Sahana Misra

Referral paths, patient profiles and treatment adherence of older alcoholic men

We sought factors affecting completion by older men of 1-year outpatient treatment for alcohol dependence. We retrospectively studied clinical datasets of 110 men, age > or =55 years, consecutively admitted over 4 years, examining the association of 18 referral, treatment and patient variables with completion of treatment. We found that referral source was the most significant correlate of completion. Legal and self/family referrals were far more likely to complete treatment than patients referred by health or social services. Referral groups had distinctive profiles. Legal referrals were the healthiest. Self/family referrals were most likely to be married, to have had prior alcoholism treatment (a factor also associated with treatment completion), and to suffer currently from depression. Health/social services referrals showed the highest levels of psychosocial and physical dysfunction. Referral pathways deserve special consideration by programs treating older alcoholics. Special strategies for engaging dysfunctional older patients in alcoholism treatment are discussed.

Delirium, depression, and anxiety

Patients who are critically ill often develop a variety of psychiatric symptoms, which require assessment and treatment. The most common psychiatric disorder in the intensive care unit is delirium. Depressed mood and anxiety also occur, at times as discrete disorders, but more often secondary to delirium. Patients with severe mental illnesses, such as schizophrenia and bipolar affective disorder, also may become critically ill--assessment and management of these patients often requires specialized psychiatric care and is not addressed here.

Psychiatric Resident and Faculty Views on and Interactions With the Pharmaceutical Industry

ObjectiveSales visits, or detailing, by pharmaceutical industry representatives at academic institutions has been increasingly criticized. The authors surveyed psychiatric residents and faculty members on their views and interactions with representatives of the pharmaceutical industry.MethodsIn 2007, a 46- item online survey measuring attitudes toward and interactions with pharmaceutical industry representatives was sent to 49 faculty psychiatrists and 40 psychiatric trainees (residents and fellows) at a Northwest academic medical center.ResultsSixty- five percent (N=58) of surveys were completed. Two- thirds of respondents did not agree that pharmaceutical representatives have an important teaching role. Only 24% of faculty and 18% of trainees agreed that pharmaceutical representatives provide useful and accurate information on new drugs. Forty- one percent of faculty and 53% of trainees agreed that pharmaceutical representatives should be restricted from making presentations on campus. Trainees were less likely than faculty to agree that they would maintain contact with representatives if no gifts or food were distributed. Nevertheless, most respondents endorsed that pharmaceutical companies supported important conferences, and more than 90% had attended an industry- sponsored event in the previous year. In open- ended questioning, respondents revealed worries that bans would undermine the ability to secure national speakers and to support other activities that residents valued.ConclusionFaculty and psychiatric residents and fellows do not view pharmaceutical representatives as having an important teaching role and mistrust the information they offer but believe that loss of industry financial support does adversely affect educational and other highly valued activities. They favor greater policy restrictions but do not support an outright ban on pharmaceutical support.

Addressing risks to advance mental health research.

IMPORTANCE Risk communication and management are essential to the ethical conduct of research, yet addressing risks may be time consuming for investigators and institutional review boards may reject study designs that seem too risky. This can discourage needed research, particularly in higher-risk protocols or those enrolling potentially vulnerable individuals, such as those with some level of suicidality. Improved mechanisms for addressing research risks may facilitate much needed psychiatric research. OBJECTIVE To provide mental health researchers with practical approaches to (1) identify and define various intrinsic research risks, (2) communicate these risks to others (eg, potential participants, regulatory bodies, and society), (3) manage these risks during the course of a study, and (4) justify the risks. EVIDENCE REVIEW As part of a National Institute of Mental Health-funded scientific meeting series, a public conference and a closed-session expert panel meeting were held on managing and disclosing risks in mental health clinical trials. The expert panel reviewed the literature with a focus on empirical studies and developed recommendations for best practices and further research on managing and disclosing risks in mental health clinical trials. No institutional review board-review was required because there were no human subjects. FINDINGS Challenges, current data, practical strategies, and topics for future research are addressed for each of 4 key areas pertaining to management and disclosure of risks in clinical trials: identifying and defining risks, communicating risks, managing risks during studies, and justifying research risks. CONCLUSIONS AND RELEVANCE Empirical data on risk communication, managing risks, and the benefits of research can support the ethical conduct of mental health research and may help investigators better conceptualize and confront risks and to gain institutional review board-approval.

A Feeling that You're Helping: Proxy Decision Making for Alzheimer's Research

Surrogate (proxy) decision makers must make research decisions for people with dementia who lack decision-making capacity. Proxies’ decision-making processes are minimally understood. We randomly assigned 82 proxies of AD patients to informed consent for one of three hypothetical protocols with differing levels of risk and benefit. Proxies answered questions about potential benefits of the described research to the patient and society, as well as about whether they would enroll their relative and why or why not. Proxies interested in enrolling their relative cited the potential for direct benefit to their relative, altruism, and trust in researchers. Those declining cited risks, inconvenience, and stage of illness. Proxies weighed numerous factors, incorporating both substituted judgment and best interests standards in their decision-making processes. Although further empirical work is needed to understand the influences on and adequacy of proxies’ decision making regarding research, these findings can help inform policy regarding surrogate consent.

Medical student views on interactions with pharmaceutical representatives.

ObjectiveIn 2006, the Housestaff Association presented the Dean at Oregon Health and Science University (OHSU) with a proposal to effectively end the influence of the pharmaceutical industry on campus. The Dean convened a workgroup to examine the issue, and faculty, residents, and medical students were surveyed on their views and interactions. Authors present here the responses from medical students.MethodsA web-based, anonymous survey was sent to all OHSU medical students in 2007; 59% completed it. The survey included items measuring attitudes about the pharmaceutical industry and interactions with pharmaceutical representatives (PRs).ResultsOnly 5% of clinical and 7% of preclinical students agreed that PRs have an important teaching role, and fewer than 1 in 6 believed that PRs provided useful and accurate information on either new or established drugs; 54% of clinical students indicated that PRs should be restricted from making presentations on campus, versus 32% of preclinical students, and only 30% of clinical students agreed that accepting gifts had no impact on their own prescribing, versus 50% of preclinical students. Students who acknowledged the influence of PRs and perceived less educational benefit were less likely to accept gifts such as textbooks; however, 84% of clinical students had attended an on-campus event sponsored by a pharmaceutical company in the previous year.ConclusionOnly a small proportion of OHSU medical students value interactions with PRs, but many still attend events sponsored by pharmaceutical companies.