Mark L. Willenbring

Integrated Psychiatric/Medical Care in a Chronic Hepatitis C Clinic: Effect on Antiviral Treatment Evaluation and Outcomes

OBJECTIVES:Psychiatric and substance use disorders are common in hepatitis C patients and represent barriers to antiviral treatment. We evaluated the effect of integrating psychiatric and medical care on evaluation for and initiation of antiviral treatment in a cohort of 184 patients with chronic hepatitis C.METHODS:Integrated care consisted of screening for psychiatric problems with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), Beck Depression Inventory (BDI), Urine Drug Screen (UDS), and Primary Care Posttraumatic Stress Disorder (PC-PTSD) screens, referral based on specified cutoff scores to an established mental health (MH) provider, to a colocated psychiatric clinical nurse specialist (PCNS), or both. Data were collected retrospectively by chart review.RESULTS:Most patients (149/184, 81.0%) had at least one positive screen, 25.5% had a positive UDS. Among patients with positive screens, 38.3% had established MH providers, 47.0% had no MH provider and were referred to the PCNS, and 15.0% refused any psychiatric referral. Patients receiving integrated care with a colocated PCNS were significantly more likely to complete evaluation for and start antiviral treatment than other patients with positive screens, and at a rate similar to that of patients with negative screens. Patients with positive screens followed by any MH provider had significantly greater adherence to antiviral therapy than patients without positive screens.CONCLUSION:An integrated MH and medical approach was associated with rates of antiviral therapy recommendation and initiation similar to patients without risks for psychiatric or substance use problems. MH care was associated with improved adherence to antiviral therapy. Integrated care offers promise as an approach for addressing psychiatric comorbidity in this traditionally difficult to treat population.

Spectrum of disease in U.S. veteran patients with hepatitis C

OBJECTIVE:Hepatitis C virus (HCV) infection is more prevalent in U.S. veterans attending Veterans Affairs Medical Centers than in the general population. The purpose of this study was to examine the risk factors, psychiatric and substance abuse conditions, and severity of liver disease in veterans with HCV.METHODS:The medical records and liver biopsies of 206 consecutive patients with HCV attending a multidisciplinary medical/psychiatric chronic hepatitis clinic and who met eligibility criteria for interferon α-2b therapy were reviewed.RESULTS:The mean age was 46.5 ± 6.8 yr and 77% were Vietnam-era veterans. Risk factors included i.v. drug use (64%), blood transfusion (15%), and cocaine use (9%), and were unknown in 12%. The average estimated duration of disease was 24 ± 7.6 yr. A history of alcohol abuse or dependence was identified in 80% of patients. Psychiatric illnesses were present in 60%, the most common being depression and posttraumatic stress disorder. Overall, 89% of patients had documented psychiatric and/or substance abuse diagnoses. Severe fibrosis (stages 3–4) was present in 32% and severe inflammation (grades 2–3) was present in 71% of biopsies. Psychiatric and substance abuse diagnoses did not correlate with severity of liver disease. A total of 145 patients (71%) were prescribed interferon-based treatment. The overall virological sustained response rates were 16% after interferon monotherapy and 28% after interferon/ribavirin therapy. Reasons for not receiving interferon therapy included minimal fibrosis on liver biopsy (37 patients [18%]), worsening medical conditions (nine [4%]), and worsening psychiatric and substance abuse problems (14 [7%]).CONCLUSIONS:Advanced fibrosis is common in this cohort of veteran patients with chronic hepatitis C, and the overwhelming majority of these patients have psychiatric and/or substance abuse diagnoses. Despite these comorbidities, the majority received interferon therapies in the context of a multidisciplinary clinic. These data emphasize the importance of hepatitis C care that includes linkage of medical care and psychiatric services.

