovative or effective treatment is available.

Behavior Therapy↗
PubMed1991

Risk of recurrence following discontinuation of lithium treatment in bipolar disorder.

Episode recurrence in bipolar disorder following discontinuation of stable maintenance treatment with lithium salts was analyzed from 14 studies involving 257 patients with bipolar I disorder. More than 50% of new episodes of illness occurred within 10 weeks of stopping an average of 30 months of treatment. By survival analysis of 124 cases in which the time to a new episode was known, the computed time to 50% failure of remission was 5.0 months after stopping therapy; the time to 25% recurrence of mania was 5.2 times earlier than for depression (2.7 vs 14 months). In 16 patients with a mean cycle length before treatment of 11.6 months, the time to a new episode when off lithium therapy was only 1.7 months. Risk of early recurrence of bipolar illness, especially of mania, evidently is increased following discontinuation of lithium use and may exceed that predicted by the course of the untreated disorder. The basis and management of risks associated with discontinuing effective long-term mood-stabilizing treatment require further study.

Bipolar Disorder↗