Biomedical subjects

A C Leon

Publications and source records attributed to A C Leon.

At least 55 records · Page 3Linked to original sources

PubMed1998

Major depressive disorder: a prospective study of residual subthreshold depressive symptoms as predictor of rapid relapse.

BACKGROUND: The study tested whether level of recovery from major depressive episodes (MDEs) predicts duration of recovery in unipolar major depressive disorder (MDD) patients. METHODS: MDD patients seeking treatment at five academic centers were followed naturalistically for 10 years or longer. Patients were divided on the basis of intake MDE recovery into residual depressive symptoms (SSD; N=82) and asymptomatic (N=155) recovery groups. They were compared on time to first episode relapse/recurrence, antidepressant medication, and comorbid mental disorders. Recovery level was also compared to prior history of recurrent MDEs ( > 4 lifetime episodes) as a predictor of relapse/recurrence. RESULTS: Residual SSD compared to asymptomatic recovery patients relapsed to their next MDE > 3 times faster (median=68 vs. 23 weeks) and to any depressive episode > 5 times faster (median=33 vs. 184 weeks). Residual SSD recovery status was significantly associated with early episode relapse (OR=3.65) and was stronger than history of recurrent MDEs (OR=1.64). Rapid relapse in the SSD group could not be attributed to higher comorbidity or lower antidepressant treatment. LIMITATIONS: Although inter-rater agreement on weekly depressive symptom ratings was very high (ICC > 0.88), some error may exist in assigning recovery levels. Antidepressant treatments were recorded, but were not controlled. CONCLUSIONS: MDE recovery is a powerful predictor of time to episode relapse/recurrence. Residual SSD recovery is associated with very rapid episode relapse which supports the idea that SSD is an active state of illness. Asymptomatic recovery is associated with prolonged delay in episode recurrence. These findings of this present study have important implications for the goals of treatment of MDD and for defining true MDE recovery.

Adult↗

PubMed1998

Human immunodeficiency virus among trauma patients in New York City.

STUDY OBJECTIVE: To determine the HIV seroprevalence rates in relation to the demographic characteristics of victims, cause of death, and toxicology findings in a sample of victims of violence and accidents who presented to emergency departments before death. METHODS: This descriptive survey of a complete 3-year sample of homicides and accidents was conducted in 5 boroughs of New York City (population 7,322,564). Persons 15 years of age and older injured by intentional violence or accidents (excluding drug overdoses, falls from short heights, and suicides) who presented to hospitals, died, and were sent to the medical examiner were included. Standard methods were used to test plasma and serum samples for HIV and cocaine or its metabolite. Chi2 Tests compared HIV seroprevalence across groups according to demographic characteristics and toxicology findings. Logistic regression analysis was done for those variables found to be significant with chi2 tests. All statistical tests were conducted with 2-tailed alpha levels of .05. RESULTS: Among the 1,242 subjects in the sample, 90 (7.2%) had positive findings. Male patients (8%) had higher rates than female patients (3.4%). HIV rates were highest among patients 35 to 44 years of age (20.8%), followed by the 45- to 54-year age group (9.6%) and 25- to 34-year age group (8.1%). Victims of homicide (8.2%) and accidents other than motor vehicle crashes (10.5%) had higher rates than victims of motor vehicle crashes (4%). Patients with positive results for cocaine (16.3%) were more likely than those with negative result (5.8%) to be HIV positive. There were no statistically significant differences by race, except that no Asians were HIV positive. Logistic regression analysis found that only age and positive cocaine results, not sex and race, were related to increased risk of HIV infection. CONCLUSION: We found the rate of HIV infection among victims of fatal trauma was significant, especially in those with evidence of cocaine use. The HIV infection rate approximates the high end of the range of HIV rates found in studies before 1990. It further emphasizes the need for use of universal precautions in the care of trauma patients.

Accidents↗

PubMed1998

Association of recurrent suicidal ideation with nonremission from acute mixed mania.