Alcoholism Screening in the Elderly

Alcoholism in the elderly is often underidentified because of the differences in the presentation and symptom patterns compared to younger individuals. One way to address this problem is through routine use of screening instruments, but up to this time, none of the instruments used to identify alcoholism in younger populations have been shown to be valid in the elderly. We studied the validity of the Michigan Alcoholism Screening Test, scored both with weighted (MAST) and unit scoring (UMAST), and two short versions: the Brief MAST (BMAST) and Short MAST (SMAST) in 52 hospitalized elderly male alcoholics and 33 nonalcoholic controls. The MAST and UMAST showed excellent sensitivity and specificity, while the SMAST was less specific, and the BMAST less sensitive and less specific. Factor structure of the two brief versions was similar to that found in younger alcoholics, suggesting that symptom constellation is not necessarily different in the elderly. We recommend the use of the MAST or UMAST for screening for alcoholism in the elderly. J Am Geriatr Soc 35:864–869, 1987

Symptom-driven lorazepam protocol for treatment of severe alcohol withdrawal delirium in the intensive care unit

Study Objective. To compare outcomes of treating alcohol withdrawal delirium (AWD) with a symptom‐driven benzodiazepine protocol versus nonprotocol benzodiazepine infusions in the intensive care unit (ICU).

Psychoneuroendocrine effects of methadone maintenance

A variety of neuroendocrine and psychiatric dysfunctions have been demonstrated in humans maintained on opiates, but both have not previously been examined in the same population. We performed a series of neuroendocrine challenge tests in men participating in a methadone maintenance clinic and in normal controls. Psychiatric diagnoses were made with DSM-III Criteria, using the Diagnostic Interview Schedule, and subjects also completed the Symptom Checklist. Our results in the methadone group suggest (a) near-maximal stimulation of prolactin secretion, with a blunted prolactin response to insulin hypoglycemia, (b) mild suppression of cortisol levels, but an exaggerated cortisol response to stimulation, (c) a delayed and inhibited insulin response to food ingestion with resulting mild hyperglycemia, (d) low body weight, but elevated calorie ingestion, and (e) inability to concentrate urine when dehydrated, which was partially corrected by administration of arginine vasopressin. Phobic disorder was associated with a lower prolactin response to both inhibitory and stimulatory challenges. Depression did not appear to be related to the increased cortisol response to stimulation. These results suggest several potentially fruitful areas for future investigation, including the prolactin system and anxiety disorders, nutrient ingestion and metabolism, and posterior pituitary function.

Timing of alcohol and smoking cessation (TASC): smoking among substance use patients screened and enrolled in a clinical trial.

Abstract Tobacco dependence is prevalent among alcohol dependent patients, and causes increased morbidity and mortality. Concurrent treatment for these disorders may be advantageous, but there are concerns about adverse effects on alcohol treatment outcomes. The Timing of Alcohol and Smoking Cessation (TASC) Study is a randomized controlled clinical trial to compare the effectiveness of smoking cessationtreatment offered concurrently or six months following intensive rehabilitation for alcohol dependence. This paper describes the study design and baseline characteristics of the study population. Participants were current smokers in intensive alcohol dependence treatment, with willingness to consider quitting smoking. Smoking intervention offered behavioral and pharmacological treatment. One thousand nine hundred forty—three patients were screened for enrollment; 499 were eligible and participated (26%). We describe demographic characteristics, smoking behavior and attitudes among participants and nonparticipants toward smoking cessation and drinking. We conclude that there is considerable interest in smoking cessation in alcohol dependent treatment populations, and recruitment to research studies is feasible.

