Impact of shorter lengths of stay on status at discharge in bipolar mania

This study assesses the impact of shortening the inpatient length of stay on status at discharge in patients with mania.

METHODS

The authors performed a chart review on 131 patients with discharge diagnoses of bipolar disorder, current episode manic type, admitted to the private attending service at Colorado Psychiatric Hospital between 1985 and 1995. In 1990, a new program (the alternatives program) that provides a continuum of acute care services and shorter inpatient lengths of stay was instituted. Retrospectively assessed GAF, CGI, treatment outcome rating scores, and length of stay (LOS) were compared for the prealternatives (1985-1989), early alternatives (1990-1992), and recent alternatives (1993-1995) program treatment eras. A progressive decrease in inpatient LOS, duration of the acute care episodes, and total service utilization was seen across eras. Despite the more recent shortening in LOS, no significant differences were seen in GAF and treatment outcome rating scores at discharge. GAF and treatment outcome rating scores on hospital days 3 and 7, however, suggested that patients were improving more rapidly in the more recent eras. Inpatient LOS and duration of the acute care episodes have significantly decreased over the last 10 years, but patients appear no more ill at discharge. The authors postulate that changes in psychopharmacologic practice and the inpatient treatment model may have facilitated the more rapid clinical improvement seen in the more recent eras. The authors caution that we need prospective studies that include postdischarge follow-up to assess further the impact of shorter inpatient stays on the posthospital course of manic patients.

Novel alternatives and supplements to lithium and anticonvulsants for bipolar affective disorder

BACKGROUND

Most clinicians are familiar with the traditional anticonvulsants as alternatives to lithium in the treatment of bipolar mood disorders.

METHOD

This review of the English, French, German, and Italian language literature on novel treatments, including electroconvulsive therapy, calcium channel blocking agents, antipsychotic drugs, benzodiazepines, thyroid hormone, psychosurgery, and two new antiepileptic drugs, that have not been studied as extensively as lithium, carbamazepine, and valproate but that may have promise as alternatives or supplements to traditional thymoleptics when the standard treatments are not effective or are poorly tolerated. We searched MEDLINE and PSYCHINFO data bases using the keywords bipolar, mood, and/or treatment. We then searched bibliographies of articles retrieved by the first strategy.

RESULTS

The theoretical rationale for each treatment is discussed, followed by a critical discussion of the evidence supporting its efficacy.

CONCLUSION

The potential risks and benefits of each treatment in actual clinical practice are placed in perspective.

Selection bias in an inpatient outcomes monitoring project

Managed care organizations increasingly tout clinical outcomes assessment as the mechanism by which we will ensure quality and compare providers. The authors report on their experience with a multisite inpatient outcomes monitoring project by comparing patients who accepted (N = 51), refused (N = 36), or were not asked (N = 110) to participate in the project. The patients who were asked to participate had significantly longer inpatient stays compared with the unasked group (11.2 vs 6.9 days). Patients who agreed to participate in the project were more likely to have a bipolar (43.1% vs 19.2%) or any affective disorder (94.1% vs 79.5%), and less likely to have a schizophrenic disorder (2.0% vs 11.6%) than the refused and unasked groups. The project participants also had higher 90-day readmit rates (27.5% vs 9.6%), more readmissions (0.51 vs 0.16), and more education (14.59 vs 13.51 years) than nonparticipating patients. In this preliminary study, patient-related variables were found to influence who the staff asked and who consented to participate in this clinical outcomes monitoring project. The authors distinguish clinical outcomes monitoring from treatment effectiveness research and discuss the need to develop methodologies that deal with nonrepresentative patient sampling and intersite variability in recruitment practices.

Dissociative symptoms in psychotic mood disorders: an example of symptom nonspecificity

Dissociative symptoms have been the subject of psychiatric inquiry since the beginning of this century (Putnam 1992; Sanders 1986; van der Kolk and van der Hart 1989). Although recent investigations have focused on the four specific dissociative disorders (American Psychiatric Association 1994) and their relationship to early traumatic experiences (Chu and Dill 1990; Putnam 1985; Terr 1991), dissociative symptoms have been reported in virtually every major psychiatric disorder (Bremner et al. 1992; Goff et al. 1992; Steinberg 1992), and, in less severe forms, even in nonpatient populations (Briere 1988; Putnam 1992; Ross and Joshi 1992). These observations raise questions about the clinical significance of dissociative symptoms that occur when other mental disorders are also present (Coons 1984; Fahy 1988).

