Assessing the cost-effectiveness of pharmacogenomics

The use of pharmacogenomics to individualize drug therapy offers the potential to improve drug effectiveness, reduce adverse side effects, and provide cost-effective pharmaceutical care. However, the combinations of disease, drug, and genetic test characteristics that will provide clinically useful and economically feasible therapeutic interventions have not been clearly elucidated. The purpose of this paper was to develop a framework for evaluating the potential cost-effectiveness of pharmacogenomic strategies that will help scientists better understand the strategic implications of their research, assist in the design of clinical trials, and provide a guide for health care providers making reimbursement decisions. We reviewed concepts of cost-effectiveness analysis and pharmacogenomics and identified 5 primary characteristics that will enhance the cost-effectiveness of pharmacogenomics: 1) there are severe clinical or economic consequence that are avoided through the use of pharmacogenomics, 2) monitoring drug response using current methods is difficult, 3) a well-established association between genotype and clinical phenotype exists, 4) there is a rapid and relatively inexpensive genetic test, and 5) the variant gene is relatively common. We used this framework to evaluate several examples of pharmacogenomics. We found that pharmacogenomics offers great potential to improve patients' health in a cost-effective manner. However, pharmacogenomics will not be applied to all currently marketed drugs, and careful evaluations are needed on a case-by-case basis before investing resources in research and development of pharmacogenomic-based therapeutics and making reimbursement decisions.

Personality disorders, history of trauma, and posttraumatic stress disorder in subjects with anxiety disorders

The purpose of the study was to examine the association of personality disorders, history of trauma, and posttraumatic stress disorder (PTSD) in a large sample of subjects with anxiety disorders. Categorical and continuous indices of personality disorders were compared in three groups from the Harvard/Brown Anxiety Disorders Research Project (HARP): subjects with no history of trauma (n = 403), subjects with a history of trauma but no history of PTSD (n = 151), and subjects with a current or past diagnosis of PTSD (n = 68). Subjects with PTSD were more likely to meet criteria for borderline or self-defeating personality disorder than subjects in the other two groups. PTSD subjects also had higher scores on the continuous measures (total number of criteria met) for borderline and self-defeating personality disorder than the other two groups. The findings suggest that a diagnosis of PTSD rather than a history of trauma is associated with borderline and self-defeating personality disorder features. Alternative conceptualizations of axis II features in individuals with PTSD are discussed.

Characteristics of memory dysfunction in body dysmorphic disorder

Although body dysmorphic disorder (BDD) is receiving increasing empirical attention, very little is known about neuropsychological deficits in this disorder. The current study investigated the nature of memory dysfunction in BDD, including the relationship between encoding strategies and verbal and nonverbal memory performance. We evaluated 17 patients with BDD and 17 healthy controls using the Rey-Osterrieth Complex Figure Test (RCFT) and the California Verbal Learning Test (CVLT). BDD patients differed significantly from healthy controls on verbal and nonverbal learning and memory indices. Multiple regression analyses revealed that group differences in free recall were statistically mediated by deficits in organizational strategies in the BDD cohort. These findings are similar to patterns previously observed in obsessive-compulsive disorder (OCD), suggesting a potential relationship between OCD and BDD. Studies in both groups have shown that verbal and nonverbal memory deficits are affected by impaired strategic processing.

Tool use in wild capuchin monkeys (Cebus albifrons trinitatis)

White-fronted capuchins were observed to use leaves as cups to retrieve water from tree cavities. On multiple occasions several individuals performed this behavior. Thus, these capuchins engage in habitual tool use, as defined by McGrew's classificatory scheme of tool using behavior.

Applying GPS to the study of primate ecology: a useful tool?

Data on the spatiotemporal distribution of resources can be collected and plotted using GPS (global positioning system) and GIS (geographical information system) technologies. By combining such data with information on foraging and ranging behavior of nonhuman primates, one can analyze the influence of resource distribution on social organization and group cohesion. We investigated the abilities of a three-channel GPS receiver to collect location data under varying canopy densities in both temperate and tropical forests. Eighty randomly selected points were sampled in a beech-maple forest in northeast Ohio, USA; 65 points also were sampled at several tropical forests in Costa Rica and Trinidad. At each point we attempted to obtain a GPS position fix; we also determined the speed of satellite acquisition and measured canopy density using a spherical densiometer. The ability to obtain a reading differed greatly between the two forest types (chi(2) = 53.79, P < 0.001). Ninety-seven percent of all attempts were successful in the temperate forest, whereas only a 34% acquisition rate was obtained in the tropical forests. Logistic regression showed that the probability of obtaining a reading in Neotropical forests was 75% but only when canopy cover was less than 20%. Thus, these minimal-channel GPS units may be of limited utility for behavioral ecologists working in closed-canopy Neotropical forests.

Implications of stroke risk criteria on the anticoagulation decision in nonvalvular atrial fibrillation: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study

BACKGROUND

Warfarin dramatically reduces the risk of stroke in patients with nonvalvular atrial fibrillation (NVAF) but increases the likelihood of bleeding. Accurately identifying patients who need anticoagulation is critical. We assessed the potential impact of prominent stroke risk classification schemes on this decision in a large sample of patients with NVAF.

METHODS AND RESULTS

We used clinical and electrocardiographic databases to identify 13 559 ambulatory patients with NVAF from July 1996 through December 1997. We compared the proportion of patients classified as having a low enough stroke risk to receive aspirin using published criteria from the Atrial Fibrillation Investigators (AFI), American College of Chest Physicians (ACCP), and the Stroke Prevention in Atrial Fibrillation Investigators (SPAF). In this cohort, AFI criteria classified 11% as having a low stroke risk, compared with 23% for ACCP and 29% for SPAF (kappa range, 0.44 to 0.85). This 2- to-3-fold increase in low stroke risk patients by ACCP and SPAF criteria primarily resulted from the inclusion of many older subjects (65 to 75 years+/-men >75 years) with no additional clinical stroke risk factors.

CONCLUSIONS

The age threshold for assigning an increased stroke risk has a dramatic impact on whether to recommend warfarin in populations of patients with NVAF. Large, prospective studies with many stroke events are needed to precisely determine the relationship of age to stroke risk in AF and to identify which AF subgroups are at a sufficiently low stroke risk to forego anticoagulation.

