Dr. Luo is associate clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California in Los Angeles; past president of the American Association for Technology in Psychiatry (AATP) in New York City; and Gores Informatics Advocacy chair at the AATP.

Disclosure: Dr. Luo is consultant to S.M.A.R.T. Link Medical, Inc., on the speaker’s bureau of Epocrates, and on the advisory board of Spyglass Consulting.

 


 

 

The ultramobile personal computer (UMPC) has not yet had the success imagined by its designers. Its small form factor, a screen from 4–7 inches diagonal, and weight of <2 pounds,  make it more portable than a laptop. However, the first versions were underpowered with a slow central processing unit (CPU), which contributed to the UMPC’s lack of commercial success in today’s marketplace. The new Origami Experience 2.0 specification by Microsoft1 will hopefully change that experience with faster CPUs, more memory, and Windows Vista. Until that time, there are numerous other products that fill the void for the new mobile office.

 

Products

Apple Computer’s iPhone2 has been extremely popular in the United States despite its exclusive sales contract with ATT Wireless. In fact, a cottage industry has emerged that provides various methods to bypass the security so that the device can be used on other wireless provider networks.3 The iPhone is an extremely capable device, with Internet browsing, video and audio playback, and e-mail; however, it is limited to these capabilities. The new third-generation data service version expands the iPhone’s repertoire with faster third-generation wireless technology, global positioning satellite (GPS), enterprise features, and now, third-party applications. The enterprise capability is significant in that support for Microsoft Exchange Activesync provides for push e-mail, calendar, and contacts from the Microsoft Exchange server, a popular server in numerous corporate environments. This feature positions the iPhone as a rival to the Research in Motion’s extremely popular Blackberry devices. With the release of the iPhone SDK (software development kit), Apple is now encouraging other developers to create applications for the iPhone such as Epocrates Rx,4 which was previously only available to iPhone users via the Safari Web browser. Applications such as a word processor or spreadsheet program—eg, iWorks5 or Documents-to-Go6 on the iPhone—are not yet in development but may be coming soon. A current alternative is to use the Glide Operating System,7 which is a Web browser-based application suite that runs on multiple operating systems such as Blackberry, Windows Mobile, Mac, Windows, Palm, and Linux. Glide is not really an operating system but a specially written Adobe Flash code to create, edit, and read various Microsoft Office compatible files. The problem with using the iPhone as a mobile office is that there is no Bluetooth keyboard for it since the iPhone’s Bluetooth is designed only to connect to Bluetooth headsets.

The RIM Blackberry is another computing alternative for the mobile office. When these devices are connected to the RIM Enterprise server, which is typically linked to the Microsoft Exchange Server for push e-mail and calendar, e-mail attachments, such as Microsoft Word and Excel, can be opened for viewing. Adobe Portable Document Format files are also viewable on the Blackberry as an image to see the true layout, or just the text, which is much more readable. As with the iPhone, Web-based office suites such as Google Docs or Thinkfree Office work for viewing but not editing. One reason to use these online document editing services is that these documents can be left on the server for editing at any Internet-connected computer with a Web browser or viewed in the field on a mobile phone that has a signal. If editing a Microsoft Office file is desired on the Blackberry, DataViz Documents-To-Go is available for the Blackberry system, which can edit the native file without any portable file conversion. Many Blackberry devices have a small thumb-based keyboard, which is not ideal for lengthy typing. For some users, the small screen is not prohibitive for document editing or viewing, which makes pairing it with the iGo Stowaway Ultraslim Bluetooth Keyboard8 an option for a truly mobile office. Presently, the Blackberry devices rely only on the mobile phone service for Internet access; however, the new Blackberry Bold9 will offer the ability to utilize WiFi networks in addition to the wireless carrier data service. This feature allows the Blackberry to compete with the iPhone as a device that works on either wireless data network, which provides flexibility in hospital settings where mobile phone signals tend to be severely attenuated.