OBJECTIVE: The authors' goal was to examine suicidality in relation to acute symptom remission in inpatients with mixed and pure bipolar disorder. METHOD: Using chart review of 184 adult inpatients with bipolar I disorder, the authors assessed patients' past and current suicidality, other psychopathology, treatment, and remission. RESULTS: Past, current, and recurrent suicidality were significantly more common among patients with mixed mania than among those with pure mania. The probability of remission declined by 49% for every suicide attempt made before the index manic episode. Mixed mania, multiple previous hospitalizations, and previous suicide attempts were significantly associated with current suicidality. CONCLUSIONS: Suicidality is linked with mixed manic states and may be a clinical marker for recurrent dysphoric mania. Multiple suicide attempts are associated with nonremission from mixed manic episodes.

Acute Disease↗

PubMed1998

Aborted suicide attempts: a new classification of suicidal behavior.

OBJECTIVE: With the goal of ultimately finding early suicide predictors, the authors undertook a study of aborted suicide attempts. They defined such an attempt as an event in which an individual comes close to attempting suicide but does not complete the act and thus sustains no injury. METHODS: The authors interviewed a random sample of 135 adult psychiatric inpatients concerning their past suicidal behavior. Using standardized scales, they assessed suicidal intent for aborted suicide attempts and actual suicide attempts, as well as degree of injury for actual attempts. RESULTS: Over half of the 135 subjects reported making at least one aborted suicide attempt. Aside from younger age, no demographic characteristics were associated with aborted attempts. Aborted attempts were reported more often in subjects with a diagnosis of borderline personality disorder than in subjects with other diagnoses. Intent scores for aborted attempts were comparable to those for actual suicide attempts. Subjects who had made an aborted attempt were nearly twice as likely to have made an actual suicide attempt as subjects with no aborted attempts. Among subjects with both aborted and actual attempts, the first aborted attempt preceded the first actual attempt approximately half the time. CONCLUSIONS: Aborted suicide attempts were reported commonly by psychiatric inpatients, had a similar level of intent as actual attempts, and were highly associated with actual attempts. Thus, clinicians should specifically ask patients about aborted attempts as a part of the suicide history. Further study is needed to examine the association between aborted suicide attempts and suicide.

Adult↗

PubMed1998

Lithium discontinuation and subsequent effectiveness.

OBJECTIVE: Several reports have raised concern that the discontinuation of lithium may result in treatment resistance following recurrence of affective disorder. This report explores this possibility. METHOD: The data derive from a large, naturalistic follow-up of patients with major depressive disorder or mania. Twenty-eight of the patients in the study were free of lithium and experiencing an episode of mania or schizoaffective mania diagnosed according to Research Diagnostic Criteria when they entered the study, recovered while taking lithium, later experienced a recurrence while not taking lithium, and then resumed lithium treatment. Survival analyses of time to recovery and, subsequently, time to recurrence, used continued lithium treatment as an additional censoring variable. RESULTS: Patients given lithium recovered no more quickly from their index episode than they did from their first prospectively observed episode. Moreover, lithium prophylaxis appeared no less effective after the first prospectively observed episode than after the index episode. CONCLUSIONS: These findings provide no evidence that lithium discontinuation results in treatment resistance when lithium is resumed.

Adult↗

PubMed1998

Rapid titration of mood stabilizers predicts remission from mixed or pure mania in bipolar patients.

