Using case vignettes to train clinicians and utilization reviewers to make level-of-care decisions

Dr. Rosenquist and his colleagues describe how their academically based health maintenance organization joined in training for level-of-care decision making with the external managed behavioral health organization that was providing utilization review and case management decisions. The academic department later took over its own utilization review and in so doing internalized the utilization review function. This development, which is beginning to occur in several states, is an important solution to the "assault" that many providers of care have experienced as a result of the utilization review process. Having taken this step to deal with the realities of 21st-century health care, the authors then seize the opportunity to use their own data to improve decision making within the clinic. This process is how we get to best practices.

Bright light therapy: improved sensitivity to its effects on rest-activity rhythms in Alzheimer patients by application of nonparametric methods

Sleep-wake rhythm disturbances in patients with Alzheimer's disease (AD) make a strong demand on caregivers and are among the most important reasons for institutionalization. Several previous studies reported that the disturbances improve with increased environmental light, which, through the retinohypothalamic tract, activates the suprachiasmatic nucleus (SCN), the biological clock of the brain. The data of recently published positive and negative reports on the effect of bright light on actigraphically assessed rest-activity rhythms in demented elderly were reanalyzed using several statistical procedures. It was demonstrated that the light-induced improvement in coupling of the rest-activity rhythm to the environmental zeitgeber of bright light is better detected using nonparametric procedures. Cosinor, complex demodulation, and Lomb-Scargle periodogram-derived variables are much less sensitive to this effect because of the highly nonsinusoidal waveform of the rest-activity rhythm. Guidelines for analyses of actigraphic data are given to improve the sensitivity to treatment effects in future studies.

A comparison of visual and computer-generated measures of "seizure quality"

We report on the first direct comparison of measures of seizure quality generated by visual rating of electroencephalographic (EEG) regularity and postictal suppression with THYMATRON-DGx computer-generated indices of seizure energy and postictal suppression. Thirty-two consecutive patients referred for electroconvulsive therapy (166 consecutive treatments) were studied. Blinded ratings of seizure duration, regularity, and postictal EEG amplitude suppression derived from the paper EEG were compared against computer-rated measures of seizure duration, seizure energy index, mean ictal amplitude, and postictal suppression. Our results confirm previous findings of high correlations between computer and visual determinations of seizure duration. Significant differences were found for computer-derived postictal suppression, seizure energy index and mean ictal amplitude for different levels of the visual rating scales. Our results provide preliminary support for the concurrent validity of these measures.

Variation of ictal electroencephalographic regularity with low-, moderate-, and high-dose stimuli during right unilateral electroconvulsive therapy

BACKGROUND

Previous work has demonstrated changes in electroencephalographic (EEG) ictal morphology during electroconvulsive therapy (ECT) as stimulus intensity is increased from barely suprathreshold to moderately suprathreshold. Our study reports on the reactivity of seizure regularity ratings in 11 subjects receiving right unilateral (RUL) ECT as the stimulus is varied over a wider range of intensities from low to medium, then high dose.

METHODS

The stimulus intensity of all 11 subjects was first increased from barely suprathreshold to moderately suprathreshold, and then randomized to either stay at a moderately suprathreshold dose or increase to a high dose. The regularity of the EEG ictal discharge was visually measured on a seven-point scale.

RESULTS

We found that seizure regularity increases as the stimulus intensity moves from the barely suprathreshold to the moderately suprathreshold dosage, but did not increase further when the stimulus increased to a high dose.

CONCLUSIONS

These results suggest that EEG regularity is unlikely to distinguish moderately suprathreshold from markedly suprathreshold stimuli during RUL ECT.

Phototherapy for patients with Alzheimer disease with disturbed sleep patterns: results of a community-based pilot study

We examined the entraining effects of phototherapy delivered by light visors on disturbed sleep patterns of community-dwelling research subjects with Alzheimer disease (AD). The pilot project used a single subject design and activity monitoring as the primary outcome measures. The protocol consisted of a 5-day baseline monitoring period, followed by 10 consecutive days of phototherapy (2,000 lux of full spectrum bright light) delivered by light visors for 2 hours each morning; this was followed by an additional 14 days of activity monitoring. Cosinor analyses found no consistent changes in acrophase, mesor, or amplitude. Observed changes in acrophase were consistent with phase advancement of the rest-activity cycle and consistent with the biological intervention. Changes in the number of nighttime awakenings were not found. One subject had a significant increase in total sleep time, whereas another had a significant decrease in total sleep time. Failure to find a consistent biological effect of light on AD subjects may be secondary to: (1) insufficient duration of light exposure; (2) timing of light administration (given at a time when circadian rhythm is refractory to the effects of light); (3) advanced stages of AD making the Y circadian pacemaker in the suprachiasmatic nucleus of the hypothalamus insensitive to the biological effects of light; and (4) inadequacy of light visors as a means of providing light.

Tourette syndrome associated with mental retardation: a single-subject treatment study with haloperidol

A Tic Checklist and direct observation tic measurement procedure were developed for the assessment of Tourette syndrome in individuals with mental retardation. Using a single-subject reversal design, we applied this assessment method to the evaluation of haloperidol treatment for a subject with Tourette syndrome and severe mental retardation. Relative to baseline, haloperidol 10 mg/day produced decreases of 66% in simple motor tics, 46% in complex motor tics, 45% in simple vocal tics, and 50% in complex vocal tics. Improvement was also seen in careprovider ratings of tic severity, hyperactivity, and compulsive behaviors.

Concurrent factitious disorder and factitious disorder by proxy. Double jeopardy

Two forms of medical dissimulation-factitious disorder and factitious disorder by proxy-present enormous challenges to clinicians accustomed to receiving valid symptom reports from their patients. The consequences of such "disease forgery" are heightened when a patient simultaneously engages in both forms of deception. We discuss a 34-year-old nurse who simulated or induced a panoply of physical and psychological ailments in both herself and her daughter. The staff's insistence on access to outside information sources proved indispensible in establishing both diagnoses, facilitating ongoing treatment for the patient and ensuring appropriate protection of the child.

Riding a Trojan horse: computerized psychiatric treatment planning using managed care principles

Efforts to curtail health care costs have triggered new emphasis on resource management and accountability, entailing explicit documentation of the rationale for treatment and the resulting outcome of care. This article discusses the development of a computerized psychiatric treatment planning database that embodies principles and language of managed care, including specific admission criteria, severity ratings, and time frames for completion of interventions. The program is designed to balance goals of clinical utility, usefulness of the database as a tool for utilization review, quality improvement, and health services research, while providing an interface that is acceptable to clinicians.

Effects of caffeine pretreatment on measures of seizure impact

Caffeine lengthens electroconvulsive therapy (ECT) seizures but has not been demonstrated to lower seizure threshold, nor to directly improve treatment outcome. We examined the effects of caffeine upon three recently proposed physiologic measures of seizure quality or impact: electroencephalography voltage suppression ratios, seizure regularity, and heart rate. None of these measures differed significantly in depressed inpatients randomly pretreated with either i.v. caffeine or saline on successive treatments during a course of right unilateral ECT. Newly defined measures of seizure impact may help identify ECT seizures of differing clinical efficacy, but these measures did not discriminate our caffeine and placebo conditions.