Continuum of care for Alzheimer's disease: a nurse education and counseling program.

This study evaluated a one year long course education and counseling program with 93 family caregivers of elders afflicted with Alzheimer's disease. The elders had received treatment for agitation in an inpatient setting and were subsequently discharged to the caregivers' home. Caregivers were randomly assigned to an experimental group (n = 68) and a control group (n = 25). Baseline assessments (Time 0) were conducted while the elder was an inpatient. Postdischarge interventions and assessments were conducted at 2 weeks, 6 weeks, 12 weeks, and 6 and 12 months (Times 1-5 respectively). There were no significant treatment effects for care recipient agitation, caregiver stress, depression, and physical health, and no significant differences between groups in rates of institutionalization for afflicted elders. Longitudinal data, however, revealed several important trends. Afflicted elders' agitation rose steadily for control group subjects at Times 3 through 5 but declined for experimental group subjects. Caregiver depression increased for control group subjects at Time 5, but declined for experimental group subjects. Caregiver physical health declined for control group subjects at Times 4 and 5 but was maintained for experimental group subjects. A significantly higher number of afflicted elders were still at home among experimental group subjects at the end of the one year study. The difficulties in demonstrating efficacy of interventions with family caregivers of Alzheimer's disease are discussed. Finally, the issue of data collection being perceived as support by control group subjects is evaluated.

Cerebrospinal fluid corticotropin-releasing factor concentrations in patients with anxiety disorders and normal comparison subjects.

Cerebrospinal fluid (CSF) concentrations of corticotropin-releasing factor (CRF) were measured in a group of patients with anxiety disorders and normal comparison subjects (NC) to explore the hypothesis that abnormalities in CRF neuronal regulation occur in patients with anxiety disorders. Analysis of variance (ANOVA) revealed no differences in CSF CRF concentrations between the four diagnostic categories: panic disorder (PD), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and NCs. Male OCD patients had higher CSF CRF concentrations than men with PD and GAD and male NCs. CSF CRF concentration was positively correlated with age in women but not in men. These findings suggest that central neuronal CRF regulation may be affected by both age and gender.

Current approaches to the psychopharmacologic treatment of depression in children and adolescents.

TOPIC: A review of major depressive disorder and antidepressant drug treatment in children and adolescents. PURPOSE: This paper provides a synthesis of current information regarding diagnosis, psychobiology, psychopharmacology, and practice guidelines for psychiatric nurses involved in the treatment of depression in children and adolescents. SOURCES: Recent journal and book publications regarding the psychopharmacological treatment of depression in children and adolescents. CONCLUSION: Although there is far less research to guide the psychopharmacological treatment of depression in children and adolescents than there is for adults, these treatments can be safely administered and effective for some individuals in this age group.

Dexamethasone for the treatment of depression: a randomized, placebo-controlled, double-blind trial.

OBJECTIVE: The authors' goal was to assess dexamethasone for the treatment of depression. METHOD: Thirty-seven outpatients (11 men and 26 women) meeting DSM-III-R criteria for major depressive disorder were randomly assigned to receive either placebo or 4 mg/day of oral dexamethasone for 4 days. Baseline Hamilton depression scale scores were compared with scores obtained 14 days after the first dose of study medication. Data were analyzed by using two-sample t tests, chi-square methods, and Fisher's exact test. RESULTS: Seven (37%) of the 19 patients given dexamethasone but only one (6%) of the 18 patients given placebo responded positively. No adverse events or side effects were reported, and all patients who entered the study completed it. CONCLUSIONS: A brief course of oral dexamethasone (4 days) was significantly more effective than placebo within 14 days for the treatment of depression in a randomized, double-blind study of depressed outpatients.

Success factors for automated systems in the clinical environment: the MUSC (Medical University of South Carolina) experience.

In today's dynamic health care environment, efficient, easy, and cost-effective access to patient information is crucial for clinical decision making. The Medical University of South Carolina's experience as alpha site for development of an open architecture clinical information system (OACIS) served as a catalyst for unprecedented organizational change in this 600-bed tertiary care teaching and research facility. This article reviews the steps in the process of preparing the hospital environment for successful testing and implementation of OACIS.

CSF cholecystokinin octapeptide in patients with bulimia nervosa and in normal comparison subjects.

