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.

A severity rating scale for body dysmorphic disorder: development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale

The authors developed the Yale Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS), a 12-item semistructured clinician-rated instrument designed to rate severity of body dysmorphic disorder (BDD). The scale was administered to 125 subjects with BDD, and interviews with 15 subjects were rated by 3 other raters. Test-retest reliability was assessed in 30 subjects. Other scales were administered to assess convergent and discriminant validity, and sensitivity to change was evaluated in a study of fluvoxamine. Each item was frequently endorsed across a range of severity. Good interrater reliability, test-retest reliability, and internal consistency were obtained. BDD-YBOCS scores correlated with global severity scores but not with a measure of general psychopathology; they were modestly positively correlated with depression severity scores. Three factors accounted for 59.6 percent of the variance. The scale was sensitive to change in BDD severity. The BDD-YBOCS appears to be a reliable and valid measure of BDD severity and is a suitable outcome measure in treatment studies of BDD.

Using cost-effectiveness/cost-benefit analysis to allocate health resources: a level playing field for prevention?

INTRODUCTION

Prevention is being promoted as a means to improve health status and to save health care costs. Economic evaluations of prevention (i.e., cost-effectiveness and cost-benefit analyses) indicate that some prevention activities, like many treatments, do not save money, although many are relatively cost-effective. It has been suggested, however, that prevention is held to a higher standard than treatment because prevention programs are expected to demonstrate cost savings, and that the methods of economic evaluation understate the cost-effectiveness of prevention. Although the converse assertion is less commonly made, economic evaluations may also overstate the cost-effectiveness of prevention. The purpose of this article is to examine how the methods of economic evaluation may systematically understate, or overstate, the cost-effectiveness (or net benefits) of prevention.

METHODS

We examine three key methods: (1) how future costs and benefits are valued ("discounting"), (2) how costs and benefits to people beyond those who are the users of prevention are valued ("externalities"), and (3) how nonmonetary costs and benefits to individuals are valued ("intangibles").

RESULTS

We discuss several recommendations for each key method, and we use a hypothetical example of the cost-effectiveness of a vaccine to prevent human immunodeficiency virus (HIV) to illustrate our points.

CONCLUSIONS

We conclude that the methods of economic evaluation may both understate and overstate the cost-effectiveness of prevention.

Are impulse-control disorders related to bipolar disorder?

We reviewed available evidence regarding a possible relationship between impulse-control disorders (ICDs) and bipolar disorder. Studies examining the phenomenology, course, comorbidity, family history, biology, and treatment response of ICDs were compared with similar studies of bipolar disorder. Although no studies directly compare a cohort of ICD patients with a cohort of mood disorder patients, available data suggest that ICDs and bipolar disorder share a number of features: (1) phenomenologic similarities, including harmful, dangerous, or pleasurable behaviors, impulsivity, and similar affective symptoms and dysregulation; (2) onset in adolescence or early adulthood and episodic and/or chronic course; (3) high comorbidity with one another and similar comorbidity with other psychiatric disorders; (4) elevated familial rates of mood disorder; (5) possible abnormalities in central serotonergic and noradrenergic neurotransmission; and (6) response to mood stabilizers and antidepressants. However, ICDs and bipolar disorder differ in important respects. In particular, some ICDs may be more closely related to obsessive-compulsive disorder (OCD) than is bipolar disorder. Although the similarities between ICDs and bipolar disorder may be coincidental, they suggest that the two conditions may be related and thus may share at least one common pathophysiologic abnormality. To explain this possible relationship, we hypothesize that impulsivity and bipolarity (or mania) are related, that compulsivity and unipolarity (or depression) are similarly related, and that each state may represent opposing poles of related, or even a single, psychological dimension.

