Fluoxetine treatment of obsessive-compulsive disorder.

Two patients suffering from severe obsessive-compulsive disorder which had proven refractory to clomipramine and/or phenelzine treatment were successfully treated with fluoxetine, a new drug with a strong serotonin uptake inhibiting action. Outcome of treatment was measured on psychometric tests including the Leyton Obsessive Inventory, Hopkins Symptom Checklist-90, Beck Depression Inventory, and daily self-reports of the duration and degree of discomfort of their most severe obsessions. The delay in responding to fluoxetine, the continuing improvement even after one year on the drug, and the prompt relapse with abrupt withdrawal of treatment were noted.

Fluoxetine in panic disorder.

This paper presents the cases of two patients who suffered from panic disorder with agoraphobia and depression. One had been refractory to alprazolam and tricyclics and to behaviour therapy; she had responded to phenelzine, but due to a weight gain of 50 lbs, had discontinued treatment and she relapsed. The second patient, who also suffered from post-traumatic stress disorder, did not respond to alprazolam, imipramine or to phenelzine, but gained weight (33 lbs) on phenelzine. Both patients responded to fluoxetine 80 mg per day without concomitant weight gain.

The fluoxetine treatment of low-weight, chronic bulimia nervosa.

Ten low-weight (mean, 87.8% of ideal), chronic bulimic patients, seven of whom were previously unsuccessfully treated with antidepressant drugs, received fluoxetine 80 mg/day for 3 months. Endpoint analysis showed a significant decrease in bulimic episodes (p = 0.01), vomiting frequency (p less than 0.05), and depression scores (Hamilton Rating Scale for Depression, p less than 0.04; Beck Depression Inventory, p = 0.05; Hopkins Symptom Checklist-90 depression subscale, p less than 0.05). In addition, trait anxiety (State-Trait Anxiety Inventory trait: p less than 0.002), obsessive symptoms (Leyton Obsessional Inventory symptom: p = 0.01; Symptom Checklist-90 obsessive-compulsive disorders subscale: p = 0.02), and traits (Leyton Obsessional Inventory trait: p = 0.005) also decreased significantly. There was no change in state anxiety or in Leyton Obsessional Inventory interference and resistance scores. There was no significant increase in weight. Two patients were in remission, two were much improved, two improved, and four showed no change. Side effects were minimal. There were no dropouts.

Psychiatric ethics and ethical psychiatry.

This paper critically examines the code of ethics that applies to practising psychiatrists. The code performs the functions for which it was designed admirably well. It does not, however, resolve moral dilemmas (i.e., complex situations in which any course of action compromises certain ethical principles). In these cases, the psychiatrist must turn to wider moral theory (i.e., psychiatric ethics) for guidance.

The validity of commitment certificates in British Columbia.

This study surveyed the content of committal forms completed at two B.C. hospitals. A profile of 50 patients at a provincial mental hospital and 50 patients on the ward of a general hospital was obtained by comparing the two groups on a number of demographic and psychiatric history variables. The medical certificates of the patients were then assessed for the inclusion of information required by the B.C. Mental Health Act. Of the 198 forms rated (two per patient), 137 (69.2%) were in compliance with the requirements of the B.C. Mental Health Act. Although a larger number of valid forms was scored for the psychiatric hospital, this difference was not significant. A total of 50 patients had a legally valid combination of medical certificates. Much of the problem associated with the invalid forms was related to the vague and confused wording of the Mental Health Act. It is suggested that a clearer definition of committal criteria and a rewording of the medical certificate may aid physicians in completing commitment documentation.

Trazodone treatment of bulimia nervosa.

Thirteen consecutive referrals of bulimic patients who met DSM-III criteria for bulimia were treated in an open-label, flexible-dose study with trazodone. Three of the 13 dropped out before the fourth week of treatment, the minimum duration of treatment for evaluable subjects, and hence were not included in the analyses. For the 10 evaluable patients, the mean duration of treatment was 6.9 weeks and the mean maximum dose of trazodone was 410 mg (range, 250-600 mg). The number of binge eating and vomiting episodes was significantly decreased (p = 0.05 and 0.06, respectively). These episodes were reduced to zero in four patients and by 55-99% in two patients. Carbohydrate cravings and urges to binge eat were significantly diminished in intensity (p less than 0.02 and 0.008, respectively). The total score (p = not significant) and three subscale scores (p = 0.04, 0.09, and 0.10) of the Eating Disorders Inventory decreased. The mean Hamilton Depression Scale score fell from 10.4 to 3.3 (p = 0.002). Only mild side effects were noted: five subjects complained of morning drowsiness and two of headache. Mean weight was essentially unchanged: pretreatment, 58.5 kg; posttreatment, 57.3 kg. The lack of weight gain represents an advantage of trazodone over other currently prescribed antidepressants, particularly for this group of patients whose fear of becoming fat is a part of their basic pathology.

Effects of caffeine on behavior of schizophrenic inpatients.

