Guillaume Galbaud du Fort

Delirium in older emergency department patients discharged home: effect on survival

OBJECTIVES: To determine whether prevalent delirium is an independent predictor of mortality in older patients seen in emergency departments (EDs) and discharged home without admission.

Psychiatric comorbidity and treatment seeking : sources of selection bias in the study of clinical populations

Population studies have shown that the co-occurrence of psychiatric disorders increases the likelihood of treatment seeking. This leads to a biased estimation of the prevalence of comorbidity in clinical samples, and this overestimation can be attributed to two different sources of selection bias. Using data from a population survey of psychiatric disorders, in which 3258 residents of Edmonton, Alberta, Canada, were interviewed with the Diagnostic Interview Schedule, we assessed the extent of each of these two mechanisms. The first source of selection bias is the mathematical bias known as Berkson’s bias and arises from the fact that an individual affected with two psychiatric disorders can seek treatment for either one or the other of these disorders. The second source of selection bias is clinical and results from the changed probability of seeking a treatment for a specific disorder because of the existence of a comorbid disorder.

Evaluation of the confusion assessment method (CAM) as a screening tool for delirium in the emergency room

The objective of this study was to compare the results of the Confusion Assessment Method (CAM) obtained by a trained non-physician interviewer to those obtained by a geriatrician, among a sample of elderly patients seen in an emergency room. A group of 110 elderly patients (> or =66 years) were evaluated in the emergency room by a lay interviewer. The geriatrician conducted an interview in the presence of the lay interviewer. Subsequently, the geriatrician and the lay interviewer completed a CAM checklist independently. Kappa statistics, sensitivity, specificity, positivity predictive value (PPV), and negative predictive value (NPV) for the geriatricians and lay interviewers results with the CAM diagnostic algorithm were compared. The kappa coefficient was 0.91, the sensitivity 0.86, the specificity 1.00, the PPV 1.00, and the NPV 0.97. In conclusion, the CAM used by a trained lay interviewer in the emergency room is sensitive, specific, reliable and easy to use for the identification of patients with delirium. The under-recognition and under-treatment of delirium is a major health issue and has important clinical and financial implications. The implementation of systematic screening in populations at risk could increase the rate of early detection and lead to the appropriate management of delirious patients.

Prevalence, Clinical Correlates, and Treatment of Migraine in Bipolar Disorder

Objective.—To investigate the prevalence, clinical correlates, and treatment of migraine in bipolar disorder.

Spouse similarity for lifetime psychiatric history in the general population

BACKGROUND Most studies of spouse similarity for psychiatric disorders have focused on clinical samples and are thus limited by selection bias. This study is, to our knowledge, the first comprehensive investigation of spouse similarity for lifetime psychiatric history in a general population sample using standardized diagnostic criteria. METHODS We studied 519 pairs of spouses residing in Edmonton, Canada who completed the Diagnostic Interview Schedule psychiatric interview. In each pair, one spouse belonged to a random subsample of persons who had participated in a large population survey and was re-interviewed. Association between spouses for lifetime DSM-III psychiatric disorders was analysed with bivariate and multivariate logistic regression analyses. RESULTS We observed significant spousal association for lifetime presence of affective disorders and for the spectrum of antisocial personality and addiction disorders. Antisocial personality in one spouse was also associated with anxiety disorders in the other spouse, namely post-traumatic stress disorder in wives and phobia in husbands; similarly, drug abuse/dependence in wives was associated with generalized anxiety in husbands and male drug abuse/dependence was associated with female post-traumatic stress disorder. Dysthymia in wives was associated with generalized anxiety and post-traumatic stress disorder in husbands. CONCLUSIONS The existence of associations between spouses for the presence of psychiatric disorders, either similar or different, has significant implications for both clinicians and researchers. Future research should aim at exploring the aetiological mechanisms of these associations.

Spouse similarity for antisocial behaviour in the general population.

BACKGROUND In contrast with the large amount of research on the familial transmission of antisocial behaviour, few studies have investigated similarity between spouses for such behaviour. In addition, none of these studies have examined child conduct disorder (CCD) and adult antisocial behaviour (AAB) separately. METHOD We studied 519 pairs of spouses who completed the Diagnostic Interview Schedule. In each pair, one spouse belonged to a random subsample of persons who had participated in a large population survey and was re-interviewed. Association between spouses for lifetime symptoms and DSM-III criteria of CCD, AAB, antisocial personality disorder and co-morbid psychiatric diagnoses was examined with bivariate and multivariate logistic regression analyses. RESULTS We observed a moderate association between spouses for the presence of CCD (OR = 4.02, 95% CI = 2.03-7.96), and a strong association for the presence of AAB (OR = 20.1, 95 % CI = 5.97-67.5). This similarity for AAB was independent of the similarity for CCD and persisted after adjustment for spousal similarity for disorders co-morbid with AAB. An examination of the relationship between marital status and the presence of CCD and/or AAB in the general population sample (from which originated our sample of couples) suggested that the spousal similarity for AAB was more likely attributable to assortative mating rather than marital contamination. CONCLUSION Our finding of a strong similarity between spouses for AAB has significant implications for both clinicians and researchers. It also suggests that adult antisocial behaviour should be considered as a distinct diagnostic entity, an approach which diverges from DSM-IV diagnostic criteria.