Barriers to care among racial/ethnic groups under managed care

We describe barriers to care reported by racial/ethnic groups and explore the extent to which barriers vary between persons enrolled in managed care and those in non-managed care plans, using data from the 1996 Medical Expenditure Panel Survey (MEPS). Most respondents expressed satisfaction with their care; however, a substantial percentage reported experiencing barriers. Minorities, particularly Hispanics and Asian Americans, were more likely than non-Hispanic whites were to report barriers. Managed care enrollees across racial/ethnic groups faced different types of barriers than non-managed care enrollees did. Although managed care enrollees were more likely to report having a usual source of care and greater continuity of care, they also reported more difficulties obtaining care and less satisfaction with their care.

Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons

Patients with body dysmorphic disorder (BDD) often present to dermatologists and cosmetic surgeons. BDD is a relatively common yet underrecognized disorder that consists of a distressing or impairing preoccupation with an imagined or slight defect in appearance. Although any body area can be the focus of concern, preoccupation with the appearance of the skin, hair, and nose are most common. Typical associated behaviors include skin picking, mirror checking, and camouflaging (e.g., with a hat or makeup). Reassurance seeking is another common behavior that may be enacted with surgeons and dermatologists. BDD is associated with marked impairment in functioning, notably poor quality of life, and a high suicide attempt rate. The disorder appears relatively common in dermatologic and cosmetic surgery settings; in fact, dermatologists may be the type of practitioner most often consulted by patients with BDD. Psychoeducation is an important element in the treatment of BDD. For patients who compulsively pick at their skin, it is generally ineffective to simply advise them to stop picking. Educating them that the picking is a symptom of BDD, and is treatable, can be helpful. For skin pickers, a combination of psychiatric and dermatologic treatment may be best. It is probably best to avoid cosmetic procedures. Although definitive data on the treatment outcome of surgery and dermatologic treatment for BDD are lacking, and although no one can predict how a given patient will respond to such treatment, available data suggest that these treatments are unlikely to be successful and may even make the patient's condition worse. Rather than referring the patient to another dermatologist or cosmetic surgeon, we recommend attempting to refer the patient to a psychiatrist for cognitive-behavioral therapy or pharmacotherapy. Available data indicate that serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are often effective for BDD. In recent years, BDD has gone from being a neglected psychiatric disorder to one that is becoming better recognized and understood. Nonetheless, research on this disorder is still in its early stages, and much more investigation of BDD is needed, especially in surgical and dermatologic settings. Treatment recommendations will be modified in the future as more research is done. In the meantime, it is important that dermatologists and surgeons screen patients for BDD and accurately diagnose this condition, as available psychiatric treatments are very promising for patients with this distressing and sometimes disabling disorder.

Cognitive function in breast cancer patients receiving adjuvant chemotherapy

PURPOSE

Breast cancer patients receiving chemotherapy have complained of difficulties in their ability to remember, think, and concentrate. This study assessed whether there are differences in cognitive function between breast cancer patients treated with standard-dose adjuvant chemotherapy compared with healthy controls.

PATIENTS AND METHODS

The High Sensitivity Cognitive Screen and the Profile of Mood States (POMS) were used to assess cognitive function and mood in a group of 107 women. The women consisted of 31 breast cancer patients receiving adjuvant chemotherapy (group A), 40 breast cancer patients who had completed adjuvant chemotherapy a median of 2 years earlier (group B), and 36 healthy controls (group C).

RESULTS

Univariate analysis showed statistically significant differences (P =.009) in overall cognitive function scores between groups A and C, with poorer function in patients receiving adjuvant chemotherapy. These differences remained significant (P =.046) when controlling for age, education level, and menopausal status. More patients had moderate or severe cognitive impairment in groups A and B than in controls (P </=.002). There were no significant differences in POMS scores between the groups, suggesting that the differences seen in cognitive scores were unlikely to be because of mood disturbance.

CONCLUSION

Cognitive differences were observed in breast cancer patients receiving adjuvant chemotherapy compared with healthy controls. These differences did not seem to be caused by significant differences in mood disturbance between the two groups. If confirmed, these results have substantial implications for informed consent, counseling, and psychosocial support of patients receiving adjuvant chemotherapy for breast cancer.

Personality disorders and traits in patients with body dysmorphic disorder

Individuals with body dysmorphic disorder (BDD) have been postulated to have schizoid, narcissistic, and obsessional personality traits and to be sensitive, introverted, perfectionistic, and insecure. However, data on personality traits and disorders in BDD are limited. This study assessed 148 subjects with BDD, 26 of whom participated in a fluvoxamine treatment study; 74 subjects were assessed for personality disorders with the Structured Clinical Interview for DSMIII-R Personality Disorders (SCID-II), 100 subjects completed the NEO-Five Factor Inventory (NEO-FFI), and 51 subjects completed the Rathus Assertiveness Scale. Forty-two subjects (57%) had one or more personality disorders, with avoidant personality disorder (43%) being most common, followed by dependent (15%), obsessive-compulsive (14%), and paranoid (14%) personality disorders. On the NEO-FFI, the mean scores were in the very high range for neuroticism, the low range for extraversion and conscientiousness, the low-average range for agreeableness, and the average range for openness to experience. On the Rathus Assertiveness Scale, the mean score was -17.1 +/- 32.0 for women and -17.0 +/- 32.3 for men. Among fluvoxamine responders, the number of personality disorders significantly decreased between the study baseline and endpoint. These findings suggest that the rate of personality disorders in BDD is relatively high, with avoidant personality disorder being most common. The high neuroticism scores and low extraversion scores are consistent with this finding.