BACKGROUND: Recent investigations have suggested that the antimanic agents divalproex sodium and carbamazepine may each hasten hospital discharge and be especially beneficial in treating mixed-state mania. This study retrospectively compared the time to remission for pure versus mixed manic bipolar inpatients who were taking lithium, divalproex, or carbamazepine, or their combination, under naturalistic conditions. METHOD: Records were reviewed for 120 bipolar inpatients from 1991 to 1995. Research DSM-III-R diagnoses of pure or mixed mania were assigned along standardized guidelines. Data were obtained on daily symptoms, medication doses, and blood levels. Weekly improvement was evaluated by Kaplan-Meier survival analysis of Clinical Global Impressions scale scores. Variables associated with "remission" versus "nonremission" were examined by logistic regression. RESULTS: Mixed mania (N = 70) was more common than pure mania (N = 50). No significant differences were observed in the time to remission for mixed or pure manic bipolar patients who took lithium compared with those who took divalproex or carbamazepine. In patients who remained symptomatic with lithium as a single-agent mood stabilizer despite therapeutic serum lithium levels, the addition of a second mood stabilizer led to rapid symptom improvement. Among all medication subgroups, the speed with which patients achieved therapeutic blood levels of any of these agents significantly affected the time to remission. CONCLUSION: Mixed manic bipolar patients taking lithium, divalproex, or carbamazepine under naturalistic conditions remit at comparable rates. Those failing to respond to single-agent mood stabilizers often receive combinations of mood stabilizers. However, delays in optimizing a medication regimen may attenuate short-term outcome, regardless of the mood stabilizer selected. Rapid achievement of therapeutic blood levels of any antimanic agent appears to be strongly related to swift symptom remission.

Adult↗

PubMed1998

A strategy to evaluate a covariate by group interaction in an analysis of covariance.

Analysis of covariance (ANCOVA) is commonly used in psychiatric research to statistically adjust for illness severity when making group comparisons. A fundamental assumption of the procedure is that the groups' differences in outcome are constant across all levels of baseline severity. This is the classic assumption of equal linear slopes. The plausibility of this assumption is rarely reported in manuscripts that use an ANCOVA. A statistical model is discussed that can be used to test the assumption, and if the assumption is not fulfilled, the model can incorporate a covariate by group interaction. An application of this model, the multiple linear regression approach to analysis of covariance, is provided using data from a large clinical trial for patients with panic disorder. The authors recommend that manuscripts reporting results from an ANCOVA also report the results of the test of the covariate by group interaction and account for the interaction when the slopes are heterogeneous.

Alprazolam↗

PubMed1997

Recovery from major depression. A 10-year prospective follow-up across multiple episodes.

BACKGROUND: Major depressive disorder is often marked by repeated episodes of depression. We describe recovery from major depression across multiple mood episodes in patients with unipolar major depression at intake and examine the association of sociodemographic and clinical variables with duration of illness. METHODS: A cohort of 258 subjects treated for unipolar major depressive disorder was followed up prospectively for 10 years as part of the Collaborative Depression Study, a multicenter naturalistic study of the mood disorders. Diagnoses were made according to the Research Diagnostic Criteria, and the course of illness was assessed with the Longitudinal Interval Follow-up Evaluation. Survival analyses were used to calculate the duration of illness for the first 5 recurrent mood episodes after recovery from the index episode. RESULTS: Diagnosis remained unipolar major depressive disorder for 235 subjects (91%). The median duration of illness was 22 weeks for the first recurrent mood episode, 20 weeks for the second, 21 weeks for the third, and 19 weeks for the fourth and fifth recurrent mood episodes; the 95% confidence intervals were highly consistent. From one episode to the next, the proportion of subjects who recovered by any one time point was similar. For subjects with 2 or more recoveries, the consistency of duration of illness from one recovery to the next was low to moderate. None of the sociodemographic or clinical variables consistently predicted duration of illness. CONCLUSION: In this sample of patients treated at tertiary care centers for major depressive disorder, the duration of recurrent mood episodes was relatively uniform and averaged approximately 20 weeks.

Adult↗

PubMed1997

Service utilization and expenditures for the treatment of panic disorder.

