Physician compliance with practice guidelines.

BACKGROUND: Physician adherence to established practice standards has become an important national issue. Despite the proliferation of formal standards of practice, there is little evidence that the mere availability of guidelines results in changes in physician practices. This paper presents the results of a study of the effectiveness of a computerized monitoring and notification system in increasing physician compliance with treatment guidelines. METHODS: This study prospectively compared medical staff practices in two one-year periods utilizing a computer system which tabulated noncompliance and provided reminders. RESULTS: Overall, there was a statistically-significant decrease in the number of alerts issued in year two compared to year one; alerts were issued on 15% vs 29% of all patients (P < .001). The average number of alerts per patient decreased to .20 from .41. CONCLUSIONS: The study results indicate that a clinical decision support system such as that described can improve adherence to treatment guidelines.

A comparison of adequately vs. inadequately treated depressed patients.

The authors reviewed the records of 201 nonbipolar depressed inpatients to a) determine the level of somatic therapies prescribed and b) compare the characteristics and global outcomes of patients given "adequate" vs. "inadequate" treatment. A stepwise multiple regression analysis revealed that patients given higher levels of somatic therapy were significantly (p less than .001) more likely to be older and have depression with psychotic features and less likely to have compulsive personality disorders. These patients also had significantly longer hospitalizations. A separate stepwise regression analysis showed that patients given higher levels of somatic therapy had superior outcomes (p less than .001). The proportion of this sample given no antidepressant medication or electroconvulsive therapy (18.4%) and the proportion given "adequate" treatment (45.3% to 63.7%, depending on the criteria applied) were comparable to the findings of other published reports.

Do DSM-III criteria for major depression define distinct subtypes?

The authors used a large (n = 437) sample of depressed inpatients to determine if DSM-III criteria applied in a clinical setting defined distinct subgroups. Patients with diagnoses of depression, depression with melancholia, and depression with psychotic features were compared by age, sex, diagnoses (Axes I-V), treatment received, and treatment outcome. These data failed to support the DSM-III distinction between a melancholic and psychotic subtype. However, compared to other patients with major depression, patients with melancholic and/or psychotic features were: (a) older, (b) more likely female, and (c) more likely to be treated with somatic therapy.

Use of clomipramine in treatment of obsessive-compulsive symptomatology.

An open clinical trial was conducted on the use of oral clomipramine in the treatment of obsessive-compulsive symptomatology in patients with various primary psychiatric diagnoses. The overall success rate of the 50 patients was 60%; those with a primary diagnosis of obsessive-compulsive disorder had an 80% success rate. No significant differences in outcome were observed by current age, age of illness onset, duration of illness, or severity of illness. Minnesota Multiphasic Personality Inventories of a subsample of the population revealed a significantly higher T score for depression in the successful patients. Since 83% of the successful patients had adequate prior treatments on other antidepressants without improvement in their obsessive-compulsive symptoms, it would appear that clomipramine is effective in treating obsessive-compulsive symptoms as well as depressive symptoms.

Quieting response training: predictors of long-term outcome.

Extensive personality, demographic, and symptom-related information from a heterogeneous group of more than 300 patients was examined for patterns that would discriminate between successful and unsuccessful outcomes in patients undergoing Quieting Response (QR) training, an 8-week program that integrated EMG and thermal biofeedback with a variety of relaxation exercises. Follow-up evaluations were at 3, 6, 12 and 24 months. Agreement between expected (from stepwise discriminant analyses) and observed outcomes was 65% (whole sample), 62% (headache only), and 70% (Raynaud's only). Unimproved patient MMPI scales D, Sc, F, Hy, and Pt were significantly elevated. A variety of additional measures used indicated elevated levels of psychological stress among unsuccessful patients. While stereotypical descriptions of successful and unsuccessful patients are proposed, patterns from outcome groups were more similar than dissimilar, and no combination of factors was identified that had sufficient predictive power for use with future patients. No statistical grounds for exclusion were found among patterns of responses to the measures employed. Factors contributing to the inaccuracy of outcome prediction are discussed.

Quieting response training: long-term evaluation of a clinical biofeedback practice.

Clinical evidence for the long-term effectiveness of biofeedback related relaxation training is accumulating. The purpose of this report is to describe the population, self-regulation procedure, outcome criteria, and final outcome for patients who received Quieting Response (QR) training. Data from 340 patients who completed at least the first follow-up at 3 months is presented. Primary presenting symptoms were headaches, 72%; primary and secondary Raynaud's, 14%; hypertension, 4%; irritable colon, 4%; and miscellaneous, 6%. QR training integrated EMG and thermal feedback with deep breathing, progressive relaxation, and autogenic exercises presented on cassette tapes. Eight 1-hour weekly sessions were given, with emphasis on daily home exercises. Follow-up evaluations were at 3 months, 6 months, 1 year, and 2 years. Outcome was based on change in frequency, severity, and duration of symptoms; changes in medication; and secondary benefits. Quieting Response training was found to be most beneficial for patients with primary Raynaud's disease (18 of 23 patients, or 78% successful), classic migraines (9 of 13, or 69%), and common migraines (20 of 32, or 62%), followed by mixed headaches (79 of 131, or 60%), Raynaud's plus other symptoms (9 of 15, or 60%), and the irritable colon syndrome (7 of 13, or 54%). Less successful were patients with headaches plus other symptoms (16 of 37, or 43%), muscle contraction headaches (13 of 33, or 39%), secondary Raynaud's phenomenon (4 of 10, or 40%), and essential hypertension (5 of 15, or 33%). Speculations about the differing outcomes across symptom groups were made.

Quieting response training: treatment of psychophysiological disorders in psychiatric inpatients.

Self-regulation methods incorporating biofeedback are known to be useful in the treatment of psychophysiological disorders in psychologically normal patients. In this study, the effectiveness of Quieting Response (QR) training for the treatment of secondary psychophysiological complaints in psychiatric inpatients was assessed. Ten male and 27 female inpatients with a variety of secondary psychophysiological diagnoses were accepted into the study. Severely disturbed, confused, or depressed patients were excluded. All patients received QR training, which integrated EMG (electromyogram) and thermal feedback with breathing, progressive relaxation, and autogenic exercises. Daily practice of a 15-minute sequence of exercises was encouraged, and a 6-second reinforcement exercise was presented for use whenever an annoyance was encountered. No other therapeutic modalities were employed. Patients were followed for up to 2 years, and outcome was assessed with a multifactor quartile system. Rate of success at final follow-up for the inpatients (51%) was found to be equivalent to that of outpatients coming to the clinic with primary psychophysiological diagnoses (55%) and was not related to psychiatric diagnosis or nature of presenting complaint. Stepwise discriminant analysis indicated that older, less depressed individuals were more successful. Inpatients differed from nonpsychiatric patients only in the number of additional sessions received. Only one minor incident of increased psychopathology was observed. It was concluded that QR training was as effective for treating secondary psychophysiological disorders in all but the most severely disturbed inpatients as it was for the outpatient clinic population.