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J P Docherty

Publications and source records attributed to J P Docherty.

At least 19 recordsLinked to original sources
PubMed2001

Treatment of depression in women: a summary of the expert consensus guidelines.

Women constitute two-thirds of patients suffering from common depressive disorders, making the treatment of depression in women a substantial public health concern. However, high-quality, empirical data on depressive disorders specific to women are limited, and there are no comprehensive evidence-based practice guidelines on the best treatments for these illnesses. To bridge the gap between research evidence and key clinical decisions, the authors developed a survey of expert opinion concerning treatment of four depressive conditions specific to women: premenstrual dysphoric disorder, depression in pregnancy, postpartum depression in a mother choosing to breast-feed, and depression related to perimenopause/menopause. The survey asked about 858 treatment options in 117 clinical situations and included a broad range of pharmacological, psychosocial, and alternative medicine approaches. The survey was sent to 40 national experts on women's mental health issues, 36 (90%) of whom completed it. The options, scored using a modified version of the RAND Corporation's 9-point scale for rating appropriateness of medical decisions, were assigned one of three categorical rankings-first line/preferred choice, second line/alternate choice, third line/usually inappropriate-based on the 95% confidence interval of each item's mean rating. The expert panel reached consensus (defined as a non-random distribution of scores by chi-square "goodness-of-fit" test) on 76% of the options, with greater consensus in situations involving severe symptoms. Guideline tables indicating preferred treatment strategies were then developed for key clinical situations. The authors summarize the expert consensus methodology they used and then, for each of the four key areas, review the treatment literature and summarize the experts' recommendations and how they relate to the research findings. For women with severe symptoms in each area we asked about, the first-line recommendation was antidepressant medication combined with other modalities (generally psychotherapy). These recommendations parallel existing guidelines for severe depression in general populations. For initial treatment of milder symptoms in each situation, the panel was less uniform in recommending antidepressants, and either gave equal endorsement to other treatment modalities (e.g., nutritional or psychobehavioral approaches in PMDD; hormone replacement in perimenopause) or preferred psychotherapy over medication (during conception, pregnancy, or lactation). In all milder cases, however, antidepressants were recommended as at least second-line options. Among antidepressants, selective serotonin reuptake inhibitors (SSRIs) were recommended as first-line treatment in all situations. The specific SSRIs that were preferred depended on the particular clinical situation. Tricyclic antidepressants were highly rated alternatives to SSRIs in pregnancy and lactation. In evaluating many of the treatment options, the experts had to extrapolate beyond controlled data in comparing treatment options with each other or in combination. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction for addressing common clinical dilemmas in women, and can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions.

Journal Article↗
PubMed2001

Pharmacotherapy of depression in older patients: a summary of the expert consensus guidelines.

Depression in older adults increases disability, medical morbidity, mortality, suicide risk, and healthcare utilization. Most studies of antidepressants are conducted in younger adults, and clinicians often have to extrapolate from findings in populations that do not present the same problems as older patients. Older patients often have serious coexisting medical conditions that may contribute to or complicate treatment of depression; they tend to take multiple medications, some of which may contribute to depression or interact with antidepressants; and they metabolize medications slowly and are more sensitive to side effects than younger patients. To address clinical questions not definitively answered in the research literature, the authors surveyed 50 experts on the pharmacotherapy of depressive disorders in older patients. The survey contained 64 questions with 857 options: 618 of the options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions; for the other 239 options, the experts were asked to write in answers or check a box. The experts reached consensus on 89% of the options rated on the 9-point scale. Categorical rankings (first line/preferred, second line/alternate, third line/usually inappropriate) were assigned to each option based on the 95% confidence interval around the mean rating. Guideline tables indicating preferred treatment strategies were then developed for common and important clinical scenarios. The authors summarize the expert consensus methodology and the experts' recommendations and discuss how they relate to research findings. The experts recommend including both antidepressant medication and psychotherapy in treatment plans for nonpsychotic unipolar major depressive disorder of any severity, as well as for dysthymic disorder or persistent minor depressive disorder. They would also consider using either medication or psychotherapy alone for milder depression. For unipolar psychotic major depression, the treatment of choice is an antidepressant plus one of the newer atypical antipsychotics, with electroconvulsive therapy another first-line option. If the patient has a comorbid medical condition that is contributing to the depression, the experts recommend treating both the depression and the medical condition from the outset. The SSRIs were the top-rated antidepressants for all types of depression, with highest ratings for efficacy and tolerability given to citalopram and sertraline. Paroxetine was another first-line option, and fluoxetine was rated high second line. The preferred psychotherapy techniques for treating depression in older patients are cognitive-behavioral therapy, supportive psychotherapy, problem-solving psychotherapy, and interpersonal psychotherapy. The experts also recommended use of psychosocial interventions (e.g., psychoeducation, family counseling, visiting nurse services) in addition to pharmacotherapy and psychotherapy. Within limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction concerning common clinical dilemmas in older patients. They cannot address the complexities of each individual patient's care and can be most helpful in the hands of experienced clinicians.

