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Accreditation organizations, financial stakeholders, legal systems, and regulatory agencies have increased the need for accountability in educational processes and curricular outcomes of graduate medical education. This demand for greater programmatic monitoring has placed pressure on institutions with graduate medical education (GME) programs to develop greater oversight of these programs. Meeting these challenges requires development of new GME management strategies and tools for institutional GME administrators to scrutinize programs, while still allowing these programs the autonomy to develop and implement educational methods to meet their unique training needs. At the Medical University of South Carolina (MUSC), senior administrators in the college of medicine felt electronic information management was a critical strategy for success and thus proceeded to carefully select an electronic residency management system (ERMS) to provide functionality for both individual programs and the GME enterprise as a whole. Initial plans in 2002 for a phased deployment had to be changed to a much more rapid deployment due to regulatory issues. Extensive communication and cooperation among MUSC's GME leaders resulted in a successful deployment in 2003. Evaluation completion rates have substantially improved, duty hours are carefully monitored, patient safety has improved through more careful oversight of residents' procedural privileges, regulators have been pleased, and central GME administrative visibility of program performance has dramatically improved. The system is now being expanded to MUSC's medical school and other health professions colleges. The authors discuss lessons learned and opportunities and challenges ahead, which include improving tracking of development of procedural competency, establishing and monitoring program performance standards, and integrating the ERMS with GME reimbursement systems.

Background: There are concerns regarding the validity of combat exposure reports of veterans seeking treatment for combat-related post-traumatic stress disorder (PTSD) within US Veterans Affairs Medical Centers., Aims: To verify combat exposure history for a relevant sample through objective historical data., Method: Archival records were reviewed from the US National Military Personnel Records Center for 100 consecutive veterans reporting Vietnam combat in a Veterans Affairs PTSD clinic. Cross-sectional clinical assessment and 12-month service use data were also examined., Results: Although 93% had documentation of Vietnam war-zone service, only 41% of the total sample had objective evidence of combat exposure documented in their military record. There was virtually no difference between the Vietnam 'combat' and 'no combat' groups on relevant clinical variables., Conclusions: A significant number of treatment-seeking Veterans Affairs patients may misrepresent their combat involvement in Vietnam. There are implications for the integrity of the PTSD database and the Veterans Affairs healthcare system.

Although posttraumatic stress disorder (PTSD) is relatively common in community epidemiologic surveys (5-6% for men, 10-12% for women), and psychiatric patients with PTSD are known to have poor functioning and high levels of psychiatric comorbidity, there are no studies that address PTSD prevalence, functioning, and burden in primary care settings. This article reports on (1) the prevalence of PTSD using Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition diagnostic criteria in Veterans Affairs (VA) primary care settings, (2) associated sociodemographic characteristics and comorbidities, (3) functional status related to PTSD, (4) the extent to which PTSD was recognized by providers and (5) health services use patterns (including specialty mental health) of PTSD patients. Patients were randomly selected from those who had an outpatient visit in FY 1999 at one of four VA hospitals; 888 patients consented (74.1% of 1198 contacted); 746 patients (84.0% of consenting patients; 62.3% of contacted patients) were reached for telephone diagnostic interviews. Diagnostic interviews with the Clinician Administered PTSD Scale yielded estimates of current PTSD prevalence of 11.5%. At statistically significant levels, PTSD was positively associated with a variety of comorbid psychiatric disorders, war zone service, age <65 years, not working, less formal education and decreased functioning. Of patients diagnosed with PTSD by study procedures, 12-month medical record review indicated that providers identified only 46.5% and only 47.7% had used mental health specialty services. PTSD-positive [PTSD(+)] patients who used mental health care in the past 12 months were more apt to be identified as having PTSD than nonmental health service users (78.0% vs. 17.8%). Although PTSD(+) patients had more medical record diagnoses than PTSD-negative [PTSD(-)] patients (6.28 vs. 4.95), their use of primary care, urgent care and inpatient care was not different from PTSD(-) patients.

We conducted a feasibility study of remote psychotherapy in 10 terminally ill cancer patients with diagnoses of adjustment disorder or major depression. Subjects received six sessions of individual cognitive therapy with the same therapist. Sessions alternated between face-to-face sessions and remote sessions delivered by analogue videophone. After each therapy session, a brief questionnaire was used to evaluate the subjects' level of satisfaction with the session, sense of connectedness to the therapist and overall progress being made in the therapy. Nine patients completed the study. Of 53 completed therapy sessions, 21 were by videophone and 32 were conducted face to face. Participants reported strong positive perceptions and acceptance after almost all therapy sessions, regardless of service delivery mode. The study suggests that there may be a role for the delivery of psychotherapy using low-bandwidth videophones.

