Comparison of adult and geriatric psychiatric practice patterns: findings from the American Psychiatric Association's Practice Research Network.

OBJECTIVE: The authors explored diagnostic and treatment patterns for patients under and over age 65 seen by a nationally representative sample of psychiatrists participating in the American Psychiatric Association's Practice Research Network. METHODS: Detailed patient information, including demographic and financial characteristics, diagnoses, service utilization, and treatment, was collected by 383 psychiatrists on 1,026 patients to assess the impact of patient age on pharmacotherapy and psychotherapy service use as well as treatment outcomes. RESULTS: Approximately 15% of the patient sample was over age 65. Compared with patients ages 19-64, a lower percentage of geriatric patients had Axis I comorbidity, but a higher percentage had Axis III comorbidity. Geriatric patients were more often treated in hospital settings, and older patients were less likely to have their visits adversely affected by financial pressures of the healthcare system. Over 60% of patients in both age-groups received antidepressants, but there was a disproportionately increased use of antipsychotics and antianxiety/benzodiazepine medications among geriatric patients. Being age 65+ was a strong predictor for "improved" clinician rating on general assessment scores, but failed to be a predictor of receiving psychotherapy or pharmacotherapy. CONCLUSION: There were important differences between subject groups. Overall, American psychiatrists treat a complex group of geriatric patients suffering from major mental disorders complicated by medical comorbidity. Additional studies would further enhance our understanding of the delivery of mental health services to elderly patients and improve training of psychiatrists who help care for our aging population.     

Problems of Subject Inclusion in Psychiatric Research: Observations from Research with Psychiatric Inpatients

Abstract: In a recent study of psychiatric disturbance and decision making behaviour¹², it was observed that a significant number of psychiatric inpatients experienced difficulties in addressing themselves to the experimental tasks at hand. Despite the large number of studies that have used psychiatric inpatients as subjects, little, if any mention has been made of these difficulties. The following report describes the difficulties that have been observed in the above research project, and examines their possible implications for clinical assessment, research, and for clinical investigations and evaluation of treatment regimes (e.g. effectiveness of particular drug therapies), which use psychiatric inpatient populations as subject sources.     

Psychiatric and neuroimaging findings in Creutzfeldt-Jakob disease

Although Creutzfeldt-Jakob disease (CJD) is the prototypical rapidly progressive dementia, clinical heterogeneity in the disease can make diagnosis difficult. Creutzfeldt-Jakob disease affects multiple brain areas, which causes multifocal deficits that involve movement, cognition, and psychiatric status. Thorough neurologic, cognitive, and psychiatric examinations are necessary for observing its clinical features. Recent advances in neuroimaging techniques have allowed researchers and clinicians to discover imaging patterns that distinguish CJD from other neurologic diseases. This article discusses how these advances may make neuroimaging the most valuable noninvasive tool for diagnosing CJD, which helps to track the progression of the disease course and provides insight into clinical-anatomic correlations.     

Psychiatric problems among returned migrants in Mexico: updated findings from the Mexican Migration Project

Social Psychiatry and Psychiatric Epidemiology - Migration is often a stressful process that can have deleterious effects on health. We study the potential mental health consequences of migration...     

Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families

OBJECTIVE: Patterns of psychiatric comorbidity were assessed in adults with and without attention deficit hyperactivity disorder (ADHD) identified through a genetic study of families containing multiple children with ADHD. METHOD: Lifetime ADHD and comorbid psychopathology were assessed in 435 parents of children with ADHD. Rates and mean ages at onset of comorbid psychopathology were compared in parents with lifetime ADHD, parents with persistent ADHD, and those without ADHD. Age-adjusted rates of comorbidity were compared with Kaplan-Meier survival curves. Logistic regression was used to assess additional risk factors for conditions more frequent in ADHD subjects. RESULTS: The parents with ADHD were significantly more likely to be unskilled workers and less likely to have a college degree. ADHD subjects had more lifetime psychopathology; 87% had at least one and 56% had at least two other psychiatric disorders, compared with 64% and 27%, respectively, in non-ADHD subjects. ADHD was associated with greater disruptive behavior, substance use, and mood and anxiety disorders and with earlier onset of major depression, dysthymia, oppositional defiant disorder, and conduct disorder. Group differences based on Kaplan-Meier age-corrected risks were consistent with those for raw frequency distributions. Male sex added risk for disruptive behavior disorders. Female sex and oppositional defiant disorder contributed to risk for depression and anxiety. ADHD was not a significant risk factor for substance use disorders when male sex, disruptive behavior disorders, and socioeconomic status were controlled. CONCLUSIONS: Adult ADHD is associated with significant lifetime psychiatric comorbidity that is not explained by clinical referral bias.     

Psychiatric co-morbidity in 75 patients undergoing epilepsy surgery: lack of correlation with pathological findings

BACKGROUND: Psychiatric disorders may occur in patients with intractable partial epilepsy after surgical treatment. Previous reports attributed the presence of psychological adverse events to specific pathological entities such as dysembryoplastic neuroepithelial tumors (DNETs) and gangliogliomas. The rationale for the present study is to evaluate the importance of the surgical pathology in individuals undergoing epilepsy surgery. METHODS: The patients were separated into three groups based on the surgical pathology: group I ganglioglioma (N=25), group II DNETs (N=25), and group III mesial temporal sclerosis (N=25). Thirteen of the 75 patients (17.3%) had a preexisting psychiatric disorder. The most common preoperative psychiatric diagnosis was depression (N=4). Sixty-three of the lesions (84%) were restricted to the temporal lobe. The operative strategy included resection of the lesion and epileptogenic cortex. Sixty-two of the 75 patients (83%) were rendered seizure-free. RESULTS: Eight of the 75 patients (10.7%) had an acquired psychiatric illness following surgical treatment. A mood disorder developed in three patients after surgery. No statistical difference emerged in preoperative psychiatric co-morbidity (no group difference; p=1.0) or in newly diagnosed postoperative psychiatric disease (group I vs. II, p=0.67; group I vs. III, p=1.0; and group II vs. III, p=0.67) within the three surgical pathology groups. CONCLUSION: This study indicates that the presence of psychiatric disease before and after surgery for intractable partial epilepsy, predominantly of temporal lobe origin, was independent of the pathological findings.     