Perceptions of Ashkenazi Jewish breast cancer patients on genetic testing for mutations in BRCA1 and BRCA2

The perceived benefits and risks of genetic testing may vary between groups of individuals with different cultural, demographic, and family history features. This multicentre study examined the factors that influenced the decision to undergo genetic testing for BRCA1 and BRCA2 in Canadian Jewish women with breast cancer. A self-administered questionnaire was developed and distributed to 134 individuals enrolled in a research-based testing program for Ashkenazi women. The questionnaire assessed demographic, social, and family history parameters, and the influence of medical, family, social, psychological, and cultural/religious factors on decision making about genetic testing. Seventy-six percent of women completed the questionnaire. Forty-one percent of study participants had no family history of breast or ovarian cancer. The most important factors influencing the decision to undergo testing were a desire to contribute to research, potential benefit to other family members, curiosity, and the potential for relief if not found to be a carrier (endorsed by 87, 78, 70, and 60% of participants, respectively). The main perceived risks of undergoing genetic testing related to insurance discrimination, confidentiality, accuracy and interpretability of results, potential impact on marriage prospects for family members, and focus on the Jewish community (endorsed by 28, 24, 30, 17, and 14% of participants, respectively). This study provides novel information on the motivating factors for BRCA1 and BRCA2 mutation testing in Canadian women of Ashkenazi Jewish descent. The focus on altruistic factors and those related to perceived psychological benefits of testing is notable.

Body dysmorphic disorder: diagnostic controversies and treatment challenges

Body dysmorphic disorder (BDD) is a distressing, impairing, and relatively common yet underrecognized disorder. This clinically focused article discusses the following diagnostic controversies and challenges associated with BDD: the underdiagnosis and misdiagnosis of BDD, the relationship between BDD and obsessive-compulsive disorder, the relationship between BDD and depression, the delusionality controversy, and whether BDD can be diagnosed in children and adolescents. This article also discusses treatment controversies and challenges associated with serotonin reuptake inhibitors, antipsychotics, cognitive-behavioral therapy, approaches to treatment-resistant BDD, and getting reluctant patients to accept psychiatric treatment.

Rate of body dysmorphic disorder in dermatology patients

BACKGROUND

Dermatologists appear to be the physicians most often seen by patients with the psychiatric condition body dysmorphic disorder (BDD), a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. The frequency of BDD among patients seeking dermatologic treatment is unknown, however.

OBJECTIVE

This study determined the percentage of patients seeking dermatologic treatment who screened positive for BDD.

METHODS

A validated self-report questionnaire and a reliable defect severity scale were used to determine the rate of BDD in 268 patients seeking dermatologic treatment.

RESULTS

A total of 11.9% (95% confidence interval [CI], 8.0%-15.8%) of patients screened positive for BDD. Rates were similar in a community general dermatology setting (14.4% [95% CI, 8.5%-20.3%]) and a university cosmetic surgery setting (10. 0% [95% CI, 6.1%-13.9%]).

CONCLUSION

BDD appears relatively common among patients seeking dermatologic treatment. Further research is needed to confirm these findings and to assist dermatologists in identifying these potentially high-risk patients.

Quality of life for patients with body dysmorphic disorder

Body dysmorphic disorder (BDD) is a relatively common, distressing, and impairing disorder. Quality of life in BDD, however, has not been investigated. In this study, 62 consecutive outpatients with BDD were evaluated with the self-report Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and other scales. SF-36 scores were descriptively compared to published norms for several populations. Physical health-related quality of life scores were generally worse than general U.S. population norms and better than norms for outpatients with a medical illness or depression. However, in all mental health domains, BDD subjects' scores were notably worse than norms for the general U.S. population and for patients with depression, diabetes, or a recent myocardial infarction. More severe BDD symptoms and greater delusionality were associated with poorer mental health-related quality of life. These results indicate that patients with BDD have notably poor mental health status and mental health-related quality of life.

Use of preventive services by managed care enrollees: an updated perspective

We examined whether enrollees in managed care plans received more preventive services than enrollees in non-managed care plans did, by conducting an updated literature synthesis of studies published between 1990 and 1998. We found that 37 percent of comparisons indicated that managed care enrollees were significantly more likely to obtain preventive services; 3 percent indicated that they were significantly less likely to do so; and 60 percent found no difference. Enrollees in group/staff-model health maintenance organizations (HMOs) were more likely to receive preventive services, but there was little evidence, outside of Medicaid managed care, that managed care plans are worse at providing preventive services. However, most of the evidence is equivocal: Provision of preventive services was neither better nor worse in managed versus non-managed care plans. Because of the blurred distinctions among types of health plans, more research is needed to identify which plan characteristics are most likely to encourage appropriate utilization.

Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study

BACKGROUND

Warfarin dramatically reduces the risk for ischemic stroke in nonvalvular atrial fibrillation, but its use among ambulatory patients with atrial fibrillation has not been widely studied.

OBJECTIVE

To assess the rates and predictors of warfarin use in ambulatory patients with nonvalvular atrial fibrillation.

DESIGN

Cross-sectional study.

SETTING

Large health maintenance organization.

PATIENTS

13428 patients with a confirmed ambulatory diagnosis of nonvalvular atrial fibrillation and known warfarin status between 1 July 1996 and 31 December 1997.

MEASUREMENTS

Data from automated pharmacy, laboratory, and clinical-administrative databases were used to determine the prevalence and determinants of warfarin use in the 3 months before or after the identified diagnosis of atrial fibrillation.

RESULTS

Of 11082 patients with nonvalvular atrial fibrillation and no known contraindications, 55% received warfarin. Warfarin use was substantially lower in patients who were younger than 55 years of age (44.3%) and those who were 85 years of age or older (35.4%). Only 59.3% of patients with one or more risk factors for stroke and no contraindications were receiving warfarin. Among a subset of "ideal" candidates to receive warfarin (persons 65 to 74 years of age who had no contraindications and had previous stroke, hypertension, or both), 62.1% had evidence of warfarin use. Among our entire cohort, the strongest predictors of receiving warfarin were previous stroke (adjusted odds ratio, 2.55 [95% CI, 2.23 to 2.92]), heart failure (odds ratio, 1.63 [CI, 1.51 to 1.77]), previous intracranial hemorrhage (odds ratio, 0.33 [CI, 0.21 to 0.52]), age 85 years or older (odds ratio, 0.35 [CI, 0.31 to 0.40]), and previous gastrointestinal hemorrhage (odds ratio, 0.47 [CI, 0.40 to 0.57]).