Although many of the document-editing options described above do work, the Web-based document services occasionally do not save properly, the synchronization may not work between the Internet storage and the local computer, or the service will just crash. DataViz’s Documents-To-Go works well on the Palm and Blackberry platform, but for complete peace of mind, it may be best for some to just stick to Microsoft. Fortunately, there are numerous manufacturers of Windows Mobile smartphone devices that offer Word Mobile, Excel Mobile, and PowerPoint Mobile since it is included in the operating system. Sony Ericsson Xperia X1 is poised to shakeup the crowded Windows Mobile smartphone market with its 3-inch diagonal, 800×480 resolution screen and slide-out built-in keyboard in addition to its multi-media–rich capabilities.10

If the screen and keyboard are too small for extensive document or e-mail reading and editing, Celio’s Redfly Mobile Companion may be the perfect solution.11 This product provides an 8-inch diagonal wide screen with 800×480 resolution, full-size keyboard, and a touchpad mouse to extend the capabilities of a Windows Mobile device. After the Redfly interface driver is installed on the smartphone, the device connects either via Bluetooth or universal serial bus (USB). One advantage of carrying this 2-pound mobile companion, besides the larger screen and keyboard, is that it will charge the smartphone in addition to allowing USB flash drives to be connected for more storage or file access. At present, this peripheral is only compatible for Windows Mobile devices listed at www.celiocorp.com/smartphone,12 but they anticipate that Blackberry, Motorola, and Nokia drivers will be developed in the future.

HTC also makes a Windows Mobile smartphone called the Touch Pro, which is in direct competition with the Sony Xperia X1.13 This device has a slightly smaller 2.8-inch diagonal screen and a slider keyboard. However, HTC’s other products, the Advantage14 and Shift15 mobile computers, are blurring the boundary between smartphone and UMPC. The HTC Advantage has a 5-inch diagonal video graphics array touch screen with a detachable keyboard and runs on Windows Mobile 6 Professional operating system. It has integrated Wi-Fi, Bluetooth, GPS, and 3G, which gives it great flexibility to connect for e-mail and Web browsing. Although it is quite portable, it is bulkier than many of the devices described so far. Similarly, the HTC Shift is more of a laptop with a 7-inch, 800×480 display, Intel processor, and 40 or 60 GB hard disk running the Windows Vista Business operating system. The keyboard slides out and the display tilts backwards for easier viewing. One significant advantage of this device is the SnapVue operating system, which is a second operating system that gives instant access to e-mail, calendar, and weather.

If deciding between an UMPC, smartphones, and ultra-portable laptops such as the HTC Shift and OQO model 02 is not confusing and difficult enough, there is another category of mobile devices called the Mobile Internet Device (MID). Intel has created a marketing and branding infrastructure around its Centrino Atom processor, which powers many of these devices.16 The MID is supposed to be smaller with 4–6-inch displays, and most run on optimized versions of Linux. Moblin.org17 is an open source community for sharing software, ideas, projects, codes, and applications to devices running Linux on the Intel Atom processor. At present, there are no planned releases of an MID based on the Intel Atom processor, although many are in development.

One company already ahead in the MID arena is Nokia. It has developed the N800 and N810 mobile Internet devices18 on a Texas Instruments processor and runs Maemo,19 another open-source development site for Internet tablets. Portability and ease of use are its key features, with a 4.13-inch screen at 800×480 pixels and weight of <8 ounces. These devices only have WiFi and Bluetooth connection, 2 GB of internal memory, and support for up to 8 GB miniSD and microSD memory cards. The main difference between the N800 and N810 models is the slide-out keyboard on the N810. These devices do not have the capabilities as of yet to run office application suites such as Open Office,20 but many are in development. Since Adobe Flash 9 is not yet ready for Maemo,21 the Glide system will not work.

 

Conclusion

Numerous devices purport to bring e-mail, calendar, Microsoft Word, Microsoft Excel, and Microsoft PowerPoint into the mobile age. Just as there are numerous antidepressants with different mechanisms of action, one mobile device does not fit all of the mobile computing needs of the health professional. Some users will want the larger screens and keyboards offered in the bigger devices, while others will crave the portability of smartphones and MIDs. Even laptops have entered the market with subnotebooks such as the MSI Wind22 and Asus EEE PC,23 both of which run the Linux operating system for better power management and lower cost of ownership. Despite the uncertainty concerning which operating system or which form-factor device will serve the mobile office needs, a laptop in the pocket is on its way.24 PP

 

