Characteristics of patients with schizophrenia in two cities in the U.S. and India.

Gender-matched samples of patients with chronic schizophrenia were randomly selected from two metropolitan psychiatric emergency departments, one in Cincinnati, Ohio, (N = 47) and the other in Pune, India (N = 48). Severity and chronicity of symptoms in the two samples were comparable. Indian patients were significantly more likely to be married and employed than their American counterparts. In India most subjects were cared for by their families, whereas in the U.S. the community mental health network assumed major responsibility for care. Compliance with prescribed antipsychotic medications was significantly greater in India than in the U.S.

The effects of race on diagnosis and disposition from a psychiatric emergency service.

BACKGROUND: Previous studies have reported that racial differences exist in patterns of clinical psychiatric diagnoses as well as the distribution of mental health services resources. The psychiatric emergency service serves as an entry point into the mental health system, so it plays a potentially important role in addressing racial disparities in diagnosis and disposition. To address this disparity, the authors studied two specific questions: (1) are there racial differences in diagnosis and (2) are there racial differences in disposition of patients visiting a psychiatric emergency service? METHOD: Demographic and clinical data were obtained by retrospective chart review of 490 patients randomly selected from 9500 visits to a large psychiatric emergency service during a 1-year period. All clinical information had been recorded by the primary treaters who had no knowledge of this study. RESULTS: Black patients were significantly more likely to be diagnosed with schizophrenia and substance abuse than similar white patients, although less likely to be diagnosed with a personality disorder. Black patients were significantly more likely to be hospitalized, particularly at a public hospital, although there were no significant differences in insurance coverage or measures of suicidal or homicidal ideation. CONCLUSION: Despite the availability of DSM-III-R criteria, black patients continue to be disproportionately diagnosed with schizophrenia. In this sample, this diagnosis may have been given in lieu of a personality disorder or affective illness diagnosis. Black patients are also more likely to be hospitalized. These observations suggest that further research is needed to clarify the effects of race on the decision-making process in diagnosis and disposition from the psychiatric emergency service.

Pitfalls in presenting and interpreting clinical trial data.

Information generated by a clinical trial, when conveyed to health professionals and prospective patients, is affected by the original design of the trial and by the manner in which the results are presented. One problem in study design is the management of comparison groups in randomized assignments. When a comparison group is treated with an accepted standard compound, the chosen standard drug may be one that is associated with more side effects and complications than later modifications of the standard. Inadequate dosing of the comparison group can inflate the relative effect size of the experimental compound. Choosing a standard with a verifiable dose reference range can avoid this pitfall. In reporting results, relative score changes on a rating scale are meaningless without reference to an absolute value reflecting a clinically relevant degree of remission. The validity of rating instruments chosen must be judged in the context of the specific population to which it is applied. In the reporting of effects, the emphasis on significance of differences may obscure the critical distinction between statistical significance and clinical relevance, and graphs can appear to overstate a change over time by truncating the ordinate axis.

Hearing impairment and psychosis.

The study explores the relationship between hearing impairment and psychotic illness in twenty hospitalized patients (aged 55-77) using as controls twenty age-matched community-based older subjects with no psychiatric illness. All subjects received full psychiatric evaluations and comprehensive audiologic assessments. Data were analyzed by discriminant analysis and ANOVA. Experimental subjects were found to have significantly poorer unilateral pure tone averages (PTA) and significantly poorer bilateral speech discrimination ability than control subjects. Patients with a mood disorder had poorer unilateral PTAs than controls, but did not exhibit significantly poorer speech discrimination. Subjects with specifically paranoid ideation were found to have significantly better left ear speech discrimination than nonparanoid subjects. Our data suggest that hearing impairment should possibly be considered a potential risk factor for the development of psychosis in the elderly.

Residency training in emergency psychiatry : changes between 1980 and 1990.

Independent random samples of residency training programs were surveyed in 1980 and in 1990 about their emergency psychiatry training. A larger percentage of the programs required daytime emergency service duty in 1990 (80%), compared with 1980 data (50%), and a larger percentage offered a daytime block training rotation, defined as at least 5 days a week of emergency psychiatry for at least 4 weeks (48%), compared with 23% in 1980. Each sample reported that the most important topics in emergency psychiatry were being taught. In 1990, two trends were noted: 1) more faculty psychiatrist time allocated to the emergency service, and 2) more emergency patient visits per shift. In 1990, the residents said they felt more stressed by the heavy patient load and lack of disposition facilities than in 1980, but less stressed by the lack of faculty interest and backup. Based on the data, the interpretation was made that emergency psychiatry training had improved over this period; however, it was indicated that further improvement was also needed.