Journal Article↗
PubMed2001

Interpretations and conclusions in the clinical trial.

Interpreting the results of a clinical trial and reaching conclusions are matters of assessing the integrity of the trial's design and methods and the validity of the findings and drawing inferences to make conclusions that will guide health care decisions; these decisions are the ultimate goal of the clinical trial. This article examines 5 clinical trials of atypical antipsychotic agents with particular attention to aspects of their validity and refers to other articles in this supplement when appropriate. Finally, the Behavioral Health Care Enterprise Model, designed to help systematize the process of drawing inferences and implications from these and other clinical trials and assessing their impact on various sectors of the health care system, is introduced.

Antipsychotic Agents↗
PubMed2001

The Expert Consensus Guideline Series. Treatment of behavioral emergencies.

OBJECTIVES: Behavioral emergencies are a common and serious problem for consumers, their communities, and the healthcare settings on which they rely to contain, assess, and ultimately help the individual in a behavioral crisis. Partly because of the inherent dangers of this situation, there is little research to guide provider responses to this challenge. Key constructs such as agitation have not been adequately operationalized so that the criteria defining a behavioral emergency are vague. The significant progress that has been made for some disease states with better treatments and higher consumer acceptance has not penetrated this area of practice. A significant number of deaths of patients in restraint has focused government and regulators on these issues, but a consensus about key elements in the management of behavioral emergencies has not yet been articulated by the provider community. The authors assembled a panel of 50 experts to define the following elements: the threshold for emergency interventions, the scope of assessment for varying levels of urgency and cooperation, guiding principles in selecting interventions, and appropriate physical and medication strategies at different levels of diagnostic confidence and for a variety of etiologies and complicating conditions. METHOD: In order to identify issues in this area on which there is consensus, a written survey with 808 decision points was developed. The survey was mailed to a panel of 52 experts, 50 of whom completed it. A modified version of the RAND Corporation 9-point scale for rating appropriateness of medical decisions was used to score options. Consensus on each option was defined as a non-random distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred choice, second line/alternate choice, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean rating. Guideline tables were constructed describing the preferred strategies in key clinical situations. RESULTS: The expert panel reached consensus on 83% of the options. The relative appropriateness of emergency interventions was ascertained for a continuum of behaviors. When asked about the frequency with which emergency interventions (parenteral medication, restraints, seclusion) were required in their services, 47% of the experts reported that such interventions were necessary for 1%-5% of patients seen in their services and 32% for 6%-20%. In general, the consensus of this panel lends support to many elements of recent Health Care Financing Administration regulations, including the timing of clinician assessment and reassessment and the intensity of nursing care. However, the panel did not endorse the concept of "chemical restraint," instead favoring the idea that medications are treatments for target behaviors in behavioral emergencies even when the causes of these behaviors are not well understood. Control of aggressive behavior emerged as the highest priority during the emergency; however, preserving the physician-patient relationship was rated a close second and became the top priority in the long term. Oral medications, particularly concentrates, were clearly preferred if it is possible to use them. Benzodiazepines alone were top rated in 6 of 12 situations. High-potency conventional antipsychotics used alone never received higher ratings than benzodiazepines used alone. A combination of a benzodiazepine and an antipsychotic was preferred for patients with suspected schizophrenia, mania, or psychotic depression. There was equal support for high-potency conventional or atypical antipsychotics (particularly liquids) in oral combinations with benzodiazepines. Droperidol emerged in fourth place in some situations requiring an injection. CONCLUSIONS: To evaluate many of the treatment options in this survey, the experts had to extrapolate beyond controlled data in comparing modalities with each other or in combination. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction for addressing common clinical dilemmas in the management of psychiatric emergencies and can be used to inform clinicians in acute care settings regarding the relative merits of various strategies.