Patients with generalized social phobia fear embarrassment in most social situations. Little is known about its functional neuroanatomy. We studied BOLD-fMRI brain activity while generalized social phobics and healthy controls anticipated making public speeches. With anticipation minus rest, 8 phobics compared to 6 controls showed greater subcortical, limbic, and lateral paralimbic activity (pons, striatum, amygdala/uncus/anterior parahippocampus, insula, temporal pole)--regions important in automatic emotional processing--and less cortical activity (dorsal anterior cingulate/prefrontal cortex)--regions important in cognitive processing. Phobics may become so anxious, they cannot think clearly or vice versa.

Objective: This project was developed to evaluate the use of and satisfaction with Veteran's Affairs (VA) medical services and disability benefits among surviving elderly prisoners of war (POWs) in South Carolina., Method: A single-assessment quantitative survey strategy was implemented to learn more about the service use patterns and satisfaction with care of two groups of male former POWs (N = 87): those who were members of a national POW service organization and those who were not., Results: Data show that the majority of these POWs had used the VA for medical care in the previous year, received disability compensation through the VA, and were satisfied with VA primary care medical services. Furthermore, differences between these two POW groups were minimal., Conclusions: Results provide preliminary evidence that many former POWs rely heavily upon the VA for provision of primary medical and specialty care and disability compensation and that POWs are generally satisfied with the VA services and benefits they receive.

Objective: This study sought to further examine the relationship between compensation-seeking status and reporting of symptoms among combat veterans who were evaluated for posttraumatic stress disorder (PTSD)., Methods: Archival data were drawn for 320 adult male combat veterans who were consecutively evaluated at a Department of Veterans Affairs (VA) PTSD outpatient clinic from 1995 to 1999. The veterans were compared on variables from their clinical evaluation, including diagnostic status and self-report measures such as the Minnesota Multiphasic Personality Inventory-2, which includes scales designed to detect feigned or exaggerated psychopathology., Results: Compensation-seeking veterans reported significantly more distress across domains of psychopathology, even after the effects of income had been controlled for and despite an absence of differences in PTSD diagnoses between groups. However, compensation-seeking veterans also were much more likely to overreport or exaggerate their symptoms than were non-compensation-seeking veterans., Conclusions: This study provided further evidence that VA disability compensation incentives influence the way some veterans report their symptoms when they are being evaluated for PTSD. These data suggest that current VA disability policies have problematic implications for the delivery of clinical care, evaluation of treatment outcome, and rehabilitation efforts within the VA.

Positive and negative symptoms of psychosis may be common in patients with chronic post-traumatic stress disorder (PTSD), but few studies have investigated the use of antipsychotic agents in these patients. This preliminary study examined the potential efficacy of risperidone in treating psychotic symptoms associated with chronic PTSD. In a 5-week, prospective, randomized, double-blind, placebo-controlled trial, adjunctive risperidone treatment was assessed in 40 combat veterans with chronic PTSD and comorbid psychotic features. Most patients were receiving antidepressants and some other psychotics with doses of concurrent medications held constant for at least 1 month prior to and during the study. Thirty-seven patients completed at least 1 week of treatment with risperidone or placebo. The Positive and Negative Syndrome Scale (PANSS) and the Clinician Administered PTSD Scale (CAPS) were used to assess symptoms. The PANSS was the primary outcome measure. At treatment endpoint, risperidone-treated patients showed a significantly greater decrease from baseline, albeit modest, in psychotic symptoms (PANSS total scores) than placebo-treated patients (P < 0.05). CAPS ratings declined significantly in both groups but did not differ significantly between groups. However, CAPS re-experiencing subscale scores had greater improvement in the risperidone-treated patients at week 5 (P < 0.05, completer analysis) with a trend towards greater improvement versus placebo a endpoint (P < 0.1, LOCF). Risperidone was well tolerated with minimal extrapyramidal symptoms. These preliminary results support studying the potential efficacy of risperidone for treating global psychotic symptoms associated with chronic PTSD with a suggestion that core re-experiencing symptoms may also be responsive. Further research using randomized, controlled trial designs in larger patient groups are needed to define more adequately the role of risperidone and other atypical agents in PTSD.