References

1.    Ultra Mobile PC with Origami Experience 2.0. Available at: www.microsoft.com/windows/products/winfamily/umpc/default.mspx. Accessed June 30, 2008.
2.    iPhone. Available at: www.apple.com/iphone. Accessed June 30, 2008.
3.    Code to Unlock iPhone Cracked. Available at: www.cnn.com/2007/TECH/09/01/apple.iphone/. Accessed June 30, 2008.
4.    Epocrates on iPhone. Available at: www.epocrates.com/iphone/compatibility/. Accessed June 30, 2008.
5.    Apple iWork. Available at: www.apple.com/iwork. Accessed June 30, 2008.
6.    DataViz Documents to Go. Available at: www.dataviz.com. Accessed June 30, 2008.
7.    Glide OS. Available at: www.glideos.com. Accessed June 30, 2008.
8.    iGo Stowaway Keyboard. Available at: http://corporate.igo.com/product_details.aspx?id=16. Accessed July 1, 2008.
9.    Blackberry Bold. Available at: www.blackberry.com/select/blackberrybold/. Accessed July 1, 2008.
10.    Sony Experia X1. Available at: www.sonyericsson.com/x1/. Accessed July 1, 2008.
11.    Celio Redfly Mobile Companion. Available at: http://celiocorp.com/products.php. Accessed July 1, 2008.
12.    REDFLY Tested Smartphones. Available at: www.celiocorp.com/smartphone. Accessed July 3, 2008.
13.    HTC Touch Pro. Available at: www.htc.com/www/product.aspx?id=49518. Accessed July 1, 2008.
14.    HTC Advantage. Available at: www.htc.com/www/product.aspx?id=436. Accessed July 1, 2008.
15.    HTC Shift. Available at: www.htc.com/www/product.aspx?id=596. Accessed July 1, 2008.
16.    Intel. Mobile Internet Devices. Available at: www.intel.com/products/mid/. Accessed July 2, 2008.
17.    Moblin.org. Available at: www.moblin.org/community/mid/. Accessed July 2, 2008.
18.    Nokia N810 Internet Tablet. Available at: www.nokiausa.com/A4626059. Accessed July 2, 2008.
19.    Maemo. Available at: www.maemo.org. Accessed July 2, 2008.
20.    Open Office. Available at: www.openoffice.org. Accessed July 2, 2008.
21.    Flash 9 Coming to Maemo? Available at: www.internettablettalk.com/2007/01/17/flash-9-coming-to-maemo/. Accessed July 2, 2008.
22.    MSI Wind. Available at: www.msimobile.com/nblist.aspx?series=u. Accessed July 2, 2008.
23.    ASUS EEE PC. Available at: http://eeepc.asus.com/us/index.htm. Accessed July 2, 2008.
24.    Machlis S. Coming soon: a laptop in your pocket. Computerworld. Available at: www.computerworld.com/action/article.do?command=viewArticleBasic&articleId=9103538&source=NLT_HW&nlid=51. Accessed July 2, 2008.

Articles

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Christine Ren Fielding, MD, and George Fielding, MD

Primary Psychiatry. 2008;15(8):40-41

 

Drs. C.R. Fielding and G. Fielding are associate professors of surgery at New York University School of Medicine in New York City.

Disclosure: Dr. C.R. Fielding is consultant to ExploraMed and the Surgical Review Committee; on the advisory boards of Allergan Health and Ethicon Endosurgery; is on the speaker’s bureau of Allergan Health; and receives grant support from Allergan Health. Dr. G. Fielding is consultant to ExploraMed; is on the advisory board and speaker’s bureau of Allergan Health; and receives grant support from Allergan Health.

Please direct all correspondence to: Christine Ren-Fielding, MD, Associate Professor, School of Medicine Surgery FGP General, NYU Medical Center, 530 First Ave, 10 S, New York, NY 10016; Tel: 212-263-3166; Fax: 212-263-3757; E-mail: Christine.ren@med.nyu.edu.

 


 

Obesity is about to surpass cigarette smoking as the number one preventable cause of death in the United States. In the year 2000, data showed that 435,000 Americans died from cigarette smoke and 400,000 from obesity.1 This represents 18.1% and 16.6%, respectively, of all deaths in the US. Greater than 33% of US adults (>72 million people) were obese in 2005–2006.2,3 Obesity in children and adolescents is also on the rise and is associated with increased morbidity and mortality in adult life.

The degree of obesity is estimated by body mass index (BMI), which is calculated as weight divided by the square of height and is reported in the metric units of kg/m2. If pounds and inches are used, the following formula can be used to convert from English to metric units: BMI=[weight (lbs)/[height (inches)]2]x703. A BMI of 18–25 is considered healthy weight, BMI of >25–30 is considered overweight, BMI of >30–40 is considered obese, and BMI of >40 is morbidly obese.

