A scale to screen for DSM-IV Axis I disorders in psychiatric out-patients: performance of the Psychiatric Diagnostic Screening Questionnaire

BACKGROUND

The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a reliable and valid self-report scale designed to screen for the most common DSM-IV Axis I disorders encountered in out-patient mental health settings. The present report is the second large-scale validation study of the PDSQ in psychiatric out-patients. Because some of the sizes of the diagnostic groups in the initial report were modest, it is important to determine whether the recommended cut-off scores to screen for psychiatric disorders remained the same in a replication study.

METHOD

Six hundred and seventy psychiatric out-patients presenting for treatment were evaluated with a semi-structured diagnostic interview after completing the PDSQ.

RESULTS

Based on receiver operating curve analysis, the PDSQ performed as well in the replication sample as in the initial validation study. For nine of the 13 PDSQ subscales the recommended cut-off score in the replication study was the same as in the initial study. After combining the data from the two studies (n=1300) the mean sensitivity across the 13 PDSQ subscales was 87% and the mean negative predictive value was 97%.

CONCLUSIONS

The PDSQ is a diagnostic aid designed to improve the efficiency of conducting initial diagnostic evaluations. From a clinical perspective it is important that a screening tool have good sensitivity so that most cases are detected, and high negative predictive value so that most non-cases on the measure are indeed non-cases. The results of this second large validation study indicate that most of the PDSQ subscales achieved this goal.

Comparison of the clock test and a questionnaire-based test for screening for cognitive impairment in Nigerians

BACKGROUND

Since it is projected that by 2020 seventy percent of the elderly will reside in developing countries, a reliable screening method for dementia and cognitive impairment in general in populations with diverse languages, culture, education and literacy will be needed. We sought to determine if the Clock Test, a screening test for dementia, was suitable for use in a Nigerian population.

STUDY DESIGN

Cross-sectional survey of 54 men and 12 women from Northern Nigeria. Researchers administered two dementia screening tools: a questionnaire-based test adapted for use in a Nigerian population and the Clock Test.

RESULTS

Overall, 53.0% of the subjects had an abnormal Clock Test whereas 10.6% of the subjects had an abnormal questionnaire score. Only 9.1% of the subjects had abnormal scores on both tests. Subjects with more schooling had a greater probability of having a positive clock concept (understanding that a circle represented a clock). Of those with more than 6 years of schooling, 91.0% had a positive clock concept. Subjects with a negative clock concept were more likely to have an abnormal Clock Test (93.3%) than a questionnaire (26.6%).

CONCLUSIONS

The main finding of our study was the discrepancy between the results of the Clock Test and the questionnaire. Performance on the Clock Test appeared to have been heavily influenced by education level, indicating the test is not universally applicable across cultures. The questionnaire-based test appears to reduce the effects of illiteracy on assessing dementia in a Nigerian population. Larger studies should be done to control for how education affects the assessment of dementia.

Hemidiaphragmatic paralysis: a rare complication of cervical herpes zoster

Herpes zoster, a sequel of the reactivation of the varicella zoster virus, usually presents with cutaneous eruptions associated with intense pain and burning sensation in the affected dermatomes. Motor weakness, however, can sometimes complicate herpes zoster. In this report we present a case that had diaphragmatic motor weakness as a sequel of herpes zoster lesions in the neck.

Paroxysmal Nocturnal Hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hemolytic disorder of acquired origin and is clinically manifested by chronic hemolysis, thromboses in various sites, and bone marrow failure. The disease isso rare that the delay in the diagnosis is not uncommon and this bears a tremendous impact on patientmanagement. We present this case to draw attention to this uncommon cause of hemolytic anemia, whichshould be considered in any patient, of any age, who has signs of chronic hemolysis.Key Words: Paroxysmal Nocturnal Hemoglobinuria, Hemolytic anemia.

Paroxysmal nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hemolytic disorder of acquired origin and is clinically manifested by chronic hemolysis, thromboses in various sites, and bone marrow failure. The disease is so rare that the delay in the diagnosis is not uncommon and this bears a tremendous impact on patient management. We present this case to draw attention to this uncommon cause of hemolytic anemia, which should be considered in any patient, of any age, who has signs of chronic hemolysis.

Smallpox DNA vaccine protects nonhuman primates against lethal monkeypox

Two decades after a worldwide vaccination campaign was used to successfully eradicate naturally occurring smallpox, the threat of bioterrorism has led to renewed vaccination programs. In addition, sporadic outbreaks of human monkeypox in Africa and a recent outbreak of human monkeypox in the U.S. have made it clear that naturally occurring zoonotic orthopoxvirus diseases remain a public health concern. Much of the threat posed by orthopoxviruses could be eliminated by vaccination; however, because the smallpox vaccine is a live orthopoxvirus vaccine (vaccinia virus) administered to the skin, the vaccine itself can pose a serious health risk. Here, we demonstrate that rhesus macaques vaccinated with a DNA vaccine consisting of four vaccinia virus genes (L1R, A27L, A33R, and B5R) were protected from severe disease after an otherwise lethal challenge with monkeypox virus. Animals vaccinated with a single gene (L1R) which encodes a target of neutralizing antibodies developed severe disease but survived. This is the first demonstration that a subunit vaccine approach to smallpox-monkeypox immunization is feasible.