The outpatient service utilization and estimated expenditures for the treatment of panic disorder for patients prior to their enrollment in a large clinical trial were examined. Data were drawn from the Cross-National Collaborative Panic Study. The sample consists of 391 patients who met DSM-III criteria for panic disorder and were enrolled at one of the US sites of the trial. The rate and frequency of outpatient mental health visits to primary care and specially mental health providers for the current episode of panic disorder are examined. Estimates of direct expenditures for these services are presented (in 1993 US dollars). Over 70% of the patients used primary care for mental health services whereas about 47% of the patients used specialty mental health services. Nearly half of the patients (46.8%) saw a nonpsychiatrist medical specialist, most often a cardiologist (20.6%). Among all patients, those with more frequent panic attacks were more likely to use some form of outpatient mental health services for panic disorder. Among users of any services, those with more severe impairment were more likely to use specialized mental health services. The mean estimated expenditure for the panic episode was $3339, about half of which was accounted for by specialty mental health expenditures. Among users, the median estimated expenditures was $518 for primary care physicians and $2122 for specialty mental health services. In conclusion, the service utilization in this sample of patients with panic disorder is highly varied. Both the primary care and specialty mental health sectors play prominent roles in the community treatment of panic disorder.

Adult↗

PubMed1997

The prevalence of aborted suicide attempts among psychiatric in-patients.

We report the prevalence of aborted suicide attempts in which the essential characteristics are (i) intent to kill oneself (ii) a change of mind before making an actual suicide attempt and (iii) the absence of physical injury. The lifetime history of aborted suicide attempts was assessed by semi-structured interview of 733 patients, aged 18-59 years, who were consecutively admitted to a psychiatric hospital. In the study group, 46% of subjects had made a suicide attempt and 29% had made at least one aborted attempt during their lifetime. Subjects who had made aborted attempts were more likely to have made actual attempts. Approximately 11% of the subjects in the study group had a history of aborted attempts of potential high lethality, such as going to a height in order to jump, or holding a gun to the head. There were no major demographic differences between those with and without a history of aborted attempts. However, among those with no prior history of actual attempts, subjects with depression and a family history of suicide were more than twice as likely as those without such a history to have made an aborted attempt. Aborted suicide attempts are a common suicidal behaviour among psychiatric in-patients. Whether they predict actual attempts or suicide warrants prospective investigation.

Adolescent↗

PubMed1997

Lower risk of suicide during pregnancy.

OBJECTIVE: The authors determined the risk of suicide during pregnancy. METHOD: The autopsy reports of all female residents of New York City, 10-44 years old, who committed suicide from 1990 to 1993 were assessed for pregnancy. These data were compared with age-adjusted and race-adjusted standardized mortality ratios for women, which were calculated by using population data from the 1990 U.S. Census as well as data obtained from the New York City Health Department on the number of live births, spontaneous abortions, and induced abortions. RESULTS: The standardized mortality ratio for suicide during pregnancy was 0.33; that is, the number of suicides of pregnant women was only one-third of that expected. CONCLUSIONS: Despite the mood swings and stresses associated with pregnancy and impending childbirth, pregnant women have a significantly lower risk of suicide than women of childbearing age who are not pregnant.

Adult↗

PubMed1997

Violence by patients admitted to a private psychiatric hospital.

OBJECTIVE: The authors determined the rates and patterns of violence toward persons by psychiatric patients before admission to the inpatient service of the Payne Whitney Clinic and determined which factors were associated with a greater risk of violence. METHOD: During hospitalization, 763 patients were interviewed by a research assistant using a structured interview instrument. The interviewer inquired about demographic and socioeconomic information and about history of violence and alcohol and drug use. RESULTS: Having physically attacked another person in the month before admission was equally likely among male (13.6%) and female (14.7%) patients. The patterns of violence were similar for men and women in terms of target, severity of injuries, use of a weapon, and place of occurrence. Univariate analyses showed that only youth was associated with violence for male patients, while youth, low socioeconomic status, substance abuse, and axis II pathology were associated with a greater risk of violence for female patients. Logistic regression analyses showed that recent cocaine use was significantly associated with violence by female patients when age, socioeconomic status, and axis II pathology were controlled for. For male patients, recent heroin use was related to a greater risk of violence. CONCLUSIONS: The frequency of violence by female patients was 150% higher than it was in a study at the Payne Whitney Clinic a decade ago. The frequency of violence by male patients was 50% higher than it was a decade ago. In the current study, substance abuse was associated with greater risk of violence by patients.