The World Health Organization has listed obesity as an epidemic.4 Being obese is not the problem; rather, the problem is the diseases that flow from it, ie, diabetes, sleep apnea, hypertension, elevated cholesterol, arthritis, cancer, and depression. The current epidemic of diabetes is already of plague-like proportions. A new diabetic is diagnosed every 10 minutes in the US. One in every three newly diagnosed diabetics is a teenager. The implications are terrifying. By 2020, the National Institutes of Health (NIH) believes 20% of all health dollars will be spent on diabetes. With few exceptions, diabetes comes from obesity.

There are individual as well as national implications for obesity. A recent publication in the Journal of the American Medical Association showed that a 45-year-old man with a BMI of 45 who smokes will lose 13 years of his life.5 If he does not smoke, he will lose 8 years of life. Furthermore, his life will be mired in disease. A BMI of 45 equates to a person who is 5’11” tall and weighs 320 lbs. The average BMI in most bariatric practices is 47 kg/m2. There are literally millions of people of this size in the US.

The medical treatment of obesity is relatively ineffective.5-9 Optimal application of a program of best practice for healthy eating, exercise, drug therapy, and psychological intervention might lead to a weight loss of up to 20 lbs, if applied continuously. Long-term application of the program is rarely achieved. Only 2% of patients can keep 50 lbs off for 1 year, and 95% of dieters regain all lost weight with an incremental increase over their base weight. The NIH recognized this in 1991 when it endorsed bariatric surgery for the morbidly obese.10 Specifically, a BMI of ≥40 is an indication for surgery. The BMI can be lowered to 35 if the individual has at least one obesity-related illness, such as diabetes.

Bariatric surgery (surgery for severe obesity) offers a surgeon the opportunity to cure disease and to prevent further diseases, possibly for the first time. Surgery has been shown to be a highly effective long-term intervention for obesity,11 and bariatric procedures have been performed with greatly increasing frequency in recent years. The two most frequently performed bariatric surgeries in the US, Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) procedures, both lead to rapid and dramatic weight loss. Bariatric surgery typically results in significant improvement or amelioration of the debilitating medical comorbidities of obesity such as Type II diabetes (86% improvement), obstructive sleep apnea (84% improvement), hypercholesterolemia (>70% improvement), and hypertension (79% improvement).11

LAGB is a restrictive operation which relies on decreased amount of intake as the mechanism for weight loss. It involves the surgical implantation of an inflatable silicone band around the uppermost part of the stomach, which is tightened in the office based on individual weight loss and appetite. This operation has minimal nutritional sequelae.

RYGB is also a restrictive operation, but it includes a component of nutrient malabsorption. The top of the stomach is cut and separated from the rest of the  stomach in order to create a new tiny stomach pouch. What is originally the size of a football, now has the capacity of a golfball. This new tiny pouch is attached to the intestine farther in the digestive tract, allowing for food to be rerouted away from the original stomach and part of the intestine. This results in appetite suppression, early satiety, and decreased absorption of nutrients. Vitamin supplements are imperative for these patients. Both operations can be performed laparoscopically with minimal surgical complication. However, the tenets of nutrition and behavior modification are critical for optimal weight-loss outcome.

Approximately 250,000 bariatric operations were performed in 2007 (American Society for Metabolic and Bariatric Surgery, personal communication, June 21, 2008); this is a reflection of the growing obesity problem. Because bariatric surgery is becoming much more prevalent, healthcare professionals of all disciplines are increasingly likely to encounter bariatric patients in their clinical practices. Therefore, it is important that even clinicians who do not specialize in working with this population become knowledgeable about surgery and the common postoperative experiences that patients face, in order to ensure the provision of appropriate care and referrals.

Warren L. Huberman, PhD, begins this issue by discussing the role of the mental health professional in both the preoperative and postoperative bariatric surgery patient setting, drawing from his personal experience of >5,000 patients. Psychosocial changes occur after bariatric surgery, in both positive and negative terms. David B. Sarwer, PhD, and colleagues discuss what these changes may be and what the mental health professional can expect. Stephanie Sogg, PhD, and Mark J. Gorman, PhD, look at the interpersonal changes that occur after bariatric surgery; these involve relationships and intimacy. This article will help the mental health professional recognize and address them. Andrea D. Vazzana, PhD, discusses the destructive effects of obesity on the adolescent population with the subsequent positive, and potentially negative, mental health outcomes after bariatric surgery. Finally, Susan F. Franks, PhD, and Kathryn A. Kaiser, BS, provide a comprehensive review of the literature regarding predictive factors in bariatric surgery outcomes.