CONCLUSIONS

In a large, contemporary cohort of ambulatory patients with atrial fibrillation who received care within a health maintenance organization, warfarin use was considerably higher than in other reported studies. Although the reasons why physicians did not prescribe warfarin could not be elucidated, many apparently eligible patients with atrial fibrillation and at least one additional risk factor for stroke, especially hypertension, did not receive anticoagulation. Interventions are needed to increase the use of warfarin for stroke prevention among appropriate candidates.

Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study

BACKGROUND

Warfarin dramatically reduces the risk for ischemic stroke in nonvalvular atrial fibrillation, but its use among ambulatory patients with atrial fibrillation has not been widely studied.

OBJECTIVE

To assess the rates and predictors of warfarin use in ambulatory patients with nonvalvular atrial fibrillation.

DESIGN

Cross-sectional study.

SETTING

Large health maintenance organization.

PATIENTS

13428 patients with a confirmed ambulatory diagnosis of nonvalvular atrial fibrillation and known warfarin status between 1 July 1996 and 31 December 1997.

MEASUREMENTS

Data from automated pharmacy, laboratory, and clinical-administrative databases were used to determine the prevalence and determinants of warfarin use in the 3 months before or after the identified diagnosis of atrial fibrillation.

RESULTS

Of 11082 patients with nonvalvular atrial fibrillation and no known contraindications, 55% received warfarin. Warfarin use was substantially lower in patients who were younger than 55 years of age (44.3%) and those who were 85 years of age or older (35.4%). Only 59.3% of patients with one or more risk factors for stroke and no contraindications were receiving warfarin. Among a subset of "ideal" candidates to receive warfarin (persons 65 to 74 years of age who had no contraindications and had previous stroke, hypertension, or both), 62.1% had evidence of warfarin use. Among our entire cohort, the strongest predictors of receiving warfarin were previous stroke (adjusted odds ratio, 2.55 [95% CI, 2.23 to 2.92]), heart failure (odds ratio, 1.63 [CI, 1.51 to 1.77]), previous intracranial hemorrhage (odds ratio, 0.33 [CI, 0.21 to 0.52]), age 85 years or older (odds ratio, 0.35 [CI, 0.31 to 0.40]), and previous gastrointestinal hemorrhage (odds ratio, 0.47 [CI, 0.40 to 0.57]).

CONCLUSIONS

In a large, contemporary cohort of ambulatory patients with atrial fibrillation who received care within a health maintenance organization, warfarin use was considerably higher than in other reported studies. Although the reasons why physicians did not prescribe warfarin could not be elucidated, many apparently eligible patients with atrial fibrillation and at least one additional risk factor for stroke, especially hypertension, did not receive anticoagulation. Interventions are needed to increase the use of warfarin for stroke prevention among appropriate candidates.

Continuing screening mammography in women aged 70 to 79 years: impact on life expectancy and cost-effectiveness

CONTEXT

Mammography is recommended and is cost-effective for women aged 50 to 69 years, but the value of continuing screening mammography after age 69 years is not known. In particular, older women with low bone mineral density (BMD) have a lower risk of breast cancer and may benefit less from continued screening.

OBJECTIVE

To compare life expectancy and cost-effectiveness of screening mammography in elderly women based on 3 screening strategies.

DESIGN

Decision analysis and cost-effectiveness analysis using a Markov model.

PATIENTS

General population of women aged 65 years or older.

INTERVENTIONS

The analysis compared 3 strategies: (1) Undergoing biennial mammography from age 65 to 69 years; (2) undergoing biennial mammography from age 65 to 69 years, measurement of distal radial BMD at age 65 years, discontinuing screening at age 69 years in women in the lowest BMD quartile for age, and continuing biennial mammography to age 79 years in those in the top 3 quartiles of distal radius BMD; and (3) undergoing biennial mammography from age 65 to 79 years.

MAIN OUTCOME MEASURES

Deaths due to breast cancer averted, life expectancy, and incremental cost-effectiveness ratios.

RESULTS

Compared with discontinuing mammography screening at age 69 years, measuring BMD at age 65 years in 10000 women and continuing mammography to age 79 years only in women with BMD in the top 3 quartiles would prevent 9.4 deaths and add, on average, 2.1 days to life expectancy at an incremental cost of $66773 per year of life saved. Continuing mammography to age 79 years in all 10000 elderly women would prevent 1.4 additional breast cancer deaths and add only 7.2 hours to life expectancy at an incremental cost of $117689 per year of life saved compared with only continuing mammography to age 79 years in women with BMD in the top 3 quartiles.

CONCLUSIONS

This analysis suggests that continuing mammography screening after age 69 years results in a small gain in life expectancy and is moderately cost-effective in those with high BMD and more costly in those with low BMD. Women's preferences for a small gain in life expectancy and the potential harms of screening mammography should play an important role when elderly women are deciding about screening.

Breast carcinomas arising in carriers of mutations in BRCA1 or BRCA2: are they prognostically different?

PURPOSE

To review the preclinical and clinical studies relevant to the prognosis and prognostic associations of BRCA1- and BRCA2-associated breast carcinomas, with an emphasis on research methodology.

METHODS

Reports of relevant studies obtained from a MEDLINE search, and references from these articles, were critically reviewed.

RESULTS

Consistent associations with both favorable (medullary or atypical medullary carcinoma) and unfavorable (high tumor grade, hormone receptor negativity, somatic p53 mutation) prognostic characteristics have been found for BRCA1-associated breast carcinomas. Inconsistent results have been demonstrated for prognostic associations of BRCA2-associated breast tumors. Clinical studies that have directly assessed the prognosis of these tumors have not shown a clear effect of BRCA1 or BRCA2 mutation, but no study has used optimal methodology. In vitro and animal model data suggest a possible influence of these mutations on response to agents that cause double-strand DNA breaks, but clinical data are limited.

CONCLUSION

The elucidation of an identifiable subgroup of breast carcinomas that result from germline mutations in BRCA1 or BRCA2 may be an important step toward genotype-based understanding of prognosis and choice of therapy in this disease. However, currently there are inadequate data to support use of BRCA1 or BRCA2 status to counsel individuals regarding their prognosis or to select treatment. Well-designed studies of population-based inception cohorts of breast cancer patients, which have adequate sample size and complete follow-up, and which use objective outcome criteria and blinding of outcome assessment, are required to optimally address this question.

