Edgardo Pérez

Computerized administration of the diagnostic interview schedule

The National Institute of Mental Health (NIMH) Diagnostic Interview Schedule (DIS) is a highly structured interview designed to be administered by lay interviewers and to yield psychiatric diagnoses. While the DIS has been used widely in large research centers, its use has been limited due to its complexity and need for extensive training to administer. In the present study 100 volunteers consisting of 80 psychiatric patients and 20 normal controls completed a self-administering computerized version of the DIS on two occasions. A standardized Computer Attitude Scale (CAS) was administered to each volunteer before the first and after the second computerized DIS (C-DIS). The C-DIS yielded acceptable test-retest reliability. Certain diagnoses were found to yield high test-retest reliability while reliability was lower for others. This general pattern was similar to the results of previous procedural validity studies. Patients found the C-DIS generally easy to use and operate, and after using the C-DIS, felt that their level of expertise in using computers had improved. Generally, the results support the use of computerized administration of the DIS.

Treatment of bulimia with fenfluramine and desipramine

Desipramine and fenfluramine were administered to bulimic patients in a 15-week study of double-blind, placebo-controlled, crossover design. The 22 patients in the study met DSM-III criteria for bulimia and were of normal weight. Twelve subjects were randomly allocated to the fenfluramine group, and 10 subjects received desipramine. Half the subjects in each group received the active drug in the first 6 weeks and half received placebo. There was a 3-week washout period, after which subjects were crossed over for the remaining 6 weeks. The Eating Disorder Inventory, profile of Mood States, bulimia symptom checklists, and Hopkins Symptom Checklist were administered at weeks 0, 2, 4, 6, 9, 11, 13, and 15. Subjects maintained a daily record of bingeing, vomiting, and laxative/diuretic abuse. Results indicated that both drugs had beneficial effects on bingeing and vomiting frequency, although a greater proportion of patients were identified who responded to fenfluramine than to desipramine. Fenfluramine and desipramine were also effective in reducing the psychological symptoms of bulimia, such as the urge to binge, and feelings of depression. Results suggest that direct alteration of central food intake regulatory centers can effectively control bulimia.

Treatment of bulimia with desipramine: a double-blind crossover study.

The purpose of this study was to evaluate the effect of desipramine, a tricyclic antidepressant with relatively specific noradrenergic effects, on bulimic behaviour, eating attitudes, and mood. Using a double-blind crossover design, 47 normal weight bulimics were randomly assigned to receive either desipramine (150 mg/day)for six weeks, no drug for three weeks, followed by placebo for six weeks, or the reverse sequence. At weeks 0, 2, 4, 6, 9, 11, 13, and 15, each subject was assessed using the EDI, SCL-90, POMS and binge records. Plasma desipramine levels were obtained at weeks 4 and 13. Twenty-four subjects completed the entire fifteen week protocol, while 23 dropped out. Desipramine was significantly more effective than placebo in reducing the frequency of weekly hinging, weekly vomiting, and the fatigue scale of the POMS. No significant effect of the drug was obtained on the EDI or the SCL-90. The clinical effect was modest. Desipramines antibulimic effects were not associated with an alleviation of depressive symptoms.

The teaching of psychotherapy in Canadian psychiatric residency programs: residents' perceptions.

In order to determine the residents’ perceptions toward their psychotherapy training, a questionnaire was distributed to 400 residents in the 16 Canadian psychiatric residency programs. The main areas studied were: i) the residents demographic and educational characteristics; ii) the residency program characteristics; iii) the type of training available in different psychotherapeutic modalities; iv) the analysis of quality and quantity of attention given to different elements of psychotherapy supervision (patient assessment, diagnostic formulation of treatment approach and goals); v) the degree of importance attributed by the residents to the above mentioned elements of psychotherapy supervision; and vi) the residents’ perception of their supervisors attributes (examples: teaching ability and rapport). Forty-two percent of the residents completed the questionnaire. Residents mentioned that the most adequate supervision was for long-term individual psychotherapy cases and that behavioral and group therapy supervision was the least adequate. The three most essential qualities in a supervisors profile were judged to be: a) capacity for the development of a good rapport with the trainee; b) ability to pinpoint residents’ psychotherapy shortcomings and his willingness to help residents to overcome them; c) ability to teach. Three factors that significantly influenced the trainees perception of their psychotherapy training were: i) residents age, ii) a seminar in individual psychotherapy in the residency core program; iii) having received more than one hour weekly of psychotherapy supervision. The understanding of patients psychodynamics was the most adequately taught element during psychotherapy supervision. The authors discuss briefly some recommendations for the teaching of psychotherapy in Canadian residency programs.

Compliance to referrals from the psychiatric emergency room.

