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PubMed2006

[Effects of a shared decision making model in psychiatric and neurologic practice].

Involving patients in medical decisions is increasingly being advocated in medical fields other than psychiatry and neurology. A model of shared decision making might prove to be an ideal way of bridging the gap between patient-centred and evidence-based medicine. This report provides a survey of this shared decision making model and a discussion of its implications in the fields of mental health and neurology.

Adaptation, Psychological↗
PubMedDate not supplied

A method of conducting therapeutic sessions with MDMA.

A method for preparing clients and conducting therapeutic sessions with 3,4-methylenedioxymethamphetamine (MDMA) is described, with emphasis on the need for careful attention to the mental set of therapists and clients and the setting of the session. The therapists' belief was that MDMA inhibited the fear response to a perceived emotional threat, allowing the client to place the emotional sequelae of past experiences into a more realistic perspective in their current emotional lives and relationships. Clients were carefully screened and prepared until they had a clear purpose for the session, including a willingness to experience and to learn from anything that might happen. Sympathomimetic effects of MDMA determined the medical contraindications, and clients with histories of serious functional psychiatric impairments were excluded. Total doses of 75-150 mg, plus 50 mg if requested later, were administered, followed by clients lying down and listening to music with eyeshades and headphones during the peak MDMA effect. Screening and follow-up questionnaires were utilized. Two case histories are presented: a man achieving relief of pain from multiple myeloma, and a woman finding relief from problems as the daughter of Holocaust survivors. Use of consciousness-altering drugs in other contexts is discussed.

Adult↗
PubMed2002

Management of the multiple limb amputee.

ISSUE: Multiple limb amputations involving at least one upper extremity are very uncommon. The amputation of both an upper and lower limb is even more uncommon. Due to the rarity of these amputations therapists are uncertain regarding the most appropriate treatment methods. While the majority of the protocols used for single limb amputations are appropriate for these multiple limb amputees, there are differences. Loss of multiple limbs creates a problem of overheating for the individual. Loss of an arm and leg results in difficulty donning the prostheses and difficulty using crutches and parallel bars during mobilization. METHOD: A review is given of 16 multiple limb amputees seen in our rehabilitation centre in the last 15 years. Return to work was seen in one third and was not related to the number of the amputations. A higher proportion of these multiple limb amputations occur through alcoholism or attempted suicide behaviour than occurs with either single upper limb amputations or lower limb amputations. This existing behaviour can create a management problem for the rehabilitation team during rehabilitation. CONCLUSION: Guidelines as to appropriate prosthetic and preprosthetic care are provided to assist the practitioner who has the acute and long term care of these patients. All multiple limb amputees should be referred to a specialized rehabilitation centre to discuss prosthetic options and long term rehabilitation requirements. This paper does not discuss bilateral lower limb amputations when not combined with an upper limb amputation.

Adult↗
PubMed2005

Parenting schemas and the process of change.

Parents' childrearing behaviors are guided by schemas of the caregiving role, their functioning in that role, what children need in general, and what their own children are like in particular. Sometimes, however, parenting schemas can be maladaptive because they are too rigid or simple, involve inappropriate content, or are dominated by negative affect. In this article, we describe parenting schemas and provide an overview of empirical work documenting the characteristics of maladaptive parenting schemas. We review how intervention practices common to multiple therapeutic approaches (cognitive-behavior therapy, family therapy, parent training, attachment-based interventions, and psychoanalytic parent-infant psychotherapy) attempt to modify schemas to promote more optimal functioning among parents. We highlight how research in cognitive science may explain, in part, treatment effectiveness.

Adaptation, Psychological↗
PubMed1999

Antidepressant treatment of depression in HIV-seropositive women.

