Diane Snow

A single blind comparison of lithium and lamotrigine for the treatment of bipolar II depression

BACKGROUND Treatment studies are lacking for patients with bipolar II disorder (BDII). The objective of this study was to compare lamotrigine (LTG) and lithium (Li) monotherapy for the treatment of BDII depression. METHODS Patients with BDII acute depression were randomized to open-label monotherapy with LTG or Li, and evaluated by trained raters blinded to treatment. Patients were titrated to 200 mg/day of LTG over 8 weeks or at least 900 mg/day of Li over 2 weeks (serum level 0.6-1.2 mEq/L), and seen biweekly for 16 weeks. The primary outcome variable was change in the Hamilton Depression Rating Scale 17-item (Ham-D(17)), evaluated using mixed effects random regression. RESULTS Both groups showed significant improvement from baseline to endpoint on the Ham-D(17) (p<0.0001), with no between group differences (p=0.95). Seventy-two percent of the population was rapid cycling by DSM-IV criteria. No differences in response were noted between rapid cyclers and non-rapid cyclers. Early termination for any cause was 42%. The Li group reported significantly more side effects, although drop-out due to side effects did not differ between groups. LIMITATIONS This study was limited by an open treatment design, a lack of placebo arm, and uneven treatment groups. CONCLUSIONS Lamotrigine and lithium were effective monotherapy for BDII depression, with comparable response and remission rates. Naturalistic design and lack of placebo limit conclusions, though patient history indicated long standing depression unlikely to be alleviated by time. Patients who received Li reported more side effects, but this did not appear to impact drop-out rates.

Exploring the Factors Influencing Relapse and Recovery Among DRUG & ALCOHOL Addicted Women

1. Both women who were in treatment for relapse to and in sustained recovery from drugs and alcohol had multiple co-occurring addictions such as relationship, spending, food, and shopping that complicated the recovery process. 2. Depression is a major trigger for relapse in women with alcohol and drug problems. Recognition and treatment of depression is critical to achieve successful outcomes of treatment for these women, and teaching them to monitor their mood changes and seek help will improve the chances of preventing relapse. 3. Subjects in neither the relapse nor recovery sample recognized the significant influence of current violent partnerships or the ending of a violent relationship on their relapse or recovery.

First controlled treatment trial of bipolar II hypomania with mixed symptoms: Quetiapine versus placebo

OBJECTIVES To compare the efficacy and safety of adjunctive quetiapine (QTP) versus placebo (PBO) for patients with bipolar II disorder (BDII) currently experiencing mixed hypomanic symptoms in a 2-site, randomized, placebo-controlled, double-blind, 8-week investigation. METHODS Participants included 55 adults (age 18-65 years) who met criteria for BDII on the Structured Clinical Interview for DSM-IV-TR (SCID). Entrance criteria included a stable medication regimen for ≥2 weeks and hypomania with mixed symptoms (>12 on the Young Mania Rating Scale [YMRS] and >15 on the Montgomery Asberg Depression Rating Scale [MADRS] at two consecutive visits 1-3 days apart). Participants were randomly assigned to receive adjunctive quetiapine (n=30) or placebo (n=25). RESULTS Adjunctive quetiapine demonstrated significantly greater improvement than placebo in Clinical Global Impression for Bipolar Disorder Overall Severity scores (F(1)=10.12, p=.002) and MADRS scores (F(1)=6.93, p=.0138), but no significant differences were observed for YMRS scores (F(1)=3.68, p=.069). Side effects of quetiapine were consistent with those observed in previous clinical trials, with sedation/somnolence being the most common, occurring in 53.3% with QTP and 20.0% with PBO. CONCLUSIONS While QTP was significantly more effective than PBO for overall and depressive symptoms of BDII, there was no significant difference between groups in reducing symptoms of hypomania. Hypomania improved across both groups throughout the study.