Cholecystokinin octapeptide (CCK-8) appears to modulate appetitive behavior, and in rodents, anxiety-related behavior. The authors studied CCK-8 in patients with bulimia nervosa. CSF concentrations of CCK-8 were measured in 11 drug-free female patients with DSM-III-R-defined bulimia nervosa and in 16 normal subjects. The bulimic patients had significantly lower levels of CCK-8 than the comparison subjects. CCK-8 concentrations were inversely correlated with scores on the anger-hostility, anxiety, and interpersonal sensitivity subscales of the SCL-90-R. They were not significantly correlated with age, percentage of standardized average body weight, or mean weekly frequency of binge eating or vomiting. The results indicate that central CCK-8 abnormalities may play a role in the pathophysiology of bulimia nervosa.

Cerebrospinal fluid thyrotropin-releasing hormone concentrations in patients with anxiety disorders.

In a study of 45 patients with anxiety disorders and 11 control subjects, mean cerebrospinal fluid (CSF) concentrations of thyrotropin-releasing hormone (TRH) were not significantly different between nonpsychiatric control subjects and those with panic disorder, generalized anxiety disorder, or obsessive-compulsive disorder. Male subjects, regardless of diagnosis, had significantly higher mean CSF concentrations of TRH than females.

Preliminary report: placebo-controlled, double-blind study of the clinical and metabolic effects of desipramine in panic disorder.

Fifty-six males and females with panic disorder with or without agoraphobia participated in a 12-week, placebo-controlled treatment study of the efficacy of desipramine (DMI). Twenty-six of 28 patients receiving DMI completed the study; 17 of 28 placebo (PBO) recipients completed 12 weeks. Patients receiving DMI responded significantly better than did PBO recipients as measured by Hamilton Anxiety Scale (HAM-A) and global phobia ratings, with a trend toward greater global improvement, but no between-group differences on panic attack frequency were discerned. By Week 12, 22 of 26 (85%) DMI patients were panic-free; 13 of 17 (76%) PBO patients were panic-free. Resting metabolic rate (RMR) was tested on a subset of the patients. Patients receiving DMI showed no effects on RMR or thyroid indices but lost a significant amount of weight; the PBO recipients exhibited no weight loss or RMR effects. In this study, the high PBO response rate obscured treatment group differences on some measures. This study underscores the need for placebo comparisons in treatment studies. In summary, DMI appears to be an effective treatment for panic disorder. DMI appears to have little effect on RMR; a slight but significant weight loss was observed in the DMI but not PBO group.

CSF diazepam-binding inhibitor concentrations in panic disorder.

Diazepam-binding inhibitor (DBI) is a neuropeptide that has been detected in the brain and cerebrospinal fluid (CSF). Previous studies have suggested the possible role of DBI as a potential endogenous anxiogenic ligand modulating GABAergic transmission at the benzodiazepine-GABA receptor complex. The measurement of DBI immunoreactivity (DBI-IR) in CSF of panic-disorder patients and normal controls was undertaken to assess whether there were differences in the CSF concentration of this peptide to assess possible relationships with other monoamines and peptides. Lumbar CSF was obtained from 18 panic patients (4 men, 14 women) and 9 controls (5 men, 4 women). As a group, no significant differences were found between panic patients' CSF concentration of DBI-IR (1.12 +/- 0.27 pmol/mL) and normal volunteers (1.23 +/- 0.27 pmol/mL). No gender differences were demonstrated. However, we did find a positive correlation between CSF levels of DBI and CSF corticotropin releasing hormone (CRH) in our panic patients.

CSF beta-endorphin and dynorphin in bulimia nervosa.

OBJECTIVE: Preclinical and clinical evidence suggests that central opioid dysfunction may play a role in the pathophysiology of the eating disorders. In particular, endogenous opioids are known to regulate feeding behavior, mood, perception, and neuroendocrine function, all of which are disturbed in patients with eating disorders. Although low concentrations of CSF beta-endorphin have been reported in low-weight patients with anorexia nervosa, central opioid activity in normal-weight patients with bulimia nervosa has not been reported. The authors therefore measured CSF concentrations of beta-endorphin and dynorphin in drug-free female patients with DSM-III-R-defined bulimia nervosa and normal comparison subjects. METHOD: After 4 days of a low monoamine diet and overnight bed rest, CSF was obtained (12-26 cc) from 11 women with bulimia and 17 normal comparison subjects (eight women and nine men). RESULTS: The women with bulimia had significantly lower CSF concentrations of beta-endorphin than did the female comparison subjects. However, CSF concentrations of dynorphin were not significantly different in patients and female or male comparison subjects. beta-Endorphin concentrations were inversely correlated with Beck Depression Inventory scores and the depression subscale of the Eating Disorders Inventory. CONCLUSIONS: These data support a role for central opiates in the mediation of the pathophysiology of the signs and symptoms of bulimia nervosa, although it is impossible to rule out the effects of depression on the results.