Thirty-three cases of body dysmorphic disorder in children and adolescents

OBJECTIVE

Body dysmorphic disorder (BDD), a preoccupation with a nonexistent or slight defect in appearance, usually begins during adolescence. Because there have been no studies of the clinical features of BDD in children and adolescents, the authors assessed these features in the largest series to date.

METHOD

Thirty-three children and adolescents with DSM-IV BDD were assessed for demographic characteristics, phenomenology, associated psychopathology, and treatment history and response.

RESULTS

Bodily preoccupations most often focused on the skin (61%) and hair (55%). All subjects had associated compulsive behaviors, most often camouflaging (e.g., with clothing) in 94%, comparing with others (87%), and mirror checking (85%). Ninety-four percent reported impairment in social functioning and 85% in academic or job functioning due to BDD. Thirty-nine percent had had psychiatric hospitalizations, and 21% had made a suicide attempt. Ten (53%) of 19 subjects treated with a serotonin reuptake inhibitor had much or very much improvement in BDD symptoms; in contrast, 0 of 8 trials with other psychotropic medications, 0 of 1 trial of cognitive-behavioral therapy, and 1 of 20 psychotherapy trials resulted in improvement. Twelve (36%) subjects received surgical, dermatological, or dental treatment, with a poor outcome in all cases.

CONCLUSIONS

BDD can cause significant morbidity in children and adolescents. These preliminary data suggest that serotonin reuptake inhibitors may be an effective treatment in this age group.

Frequency of p53 mutations in breast carcinomas from Ashkenazi Jewish carriers of BRCA1 mutations

BACKGROUND

Breast carcinomas occurring in carriers of BRCA1 gene mutations may have a distinctly different pathway of molecular pathogenesis from those occurring in noncarriers. Data from murine models implicate loss of p53 (also known as TP53) gene function as a critical early event in the malignant transformation of cells with a BRCA1 mutation. Therefore, breast tumors from BRCA1 mutation carriers might be expected to exhibit a high frequency of p53 mutations. This study examined the frequency of p53 mutations in the breast tumors of Ashkenazi Jewish carriers and noncarriers of BRCA1 mutations.

METHODS

Tumor DNA from carriers and noncarriers of BRCA1 mutations was screened for mutations in exons 4 through 10 of the p53 gene by use of the polymerase chain reaction and single-strand conformation polymorphism (SSCP) analysis of the amplified DNA. Direct sequencing was performed on gene fragments that showed altered mobility in SSCP analysis.

RESULTS

Mutations in the p53 gene were detected in 10 of 13 tumors from BRCA1 mutation carriers versus 10 of 33 tumors from non-carriers (two-sided P = .007). The p53 mutations were distributed throughout exons 4 through 10 and included both protein-truncating and missense mutations in both groups.

CONCLUSIONS

A statistically significantly higher frequency of p53 mutations was found in breast tumors from carriers of BRCA1 mutations than from noncarriers, which adds to the accumulating evidence that loss of p53 function is an important step in the molecular pathogenesis of BRCA1 mutation-associated breast tumors. This finding may have implications for understanding phenotypic differences and potential prognostic differences between BRCA1 mutation-associated hereditary breast cancers and sporadic cancers.

Body dysmorphic disorder and depression: theoretical considerations and treatment strategies

Body dysmorphic disorder (BDD), also known as dysmorphophobia, consists of a distressing and impairing preoccupation with an imagined or slight defect in appearance. BDD is an underrecognized and relatively common disorder that is associated with high rates of occupational and social impairment, hospitalization, and suicide attempts. BDD is unlikely to simply be a symptom of depression, although it often coexists with depression and may be related to depression. It is important to recognize BDD in depressed patients, because missing the diagnosis can result in refractory BDD and depressive symptoms. Available data indicate that BDD may not respond to all treatments for depression and may instead respond preferentially to serotonin-reuptake inhibitors. In addition, lengthier treatment trials than those required for depression may be needed to successfully treat BDD and comorbid depression. It can be difficult and challenging to diagnose BDD in depressed patients because the symptoms are often concealed due to embarrassment and shame. This paper discusses the relationship between BDD and depression and discusses practical strategies for recognizing and treating BDD and depressive symptoms in patients with depression.

Body dysmorphic disorder: clinical aspects and treatment strategies

Body dysmorphic disorder (BDD), a distressing and impairing preoccupation with an imagined or slight defect in appearance, is an "OCD-spectrum disorder" that appears to be relatively common. BDD often goes unrecognized and undiagnosed, however, due to patients' reluctance to divulge their symptoms because of secrecy and shame. Any body part can be the focus of concern (most often, the skin, hair, and nose), and most patients engage in compulsive behaviors, such as mirror checking, camouflaging, excessive grooming, and skin picking. Approximately half are delusional, and a majority experience ideas or delusions of reference. Nearly all patients suffer some impairment in functioning as a result of their symptoms, some to a debilitating degree. Psychiatric hospitalization, suicidal ideation, and suicide attempts are relatively common. While treatment data are preliminary at this time, selective serotonin reuptake inhibitors (SSRIs) appear to often be effective for BDD, even if symptoms are delusional. Cognitive-behavioral therapy is another promising approach. While much remains to be learned about BDD, it is important that clinicians screen patients for this disorder and accurately diagnose it, as available treatments are very promising for those who suffer from this distressing and sometimes disabling disorder.

A comparison study of body dysmorphic disorder and obsessive-compulsive disorder

BACKGROUND

Body dysmorphic disorder, a preoccupation with an imagined or slight defect in appearance, is classified as a somatoform disorder, but has been hypothesized to be related to obsessive-compulsive disorder. A reflection of this hypothesis, body dysmorphic disorder is included in the Yale-Brown Obsessive Compulsive Scale symptom checklist, and its transfer to the anxiety disorders' section was considered for DSM-IV. However, the similarities and differences between body dysmorphic disorder and obsessive-compulsive disorder have received little investigation.