We tested the hypothesis that race may influence clinical presentation and symptomatology in combat veterans with posttraumatic stress disorder (PTSD). African-American and Caucasian veterans were administered the Psychotic Screen Module of the Structured Clinical Interview for DSM, Minnesota Multiphasic Personality Inventory-2 (MMPI-2), and other psychometric measures at a Veterans Affairs outpatient PTSD clinic. Subjects were consecutive referrals who were not matched for level of combat trauma or preexisting trauma; however, there were no group differences in other relevant demographic or diagnostic variables. Significant racial differences, with modest effect sizes, were found on clinician ratings of psychotic symptoms, MMPI-2 scale 6 ("paranoia"), and a measure of dissociation. No significant differences were found for the MMPI-2 scale 8 ("schizophrenia"), or on measures that might suggest comorbid depression or anxiety. African-Americans with PTSD endorsed more items suggesting positive symptoms of psychosis, without higher rates of primary psychosis, depression, or anxiety than Caucasians., (Copyright 2002 Wiley-Liss, Inc.)

We examined archival data to test the hypothesis that absenteeism is inversely related to work productivity among mental health employees at a Veterans Affairs Medical Center outpatient clinic. Results provided partial support for this hypothesis in that there was an inverse correlation between one measure of productivity and the percentage of sick and family care leave taken on Mondays and Fridays (r=.54). No significant relationship between work productivity and total sick and/or family care leave was found, although there was a trend in that direction (r=.34). These data suggest that mental health clinicians who use high levels of sick and/or family care leave are not necessarily unproductive workers. However, high percentages of absenteeism on Mondays and Fridays may represent a red flag for identifying under-performing clinicians. Examination of absenteeism patterns may prove useful for administrators. Management policy strategies to reduce absenteeism are suggested.

As health care delivery and its associated costs have been scrutinized carefully over the past decade, educational institutions have been expected to demonstrate how a particular educational requirement such as residency training brings benefit to the purchasers and users of their health care services. As part of this trend, the Accreditation Council for Graduate Medical Education recently enacted new accreditation standards mandating the inclusion of curricular elements that expose residents to basic concepts and principles of the non-technical areas of health care across a variety of topics, including ethics, cost containment, socioeconomics, medical-legal issues, communication skills, research design, statistics, and critical review of the medical literature. The authors report the efforts at the Medical University of South Carolina to overcome obstacles and successfully implement an institution-wide core curriculum program, dealing with the kinds of topics mentioned above, across 47 specialty and subspecialty programs with over 500 residents and fellows. The seminal events and critical strategies are described, along with lessons learned along the way. The following were key elements to success: (1) adhering to a strategic plan assigning oversight of residency education to the graduate medical education (GME) office; (2) gaining strong support from the dean and other college officials; (3) creating a stepwise centralization of residencies in college via the GME committee; (5) making the first core curriculum element one that had an excellent chance to succeed; (6) having core curriculum sessions begin in evenings and weekends to not interfere with regular curriculum, but later, when the value of the curriculum became evident to departments, moving the sessions to be within the week; (7) having the philosophy of the GME office be to maintain a flexible approach and serve departments.

Many antidepressants are known to cause adverse sexual effects. Bupropion is an antidepressant with fewer reported adverse sexual effects. Studies of sexual side effects are often confounded by psychiatric and medical conditions affecting sexual function. In this study, the effects of bupropion on subjective and objective sexual functioning were measured in healthy men. Thirteen men without psychiatric or medical illness completed a 2-week, placebo-controlled, double-blind, crossover trial of bupropion sustained-release 300 mg/day. Subjects had a 1-week washout period between trials. Sexual function was measured using a validated, self-administered questionnaire and the RigiScan, an instrument measuring nocturnal penile tumescence and rigidity. No differences were found in self-reported sexual function, number of erections, total erection time, or penile rigidity in subjects taking bupropion compared with those taking placebo or baseline. These findings support that bupropion does not have subjective adverse sexual side effects and does not affect nocturnal erections in healthy men.