Factor structure of the Psychiatric Diagnostic Screening Questionnaire (PDSQ), a screening questionnaire for DSM-IV axis I disorders

We examined the factor structure of the Psychiatric Diagnostic Screening Questionnaire (PDSQ), a 125-item self-report scale that screens for 15 of the most common Axis I psychiatric disorders for which patients seek treatment in outpatient settings. The sample consisted of 2440 psychiatric outpatients. Thirteen factors were extracted. Ten mapped directly onto the DSM-IV diagnosis for which they were designed and one represented suicidal ideation. The remaining two factors reflected closely related disorders: Panic Disorder/Agoraphobia, and Somatization/Hypochondriasis. A psychosis factor was not extracted. Overall, the factor structure of the PDSQ was consistent with the DSM-IV nosology upon which it was developed.

Complication rates of colonoscopy in an Australian teaching hospital environment

BACKGROUND

Quality assurance is an important part of health-care delivery. With the high level of awareness relating to adverse events from medical care, demonstration of a high standard of practice in gastroenterology is desirable.

AIMS

To determine the incidence of significant complications or death within 30 days of an outpatient colonoscopy, and confirm that these are in keeping with international standards.

METHODS

A retrospective audit of linked endoscopy and other hospital databases and selected medical records was carried out, based on reports of 30,463 colonoscopies performed between 5 September 1989 and 31 December 1999 in the three Western Australian public teaching hospitals.

RESULTS

A total of 23,508 colonoscopies was performed on an outpatient basis between 5 September 1989 and 31 December 1999. Post-procedural complications identified (and incidence) were: bleeding episodes 49 (0.21%), colonic perforation 23 (0.1%), abdominal pain 22 (0.09%), and others 19 (0.08%). A total of 196 patients died within 30 days of undergoing colonoscopy (0.83%), although only three deaths were attributable to the procedure itself (incidence 0.01%). Two were inpatients at the time of the procedure (outpatient mortality rate 0.004%). The combined incidence of bleeding and perforation was not significantly different between consultant endoscopists and unassisted trainees (incidence 0.21% vs 0.20%, P=0.98).

CONCLUSIONS

The incidence of bleeding and perforation is similar to other reported series and reflects procedures performed by personnel with a wide range of endoscopic experience. The incidence of complications was not greater for trainees compared with consultant endoscopists. All bleeding episodes and the majority of perforations were associated with a therapeutic intervention. Diagnostic colonoscopy in particular is a very safe procedure.

Telemedicine--the way ahead for medicine in the developing world

An e-mail link with the facility to send high-resolution digital images is a cheap and uncomplicated telemedicine method. The Swinfen Charitable Trust helped establish such a link in Patan Hospital Kathmandu, Nepal in March 2000. Over 12 months using this link 42 telemedicine referrals were sent to specialists throughout the world. Referrals were: 36% respiratory medicine; 21% neurology, 21% dermatology; 14% cardiology; 5% nephrology; and 3% radiology--28 had digital pictures attached, of which 96% were of high enough quality on which specialists were able to comment. Thirty-nine replies were received. The average time for a specialist reply was 2 days, and 45% were answered within 24 hours. All replies were judged by independent assessors to be helpful or very helpful for diagnosis, management and education. The assessors decided that in 50% of cases the advice if acted upon would have shortened hospital stay. This pilot study has shown that a low-cost telemedicine link is technically feasible and can be of significant benefit for diagnosis, management and education in a developing world setting.

Electrocardiography: "Diseases" of Technique

Abstract

Gender differences in patients with posttraumatic stress disorder in a general psychiatric practice

OBJECTIVE

This report examined gender differences in the clinical manifestations of current posttraumatic stress disorder (PTSD) in treatment-seeking patients.

METHOD

Outpatients with PTSD (N=138) were interviewed with the Structured Clinical Interview for DSM-IV.

RESULTS

Compared with male patients, female patients experienced more reexperiencing symptoms and were more likely to meet criteria for current PTSD and to report sexual trauma as their index trauma. Men with PTSD were more likely than women with PTSD to meet criteria for a substance use disorder and for antisocial personality disorder. No gender differences were found in the frequency of other types of comorbid disorders, the number of comorbid disorders, or the presence of PTSD as a primary disorder.

CONCLUSIONS

Overall, male and female patients with current PTSD present with fairly comparable clinical profiles.

Symptoms of atypical depression

Studies examining the demographic and clinical features of depressed patients who meet criteria for the atypical features subtype have often yielded conflicting results. The present study sought to evaluate the demographic and clinical correlates associated with each of the five symptoms (mood reactivity, hypersomnia, hyperphagia, leaden paralysis and rejection sensitivity) that constitute the DSM-IV criteria set of atypical depression. Symptom prevalence rates were determined for 661 psychiatric outpatients diagnosed with a major depressive disorder, and were analyzed as a function of age, sex, severity, and episode duration. We found that: (1) younger age was positively associated with hypersomnia and negatively associated with leaden paralysis, while middle age was positively associated with both hyperphagia and rejection sensitivity; (2) female sex was associated with all of the atypical symptoms except rejection sensitivity; (3) a greater severity of illness was positively associated with leaden paralysis and rejection sensitivity, and negatively associated with mood reactivity; and (4) a duration of illness of greater than 3 months was positively associated with hyperphagia, leaden paralysis, and rejection sensitivity. Thus, the five atypical features do not appear to be associated with the same clinical profiles.

The effectiveness of CAHPS among women enrolling in Medicaid managed care

The large-scale transition of public health insurance programs to managed care has shifted much of the responsibility for selecting appropriate coverage to beneficiaries--a role for which many have had little preparation. This study evaluates the impact of a CAHPS (Consumer Assessment of Health Plans Study) health care report card in assisting newly enrolled Medicaid case heads in selecting a managed care plan. The major finding is that the CAHPS report card helped consumers make more informed decisions. Those who received the report cards found judging quality between plans easier, felt that they had significantly more information on which to make decisions, and recognized the importance of their decision more often than those receiving only standard enrollment packets.