Alpha-fetoprotein production by a malignant mixed müllerian tumour of the uterus

A case of alpha-fetoprotein production by a uterine malignant mixed müllerian tumour is described. The patient was a 68 year old woman who developed intraabdominal recurrence of a stage 1 uterine tumour which had been treated surgically seven years previously. Her serum alpha-fetoprotein was raised at 21,000 micrograms/l (normal < 10 micrograms/l) and staining with immunoperoxidase confirmed that the tumour was the site of alpha-fetoprotein production. The patient was treated with combination chemotherapy but died two weeks after the first course. This is believed to be only the second such case reported.

Trichotillomania and self-esteem: a survey of 62 female hair pullers

BACKGROUND

The psychological features of trichotillomania have received little empirical attention, despite the fact that sufferers commonly report negative self-image to be one of the most disturbing aspects of the disorder. We conducted the current study to identify specific factors that predict self-esteem problems in hair pullers.

METHOD

Sixty-two women with trichotillomania or repetitive hair pulling completed self-report forms assessing factors possibly related to self-esteem in hair pullers. The survey included questions related to demographics, hair-pulling symptoms, mood and anxiety symptoms, and body image concerns.

RESULTS

Self-esteem did not appear to be directly related to age at onset of hair pulling or severity of hair loss. However, self-esteem was related to level of depression, frequency of hair pulling, level of anxiety, and body dissatisfaction unrelated to hair pulling.

CONCLUSION

Several factors, including the frequency of hair pulling, are associated with low self- esteem in patients with trichotillomania. Specific efforts should be made to address these issues in treatment.

Decisions to get HIV tested and to accept antiretroviral therapies among gay/bisexual men: implications for secondary prevention efforts

The objective of this study was to report prevalence rates of adherence by HIV-seropositive individuals to medical recommendations for the treatment of HIV infection, a behavioral pattern referred to as AIDS secondary prevention. We report cross-sectional data (n = 2,593) from two household-based and two bar-based samples of gay/bisexual men, gathered in 1992 in Tucson, Arizona, and Portland, Oregon. The main outcome variables were prevalence of HIV antibody testing and adherence to recommended secondary prevention behaviors to prevent onset of AIDS symptoms. Approximately one-third of the gay/bisexual men in these samples do not know their current HIV status. Of the gay/bisexual men who do know that they are HIV-seropositive, approximately three-fourths adhere to each of the secondary prevention recommendations, as appropriate to their stage of disease progression. In a multivariate logistic model, three variables distinguished between HIV-seropositive men who did and did not adhere: perceived antiviral treatment norms (OR = 1.4, CI = 1.1-1.7), perceived efficacy of secondary prevention treatments (OR = 1.4, CI = 1.1-1.7), and quality of the relationship with one's health-care provider (OR = 2.5, CI = 1.6-4.0). These findings indicate that efforts to support AIDS secondary prevention behaviors can occur not only through health education to change the perceptions of at-risk communities about the options available to delay the onset of opportunistic infections among HIV-seropositive individuals but also by enhancing effective doctor/patient communication.

Improving the use of information in medical effectiveness research

There is increased emphasis on improving the quality of health care by obtaining and disseminating information about the effectiveness and outcomes of care and by facilitating more consumer input participation in decision-making. We examine barriers to information use and the challenges that these barriers pose for effectiveness research. We divide our discussion into four goals of effectiveness research. These are: (1) to provide more information so that consumers, providers and policymakers can make "rational" decisions; (2) to incorporate patient preferences into health care decisions; (3) to develop guidelines that incorporate both individual perspectives and societal perspectives; (4) to use information to improve the practice of health care. We discuss four recommendations for improving the use of information: (1) the evidence on how people actually make decisions should be used to inform the design and implementation of effectiveness research; (2) decision-making should be structured through guidelines and policies; (3) criteria should be developed for determining which guidelines should fully incorporate patient preferences; (4) safeguards should be established to guard against misuse of information.