METHOD

We compared patients with DSM-IV body dysmorphic disorder (N = 53), obsessive-compulsive disorder (N = 53), or both disorders (N = 33) in terms of demographic features, clinical features, comorbidity, and family history. We also assessed the rate of body dysmorphic disorder among 62 of these subjects initially diagnosed with obsessive-compulsive disorder.

RESULTS

14.5% (9 of 62) of subjects initially diagnosed with obsessive-compulsive disorder had comorbid body dysmorphic disorder. The 2 disorders did not differ significantly in terms of sex ratio; most other demographic, course, and impairment variables; illness severity; or lifetime frequency of most associated disorders in probands or first-degree relatives. However, subjects with body dysmorphic disorder were less likely to be married and more likely to have had suicidal ideation or made a suicide attempt because of their disorder. They also had an earlier onset of major depression and higher lifetime rates of major depression, social phobia, and psychotic disorder diagnoses, as well as higher rates of substance use disorders in first-degree relatives.

CONCLUSION

Body dysmorphic disorder appears to be relatively common among patients with obsessive-compulsive disorder. While the 2 disorders have many similarities, they also have some differences and should be differentiated in clinical and research settings.

Design and interpretation of clinical trials that evaluate agents that may offer protection from the toxic effects of cancer chemotherapy

PURPOSE

To review the features of randomized clinical trials (RCTs) used in the development of agents that may protect against chemotherapy-induced toxicities, including trials of the cardioprotective agent dexrazoxane, hematologic growth factors, and amifostine; to suggest recommendations based on information gained from such trials and improvements in the design of ongoing and future trials.

METHODS

Critical review of reports of RCTs obtained from a Medline search, references from these articles, and review of trials listed in the physician data query (PDQ) clinical trials data base.

RESULTS

Several of the phase III trials did not use a format of comparing widely accepted strategies of chemotherapy with and without a protective agent. Instead, patients in the control arms of some of the trials have been exposed to more prolonged use or increased dosage of toxic chemotherapy that placed them at greater risk of the toxicity the protective agent was designed to prevent (eg, cardiotoxicity in trials of dexrazoxane, myelosuppression or thrombocytopenia in trials of growth factors).

CONCLUSION

RCTs have shown clear evidence of biologic activity for the protective agents, but this does not imply therapeutic benefit as compared with alternative strategies such as avoidance of prolonged use of cardiotoxic agents or use of standard doses of chemotherapy. Ongoing and future trials of protective agents should be modified to avoid undue risk to patients.

Reliability and validity of depressive personality disorder

OBJECTIVE

Depressive personality disorder was introduced into DSM-IV's appendix amid controversy. While that disorder appears to be a reliable and valid one, the authors offer new data about its relationship to major depression, dysthymic disorder, and other personality disorders.

METHOD

The authors assessed 54 subjects with early-onset, long-standing mild depressive features for depressive personality disorder, axis I and axis II disorders, family history, and treatment history; they conducted follow-up interviews 1 year after the baseline assessment. Subjects with (N=30) and without (N=24) depressive personality disorder were characterized and compared in terms of those variables.

RESULTS

Although depressive personality disorder and dysthymia co-occurred in some subjects, 63% of subjects with depressive personality disorder did not have dysthymia, and 60% did not have current major depression. Although subjects with depressive personality disorder were more likely than the mood disorder comparison group to have another personality disorder, 40% had no such disorder. Contrary to study hypotheses, mood disorder was not more common in first-degree relatives of subjects with depressive personality disorder than in relatives of the comparison group. Subjects with and without depressive personality disorder had similar rates of past treatment with medication and psychotherapy; however, the duration of psychotherapy was significantly longer for subjects with than for those without depressive personality. The depressive personality diagnosis was relatively stable over the 1-year follow-up period.

CONCLUSIONS

Depressive personality disorder appears to be a relatively stable condition with incomplete overlap with axis I mood disorders and personality disorders. Further studies are needed to better characterize its treatment response and relationship to axis I mood disorders.

Understanding the context of healthcare utilization: assessing environmental and provider-related variables in the behavioral model of utilization

OBJECTIVE

The behavioral model of utilization, developed by Andersen, Aday, and others, is one of the most frequently used frameworks for analyzing the factors that are associated with patient utilization of healthcare services. However, the use of the model for examining the context within which utilization occurs-the role of the environment and provider-related factors-has been largely neglected.

OBJECTIVE

To conduct a systematic review and analysis to determine if studies of medical care utilization that have used the behavioral model during the last 20 years have included environmental and provider-related variables and the methods used to analyze these variables. We discuss barriers to the use of these contextual variables and potential solutions.

DATA SOURCES

The Social Science Citation Index and Science Citation Index. We included all articles from 1975-1995 that cited any of three key articles on the behavioral model, that included all articles that were empirical analyses and studies of formal medical care utilization, and articles that specifically stated their use of the behavioral model (n = 139).

STUDY DESIGN

Design was a systematic literature review.

DATA ANALYSIS

We used a structured review process to code articles on whether they included contextual variables: (1) environmental variables (characteristics of the healthcare delivery system, external environment, and community-level enabling factors); and (2) provider-related variables (patient factors that may be influenced by providers and provider characteristics that interact with patient characteristics to influence utilization). We also examined the methods used in studies that included contextual variables.

PRINCIPAL FINDINGS

Forty-five percent of the studies included environmental variables and 51 percent included provider-related variables. Few studies examined specific measures of the healthcare system or provider characteristics or used methods other than simple regression analysis with hierarchical entry of variables. Only 14 percent of studies analyzed the context of healthcare by including both environmental and provider-related variables as well as using relevant methods.

CONCLUSIONS

By assessing whether and how contextual variables are used, we are able to highlight the contributions made by studies using these approaches, to identify variables and methods that have been relatively underused, and to suggest solutions to barriers in using contextual variables.

Personality dimensions associated with depressive personality disorder

Depressive personality disorder (DPD) is a historically important construct that requires empirical attention. This study compares 26 subjects with this disorder to 20 non-DPD subjects who have similar histories of longstanding early-onset depression on three personality measures, the Tridimensional Personality Questionnaire (TPQ), NEO-Five Factor Inventory, and Defense Style Questionnaire (DSQ). The samples were demographically similar and had similar rates of comorbid depression and dysthymia. They differed in that DPD subjects scored significantly higher on Harm Avoidance and Neuroticism, and significantly lower on Novelty Seeking, Extroversion, and Adaptive defense mechanisms. Implications for clinical care and nosology are discussed.