Aggression↗
PubMed2001

The Expert Consensus Guideline Series. Treatment of depression in women.

OBJECTIVES: Women constitute two-thirds of patients suffering from common depressive disorders. The treatment of depression in women is therefore a substantial public health concern. High-quality, empirical data on depressive disorders specific to women are limited. As a result, there are no comprehensive evidence-based practice guidelines on the best treatment approaches for these illnesses. We conducted a consensus survey of expert opinion on the treatment of 4 depressive conditions specific to women: premenstrual dysphoric disorder (PMDD), depression in pregnancy, postpartum depression in a mother choosing to breast-feed, and depression related to perimenopause/menopause. METHOD: After reviewing the literature and convening a work group of leading experts, we prepared a written survey covering a total of 858 treatment options in 117 specific clinical situations. Depression severity (mild to severe) was specified for most clinical situations. Treatment options included a broad range of pharmacological, psychosocial, and alternative medicine approaches. Most options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions. We identified 40 national experts, 36 (90%) of whom completed the survey. Consensus on each option was defined as a non-random distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred choice, second line/alternate choice, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean rating. Guideline tables indicating preferred treatment strategies were then developed for key clinical situations. RESULTS: The expert panel reached consensus on 76% of the options, with greater consensus in situations involving severe symptoms. For women with severe symptoms in each of the 4 central disorder areas we asked about, the first-line recommendation was for antidepressant medication combined with other modalities (generally psychotherapy), paralleling existing guidelines for severe depression in general populations. For milder symptoms in each situation, the panel was less uniform in recommending antidepressants. For the initial treatment of milder symptoms, the panel either gave equal endorsement to other treatment modalities (e.g., nutritional or psychobehavioral approaches in PMDD; hormone replacement in perimenopause) or preferred psychotherapy over medication (in conception, pregnancy, or lactation). In all milder cases, however, antidepressants were recommended as at least second-line options. Among antidepressants, selective serotonin reuptake inhibitors (SSRIs) as a class were recommended as first-line treatment in all situations. The specific SSRIs that were preferred depended on the particular clinical situation. Tricyclic antidepressants were highly rated alternatives to SSRIs in pregnancy and lactation. CONCLUSIONS: The experts reached a high level of consensus on the appropriateness of including both antidepressant medication, specifically SSRIs, and nonpharmacological modalities in treatment plans for severe depression in 4 key clinical situations unique to women. To evaluate many of the treatment options in this survey, the experts had to extrapolate beyond controlled data in comparing modalities with each other or in combination. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction for addressing common clinical dilemmas in women. They can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions.

Antidepressive Agents↗
PubMed2001

The expert consensus guideline series. Pharmacotherapy of depressive disorders in older patients.

