The impact of opioid-induced constipation among chronic pain patients with sufficient laxative use.

BACKGROUND: The impact of sufficient laxative use on opioid-induced constipation (OIC) is not known. AIM: To understand the experience and symptom burden over time among chronic non-cancer pain patients with OIC who are sufficient laxative users. METHODS: A prospective longitudinal study was conducted in United States, Canada, Germany and UK which included medical record abstraction, patient surveys and physician surveys. Patients on daily opioid therapy for ≥ 4 weeks for chronic non-cancer pain with OIC were recruited from physician offices and completed the survey at Baseline and Weeks 2, 4, 6, 8, 12, 16, 20 and 24. Sufficient laxative use was defined as at least one laxative remedy 4 or more times in the prior 2 weeks. RESULTS: Of the 489 patients who completed the Baseline survey and met OIC criteria, 234 (48%) were categorised as sufficient laxative users; 65% were female; 90% were white and 75 (32%) maintained sufficient laxative use for > 7 of the 8 follow-up periods. Patient Assessment of Constipation-Symptom (PAC-SYM) and Patient Assessment of Constipation-Quality of Life (PAC-QOL) scores indicated moderate symptom severity and impact. PAC-SYM and PAC-QOL scores remained relatively unchanged over time with a maximum score change of 0.5 points. Work productivity and activity impairment remained relatively constant. Mean per cent activity impairment because of constipation was 37% at Baseline and 34% at Week 24. CONCLUSIONS: These findings demonstrate constipation persists despite sufficient laxative use with little improvement in symptoms, HRQL or activity impairment. This ongoing burden emphasises the need to identify more efficacious constipation therapies for this chronic pain patient population.

Impact of maintenance ECT on concentration and memory.

INTRODUCTION: With the increased administration of outpatient electroconvulsive therapy (ECT), it is important to develop methods for monitoring patients for adverse effects of treatment. This pilot study was designed to evaluate the utility of using telephone assessments to determine whether patents receiving maintenance ECT (MECT) experience cognitive deficits related to individual treatments. METHOD: Patients were recruited from an existing population of outpatients receiving MECT. The consenting patients were called on three occasions and given a battery of telephone cognitive assessments including Orientation-Memory-Concentration, Buschke Selective Reminding, Verbal Fluency, "World" Backwards, Serial Sevens, and Wechsler Logical Memory. The occasions for the telephone interviews were the day before ECT, the day after a treatment, and a week later. RESULTS: Sixteen patients completed the study. The correlation between baseline and time 3 ranged from 1.00 for spelling "world" backward to 0.509 for Verbal Fluency Category, indicating considerable variability in test-retest reliability. One test, Verbal Fluency Category, showed group level effects, with decrements in performance the day after a treatment. One of the 16 patients showed global cognitive deficits the day after a treatment. DISCUSSION: The pilot results suggest that telephone assessment may be a useful approach for monitoring patients receiving outpatient ECT. Monitoring may serve to guide clinicians in advising individuals and their caregivers about the return to activities after an individual treatment. Overall these findings support the tolerability of MECT.

The benefits of a broader perspective in case-finding for disease management of depression: early lessons from the PROSPECT Study.

The PROSPECT (Prevention of Suicide in Primary Care Elderly - Collaborative Trial) Study evaluates collaborative care for the treatment of current depressive disorders in older primary care patients. Using screening data, we evaluate implications of expanding the focus to additional patients who report taking psychotropic medication or having a history of depression. Some 13.8% of the patients screened were taking a psychotropic medication and 7.3% were both taking an antidepressant and had a Center for Epidemiologic Studies - Depression Scale (CES-D) score of > 15. Patients who reported current antidepressant use and those with a history of depression also had elevated CES-D scores. Conversely, most patients having an elevated CES-D score also reported taking an antidepressant or having a history of depression. These latter criteria for potential caseness yielded a larger number of patients than those identified by the CES-D alone. More comprehensive approaches to the management of depression should attend to patients already taking psychotropic medication and symptomatic patients with a history of depression, as well as those with current syndromal depression.

Detection and diagnosis of psychiatric disorders in primary medical care settings.

Research efforts accelerated in the 1990s to define the presentation of common psychiatric disorders in primary care settings. Two diagnostic instruments, the DSM-IV-PC and the PRIME-MD, were introduced in 1994, and a self-report form of the PRIME-MD, the PHQ, was published in 1999. These tools have streamlined the larger, often cumbersome psychiatric nomenclature of the DSM-III and DSM-IV and appear to be more useful in general medical settings. It still is not practical to use either instrument in its entirety for all patients in a busy primary care practice. Studies have suggested an efficient and effective, two-step method of screening primary care patients for psychiatric disorders, however. In this approach, a limited number of probing questions extracted from the PRIME-MD or PHQ (or DSM-IV-PC) are posed to patients, either in person or by a written self-report (i.e., a general health update or review of systems). Then a follow-up evaluation is done to confirm or refute positive screening results. Short, simple questionnaires that address specific topics (e.g., CAGE for alcohol screening or the GDS for mood disorders in older adults) complete and complement this approach. This method has the advantage of being easy to incorporate into routine office practice using minimal physician or office staff time, while showing acceptable sensitivity and specificity in studies to date. More research, particularly prospective studies, is needed to confirm the effectiveness of this approach and expand it beyond the few available studies that have focused mostly on depressive disorders.

Side effects of electroconvulsive therapy.

Electroconvulsive therapy is extremely effective and is the fastest acting antidepressant treatment now available, although not necessarily limited to use with depression. Despite years of experience with this technique and its unparalleled successes, patients continue to be affected by mostly transient, but sometimes impairing side effects from memory problems and cardiovascular changes associated with ECT treatments. Nausea, headache, muscle aches, and other side effects that have been referenced in the literature and clinical experience will also be discussed in this review. Helpful literature with recommendations on minimizing the risks of these side effects and improving the tolerability of the electroconvulsive treatments will also be presented.