The status of sleep abnormalities as a diagnostic test for major depressive disorder.

BACKGROUND: Psychiatry lags other fields in development of diagnostic tests. METHODS: A literature review and meta-analysis was conducted to ascertain if polysomnographic abnormalities (REM density, REM latency, sleep efficiency, slow wave sleep, stage 1 and stage 2 sleep) warrant additional effort to develop them into a clinical diagnostic test for major depressive disorder (MDD). The 31 publications meeting inclusion criteria were then classified into one of three progressive steps using guidelines for evaluating the clinical usefulness of a diagnostic test. RESULTS: Most of the abnormalities found in MDD patients, when compared to healthy controls, occurred in the expected direction with moderate effect sizes but with substantial publication bias and heterogeneity. Eleven studies compared abnormalities in MDD to other psychiatric disorders (step 2a), and four studies provided data on the sensitivity or specificity of the findings in differentiating among the psychiatric disorders that frequently appear on the same differential diagnostic list as MDD (step 2b). No multicenter trial has been conducted prospectively to test the clinical utility of the diagnostic test (step 3). LIMITATIONS: Only published articles in the English language were used. CONCLUSIONS: Sleep studies for the detection of MDD appear replicable with a moderate effect size. However, additional step 1 studies are needed to define the sensitivity and specificity. The heterogeneity of sleep recording, scoring techniques, and MDD must also be addressed.

Projections of the future supply of family physicians in Connecticut: a basis for regional planning.

BACKGROUND: There is a growing consensus that there is a shortage of primary care physicians in the United States. Many proposals have been made to increase the national supply of such physicians; however, because regional physician distribution and needs are highly variable, such proposals require evaluation in light of regional physician demands. METHODS: An examination was conducted of the projected supply in the year 2002 of active, nonfederal family physicians and general practitioners (FP/GPs) involved in direct patient care on a state-by-state basis, with particular focus on Connecticut. Data on the 1992 supply and demographics of FP/GPs were obtained from the American Medical Association Physician Masterfile. These data together with residency graduation, regional retention, and interstate migration data were used to project state FP/GP supplies in 2002 by estimating additions to and losses from state supplies between 1992 and 2002. RESULTS: In 1992, Connecticut had relatively fewer and older FP/GPs than the nation as a whole. By 2002, the supply of Connecticut FP/GPs is projected to decrease by 9%. Nine other states have similar potential for a net loss of FP/GPs over the same period. CONCLUSIONS: In the context of a national shortage of primary care physicians, a decline in the supply of FP/GPs in 10 states would be undesirable. Such a decline in the number of FP/GPs in undersupplied states could be averted by increasing the number of graduates from state residency programs, importing FP/GPs from out of state, promoting retention of state FP/GPs and residency graduates, and retraining existing state physicians in family practice or primary care.

Projections of physician supply in internal medicine: a single-state analysis as a basis for planning.

BACKGROUND: Physician supply planning has become an issue of increasing national debate over the past decade, particularly with the recent focus on health care reform. Most authorities agree that the United States has an increasing surplus of physicians. OBJECTIVE: The physician supply debate focuses on how to determine current and future physician supply and define appropriate specialty mix needs and then choose the measures that will appropriately influence the current and future size and specialty mix of the physician workforce. We examine these issues in the context of internal medicine in Connecticut, which may provide a single-state model for physician supply planning. METHODS: Data on the past and current supply of Connecticut internists and projections for future supply and need are examined. Particular attention is given to adult primary care (provided largely by general internists) and public policy implications. RESULTS: We find Connecticut has a disproportionate number of internists compared with the nation. Further, internist supply is growing faster than the population. Almost all subspecialties are in surplus and projected to increase further by the year 2000. CONCLUSIONS: Several approaches are available to limit excesses and produce more primary care physicians, including controls on residency and fellowship positions. Each approach presents both opportunities and challenges, and their implications must be carefully considered.

How many physicians is enough?: the debate over the supply of United States' physicians in context.

Physician manpower policy is a vital part of current efforts at United States health-care reform. The fundamentals of the ongoing debate over the adequacy of the national physician supply are: (1) what constitutes an adequate supply of physicians? (2) how does one determine if supply will be adequate in the future? (3) what are the consequences of having too many or too few physicians? and (4) what approaches could be taken to influence the size, specialty composition, or geographic distribution of the physician work force? Virtually all forecasts agree that the United States faces a future aggregate oversupply of physicians, with significant specialty imbalances. With these surpluses come economic costs that the nation appears unwilling to assume. Options for bringing physician supply into balance with requirements include reducing the numbers of new physicians entering active practice, increasing retirements, limiting availability of positions in oversubscribed specialties, and encouraging physicians to work in underserved areas.