Treatment seeking for depression: role of depressive symptoms and comorbid psychiatric diagnoses

BACKGROUND General population research has indicated that many persons with lifetime major depression report they have never sought medical help for their illness. We examined the role played by both depressive symptoms and comorbid psychiatric diagnoses in treatment seeking. METHODS From standardized psychiatric interviews of 7214 Edmonton residents, we identified 1348 subjects with lifetime depressive illness; 866 subjects (64%) had sought medical treatment. RESULTS Psychomotor retardation (odds ratio, OR = 1.4), suicidal ideation (OR = 1.4), comorbid mania (OR = 9.5), comorbid panic disorder (OR = 3.0), and comorbid drug abuse/dependence (OR = 0.6) were significantly associated with treatment seeking in multivariate analysis. CONCLUSION The finding that only a few depressive symptoms were associated with treatment seeking underlines the importance of public health education to address the undertreatment of depression.

Suboptimal Duration of Antidepressant Treatments in the Older Ambulatory Population of Quebec: Association with Selected Physician Characteristics

OBJECTIVES: To assess the association between selected physician characteristics and suboptimal duration of antidepressant use in the older outpatient population.

Concurrent use of tamoxifen with CYP2D6 inhibitors and the risk of breast cancer recurrence.

Concurrent use of tamoxifen and cytochrome P450 2D6 (CYP2D6) inhibitors, such as selective serotonin reuptake inhibitors, has been shown to decrease plasma concentrations of tamoxifen metabolites. However, it is still unclear whether such concurrent use affects tamoxifen’s effectiveness. Thus, the objective of this study is to determine whether concurrent use of tamoxifen with CYP2D6 inhibitors increases the risk of recurrence in patients newly diagnosed with breast cancer. We conducted a nested case–control analysis within a population-based cohort from the UK General Practice Research Database. The cohort included women with a first-ever diagnosis of breast cancer who were prescribed tamoxifen between January 1, 1998 and June 30, 2008. Cases consisted of all patients with a breast cancer recurrence occurring during follow-up. Up to ten controls were matched to each case on year of birth, date of cohort entry, and duration of follow-up. Conditional logistic regression was used to estimate rate ratios (RR) of breast cancer recurrence in patients who concurrently used tamoxifen with CYP2D6 inhibitors, compared to patients who only used tamoxifen. The cohort included 9,209 incident users of tamoxifen, of whom 807 were diagnosed with a breast cancer recurrence. Concurrent use was not associated with an increased incidence of breast cancer recurrence (adjusted RR 1.07, 95% 0.88, 1.30). Type and strength of CYP2D6 inhibitors, as well as duration of concurrent use did not affect breast cancer recurrence. These results remained consistent after performing sensitivity analyses. The results of this large population-based study indicate that concurrent use of tamoxifen with CYP2D6 inhibitors does not increase the risk of recurrence.

Economic impact of non-persistence to antidepressant therapy in the Quebec community-dwelling elderly population.

BACKGROUND In a real-life setting, differences across newer antidepressants in patterns of use remain poorly explored, particularly in the older patients despite the high prevalence of late-life depression. METHODS An observational retrospective cohort study was conducted in the community-dwelling elderly population of Quebec using health databases to compare the newer antidepressants with respect to non-persistence, associated health care costs and cost/persistence ratio. A random sample of 12,825 outpatients who initiated an antidepressant treatment in 2000 were followed for 12 months. Non-persistence was defined as treatment duration of less than 180 days. Economic variables included direct costs of prescribed medications, medical services and hospitalizations assessed through RAMQ claims databases and Med-Echo hospitalization database. Cost/persistence ratio and incremental cost/persistence ratio were obtained for each antidepressant product; persistence being considered as an indicator of effectiveness. RESULTS 55.6% of antidepressant treatments were non-persistent. Products associated with low antidepressant costs were often associated with high costs of other medications and health care services, and vice versa. Paroxetine was associated with the lowest non-persistence (50.5%; 95%CI 48.5-52.5) and one of the most favourable cost/persistence ratios (CDN