Body dysmorphic disorder: diagnosis and treatment of imagined ugliness

Body dysmorphic disorder (BDD), a preoccupation with an imagined or slight defect in appearance, has been described for more than a century and reported around the world. However, this distressing and impairing disorder often goes undiagnosed, even though available data suggest that it is relatively common. Virtually any body part can be the focus of concern, with preoccupations most often involving the hair, nose, or skin. Most patients engage in excessive and repetitive behaviors such as mirror checking, skin picking, and reassurance seeking. Insight is generally poor, and many patients are frankly delusional. Most patients experience significant impairment in functioning, and suicide attempts are relatively common. Although the majority of patients with BDD seek often costly nonpsychiatric treatment-most often, surgical or dermatologic-such treatment usually appears to be unsuccessful. In contrast, preliminary data from open studies suggest that the serotonin reuptake inhibitors are often, and perhaps preferentially, effective for BDD. Augmentation, combination, and switching strategies may be useful in treatment-resistant cases. Preliminary data suggest that cognitive-behavioral strategies using exposure and response prevention may also be effective. Investigation of all aspects of this understudied disorder, including controlled treatment trials, is greatly needed.

Body dysmorphic disorder in patients with anxiety disorders and major depression: a comorbidity study

OBJECTIVE

The authors evaluated the frequency of body dysmorphic disorder in patients with a primary diagnosis of anxiety disorders and major depression.

METHOD

Patients with social phobia (N = 54), obsessive-compulsive disorder (N = 53), generalized anxiety disorder (N = 32), panic disorder (N = 47), and major depression (N = 42) and normal comparison subjects (N = 33) were studied.

RESULTS

Body dysmorphic disorder was most common in patients with social phobia (11%) and obsessive-compulsive disorder (8%); it was less prevalent among patients with panic disorder (2%), generalized anxiety disorder (0%), and major depression (0%) and among normal subjects (0%).

CONCLUSIONS

These findings suggest that body dysmorphic disorder may share etiologic elements with social phobia and obsessive-compulsive disorder.

Case study: body dysmorphic disorder in adolescents

Body dysmorphic disorder, an often-secret preoccupation with an imagined or slight defect in appearance, is an underrecognized disorder that is unknown to many clinicians. This disorder has gone virtually unmentioned in the adolescent literature, despite the fact that it often occurs during adolescence. Body dysmorphic disorder is more common than is realized and causes significant distress and impairment in functioning. This report presents four cases of adolescents with body dysmorphic disorder, all of who responded to a serotonin reuptake inhibitor. The clinical features of body dysmorphic disorder are reviewed, as are available data on the treatment of this distressing and often-disabling disorder.

Australasian multicentre phase II study of paclitaxel (Taxol) in relapsed ovarian cancer

BACKGROUND

Until recently there has been no effective therapy for patients with relapsed ovarian carcinoma following standard platinum based chemotherapy. Paclitaxel has recently been approved for clinical use in this malignancy.

AIMS

To evaluate the objective response rate and toxicity of paclitaxel in patients with relapsed ovarian cancer.

METHODS

Paclitaxel was given on an outpatient basis as a three hour infusion every 21 days for a maximum of ten cycles to 72 patients with advanced ovarian cancer previously treated with at least one platinum containing regimen. The starting dose was either 175 mg/m2 (patients with one or two prior chemotherapy regimens) or 135 mg/m2 (three previous regimens). Premedication was given because of the documented risk of hypersensitivity reactions to paclitaxel.

RESULTS

The overall response rate was 22% (95% confidence interval [CI] 13% to 34%) in the 72 patients enrolled in the study: four patients had a complete response. Three patients (4%) ceased treatment due to hypersensitivity reactions. Other significant (WHO grade 3 or 4) toxicities included neutropenia (51%), myalgia (14%), neurological (3%), alopecia (93%) and nausea and vomiting (3%). The estimated median survival of all patients was 9.8 months (95% CI: 9.1-13.0 months) with 44% alive at one year (standard error [SE] 7%).

CONCLUSIONS

This study confirms that paclitaxel given as a three hour infusion has significant activity and acceptable toxicity in advanced ovarian carcinoma previously treated with platinum regimens.