Background: Transcranial magnetic stimulation (TMS) is a new technology for noninvasively stimulating the brain. Several studies have suggested that daily stimulation of the left prefrontal cortex with TMS for 2 weeks has probable antidepressant effects. We conducted a parallel-design, double-masked, sham-controlled study to address whether 2 weeks of daily TMS over the left prefrontal cortex has antidepressant activity greater than sham., Methods: Thirty medication-free adult outpatients with nonpsychotic, major depressive (n = 21) or bipolar (n = 9) (depressed phase) disorder who were in a current major depression (Hamilton Rating Scale for Depression [HRSD] 21-item score of >18) were treated each weekday for 2 weeks. Subjects were randomly assigned to receive either daily active (20 subjects) or sham (10 subjects) stimulation. Additionally, the 20 active subjects were equally divided between slower (5 Hz) and faster (20 Hz) frequency treatment. Antidepressant response was defined as greater than a 50% improvement in the baseline HRSD., Results: Active TMS resulted in significantly more responders (9/20) than did sham (0/10) (chi(2) = 6.42, p <.01). The number of responders did not differ significantly between the two active cells (3/10 faster and 6/10 slower). Expressed as a percent change from baseline, active TMS subjects had significantly greater improvement on the Beck Depression Inventory as well as the Hamilton Anxiety Rating Scale than did those who received sham., Conclusions: Daily left prefrontal TMS for 2 weeks significantly reduced depression symptoms greater than did sham. The two forms of active TMS treatment did not differ significantly.

Psychotic features are frequent in combat veterans with chronic posttraumatic stress disorder (PTSD), may correlate with severity of PTSD symptoms, and may reflect a distinct subtype of the disorder. These psychotic features include auditory and visual hallucinations and delusional thinking that is usually paranoid in nature. Psychotic features may be under-recognized in chronic PTSD because patients are reluctant to report these symptoms and because they may not have overt changes in affect or bizarre delusions characteristic of other psychoses, e.g., schizophrenia. To further assess these phenomena, we compared clinical ratings on the Positive and Negative Syndrome Scale (PANSS) and other assessments, including the Clinical Global Impression Scale and the Structured Clinical Interview with Psychotic Screen, in veterans meeting DSM-IV criteria for chronic PTSD with well-defined comorbid psychotic features (N = 40) or chronic schizophrenia (N = 40). The patients with schizophrenia had modestly higher composite PANSS scores and positive symptom scores although average scores in both groups were moderate to severe in intensity. Negative symptom and general psychopathology subscale scores were comparable in both groups. Regarding specific positive symptoms, hallucinations were comparable between groups in severity; however, schizophrenia patients had slightly more intense delusions and conceptual disorganization. These data further validate the occurrence of positive as well as negative symptoms of psychosis in chronic PTSD in a range of severity that may approach that of patients with schizophrenia. Although meeting DSM-IV criteria for two different major psychiatric disorders, these two patient populations were remarkably similar with respect to not only positive but also negative symptoms.

Typical antipsychotics often combine efficacy in treating antipsychotic illnesses with a side effect profile that can affect every system of the body and range from the annoying-photosensitivity and jaundice, for example-to the disabling-seizures and blindness, among others-to the potentially fatal-agranulocytosis and neuroleptic malignant syndrome. The side effects of conventional antipsychotics are associated with effects at CNS transmission and receptor sites and appear in relation to dose levels and potency of the drug. Characteristics of patients-including gender, age, and comorbid medical illness-can make them more or less susceptible to particular antipsychotic side effects. Side effects influence patient quality of life and affect patient compliance with medications. This article will consider the physiologic systems affected by conventional neuroleptics, the sexual and reproductive side effects of typical antipsychotics, and the central nervous side effects of the conventional neuroleptics in the light of these concerns.

Objectives: Transcranial magnetic stimulation (TMS) affects the brain by non-invasively stimulating the cerebral cortex and inducing electrical currents in neurons. The powerful magnetic field acts as a vector that passes across the scalp and the skull, and then converts into an electrical energy within the brain. Originally used in neurophysiology, TMS has since been applied in a variety of neuropsychiatric conditions, including mood disorders. Imaging studies in mood-disordered patients have pointed to dysfunctional limbic and prefrontal cortex activity. TMS researchers have thus postulated that dorsolateral prefrontal cortex (DLPFC) stimulation might change brain activity both locally and in paralimbic areas through transynaptic connections, and alter mood., Methods: We will describe the technology of TMS, its applications to date, and explore its mechanisms of action., Results: Several clinical trials have demonstrated TMS effects on mood in health and disease. There is a growing consensus that TMS has antidepressant effects, although little is known about the role played by a variety of stimulation parameters such as the intensity or frequency of stimulation. One study has found an antimanic effect of right prefrontal TMS., Conclusion: TMS is relatively safe; however, much more research is needed before TMS can be integrated into routine clinical practice.