A role for calcium in stabilizing transport vesicle coats

Calcium has been implicated in regulating vesicle fusion reactions, but its potential role in regulating other aspects of protein transport, such as vesicle assembly, is largely unexplored. We find that treating cells with the membrane-permeable calcium chelator, 1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid tetrakis(acetoxymethyl ester) (BAPTA-AM), leads to a dramatic redistribution of the vesicle coat protein, coatomer, in the cell. We have used the cell-free reconstitution of coat-protomer I (COPI) vesicle assembly to characterize the mechanisms of this redistribution. We find that the recovery of COPI-coated Golgi vesicles is inhibited by the addition of BAPTA to the cell-free vesicle budding assay. When coatomer-coated membranes are incubated in the presence of calcium chelators, the membranes "uncoat," indicating that calcium is necessary for maintaining the integrity of the coat. This uncoating is reversed by the addition of calcium. Interestingly, BAPTA, a calcium chelator with fast binding kinetics, is more potent at uncoating the coatomer-coated membrane than EGTA, suggesting that a calcium transient or a calcium gradient is important for stabilizing COPI vesicle coat. The primary target for the effects of calcium on coatomer recruitment is a step that occurs after ADP-ribosylation factor binding to the membrane. We suggest that a calcium gradient may serve to regulate the timing of vesicle uncoating.

Comorbidity burden and its impact on psychosocial morbidity in depressed outpatients

BACKGROUND

Many studies have examined the co-occurrence of depression and one or two nondepressive disorders; however, little research has looked at broad spectrum comorbidity (i.e., comorbidity across several diagnostic categories) in depressed patients. Research on diagnostic practices in routine clinical settings--in which unstructured interviewing is the norm--suggests that comorbid conditions are often not detected [Zimmerman, M., Mattia, J. 1999. Psychiatric diagnosis in clinical practice: Is comorbidity being missed? Compr. Psychiatry, 40, 182-191]. In this study we examined the independent impact of different comorbid diagnostic categories on psychosocial morbidity in psychiatric outpatients with Major Depressive Disorder (MDD).

METHODS

Participants were drawn from a pool of 1000 psychiatric outpatients interviewed with the Structured Clinical Interview for DSM-IV diagnoses (SCID-IV; [First, M.B., Spitzer, R.L., Williams, J.B.W., Gibbon, M., 1995. Structured Clinical Interview for DSM-IV (SCID). American Psychiatric Association, Washington, D.C.]). We compared the demographics, clinical characteristics, and psychosocial functioning of depressed outpatients with and without different axis I comorbidities, then conducted multivariate analyses to determine the respective impact of comorbid axis I disorders.

RESULTS

Three hundred and seventy-three patients had a principal diagnosis of unipolar MDD. One hundred twenty-nine (34.6%) were diagnosed with MDD only, and 244 (65.4%) had MDD and at least one other axis I disorder. Comorbidity was associated with longer duration of index episode, more psychiatric morbidity, and more social and occupational impairment. There was also a significant relationship between increasing number of comorbid axis I disorders and greater psychiatric and psychosocial impairment. In regression analyses, comorbidity burden (i.e., the number of comorbid axis I disorders) showed the strongest relation to psychiatric and psychosocial impairment.

LIMITATIONS

This is not a random sample of depressed outpatients and, thus, may not be generalizable to all outpatients with depression. Second, Axes II and III comorbidity were not assessed.

CONCLUSIONS

Comorbidity burden showed the strongest relation to impairment over and above the presence of any particular class of disorders.

A self-report scale to help make psychiatric diagnoses: the Psychiatric Diagnostic Screening Questionnaire

BACKGROUND

The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a brief, psychometrically strong, self-report scale designed to screen for the most common DSM-IV Axis I disorders encountered in outpatient mental health settings. In the present report, we describe the diagnostic performance (sensitivity, specificity, and positive and negative predictive values) of the PDSQ in an outpatient setting.

METHODS

Six hundred thirty psychiatric outpatients presenting for treatment were evaluated with the Structured Clinical Interview for DSM-IV after completing the PDSQ. Patients arrived approximately 20 minutes before the scheduled time of the appointment to complete the scale. Diagnostic raters were blind to responses on the scale.

RESULTS

The PDSQ's subscales' diagnostic performance varied in a predictable manner according to the cutoff score-as the threshold for case identification increased, subscale sensitivity decreased and specificity increased. Mean subscale sensitivities of 80%, 85%, and 90% resulted in mean subscale specificities of 78%, 73%, and 66%, respectively, and negative predictive values of 95%, 96%, and 97%. Receiver operating curves were determined for each subscale and all areas under the curve were significant.

CONCLUSIONS

The PDSQ is a diagnostic aid designed to be used in clinical practice to facilitate the efficiency of conducting initial diagnostic evaluations. From a clinical perspective, it is most important that a diagnostic aid have good sensitivity, so that most cases are detected, and high negative predictive value, so that most noncases on the measure are indeed noncases. Our results indicate that most of the PDSQ subscales were able to achieve this goal.

