Medical services utilization and charge comparisons between elderly patients with and without Alzheimer's disease in a managed care organization.

OBJECTIVES: The purposes of this study were to describe the health service utilization patterns and the associated charges for elderly patients (aged > or = 65 years) diagnosed with Alzheimer's disease (AD) enrolled in a managed care organization (MCO), and to compare these patterns and charges with those of elderly enrollees not diagnosed with AD (non-AD). METHODS: We analyzed medical claims data over a 12-month period for the population of elderly patients with a diagnosis of AD or AD-related dementia, and for all other elderly patients enrolled in an integrated MCO. Comparisons were made at the level of service location (eg, inpatient hospital, outpatient hospital, physician's office). RESULTS: For a total of 250 patients diagnosed with AD (66.0% female, 34.0% male; mean age. 80.5 years), health care charges were 1.6 times higher per patient per year than the corresponding charges for 13,553 non-AD patients (58.6% female, 41.4% male; mean age, 73.3 years). AD patients received 1.7 times more health care services per patient per year than their non-AD counterparts. CONCLUSIONS: Despite the lack of nursing home and prescription drug data, our results show that AD patients in this MCO used more health care services and had higher annual medical care charges than non-AD patients. If MCOs conduct similar analyses of elderly AD patients' patterns of care and compare these with the patterns of elderly non-AD patients, they may be able to pinpoint areas of disparity in medical care and improve service delivery for AD patients.

Luteal phase sertraline treatment for premenstrual dysphoric disorder. Results of a double-blind, placebo-controlled, crossover study.

OBJECTIVE: To test the efficacy of late-luteal phase dosing of sertraline hydrochloride in women with moderate-to-severe premenstrual dysphoric disorder. This highly prevalent disorder often causes significant psychosocial impairment. DESIGN: Double-blind, crossover trial of each 2-menstrual cycle of baseline, sertraline treatment, and placebo. Randomization to sertraline treatment vs placebo occurred after a 2-cycle, drug-free period. SETTING: A large outpatient multispecialty clinic in central Texas. PATIENTS: Fifty-seven women aged 19 to 49 years with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of premenstrual dysphoric disorder. INTERVENTIONS: Late-luteal phase treatment with sertraline hydrochloride in daily doses of 50 mg (cycle 1) followed by 100 mg (cycle 2) vs placebo. MAIN OUTCOME MEASURES: The 22-item calendar of premenstrual experiences was completed daily and constituted the primary outcome measure, consisting of a total score and behavioral and physical factor scores. RESULTS: A repeated-measures analysis of variance for crossover designs found a significant beneficial effect from sertraline treatment in improving the calendar of premenstrual experiences total (P < .01), behavioral factor (P < .01), and physical factor (P < .04) scores. Most women improved when taking sertraline, 50 mg, although a dose increase to 100 mg yielded further improvement in approximately 25% of women. Use of sertraline was extremely well tolerated; the only adverse event reported by 10% or more of women was insomnia in 8 (14%) of them. CONCLUSIONS: Luteal phase treatment with sertraline was a safe and effective treatment for moderate-to-severe premenstrual dysphoric disorder. Further controlled studies are needed to confirm the results of this preliminary study.

Affective spectrum disorders: how to recognize and treat depression.

Depression often goes undiagnosed. Even when pharmacotherapy is initiated, many patients discontinue therapy and thus risk relapse. Depression may occur at any age; however, the average age of onset is the late twenties. Acronyms have been developed to help the clinician recognize depression in the clinical setting. Common medications, abused substances, and medical disorders may cause and/or mimic depression. If pharmacotherapy is deemed appropriate, the choice of antidepressant is based on personal/family history of response to a particular agent and the side effect profile of the agent, as well as suicide risk. The tricyclic antidepressants and monoamine oxidase inhibitors are associated with anticholinergic effects, orthostasis, and risk of death in overdose. The selective serotonin reuptake inhibitors may have more tolerable adverse effects. Newer agents have also been marketed; however, the selective serotonin reuptake inhibitors are generally the drugs of first choice.

Probable nefazodone-induced mania in a patient with unreported bipolar disorder.

Nefazodone is a new antidepressant exhibiting properties of selective serotonin reuptake inhibition and serotonin-2 receptor antagonism. There has been only one other published case of induction of mania in a patient treated with nefazodone. This report describes a second case of probable induction of mania with nefazodone therapy and briefly reviews clinical and theoretical considerations involved in this process.

Fluoxetine and tics in an adolescent.

OBJECTIVE: To describe a case of tics associated with fluoxetine. CASE SUMMARY: A depressed adolescent was treated with fluoxetine. The patient had not been exposed to any other pharmacologic agents prior to this treatment. Following eight months of fluoxetine therapy the patient developed numerous tics. The movements subsided six months after discontinuation of fluoxetine. DISCUSSION: Antidopaminergic effects have been reported in patients treated with fluoxetine. Because fluoxetine is a specific serotonin reuptake inhibitor, one plausible explanation for the extrapyramidal symptoms observed in these patients is that serotonin modulates dopaminergic neurons. CONCLUSIONS: Extrapyramidal symptoms have been reported in patients receiving fluoxetine, although never previously in an adolescent. This case report provides further evidence that fluoxetine may be associated with severe extrapyramidal adverse reactions.

Psychotropic drug-related rhabdomyolysis.