Predictors of repeat HIV testing among gay and bisexual men

OBJECTIVE

To examine the prevalence and predictors of repeat HIV testing.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional data from two random household-based and bar-based samples of gay/bisexual men in two medium-size cities (Tucson, Arizona and Portland, Oregon) with substantial numbers of AIDS cases, in 1992 (n = 2602).

MAIN OUTCOME MEASURE

The prevalence and predictors of repeat testing among men who reported being HIV-tested at least once but not being HIV-positive (n = 1583).

RESULTS

In total, 51% of the sample had been tested three or more times, and 15% were tested more than once every 6 months. Men with higher risk were more likely to be repeatedly tested, although oral but not anal risk was a significant predictor of repeat testing in regression analyses. Men who did not know the HIV status of their primary partner were less likely to be repeatedly tested. Men who perceived that social norms favored secondary prevention, specifically adherence to medical recommendations for the treatment of HIV infection, and who communicated more often about testing were more likely to be repeatedly tested.

CONCLUSIONS

Policy and clinical recommendations for repeat testing must be based on consideration of the complexity and multi-faceted nature of repeat testing. For some individuals, repeat testing may play a legitimate role in HIV prevention by reinforcing safe behavior and providing confirmation of HIV-negative status. However, for others repeat testing may indicate a need for different or more intensive interventions to encourage safe sex.

Body image disturbance in body dysmorphic disorder and eating disorders. Obsessions or delusions?

At this time, the question posed by this article's title--body image disturbance in body dysmorphic disorder and eating disorders: obsessions or delusions?--is probably best answered "both." Both disorders appear to be characterized by obsessional and delusional thinking. In addition, it is likely that their nondelusional and delusional variants constitute a single disorder encompassing a spectrum of insight, with the entire spectrum characterized by obsessional thinking. This view represents a considerable departure from DSM-III-R, in which the psychotic disorders were encapsulated in a separate section of the manual and considered different disorders from their nonpsychotic variants. The one exception was the mood disorders, which were acknowledged to have psychotic variants that were classified in the manual's "nonpsychotic" section. In DSM-IV, on the basis of emerging empirical evidence about the dimensional nature of the psychotic/nonpsychotic boundary, the dichotomy between delusional and nondelusional disorders is less clear. The double coding allowed for BDD acknowledges that BDD and its delusional disorder variant may constitute a single disorder; that allowed for OCD acknowledges that OCD may be delusional. With regard to eating disorders, however, DSM-IV is surprisingly silent, perhaps because delusional preoccupations are less common than in BDD. These issues also may apply to other disorders. Like BDD, hypochondriasis is classified as a somatoform disorder, with its delusional variant a type of delusional disorder, somatic type. Do the delusional and nondelusional variants of hypochondriasis constitute the same disorder? Do other types of somatic delusional disorder, such as parasitosis and olfactory reference syndrome (the belief that one emits a foul body odor) have nondelusional variants? It is likely that a number of disorders span a spectrum from delusional to nondelusional thinking, with unlimited shades of gray in between. Future research may indicate that obsessional disorders such as BDD, anorexia, OCD, and hypochondriasis, as well as other disorders such as major depression, should have qualifiers or subtypes--for example, "with good insight," "with poor insight," and "with delusional (or psychotic) thinking"--with an implied continuum of insight embraced by a single disorder. Such an approach, which scatters psychosis throughout the nomenclature, ultimately may be shown to be a more valid and clinically useful classification approach. Answers to these questions will not only improve our classification system but also may have important treatment implications. For example, the preliminary finding that delusional BDD responds preferentially to SRIs but not to neuroleptic agents contradicts conventional wisdom about the treatment of psychosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Who plans to be tested for HIV or would get tested if no one could find out the results?