Posttraumatic stress disorder and major depressive disorder: investigating the role of overlapping symptoms in diagnostic comorbidity

Studies of posttraumatic stress disorder (PTSD) have found high levels of comorbid major depressive disorder (MDD). One reason suggested for the comorbidity is the symptom overlap (contaminated symptoms) between the disorders. The present study investigated the contribution of contaminated symptoms (anhedonia, concentration, and sleep problems) to the comorbidity of PTSD and MDD. PTSD symptoms were subdivided into two groups: the contaminated symptoms and the 14 unique symptoms. It was speculated that if the contaminated symptoms are responsible for the comorbidity, then they will show less specificity than the unique symptoms, will be less highly correlated with a PTSD symptom total count, and be more frequently endorsed in PTSD patients with than without MDD. These hypotheses were tested in a sample (N = 1300) of psychiatric outpatients, 260 of whom had lifetime PTSD. None of the hypotheses were supported, thereby suggesting that the comorbidity between PTSD and MDD is not an artifact of symptom overlap.

Development of a three-dimensional transmigration assay for testing cell--polymer interactions for tissue engineering applications

The ability of synthetic or natural scaffolds to support invasion of cells from surrounding tissue is a key parameter for tissue engineering (TE). In this study, the migration of fibroblasts, chondrocytes, and osteoblasts into biodegradable polymer scaffolds was evaluated using a novel, three-dimensional (3-D) transmigration assay. This assay is based on a cell-populated contracted collagen lattice with a biodegradable polymer scaffold implanted at the center of the collagen gel. Cell migration into the scaffolds was assessed both quantitatively and qualitatively following various time lengths in culture using image analysis. Chondrocytes, incorporated within the collagen lattice, migrated into polymer scaffolds, when cultured both statically or in a rotating bioreactor. However, the bioreactor cultures resulted in a significantly greater cell invasion as compared to static cultures. There was a cell density-dependent osteoblast migration from collagen lattice into polymer scaffold, when tested in the transmigration assay. In addition, polymer scaffolds, treated with or without recombinant human platelet-derived growth factor (rh-PDGF-BB) were evaluated for fibroblast migration. The presence of rh-PDGF-BB resulted in significantly greater fibroblast invasion as compared to untreated scaffolds. Our studies suggest that the transmigration model provides a rapid system for testing cell invasion of potential scaffolds for tissue engineering applications.

The Psychiatric Diagnostic Screening Questionnaire: development, reliability and validity

The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a self-report scale designed to screen for the most common DSM-IV axis I disorders encountered in outpatient mental health settings. We report the results of four studies of the PDSQ involving more than 2,500 subjects receiving outpatient mental health care. In two studies we examined the understandability of the items on the PDSQ. Items that initially were less well understood were rewritten, and all items of the final version of the scale were understood by more than 90% of the respondents. In the other two studies, the reliability and validity of the PDSQ subscales was examined. A priori criteria were established to guide the revision of subscales. The final version of the questionnaire contains 13 subscales (major depressive disorder [MDD], bulimia, post-traumatic stress disorder [PTSD], panic disorder, agoraphobia, social phobia, generalized anxiety disorder [GAD], obsessive-compulsive disorder [OCD], alcohol abuse/dependence, drug abuse/dependence, somatization, hypochondriasis, and psychosis), each of which achieved good to excellent levels of internal consistency, test-retest reliability, and discriminant, convergent, and concurrent validity.

Clinical features of survivors of sexual abuse with major depression

OBJECTIVE

This study examined differences in rates of trauma-related disorders between patients with histories of childhood sexual abuse and those without such histories in a sample of depressed outpatients. Another aim of this study was to determine whether childhood sexual abuse is associated with recent suicidal attempts, affect dysregulation and duration of index depressive episode, independent of posttraumatic stress disorder and borderline personality disorder.

METHOD

Subjects were 235 treatment-seeking outpatients with major depression. Structured interviews were administered to assess for Axis I and Axis II disorders, childhood sexual abuse, and various clinical features.

RESULTS

Patients with sexual abuse compared to those without sexual abuse histories had higher rates of comorbidity, primarily borderline personality disorder, posttraumatic stress disorder and multiple Axis I diagnoses. Childhood sexual abuse status was linked to a longer duration of the index depressive episode, independent of borderline personality disorder and/or posttraumatic stress disorder. However, childhood sexual abuse status was not independently related to affect dysregulation and suicidal attempts.

CONCLUSION

The findings suggest that patients with histories of sexual abuse represent a subgroup of depressed patients who are at especially high risk for psychiatric morbidity and a prolonged episode of depression.

Switching versus augmentation: a prospective, naturalistic comparison in depressed, treatment-resistant patients

OBJECTIVE

(1) To directly compare the effectiveness of switching antidepressants with augmenting them in depressed patients who do not respond to an initial adequate trial and (2) to determine whether there is a decreased likelihood of response to a second switch or augmentation trial in those patients who did not respond to the first intervention for treatment-resistant depression.

METHOD

In a naturalistic, open-label design, all depressed outpatients (DSM-IV criteria) who were treatment resistant were prospectively assessed. Short- and long-term outcomes of switching versus augmentation were compared using the Clinical Global Impressions scale.

RESULTS

In the acute phase, 37 (50.0%) of 74 subjects responded to 1 of the 2 interventions for treatment-resistant depression. Forty-five percent (N = 17) and 56% (N = 20) of the patients who had their antidepressant switched or augmented, respectively, responded to that intervention. Nearly three fourths (71.4%) of the acute responders maintained their response through 6 months of follow-up. In 18 patients who did not respond to the first switch or augmentation, 9 (50.0%) responded to a second trial.

CONCLUSION

Switching antidepressants was somewhat less effective than augmentation, although this difference was not statistically significant. For patients who do not respond to an augmentation or switch, our results suggest that a second trial for treatment-resistant depression may be as effective as the first.