Tardive dyskinesia associated with fluoxetine

Three cases in which patients who were taking fluoxetine for relief of depression showed patterns of abnormal movements suggestive of tardive dyskinesia are presented. In the first case, abnormal facial movements began four weeks after fluoxetine was added to doxepin and lithium and remitted after fluoxetine was discontinued. In the second case, abnormal movements of the mouth and hands were noticed four years after the patient started taking fluoxetine and continued to be present a year after withdrawal of the medication. In the third case, orofacial dyskinesia that had remitted after withdrawal of sertraline and paroxetine and reappeared with fluoxetine was still present eight months after fluoxetine was withdrawn.

Shortening length of stay without increasing recidivism on a university-affiliated inpatient unit

The impact of reducing length of stay on readmission rates was examined for privately insured patients treated on a traditional inpatient unit or in an alternatives program with a shorter stay and a continuum of acute care. Billing data were analyzed for length of stay and readmission rates for all admissions between 1985 and 1992 (N = 1,363). The traditional unit was reorganized in 1990 into the alternatives program. Although the program decreased mean length of stay from 20.2 days to 6.2 full-day equivalents, overall readmission rates did not increase (17.2 percent, compared with 18.6 percent for the traditional unit). Rates increased for a subgroup of patients with psychotic disorders (from 13.7 to 35.2 percent).

Ethical concerns in the use of palliative drug treatment for Alzheimer's Disease

The cases of 3 patients with Alzheimer's disease (AD) who had varied outcomes from treatment with tacrine or other palliative drugs illustrate the need to consider the benefits of such agents for each case on an individual basis. In the absence of a cure, the most important factor in the care of AD patients may be the physician's attitude that irreversibility does not imply untreatability.

Valproate-associated pancreatitis and cholecystitis in six mentally retarded adults

BACKGROUND

Pancreatitis is usually considered a rare side effect of valproate. We describe five cases of pancreatitis and one case of cholecystitis associated with the use of valproate.

METHOD

Through chart review, we identified all patients in our facility treated with valproate between 1989 and 1994, and all cases of pancreatitis and cholecystitis identified during that same period in our population of 322 mentally retarded patients. We also searched MEDLINE for all published cases of pancreatitis or cholecystitis associated with valproate treatment.

RESULTS

Five (7%) of 72 valproate-treated patients experienced pancreatitis, and one experienced cholecystitis; all recovered fully. This brings the total number of reported cases of valproate-associated pancreatitis to 55.

CONCLUSION

Pancreatitis may occur more frequently than previously recognized in mentally retarded adults treated with valproate. Developmentally disabled patients should be carefully monitored for this potentially lethal side effect.

Opiate antagonists for recurrent self-injurious behavior in three mentally retarded adults

Opiate antagonists have shown promise for treating a subset of self injurious patients. The authors report on the use of naltrexone with three mentally retarded adults who had long histories of self-injurious behavior and unsuccessful behavioral and drug treatments; for all three, the self- injurious behavior was substantially decreased. The authors have found a positive response for half the self-injurious patients for whom naltrexone has been tried. Before any drug therapy is initiated, environmental reinforcers of the behavior should be sought out and modified, and any reversible medical and psychiatric disorders should be treated.

Beyond specificity: effects of serotonin and serotonergic treatments on psychobiological dysfunction

Serotonin is a ubiquitous neurotransmitter with widespread projections that provide for the involvement of serotonin in the regulation of many biological and psychological functions. A variety of serotonin receptor subtypes exist that mediate overlapping psychobiological functions and that are targets for a new generation of medications. Although these new generation medications appear to possess great biochemical specificity, their actions extend to many psychiatric disorders, reflecting the many interactions of serotonergic subsystems.

The use of opiate antagonists for recurrent self-injurious behavior

Despite a plethora of studies on the behavioral and pharmacologic treatment of self-injurious behavior, and despite our best efforts, many patients continue to harm themselves. The authors review the literature on the use of opiate antagonists for the treatment of self-injurious behavior.