Factors associated with women's adherence to mammography screening guidelines

OBJECTIVE

To examine individual and environmental factors associated with adherence to mammography screening guidelines.

DATA SOURCES

A unique data set that combines a national probability sample (1992 National Health Interview Survey); a national probability sample of mammography facility characteristics (1992 National Survey of Mammography Facilities); county-level data on 1990 HMO market share; and county-level data on the supply of primary care providers (1991 Area Resource File).

STUDY DESIGN

The design was cross-sectional. DATA EXTRACTION/ANALYSIS: Data sets were linked to create an individual-level sample of women ages 50-74 (weighted n = 2,026). We used multipart, sequential logistic regression models to examine the predictors of having ever had mammography, having had recent mammography, and adherence to guidelines. We categorized women as adherent if they reported a lifetime number of exams appropriate for their age (based on screening every two years) and they reported having had an exam in the past two years.

PRINCIPAL FINDINGS

Only 27 percent of women had the age-appropriate number of screening exams (range 16 percent-37 percent), while 59 percent of women had been screened within two years. Women were significantly more likely to adhere to screening guidelines if they reported participating with their doctor in the decision to be screened; were younger; had smaller families, higher education and income, and a recent Pap smear; reported breast problems; and lived in an area with a higher percentage of mammography facilities with reminder systems, no shortage of primary care providers, higher HMO market share, and higher screening charges.

CONCLUSIONS

A small percentage of women adhere to screening guidelines, suggesting that adherence needs to become a focus of clinical, programmatic, and policy efforts.

Efficacy and safety of fluvoxamine in body dysmorphic disorder

BACKGROUND

Body dysmorphic disorder (BDD), a preoccupation with an imagined or slight defect in appearance, has been noted in case reports, retrospective studies, and clinical series to respond to serotonin reuptake inhibitors (SRIs). These data further suggest that the delusional variant of BDD (delusional disorder, somatic type) may also respond to SRIs. However, systematic pharmacologic treatment studies of BDD and its delusional variant are needed.

METHOD

Thirty subjects with BDD or its delusional variant (DSM-IV) were prospectively treated in an open-label fashion with fluvoxamine for 16 weeks. Subjects were assessed at regular intervals with the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS), the Clinical Global Impressions (CGI) scale, the Hamilton Rating Scale for Depression, the Brown Assessment of Beliefs Scale, and other measures.

RESULTS

BDD-YBOCS scores (mean +/- SD) decreased from 31.1 +/- 5.4 at baseline to 16.9 +/- 11.8 at termination (p < .001). Nineteen (63.3%) subjects were rated as responders on the BDD-YBOCS and the CGI (10 [33.3%] were much improved, and 9 [30.0%] were very much improved). Delusional subjects were as likely to respond to fluvoxamine as nondelusional subjects, and delusionality significantly improved. All 5 responders who were delusional at baseline were no longer delusional at study endpoint. The mean dose of fluvoxamine was 238.3 +/- 85.8 mg/day, and mean time to response was 6.1 +/- 3.7 weeks. Fluvoxamine was generally well tolerated.

CONCLUSION

These results suggest that fluvoxamine is a safe and effective treatment for BDD, including its delusional disorder variant. Controlled treatment trials are needed to confirm these findings.

The costs and outcomes of restricting public access to poison control centers. Results from a natural experiment

OBJECTIVES

The authors examined the costs and outcomes resulting from a natural experiment during which direct public access to poison control centers was restricted and then restored.

METHODS

Both societal and health care purchaser perspectives were used. Probability data were obtained from a natural experiment during which public callers from a large county in California were electronically blocked from directly accessing the poison control center. Callers were referred to 911, which had direct access to the poison control center, if they thought they had a poisoning emergency. We conducted telephone interviews of: (a) persons who attempted to call the poison control center for a child's poisoning exposure but who did not have direct access (n = 270) and (b) persons who called the poison control center after direct access was restored (n = 279). Cost data were obtained from primary data collection and from other sources. The outcome measure was the appropriateness of the treatment location (at home or at a health care facility). Caller-reported outcomes were also examined.

RESULTS

The average additional cost per blocked call was $10.89 from a societal perspective, or $33.14 from a health care purchaser perspective. Fourteen percent of callers with restricted access were treated at an inappropriate location, compared with only 2% of callers with direct poison control center access. Also, 14% did not obtain any professional advice after they attempted to call the poison control center, although 66% of these cases involved potentially toxic substances. Results were robust across a range of sensitivity analyses.

CONCLUSION

Restricting direct public access to poison control centers created additional costs to society, the health care sector, and callers.

The Brown Assessment of Beliefs Scale: reliability and validity

OBJECTIVE

The authors developed and evaluated the reliability and validity of the Brown Assessment of Beliefs Scale, a clinician-administered seven-item scale designed to assess delusions across a wide range of psychiatric disorders.

METHOD

The authors developed the scale after reviewing the literature on the assessment of delusions. Four raters administered the scale to 20 patients with obsessive-compulsive disorder (OCD), 20 patients with body dysmorphic disorder, and 10 patients with mood disorder with psychotic features. Audiotaped interviews of scale administration conducted by one rater were independently scored by the other raters to evaluate interrater reliability. The scale was administered to 27 patients twice to determine test-retest reliability. Other insight instruments as well as scales that assess symptom severity were administered to assess convergent and discriminant validity. Sensitivity to change was assessed in a multicenter treatment study of sertraline for OCD.

RESULTS

Interrater and test-retest reliability for the total score and individual item scores was excellent, with a high degree of internal consistency. One factor was obtained that accounted for 56% of the variance. Scores on the Brown Assessment of Beliefs Scale were not correlated with symptom severity but were correlated with other measures of insight. The scale was sensitive to change in insight in OCD but was not identical to improvement in severity.