Short-term spontaneous improvement rates in depressed outpatients

The objectives of the present report were: a) to determine the spontaneous remission rate in depressed outpatients who do not receive antidepressant medication; b) to develop a novel method for obtaining a control group that can be used to gauge the effectiveness of antidepressant medication in clinical practice; and c) to compare response rates from the present sample with outcomes of depressed patients in our practice who were treated with antidepressant medications. By using a naturalistic design, prospective assessments were made on all depressed outpatients. Twenty-five patients who met full criteria for a major depressive episode ended up not taking antidepressant medication for a variety of reasons. "Response" rates to a no-treatment trial were determined with standard outcome criteria using the Clinical Global Impression-Improvement scale. Eight patients (32.0%) had a positive response, 5 patients (20.0%) had a partial response, and 12 patients (48.0%) were nonresponders to a no-treatment trial. These response rates were higher than expected, but significantly lower than what we had found in a cohort of depressed patients who underwent an antidepressant trial (p = .02). Likewise, treatment-resistant patients fared better on pharmacotherapy, though this difference was not statistically significant. These results suggest that the occurrence of spontaneous remissions may be common in clinical practice, and therefore the specific short-term benefits of antidepressant medication in clinical practice may frequently be overestimated. Despite the high rate of spontaneous remission in our sample, the present study allowed us to confirm the effectiveness of antidepressant medication in clinical practice using a novel method for obtaining a control comparison group.

Comparison of three oral appliances for treatment of severe obstructive sleep apnea syndrome

Objective: To compare three different oral appliances: a mandibular advancement device (Snoreguard), a tongue retaining device, and a soft palate lift, for treatment of severe obstructive sleep apnea syndrome (OSAS).Background: Oral appliances are therapeutic options for patients with OSAS.Methods: Eight patients with a mean apnea hypopnea index (AHI) of 72.1 (SD+/-39.9) were studied. Polysomnographic measures during each of the treatment nights were compared to baseline.Results: Eight out of 8 patients completed the mandibular advancement device (MAD) night; 5/8 tolerated the tongue retaining device (TRD); only 2/8 could sleep with the soft palate lift (SPL) in place. Improvement using the MAD reached significance: overall AHI (mean+/-SD) decreased from 72.1+/-39.9 at baseline to 35.5+/-39.4 with the appliance in place (P<0.02). There was a non-significant increase in slow wave sleep (SWS) from 9.6%+/-8.7 to 14.4%+/-10.5 with the MAD in place. In five responders, the mean AHI decreased from 60.0+/-36.6 to 9.0+/-4.8; all were subjectively improved, using the MAD at 1 year follow-up. However, three non-responders had persistence of AHI>40. With the TRD, AHI decreased from 50.3+/-18.9 at baseline to 43.5+/-32.5 (ns). The SPL was not effective with an AHI at baseline of 52.4+/-8.0, and 47.3+/-31.0 with the device in place (ns), and not well tolerated.Conclusions: A mandibular advancement device is an effective treatment alternative in some patients with severe OSAS. In comparison, the tongue retaining device and the soft palate lift do not achieve satisfactory results.

Principal and additional DSM-IV disorders for which outpatients seek treatment

OBJECTIVE

Epidemiological studies indicate that most patients in the community do not get treatment for psychiatric disorders. It is unknown whether persons who present for outpatient psychiatric services seek treatment for all the disorders they have or only for the principal disorder for which they are seeking treatment. The goal of this study was to determine which axis I psychiatric disorders motivate patients to seek treatment.

METHODS

Four hundred outpatients at a hospital-affiliated, community-based, psychiatric clinical practice were interviewed with the Structured Clinical Interview for DSM-IV (SCID). For patients with more than one disorder, the diagnoses were assigned as principal or additional according to the DSM-IV convention of whether it was the patient's stated primary reason for presenting for treatment or was an additional disorder. For all current disorders, patients were asked whether the symptoms of each diagnosed disorder were a reason, or one of the reasons, for seeking treatment.

RESULTS

Nearly all patients with major depression wanted treatment for this disorder, and more than 85 percent of patients with panic disorder, posttraumatic stress disorder, and generalized anxiety disorder indicated that the symptoms of these disorders were a reason for seeking treatment. Half to two-thirds of patients with social phobia, obsessive-compulsive disorder, intermittent explosive disorder, body dysmorphic disorder, and substance use disorders reported that the symptoms of these disorders were a reason for seeking treatment. Only 30 percent of those with specific phobia indicated that their phobic fears were a reason for seeking treatment.

CONCLUSIONS

Patients often seek treatment for symptoms of disorders that are diagnosed as comorbid, rather than principal, conditions. It is important for clinicians to conduct thorough diagnostic interviews in order to diagnose disorders that are not related to the patient's chief complaint, as patients often desire treatment for these additional diagnoses.

Mechanical environment affects allograft incorporation

In a bilateral canine tibial model, the mechanical, radiologic, and histologic characteristics of intercalary allografts stabilized with locked intramedullary nails were compared with those of allografts fixed with compression plates. Both methods of fixation achieved healing to host bone. Tibiae that were plated had more callus with statistically greater mean torsional rigidity and strength than those treated with nails (paired t-test, p </= 0.05). On average, tibiae which had been plated had much higher bending rigidity than those fixed with locked nails; however, the difference in means was not statistically significant. Histomorphometric analysis showed an overall greater total bone formation in those limbs treated with plates compared to nails (paired t-test, p </= 0.04). The mechanical environment created by the different fixation methods are thought to be responsible for the observed differences in healing pattern. The traditional concept of fixation for allografts to achieve maximum rigidity of the construct may not necessarily promote the most appropriate host healing response in all situations. A less rigid fixation method (plates) produced more callus resulting in superior torsional and bending properties. These data show that in this canine intercalary allograft model, limbs fixed with plates produced more external callus resulting in stronger, more rigid healing.