Psychiatric comorbidity among adolescents with substance use disorders: findings from the MECA Study.

OBJECTIVE: To investigate the extent to which adolescents in the community with current substance use disorders (SUD) experience co-occurring psychiatric disorders. METHOD: Diagnostic data were obtained from probability samples of 401 children and adolescents, aged 14 to 17 years, and their mothers/caretakers, who participated in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. RESULTS: The rates of mood and disruptive behavior disorders are much higher among adolescents with current SUD than among adolescents without SUD. Comparison with adult samples suggests that the rates of current comorbidity of SUD with psychiatric disorders are the same among adolescents as adults, and lower for lifetime disruptive disorders/antisocial personality disorder among adolescents than adults. CONCLUSIONS: The high rate of coexisting psychiatric disorders among adolescents with SUD in the community needs to be taken into account in prevention and treatment programs.     

Psychiatric problems in patients from Arab countries

In 1979-1988 at the Prague Psychiatric Clinic 26 patients from Arab areas were hospitalized. The reason for admission were acute mental disorders involving paranoid, paranoid hallucinatory, manic or depressive syndromes, alcoholism and aggressive behaviour. No bizarre or at least remote psychopathological symptoms were recorded. The author draws attention to the frequent incidence of alcoholism and aggressiveness: these manifestations are at variance with traditions of Arab morality. In the diagnostic evaluation syndromological conclusions proved more useful than nosological ones.     

AAPL Practice Guideline for the Forensic Psychiatric Evaluation of Competence to Stand Trial: an American legal perspective

The AAPL Practice Guideline for the Forensic Psychiatric Evaluation of Competence to Stand Trial provides a rich discussion of the legal standards and procedures for evaluating and determining a criminal defendant's trial competence and for restoring to competence defendants found to be incompetent. The document includes an up-to-date discussion of the applicable case law, examines ethics considerations for forensic examiners, addresses cultural issues, and offers practical templates for interviewing defendants and preparing reports. Although its focus is on trial competence in adult criminal court, the document also attends to competency considerations for minors facing delinquency proceedings in juvenile court. Comprehensive and incisive, if not optimally organized and tabulated, the Guideline will serve as the standard reference for psychiatrists asked to provide trial competence assessments in criminal and juvenile court cases.     

Update of geriatric psychiatry practices among American psychiatrists: Analysis of the 1996 National Survey of Psychiatric Practice.

Using data from the 1996 National Survey of Psychiatric Practice from the American Psychiatric Association (APA), the authors updated information on psychiatrists who are high geriatric providers (HGPs). In 1996, HGPs comprised 18% of the sample. Only 23% reported no geriatric patients in their practice, a 51% reduction from 1988-89; the proportion of HGPs is increasing. HGPs were more often male, minority, international medical school graduates, certified in geriatric psychiatry, and not medical school-affiliated. HGPs worked longer hours/week in direct patient care, had more patient visits/week, and saw more new patients/month, spending more time in hospitals and nursing homes and less time in office-based practice, and seeing more patients with mood disorders, psychotic disorders, and other disorders. Medicare was a proportionally higher payment source. Older psychiatrists were likely to have more patients over age 65. Tracking practice activities of HGPs may help inform policy discussion regarding staffing needs for geriatric patients with late-life mental disorders.     

Cost-effectiveness of ADHD treatments: findings from the multimodal treatment study of children with ADHD

OBJECTIVE: Attention deficit hyperactivity disorder (ADHD) is a costly public health problem. To the authors' knowledge, this is the first study on the cost-effectiveness of the major forms of ADHD treatments used in NIMH's Multimodal Treatment Study of Children With ADHD (MTA Study). METHOD: Five hundred seventy-nine children with ADHD, combined type, ages 7 to 9.9, were assigned to 14 months of medication management, behavioral treatment, both combined, or community care. Services were tallied throughout the study, including medication, health care visits, behavioral treatments, and rental costs. Provider specialty, total time, and number of visits with providers were used to calculate costs, adjusted to FY 2000 dollars with the consumer price index. RESULTS: Treatment costs varied fourfold, with medication management being the least expensive, followed by behavioral treatment, and then combined treatment. Lower costs of medication treatment were found in the community care group, reflecting the less intensive (and less effective) nature of community-delivered treatment. Medical management was more effective but more costly than community care and more cost-effective than combination treatment and behavioral treatment alone. Under some conditions, combination treatment (medical management and psychotherapy) were somewhat more cost-effective, as demonstrated by lower costs per additional child "normalized" among children with multiple comorbid disorders. CONCLUSIONS: Medical management treatment, although not as effective as combined medical management and behavioral treatment, is likely to be more cost-effective in routine treatment for children with ADHD, particularly those without comorbid disorders. For some children with comorbid disorders, it may be cost-effective to provide combination treatment.