BACKGROUND: This study aimed to assess the effectiveness of fluoxetine and sertraline in treating depressed women who are seropositive for the human immunodeficiency virus (HIV) and to document barriers to study participation. METHOD: Ambulatory HIV-seropositive women with DSM-IV depressive disorders were enrolled in an 8-week, open trial of fluoxetine (N = 21) or sertraline (N = 9) initiated at standard dosages. Outcome measures included the Clinical Global Impressions-Improvement scale (CGI), Hamilton Rating Scale for Depression (HAM-D), Beck Depression Inventory (BDI), physical function ratings, and CD4 count. RESULTS: Thirty-six women were screened for the study and 30 were enrolled. Mean age was 35.5 years and HIV risk was primarily intravenous drug use (N = 16; 53%) or heterosexual contact (N = 12; 40%). Sixteen (53%) were Hispanic, 11 (37%) were African American, and 3 (10%) were white. Mean +/- SD CD4 count was 463+/-312 cells/microL, and 30% had acquired immunodeficiency syndrome (AIDS). Eighteen women (60%) completed the trial (14 fluoxetine: dose range, 10-40 mg/day; 4 sertraline: dose range, 25-100 mg/day). Of completers, 14 (78%) were clinical responders by CGI and reduction in HAM-D > 50%. Statistically significant reductions were seen in HAM-D and BDI scores, but not in measures of physical function or CD4 count. The most frequent adverse effects were anxiety, overstimulation, and insomnia. Reasons for nonparticipation or dropout included refusal to accept antidepressants on account of negative bias, preferring psychotherapy alone, adverse effects, and relapse to illicit drugs. CONCLUSION: While HIV-seropositive women may benefit from antidepressant treatment, multiple barriers to successful treatment exist. Aggressive outreach, education, and attention to the complex psychosocial needs of HIV-seropositive women are essential components of depression treatment in this population.

Ambulatory Care↗
PubMedDate not supplied

A framework for the analysis of psychotherapeutic approaches to schizophrenia.

A conceptual framework is articulated which clarifies the importance of psychotherapy as part of the treatment armamentarium in working with individuals carrying schizophrenic diagnoses. The author looks at the goals and appropriate role relationships for understanding and treating schizophrenic individuals from multiple psychotherapeutic perspectives. The goal is to present an overview within which different psychotherapeutic approaches to schizophrenia can be understood and compared and then reconnected in actual practice.

Adaptation, Psychological↗
PubMed2000

Severe self-injurious behavior associated with treatment-resistant schizophrenia: treatment with maintenance electroconvulsive therapy.

A 35-year-old man with schizophrenia associated with a 10-year history of repetitive and often severe self-injurious behaviors was treated successfully with maintenance electroconvulsive therapy. Initially his condition did not respond to multiple psychotropic agents (including a year-long trial of clozapine), 27 hospitalizations, two courses of bilateral electroconvulsive therapy, and supportive psychotherapy with partial hospitalization. After the initiation of maintenance electroconvulsive therapy, this patient was able to tolerate residential placement and begin a work therapy program with only one instance of self-injurious behavior in the past 17 months.

Adult↗
PubMed2006

Improving care for depression in patients with comorbid substance misuse.

OBJECTIVE: The authors investigated whether quality improvement programs for depression would be effective among substance misusers and whether there would be a differential program-by-comorbidity effect. METHOD: A group-level randomized controlled trial (Partners in Care) compared two quality improvement programs for depression with usual care. Consecutive patients (N=27,332) from six managed care organizations in five states were screened, and 1,356 were enrolled: 443 received usual care while the rest entered a quality improvement program involving either medication (N=424) or therapy (N=489). Multiple logistic regression was used to test hypotheses and compute standardized predictions of the adjusted rates of depression and use of psychotherapy and antidepressants. RESULTS: Under usual care conditions, depressed patients with substance misuse had an increased probability of ongoing depression despite higher rates of overall appropriate treatment. Among clients with comorbid substance misuse, the quality improvement programs were associated with improved depression outcomes at 12 months and increased antidepressant use at 6 months. Among clients with no substance misuse, the quality improvement programs improved depression outcomes at 6 months and were associated with increased treatment utilization. CONCLUSIONS: Co-occurring substance misuse is associated with depression and with increased risk for poorer depression treatment outcomes under usual care conditions. Quality improvement programs can significantly reduce the likelihood of probable depressive disorders in depressed patients with and without comorbid substance misuse. No consistent evidence was found for a differential program-by-comorbidity effect except for a suggestion of greater increase in psychotherapy among individuals with no substance misuse.

Adult↗
PubMed1986

Schizophrenia and antipsychotic drugs.

A variety of effective drugs are available for the treatment of schizophrenia. Knowledge of the side-effect spectrum of the various classes of antipsychotic drugs is necessary for the clinician to arrive at a rational choice of medication. In general, the preferred drug will be a high-potency neuroleptic. The following basic principles of clinical psychopharmacology should be followed: Consider risk and benefits; clinical experience is prerequisite; establish the diagnosis; select the appropriate class of psychotropic drug for the primary diagnosis; within drug class, the drugs are usually equally effective for patients with the diagnosis; give a dose that is high enough to be effective; choose target symptoms that can be monitored to indicate when to stop or increase the drug; avoid use of multiple drugs when possible; drugs are only one element in a comprehensive treatment strategy. Other modalities need equally careful consideration, e.g., psychotherapy, group therapy, family treatment, and vocational rehabilitation; and consultation with other subspecialists should be sought readily when indicated.