We analyzed the characteristics of individuals at risk for HIV who have not been tested but who (1) planned to be tested, or (2) would get tested "if no one other than you (the respondent) could find out your results." Data were from the 1991 National AIDS Behavioral Surveys, a probability sample of the U.S. population. Logistic regression was used to analyze the correlates of testing behavior among the 41% of individuals in high-prevalence cities who had HIV risk factors (n = 3,175). Of this group, 7% planned to be tested and 30% would get tested "if no one other than you could find out the results." Minorities and individuals with less education and without insurance were more likely to plan to be tested (versus previously tested), and individuals with less education and lower incomes were more likely to be willing to be tested "if no one other than you could find out the results" (versus previously tested). We conclude that a variety of options to increase testing rates should be explored, including accessible testing services, policies and procedures to increase perceptions of testing privacy, and home testing.

The association of hospital volumes of percutaneous transluminal coronary angioplasty with adverse outcomes, length of stay, and charges in California

The objective of this study was to examine whether hospital volumes of percutaneous transluminal coronary angioplasty (PTCA) are associated with adverse outcomes (coronary artery bypass graft surgery after PTCA and/or in-hospital mortality), post-PTCA length of stay (LOS), and hospital charges. Discharge data for 24,856 patients undergoing PTCA in 1989 from 110 California hospitals were analyzed. Regression analysis was used to adjust patient discharge data for risk factors. Actual and predicted adverse outcomes, LOS, and charges were compared for hospital volume categories (using 95% confidence intervals). Rates of adverse outcomes were significantly higher than expected in low-volume hospitals (< 201 PTCAs) and significantly lower than expected in high-volume hospitals (> 400 PTCAs). The results were similar for LOS and charges, although the results for charges were less conclusive. The associations of volumes and outcomes were generally consistent for both unadjusted and adjusted analyses, for patients with and without principal diagnoses of acute myocardial infarction, and using different methods and functional forms. Given this association between hospital volumes of PTCA and outcomes, future research should assess the underlying causes of this association and whether limiting the use of low-volume facilities would improve outcomes.

HIV counselling and testing: research and policy issues

The research and policy issues pertaining to HIV counselling and testing (C&T) have evolved since 1985, when a test to detect HIV antibodies first became available. In this paper we examine current and future research and policy issues relevant to C&T. We divide our discussion into three general areas which provide an illustration of key issues: (1) barriers to testing; (2) the role of public policy; and (3) the role of C&T in HIV prevention.

Consistency in self-reports of HIV testing: longitudinal findings from the National AIDS Behavioral Surveys

This paper assesses consistency in self-reports of human immunodeficiency virus testing using two waves of longitudinal data from a large, national probability survey, the National AIDS Behavioral Survey. Of those reporting at Wave I that they had been tested for reasons other than blood donation, 18 percent reported at Wave 2 that they had never been tested. Of those reporting at Wave I that they had been tested when they donated blood, 29 percent reported at Wave 2 that they had never been tested. Inconsistent responses may be due to poor recall and to high self-presentation bias, that is, a desire to provide socially acceptable answers. Poor recall may be exacerbated by passive conditions such as blood donation. The authors conclude with recommendations for reducing measurement error in surveys of testing behavior.

The cost-effectiveness of voluntary counseling and testing of hospital inpatients for HIV infection

OBJECTIVE

To evaluate the cost-effectiveness of voluntary counseling and testing of US hospital inpatients for the human immunodeficiency virus (HIV).

DATA SOURCES

Data for entry into the model were derived from a review of the literature, consultation with experts, and consensus of the authors.

DATA EXTRACTION

We rated our confidence in these probabilities and costs by grading the data inputs using methods adapted from those of the US Preventive Services Task Force.