[Plasma anticholinergic activity and cognitive function in geriatric patients]. / Anticholinergische Plasmaaktivität und kognitive Funktion bei geriatrischen Patienten.

This study evaluated the putative impact of circulating anticholinergic equivalents on cognitive functional performance in non-demented geropsychiatric inpatients. Standard rating instruments were administered to measure memory functions, concentration and overall functional competency. Anticholinergic plasma activity was assayed, using a radioreceptor technique with tritiated quinuclidinyl benzilate as the active reagent. None of the cognitive tests employed indicated a statistically significant change in the subjects' quantifiable level of cognitive performance. All changes in anticholinergic activities were related to adjustments in psychotherapeutic medications. The possible role of reversal of pseudodementing features is discussed as well as the potential for monitoring anticholinergic activity when treating elderly individuals with more than one centrally active medication having anticholinergic properties.

A study of the clinical efficacy of maintenance ECT.

Six cases of maintenance electroconvulsive treatment (ECT) in elderly patients with major mood disorders were followed for 1 to 6 years. Documented duration of illness before instituting maintenance ECT ranged from 6 to 53 years (mean +/- SD = 22 +/- 18 years). Measures of effectiveness and safety of maintenance treatment and measures of functional status were prospectively obtained during periods of outpatient ECT administration, and functional status measures were retrospectively obtained for equivalent pre-ECT periods. Such measures included mean frequency of annual hospital admissions and average annual length of inpatient stay, mean scores on standard rating instruments of global functioning and cognitive performance, the average number of prescribed psychotropic medications, and ratings of affect. Some of the authors' findings support the contention that maintenance ECT may help sustain remission in the course of affective illness.

Length of psychiatric hospitalization and prediction of antipsychotic response.

1. Clinical variables determining length of psychiatric hospitalization for psychotic inpatients were explored. Forty psychotic inpatients received a 14 day fixed dose neuroleptic trial. 2. Neuroleptic responders (25/40) were discharged 15 +/- 2 days after initiation of pharmacotherapy. For neuroleptic non-responders (15/40) antipsychotic medication was then altered as clinically indicated. Patients requiring one change in medication (N = 8) were discharged after 27 +/- 5 days; those requiring two medication adjustments (N = 4) were discharged after 33 +/- 3 days and those requiring three alterations in pharmacotherapy (N = 3) were discharged after 42 +/- 12 days. 3. Statistical analysis of clinical and diagnostic variables indicated that 84% of the variation in length of hospitalization was accounted for by the number of alterations in pharmacotherapy required for symptom remission and discharge. It is suggested that length of hospitalization may be decreased by decreasing the length of time a clinician prescribes pharmacotherapy that subsequently proves not effective. 4. Bayesian analysis was employed to identify the minimum length of pharmacotherapy which accurately predicts subsequent antipsychotic response/non-response. During the fixed dose neuroleptic trial response/non-response could be accurately predicted for 65% of the patients by Day 3 of the trial while by Day 7 response/non-response could be predicted for 80% of the patients. 5. The present data indicate that a three to seven day trial of antipsychotics may be sufficient for making pharmacotherapy decisions as such a trial demonstrates a diagnostic efficiency similar to other predictive tests employed in clinical medicine.

Anticholinergic serum levels and cognitive performance.

Integrity of central cholinergic neurotransmission is essential for adequate cognitive functioning. Many psychotherapeutic medications have anticholinergic side-effects. In order to determine the impact of circulating anticholinergic activity on cognitive performance, 28 geropsychiatric inpatients underwent cognitive testing at different levels of anticholinergic serum activity. In 10 subjects with a diagnosis of probable Alzheimer's disease, significant deterioration of selected cognitive functions was observed at anticholinergic serum levels that caused no dysfunction in the 18 non-demented subjects. The data suggest that non-demented elderly patients with psychiatric problems tolerate psychotropic pharmacotherapy without significant negative impact on their cognitive competency. By contrast, patients with Alzheimer's disease are at risk of additional impairment. The introduction of anticholinergic serum activity as a monitoring technique for safe psychopharmacotherapy in geriatric patients is discussed.