Treatment of schizophrenia is often complicated by substance abuse. We report here findings of a retrospective study evaluating readmission rates of patients meeting DSM IV criteria comorbid for schizophrenia and alcohol or drug dependence treated with depot haloperidol or fluphenazine over a 2-year period. During the study period, 14 of the 26 (54%) male veteran patients were admitted to the VAMC, Charleston; 46% of patients met criteria for alcohol, marijuana or cocaine dependence. Patients with alcohol dependence appeared to be at highest risk for hospital admission (p < 0.05). Moreover, patients with alcohol dependence had longer hospital stays (p < 0.05) than patients without alcohol dependence. Marijuana or cocaine dependence was slightly, but not statistically more common among admitted patients. Marijuana or cocaine dependence did not predict length of stay or number of admissions. Alcohol dependence may be an important factor in schizophrenic exacerbation, and may be an important target for treatment.

Objective: To determine the frequency of panic attacks and panic disorder in patients with chronic schizophrenia or schizoaffective disorder., Method: Fifty-three male outpatients meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for chronic schizophrenia or schizoaffective disorder were administered sections of the Structured Clinical Interview for DSM-IV (SCID). If panic attacks were reported, patients were queried about treatment and about onset relative to psychotic symptoms., Results: Forty-nine patients were sufficiently organized to participate in the evaluation. Twenty-one (43%) experienced panic attacks, and 16 (33%) had current or past panic disorder. Eight (50%) of the 16 with panic disorder had been treated for panic. Substance dependence was not associated with having panic attacks or current or past panic disorder. Patients with paranoid schizophrenia were more likely than patients with schizoaffective or undifferentiated schizophrenia to have experienced panic attacks (57% versus 20%, chi 2 = 6.0, P < 0.02) or panic disorder (47% versus 10%, chi 2 = 6.9, P < 0.01)., Conclusion: Panic attacks and panic disorder are common in men with schizophrenia or schizoaffective disorder. Panic disorder may be an overlooked comorbid diagnosis in patients with schizophrenia.

Background: Psychotic symptoms may be present in up to 40% of patients with combat-related posttraumatic stress disorder (PTSD). In this study, we hypothesized that severity of psychotic symptoms would also reflect severity of PTSD symptoms in patients with well-defined psychotic features., Methods: Forty-five Vietnam combat veterans with PTSD but without a primary psychotic disorder diagnosis underwent a Structured Clinical Interview for DSM-III-R with Psychotic Screen, and the Clinician Administered PTSD Scale (CAPS). Patients identified as having psychotic features (PTSD-P), (n = 22) also received the Positive and Negative Syndrome Scale (PANSS) and the Hamilton Depression Rating Scale (HDRS)., Results: There was a significant positive correlation between the CAPS and PANSS global ratings (p < .001) and the HDRS and PANSS (p < .03) in the PTSD-P patients. Many CAPS and PANSS subscales also demonstrated significant intercorrelations; however, the CAPS-B subscale (reexperiencing) and the PANSS positive symptom scale were not correlated, suggesting that psychotic features may not necessarily be influenced or accounted for by more severe reexperiencing symptoms. Fifteen (68%) of the PTSD-P patients had major depression (MDD). Both CAPS and PANSS ratings were significantly higher in the PTSD-P patients with comorbid MDD., Conclusions: As postulated, patients with more severe psychosis ratings are likely to have more severe PTSD disease burden if psychotic features are present. This study further documents the occurrence of psychotic features in PTSD that are not necessarily due to a primary psychotic disorder, suggesting that this may be a distinct subtype; however, a significant interaction likely exists between PTSD, depression, and psychotic features.

Background: Serotonin reuptake inhibitor (SRI) antidepressants have been associated with sexual dysfunction, though there have been few prospective reports specifically examining this problem. The purpose of this study was to determine if three SRIs affected sexual function in anxiety disorder patients over a 3-month period., Methods: Thirty-one patients were enrolled in a prospective study of the effect of three SRIs, fluoxetine, sertraline, and paroxetine, on five aspects of sexual function: libido, erection/lubrication, orgasm quality, orgasm delay, and sexual frequency. Measurements were made at baseline and at each month on visual analogue scales., Results: For men and women, orgasm quality was lower and orgasm delay longer at months one, two, and three compared to baseline (p < .01). Erection scores were lower over time, but this change was not statistically significant. Lubrication, libido, and sexual frequency were not appreciably changed over 3 months. A higher rate of anorgasmia was noted in women at months one and two, but this did not achieve significance., Conclusions: Orgasm appears to be a primary sexual function affected by SRIs.