DATA SYNTHESIS

Decision analysis models were developed to evaluate two outcomes: (1) cost per health care worker (HCW) HIV infection averted if measures are taken by the HCW to reduce his or her risk of acquiring HIV; and (2) cost per inpatient HIV infection detected. Sensitivity analyses were also conducted. Using baseline input values, testing to avert HCW infection may prevent 3.6 HIV infections per year at a total program cost of $2.7 billion, or a cost of $753 million per infection averted. At baseline assumptions (seroprevalence = 1%), testing to detect inpatient HIV infection would cost $16,104 per year per infection detected. Cost-effectiveness at baseline drops to $8353 per HIV infection detected if the seroprevalence is 10%. If testing is limited to hospitals with inpatient seroprevalences of at least 1%, approximately 5400 persons per year will be falsely labeled HIV-positive.

CONCLUSIONS

This analysis provides no justification for testing inpatients to prevent HIV infection of HCWs. Screening inpatients to detect HIV infection may be justified at seroprevalences exceeding 1%, but issues of medical or social discrimination, false-positive results, informed consent, and logistics must be resolved first.

Rash complicating carbamazepine treatment

Carbamazepine--widely used in the treatment of trigeminal neuralgia, seizure disorders, and more recently, manic-depressive illness--is generally safe and well tolerated. Although serious adverse reactions, such as hematologic toxicity, may occur rarely, we have found that carbamazepine-induced rash is common, occurring in 13 (12%) of 113 patients. We describe our experience with carbamazepine-induced rash, including clinical characteristics, demographic features, and associated laboratory findings. Integrating our findings with the literature, we also discuss incidence, possible mechanisms, and implications for treatment because these benign rashes can occasionally progress to more fulminant and life-threatening eruptions.

Obsessive compulsive spectrum disorder

A wide range of psychiatric and medical disorders have been hypothesized to be related to obsessive compulsive disorder (OCD) and thus, together, to form a family of disorders known as obsessive compulsive (or OCD) spectrum disorder. The grouping of these conditions is based on their phenomenological similarities with OCD (i.e., obsessive thinking and/or compulsive behaviors), as well as their having courses of illness, comorbidity and family history patterns, biological abnormalities, and treatment responses similar to OCD. Proposed OCD spectrum disorders have included body dysmorphic disorder, hypochondriasis, anorexia nervosa, trichotillomania, and some forms of delusional disorder, among others. However, conditions with impulsive features have also been hypothesized to belong to this family, including impulse control disorders in general, paraphilias and nonparaphilic sexual addictions, bulimia nervosa and binge eating disorder, and Tourette's disorder. We review the evidence supporting the grouping of these conditions into an OCD spectrum disorder family. We conclude that these disorders are different in some ways from OCD, but that they also have many similarities with OCD, and may therefore be related to one another and to OCD. In addition, we hypothesize that some of the differences among them may be explained in part by variation along a dimension of compulsivity versus impulsivity. Finally, because most of these conditions appear to be related to mood disorder, we hypothesize that the OCD spectrum disorder family may belong to the larger family of affective spectrum disorder.

The Diagnostic Interview for Depressive Personality

OBJECTIVE

The development of a new structured interview for depressive personality disorder is described.

METHOD

A literature search yielded 32 traits associated with depressive personality; these traits were then used to develop the interview. Interrater reliability for the interview was tested in an initial group of 16 patients with longstanding depressive personality traits. Data from a second group of 67 subjects--54 with a possible clinical diagnosis of depressive personality and 13 normal volunteers--were used to examine the interview's psychometric properties and to modify its content. Factor analysis of the traits in the interview and modification of the instrument's structure was carried out on the basis of data from a third group of 526 subjects who were participating in a large epidemiologic study of mood disorders.

RESULTS

The Diagnostic Interview for Depressive Personality, which emerged from this process, assess 30 personality traits that were shown to have satisfactory interrater reliability (kappa = 0.67), test-retest reliability (kappa = 0.41), and diagnostic reliability (kappa = 0.62). A cutoff score of 42 (from a total possible score of 60) on the interview offers a useful threshold for diagnosis.

CONCLUSIONS

This interview provides a reliable method for assessing depressive personality traits and establishing the diagnosis of depressive personality disorder.