SPIRITUAL PERSPECTIVE AND NEEDS: A COMPARATIVE STUDY OF NURSING FACULTY IN A CHRISTIAN UNIVERSITY AND A STATE UNIVERSITY

To care for the whole person, nurses must provide spiritual care (Narayanasamy, 1995; Wright, 1998). The inability to consistently and effectively provide spiritual care has been linked to the lack of educational preparation in our basic nursing programs (Govier, 2000; Piles, 1990). This lack of preparation is unacceptable because patients experiencing serious illness, life transitions, loss, grief, or pain have an increased awareness of spiritual needs (Charlton, 1992; Clark, Cross, Deane, and Lowry, 1991; Narayanasamy, 1995; Taylor, Highfield, and Amenta, 1999). During these experiences, patients are likely to interact with nurses—professionals that advocate holistic care (Martsolf and Mickley, 1998; McSherry and Draper, 1998). Nurses must be prepared to provide spiritual care since spirituality is an integral part of being human. Nurses are not likely to receive this preparation unless faculty value spiritual care. Faculty who are aware of spiritual needs, value spiritual care, and have the skills to provide spiritual care are more likely to teach those skills. They are also more likely to role model or encourage the provision of spiritual care during clinical experiences. For some faculty, teaching spirituality may seem inconsistent with the dominant paradigm of scientific based practice (Govier, 2000). Nursing faculty at state universities may question whether the overt inclusion of spiritual care in the curriculum is appropriate or permissible. The study reported in this paper explored the spiritual perspectives and identified the spiritual care practices of nursing faculty in a state university and a private Christian university. Along with describing the findings, spirituality related to patients, nurses, and nursing education is discussed.

Quality and Safety Graduate Competencies in Psychiatric Mental Health Nurse Practitioner Education

Education of the psychiatric mental health nurse practitioner (PMHNP) is undergoing massive change, partially driven by practice requirements and national certification changes, the development of new nurse practitioner competencies, and the development of the graduate quality and safety in nursing (QSEN) competencies. We are in the middle of a paradigm shift of expectations, not only just from these new competencies but also from the context of care and the impact PMHNP graduates will have on policy and health care delivery in the future. In this review article, the authors will discuss the general categories of the graduate QSEN competencies and how they relate to PMHNP education, competency development, and the application to curricular development in PMHNP programs across the United States. Importantly, these changes into PMHNP education, while remaining true to the fundamental tenants of advanced practice psychiatric nursing, prepare the PMHNP to meet the challenges of health care reform and service delivery.

Comparison of two anticonvulsants in a randomized, single-blind treatment of hypomanic symptoms in patients with bipolar disorder

Objective: Oxcarbazepine was compared to divalproex to assess clinical effectiveness of a proven agent, divalproex, against a newer, less studied agent, oxcarbazepine, in the treatment of hypomania. Method: Thirty patients with bipolar disorder, currently hypomanic, were randomized to receive oxcarbazepine or divalproex as add-on or monotherapy for 8 weeks. A rater blind to treatment assignment performed all symptom ratings. Hypomania and depression were rated using the Young Mania Rating Scale (YMRS) and the Inventory of Depressive Symptoms–Clinician Version (IDS-C). Random regression models were used to assess clinical symptom scores. Results: There were no significant differences of YMRS or IDS-C scores between groups. Mean YMRS scores at baseline were 22.07±5.86 and 20.53±6.02 for the oxcarbazepine and the divalproex groups, respectively. Mean percent reduction from baseline to week 8 for the YMRS was 63.8% and 79.0% for oxcarbazepine and divalproex groups, respectively. Mean percent reduction from baseline to week 8 for the IDS-C was 48.7% versus 19.7% for oxcarbazepine and divalproex groups, respectively. Significant antimanic efficacy was noted for each medication. Both medications were generally well tolerated. Conclusion: In this pilot study, oxcarbazepine was as effective as divalproex in the treatment of hypomania. Further controlled trials are warranted.

Integrating the 2013 Psychiatric Mental Health NP Competencies Into Educational Programs: Where Are We Now?

Since the introduction of the revised National Organization of Nurse Practitioner Faculties (NONPF) Nurse Practitioner Core Competencies and Population Focused Psychiatric Mental Health Nurse Practitioner (PMHNP) Competencies, a national forum took place to hear from many PMHNP program directors in the field comparing how they have integrated the lifespan competencies and the masters (MS)/or doctor of nurse practice (DNP) essentials into their curriculum. In this paper, we will report first on the major areas of change in the structure and content of the PMHNP-lifespan curriculum as well as the comments made by many faculty from across the country as to challenges and innovative strategies used to meet these challenges. We will review some of the major issues in content, pedagogy, and evaluation methods as well as examples of how these curricular elements have been infused into select programs across the country. We conclude highlighting several key areas, suggested foci for change, and how the specialty might focus attention and accelerate the significant growth we are seeing in PMHNP programs.

Prevalence of Alcohol and Other Drug Use and Abuse Among Nurses

Over the past two decades, the use and abuse of alcohol and other drugs (AODs) among nurses has received increasing attention in the United States. Most reports in the literature suggest that nurses are at higher risk than the general population for substance abuse and addiction; however, several recent studies suggest that nurses’ risk may have been overstated. Common reasons posited for nurses’ higher risk status include access to and attitudes toward drugs, and job-related stress. Prevalence estimates from early studies and reports have likely influenced perceptions of nurses’ risk. For example, in one of the earliest published articles on substance abuse in health care professionals, Garb (1965) examined reports of Demerol addiction from various agencies (e.g., Boards of Health, Boards of Nursing, and State Police) in 13 states and concluded that nurses were 100 times more likely than the general population to be addicted to Demerol. Later, Bissell and Haberman (1984) estimated that at least 40,000 nurses were alcoholics, a figure that has been frequently quoted in the literature. More recently researchers have begun to question whether rates of substance use are in fact higher among nurses than among the general population. This review summarizes findings from several probability studies published over the past ten years related to the prevalence of alcohol and other drug use among nurses.

