Dennis P. McNeilly

A randomized, placebo-controlled trial of citalopram for the prevention of major depression during treatment for head and neck cancer.

OBJECTIVE To determine whether prophylactic treatment with the antidepressant citalopram hydrobromide, compared with placebo, could prevent major depressive disorder in patients undergoing therapy for head and neck cancer (HNC). DESIGN Prospective, randomized, placebo-controlled trial. SETTING Academic medical center. PATIENTS Thirty-six subjects were randomized, and 23 completed the study. INTERVENTIONS Subjects were randomized to receive 40 mg of citalopram hydrobromide or matching placebo (herein after, citalopram group and placebo group, respectively) for 12 weeks with a final visit at 16 weeks. MAIN OUTCOME MEASURES The Hamilton Depression Rating Scale, psychiatric interview, and the University of Washington Quality of Life (UW-QOL) and Clinician Global Impression-Severity (CGI-S) scales. RESULTS The numbers of subjects who met predefined cutoff criteria for depression during the 12 weeks of active study were 5 of 10 (50%) taking placebo and 2 of 12 (17%) taking citalopram (Fisher exact test, P = .17). No patients in the citalopram group became suicidal, compared with 2 in the placebo group. Global mood state at the conclusion of the study as measured by the CGI-S scale was rated as at least mildly ill in 15% of those receiving citalopram compared with 60% in the placebo group (Fisher exact test, P = .04). Quality of life, measured by the UW-QOL, deteriorated in both groups from baseline but less so in the citalopram group. CONCLUSIONS This study reports data from the first depression prevention trial in HNC and suggests that prophylactic treatment may decrease the incidence of depression during HNC therapy. The clinical significance of the reduction in depression was best demonstrated by the CGI-S scale, which showed a notable difference in global psychiatric and physical well-being.

The effect of HMG-CoA reductase inhibitors on cognition in patients with Alzheimer's dementia: a prospective withdrawal and rechallenge pilot study.

BACKGROUND Statins are well-known for their cardiovascular benefits. However, the cognitive effects of statins are not well understood. We hypothesized that individuals with preexisting dementia would be more vulnerable to statin-related cognitive effects. OBJECTIVE The aim of this study was to evaluate the impact on cognition of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor (statin) discontinuation and rechallenge in individuals with Alzheimers dementia (AD) on statins at baseline. METHODS A 12-week prospective, open-label study was conducted in a geriatric clinic setting. Eighteen older subjects underwent a 6-week withdrawal phase of statins followed by a 6-week rechallenge. The primary outcome measure was cognition, measured by the Mini-Mental State Examination (MMSE); secondary outcome measures were the Consortium to Establish a Registry for Alzheimers Disease (CERAD) neuropsychological battery, Activities of Daily Living (ADL) scale, Instrumental ADL (IADL) scale, and fasting cholesterol. The change in outcome measures was assessed using repeated-measures ANOVA and paired t tests. RESULTS At the end of the intervention, there was a significant difference across time for MMSE score (P = 0.018), and total cholesterol (P = 0.0002) and a trend toward change across time for ADL (P = 0.07) and IADL (P = 0.06) scale scores. Further analyses using paired t tests indicated improvement in MMSE scores (Δ1.9 [3.0], P = 0.014) with discontinuation of statins and a decrease in MMSE scores (Δ1.9 [2.7], P = 0.007) after rechallenge. Total cholesterol increased with statin discontinuation (P = 0.0003) and decreased with rechallenge (P = 0.0007). The CERAD score did not show a change across time (P = 0.31). There was a trend toward improvement in ADL (P = 0.07) and IADL (P = 0.06) scale scores with discontinuation of statins, but no change with rechallenge. CONCLUSIONS This pilot study found an improvement in cognition with discontinuation of statins and worsening with rechallenge. Statins may adversely affect cognition in patients with dementia.

Stealing lately: a case of late-onset kleptomania.

The case of a 77‐year‐old woman first diagnosed with kleptomania is presented to indicate a possible late‐onset course of this disorder. Particularly striking about this patients history of shoplifting behaviors was the absence of an onset prior to the age of 73. Her pattern of stealing did not begin at an early age, and was not sporadic or episodic over the course of several years. The treatment course and patient outcome are discussed in light of DSM‐IV diagnostic criteria.

Refinement of the IPEC Competency Self-Assessment survey: Results from a multi-institutional study

ABSTRACT Effective interprofessional practice requires interprofessional education that facilitates learners’ achievement of competency in the interprofessional domains. Unfortunately, educators currently have a limited number of tools to identify the level of competency of their learners. Previous investigations by some of the authors described the initial characteristics of a tool based on the Competencies for Interprofessional Collaborative Practice. Building on this work, this study describes a multi-institutional, three-part study refining this tool. The series of studies further established the validity, reliability, and usability of the assessment tool. Based on the data derived from this study, we created a shorter, more easily utilised version of the tool that retains previous psychometric strengths. This article describes a tool that consists of two domains, one linked to interprofessional interaction and one linked to interprofessional values. It is believed that this assessment tool may help educators define competence in interprofessional practice and guide assessment of both programmes and learners.