CONCLUSIONS

The Brown Assessment of Beliefs Scale is a reliable and valid instrument for assessing delusionality in a number of psychiatric disorders. This scale may help clarify whether delusional and nondelusional variants of disorders constitute the same disorder as well as whether delusionality affects treatment outcome and prognosis.

Muscle dysmorphia. An underrecognized form of body dysmorphic disorder

In the course of several ongoing studies, the authors have encountered men and women who display a form of body dysmorphic disorder in which they become pathologically preoccupied with their degree of muscularity. This condition, which the authors have tentatively termed "muscle dysmorphia," may cause severe subjective distress, impaired social and occupational functioning, and abuse of anabolic steroids and other substances. Epidemiologic data suggest that muscle dysmorphia, though rarely recognized, may afflict substantial numbers of Americans. The authors summarize the features of muscle dysmorphia, present several case examples, and offer proposed diagnostic criteria that may be useful for subsequent research.

The policy implications of using hospital and physician volumes as "indicators" of quality of care in a changing health care environment

There is growing interest in the quality of health care and in using quality measures to direct patients to hospitals and providers offering high quality, low cost health care. The dilemma is that, while there is an increasing need for quality indicators as a result of a changing health care environment, this changing environment has important implications for the use of some of these measures. Since the 1970s, a growing body of research in the U.S. has addressed the empirical relationship between the number of patients with a specific diagnosis of surgical procedure and their outcomes after treatment in a particular hospital or by a particular physician ("volume-outcome" studies). In this paper, we examine the policy implications of using hospital and physician volume information as an "indicator" of quality in a rapidly changing health care environment with new players and new incentives. We begin by describing the evolution of the use of volumes within both regulatory and market-oriented contexts in the U.S. We then discuss policy considerations and cautions in using volumes, along with suggestions for future research. Our purpose is to point out potential problems and clarify confusions about the use of volumes, so that policymakers and practitioners can be sensitive to the potential minefields they are traversing.

Gender differences in body dysmorphic disorder

Gender differences in body dysmorphic disorder (BDD) have received little investigation. This study assessed gender differences in 188 subjects with BDD who were evaluated with instruments to assess demographic characteristics, clinical features of BDD, treatment history, and comorbid Axis I disorders. Ninety-three (49%) subjects were women, and 95 (51%) were men. Men and women did not significantly differ in terms of most variables examined, including rates of major depression, although women were more likely to be preoccupied with their hips and their weight, pick their skin and camouflage with makeup, and have comorbid bulimia nervosa. Men were more likely to be preoccupied with body build, genitals, and hair thinning, use a hat for camouflage, be unmarried, and have alcohol abuse or dependence. Although men were as likely as women to seek nonpsychiatric medical and surgical treatment, women were more likely to receive such care. Men, however, were as likely as women to have cosmetic surgery. Although the clinical features of BDD appear remarkably similar in women and men, there are some differences, some of which reflect those found in the general population, suggesting that cultural norms and values may influence the content of BDD symptoms.

Willingness to pay for poison control centers

We used the willingness-to-pay (WTP) method to value the benefits of poison control centers when direct access was blocked, comparing WTP among: (1) blocked callers (n = 396), (2) callers after access was restored (n = 418), and (3) the general population (n = 119). Mean monthly WTP was $6.70 (blocked callers), $6.11 (non-blocked callers), and $2.55 (general population). Blocked and non-blocked callers had a significantly higher WTP than general population respondents (p < 0.001). We conclude that the WTP method measured benefits that are difficult to quantify; however, WTP surveys need to be carefully conducted to minimize bias. We discuss how this approach could be useful for other health care services.

Predictors of follow-through on plans to be tested for HIV

INTRODUCTION

Fewer than 40% of people in the United States with HIV risk factors have been tested. However, almost 40% of untested individuals with HIV risk factors in high AIDS prevalence cities stated in the 1991 National AIDS Behavioral Surveys (NABS) that they (1) "planned to be tested" or (2) "would get tested if no one could find out."

METHODS

We used longitudinal data from the 1991 and 1992 NABS (n = 5,543), which are nationally representative telephone surveys. We assessed whether untested individuals were tested one year later, and we used logistic regressions to address two research questions: What are the predictors of testing among untested individuals? What are the predictors of testing among untested individuals who "planned to be tested" or "would get tested if no one could find out?"

RESULTS

We found that 30% of individuals who "planned to be tested," 16% of individuals who "would get tested if no one could find out," and 11% of persons with no intentions to be tested had been tested one year later (P < .001). In regression analyses, risk factors and higher education were key predictors of testing.

CONCLUSIONS

It is encouraging that 30% of individuals who plan to be tested did get tested within one year. Further research, however, needs to examine testing barriers for the 70% of individuals who do not follow through on testing plans. The results provide important information for targeting testing programs, developing effective public policies, and addressing the debate over issues such as name reporting and the availability of home HIV tests.

HIV counseling and testing of pregnant women and women of childbearing age by primary care providers: self-reported beliefs and practices

This study describes primary care providers' beliefs and self-reported practices regarding HIV counseling and testing of pregnant women and women of childbearing age. The Centers for Disease Control and Prevention (CDC) recommends that providers counsel and encourage all pregnant women and women of childbearing age to be voluntarily tested, and California requires providers to offer voluntary testing to all pregnant women. We randomly sampled 180 primary care providers in 1995 from the nine-county San Francisco Bay area using a self-administered, mailed survey (response rate = 73%, N = 121). Eighty-six percent of primary care providers (obstetricians/gynecologists, internists, family practitioners, or general practitioners) support voluntary testing, 61% support routine testing without explicit consent, and 55% support mandatory testing. Although 90% of providers are very likely to encourage pregnant women with risk factors to be tested, only 34% are very likely to encourage pregnant women without risk factors to be tested and only 9% are very likely to encourage women of childbearing age without risk factors to be tested. Few providers state that they support policies targeting testing to women with risk factors, yet in practice, providers are much more likely to encourage testing for women with risk factors than those without risk factors. We conclude that providers may be missing opportunities to encourage women to be tested, and women may not be receiving adequate information to make an informed testing decision. Future research is needed to determine the viability of voluntary testing and how to remove barriers to its implementation.