Frequency of anxiety disorders in psychiatric outpatients with major depressive disorder

OBJECTIVE

The authors determined the frequency of anxiety disorders in a large group of depressed outpatients seeking treatment.

METHOD

The Structured Clinical Interview for DSM-IV was administered to 373 depressed outpatients.

RESULTS

More than one-half of the patients met the full criteria for a current anxiety disorder, and more than one-half of the patients with an anxiety disorder had more than one. When partial remissions and anxiety disorder diagnoses classified as "not otherwise specified" were included, two-thirds of the patients had a current anxiety disorder and three-quarters had a lifetime history of an anxiety disorder.

CONCLUSIONS

The majority of patients with a principal diagnosis of unipolar major depressive disorder have a comorbid anxiety disorder. Because antidepressant medications have differential efficacies for anxiety disorders, knowledge of the presence of a comorbid anxiety disorder in a depressed patient may have treatment implications.

Normal values of signal-averaged electrocardiographic parameters and QT dispersion in infants and children

Ventricular late potentials, and dispersion of the QT interval, are markers for risk of ventricular arrhythmias. Normal values for these parameters are well established in adults, but may not apply for children. This study has investigated the age dependency of signal averaged electrocardiographic parameters and QT dispersion in 111 normal children aged from 5 days to 16 years. The results indicate that parameters change with age: duration of filtered QRS and low amplitude (< 40 microV) terminal signal increase with age, especially in the younger patients. Filtered QRS is 88.9 +/- 7.87 ms in infants, and increases to 108.7 +/- 8.51 in teenagers (p<0.001). Low amplitude terminal signals are 17.0 +/- 3.44 ms in infants, and 24.5 +/- 5.64 ms in teenagers (p<0.001). Root mean square of the last 40 ms decreases with age, but remains stable after the age of 10 years (122.4 +/- 33.30 microV in infants, 60.9 +/- 31.27 in teenagers, p<0.001). QT dispersion, on the other hand, does not change significantly with age. The mean value for the whole group is 36 +/- 13.7 ms. A weak but significant correlation exists between QT dispersion and filtered QRS. Thus, age must be taken into consideration when interpreting signal-averaged electrocardiograms, but not when measuring QT dispersion.

The reliability and validity of a screening Questionnaire for 13 DSM-IV Axis I disorders (the Psychiatric Diagnostic Screening Questionnaire) in psychiatric outpatients

BACKGROUND

The purpose of this study was to examine the reliability and validity of a new multidimensional screening instrument for 13 DSM-IV Axis I disorders.

METHOD

The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a 90-item self-administered questionnaire that screens for 13 DSM-IV disorders in 5 areas (eating, mood, anxiety, substance use, and somatoform disorders). A consecutive series of 500 psychiatric outpatients completed the PDSQ immediately before their intake evaluation. Seventy-four patients completed the scale a second time less than a week after the initial administration, and 51 patients completed a booklet of questionnaires that included established measures of the same symptom domains assessed by the PDSQ.

RESULTS

The PDSQ subscales achieved moderate-to-high levels of internal consistency (mean Cronbach's alpha coefficient = 0.82) and test-retest reliability (mean correlation coefficient = 0.84). Subscale scores were significantly associated with blind clinical diagnoses, and individual PDSQ items correlated much more highly with their own subscale than with other subscales. The PDSQ subscales were much more highly correlated with established measures of the same symptom domain (mean correlation coefficient = 0.72) than with measures of other types of psychopathology (mean correlation = 0.17).

CONCLUSION

The PDSQ is a reliable and valid measure of multiple DSM-IV disorders that is brief enough to be incorporated into routine clinical outpatient practice without disruption, yet lengthy enough to be a psychometrically sound instrument.

Differences between clinical and research practices in diagnosing borderline personality disorder

OBJECTIVE

It has been reported that clinicians are less inclined than researchers to use direct questions in ascertaining the presence of personality disorders, and questions have been raised about the validity of research on personality disorders in which diagnoses are based on semistructured diagnostic interviews. This study examined the influence of assessment method on the diagnosis of borderline personality disorder.

METHOD

Diagnoses of borderline personality disorder derived from structured and unstructured clinical interviews were compared in two groups of psychiatric outpatients seen in the same practice setting. Five hundred individuals presenting to a general adult psychiatric practice for an intake appointment underwent a routine unstructured clinical interview. After the completion of that study, the method of conducting diagnostic evaluations was changed, and 409 individuals were interviewed with the borderline personality disorder section of the Structured Interview for DSM-IV Personality.

RESULTS

Individuals in the structured interview group were significantly more often diagnosed with borderline personality disorder than individuals in the clinical group. When information from the structured interview was presented to the clinicians, borderline personality disorder was much more likely to be diagnosed by them.

CONCLUSIONS

The method used to assess borderline personality disorder has a great impact on the frequency with which it is diagnosed. Without the benefit of detailed information from a semistructured diagnostic interview, clinicians rarely diagnose the disorder during a routine intake evaluation. Providing the results of a semistructured interview to clinicians prompts them to diagnose borderline personality disorder much more frequently. This is inconsistent with the notion that personality disorder diagnoses based on semistructured interviews are not viewed as valid by clinicians.

