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Objective: This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use.Methods: Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score.Results: After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions.Conclusions: Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations. [ABSTRACT FROM AUTHOR]

Objective: It has been suggested that there is a mechanism by which nonsteroidal anti-inflammatory drugs (NSAIDs) may interfere with antidepressant response, and poorer outcomes among NSAIDtreated patients were reported in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. To attempt to confirm this association in an independent population-based treatment cohort and explore potential confounding variables, the authors examined use of NSAIDs and related medications among 1,528 outpatients in a New England health care system. Method: Treatment outcomes were classified using a validated machine learning tool applied to electronic medical records. Logistic regression was used to examine the association between medication exposure and treatment outcomes, adjusted for potential confounding variables. To further elucidate confounding and treatment specificity of the observed effects, data from the STAR*D study were reanalyzed. Results: NSAID exposure was associated with a greater likelihood of depression classified as treatment resistant compared with depression classified as responsive to selective serotonin reuptake inhibitors (odds ratio=1.55, 95% Cl=1.21-2.00). This association was apparent in the NSAIDs only group but not in those using other agents with NSAID-like mechanisms (cyclooxygenase-2 inhibitors and saucylates). Inclusion of age, sex, ethnicity, and measures of comorbidity and health care utilization in regression models indicated confounding; association with outcome was no longer significant in fully adjusted models. Reanalysis of STAR*D results likewise identified an association in NSAIDs but not NSAID-like drugs, with more modest effects persisting after adjustment for potential confounding variables. Conclusions: These results support an association between NSAID use and poorer antidepressant outcomes in major depressive disorder but indicate that some of the observed effect may be a result of confounding. [ABSTRACT FROM AUTHOR]

Objective: The appropriateness and effectiveness of the outpatient medical management of cardiac risk factors for patients with diabetes who had a diagnosis of schizophrenia or a related psychotic syndrome were examined.Methods: In a cross-sectional analysis of 4,236 patients with diabetes, ICD-9 billing codes were used to identify 214 patients with schizophrenia or a schizophrenia-related syndrome. Measures of treatment appropriateness and effectiveness for the management of cardiac risk factors (control of blood sugar, blood pressure, and lipids) were assessed for this group and compared with measures from patients with diabetes but no severe mental illness (N = 3,594). Odds ratios were adjusted for between-group differences in gender, race, age, and clinic setting.Results: There were no statistically significant between-group differences on any of the five measures of treatment appropriateness, indicating that patients with schizophrenia received a similar regimen of medical treatment for cardiac factors. However, two of the seven measures of treatment effectiveness indicated significant deficiencies, with fewer patients with schizophrenia meeting the clinical quality benchmarks for cholesterol and low-density lipoprotein control. This disparity may have been caused by factors other than the measured treatment appropriateness variables, including the prescription of older lipid-lowering agents and a higher rate of missed appointments in the group with schizophrenia.Conclusions: Effective lipid control may be more difficult to attain for at least some patients with schizophrenia. Given that population's high rates of cardiovascular mortality, additional research to clarify the barriers to effective lipid management is essential. [ABSTRACT FROM AUTHOR]

Evaluates the adequacy of the outpatient antidepressant treatment in the U.S. Rates and determinants of the adequacy of antidepressant treatment among all outpatients who receive antidepressants; Importance of the effectiveness of antidepressant prescribing in determining the outcome of and cost of mental health and overall health care.

The authors report four cases in which magnetic resonance imaging (MRI) provided diagnostic information not apparent by X-ray CAT in clinical investigations of patients with neuro psychiatric disorders. The relative capabilities and contraindications for MRI and CAT are reviewed. The authors suggest that MRI is indicated 1) instead of CAT when there is suspicion of neuropathology that is better visualized by MRI because of its type or location and 2) after CAT when an atypical psychiatric symptom or presentation has not been definitively evaluated by means of CAT. [ABSTRACT FROM AUTHOR]

The authors present the cases of three patients in whom panic attacks and epilepsy appeared together. These cases illustrate various possible relationships between panic attacks and epilepsy. These relationships include 1) panic attacks representing the aura of a complex partial seizure, 2) panic attacks representing a manifestation of interictal behavior change, and 3) panic attacks and seizure coexisting independently. The authors conclude that exploration of the mechanisms operating in unusual cases like these may provide a vehicle for clarifying the neurobiological basis of anxiety. [ABSTRACT FROM AUTHOR]

Clomipramine was significantly superior to placebo in a 10-week double-blind, placebo-controlled trial in 27 outpatients who met DSM-III-R criteria for obsessive-compulsive disorder. [ABSTRACT FROM AUTHOR]

A letter to the editor regarding the uncomfortable effects experienced by two patients after a switch from Norpramin to generic desipramine is presented.

A response by H. Jordan Garber and Jeffrey B. Weilburg to a letter to the editor about their article about white matter abnormalities detected by magnetic resonance imaging in elderly depressed patients, published in the previous issue is presented.