This issue of Primary Psychiatry assesses the psychological impact of weight-loss surgery, possibly even more important to the patient than the medical benefits. As bariatric surgery continues to become the mainstream treatment for severe obesity, these psychological issues will be met by all doctors caring for their obese patients. PP

 

References

1.    Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-1555.
2.    Obesity among adults in the United States–no statistically significant change since 2003-2004. Data Brief Number 1, November 2007. 8 pp.  Available at: www.cdc.gov/nchs/pressroom/07newsreleases/obesity.htm. Accessed July 15, 2008.
3.    Baskin ML, Ard J, Franklin F, Allison DB. Prevalence of obesity in the United States. Obes Rev. 2005;6(1):5-7.
4.    WHO Consultation on Obesity. Obesity: Preventing and Managing The Global Epidemic: Report of a WHO Consultation. Geneva, Switzerland: World Health Organization; 2004.
5.    Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003;289(2):187-193.
6    Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.
7.    Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344(18):1343-1350.
8.    Stern L, Iqbal N, Seshadri P, et al. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Ann Intern Med. 2004;140(10):778-785.
9.    Foster GD, Wyatt HR, Hill JO, et al. A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med. 2003;348(21):2082-2090.
10.    Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr. 1992;55(2 suppl):615S-619S.
11. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724-1737.

 

This interview took place on June 25, 2008, and was conducted by Norman Sussman, MD.

 

This interview is also available as an audio PsychCastTM at http://psychcast.mblcommunications.com.

Disclosure: Dr. Hutcher is investigator for a research project for Cook Biotech, Inc. is on the advisory boards of Ethicon Endo-Surgery, Inc.; Novus, RRG; the Obesity Action Coalition; and the Surgical Review Corporation; and receives grant support from the Mayo Clinic.

 

Dr. Hutcher serves on the advisory board of the American Obesity Association. As past president of the American Society for Metabolic and Bariatric Surgery, he is proactive in issues concerning insurance coverage and medical access for severely obese patients. He was chairman of the Department of Surgery at St. Mary’s Hospital and clinical associate professor at the Medical College of Virginia and the McGuire Veterans Administration Hospital in Richmond, Virginia. Dr. Hutcher’s current practice is devoted almost entirely to the surgical treatment of morbid obesity.

 

What is bariatric surgery and when was it first used?

Bariatric surgery originated as the first treatment for severe obesity. The procedure developed during the 1960s when a series of operations was conducted to purposely create the short bowel syndrome, which would allow patients to eat normal amounts of food but not absorb their nutrients. It was a great concept, but it was fraught with difficulties of multiple bowel movements as well as electrolyte and nutrient deficiencies. Though the operation fell into disrepute in the mid 1970s, it was resurrected by Edward E. Mason, MD, PhD, at the University of Iowa. Instead of using principles of short bowel syndrome as a base, he began to think about reducing the ability of the stomach to accept food. One would be restricted in the amount he or she could eat at one time. Unlike the short bowel syndrome created a decade earlier, one would be able to absorb the calories ingested.

Over the subsequent few years, Mason and colleagues decided to add malabsorption to the restrictive nature of the stomach’s capacity, which is what the current procedure entails. There are operations that are essentially restrictive (eg, adjustable gastric band surgery) and there are surgeries that are a combination of restrictive and malabsorptive. For example, gastric bypass surgery restricts the amount one can eat at one time but also adds a non-dangerous level of malabsorption to the base procedure. While these types of procedures were developed for weight loss, they have a far greater value than that. Over the last few years, the American Society for Bariatric Surgery has evolved into the  American Society for Metabolic and Bariatric Surgery (ASMBS) to emphasize the metabolic changes both dependent on and independent of the weight loss that takes place after surgery.

 

What techniques are used for the procedure?

Gastric band surgery and gastric bypass surgery are the two most popular techniques. There is a third technique that is fairly popular in New York City called the biliopancreatic diversion and duodenal switch. It is a more complex operation that is almost more dependent on malabsorption. Because it introduces a greater amount of malabsorption, it is the least popular operation in the United States despite its being the most effective one as far as weight loss and reduction of associated illnesses. It requires complete patient compliance, as it has the most risk for actual nutritional deficiencies.