Cigarette smoking and psychiatric disorder in a community sample

We examined the lifetime prevalence of psychiatric disorders in cigarette smokers and nonsmokers in a non-patient sample. First-degree relatives of psychiatric patients (n = 697) and normal controls (n = 360) were interviewed with the Diagnostic Interview Schedule and the Structured Interview for DSM-III Personality Disorders. Using these interviews we diagnosed the major mental (Axis I) disorders and personality (Axis II) disorders. A cigarette smoker was defined as someone who smoked daily for a month or more at some time in their lives. We found that smokers more frequently had a lifetime history of major depression, alcohol and drug abuse/dependence, agoraphobia, unstable/acting out and anxious/fearful personality disorders. In a logistic regression analysis, the only significant variables independently associated with smoking status were the alcohol and drug use disorders. Age was an important modifying variable--the smoking-illness relationship was robust in the youngest age cohort and negligible in the oldest cohort. We conclude that cigarette smokers have increased rates of mood, anxiety, substance use, and personality disorders. However, after controlling for the comorbidity among the disorders only alcohol and drug abuse/dependence were independently associated with smoking. Young smokers had particularly high rates of substance use disorders. This age effect may reflect the impact of a quarter century of health education.

Axis I diagnostic comorbidity and borderline personality disorder

Borderline personality disorder (PD) has been the most studied PD. Research has examined the relationship between borderline PD and most axis I diagnostic classes such as eating disorders, mood disorders, and substance use disorders. However, there is little information regarding the relationship of borderline PD and overall comorbidity with all classes of axis I disorders assessed simultaneously. In the present study, 409 patients were evaluated with semistructured diagnostic interviews for axis I and axis II disorders. Patients with a diagnosis of borderline PD versus those who did not receive the diagnosis were assigned significantly more current axis I diagnoses (3.4 v 2.0). Borderline PD patients were twice as likely to receive a diagnosis of three or more current axis I disorders (69.5% v 31.1%) and nearly four times as likely to have a diagnosis of four or more disorders 147.5% v 13.7%). In comparison to nonborderline PD patients, borderline PD patients more frequently received a diagnosis of current major depressive disorder (MDD), bipolar I and II disorder, panic disorder with agoraphobia, social and specific phobia, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), eating disorder NOS, and any somatoform disorder. Similar results were observed for lifetime diagnoses. Overall, borderline PD patients were more likely to have multiple axis I disorders than nonborderline PD patients, and the differences between the two groups were present across mood, anxiety, substance use, eating, and somatoform disorder categories. These findings highlight the importance of performing thorough evaluations of axis I pathology in patients with borderline PD in order not to overlook syndromes that are potentially treatment-responsive.

Is posttraumatic stress disorder underdiagnosed in routine clinical settings?

The goal of the present study was to examine whether posttraumatic stress disorder (PTSD) is underrecognized in routine clinical practice. One thousand patients were evaluated at the Rhode Island Hospital Department of Psychiatry outpatient practice. The first 500 patients completed a psychiatric diagnostic screening questionnaire that included a PTSD subscale. The next 500 individuals were interviewed with the Structured Clinical Interview for DSM-IV (SCID). In the first 500 patients, 36 (7.2%) patients were diagnosed by their clinicians with PTSD and an additional 18.6% of the sample screened positive on the questionnaire but were not diagnosed with PTSD. The patients who were diagnosed with PTSD and the patients who screened positive but were not given the diagnosis were significantly younger, had lower GAF scores, and less frequently graduated from college than the non-PTSD group. The frequency of suicidal thoughts was identical in the two PTSD groups and twice as high as the frequency in the non-PTSD group. Scores on 9 of the other 12 psychopathology dimensions assessed by the screening questionnaire were significantly higher in the two PTSD groups than the non-PTSD group. In the 500 patients interviewed with the SCID the prevalence of PTSD was two times higher than in the 500 patients diagnosed with an unstructured clinical interview (14.4% vs. 7.2%). The difference in prevalence rates of PTSD between the SCID and clinical samples was significant when considering PTSD as an additional diagnosis; there was no difference in prevalence rates when restricting the analysis to principal diagnoses. The results of this study suggest that PTSD is frequently overlooked in routine clinical practice when symptoms of PTSD are not the presenting complaint.

Clinical evaluation of efficacy and safety of a new method for chemo-mechanical removal of caries. A multi-centre study

The aim of the study was to evaluate the clinical efficacy and safety of a new method (Carisolvtrade mark) for chemo-mechanical removal of caries. At four centres, 137 consecutive patients (64 females and 73 males aged 3-85 years, mean 35) entered a prospective, controlled, randomised open study. One primary caries lesion with distinct dentine involvement was selected per patient. A total of 116 lesions in permanent and 21 in deciduous teeth were selected. Caries was removed with traditional drilling or the new method. Gel was applied onto the carious dentine and the softened caries gently removed with specially designed hand instruments. New gel was applied and the procedure was repeated until no more debris could be removed and the surface was hard as judged by clinical criteria (probing and visual inspection). An independent examiner judged the cavity being caries-free or not, using clinical criteria. One hundred and thirteen patients were randomised for gel treatment and 24 for drilling. Three patients selected for drilling did not complete the treatment. Total caries removal was achieved in 106 cases with gel and in 19 with drilling. The reasons for incomplete caries removal were step-by-step excavation in 5 cases, unsuccessful caries removal in 1 case for each treatment, while 2 cases refused inspection. Mean (+/- SD) time for caries removal was 10.4 (+/-6.1) min with the gel method and 4.4 (+/-2.2) min with drilling. Mean volume of gel used was 0.4 (+/-0.2) ml. Eighty-two of 107 patients perceived that the new method caused less discomfort compared to drilling. Dentine caries was effectively removed using the Carisolv method without any adverse reactions.

Psychiatric diagnosis in clinical practice: is comorbidity being missed?

