Marshall R. Thomas

Intracellular calcium signalling in peripheral cells of patients with bipolar affective disorder.

SummaryConsistent with previous studies, elevated free intracellular calcium ion concentrations ([Ca2+]i) were found in blood platelets and lymphocytes of patients with mania and bipolar depression. Incubation with an ultrafiltrate of plasma from patients with bipolar illness had no effect on intracellular calcium ion concentration in platelets from normal subjects, suggesting that elevated [Ca2+]i is not due to a circulating factor. As was true in an earlier study of the effect of lithium on platelets, incubation with therapeutic levels of carbamazepine lowered [Ca2+]i in lymhocytes from affectively ill patients but not controls. Increased [Ca2+]i in peripheral cells may reflect a diffuse change in cellular homeostasis and may contribute to mixtures as well as rapid alternations of activity of affective, behavioral and physiologic systems in bipolar illness. Correction of the abnormality may at least be a marker of a relevant therapeutic action if it is not the action itself.

Nicardipine improves the antidepressant action of ECT but does not improve cognition.

Introduction Cognitive impairment, the most important adverse effect of electroconvulsive therapy (ECT), may involve elevated intracellular calcium ion signaling. Animal research suggests that calcium channel-blocking agents, which attenuate excessive intracellular calcium activity, may reduce cognitive dysfunction caused by ECT. Method The lipid-soluble calcium channel-blocking drug nicardipine or matching placebo were randomly assigned to 26 patients with major depressive disorder receiving ECT. A rater blind to the experimental condition administered the Hamilton Depression Rating Scale, the Montgomery-Asberg Depression Rating Scale, the Beck Depression Inventory, the Mini-Mental State Examination and a comprehensive battery of neuropsychological tests prior to ECT, at the completion of ECT, and 6 months after ECT completion. Results Compared with patients receiving placebo, patients taking nicardipine had significantly lower scores on the Hamilton and Montgomery-Asberg but not the Beck Depression rating scale scores at the completion of ECT. There were no differences between placebo and nicardipine groups in depression scores 6 months after ECT. Cognitive function declined over the course of ECT and improved over the next 6 months in both groups, but changes were statistically significant for only two subtests on the neuropsychological battery. Changes in Mini-Mental State Examination scores were small and were not significant at any point. There were no significant differences between nicardipine and placebo treated groups in any assessment of cognition. Discussion Standard approaches to ECT in younger patients without preexisting neurological impairment do not produce cognitive side effects of sufficient severity for calcium channel-blocking agents to reduce these side effects demonstrably. Studies of treatments for cognitive impairment should be conducted in patients with risk factors for more severe cognitive impairment such as geriatric patients or patients with a history of interictal delirium during previous treatment with ECT. A possible effect of nicardipine in enhancing the antidepressant action of ECT requires further investigation in a study designed to test this action.

BEYOND SPECIFICITY: EFFECTS OF SEROTONIN AND SEROTONERGIC TREATMENTS ON PSYCHOBIOLOGICAL DYSFUNCTION

Serotonin is a ubiquitous neurotransmitter with widespread projections that provide for the involvement of serotonin in the regulation of many biological and psychological functions. A variety of serotonin receptor subtypes exist that mediate overlapping psychobiological functions and that are targets for a new generation of medications. Although these new generation medications appear to possess great biochemical specificity, their actions extend to many psychiatric disorders, reflecting the many interactions of serotonergic subsystems.

Public-Academic Partnerships: Evidence-Based Implementation: The Role of Sustained Community-Based Practice and Research Partnerships

This column describes a process for adapting an evidence-based practice in community clinics in which researchers and community providers participated and the resulting framework for implementation of the practice-Replicating Effective Programs-Facilitation. A two-day meeting for the Recovery-Oriented Collaborative Care study was conducted to elicit input from more than 50 stakeholders, including community providers, health care administrators, and implementation researchers. The process illustrates an effective researcher-community partnership in which stakeholders worked together not only to adapt the evidence-based practice to the needs of the clinical settings but also to develop the implementation strategy.

Teaching psychiatry to primary care internists

Many patients who seek the care of primary care physicians are suffering from a wide variety of psychiatric disorders. Primary care physicians should become skilled in interviewing techniques and basic psychiatric differential diagnosis, management, and treatment approaches for some types of psychiatric disorders and learn to regularly consult with and make referrals to psychiatrists when appropriate. Psychiatrists should play a very active role in the education of primary care specialists. This should include observation of the physician interviewing patients with different types of psychiatric disorders in addition to didactic teaching and supervision on topics such as psychopharmacology. With mutual collaboration between primary care interests and psychiatrists the patients of both groups of physicians should receive better care and continuing education of both may occur through an ongoing dialogue.