The relationship of 1988 state HIV testing policies to previous and planned voluntary use of HIV testing

This study analyzed whether state HIV testing policies were related to individuals' previous and planned voluntary use of HIV testing. Testing plays an important role in the prevention and treatment of HIV infection, yet little is known about how policies are related to testing use. Most states mandate the conditions under which testing is performed, but states vary widely in their policies. This cross-sectional study analyzed individual-level data from the 1988 AIDS Knowledge and Attitudes Survey, which was merged with state-level data on testing policies and incidence of AIDS cases. A multivariate regression model was used to assess the relationship of state policies to testing use, holding state AIDS incidence and individual characteristics (sociodemographics, AIDS knowledge, and risk status) constant. Individuals in states with policies protective of individual rights (i.e., early adoption of comprehensive antidiscrimination laws restricting screening by insurers and employers; provision of voluntary, anonymous testing) were significantly more likely to have been tested than individuals in comparison states (odds ratio = 1.5). Individual characteristics such as risk status, however, had the strongest relationships to testing use. No evidence was found that name-reporting requirements were related to previous or planned use of testing. Future research must address emerging testing issues such as policies covering the use of new testing technologies.

The cost-effectiveness of HIV testing of physicians and dentists in the United States

OBJECTIVE

To evaluate the cost-effectiveness of alternative policies for human immunodeficiency testing (HIV) testing of physicians and dentists.

METHODS

Decision analysis and cost-effectiveness analysis from a societal perspective were used. Data were derived from extensive literature review and consultation with experts. We conducted sensitivity analyses and also performed a cost-benefit analysis.

ANALYSES

We analyzed policies for mandatory or voluntary testing of all physicians, surgeons, and dentists; for those testing positive, we analyzed mandatory or voluntary exclusion from practice, restriction from performance of invasive procedures, or requirements to inform patients of serostatus.

MAIN OUTCOME MEASURE

Cost per patient infection averted.

RESULTS

Although one-time mandatory testing of surgeons and dentists with mandatory restriction of those found to be HIV-positive is more cost-effective than other policies, the cost-effectiveness varies tremendously under different scenarios. Results were highly sensitive to several data inputs, especially HIV seroprevalence of surgeons and dentists and transmission risk. For example, under a medium seroprevalence and transmission risk scenario, mandatory testing of all surgeons might avert 25 infections at a total cost of $27.9 million or $1,115,000 per infection averted and an incremental cost of $291,000 compared with current testing; however, the incremental cost-effectiveness per patient infection averted ranges from $29,807,000 under a low-risk scenario to a savings of $81,000 under a high-risk scenario.

CONCLUSION

Our analysis neither justifies nor precludes a mandatory testing policy. Further research on the key data inputs is needed. Given the ethical, social, and public health implications, mandatory testing policies should not be implemented without greater certainty as to their cost-effectiveness.

The assessment and treatment of refractory depression

Although treatment-refractory patients are well known to clinicians, refractory depression has received little empirical attention. Nonetheless, useful assessment and treatment strategies are available. First, it is important to determine whether a patient is truly treatment-refractory or simply has received inadequate treatment. Failure to provide adequate doses of medication for adequate periods of time is perhaps the most common cause of apparent treatment resistance. Other factors that may contribute to apparent treatment resistance are undiagnosed medical conditions, unrecognized depression subtypes, and unrecognized comorbid Axis I and II disorders. It is particularly important to detect the presence of "secret" comorbid disorders, which often go undiagnosed and contribute to refractory depression. Once the clinician has determined that a patient is truly treatment-refractory, many treatment approaches can be tried, including augmentation with lithium and perhaps other agents, combining antidepressants, and switching antidepressants. A modified treatment approach should be used for psychotic depression and perhaps for other depression subtypes as well (such as bipolar depression and atypical depression). Similarly, the depression associated with borderline personality disorder may best respond to a modified treatment approach. Finally, it is important to consider combining somatic treatments with psychosocial treatments in treating refractory patients.