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A 21.3% decrease was observed in risk-adjusted per–patient-year utilization of outpatient high-cost imaging procedures ordered by primary care and specialty care physicians caring for patients regularly seen in our primary care practices during a 7-year period.

According to the DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, third edition, revised), obsessive-compulsive disorder, or obsessive-compulsive neurosis, is a condition characterized by recurrent obsessions or compulsions which are severe enough to cause marked distress, become time consuming, or interfere with one's normal activities or relationships with others. A study was performed of 27 outpatients who suffered from an obsessive-compulsive disorder and who met the criteria indicated in the DSM-III-R. The objective was to test the effectiveness of the drug clomipramine. A ten-week trial study was performed where 13 subjects were randomly given clomipramine and 14 subjects were given an inactive substance, a placebo. Clomipramine is a tricyclic antidepressant manufactured by the Ciba-Geigy Pharmaceutical Company, which partially supported this research. The drug is not available in the US but can be obtained by prescription in Europe, Canada and Mexico. Four measurements of the patients were taken using the following scales: the Hamilton Rating Scale for Depression, the Global Assessment of Obsessive-Compulsive Symptoms, the Yale-Brown Obsessive-Compulsive Scale, and the National Institute of Mental Health (NIMH) Obsessive-Compulsive Scale. The results of these tests indicated that clomipramine was much more effective in relieving the symptoms of obsessive-compulsive neurosis than the placebo, and these results are consistent with earlier conclusions of smaller studies. Other antidepressants, such as fluvoxamine, sertraline, and fluoxetine, are also mentioned as therapeutic options because clomipramine is not available in the US.

A total of 27 subjects began active treatment in this double-blind study comparing the efficacy and safety of trazodone and fluoxetine in geriatric depressed patients, but only 13 completed 6 weeks on study medication. Both agents were effective according to weekly and endpoint analyses, and there was no evidence of significant effects on blood pressure, pulse, or weight. Separate analysis of patients who had received an adequate trial of medication indicated a trend toward relatively more fluoxetine-treated patients meeting clinical criteria for resolved depression. (J Geriatr Psychiatry Neurol1989;2:208-214.)

As physician groups consolidate and value-based payment replaces traditional fee-for-service systems, physician practices have greater need to accurately measure individual physician clinical productivity within team-based systems. We compared methodologies to measure individual physician outpatient clinical productivity after adjustment for shared practice resources.

• A young man with obsessive-compulsive disorder is described who was found on magnetic resonance imaging to have unilateral left-sided abnormalities in the head of the caudate nucleus and putamen, and a discussion of the possible role of the striatum in obsessive-compulsive disorder is presented.

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ObjectiveTo quantify the impact of citalopram and other selective serotonin reuptake inhibitors on corrected QT interval (QTc), a marker of risk for ventricular arrhythmia, in a large and diverse clinical population.DesignA cross sectional study using electrocardiographic, prescribing, and clinical data from electronic health records to explore the relation between antidepressant dose and QTc. Methadone, an opioid known to prolong QT, was included to demonstrate assay sensitivity. SettingA large New England healthcare system comprising two academic medical centres and outpatient clinics.Participants38 397 adult patients with an electrocardiogram recorded after prescription of antidepressant or methadone between February 1990 and August 2011.Main outcome measuresRelation between antidepressant dose and QTc interval in linear regression, adjusting for potential clinical and demographic confounding variables. For a subset of patients, change in QTc after drug dose was also examined.ResultsDose-response association with QTc prolongation was identified for citalopram (adjusted beta 0.10 (SE 0.04), P<0.01), escitalopram (adjusted beta 0.58 (0.15), P<0.001), and amitriptyline (adjusted beta 0.11 (0.03), P<0.001), but not for other antidepressants examined. An association with QTc shortening was identified for bupropion (adjusted beta 0.02 (0.01) P<0.05). Within-subject paired observations supported the QTc prolonging effect of citalopram (10 mg to 20 mg, mean QTc increase 7.8 (SE 3.6) ms, adjusted P<0.05; and 20 mg to 40 mg, mean QTc increase 10.3 (4.0) ms, adjusted P<0.01).ConclusionsThis study confirmed a modest prolongation of QT interval with citalopram, and identified additional antidepressants with similar observed risk. Pharmacovigilance studies using electronic health record data may be a useful method of identifying potential risk associated with treatments.