Psychosocial factors in noncompliance during liver transplant selection.

This exploratory study attempted to identify characteristics of patients selected for transplant compared to those who had not demonstrated 6 months alcohol, drug and tobacco abstinence at the time of candidacy assessment. In a consecutive sample of 112 patients referred for liver transplant, almost half failed this criteria. Comparisons on psychometric measures of coping, social support, and health status revealed noncompliant patients to be significantly less authority abiding, less concerned about their illness, and less spiritually-oriented. Persisting alcohol use was paradoxically associated with greater psychosocial support whereas depression was related to smoking. Prior drug use was associated with more cognitive symptom complaints, emotional constriction, a vulnerability to feel dejection and a proneness to abuse medications These findings were discussed as a possible opportunity to identify and address characteristics of transplant candidates to reduce their risk of perpetuating noncompliance while competing for a life saving intervention.

Acquired obsessive-compulsive disorder associated with basal ganglia lesions.

The authors report 5 cases of acquired obsessive-compulsive disorder occurring later in life. Patients' presentations, which could be readily mistaken for a delusional disorder, were associated with depressive symptoms and basal ganglia lesions, implicating dysfunction of the cortical-basal ganglia-thalamic-cortical neuroanatomical circuit.

Episodically remitting akinetic mutism following subarachnoid hemorrhage.

Akinetic mutism is characterized by alertness with near complete absence of volitional activity. The authors report a case of episodically remitting akinetic mutism following subarachnoid hemorrhage.

Self-report evaluation of health behavior, stress vulnerability, and medical outcome of heart transplant recipients.

OBJECTIVE: The purpose of this study was to explore the value of patient self-report assessment in heart transplant candidacy evaluation, utilizing the Millon Behavioral Health Inventory (MBHI). Patient's MBHI measures were related to important pretransplant patient characteristics and posttransplant measures of health behavior, medical morbidity, and mortality. METHOD: Ninety heart patients with end-stage cardiac disease completed the MBHI during pretransplant candidacy evaluations, and also were interviewed concerning their coping effectiveness, support resources, and compliance history. Postransplant follow-up of 61 living and 29 deceased patients included measures of survival time, postsurgical medical care, rejection and infection episodes, and nurse ratings of medication compliance and problematic interpersonal health behaviors. RESULTS: The MBHI coping scales were found to significantly discriminate good and poor pretransplant compliance, and interview judgments of good and poor coping and support resources, with modest accuracy. The MBHI also was superior to these interview judgments in predicting posttransplant survival time and medical care used. Certain scales were also positively associated with physical parameters of pretransplant and posttransplant status. CONCLUSIONS: Patient self-report with the MBHI can contribute to identification of patients at risk for a problematic outcome with transplant, by providing information pertinent to clinical decision making and outcome management analysis with this special population of cardiac patients.

Psychiatric interview and psychometric predictors of cardiac transplant survival.

OBJECTIVE: This study prospectively investigated the relation between pretransplant assessment of psychiatric diagnosis, coping skills, and social support and outcome measures of survival and health care utilization. METHOD: Ninety-four heart transplant patients underwent structured interviews and completed a battery of self-report psychometric tests assessing coping style, health status, and psychosocial supports. Follow-up that ranged from 9 to 56 months after transplant produced a group of 63 survivors and 31 nonsurvivors, who were found to be comparable in terms of pretransplant cardiac status and severity of illness. RESULTS: Survival analysis showed that dimensional psychometric measures of coping and social support based on patient self-assessment were the best significant predictors of survival. Considered separately, interview-determined ratings of social support and pretransplant compliance with treatment regimens were also potential predictors. Formal DSM-III-R diagnoses were related specifically to posttransplant hospital utilization (axis I diagnoses) and posttransplant health behavior (axis II diagnoses). CONCLUSIONS: The data demonstrate the value of multifaceted assessment, since psychiatric diagnosis, coping style, and psychosocial support may contribute differently to prediction of such aspects of outcome as mortality and health care utilization.

Relationship of psychiatric morbidity and psychosocial factors in organ transplant candidates.

The purpose of this study was to explicate the statistical relationship between psychiatric diagnosis and psychosocial adjustment and health status in organ transplant candidates. Interview and psychometric data were obtained from 311 heart, kidney, lung, and liver transplant candidates. Over 60% of the cases met criteria for DSM-III-R Axis I diagnoses, nearly 32% for Axis II disorders. Axis II disorders were significantly associated with medical compliance problems, whereas Axis I disorders were predominantly associated with poorer psychosocial adjustment and health status. Nearly one-quarter of the patients had comorbid Axis I and Axis II disorders, and evidenced poorest premorbid coping and degree of marital harmony, defining a subgroup at special risk for problematic outcome. The incidence of psychiatric disorders and their association with lack of psychosocial resources and poor physical health supports the use of systematic, multidisciplinary assessment of transplant candidates.

SPECT findings on psychosis in Alzheimer's disease.

OBJECTIVE: This study examined whether psychosis in Alzheimer's disease is associated with cerebral perfusion patterns appreciable by single photon emission computed tomography (SPECT) scans. METHOD: All cooperative outpatients enrolled in an Alzheimer's disease research center with the diagnosis of probable Alzheimer's disease and a Clinical Dementia Rating of mild or moderate were interviewed with their primary caregivers. Current and past psychiatric functioning was assessed by using the Hamilton Depression Rating Scale, the Structured Clinical Interview for DSM-III-R, and the Behavioral Pathology in Alzheimer's Disease Rating Scale. Patients without premorbid psychosis received SPECT scans, and the scans of the patients with delusions or hallucinations (N = 30) were compared to the scans of patients without these symptoms (N = 16). RESULTS: The patients with delusions (N = 29) had hypoperfusion of the left frontal lobe in relation to the right frontal lobe. The patients with hallucinations (N = 10) had hypoperfusion in the parietal lobe. CONCLUSIONS: Psychotic patients with Alzheimer's disease had a pattern of cerebral blood flow deficits significantly different from that of nonpsychotic patients. This suggests that patterns of cerebral dysfunction may be expressed symptomatically as psychosis.