OBJECTIVES: Depression in older patients contributes to personal suffering and family disruption and increases disability, medical morbidity, mortality, suicide risk, and healthcare utilization. The majority of clinical trials of antidepressant treatments are conducted in younger patients. For this reason, clinicians often have to extrapolate from studies in populations that do not present the same problems as older patients. For example, older patients often have serious coexisting medical conditions that may contribute to the depression and complicate the choice of treatment. Older patients as a rule need to be on many medications, some of which may contribute to depression and/or interact with antidepressants. Finally, older adults metabolize medications slowly and are more sensitive to side effects than younger patients. Because of these complexities, we conducted a consensus survey of expert opinion on the pharmacotherapy of depressive disorders in older patients to address clinical questions not definitively answered in the research literature. METHOD: After reviewing the literature and convening a work group of experts, we prepared a written survey with 64 questions that asked about 857 options. 618 of the options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions. For the other options, the experts were asked to write in answers (e.g., average doses) or to check a box to indicate their preferred answer. We sent the survey to 50 national experts on geriatric depression, all of whom completed it. Consensus on each option was defined as a nonrandom distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred choice, second line/alternate choice, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean rating. Guideline tables indicating preferred treatment strategies were then developed for key clinical situations. RESULTS: The expert panel reached consensus on 89% of the options rated on the 9-point scale. The experts stress the importance of identifying coexisting medical conditions that may be contributing to the depression or complicate treatment. For unipolar nonpsychotic major depression, the preferred strategy is an antidepressant (selective serotonin reuptake inhibitor [SSRI] or venlafaxine XR preferred) plus psychotherapy. For unipolar psychotic major depression, the treatment of choice is an antidepressant (SSRI or venlafaxine XR) plus one of the newer atypical antipsychotics. Electroconvulsive therapy is also first line. For dysthymic disorder or persistent milder depression, the experts recommend combining an antidepressant (SSRIs preferred) and psychotherapy. If the patient has a comorbid medical condition (e.g., hypothyroidism) that is contributing to the depression, the experts recommend treating both the depression and the medical condition from the outset. The SSRIs were the top-rated antidepressants for all types of depression. Among them, the experts gave the highest ratings for efficacy and tolerability to citalopram and sertraline. Paroxetine was another first-line option, and fluoxetine was rated high second line. The preferred psychotherapy techniques for treating depression in older patients are cognitive-behavioral therapy, supportive psychotherapy, problem-solving psychotherapy, and interpersonal psychotherapy. The experts also give strong support to including appropriate psychosocial interventions (e.g., psychoeducation, family counseling, visiting nurse services) in the treatment program. The majority of experts would continue treatment with antidepressant medication for at least 1 year if a patient has had a single episode of severe unipolar major depression, for 1-3 years for a patient who has had 2 such episodes, and for longer than 3 years if there is a history of 3 or more episodes. CONCLUSIONS: The experts reached a high level of consensus on the appropriateness of including both antidepressant medication, specifically SSRIs, and nonpharmacological modalities in treatment plans for severe depression. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction for addressing common clinical dilemmas in older individuals. They can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions. Nonetheless, the guidelines cannot address the complexities involved in the care of each individual patient and can be most helpful in the hands of experienced clinicians.

Aged↗
PubMed2000

Medication treatment of bipolar disorder 2000: a summary of the expert consensus guidelines.

The original Expert Consensus Guidelines on the Treatment of Bipolar Disorder were published in 1996. Since that time, a variety of new treatments for bipolar disorder have been reported; however, evidence for these treatments varies widely, with data especially limited regarding comparisons between treatments and how to sequence them. For this reason, a new survey of expert opinion was undertaken to bridge gaps between the research evidence and key clinical decisions. The results of this new survey, which was completed by 58 experts, are presented in The Expert Consensus Guideline Series: Medication Treatment of Bipolar Disorder 2000, which was published in April 2000 as a Postgraduate Medicine Special Report. In this article, the authors describe the methodology used in the survey and summarize the clinical recommendations given in the resulting guidelines. The expert panel reached consensus on many key strategies, including acute and preventive treatment of mania (euphoric, mixed, and dysphoric subtypes), depression, rapid cycling, and approaches to managing treatment resistance and comorbid psychiatric conditions. Use of a mood stabilizer is recommended in all phases of treatment. Divalproex (especially for mixed or dysphoric subtypes) and lithium are the primary mood stabilizers for both acute and preventive treatment of mania. If monotherapy with these agents fails, the next recommended intervention is to combine them. This combination of lithium and divalproex can then serve as the foundation to which other medications are added if needed. Carbamazepine is the leading alternative mood stabilizer for mania. The experts rated the other new anticonvulsants as second-line options (i.e., their use is recommended if lithium, divalproex, and carbamazepine fail or are contraindicated). For milder depression, a mood stabilizer, especially lithium, may be used as monotherapy. Divalproex and lamotrigine are other first-line choices. For more severe depression, the experts recommend combining a standard antidepressant with lithium or divalproex. Bupropion, selective serotonin reuptake inhibitors (SSRIs), and venlafaxine are preferred antidepressants. The antidepressants should usually be tapered 2-6 months after remission. Monotherapy with divalproex is recommended for the initial treatment of either depression or mania in rapid-cycling bipolar disorder. Antipsychotics are recommended for use in combination with the above regimens for mania or depression with psychosis, and as potential adjuncts in nonpsychotic episodes. Atypical antipsychotics, especially olanzapine and risperidone, were generally preferred over conventional antipsychotics. The guidelines also include recommendations concerning the use of electroconvulsive therapy (ECT), clozapine, thyroid hormone, stimulants, and various novel agents for patients with treatment-refractory bipolar illness. The experts reached high levels of consensus on key steps in treating bipolar disorder despite obvious gaps in high-quality data. To evaluate many of the treatment options in this survey, the experts had to extrapolate beyond controlled data; however, their recommendations are generally conservative. Experts give their strongest support to initial strategies and medications for which high-quality research data or longstanding patterns of clinical usage exist. Within the limits of expert opinion and with the understanding that new research data may take precedence, these guidelines provide clear pathways for addressing common clinical questions and can be used to inform clinicians and educate patients about the relative merits of a variety of interventions.