Effective Strategies for Nurses Empowering Clients With Schizophrenia: Medication Use as a Tool in Recovery.

Clients with schizophrenia require maintenance treatment with antipsychotic medication and psychosocial therapy to maintain symptom control. Rates of medication adherence or follow-through are low in clients with schizophrenia. This increases the risk of relapse and contributes to poor quality of life. As educators and advisers, psychiatric nurses can collaborate with clients to improve adherence and other outcomes using shared decision-making techniques and tools that engage and empower clients to actively participate in decisions about their treatment. This article outlines effective strategies used by psychiatric nurses to improve outcomes in clients with schizophrenia and uses a case example for demonstrating this strategy in a client with schizophrenia.

Evaluation of Psychometric Properties of Variations of the Addiction Severity Index

The Addiction Severity Index now in its fifth edition (ASI5), is a highly acclaimed and utilized substance abuse assessment instrument for clinical and research purposes. It is considered by many to be the standard assessment in the substance abuse field (Butler, Redondo, Fernanez, & Villapiano, 2008). The instrument assesses an individual’s current and lifetime status in seven domains: alcohol and drug use, medical and psychiatric health, employment/self-support, familysocial relations, and illegal activity. For each domain, a severity rating and composite scores are calculated. Family history in relation to alcohol, drug, and psychiatric problems is also assessed. It can take approximately 45 to 60 minutes to administer the 227-item instrument. An ASI-Lite-Veterans Administration Version (ASI-L-VA), an abbreviated version containing 161 items, reduced administration time to an average of 31 minutes. The study purpose was to evaluate the psychometric properties of the Addiction Severity Index (ASI)-LVA. The study participants were 195 substance use disorder patients entering substance abuse treatment and were divided into two groups. Group one (n = 145) was administered the ASI-5 and the ASI-L-VA two to three days apart. The alpha coefficients for the ASI-5 on 19 available summary scores ranged from 0.59– 0.89 and internal consistency for 11 out of 19 summary scores was interpreted as 5 good, 4 fair and 4 unacceptable. The alpha coefficients for the summary scores of ASI-L-VA ranged from 0.61 to 0.89 and the internal consistency for the summary scores was interpreted as 8 were good, 6 were fair, and 5 unacceptable. All internal consistency scores were assessed using Cicchetti’s (1994) guidelines. For both the ASI-5 and the ASI-L-VA the correlations between ASI problem areas were generally low and there were no statistical significances found by t-tests comparing corresponding correlations between the two versions. There was, at a minimum, fair agreement in all but one instance for the intraclass correlation (ICC) results evaluating agreement of the summary scores derived from the ASI-5 and those derived from the ASI-L-VA. Group two (n = 50) was administered the ASI-5 two to three days apart. There were 26 ICC coefficients calculated from the two administrations and were interpreted as 12 indicating excellent agreement, 7 good, 4 fair, and 3 poor. Thirteen of the 26 cases of the ICC were at the same level of agreement when comparing the ICC results from group one and group two. Comparison of summary scales of the ASI-L-VA to the ASI-5 showed essentially the same level of internal reliability. The validity of the ASI-L-VA was supported because the relationship of the ASI-L-VA with the ASI-5 was comparable to the two administrations of the ASI-5. Therefore, the ASI-5-VA yielded similar information on problem severity as the ASI-5. The researchers concluded that psychometric properties of the ASI-L-VA were similar to those of the ASI-5. Comment: When considering there are ever increasing demands to see more patients in shorter periods of time it is of value to examine if a shorten version of the ASI-5 is an appropriate alternative for examining patients with substance use issues. Any time an instrument is altered from its original version there can be concerns about its reliability and validity. Therefore, the psychometric properties need to be reestablished for any differing versions. Schwartz (1999) delineates that the meaning of questions may be changed any time the context in which they are embedded is altered. Additionally, decreasing the number of items on an instrument typically results in reductions of validity (Smith, McCarthy & Kristen, 2000). Further study is needed to determine appropriateness of the ASI-L-VA for other populations, since the study sample were largely male with extensive histories of substance use with multiple episodes of prior treatment.