Serotonin reuptake inhibitor (SRI) antidepressants have been associated with sexual dysfunction, though there have been few prospective reports specifically examining this problem. The purpose of this study was to determine if three SRIs affected sexual function in patients with an anxiety disorder or major depressive disorder over a 3-month period. Sixty-one patients were evaluated for at least 2 months in a prospective study of the effects of fluoxetine, sertraline, and paroxetine on five aspects of sexual function: libido, erection/lubrication, orgasm quality, orgasm delay, and sexual frequency. Measurements were made at baseline and at each month on visual analog scales. For men and women, orgasm quality was lower and orgasm delay longer at Months 1, 2, and 3 compared with baseline (p < .001). Erection scores were lower over time (p < .02) but this change was less dramatic. Lubrication, libido, and sexual frequency were not appreciably changed over 3 months. Anorgasmia was significantly more common in women than men at Months 1 and 2. Orgasm appears to be a primary sexual function affected by SRIs.

As a market economy continues to permeate U.S. health care, fiscal accountability imposed by purchasers of medical services will reduce funds for medical education and will heighten the scrutiny of that activity. The authors propose that U.S. academic health centers must respond to these changes in the health care environment by critically examining their culture and values. This process will call for a reorientation of their values to place clinical education at the center of the academic enterprise. The authors challenge the notion that research- and publications-oriented faculty are the best group to train optimally effective clinical practitioners. They argue that although faculty promotion and rank in American medical schools are highly correlated with publications and funded research, there is no body of evidence that shows that fecundity in research or publications is essential for faculty to be excellent medical educators. The authors maintain that the main tool for realigning the fundamental values of academic health centers will be a new form of faculty management by the medical leadership. After outlining the current approach to research, teaching, clinical service, and administration at academic health centers, the authors challenge the traditional view that a faculty member should master all of these four elements, and state that the era of the "quadruple-threat" faculty member is passing. What can emerge is an emphasis on departments' and institutions' becoming "quadruple threats," which can occur only if institutions' leaders become better managers of their individual faculty members' priorities.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: The authors' goal was to assess dexamethasone for the treatment of depression., Method: Thirty-seven outpatients (11 men and 26 women) meeting DSM-III-R criteria for major depressive disorder were randomly assigned to receive either placebo or 4 mg/day of oral dexamethasone for 4 days. Baseline Hamilton depression scale scores were compared with scores obtained 14 days after the first dose of study medication. Data were analyzed by using two-sample t tests, chi-square methods, and Fisher's exact test., Results: Seven (37%) of the 19 patients given dexamethasone but only one (6%) of the 18 patients given placebo responded positively. No adverse events or side effects were reported, and all patients who entered the study completed it., Conclusions: A brief course of oral dexamethasone (4 days) was significantly more effective than placebo within 14 days for the treatment of depression in a randomized, double-blind study of depressed outpatients.

Background: There are no published reports of an association between triphasic oral contraceptives and the development of panic disorder., Method: The authors describe two cases in which the use of triphasic oral contraceptives in women appear to have precipitated panic disorder. Treatment with the triphasic oral contraceptives was stopped and the patients were followed for 2 years., Results: Both subjects had rapid and total resolution of their panic disorder symptoms following cessation of triphasic oral contraceptive medications., Conclusion: Triphasic oral contraceptives in some predisposed women may lead to precipitation of panic disorder.

Background: This preliminary uncontrolled trial of intravenous dexamethasone addresses the question of the utility of a glucocorticoid for the treatment of depression., Method: Patients with a DSM-III-R (SCID confirmed) diagnosis of major depression or bipolar disorder, depressed type, and a Hamilton Rating Scale for Depression (HAM-D) score of greater than or equal to 20 were selected. Baseline HAM-D scores were compared with scores within 10 days after intravenous infusion of dexamethasone; data were analyzed by t tests. Control subjects (no psychiatric illness and HAM-D scores less than 5) were given intravenous dexamethasone to test for its mood-altering effect., Results: The mean HAM-D scores in 16 depressed subjects 10 days after intravenous dexamethasone dropped by 56% (p less than .0001), and 75% of the patients experienced a greater than 50% reduction in HAM-D scores. Additionally, 6 nonpsychiatric, nondepressed control subjects were given intravenous dexamethasone and found to have no changes in mental status examination., Conclusions: Intravenous dexamethasone may be an effective treatment for depressive illnesses. Because this was an uncontrolled, unblinded trial, further studies need to be done in nonpsychiatric and psychiatric controls to ascertain the validity of this finding.

