Jeffrey S. Markowitz

Suicidal Ideation and Suicide Attempts in Panic Disorder and Attacks

Panic disorder, which is found in about 1.5 percent of the population at some time in their lives, includes recurrent episodes of sudden, unpredictable, intense fear accompanied by symptoms such as palpitations, chest pain, and faintness. Panic attacks, which do not meet these diagnostic criteria fully, are two to three times more prevalent. Since panic symptoms can mimic those of other medical disorders, patients with these symptoms use medical services frequently. To determine the risk of suicidal ideation and suicide attempts in panic disorder and attacks, we studied a random sample of 18,011 adults drawn from five U.S. communities. Subjects who had panic disorder, as compared with other psychiatric disorders, had more suicidal ideation and suicide attempts, with an adjusted odds ratio for suicide attempts of 2.62 (95 percent confidence interval, 1.83 to 3.74). The odds ratio was 17.99 (95 percent confidence interval, 12.18 to 26.58) when the group with panic disorder was compared with subjects who had no psychiatric disorder. Twenty percent of the subjects with panic disorder and 12 percent of those with panic attacks had made suicide attempts. These results could not be explained by the coexistence of major depression or of alcohol or drug abuse. We conclude that panic disorder and attacks are associated with an increased risk of suicidal ideation and suicide attempts. Physicians working in general medical settings and emergency departments should be alert to this problem.

Cost of Alzheimer's disease and related dementia in managed-medicare.

BACKGROUND: Managed care organizations (MCOs) will have increased responsibility for the care of large numbers of persons with dementia. There are, however, few studies that inform about decisions of healthcare utilization and expenditures for individuals with dementia in managed care.

Social functioning in chronic depression: effect of 6 weeks of antidepressant treatment

Social functioning was assessed in 189 nonmelancholically depressed outpatients. Patients were then treated for 6 weeks in a double-blind trial of phenelzine, imipramine, or placebo and functioning was reassessed. Before treatment, younger, more severely depressed, more chronically depressed patients and those with a DSM-III diagnosis of major depression plus dysthymic disorder were more functionally impaired than patients without these characteristics. Chronically depressed patients who responded to treatment reported significantly improved functioning while nonresponders did not. These results suggest that for some chronically depressed patients, impaired functioning results at least partly from the Axis I mood disorder instead of being entirely attributable to Axis II character pathology.

How blind is blind? Assessment of patient and doctor medication guesses in a placebo-controlled trial of imipramine and phenelzine

The purpose of the double blind is to protect the internal validity of a clinical trial by preventing knowledge of treatment conditions from influencing outcome or its assessment. We studied medication guesses of 137 depressed patients and/or their doctors at the end of a 6-week randomized trial of placebo, imipramine, and phenelzine. Overall, 78% of the patients and 87% of the doctors correctly distinguished between placebo and active medication. Clinical outcome, treatment condition, and their interaction each contributed to guessing accuracy, while medication experience and side effects assessed only in week 6 did not. Accuracy was high, however, even when cases were stratified for clinical outcome, indicating that other cues were available to the patients and doctors. These may include patterns and timing of side effects and clinical response not detectable in this end-point analysis.

General versus systematic inquiry about emergent clinical events with SAFTEE: implications for clinical research.

This study compares two methods for elicitation of treatment-emergent side effects. One is the open-ended general inquiry and the other is a specific inquiry that asks about a wide range of events thought to be treatment-related. The study goal was to determine the extent to which the specific inqui

General Versus Systematic Inquiry about Emergent Clinical Events with SAFTEE: Implications for Clinical Research

This study compares two methods for elicitation of treatment-emergent side effects. One is the open-ended general inquiry and the other is a specific inquiry that asks about a wide range of events thought to be treatment-related. The study goal was to determine the extent to which the specific inquiry method elicits clinically useful information over and above that elicited by the general inquiry method. The assessment instrument we used is SAFTEE, a structured interview schedule developed by the National Institute of Mental Health. We looked for differences between general and specific inquiry formats in terms of number of events elicited, type of event, severity, functional impairment, and clinician action taken. We found that both methods contributed to elicitation of events that, in the clinicians opinion, required some change in management. However, events reported on the General Inquiry form were significantly more distressing, more often interfered with daily functioning, and elicited more extensive changes in clinical management. No medically serious events were elicited on the specific inquiry form alone. Based on these findings, and in view of the amount of time and effort required to administer and score it, we do not recommend the specific inquiry form of SAFTEE as a standard assessment tool for routine use in all clinical trials. We do consider it to be a useful method for comprehensive elicitation about treatment-emergent effects in targeted and specific research contexts. We see the schedule as a comprehensive document or library of queries to be tailored to the needs of individual protocols.

Phenelzine and imipramine in mood reactive depressives. Further delineation of the syndrome of atypical depression

Sixty patients who met Research Diagnostic Criteria for major, intermittent, or minor depressive disorder and had reactive mood without atypical symptoms were treated with imipramine hydrochloride, phenelzine sulfate, or a placebo. These patients, referred to as simple mood reactive depressives, were contrasted with previously published data from 180 atypical depressives. Atypical depressives had the presence of at least one vegetative atypical sign (hypersomnia, hyperphagia, leaden feeling, or rejection sensitivity) but were otherwise indistinguishable from simple mood reactive depressives. In contrast to the atypical depressives for whom phenelzine was effective and imipramine was relatively ineffective, both medications were equivalently good in simple mood reactive depressives. Since all groups did poorly when given a placebo and well when given phenelzine, the salient feature of atypical symptoms may be that they predict poor response to imipramine. Since the difference between imipramine and placebo depends on the diagnostic group, pharmacologic dissection suggests that atypical symptoms in patients with nonautonomous mood may delineate a qualitatively distinct subgroup.