Portrait of a process: arts-based research in a head and neck cancer clinic

The role of art in medicine is complex, varied and uncertain. To examine one aspect of the relationship between art and medicine, investigators analysed the interactions between a professional artist and five adult patients with head and neck cancer as they cocreated portraits in a clinical setting. The artist and four members of an interdisciplinary team analysed the portraits as well as journal entries, transcripts of portrait sessions and semistructured interviews. Over the course of 5 months, 24 artworks evolved from sittings that allowed both the patients and the artist to collaborate around stories of illness, suffering and recovery. Using narrative inquiry and qualitative arts-based research techniques five emergent themes were identified: embracing uncertainties; developing trusting relationships; engaging in reflective practices; creating shared stories; and empowerment. Similar themes are found in successful physician–patient relationships. This paper will discuss these findings and potential implications for healthcare and medical education.

Populations at Risk for a Gambling Disorder: Older Adults

Purpose of reviewOlder adults who gamble are a population of concern, yet older adult problem gambling remains a topic of limited examination. This article seeks to critically evaluate the existing older adult problem gambling literature.Recent findingsRecent literature uses generational comparisons to predict gambling behaviors of those newest to older adulthood, the Baby Boomers. These studies indicate that Baby Boomers participate in gambling activities at a higher rate than previous generations and that they may be further negatively impacted as access to gambling expands. Prevalence rates of problem gambling vary across countries suggesting that culture influences perceptions of gambling for older adults. While poorer health outcomes have also been associated with problem gambling, positive effects of gambling on cognition have also been suggested.SummaryFinally, the authors offer personal observations and hypothetical discussion about these research implications and emphasize the need for better awareness, screening, and study of gambling disorders among older adults.

The Potential of Failure: Resulting Questions About Faculty Engagement.

To the Editor: Inspired by a faculty peer mentoring program presentation at a national academic psychiatrists meeting [1], the authors returned to their psychiatry department faculty and attempted to initiate a similar faculty peer mentoring program. As the need for faculty mentoring programs receives increased national attention through professional meeting workshops and as medical school deans seek to foster successful careers in academic medicine through in-house mentoring programs, the authors assumed a locally adapted peer mentoring initiative would be both welcomed and ultimately successful. Twelve psychiatry department junior faculties eligible for promotion were invited by email to an afterhours “on-yourway-home” restaurant dinner meeting, where the new peer mentoring initiative would be explained. Conflicting faculty schedules and previous commitments ultimately delayed (18 weeks later) that dinner meeting date to which eight psychiatry faculties were able to attend. During that meeting, the authors outlined a model for psychiatry peer mentoring groups, modeled after innovative and collaborative peergroup mentoring programs that helped junior faculty to identify and plan for core values, develop collaborative relationships, skills and to increase satisfaction [2]. Following the review of the College of Medicine’s promotion criteria, invited faculty expressed their concerns which centered on the time commitment and the amount of support and resources they would be provided. Somewhat surprising was a related question about whether the department might hire a PhD researcher to assist them in the writing and publishing process. Following the dinner meeting and for the next 30 weeks, the authors sent staggered emails of encouragement, offers of personal assistance, and humorously cajoling promptings to the eight faculties who had agreed to form peer mentoring groups organized around their common writing interests. Faculty responses to those emails most often expressed gratitude for continued encouragement and ongoing plans to organize and self-identify peer mentoring groups. Now, 20months after that faculty dinner meeting, the authors are unable to identify the local faculty peer mentoring groups that have actually gotten off the ground. While the authors’ program design, leadership execution errors and naiveté likely contributed to the failure of a successful faculty peer mentoring program, at the same time, does this recent failure also suggest something more about the larger cultural landscape of academic psychiatry and where both junior and senior psychiatry currently find themselves? Is this generational, cultural, systemic, or all of the above? Does this local failure provide for a potential discussion of how academic psychiatry might better navigate itself amidst the ever changing questions of clinical time demands, career engagement, career encouragement, the RVU clinical culture, and a promotion system that may no longer seem the reward it once was? Have the daily realities of “RVU’s,” “billable hours,” “EMR’s,” and the ever-increasing demands on the clinician’s time—even those on “physician-educator” academic tracks— deflated faculties’ career engagement of what it has traditionally meant to be an academic psychiatrist? Have those same clinical culture and time demands similarly deflated those already published and promoted to be less likely to engage in career encouragement and both formal and informal mentoring of their junior psychiatry colleagues? Do junior psychiatry faculties currently eligible for a successful and satisfying academic career no longer value these * Dennis P. McNeilly dmcneill@unmc.edu