The present study replicates that of De Freitas and Schwartz (1979), using more typical chronic patients (on open wards rather than locked wards), and monitoring coffee intake with serum caffeine levels. The serum caffeine levels observed indicate that caffeine can be effectively manipulated on an open ward by switching the type of coffee served. Contrary to our predictions, no significant improvements in patients' behavior occurred when decaffeinated coffee was first introduced, nor was there any deterioration when regular coffee was reinstated. Only after decaffeinated coffee was introduced for the second time did any of the predicted changes occur; however, the improvements were few in number and may be accounted for by the considerable effect of time per se across all time periods. Although the findings cannot be generalized to all psychiatric patients, the results do not support recent calls for a switch to decaffeinated coffee for this population of inpatients (i.e., chronic schizophrenic patients on high doses of neuroleptics who drink large amounts of coffee).

The relationship between neuroleptic dosage and cognitive functioning in chronic schizophrenic patients.

A review of the effects of phenothiazines on cognitive function suggests that phenothiazine derivatives facilitate performance on tests of cognitive function, at least in subjects who are thought disordered. Drug effects frequently depend on the dose administered, however, and the response to various doses of some drugs (e.g., antidepressants) is frequently nonlinear. In our study, 23 hospitalized males with chronic psychotic disorders, and stabilized on dosages of neuroleptics with chlorpromazine equivalents of from 50 to 7,200 milligrams daily, were tested in the morning and in the evening of the same day with the Mini-Mental State examination [1]. Cognitive functioning was positively correlated (+0.49) with dosage, but the relationship was curvilinear. Functioning improved with increasing dose up to a dose of about 2,000 milligrams daily; beyond that dosage (and up to 7,200 milligrams daily) functioning plateaued. Scores on same-day retest were essentially unchanged regardless of dose. The implication of these findings for the management of chronic psychotic patients is discussed.

The review panel process: interpretation of the findings and recommendations.

In a series of three studies, the present authors and others in this research group have examined the Review Panel process: (a) before the hearing (which patients apply for a hearing?); (b) at the hearing (how do the patients released by the Panel differ from those retained by the Panel and; (c) after the hearing, how are the Panel-released patients faring one and two years after being released by the Panel, compared to patients released by the attending psychiatrist?) In the present paper, the findings of these three studies are summarized and an attempt is made to explain the findings, some of which are surprising (for example, the 35% disagreement between Panel and attending physician with respect to suitability for discharge and the finding that Panel-released patients survive as long in the community as do physician-discharged patients). Based on the findings and the interpretation placed on them, the authors make a series of recommendations with respect to the operation of Panels, the management of defiant involuntary patients and future research in this area.

Controlled follow-up of patients released by a review panel at one and two years after separation.

Fifty patients released by the Review Panel are compared with a matched group of 50 patients discharged by the attending physician at one and at two years after separation from hospital. The two groups did not differ with respect to readmission rate or time spent in the community. At two years the physician-discharged patients were functioning better than the Panel-discharged patients in two of the seven areas of functioning; in the other five areas of functioning the adjustment of the two groups did not differ. The implications of these findings for the operation of the Review Panel and for the timely discharge of involuntary patients by attending physicians is discussed.

Delineating social phobia.

The natural history--including psychiatric symptoms, precipitating factors, onset and course of illness, and personality characteristics--of 47 social phobics, 80 agoraphobics, and 72 simple phobics was examined. The social phobia group differed from the agoraphobia group by having a lower mean age, fewer females and married members, and a higher educational and occupational status. They were less fearful generally, less obsessive, and less likely to follow a fluctuating or phasic course. There was overlap between the two groups with regard to main phobias, and they were similar with regard to adjacent symptomatology. Both the social and agoraphobia groups differed in similar and significant ways from simple phobics.

Review panels for involuntary psychiatric patients: which patients apply?

This study attempted to identify which involuntary patients apply to Review Panels for discharge. Four hundred and eighty-seven (487) patients who applied for review at a provincial mental hospital during a five-year period were compared, on 27 variables, with 2,966 patients who, although eligible to apply, chose not to do so. The groups differed on nineteen of the twenty-seven variables. Discriminant analysis was used to identify the ten best predictors of who will apply to the Review Panel. The profile thus derived of the Review Panel applicant, may be useful to management teams who could try to formulate a plan that would reduce the probability that the patient will apply.

Variables affecting the decision making of a review panel.

This study was designed to identify the variables that influence a review panel's decision to discharge or detain an involuntary patient. A group of fifty patients consecutively discharged by the review panel of a provincial mental hospital were compared according to thirty-five variables, with a group of forty-five patients consecutively detained by the panel. The variable set included information on the patient's psychiatric history, current hospitalization and treatment as well as ratings of dangerousness, insight and psychopathology, as reflected in the attending physician's case summary prepared for the review panel. The released and detained groups were found to be remarkably similar. They differed on ten of the thirty-five variables measured, but they did not differ on some variables that one would expect to form the basis of the panel's decision, including diagnosis and a history of suicide attempts. On the other hand, when the predictive value of the variable set as a whole was examined using discriminant analysis, the results indicated that there was a substantial amount of predictability to the review panel process. The group membership of 77.5% of the patients can be predicted from only nine variables that contribute to the discriminant function. The results will be of interest to clinicians who deal with review panels on a regular basis and the findings have implications for other practical issues including discharge planning and readiness for community living.