Serotonergic mechanisms and current and future psychiatric practice

The participation of serotonin (5-HT) in the regulation of diverse biological and psychological functions makes it possible for medications acting on 5-HT subsystems to play a role in the treatment of a growing number of psychiatric and medical disorders. The actions of new medications on the 5-HT reuptake mechanism are complemented by actions on the 5-HT receptors and on other neurotransmitter systems that may be effective in complex and treatment-resistant syndromes. New drugs acting on one or more of the seven major 5-HT receptor classes that have been identified thus far appear to be promising for the treatment of specific subtypes of psychiatric syndromes, from depression to anxiety to schizophrenia. A given serotonergic medication may be useful for more than one disorder because it acts on specific dimensions of psychobiological malfunction that characterize more than one disorder, dimensions that are mediated by more than one receptor.

Beyond the serotonin reuptake inhibitors: rationales for the development of new serotonergic agents

Serotonin (5-HT) is a neurotransmitter involved in the regulation of mood, arousal, aggression, sleep, learning, nociceptions, nerve growth, and appetitive functions. Medications that act on 5-HT and its receptors have applications in the treatment of a variety of psychiatric disorders, among them depression, anxiety, psychoses, eating disorders, obsessive compulsive disorder, body dysmorphic disorder, posttraumatic stress disorder, and conditions associated with aggression. The clinical effects of these medications depend not only on their capacity to increase synaptic concentrations of 5-HT, but also on their effects on subtypes of 5-HT receptors and on other neurotransmitter systems. A new generation of drugs acting on specific 5-HT receptors has the advantage of a low frequency of adverse effects, applicability in mixed and complicated syndromes, and usefulness as probes of the psychobiology of mental disorders. An understanding of the specific actions of these medications on cellular communication and signaling makes it easier to predict their applications and disadvantages in specific clinical syndromes. The diverse applications of this new generation of drugs suggest a reconceptualization of the categorical approach to diagnosis and the addition of a more dimensional approach, at least to psychopharmacology.

Intracellular calcium signalling in peripheral cells of patients with bipolar affective disorder

Consistent with previous studies, elevated free intracellular calcium ion concentrations ([Ca2+]i) were found in blood platelets and lymphocytes of patients with mania and bipolar depression. Incubation with an ultrafiltrate of plasma from patients with bipolar illness had no effect on intracellular calcium ion concentration in platelets from normal subjects, suggesting that elevated [Ca2+]i is not due to a circulating factor. As was true in an earlier study of the effect of lithium on platelets, incubation with therapeutic levels of carbamazepine lowered [Ca2+]i in lymphocytes from affectively ill patients but not controls. Increased [Ca2+]i in peripheral cells may reflect a diffuse change in cellular homeostasis and may contribute to mixtures as well as rapid alternations of activity of affective, behavioral and physiologic systems in bipolar illness. Correction of the abnormality may at least be a marker of a relevant therapeutic action if it is not the action itself.

Approaches to developing new anxiolytics and antidepressants

The empirical approach to new treatments for anxiety and depression has been to test series of compounds that resemble medications in current use until one is found with similar actions but with fewer side effects. With the explosion of knowledge in neurobiology, it is becoming possible to develop treatments aimed more precisely at specific links in the chain of mood dysregulation. Examples of this informed approach include agonists for limbic but not cortical benzodiazepine receptors; compounds to stabilize serotonergic and noradrenergic transmission; and drugs that act on intracellular signals, such as the calcium ion and cyclic AMP. This article reviews neurobiologically informed approaches to developing new medications for anxiety and depression and discusses some of the innovative treatments that are emerging from such a strategy.

Psychotic depression: advances in conceptualization and treatment

Psychotic depression is a unique subtype of depressive illness in which mood disturbance is accompanied by delusions, hallucinations, or both. Once considered relatively uncommon, it is frequently encountered in clinical practice, particularly in treatment-resistant depressed patients. Psychotically depressed patients respond poorly to antidepressants, but remission is likely with neuroleptic-antidepressant combinations or electroconvulsive therapy. Psychotic depression may be unipolar or bipolar with early or late onset and may be more likely to occur in patients with a history of childhood psychic trauma. Much is known about the course and treatment response of obvious presentations of psychotic depression, but more must be learned about depressed patients who have intermittent, subtle, or mild psychotic symptoms and about the ways in which the capacity to become psychotic interacts with the capacity to become depressed to produce a syndrome greater than the sum of its parts.

