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Biomedical subjects

K Z Altshuler

Publications and source records attributed to K Z Altshuler.

At least 19 recordsLinked to original sources
PubMed2002

Development and implementation of computerized clinical guidelines: barriers and solutions.

Research indicates that computerized decision support systems (CDSSs) can improve clinical performance and patient outcomes, and yet CDSSs are not in widespread use. Physician guidelines, in general, face barriers in implementation. Guidelines in a computerized format can overcome some of the barriers to conventional text-form guidelines; however, computerized programs have novel aspects that have to be considered, aspects such as technical problems/support and user interface issues that can act as barriers. Though the literature points out that human, organizational, and technical issues can act as barriers in the implementation of CDSSs, studies clearly indicate that there are methods that can overcome these barriers and improve CDSS acceptance and use. These methods come from lessons learned from a variety of CDSS implementation ventures. Notably, most of the methods that improve acceptance and use of a CDSS require feedback and involvement of end-users. Measuring and addressing physician or user attitudes toward the computerized support system has been shown to be important in the successful implementation of a CDSS. This article discusses: 1) the barriers of implementation of guidelines in general and of CDSSs; 2) the importance of the physician's role in development, implementation, and adherence; 3) methods that can improve CDSS acceptance and use; and 4) the types of tools needed to obtain end-user feedback.

Attitude of Health Personnel↗
PubMed2001

Texas Medication Algorithm Project: development and feasibility testing of a treatment algorithm for patients with bipolar disorder.

BACKGROUND: Use of treatment guidelines for treatment of major psychiatric illnesses has increased in recent years. The Texas Medication Algorithm Project (TMAP) was developed to study the feasibility and process of developing and implementing guidelines for bipolar disorder, major depressive disorder, and schizophrenia in the public mental health system of Texas. This article describes the consensus process used to develop the first set of TMAP algorithms for the Bipolar Disorder Module (Phase 1) and the trial testing the feasibility of their implementation in inpatient and outpatient psychiatric settings across Texas (Phase 2). METHOD: The feasibility trial answered core questions regarding implementation of treatment guidelines for bipolar disorder. A total of 69 patients were treated with the original algorithms for bipolar disorder developed in Phase 1 of TMAP. RESULTS: Results support that physicians accepted the guidelines, followed recommendations to see patients at certain intervals, and utilized sequenced treatment steps differentially over the course of treatment. While improvements in clinical symptoms (24-item Brief Psychiatric Rating Scale) were observed over the course of enrollment in the trial, these conclusions are limited by the fact that physician volunteers were utilized for both treatment and ratings. and there was no control group. CONCLUSION: Results from Phases 1 and 2 indicate that it is possible to develop and implement a treatment guideline for patients with a history of mania in public mental health clinics in Texas. TMAP Phase 3, a recently completed larger and controlled trial assessing the clinical and economic impact of treatment guidelines and patient and family education in the public mental health system of Texas, improves upon this methodology.

Adolescent↗
PubMed2000

Computerizing medication algorithms and decision support systems for major psychiatric disorders.

In this article, the authors discuss the rationale for the use of computerized medication algorithms and decision support systems in the treatment of major psychiatric disorders. The field of psychopharmacology has advanced tremendously in the last two decades, with the resulting vast array of new information yielding a marked disparity between actual practice and what is commonly called "best practice." As a remedy, clinical practice guidelines and algorithms have been widely developed. These algorithms are used to disseminate up-to-date information, effect change in physician behavior, and reduce untoward variation in care. Review of the literature reveals advantages and limitations in trying to implement these paper and pencil guidelines and algorithms. Available research also suggests that computerized decision support systems have the potential to overcome such limitations, increase the use of treatment guidelines and algorithms, and improve physician adherence to recommended practices. The advantages of computerized medication algorithms and decision support systems are discussed. Finally, the computer platform elements that are necessary to make such systems effective and user-friendly are described.

Journal Article↗
PubMed1999

Medication treatment for the severely and persistently mentally ill: the Texas Medication Algorithm Project.