The effects of pregnancy on preexisting panic disorder.

BACKGROUND: Limited evidence suggests that pregnancy may be associated with a reduction of panic and related symptoms. The authors investigate reported changes in panic symptoms during pregnancy. METHOD: Questionnaires asking about changes in panic and phobic avoidance symptoms during pregnancy were mailed to 129 women who had previously participated in our Anxiety Disorders Program over a 5-year period; all had diagnoses of panic disorder by DSM-III-R criteria. Reported here are responses from 22 of the women who experienced pregnancy after the onset of panic disorder. RESULTS: A majority of women (14 of 22) reported a decrease in panic symptoms during pregnancy, but significant variability in this phenomenon occurs between and within individuals. CONCLUSION: A subpopulation of women may experience improvement in panic symptoms during pregnancy, which has implications for management of these patients. Further research is needed to verify the existence of such a subpopulation and to determine an etiology.

CSF cholecystokinin concentrations in patients with panic disorder and in normal comparison subjects.

Cholecystokinin concentrations in the CSF of 25 patients with panic disorder and 16 normal comparison subjects were ascertained by radioimmunoassay. The patients with panic disorder had significantly lower CSF concentrations of cholecystokinin, which may reflect increased CNS cholecystokinin receptor sensitivity, reduced numbers of receptors, or a compensatory reduction in cholecystokinin octapeptide secondary to theoretically increased central cholecystokinin tetrapeptide activity.

Biological correlates of panic disorder with agoraphobia: practice perspectives for nurses.

The literature on panic disorder is summarized with regard to epidemiological, environmental, cultural, psychological, family, and genetic factors. Laboratory provocation of anxiety is reviewed with emphasis on the noradrenergic model of panic from a biological perspective. Positron emission tomography results involving brain asymmetries in lactate-sensitive panic patients are discussed, as are the psychopharmacological agents currently effective in the treatment of panic disorder. It is suggested that psychiatric nurses base their clinical practice on a holistic understanding of treatment implications as they relate to an individual's broader functioning. Areas for future nursing research are also identified.

Dopamine blocking activity of clomipramine in patients with obsessive-compulsive disorder.

While many data suggest that Obsessive-Compulsive Disorder (OCD) is an illness accompanied by dysregulation of the serotonergic system, interesting clinical evidence and animal studies also suggest possible dysregulation of the dopaminergic (DA) system. In order to determine whether clomipramine (CMI), an antiobsessional agent, is capable of altering DA function, we performed a neuroleptic radioreceptor assay (NRRA) on plasma samples from OCD patients before and after treatment in a double-blind, placebo controlled trial of CMI. CMI produced mild but significant DA D-2 receptor binding activity in an in vitro assay. The degree of dopamine binding activity did not correlate with clinical response to clomipramine. Because it has been suggested that another drug with antiobsessional efficacy, fluoxetine, may also have dopamine blocking properties, it may be speculated that antidopaminergic activity in combination with serotonergic effects is involved in antiobsessional activity of effective agents for some patients.

Inpatient management of violent behavior: nursing prevention and intervention.

Psychiatric nurses in inpatient settings play a critical role in the management of potentially violent patients. One of their primary objectives is to ensure the safety of patients and staff 24 hours a day. This requires skillful observation of patients' motor behavior, verbal clues, and change in mental status, which may indicate an increase in agitation or possible aggressive behavior. It requires experience in prevention strategies and skill in acute crisis intervention techniques. To effectively intervene with potentially violent patients, psychiatric nurses must be able to work well under stress and be able to organize and execute a plan of immediate action. After the acute stage of the patient's illness, nurses should focus their work on assisting patients to manage their own behavior and supporting their newly acquired skills.