OBJECTIVE: The objective of this review is to discuss the pathophysiology and potential etiologies of rhabdomyolysis in psychiatric patients, with an emphasis on psychotropic drug-induced rhabdomyolysis. DATA SOURCES: References were obtained through an on-line search of MEDLINE, using English-language and human literature only. STUDY SELECTION: Because the topic is a potential drug-induced adverse effect, no controlled studies are available. Most of the literature are case reports and series of case reports. DATA EXTRACTION: The quality of case reports was assessed using the Food and Drug Administration guidelines for assessing the causality of a potential adverse drug reaction. DATA SYNTHESIS: The results of this review are based on qualitative data and indicate that rhabdomyolysis in psychiatric patients can be from multiple etiologies, including agitation, dehydration, and intramuscular injections, as well as an adverse effect of psychotropic medications. Although the deficiencies of this type of data are recognized, it is the only type of data often available to assess the etiology and causality of an uncommon adverse event. CONCLUSIONS: Rhabdomyolysis in psychiatric patients can be caused by many factors, both drug- and non-drug-related. Rhabdomyolysis is more likely to occur when patients are faced with a combination of risk factors. When combinations of factors are present (e.g., aggression and restraints, intramuscular injections, and extrapyramidal effects), or when muscle trauma from an individual factor is sufficiently traumatic, muscle necrosis may occur to the point that rhabdomyolysis ensues.

Controversies over the use of magnesium sulfate in delirium tremens.

OBJECTIVE: To critically address the controversy of using parenteral magnesium sulfate in delirium tremens (DT). DATA SOURCES: English-language journal articles published between 1954 and 1987. STUDY SELECTION: All literature available, mostly case reports, that either support or discourage magnesium sulfate administration to patients with DT. DATA EXTRACTION: Pertinent information (as judged by the authors) was summarized and interpreted. DATA SYNTHESIS: DT has long been associated with magnesium deficiency because many alcoholic patients with DT have low serum magnesium concentrations. Recent literature, however, suggests that hypomagnesemia is not noted universally in this patient population and that patients' serum magnesium concentrations may return to normal without exogenous magnesium administration. Thus, there is most likely not a specific causal relationship of hypomagnesemia in DT. CONCLUSIONS: Routine administration of parenteral magnesium sulfate in patients with DT is not recommended.

Population pharmacokinetics of lithium.

The population pharmacokinetics of lithium was determined. Psychiatric inpatients who were at least 18 years old, had normal renal function, and were receiving lithium two or three times daily were the subjects of the study; 79 patients met the criteria. Serum lithium concentrations were measured by flame photometry 12 hours after the evening dose. Other data collected included age, gender, race, height, weight, serum creatinine and sodium concentrations, diet, and concurrent drug use. The nonlinear mixed-effects model (NONMEM) program was used to estimate lithium clearance, lithium volume of distribution, and error variability and to determine the influence of patient characteristics on lithium clearance. With the initial model, the mean lithium volume of distribution was 32.8 L and mean lithium clearance was 1.36 L/hr. With an intermediate model, lithium clearance estimates improved on the basis of patient size (weight and body surface area), daily lithium dosage, age, gender, and race. When only the most significant variables--lean body weight and creatinine clearance--were retained, a final model was obtained that yielded a coefficient of variation for lithium clearance of about 24% and gave fairly accurate predictions of steady-state lithium concentrations (coefficient of variation, about 16%). Analysis of lithium pharmacokinetics with the NONMEM program suggested that lean body weight and creatinine clearance are important predictors of lithium clearance.

Attitudes of pharmacy students toward mental illness.

Undergraduate pharmacy students' attitudes toward mental illness were measured by a questionnaire that also included questions about students' demographic variables and previous exposure to mental illness. Baccalaureate pharmacy students entering their first week of clinical rotations were asked to voluntarily complete a questionnaire that included Whatley's social distance scale and Morrison's Client Attitude Questionnaire version B (CAQ-B). Information was also sought about demographics, socio-economic factors, and prior exposure to mental illness. Possible total scores for Whatley's social distance scale range from 8 to 24, with lower scores implying more favorable attitudes toward mentally ill patients. Possible total scores for the CAQ-B range from 20 to 60, with scores lower than 40 indicative of a medical-model orientation and scores higher than 46 indicative of a psychosocial-model orientation. A total of 250 students completed the questionnaire. The first 85 students received Morrison's CAQ-B; the other 165 students completed both scales. The mean +/- S.D. score of 13.6 +/- 3.5 on the social distance scale indicates that the pharmacy students generally had favorable attitudes towards patients with mental illness. The mean +/- S.D. score of 32.8 +/- 3.6 on the CAQ-B indicates that the pharmacy students accepted a medical-model orientation. Students reporting a family history of psychiatric diagnoses and hospitalizations, a personal psychiatric diagnosis, or a history of visiting a psychiatric hospital had more favorable attitudes toward mentally ill patients. Female students and students who had a family history of psychiatric hospitalizations and diagnoses were significantly more oriented toward the medical model than students without this history.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacotherapy of obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is a potentially devastating illness, both to the patient and family members. Its etiology is unclear, but some evidence points toward dysfunction in an orbitofrontal striatal-limbic neuronal loop. Although many agents have been used, clomipramine, a tricyclic antidepressant, appears to be the most promising therapy. Clomipramine was approved by the Food and Drug Administration and released for general use in early 1990 under the brand name Anafranil. Clomipramine's adverse effect profile is similar to that of currently marketed tricyclic antidepressants; however, it is associated with a higher frequency of seizures, estimated to be 0.7%. Although other serotonergic agents such as fluoxetine have shown promise in OCD, they have been studied only in a limited number of patients. Other agents, with the possible exception of monoamine oxidase inhibitors, either have resulted in inconsistent improvement or have been reported in an anecdotal fashion.