This article provides an overview of the issues involved in developing, using, and evaluating specific medication guidelines for patients with psychiatric disorders. The potential advantages and disadvantages, as well as the essential elements in the structure of algorithms, are illustrated by experience to date with the Texas Medication Algorithm Project, a public-academic collaboration. Phase 1 entailed assembling research findings on the efficacy of medications for schizophrenic, bipolar, and major depressive disorders. This knowledge was evaluated for its quality and relevance, integrated with expert clinical judgment as well as input by practicing clinicians, family advocates, and patients. Phase 1 (the design and development of the algorithms) was followed by a feasibility test (Phase 2). Phase 3 is an ongoing evaluation comparing the clinical and economic effects of using specific medication guidelines (algorithms) versus treatment as usual in public sector patients with severe and persistent mental illnesses.

Algorithms↗
PubMed1998

Texas Medication Algorithm Project: definitions, rationale, and methods to develop medication algorithms.

BACKGROUND: The Texas Medication Algorithm Project (TMAP), a public-academic collaborative effort, is a 3-phase project to develop, implement, and evaluate medication treatment algorithms for public sector patients with schizophrenia, major depressive disorders, or bipolar disorders. DISCUSSION: This paper, the first in a series describing the activities of the TMAP, focuses on the various definitions and reasons why guidelines have gained popularity. Also discussed are their strengths, the limitations of the various methods used to develop them, and potential barriers to their implementation.

Algorithms↗
PubMed1998

Consensus guidelines in the treatment of major depressive disorder.

The number of available antidepressant medications has increased dramatically in the last 10 years. Furthermore, no single medication is a panacea for all depressed patients-a fact underscored by randomized, controlled trial evidence showing that when one medication fails, an alternative may succeed. Thus, a key issue in the treatment of depression is how to optimally orchestrate available medication options to maximally benefit the greatest number of patients most rapidly. One approach is the use of consensus guidelines or medication algorithms. This paper discusses the rationale for and critical issues in the development of medication algorithms, and the timely use of symptom measures to ensure proper implementation. Once developed, guidelines must be appropriately implemented by clinicians, adhered to by patients, and supported by administrators. These three stakeholder groups often need education, incentives, and ongoing support to implement such guidelines. Whether guidelines actually improve outcome is largely uninvestigated, although a recent study of depressed patients in primary care found that using guidelines did improve outcome but at an increased treatment cost. The clinical and economic impact of guideline-driven treatment for the severe and persistently depressed deserves study.

Algorithms↗
PubMed1990

Whatever happened to intensive psychotherapy?

Of 163 residency programs responding to a survey about training requirements in long-term psychotherapy, more than 100 did not require that any patients be seen more than once a week. Among 41 psychotherapy protocols representing outcome-related research that were reported at an annual meeting of the Society for Psychotherapy Research, the studies employing more than once-a-week treatment for 6 or more months were rare. Intensive psychotherapy is clearly on the wane in training programs and in psychotherapy research paradigms.

Appointments and Schedules↗
PubMed1989

Will the psychotherapies yield differential results? A look at assumptions in therapy trials.

Differential results in psychotherapy should be both clinically substantial and attributable to the differences alleged in various treatments. This paper reviews the nonspecific elements of psychotherapy, and inspects cognitive, interpersonal, and analytically oriented therapies to see whether claimed differences are, in fact, sufficient to make differential results likely. It also calls attention to assumptions implicit in most clinical trials about the effectiveness of once-a-week, short-term treatment, and how these assumptions limit the likelihood that research will discriminate differential outcome.

Cognitive Behavioral Therapy↗
PubMed1986

Perspectives on patient noncompliance.

Patient noncompliance can sabotage the best clinical efforts to provide effective treatment. Psychiatrists consulting in a medical setting can promote patient compliance by using insights from four conceptual models of psychiatry: medical, psychodynamic, behavioral, and social. The authors describe the models and illustrate their clinical application with examples from their work with diabetic patients.

Adolescent↗
PubMed1985

Anorexia nervosa and depression: a dissenting view.

The frequency of depressive symptoms in anorexic patients, the response of some anorexic patients to antidepressants or ECT, the occurrence of comparable physiologic abnormalities in major depression and anorexia nervosa, and family studies of incidence increasingly link depression and anorexia in the literature. A review of the problems in making this linkage shows that the possibility of anorexia nervosa as a depressive equivalent or a depressive spectrum disorder must be seriously questioned.