The Sleep Disorders Questionnaire. I: Creation and multivariate structure of SDQ.

The development of the Sleep Disorders Questionnaire (SDQ) from the Sleep Questionnaire and Assessment of Wakefulness (SQAW) of Stanford University is described in detail. The extraction of the best question items from the SQAW and their subsequent rewording in the SDQ to insure greater completion rates are described. Two item test-retest reliability studies are reported on 71 controls and on 130 sleep-disorder patients, which confirmed adequate reliability. To create multivariate scoring scales, SDQ was then given in a multicenter study to 519 persons, 435 of whom were sleep-disorder patients with full polysomnography. Canonical Discriminant Function Analysis was employed, which resulted in four clinical-diagnostic scales: SA for sleep apnea, NAR for narcolepsy, PSY for psychiatric sleep disorder and PLM for periodic limb movement disorder. Each was adjusted for male and female responses and transformed to a percentile using the observed distribution of raw scores. Using Receiver Operating Characteristics analysis, cutoff points were determined for each scale to maximize its sensitivity and specificity. Positive and negative predictive values were also calculated. The SA and NAR scales proved to be the most discriminating.

Schizophrenia, narcolepsy, and HLA-DR15, DQ6.

A strong association between HLA-DR2, DQ1 and narcolepsy-cataplexy has been known since 1986. In 1990 a subdivision (HLA-DR15, DQ6) was shown to be equally associated. Narcolepsy symptoms include rapid eye movement (REM)-sleep intrusion hallucinations during the day. Some narcoleptics may be so hallucinated that they become delusional and receive a diagnosis of schizophrenia. Fifty-six inpatient schizophrenics and 56 normal controls were compared to see if there was an excess of the narcolepsy-associated antigens (NAA) among schizophrenics. Patients had frequency of the NAA 3.89 times higher than controls. After a subset was studied by night (n = 9) and day (n = 7) polysomnography, two patients were found to be true narcoleptics. Their psychosis improved with treatment for narcolepsy. When NAA(+) and NAA(-) schizophrenics were compared, the NAA(+) subgroup had significantly higher Brief Psychiatric Rating Scale (BPRS) scores and more hospitalizations. There were no effects attributable only to gender or race. We conclude that narcolepsy can simulate schizophrenia in some cases, and that even in nonnarcoleptic patients, the HLA-DR15,DQ6 antigens mark a group of severe schizophrenics that merits further study.

Urinary excretion of MHPG and normetanephrine in attention deficit hyperactivity disorder.

Twenty-four-hour excretion (expressed per gram of creatinine) of the norepinephrine metabolites 3-methoxy-4-hydroxyphenylethylene glycol (MHPG) and normetanephrine (NME) was measured in children with attention deficit hyperactivity disorder (ADHD) and in normal subjects matched for age and education. In contrast to findings with Tourette syndrome patients, in the ADHD patients there was no significant difference in excretion of MHPG and NME from control values.

Markovian analysis of phasic measures of REM sleep in normal, depressed, and schizophrenic subjects.

Rapid eye movement (REM) phasic activity refers to brief events that occur in periods of REM sleep, such as individual eye movements (EMs). REM density (RD) is the best-known measure of such activity, although reports of RD differences among normal, depressed, and schizophrenic subjects have been equivocal. RD is a measure with a large variability, and its physiological substrate is not known. We sought a more consistent measure which might also suggest the underlying physiology. Using the time intervals between individual EMs, we calculated empirical probability distributions which showed that EMs fell into two subgroups or states: "burst" and "isolated." Then, a novel Markov chain model of sequential transition between the states was calculated for nine normal, eight schizophrenic, and seven depressed male veterans. A significantly higher probability of remaining in the burst state was observed in both patient groups. The actual number of EMs in the isolated state was nearly identical in the three groups. Possible pontine neurochemical explanations involving cholinergic and serotonergic mechanisms are discussed.

Tourette syndrome and neuropsychological performance.

This study examined performance on a battery of neuropsychological tests in a sample of 28 patients with Tourette's syndrome (TS). Test scores were converted to age-corrected T-scores to control for the effect of age on test performance. The frequency of abnormal test performances was variable, but more frequent on motor and sensory tasks. Symptom severity as measured by the Tourette Syndrome Global Scale was inversely related to neuropsychological performance. In general, neuropsychological performance was mildly below average. The pattern of performance was similar to previous studies of TS patients.