Adolescent↗

PubMed1997

False positive results: a challenge for psychiatric screening in primary care.

OBJECTIVE: The goal of this study was to characterize primary care patients with false positive results on screens for mental disorders. METHOD: A sample of 1,001 primary care patients completed self-administered screens and structured interviews for DSM-IV diagnoses. RESULTS: A substantial proportion of the patients with false positive screen results for at least one diagnosis met the diagnostic criteria for other psychiatric disorders. They also had significantly greater functional impairment and higher rates of recent use of mental health services than the subjects with true negative results on the screens. CONCLUSIONS: Although the positive predictive values of screens for specific mental disorders are in line with those of other medical screens, false positive results are not uncommon. This may be due in part to the sensitivity of brief screening instruments to nonspecific symptoms. The results suggest that as with other screens used in primary care, patients with false positive results on screens for mental disorders should receive clinical attention.

Adolescent↗

PubMed1997

HIV seroprevalence among suicide victims in New York City, 1991-1993.

OBJECTIVE: The authors sought to determine the HIV seroprevalence among suicide victims in New York City. METHOD: All suicides of city residents from 1991 through 1993 were studied. The crude proportion of all suicide victims who were HIV positive and the proportion adjusted to the age, gender, and racial/ethnic characteristics of the New York City population were determined. The demographically adjusted proportion was then contrasted with HIV seroprevalence estimates for the New York City general population. HIV-seropositive suicide victims were assessed for pathological findings suggestive of HIV-related illnesses. RESULTS: The crude proportion of all suicide victims who were HIV seropositive was 0.088, and the demographically adjusted proportion was 0.049. Over 90% of all HIV-positive suicide victims were aged 25 to 54 years, and almost 90% were men. Among black and Hispanic men aged 35 to 54 years who committed suicide, the proportion who were HIV seropositive was 0.252--the highest seropositive rate of any demographic group. More than two-thirds of HIV-seropositive suicide victims had no HIV-related pathology or AIDS-indicator conditions at autopsy. CONCLUSIONS: The demographically adjusted proportion of suicide victims who were HIV positive (approximately 0.038 to 0.059), contrasted with the HIV seroprevalence estimates for the New York City general population (approximately 0.014 to 0.032), the absence of HIV-related pathology among suicide victims, and the likelihood that many HIV-positive individuals had other risk factors for suicide, such as substance abuse, suggests that a positive HIV serostatus is associated, at most, with a modest elevation in suicide risk.

Adult↗

PubMed1997

Mental disorders and disability among patients in a primary care group practice.

OBJECTIVE: This article examines social and occupational disability associated with several DSM-IV mental disorders in a group of adult primary care outpatients. METHOD: The subjects were 1,001 primary care patients (aged 18-70 years) in a large health maintenance organization. Data on each patient's sociodemographic characteristics and functional disability, including scores on the Sheehan Disability Scale, were collected at the time of a medical visit. A structured diagnostic interview for current DSM-IV disorders was then completed by a mental health professional over the telephone within 4 days of the visit. RESULTS: The most prevalent disorders were phobias (7.7%), major depressive disorder (7.3%), alcohol use disorders (5.2%), generalized anxiety disorder (3.7%), and panic disorder (3.0%). A total of 8.3% of the patients met the criteria for more than one mental disorder. The proportion of patients with co-occurring mental disorders varied by index disorder from 50.0% (alcohol use disorder) to 89.2% (generalized anxiety disorder). Compared with patients who had a single mental disorder, patients with co-occurring disorders reported significantly more disability in social and occupational functioning. After adjustment for other mental disorders and demographic and general health factors, compared with patients with no mental disorder, only patients with major depressive disorder, bipolar disorder, phobias, and substance use disorders had significantly increased disability, as measured by the Sheehan Disability Scale. CONCLUSIONS: Primary care patients with more than one mental disorder are common and highly disabled. Individual mental disorders have distinct patterns of psychiatric comorbidity and disability.