Clinical variables associated with psychosis in Alzheimer's disease.

OBJECTIVE: The authors explored whether personal or family history of major mental illness, negative symptoms, or behavioral measures are associated with positive psychotic symptoms in Alzheimer's disease. METHOD: Fifty-seven patients with Alzheimer's disease were studied prospectively during interviews with the patients and their primary caregivers. RESULTS: Psychotic patients with Alzheimer's disease did not differ in cognitive functioning from nonpsychotic patients with Alzheimer's disease. No association was found between personal or family history of mental illness and psychosis. Asociality was the only negative symptom associated with psychosis. Psychotic patients had more behavioral disturbances. CONCLUSIONS: Positive psychotic symptoms in Alzheimer's disease are not associated with certain aspects of cerebral functioning but are associated with behavioral disturbances.

Clozapine for acute and maintenance treatment of psychosis in Parkinson's disease.

In a prospective, open-label study, 12 patients manifesting psychosis associated with Parkinson's disease were treated with clozapine. Cognitive functioning and type of psychotic symptoms were measured prior to treatment, and changes in psychiatric and behavioral symptoms were studied by using the Behave-AD Scale. Significant resolution in psychotic symptoms was found and improvement in global behavioral status observed in all cases, with 10 patients maintaining improvement at follow-up. Careful initiation and titration of the drug resulted in few side effects, and dementia was not found to be a contraindication to such treatment.

A case of organic mania associated with open heart surgery.

Organic mania has been reported to have multiple etiologies. A case is described of a patient who developed mania following a coronary artery bypass graft and mitral valve replacement. Cerebral abnormalities were not detected by computed tomographic or magnetic resonance imaging scans, but an area of dysfunction was found using single photon emission computed tomographic (SPECT) imaging. The lesion resolved when the patient became clinically asymptomatic. The area of decreased cerebral perfusion associated with the patient's mania was in an atypical location, raising questions about which brain regions can result in well-defined psychiatric syndromes.

Clozapine use in diffuse Lewy body disease.

Diffuse Lewy body disease, a severely disabling neuropsychiatric disease, presents with progressive dementia, psychotic symptoms, depression, and parkinsonian symptoms. The authors report a case illustrating that clozapine, a novel neuroleptic drug, has special efficacy in treating psychotic symptoms in these patients.

Comparison of two cognitive screening measures for efficacy in differentiating dementia from depression in a geriatric inpatient population.

The Folstein Mini-Mental State Examination (MMSE) and dementia screening measures developed by Benton (temporal orientation, oral word association, and visual reconstruction tasks) were compared for diagnostic efficacy with geriatric inpatients manifesting depression without dementia or mild or moderate dementias complicated by depression. Both instruments showed generally acceptable differentiation between dementia and depression-only cases overall. The MMSE was less sensitive in identifying mild and moderate multi-infarct dementias but showed better specificity than the Benton measures. The degree and type of dementia and the associated risk of classification error were found to be important factors in the choice of screening instruments.

Lithium side effects in elderly bipolar outpatients.

A group of 19 geriatric bipolar lithium patients were interviewed in order to assess the incidence, bothersomeness and intensity of medication side effects. The role of subject variables was also examined. Most often reported side effects included excessive thirst, hand tremor, excessive urination and dry mouth. Although many side effects were experienced, these effects were generally tolerated with minimal intensity and bothersomeness. Results indicate that with proper precautions and monitoring, lithium can be safely administered to geriatric bipolar patients.

The prevalence of tardive dyskinesia in geropsychiatric outpatients.

The prevalence of tardive dyskinesia was studied in a geropsychiatric outpatient clinic. All currently active patients were examined using the Abnormal Involuntary Movement Scale (AIMS) and a standardized procedure. Data were collected on a number of previously reported risk factors. A higher prevalence was noted in both tardive dyskinesia and spontaneous involuntary movement disorders in this patient population. Only sex and duration of exposure to antipsychotic drugs were noted to be significant risk factors.

ECT and tardive dyskinesia: two cases and a review.

A brief review of the literature on electroconvulsive therapy in the management of tardive dyskinesia is presented and two patients are described who were treated for major functional disorders with ECT and showed dramatic remissions in tardive dyskinesia. This response was noted during the course of ECT and has been sustained at 1-year follow-up.

Attitudes in the development of public sector clinicians.

Attitudes have been a neglected variable in the development of public sector clinicians. Clinicians of differing disciplines may commonly possess attitudes which would affect their role in the public sector. The Houston Consortium assessed some of these attitudes in their students and faculty. The results may have heuristic implications for improving mental health care.

Boom areas: implications for mental health care systems.

Areas of rapidly shifting population are a perennial phenomenon. Such occurrences offer particular challenges to mental health services. The boom areas which have developed recently in the southwestern rim of the United States have highlighted certain inadequacies in our mental health system. The Houston Consortium, a multi-institutional endeavor, offers one model for addressing these problems. This model emphasizes innovative educational programs geared to local service needs.