Realigning Clinical and Economic Incentives to Support Depression Management Within a Medicaid Population: The Colorado Access Experience

The authors describe their experiences in developing an economically sustainable depression care management program within Colorado Access, a non-profit Medicaid health plan. They describe high rates of mental health issues, medical comorbidities, and psychosocial barriers to care within the plan’s Medicaid population. They discuss how the company redirected resources to incorporate depression care management into an intensive care management program focused on high-cost members with multiple chronic medical conditions. This strategy allowed Colorado Access to cost effectively care manage a targeted group of high-cost Medicaid recipients across multiple primary care physician (PCP) practices without requiring changes in provider workflow.

The Role of Clinical Information Technology in Depression Care Management

We examine the literature on the growing application of clinical information technology in managing depression care and highlight lessons learned from Robert Wood Johnson Foundation’s national program “Depression in Primary Care-Incentives Demonstrations.” Several program sites are implementing depression care registries. Key issues discussed about implementing registries include using a simple yet functional format, designing registries to track multiple conditions versus depression alone (i.e., patient-centric versus disease-centric registries) and avoiding violations of patient privacy with the advent of more advanced information technologies (e.g., web-based formats). Finally, we discuss some implications of clinical information technology for healthcare practices and policy makers.

Dissociative symptoms in psychotic mood disorders: an example of symptom nonspecificity.

Dissociative symptoms have been the subject of psychiatric inquiry since the beginning of this century (Putnam 1992; Sanders 1986; van der Kolk and van der Hart 1989). Although recent investigations have focused on the four specific dissociative disorders (American Psychiatric Association 1994) and their relationship to early traumatic experiences (Chu and Dill 1990; Putnam 1985; Terr 1991), dissociative symptoms have been reported in virtually every major psychiatric disorder (Bremner et al. 1992; Goff et al. 1992; Steinberg 1992), and, in less severe forms, even in nonpatient populations (Briere 1988; Putnam 1992; Ross and Joshi 1992). These observations raise questions about the clinical significance of dissociative symptoms that occur when other mental disorders are also present (Coons 1984; Fahy 1988).

Selection bias in an inpatient outcomes monitoring project

Managed care organizations increasingly tout clinical outcomes assessment as the mechanism by which we will ensure quality and compare providers. The authors report on their experience with a multisite inpatient outcomes monitoring project by comparing patients who accepted (N = 51), refused (N = 36), or were not asked (N = 110) to participate in the project. The patients who were asked to participate had significantly longer inpatient stays compared with the unasked group (11.2 vs 6.9 days). Patients who agreed to participate in the project were more likely to have a bipolar (43.1% vs 19.2%) or any affective disorder (94.1% vs 79.5%), and less likely to have a schizophrenic disorder (2.0% vs 11.6%) than the refused and unasked groups. The project participants also had higher 90-day readmit rates (27.5% vs 9.6%), more readmissions (0.51 vs 0.16), and more education (14.59 vs 13.51 years) than nonparticipating patients. In this preliminary study, patient-related variables were found to influence who the staff asked and who consented to participate in this clinical outcomes monitoring project. The authors distinguish clinical outcomes monitoring from treatment effectiveness research and discuss the need to develop methodologies that deal with nonrepresentative patient sampling and intersite variability in recruitment practices.

Meaningful Use: A National Framework for Integrated Telemedicine

INTRODUCTION The Centers for Medicare and Medicaid Services has incentivized electronic health records (EHRs) implementation through meaningful use (MU) to improve healthcare quality and efficacy. Telemedicine is a key tool that has shown its ability to facilitate MU through technological innovation with cost savings and has shown promise in the area of integrated behavioral healthcare. The purpose of this article is to propose a model of MU to frame the incentivized implementation of an integrated telemedicine (ITM)-specific model to effect system-level change. MATERIALS AND METHODS We reviewed the background, principles, and a justification for the ITM Model including cost issues, the development and structure of MU in the context of EHRs, the benefits of integrated behavioral healthcare and telemedicine, and the case for their combined implementation in the form of ITM. RESULTS The model proposed, the ITM Incentive Program, parallels the current MU program and is composed of three stages. Stage 1 focuses on incentivizing current and new Medicaid providers to adapt, implement, and upgrade technology needed to conduct virtual meetings with patients and other healthcare professionals. Stage 2 is a tiered incentive system with process-focused and track metrics related to increasing the number of consultations with patients. In Stage 3, providers are encouraged to continue use of ITM by meeting thresholds for several objectives focused on clinical outcomes. Recommendations for implementing this model within a payment waiver system are discussed. CONCLUSIONS The ITM Model offers a needed union of integrated care and telemedicine through the combination of technology, business, and clinical processes. The success of MU as a tiered incentive program for EHRs, as well as the precedent of using waiver opportunities for incentive funding repayments, sets forth a strategic framework to successful implementation of ITM to address cost issues and improve quality and access to care in the healthcare system.