Persons with Disabilities↗

PubMed1997

Sexual functioning in chronically depressed patients treated with SSRI antidepressants: a pilot study.

OBJECTIVE: This prospective study assessed changes in depression and sexual functioning in chronically depressed men and women during treatment with selective serotonin reuptake inhibitors (SSRIs). METHOD: Twenty-five subjects (14 women, 11 men) with DSM-III-R dysthymia, chronic major depression, or double depression were administered the Arizona Sexual Experience Scale and the Hamilton Depression Rating Scale before and after 6 weeks of treatment with sertraline or paroxetine. RESULTS: As measured by scores on the Arizona Sexual Experience Scale, desire, psychological arousal, and overall sexual functioning significantly improved in women; orgasm delay, orgasm satisfaction, and overall sexual functioning significantly worsened in men. CONCLUSIONS: This study suggests that after SSRI treatment, difficulties with desire and psychological arousal in depressed women tend to remit, whereas in men orgasmic dysfunction appears to be a side effect to medication.

Adult↗

PubMed1997

A prospective study of violence by psychiatric patients after hospital discharge.

OBJECTIVE: The study assessed the frequency of violence by patients two weeks after discharge from a psychiatric hospital and identified characteristics of patients with an increased risk of violence after discharge. METHODS: A structured form was used to interview patients aged 18 to 59 years in a private university psychiatric hospital. Patients provided self-reports of past violence, and violence while in the hospital was assessed by routine nurse ratings. Patients were telephoned two weeks after discharge to assess violence since discharge. RESULTS: Sixteen of 430 patients who were interviewed by telephone two weeks after discharge reported violence against persons since their discharge. Patients who were violent in the month before admission were nine times more likely to be violent in the two weeks after discharge, compared with patients who were not violent just before admission. Patients with a personality disorder were four times more likely than patients without a personality disorder to be violent after discharge. The targets of violence were often family members or other intimates and often the same persons attacked before hospitalization. CONCLUSIONS: Patients who were violent just before admission were more likely to be violent after discharge and to attack the same persons they had attacked in the past. Clinicians should routinely evaluate past violence and work with the patient and potential targets of violence to prevent future violence.

Adult↗

PubMed1997

Assessing psychiatric impairment in primary care with the Sheehan Disability Scale.

OBJECTIVE: Several recent studies have documented that substantial functional impairment is associated with many of the mental disorders seen in primary care. However, brief measures of mental health-related functional impairment are not commonly applied in primary care settings. The Sheehan Disability Scale (SDS), a three-item instrument for assessing such impairment, is evaluated in this study. METHOD: A psychometric analysis of the SDS was conducted with a sample of 1001 primary care patients at Kaiser Permanente In Oakland, California. The SDS and the Symptom Driven Diagnostic System for Primary Care assessments were completed. RESULTS: The internal consistency reliability of the SDS is high, with coefficient alpha of 0.89. The construct validity was substantiated in two ways. A one-factor model fit the data quite well. Furthermore, patients with each of six psychiatric disorders had significantly higher impairment scores than those who did not. Finally, over 80 percent of the patients with mental disorder diagnoses had an elevated SDS score and nearly 50 percent of those with elevated SDS scores had at least one disorder. CONCLUSIONS: The psychometric properties of the SDS were evaluated in primary care. The internal consistency reliability was high. The analyses also lend empirical support for the construct validity. The scale is a sensitive tool for identifying primary care patients with mental health-related functional impairment, who would warrant a diagnostically-oriented mental health assessment.

Adolescent↗