Factors affecting compliance to referrals in the psychiatric emergency room (ER) were studied in a sample of 468 patients referred for ambulatory care. Compliance was defined as attendance at the first appointment. The overall compliance rate was 59%. Compliance rates were higher among those patients who were receiving psychiatric treatment (active) when they visited the ER. Those in treatment tended to have either Schizophrenic or Personality Disorders with fewer social supports. Different factors affected those in treatment and those not in treatment. The results suggest that those not in treatment would comply more frequently with specific instructions outlining the benefits of psychiatric follow-up.

Utilization pattern of a Canadian psychiatric consultation service

The authors reviewed 255 psychiatric consultations in a Canadian teaching general hospital over a one-year period. The majority of the patients were referred from the medical and surgical services. The three most commonly stated reasons for referral were either parasuicidal behavior, depression, or psychological conflicts affecting physical illness. The three most common primary psychiatric diagnoses were: affective disorders, organic brain syndromes, and transient situational disturbances. The factors influencing compliance among the patients referred for psychiatric ambulatory treatment were studied. Compliance was defined as attendance at the first appointment. Of the 42.8% of the patients referred for ambulatory psychiatric treatment, 54% complied.

Repeated users of a psychiatric emergency service in a Canadian general hospital

The authors of this study examine the demographic and clinical characteristics of repeated users of psychiatric emergency room services in a general hospital. 37.8% of all the patients (913) seen during one year had one or more visits to the emergency room in the six months preceding the index emergency room consultation. Repeaters were more likely than non-repeaters to be unmarried, self referred and with a history of previous psychiatric treatment for a chronic psychiatric disorder. Factors affecting frequency of use of psychiatric emergency room services among different diagnostic groups were also studied. These results demonstrated the heterogeneity of the needs of the diverse diagnostic groups who over-utilize costly emergency room services. Our findings showed that in a country with universal health insurance, psychiatric emergency services also tend to reflect the gaps in the delivery of health services in the hospital and the community.

Bulimia: independence of antibulimic and antidepressant properties of desipramine.

The purpose of this study was to identify variables useful for predicting a positive response to the tricyclic antidepressant desipramine, amongst bulimic subjects. Using a randomized double-blind cross-over design, 24 normal weight bulimics completed a 15-week protocol in which they received either desipramine (150 mg/day)for six weeks, no drug for three weeks, followed by placebo for six weeks, or the reverse sequence. At weeks 0, 2, 4, 6, 9, 11, 13, and 15, each subject was assessed using the EDI, SCL-90, POMS and binge records. The DST, Diagnostic Interview Schedule (DIS), and a personal and family medical-psychiatric history questionnaire were administered at initial assessment, while plasma desipramine levels were obtained at weeks 4 and 13. Responders were defined in terms of both binge frequency reduction, and decrease in depressive symptoms. In the sample of 24 subjects, desipramine was significantly more effective than placebo in reducing the frequency of weekly hinging and vomiting, as well as causing a reduction in the fatigue scale of the POMS. No significant effect of the drug was obtained on the EDI or the SCL-90. In terms of reduction in binge frequency, seven responders were identified; another seven were found to be borderline responders, while 10 were labeled as non-responders. The three groups did not differ in terms of their initial scores on the SCL-90, POMS, DST, DIS results, or psychological subscales of the EDI. However, responders were found to have lower EDI bulimia subscale scores, but a higher frequency of purging episodes than were non-responders. Eight patients were identified as borderline responders with respect to depressive symptoms. They differed from depression non-responders in that they had abnormal DST results, and were more likely to report a family history of depression. These results indicate that the predictors of the antibulimic effect of desipramine in bulimia are independent of its antidepressant properties.

A study of the drop-outs in psychopharmacological research with bulimics.

Given the high drop-out rates frequently noted in drug trials with bulimic subjects, we have attempted to correlate drop-out status with a greater level of psychopathology as measured by a thorough standardized psychological assessment battery (NIMH-DIS, EDI, POMS and SCL-90). Despite a trend toward higher scores on the Paranoid Ideation Sub scale of the SCL-90 among drop-outs compared to completers, there were no significant differences found between the two groups participating in a fifteen week double blind crossover study on the effectiveness of desipramine in bulimia.

Psychiatric Emergency Consultations to Elderly Patients in a Canadian General Hospital

The authors compared the demographic and clinical characteristics and treatment recommendations for elderly (greater than or equal to 60 years) and younger patients (17 to 59 years) seen for an emergency psychiatric consultation in a teaching general hospital. Findings revealed 11 distinctive characteristics that differentiated elderly from younger patients. Most notably, the elderly experienced their chief complaint for a longer time before referral to the emergency room by their primary care physician and had higher prevalence of affective disorders and psychologic factors affecting physical condition. Some of the implications of these results are discussed with the view to planning psychiatric services for the elderly and education programs.