Factors Associated with Readiness to Stop Smoking among Patients in Treatment for Alcohol Use Disorder

The Timing of Alcohol and Smoking Cessation (TASC) Study is a randomized controlled trial that examines the optimal timing of intervention for nicotine dependence in patients with alcohol use disorders. A cross-sectional analysis of baseline characteristics of study participants was used to identify characteristics associated with readiness of patients in intensive treatment for alcohol abuse or dependence to quit smoking. Baseline characteristics of 499 subjects enrolled in the TASC trial were analyzed. Readiness to quit was assessed by two self-rated measures: being in the preparation/action stages of change and scoring at least an 8 on the Contemplation Ladder. Univariate analyses showed a higher prevalence of African-Americans and other minorities than Caucasian, among participants planning to quit in the next month (p = 0.005). There were no other differences between groups. Participants in the preparation/action stages of change experienced significantly lower rates of current (p = 0.011) and past (p = 0.014) major depressive disorder and displayed significantly less current depressive symptoms on the Beck Depression Inventory (p = 0.008). Patients with Contemplation Ladder ratings between 8 and 10 showed similar results. Logistic regression models consistently confirmed that the degree of depression was negatively associated with the intention to quit, but different models suggested that increasing age, shorter duration of smoking history, race other than white, and a greater number of past quit attempts were positively associated with readiness to quit. Among patients in intensive treatment for alcohol use disorders who smoke, a history of depressive disorder and depressive symptoms predict less interest in quitting smoking.

Sexual Dysfunction and Psychological Distress in Methadone Maintenance

We administered the Derogatis Sexual Functioning Inventory to 25 methadone maintenance patients who had been on a stable dose of methadone for at least 2 months, and obtained ratings of depression and anxiety, levels of sex hormones, and liver function tests. Five subjects with significantly lower Global Sexual Satisfaction Index scores (p < .0001) had more psychological symptoms, higher methadone doses, poorer body image, and less sexual drive and satisfaction, but normal fund of sexual information and lifetime experience. Sexual dysfunction among methadone maintenance patients may be due to coexisting psychiatric problems rather than caused by opiates. Methadone patients presenting with sexual dysfunction should receive psychiatric evaluation.

Psychiatric illness among drug court probationers.

The purpose of this study was to identify the level of psychiatric symptoms reported by probationers involved with a drug court in Hennepin County, Minnesota. Sixty probationers completed a brief demographic interview, the Beck Depression and Anxiety Inventories (BDI and BAI) and a measure of medical quality of life. Fifteen participants completed a structured interview for psychiatric diagnosis (SCID‐I). The sample was predominantly male, African American, and unemployed. Over 40% had received treatment for psychiatric problems, including 20% who reported a history of inpatient psychiatric admission and 15% currently taking a psychotropic medication. More than 1/3 of BDI and BAI scores were moderate to severe. The mean Short Form (SF)‐36 scores were significantly lower than in the general population. Trends suggested more distress associated with: Caucasian race, female gender, less education, unemployment, and less previous legal involvement. Of 15 participants that completed a SCID‐I, 13 participants met lifetime diagnostic criteria for at least one psychiatric disorder. The most common diagnoses were major depressive disorder and posttraumatic stress disorder (PTSD). Three participants met diagnostic criteria for current psychotic disorder. Half of participants who currently met criteria for a disorder reported that they had never received psychiatric treatment. Results indicate participants currently were experiencing high rates of emotional symptoms. Serious mental illness was common. Many of these individuals had not been identified previously as needing psychiatric treatment. More frequent and thorough screening for psychiatric illness in drug court settings is necessary to identify serious psychiatric illnesses.

Improving the quality of VA care for patients with substance-use disorders: the Quality Enhancement Research Initiative (QUERI) substance abuse module.

Substance-use disorders are costly in both human and economic terms and are highly prevalent among patients in the VA Health Care System. The Quality Enhancement Research Initiative (QUERI) Substance Abuse Module (SAM) seeks to enhance identification and management of patients with substance-use disorders seen in primary care and other medical settings; bolster specialized substance-abuse treatment practices; improve care for patients with multiple comorbidities; and strengthen treatment for high-risk and underserved substance-abuse patient subgroups. This article describes how the SAM will achieve these aims by following the QUERI process steps and conducting an integrated set of research projects that incorporates literature reviews and meta-analyses, naturalistic and randomized controlled trials of promising treatments, studies of barriers to guideline implementation, and outcome-oriented evaluations of the implementation of practice guidelines.