Calcium antagonists in manic-depressive illness

Increased free intracellular calcium ion concentration ([Ca2+]i) has been found in lymphocytes and blood platelets of patients with bipolar affective disorders when they are acutely ill, but not after recovery. Because lithium alters intracellular calcium ion dynamics and lowers platelet [Ca2+]i in affectively ill patients but not controls, drugs whose primary action is to modulate [Ca2+]i in hyperactive cells have been used as antimanic agents. The best studied of these is verapamil, a calcium channel blocking agent (CCB) that appears most effective for lithium-responsive patients. Because they interact with different central CCB receptors, second-generation CCBs may have a different spectrum of action. CCBs are usually well tolerated and may be useful for a number of other psychiatric, neurological and medical conditions.

Abnormal intracellular calcium ion concentration in platelets and lymphocytes of bipolar patients

The authors measured intracellular Ca2+ concentrations in four manic and five bipolar depressed patients and seven comparison subjects. Platelet and lymphocyte intracellular Ca2+ concentrations were comparable. The patients' mean intracellular Ca2+ concentrations were higher than those of the comparison subjects and demonstrated more interindividual variation. These findings suggest a diffuse abnormality in mechanisms affecting intracellular calcium homeostasis in bipolar disorder.

The calcium second messenger system in bipolar disorders: data supporting new research directions

Studies of aberrations in second messenger function may help to elucidate some of the multiple complex neurobiological alterations in bipolar affective disorders. The phosphatidylinositol and calcium ion (Ca2+) second messengers are of particular interest because of evidence of hyperactivity of these signaling mechanisms in both mania and bipolar depression and of their normalization by lithium and other mood-stabilizing treatments. Because the intracellular Ca2+ signal has a biphasic action, a single aberration could explain diverse clinical manifestations of the same illness, and a single action on the messenger could explain the biphasic actions of many treatments for bipolar disorders.

Elevated platelet intracellular calcium concentration in bipolar depression

Baseline and thrombin-stimulated free intracellular calcium concentrations in blood platelets were significantly higher in untreated depressed bipolar patients than in untreated unipolar depressed patients or controls. Platelet intracellular calcium ion concentrations in euthymic-treated bipolar patients were equivalent to control values, suggesting but not proving a state-dependent change in intracellular calcium ion dynamics in bipolar depression. Unipolar and some subsets of bipolar patients appear not to exhibit this change.

Depression and suicide assessment

Depressed patients and suicidal patients are common Emergency Department patrons with the potential for serious morbidity or death. Dysphoric mood, vegetative symptoms, and negative perceptions of oneself, the environment, and the future are characteristic of depression. Often, the patient is unaware of the depression and presents with a variety of somatic complaints, chronic fatigue, or pain syndromes. In these instances, the physician must consider the diagnosis of depression and ask the patient about any history of depressive symptoms. In all depressed patients, a careful history and physical examination are needed to identify any drugs or concurrent medical illnesses which might cause or exacerbate the depression. If depression is suspected or if the patient presents after a suicide attempt, then a thorough evaluation of suicide potential is mandatory. Several risk factors for completed suicide exist. Male sex, age under 19 or over 45, few social supports, and a history of previous suicide attempts are all factors associated with increased suicide rates. Concurrent chronic or severe medical illnesses and certain psychiatric illnesses, notably depression, schizophrenia, and substance abuse, also increase an individual's risk for suicide. The method of suicide attempt and the chance for rescue must also be considered when determining risk as well as the presence of an organized plan. Acute psychosis in the suicidal patient is an ominous finding and these patients should be admitted to the hospital. The physician must adopt an empathetic and nonjudgmental attitude when caring for potentially suicidal patients. Disposition can be determined after careful evaluation of risk factors, circumstances surrounding the attempt, and the patient's current feelings. Consultation with a psychiatrist or another mental health professional is desirable for any potentially suicidal patient. Many such patients can be safely treated as outpatients with proper referral; certain high-risk individuals will need to be admitted to the hospital. The decision to either hospitalize or discharge can be difficult and the emergency physician should admit the patient if doubt exists.