Anorexia Nervosa↗
PubMed1984

Psychoanalytic and cognitive therapies: a comparison of theory and tactics.

The theory and tactics of psychoanalytic and cognitive therapies for depression are explored. Tactics developed from either theoretical base are often similar, though described in different terms. Analytic therapies, being derivative from psychoanalysis, are broader in the possibilities prescribed, and therefore less rigorous in the application of several active techniques. In part because of this, there are differences between analytic and cognitive therapies in session structure, in history taking, in dealing with transference and countertransference, and with paranoid patients. A paradigm is offered regarding the reasons for success or limited success with either method.

Cognition↗
PubMed1984

On the question of bisexuality.

If the homosexual-heterosexual range is a continuum, individuals at the midpoint should be characterized by equal frequency, equal pleasure, and relatively random sex choice of their partners. A small sample of bisexuals, self-identified according to these criteria, was interviewed. If these individuals are typical, sexual choice is dichotomous, rather than continuous, and inferences based on a continuum are untenable.

Adult↗
PubMed1983

The genetics of affective disorder: data, theory, and clinical applications.

A genetic factor in the etiology of the affective disorders has been a subject of considerable interest and investigation during the last five decades. Data from twin studies, family studies, and adoption studies strongly support three major findings: genetic factors are significant in the etiology of both bipolar and unipolar affective disorder; bipolar and unipolar affective disorder tend to breed true and are genetically distinct diseases; and both bipolar and unipolar affective disorder are genetically distinct from schizophrenia. While the mode of transmission for the affective disorders remains unclear, the genetic data already afford clinical applications pertinent to diagnosis, prognosis, treatment response, and both immediate and longitudinal clinical course. Pharmacogenetic factors unrelated to the illness are also relevant to the management of antidepressant pharmacotherapy.

Adoption↗
PubMed1982

The effect of dosage on the dexamethasone suppression test in normal controls.

A sample of 23 drug-free, normal adult subjects, aged 23 to 50 years, received 1 mg dexamethasone p.o. at midnight. Serum cortisols were obtained at 0800h, 1600h, and 2330h pre- and postdexamethasone. Only 1 of these 23 subjects (4.3%) evidenced nonsuppression, as defined by any postdexamethasone serum cortisol value of greater than 4.0 micrograms/dl. A dose of 0.75 mg dexamethasone was administered to 23 drug-free, normal adult subjects, 20 of whom participated in the above 1 mg trial. Six of these 23 (26.1%) showed nonsuppression at a threshold of 4.0 micrograms/dl. Another 11 normal adults who were taking various prescription medications (e.g., sympathomimetics, nasal decongestants, birth control pills, thyroid hormones) or who were suffering from untreated upper respiratory infections, venereal infections, or allergies were tested with 1 mg of dexamethasone. In this sample, 7 of 13 (53.8%) showed nonsuppression. These findings suggest that: (1) 1 mg of dexamethasone is the lowest effective dose that can be used in diagnostic testing for melancholic depression; (2) a false-positive response to the dexamethasone suppression test (DST) may occur with infections, allergies, or possibly with certain prescription medications. Further studies of the effects of illness and/or medications on DST responses are needed.

Adult↗
PubMed1978

On the inter-relationship of cognition and affect: fantasies of deaf children.

A few projective studies focusing on the impact of cognition on affect in the deaf have reported strikingly disparate results with little systematic inquiry. A new and previously unreported play situation (with the deaf) was devised to elicit a detailed story. Fantasies were obtained in a uniform fashion from four groups of five-year-old boys comprising middle-class deaf and hearing children and lower socio-economic-class deaf and hearing children. Results suggest that: (1) The impact of deafness on cognitive functioning in these children is akin to--but apparently no worse than--the cultural deprivation phenomenon experienced by low socio-economic-status children. (2) There is no paucity of fantasy life in the deaf or deprived child, despite the absence or relative lack of verbal skills. (3) A problem common to both disadvantaged children and the deaf children tested in the intrusion of anxiety into autonomous ego functions, so that practice necessary for the firm development of cognitive schemata is interfered with. (4) The clinical impulsivity secondary to these emotional pressures may perpetuate itself by interfering with cognitive decentration in time and space in relation to others.

Affect↗