Journal Article↗
PubMed2000

The Expert Consensus Guideline Series: Medication Treatment of Bipolar Disorder 2000.

OBJECTIVES: New treatments for bipolar disorder have been reported since we first published survey-based expert consensus guidelines in 1996. The evidence for these treatments varies widely; data are especially limited regarding comparisons between treatments and how to sequence them. We therefore undertook a new survey of expert opinion in order to bridge gaps between the research evidence and key clinical decisions. METHOD: Based on a literature review, a written survey was prepared which asked about 1,276 options for psychopharmacologic interventions in 48 specific clinical situations. Most options were scored using a modified version of the RAND Corporation 9-point scale for rating appropriateness of medical decisions. We contacted 65 national experts, 58 of whom (89%) completed the survey. Consensus on each option was defined as a non-random distribution of scores by chi-square test. We assigned a categorical rank (first-line/preferred choice, second-line/alternate choice, third-line/usually inappropriate) to each option based on the confidence interval of its mean rating. Guideline tables indicating preferred treatment strategies were then developed for key clinical situations. RESULTS: The expert panel reached consensus on many key strategies, including acute and preventive treatment for mania (euphoric, mixed, and dysphoric subtypes), depression, and rapid cycling, and approaches to managing the complications of treatment resistance and comorbidity. Use of a mood stabilizer is recommended in all phases of treatment. Divalproex (especially for mixed or dysphoric subtypes) and lithium are the cornerstone choices among this class for both acute and preventive treatment of mania. Regardless of which is selected first, if monotherapy fails, the next recommended intervention is to use these agents in combination. The combination can then serve as the foundation on which other medications are added, if needed. Carbamazepine is the leading alternative mood stabilizer for mania. Expert opinion regards other new anticonvulsants as second-line options (e.g., if the previously mentioned mood stabilizers fail or are contraindicated). For milder depression, a mood stabilizer, especially lithium, may be used as monotherapy. Divalproex and lamotrigine are other first-line choices. For more severe depression, a standard antidepressant should be combined with lithium or divalproex. Bupropion, selective serotonin reuptake inhibitors (SSRIs), and venlafaxine are preferred antidepressants, and should be tapered 2 to 6 months after remission. Divalproex monotherapy is recommended for initial treatment of either depression or mania with rapid cycling. Antipsychotics are recommended for use with the above regimens for mania or depression with psychosis, and as potential adjuncts in non-psychotic episodes. Atypical antipsychotics, especially olanzapine and risperidone, were generally preferred over conventional antipsychotics. Recommendations are also given concerning the use of electroconvulsive therapy (ECT), clozapine, thyroid hormone, stimulants, and various novel agents for patients with treatment-refractory illness. CONCLUSIONS: The experts reached high levels of consensus on key steps in treating bipolar disorder despite obvious gaps in high-quality data. To evaluate many of the treatment options in this survey, the experts had to extrapolate beyond controlled data; however, their recommendations are generally conservative. Experts reserve strongest support for initial strategies and individual medications for which there are high-quality research data, or for which there are longstanding patterns of clinical usage. Within the limits of expert opinion and with the understanding that new research data may take precedence, these guidelines provide clear pathways for addressing common clinical questions in a manner that can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions.

