Christian R. Miner

A Pilot Open Randomized Trial of Valproate and Phenobarbital in the Treatment of Acute Alcohol Withdrawal

The authors conducted a randomized, open comparison of the GABAergic anticonvulsant sodium valproate (divalproex sodium; Depakote) and phenobarbital as an active control in the management of acute withdrawal from alcohol. Repeated measures ANOVA was used to assess treatment effects in the first 37 inpatients, evaluating mood, hostility, and subjective and objective measures of withdrawal at index, 3, and 5 days of detoxification. Subjective and objective ratings of abstinence symptoms and subjective mood disturbance decreased significantly in intensity in both groups over 5 days, but there were no significant treatment differences nor treatment by time interactions. Hostility scores did not differ overall, but a group by time effect was observed (F = 5.42, df = [1,13], P < 0.05), with phenobarbital subjects reporting less hostility/aggression than those in the valproate group. There were no withdrawal-related seizures or other acute sequelae. This study offers pilot confirmation that sodium valproate is as effective as phenobarbital in the management of acute alcohol withdrawal, but it is unclear whether valproate offers a clinical advantage with respect to stabilizing changes in mood and interpersonal hostility during detoxification.

Integrating Services for Schizophrenia and Substance Abuse

Over the past decade, several studies have attempted to determine whether integrating psychiatric and substance abuse treatment leads to better outcome for patients with comorbid schizophrenia and substance use disorders. A recent (1999) Cochrane Review (1) analyzed the effectiveness of prospective randomized studies of integrated treatment approaches, and concluded that there was no clear evidence for superiority of integrated treatment. This paper describes one such integrated treatment approach, in Beth Israel Medical Centers COPAD (Combined Psychiatric and Addictive Disorders) program. We summarize findings from an initial outcome study and a recent replication study; and describe clinical and research issues relevant to this population. Our data suggests the benefits of integrated treatment for patients with addictive disorders and schizophrenia, at least with regard to treatment retention. Clinical issues for such patients include identification of patients at risk, proper assessment and treatment planning, decision-making about mainstreaming vs. referral to specialized programs, and the importance of initial engagement and ongoing reengagement in successful treatment.

Integrated services for treatment of schizophrenic substance abusers: Demographics, symptoms, and substance abuse patterns

We have previously described a model of outpatient integrated treatment for patients with comorbid psychoactive substance use disorders and schizophrenia (PSUD/S)(1). Here we review relevant literature on comorbidity and outline the rationale for integrated services. Further, we describe results from 3 related studies: First, we document the approximate incidence of PSUD among a heterogeneous group of 602 schizophrenic inpatient admissions to our hospital. Second, we describe in greater detail the psychiatric symptoms and patterns of substance abuse among a subsample of 106 inpatients with PSUD/S, contrasting them with 112 patients with PSUD and mixed psychotic disorders, but who are not schizophrenic. Third, we present a prospective research project and describe a sample of 30 patients with PSUD/S, detailing demographic characteristics, psychiatric symptoms and substance abuse history. Attention is given to current issues in the differential diagnosis of patients with PSUD/S using standardized instruments.

Dimensions of Sexual Dysfunction in Parkinson Disease

OBJECTIVE The authors sought to better understand the factors related to sexual dysfunction in Parkinson disease (PD). METHODS Twenty-one PD patients and their partners received the Derogatis Interview for Sexual Functioning-Self Report (DISF-SR). Additional measures assessed disease severity, autonomic dysfunction, mood, and social circumstance. RESULTS Data from 17 male patients demonstrated profound impairment in the dimensions of sexual arousal, behavior, orgasm, and drive, with most patients scoring below the 1st percentile on these Derogatis Interview subscales. All four dimensions showed significant intercorrelations. In contrast, 53% of patients scored above the 50th percentile in sexual fantasy. Sexual fantasy subscale scores were positively correlated with duration of PD. CONCLUSIONS The usefulness of the DISF-SR in this PD population was limited by extremely low scores and strong correlations among the subscales. The increase in sexual fantasy with greater PD duration suggests that patients with advancing disease remain interested in sex and that sexual dysfunction in PD is clinically relevant in this group.

Positive and negative syndrome typology in schizophrenic patients with psychoactive substance use disorders

Our objective was to begin to elucidate the interrelationship between psychoactive substance use disorders (PSUD) and schizophrenia in patients who concurrently have both disorders. A series of 29 psychiatric inpatients with concurrent Research Diagnostic Criteria (RDC)-diagnosed schizophrenia and PSUD (PSUD/S patients) were evaluated with rating inventories including the Schedule for Assessment of Negative Symptoms (SANS) and the Schedule for Assessment of Positive Symptoms (SAPS). Subjects had chronic schizophrenia with a mean duration of 9.9 years, and virtually all (93.1%) regularly abused cocaine and alcohol, as well as marijuana. The majority of subjects (58.6%) had mixed-syndrome typology, as defined by Andreasen; 24.1% had negative syndrome; and 16.7% had positive syndrome. Contrary to predictions, negative-syndrome PSUD/S patients had fewer years post-onset of schizophrenia than those patients with positive syndrome. In contrast to other schizophrenic patients, in whom the trajectory of symptoms is believed to change from a predominance of positive symptoms to a predominance of negative symptoms over the course of illness, in a sample of patients with comorbid PSUD/S we found the opposite pattern. This may have implications in the development of PSUD among certain schizophrenics, and may help to guide both psychiatric and substance abuse treatment of such patients.

Cognitive impairment in psychiatric patients and length of hospital stay

The purpose of this study was to determine whether brief neuropsychologic screening at the time of admission to an acute-care psychiatric unit predicts the length of inpatient hospital stay (LOS). Over a 4-month period, 41 consecutively admitted patients on a general psychiatric inpatient unit were administered the Mini-Mental State Examination (MMSE), the Trails A and B subtests from the Halstead-Reitan Neuropsychological Battery, and the Visual Reproduction subtest (VR) of the Wechsler Memory Scale within 72 hours of admission. A setwise, hierarchic multiple regression model examined the contributions of demographic factors, clinical features, and the four neuropsychologic tests to LOS variance. VR and Trails A were the best predictors of LOS, responsible for 21.6% and 16.3% of outcome variance, respectively. The independent variables (IVs) comprising the best-fitting model include Trails A, VR, MMSE, and patient diagnosis. These variables collectively accounted for 48.8% of the variance in LOS, and predicted 70.4% of patients with LOS < 21 days and 82.4% of patients with LOS > 21 days. The results of this study support the hypothesis that LOS is related to cognitive impairment associated with psychiatric illness, and suggest that neuropsychologic testing upon admission to an inpatient unit can be useful in predicting LOS.