Psychiatric nurses in inpatient settings play a critical role in the management of potentially violent patients. One of their primary objectives is to ensure the safety of patients and staff 24 hours a day. This requires skillful observation of patients' motor behavior, verbal clues, and change in mental status, which may indicate an increase in agitation or possible aggressive behavior. It requires experience in prevention strategies and skill in acute crisis intervention techniques. To effectively intervene with potentially violent patients, psychiatric nurses must be able to work well under stress and be able to organize and execute a plan of immediate action. After the acute stage of the patient's illness, nurses should focus their work on assisting patients to manage their own behavior and supporting their newly acquired skills.

Twenty-nine inpatients with major psychotic disorders were treated for 14 days with a clinician-determined dose of haloperidol and with either benztropine or placebo given by double-blind random assignment on days 1 through 7. No differences were noted in haloperidol mean dose, haloperidol blood levels, or BPRS scores during the first seven days between benztropine (N = 14) and placebo (N = 15) groups. Benztropine-treated patients demonstrated increased dry mouth and diminished sweat and a non-significantly lower rate of dystonia compared to placebo (14% vs. 33%). Dystonic patients were significantly younger than nondystonic patients, but did not differ in haloperidol mean dose or plasma concentration. The effect of benztropine on the incidence of dystonia was consistent with other studies, which, when analyzed together, demonstrate the efficacy of anticholinergic prophylaxis. The relatively low incidence of anticholinergic side effects, coupled with the lack of effect on haloperidol blood levels or antipsychotic efficacy, suggest that moderate doses of benztropine in conjunction with haloperidol are a rational approach for the treatment of acute psychosis in young patients.

The authors review over 50 reports comparing test sensitivity of the thyrotropin-releasing hormone (TRH) stimulation test using either DSM-III or Research Diagnostic Criteria (RDC) criteria for depression. Ten reports with a total of 410 patients and 458 test results were analyzed that met specific criteria for diagnosis for the TRH test. The sensitivity for depression with the TRH test in the DSM-III reports was 34.8% compared with six RDC reports in which the sensitivity was 51% (chi 2 10.41, p less than 0.001). The authors discuss possible endocrine and psychiatric implications of this finding and encourage researchers to use two methods for diagnosis in future clinical research in order that this type of comparison can be undertaken in the same patients. This will help in future modifications and revisions of the DSM.

Lithium augmentation of antidepressant treatment is a commonly used strategy for treatment-resistant cases of depression. Two cases are described in which significant neurotoxicity developed in elderly patients despite therapeutic doses of antidepressant and lithium.

To shorten the latency-to-response time for antidepressant treatment, three patients diagnosed with major depression were treated simultaneously with lithium and nortriptyline. Symptoms responded markedly by Day 7 and completely resolved by Day 14. Patients experienced few side effects.

Lactate infusion is the most extensively studied of the pharmacological challenge tests in panic disorder. We assessed the value of this test in the diagnosis and subtyping of panic in clinical and research settings. Analysis of lactate infusion studies to date suggests that patients with panic attacks are significantly more sensitive to lactate than are healthy controls or patients with other psychiatric disorders without panic attacks. However, the usefulness of lactate infusion is limited by the lack of standardized, objective criteria for lactate-induced panic and uncertainty as to the sensitivity and specificity of the test for current, clinically significant panic attacks. Except in rare cases, the clinical history is likely to be of more value than lactate response in diagnosing panic disorder. Determination of the role of the test in subtyping patients with panic disorder awaits further study of the diagnostic, prognostic, genetic, and pathophysiologic significance of lactate sensitivity.

There is a great interest in the potential usefulness of biomedical tests in psychiatry, but basic statistical principles required for critical evaluation of their value remain poorly integrated into clinical thinking. We developed a useful scheme for organizing clinical test data so as to permit simple calculations of the sensitivity, specificity, and predictive power of medical tests. Some loss of predictive power is inherent in moving from artificial populations used for test development into more typical clinical settings, where prevalence is usually substantially lower.