Foreign-born and educated physicians in Connecticut who have not entered residency training.

Twenty-seven foreign-born, foreign-educated physicians who had not yet entered residency training were located in the Hartford, Connecticut area. Twenty-two completed a written survey and were interviewed. Fairly complete information was available on another two, for a total of 24. The physicians fell into two distinct groups. One group of young, single physicians with an average of two years of experience after medical school, were in the United States on student visas for further training, and generally planned to return home upon completion of training. The second group were older, experienced physicians who had come to the United States with their families for political reasons and planned to settle here permanently. Both groups had great difficulty passing FMGEMS Part I, but few had problems with Part II. Ninety percent were preparing at a commercial test preparation center, and 42% were employed, almost exclusively in the health-care field. Forty-four percent had been observers in a Connecticut hospital. The presence of these individuals, especially the older, more experienced group, raises many public policy questions in the areas of physician evaluation and licensing in the United States.

Florid refractory schizophrenias that turn out to be treatable variants of HLA-associated narcolepsy.

Narcolepsy in which the hallucinatory component is unusually prominent may lead to the development of an illness indistinguishable from the schizophrenic syndrome. Psychotic symptoms dominate the symptomatology, so that the primary illness is obscured. Five patients are described for whom conventional antipsychotic drugs were ineffectual, but for whom treatment with stimulants produced substantial improvement. The diagnosis of narcolepsy was confirmed by Human Leukocyte Antigen typing and sleep laboratory testing. These results support the "REM intrusion" hypothesis of the causation of schizophrenia in as many as 7% of a series of schizophrenic patients. Implications for diagnosis and treatment are discussed.

Depression and memory in major depressive disorder.

The relationship between memory function and depression was examined in 23 patients who met DSM-III criteria for major depression. All patients were unmedicated at the time of examination, which included the Wechsler Memory Scale, Minnesota Multiphasic Personality Inventory-Depression Scale (MMPI-D), and Hamilton Depression Rating Scale (HDRS). Consistent with previous studies, there was no relationship between the MMPI-D and any of the Wechsler Memory Scale measures. In contrast, poor memory was related to elevated scores on the HDRS. These data indicate that depression does influence memory performance. The most important implication of this study is the need for the use of appropriate measurement instruments in studies of neuropsychological correlates of neuropsychiatric disorders.

Urinary excretion of metabolites of norepinephrine in Tourette's syndrome.

Urinary excretion of the norepinephrine metabolites 3-methoxy-4-hydroxyphenylethylene glycol (MHPG) and normetanephrine (NMR) was measured in Tourette's Syndrome (TS) patients and in control subjects matched for age and education. The 24-h excretion (expressed per gram of creatinine) of total MHPG and of free and total (free + conjugated) NME was significantly lower in TS patients than in the normal subjects.

Plasma amino acids in attention deficit disorder.

This study examines plasma amino acids in a group of 28 patients meeting DSM-III criteria for attention deficit disorder (ADD) and 20 control subjects. Compared with controls, the ADD subjects had significantly lower levels of phenylalanine, tyrosine, tryptophan, histidine, and isoleucine. These data suggest a general deficit in amino acid transport, absorption, or both.

Monozygotic twins concordant for the narcoleptic syndrome.

We report the first documented monozygotic twins who both had the narcoleptic syndrome. We assessed monozygosity by HLA antigens and by blood groups. In contrast to virtually all other narcoleptics, they had HLA-DQ1 instead of HLA-DR2; this helped to localize the gene, and perhaps explains its greater expressivity in these than in other twins.

Short-term retest reliability of the Halstead-Reitan Battery in a normal sample.

Very few studies have examined short-term retest reliability of the Halstead-Reitan Battery in patient samples or normal subjects. The present study examined 3-week retest reliability in a sample of normal healthy subjects. Both psychometric and clinical reliability issues were addressed. On most of the tests the changes between testing were nonsignificant. The measures with the greatest changes were those that appear to incorporate a problem-solving or adaptability component. It was concluded that some of the Halstead-Reitan measures may not be useful in studying short-term changes in performance. On the other hand, most of the measures did not demonstrate significant changes over the 3-week interval and may be useful in examining such short-term changes in performance.

Three simultaneous major sleep disorders.

A patient with complex symptomatology is described. Progress in the diagnosis of sleep disorders gradually led to successful diagnosis-based treatment.