Bipolar Disorder↗
PubMed1999

Cost of treating mental illness from a managed care perspective.

The issue of cost-effectiveness in the pharmacoeconomics of mental illness is a new concept. As methodologies for exploring this subject unfold, the most fundamental objective for health care professionals and managed care officials is to find ways in which currently available resources can be used most effectively. The managed care perspective is highly cost-based within the market it serves. In addition to cost, other factors that influence the managed care perspective are a short-term focus, segmentation of budgets, and measurable indicators of outcome, cost, and quality of care. The cost of new psychopharmacology--especially antidepressants and antipsychotics--may be many times that of traditional drugs, and concern about increased drug costs is present in many managed care organizations. Several issues must be addressed to prevent restriction of pharmacotherapeutics in managed care settings. For example, a focus on both outcomes and practice guidelines is needed to help allocate limited resources fairly. This article suggests ways in which available resources can be used more effectively to treat mental illness within the present health care system.

Antidepressive Agents↗
PubMed1998

Standards of care and clinical algorithms for treating schizophrenia.

Health care changes and improved understanding of the course and management of schizophrenia have provided the propitious environment to develop guidelines for treating patients with schizophrenia. This article describes two recent guidelines and highlights how these may be used to enhance clinical practice. Although still at a nascent stage that is awaiting more widespread acceptance by clinicians, the introduction of guidelines represent a significant advance in mental health care.

Algorithms↗
PubMed1998

Dialogue. Prescription for problems? Capitating mental health drugs--the great debate.

With the issue of physician capitation far from being resolved, mental health drug capitation is understandably up for debate. Those who deem it essential point to the rising cost of mental health drugs and urge management techniques which they believe can hold the delicate balance between a plan's budgetary limitations and a patient's appropriate care. They suggest that with an objectively calculated capitation rate, based not on expenditure alone, but on a defined population and their care needs, providers will not have to choose between profitability and optimal care. But others, responding to increasing quality concerns under capitation, worry that the increasing use of formularies will preclude patients and their providers from ready access to newer, more effective medications. With advocates still striving for nationwide parity for mental health benefits, capitating medications is not likely to assuage their concerns. Driving the debate is the fact that new technology drugs are expensive and most health plans are unable to anticipate the funding of breakthrough pharmaceuticals. With the advent of marketing to consumers directly through television and print media, plans and providers are increasingly pressured to provide these medications. The recent clamor for Viagra is an excellent example of how quickly the word can spread. New mental health medications may be even more expensive and offer patients and their families greater effectiveness with far fewer side effects. Plans, providers, and patients are caught in the middle, each holding their distinct view of the problems and solutions. This issue's dialogue brings our readers a discussion of capitation of pharmaceuticals as a primary answer to the sharp rise in mental health drugs. Three points of view lay out the viability and cautions of developing formularies and systems that could keep costs under control while still providing patient access. Without question, the debate will continue as legislative and consumer pressure continues to focus on managed care's techniques for cost savings and patient management. More sophisticated systems, designed for increasingly integrated and complex treatment plans, are certain to be required in the future. However, decisions about how to develop practice guidelines and integrate formularies with expensive new pharmaceutical technology, must begin to take shape now.

Budgets↗
PubMed1998

The Expert Consensus Guidelines for treating depression in bipolar disorder.

We present expert consensus guideline recommendations for the treatment of bipolar depression. These were arrived at through the statistical aggregation of the survey responses of 61 leading clinical researchers to eight questions about the key decision points in the management of bipolar depression. The experts' first-line recommendation for treating psychotic depression in bipolar disorder is to provide a combination of mood stabilizer, antidepressant, and neuroleptic medication. For severe, but nonpsychotic bipolar depression, the experts recommend the combination of a mood stabilizer and an antidepressant. For milder bipolar depression, a mood stabilizer and an antidepressant together or a mood stabilizer alone would be first line. The experts' antidepressant dose and dosing schedule recommendations are equivalent for unipolar and bipolar depression, but the experts recommend a faster discontinuation of antidepressants during the maintenance phase in bipolar patients--probably to reduce the risk of rapid cycling. Among the antidepressants, the experts prefer bupropion and the serotonin reuptake inhibitors as first line. They also believe that bupropion is least likely among antidepressants to cause switches to mania. Among mood stabilizers, the experts rate lithium as most likely to have a direct antidepressant effect.