Psychological and emotional impairment among physicians represents a serious, widespread, and difficult problem. For unclear reasons, it has been problematic to effectively identify and treat this group of professionals whose performance is so intimately associated with the health and wellbeing of the general population. The severity of the problem, the resistance to treatment which seems evident from the data presented, and the fact that most of the conditions afflicting physicians are treatable and reversible, compels us to seek a viable solution. Diligence in the pursuit of understanding and correction of the dilemma is a social and personal imperative.

The dexamethasone suppression test has undergone unprecedented study among the biologic tests proposed for clinical use in psychiatry. Since the 1970s, its study has involved hundreds of reports and thousands of patients. Although important technical aspects of the test appear to be well accepted and validated, additional information is needed regarding the pharmacokinetics of dexamethasone. Marked interindividual differences in plasma dexamethasone suggest that performance of the test might be improved by factoring dexamethasone levels into test interpretations. There also may be advantages to the development of a modified test involving other exogenous and index steroids, such as monitoring corticosterone levels. Although it is too early to determine how ROC analysis will alter the clinical application of the test, some implications for methodology and data presentation are already clear. First, because the test is a diagnostic system with nonbinary outcomes, ROC analysis can augment traditional performance indices such as sensitivity, specificity, and positive predictive power. Second, ROC analysis will improve comparisons between the studies of different research groups and will help assess innovations in the application of the test. Third, ROC analytic techniques permit appropriate planning of sample size given estimates of the expected values of AUC that would be obtained from the studies. ROC theory thus promises to play an increasingly important role in the evaluation and future improvement of the dexamethasone suppression test and other biologic markers in clinical psychiatry. In conclusion, neither uncritical enthusiasm nor excessive skepticism is warranted about the use of the dexamethasone suppression test in clinical psychiatry. Evidence to date should encourage investigators to pursue refinement of the test or other tests of hypothalamic-pituitary-adrenal functioning to increase their accuracy and clinical utility.

In psychiatric inpatients, positive results on 40 dexamethasone suppression tests (elevated cortisol levels) were strongly associated with low plasma levels of dexamethasone. Bioavailability or pharmacokinetic factors may contribute importantly to the outcome of the dexamethasone suppression test.

The presence of the A ring of aporphines and the addition of substituents to it and to other portions of the aporphine ring systems can extend explorations of the dimensions and other characteristics of the dopamine receptors. Accordingly, the synthesis and some physical and pharmacological properties of a series of (-)-2,10,11-trihydroxyaporphines (3a-g) are described. Structure-activity relationships among mono-, di-, and trihydroxyaporphines were evaluated against the high-affinity (nanomolar) binding of [3H]apomorphine (APO) and [3H]spiroperidol (SPR) with a subcellular fraction (P4) of caudate nucleus from bovine brain. In addition, DA-sensitive adenylate cyclase activity was evaluated in homogenates of rat brain striatal tissue. The rank order of displacement of [3H]APO by potent aporphines (IC50 less than or equal to 30 nM) correlated approximately with their ability to stimulate cyclic AMP synthesis. Potency orders against two ligands were dissimilar; for example, increasing the size of N6-alkyl substituents increased potency vs. [3H]SPR but not vs. [3H]APO binding. Moreover, [3H]SPR binding correlated poorly with cyclase activity or [3H]APO binding, suggesting a closer relationship of [3H]APO binding to dopamine-sensitive adenylate cyclase activity.

Two isomeric 6-endo- and 6-exo-(3',4'-dihydroxyphenyl) derivatives (1 and 2) of 2-azabicyclo[2.2.2]octane were synthesized as semirigid analogues of dopamine (DA) to help evaluate the preferred conformation of dopamine at the uptake site of the presynaptic nerve terminal and at the DA receptor. Against the uptake of 0.1 microM [3H]DA by a synaptosomal preparation of corpus striatum from the reserpine-pretreated rat, 2 was found to have a weak inhibitory effect that was three times greater than that of 1 (IC50 = 32 vs. 110 microM). Interactions with DA receptors were assessed with competition for binding of [3H]apomorphine (APO) and on the effect on DA-sensitive adenylate cyclase. Compounds 1 and 2 were both virtually inactive against the binding of 0.5 nM [3H]APO at a screening concentration of 100 microM. The experimental compounds also exhibited only slight adenylate cyclase stimulation in rat striatal homogenates, with 1 appearing to be somewhat more active (at 50 or 400 microM). The weak activities of 1 and 2 and their relatively small differences in activity in these test systems suggest that the DA analogues interact only weakly with the DA transport and receptor sites, possibly as a result of the steric interference caused by the bulky bicyclic ring.