Antipsychotic Agents↗
PubMed1993

Use of botulinum toxin in the treatment of cervical dystonia.

Idiopathic cervical dystonia, like other adult-onset focal dystonias, has been notoriously difficult to treat. Multiple approaches, including systemic drug treatment with anticholinergics, antidopaminergics, anticonvulsants, muscle relaxants and many other drugs as well as physiotherapy and psychotherapy, usually lead to only temporary amelioration in a minority of patients. Surgical selective EMG-controlled denervation of dystonic neck muscles produces better and, in the hands of some, lasting improvement. However, the procedure is invasive and as such less well accepted by patients. Local injections of botulinum toxin are strikingly successful in improving postural deviation and pain in about 80% of patients. They can be made on an outpatient basis and appear to be safe even over many repeat sessions. Dysphagia is potentially the most serious side-effect but can be decreased in incidence and severity by injecting lower doses, particularly into the sternomastoid. Major drawbacks at present are a lack of prospective data to establish optimal dosage and volume of injection guidelines to preserve good efficacy at a reduced risk of side-effects, and the need to continue indefinitely with repeat injections approximately every 3 months.

Botulinum Toxins↗
PubMed1998

Patient ethnicity and diagnosis of emotional disorders in women.

BACKGROUND AND OBJECTIVES: Ethnic background and family resources have not been sufficiently examined in relation to emotional disorders and their treatment in primary care settings. This study examined the diagnosis and management of psychological disorders in family practice patients to explore how ethnicity may affect the diagnosis and treatment of emotional disorders. METHODS: A random sample of family practice patients was selected from 1 year of office visits. The charts of 100 African-American and 100 Caucasian women were audited for primary and secondary diagnoses, presenting symptoms, prescriptions, psychotherapy referrals, history of domestic violence and substance use, and family and demographic characteristics. Chi-square tests of association and multiple regression were used to analyze the data. RESULTS: Ethnic background was significantly associated with a diagnosis of a psychiatric disorder; 44% of Caucasian patients were diagnosed with an emotional disorder, compared with 24% of African-Americans. Proportionately more Caucasian patients with psychiatric diagnoses were treated with psychotropic medications. Patient race, marital status, and insurance status explained 15% of the variance in psychiatric diagnoses. CONCLUSIONS: Women's ethnicity is significantly associated with the diagnosis of emotional disorders and their treatment.

Adult↗
PubMed1999

A clinical demonstration model for assessing the effectiveness of therapeutic interventions: an expanded clinical trials methodology.

Both the evaluation of current treatment interventions and the innovation of new ones are vital to maintaining a viable clinical profession. In the field of psychology, however, often there are serious challenges facing these worthy endeavors. This article reviews several problems and limitations with evaluation of innovative psychotherapy treatments in clinical practice and suggests a strategy to overcome these. This approach, which we term the "Systematic Clinical Demonstration Methodology," (SCDM) combines the skills of clinicians with the rigors of clinical trials methods and permits concurrent clinical innovation and scientific evaluation. Here we suggest that the SCDM approach allows innovative practitioners to assist in the development and evaluation of promising clinical interventions by working closely with clinical trials researchers. This allows innovative clinicians to demonstrate new treatment approaches, while clinical researchers evaluate the effectiveness and safety of these interventions using clinical trials methods that incorporate qualitative data. We suggest that this approach can result in the development and evaluation of new treatment innovations more quickly and cost effectively than traditionally has been the case. In addition, some limitations commonly associated with clinical trials, such as not treating patients typically found in clinical practice, failing to treat patients with multiple disorders, or treating patients from different cultural or sociodemographic groups, can be more effectively addressed. Our experiences with using this method to evaluate different psychotherapy treatments for posttraumatic stress disorder are presented as an example of this new approach.

Clinical Competence↗
PubMed2001

Neurologic erectile dysfunction.

Neurologic erectile dysfunction presents a diagnostic and treatment challenge to the internist and urologist. Multiple chronic disease modalities and traumatic etiologies exist. Education regarding these conditions and a detailed and thorough history and office work-up are the best resources for the clinician. Treatment can follow the model of proceeding from the least to most invasive procedure (process of care), taking into account patient and partner satisfaction. Because the psychology of grief and loss may enter into treatment of some neurologic conditions (e.g., erectile dysfunction after radical retropubic prostatectomy, spinal cord injury, or chronic diseases), a whole-patient approach encompassing psychotherapy is warranted.

Chronic Disease↗