Algorithms↗
PubMed1997

Barriers to the diagnosis of depression in primary care.

Approximately 50% of people treated for depression receive treatment in primary care settings. However, studies have demonstrated that specific factors interfere with recognition of this disorder in the primary care setting and decrease the likelihood of an accurate diagnosis. Variables that relate to the patient include lack of awareness and understanding of the nature of the disease and its symptoms so that they can be accurately reported to the physician. Variability in clinical presentation and the presence of comorbid medical disorders also make detection difficult. Complaints of physical symptoms confuse the clinical picture. In addition, patients are ashamed to admit to psychological symptoms of depression and fear the stigma attached to it. Interfering factors that relate to the physician include a lack of knowledge about the disease and lack of training in its management that reduce the physician's ability to render a diagnosis and undermine confidence in the capacity to treat the illness successfully. Reluctance on the part of the physician to inquire frankly about depression also plays a role. Barriers that stem from the system include financing of care under capitated systems, other reimbursement issues, time available to care for patients, and continuity of the physician/patient relationship. A variety of tools are available to assist primary care physicians in the recognition and accurate diagnosis of depression. Use of these tools would increase the recognition and effective management of depression.

Clinical Competence↗
PubMed1997

Preparing psychiatric residents for managed care. Values, proficiencies, curriculum, and implications for psychotherapy training.

As managed care psychiatric service systems become increasingly prominent in academic centers and the larger world of psychiatric practice, residency programs find themselves having to adapt to the value systems and training paradigms necessary for preparing house staff to deal with these systems. Many of the values and some of the necessary proficiencies differ considerably from those of traditional fee-for-service psychiatric practice. This article delineates the value systems under which managed care systems operate, the clinical proficiencies that will be needed by psychiatrists practicing in such settings, the experiential and didactic curriculum necessary to prepare today's psychiatric residents for adapting to managed care-oriented practices, and the implications of these changes for psychotherapy education and training.

Curriculum↗
PubMed1997

Consensus methods in practice guideline development: a review and description of a new method.

Practice guidelines are an increasingly important means of conveying to practitioners and administrators the most appropriate methods of treating patients. Although the development of practice guidelines relies on scientific evidence, the consensus of expert opinion is an important ingredient, particularly in many key areas of clinical decision making that are insufficiently informed by experimental data. The authors review current methods in the assessment of expert opinion for practice guideline development and the problem of the lack of quantification. A new method is presented for quantification of expert opinion on surveys, and the development of expert consensus practice guidelines from the resulting data.

Clinical Medicine↗
PubMed1996

A comprehensive system for value accounting in psychiatry.

This article describes a clinical management tool, the Value Accounting System, developed for use by a national organization of psychiatric treatment facilities. The system integrates patient case-mix variables with data on services provided, key administrative and clinical processes, clinical effectiveness, and cost/price. A comprehensive database links critical quality information with fiscal information, yielding a management tool that is national in scope, standardized, and versatile enough (1) to address general questions of the effectiveness and value of psychiatric services and (2) to provide an empirical base for rational, clinical management decision making. Descriptive data are presented from an attempt to establish a database and implement the system. The management and scientific potential of the Value Accounting System to improve the quality and efficiency of mental health services are discussed.

Adolescent↗
PubMed1996

Disease management strategy: initiative links pharmaceutical and mental health data.

The emphasis in healthcare is shifting to practical applications of medical knowledge for the provision of more cost-effective care. This requires greater linkages among clinical information systems across multiple organizations. This article describes new initiatives in disease management to link the traditionally separate data systems fo pharmaceutical, behavioral and general medical care. The potential for improved patient care is highlighted. The author is an expert consultant for a large pharmaceutical manufacturer's disease state management initiative, and has an extensive leadership background in many segments of the behavioral healthcare industry.

Clinical Pharmacy Information Systems↗