The recognition of comorbidity has important clinical significance. Comorbidity predicts a poorer outcome for patients with depressive and anxiety disorders, and the presence of multiple psychiatric disorders is associated with greater psychosocial impairment. In routine clinical settings, an unstructured interview is typically used to assess patients. However, unstructured interviews may result in missed diagnoses, with potential negative clinical consequences. The goal of the present study was to examine whether diagnostic comorbidity is less frequently identified during a routine clinical evaluation versus a semistructured diagnostic interview. Axis I diagnoses derived from structured and unstructured clinical interviews were compared in two groups of psychiatric outpatients in the same practice setting. Five hundred individuals presenting for an intake appointment to a general adult psychiatric practice underwent a routine unstructured clinical interview. Subsequent to completion of the first study, the method of conducting diagnostic evaluations was changed and 500 individuals were interviewed with the Structural Clinical Interview for DSM-IV Axis I Disorders (SCID). The two groups had similar demographic characteristics and scored similarly on symptom questionnaires. Individuals interviewed with the SCID were assigned significantly more axis I diagnoses than individuals assessed with an unstructured interview. More than one third of the patients interviewed with the SCID were diagnosed with three or more disorders, in contrast to fewer than 10% of the patients assessed with an unstructured interview. Fifteen disorders were more frequently diagnosed in the SCID sample, and these differences occurred across mood, anxiety, eating, somatoform, and impulse-control disorder categories. The results suggest that in routine clinical practice, clinicians underrecognize diagnostic comorbidity. Anxiety, somatoform, and not otherwise specified (NOS) disorders were the most frequently underdetected disorders. The implications of underdiagnosis for the treatment outcome are discussed.

Psychotic subtyping of major depressive disorder and posttraumatic stress disorder

BACKGROUND

Many studies have established that a large percentage of patients with posttraumatic stress disorder (PTSD) have comorbid major depressive disorder. Other studies have found that patients with PTSD or a history of childhood trauma have an increased rate of psychotic symptoms. In the present report from the Rhode Island Methods to Improve Diagnosis and Services project, we examine whether an association exists between psychotic subtyping of major depressive disorder and PTSD.

METHOD

Five hundred psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV.

RESULTS

Almost half of the 500 patients had nonbipolar major depressive disorder (N = 235, 47.0%), 45 (19.1%) of whom had PTSD. Nineteen patients had psychotic depression, 216 had nonpsychotic depression. Compared with patients with nonpsychotic depression, the patients with psychotic depression were nearly 4 times more likely to have PTSD (57.9% vs. 15.7%, Fisher exact test, p = .0001).

CONCLUSION

The results of the present study suggest that the presence of psychosis in psychiatric outpatients with major depressive disorder is associated with concurrent PTSD. It is hypothesized that the poorer longitudinal course of psychotic versus nonpsychotic depression may be due to the underrecognition of PTSD in psychotically depressed patients.

Clinical correlates of self-mutilation in a sample of general psychiatric patients

The aims of this study were to examine whether certain axis I disorders characterized by impulsive aggression were associated with self-mutilative behavior and to evaluate the clinical correlates of self-mutilation in a sample of general psychiatric outpatients. Two hundred fifty-six outpatients were administered diagnostic interviews for axis I and axis II disorders. In addition, questionnaires that measured self-mutilative acts within the last 3 months, dissociation, and childhood abuse were completed. This study found that axis I disorders of substance abuse, posttraumatic stress disorder, and intermittent explosive disorder were significantly related to self-mutilative behavior, independent of borderline personality disorder and antisocial personality disorder. Also, a higher level of dissociation was related to self-mutilation, controlling for borderline personality disorder and childhood abuse. Outpatients with certain axis I disorders and those who dissociate may represent a sizable group of patients who are at risk for self-mutilative behavior.

Neutralizing anti-vascular endothelial growth factor antibody inhibits further growth of established prostate cancer and metastases in a pre-clinical model

PURPOSE

The formation of new blood vessels from the pre-existing vasculature is necessary for support of primary tumor growth and appears coincident with the development of metastasis. In previous studies, inhibition of vascular endothelial growth factor (VEGF), a potent angiogenic factor and mediator of vascular permeability, inhibited tumor neovascularization with consequent inhibition of both primary tumor growth and micrometastases when administered at the time of tumor inoculation. In the present study, we examined the effect of inhibiting VEGF on primary tumor growth and metastases in an in vivo model of established metastatic prostate cancer.

MATERIALS AND METHODS

The human prostate cancer cell line DU-145 was found to secrete VEGF. DU-145.luciferase, a subclone stably transfected with an expression vector encoding the luciferase gene, injected subcutaneously, consistently formed tumors in C.B.-17 scid/scid mice. After 6 weeks, assay of whole lung lysates showed significant luciferase activity, consistent with the presence of micrometastasis.

RESULTS

Twice weekly treatment of the animals with a monoclonal anti-VEGF neutralizing antibody, A4.6.1, not only suppressed primary tumor growth, but inhibited metastatic dissemination to the lung. When treatment was delayed until the primary tumors were well-established, further growth was still inhibited, as was the progression of metastatic disease.

CONCLUSION

Inhibition of tumor-secreted VEGF by a neutralizing antibody is sufficient to significantly impair prostate tumor growth and its subsequent metastasis in an in vivo model of established advanced prostate cancer. These data suggest a critical role for VEGF in initiation and maintenance of tumor angiogenesis in prostate cancer. Inhibition of VEGF in patients with VEGF-secreting prostate cancers may prove an effective approach for inhibiting disease progression even after micro-metastatic dissemination has occurred.