The least invasive operation is adjustable gastric band surgery. A silastic collar is placed around the stomach just beyond the gastroesophageal junction. The inner part of the collar has a balloon attached to a small tube and chamber that fits under the skin. By transcutaneous access to that chamber, the balloon inflated and deflated, adjusting the amount of difficulty the person experiences while eating.

 

Overall, is there a reliable rate of mortality associated with these procedures?

Yes. The mortality rate has decreased drastically, as the operations have become more standardized. The mortality rate associated with the adjustable gastric band surgery is 0.1%, which is <1 person per every 1,000 patients. Considering a patient has to qualify for the procedure based on strict ASMBS criteria (ie, the patient must be very big and very sick), that is an amazingly low mortality rate.

The in-hospital mortality rate for gastric bypass surgery is approximately 0.14%, which is <1.5 people per every 1,000 patients. The 30-day mortality rate is 0.2%, meaning this procedure has become the safest intra-abdominal procedure a person can undergo. It is almost the equivalent of a woman giving birth to her first child, an amazing transformation from horror stories previously published in media.

There is tremendous discrimination against severely overweight people and there is the belief that obesity is not a disease but a behavior undeserving of any kind of help. However, the Agency for Health Research and Quality has stated that from 1999–2004 the risk of a bariatric procedure decreased by 78%.

 

How does a patient qualify for surgery?

A patient is required to have a body mass index (BMI), which is the ratio of weight to height, of 40. The average person should have a BMI of ≤25. Overweight patients are those with a BMI of 25–30. At 30, the term “obese” may be applied, as that is the point at which true health-related issues develop. If the patient has a major comorbid condition (eg, type-2 diabetes, hypertension, obstructive sleep apnea, heart disease) and a BMI of 35, he or she becomes a candidate. If the patient’s BMI is ≥40, that is considered enough of a risk to justify him or her for consideration as a surgical candidate, even if he or she has yet to develop a serious comorbid conditions.

 

Which factors are associated with successful outcomes after surgery?

There is no simple criteria for that. It is known that patients consider surgery for approximately 2 years before they make their first appointment. They conduct their own research via the Internet before they see a professional. As a result, they already know the answers to the questions they are asked. However, patients should fully understand that surgery is just the beginning. It enables them to make the lifestyle changes needed to lose weight and maintain weight loss. It is difficult for patients who have not undergone surgery to make these changes (ie, caloric restriction, dedication to a healthier lifestyle). Surgery gets patients “into the game.” Then, through counseling, coaching, and a “one step at a time” attitude, taking supplements and exercising consistently become easily reached goals. Most importantly, successful patients are those who continue to follow up with the physician, come to the support groups, and follow through with what they did during their first year. The leading indicator of unsuccessful outcome after surgery is when patients stop coming to their follow-up visits.

 

Are patients routinely evaluated psychiatrically before surgery?

Though numerous insurance companies require it as a preoperative event, a psychiatric evaluation is not a requirement for patients. In my practice, all patients see a mental health professional, but most of them already have an established relationship with a physician before they come to the office.A majority of patients have had an either health- or weight-related indication of depression at some point in their lives. I separate depression into the disease versus the reaction to situational issues. With the combination of those two factors, approximately 70% of patients have been seen for depression issues at one time or another.

 

Are there studies revealing patients suffer psychological sequelae as a result of surgery?

There was a recent study by Adams and colleagues1 that compared thousands of people with surgery to exact matches of people without surgery. They found that the mortality rate of the surgery group was 63% less than the non-surgery cohort. Mortality from diabetes, cancer, and heart disease decreased by 92%, 60%, and 56%, respectively. However, post-surgery patients had a higher suicide rate and a higher rate of death from accidents. Immedately after bariatric surgery, numerous patients experience a honeymoon of euphoria from the weight loss. However, after 2–3 years, they realize that all of their problems were not just about their weight; that is, the procedure helps a person lose weight and it may make diseases go away, but it does not make the world go away. For example, maybe their significant other is still mean, their son still takes drugs, or they still owe money. These are issues of every day life. Patients could possibly undergo a rebound issue when they come to that realization. This is most likely a danger area, particularly if they could possibly commit suicide.

 

With gastric bypass surgery, is it possible to affect the equivalent of a poorly understood endocrine gland that may have sequelae?

The anorexia effect of the gastric bypass surgery versus the gastric band surgery is dramatic in that the ghrelin secreting part of the fundus of the stomach is bypassed. As the immediate solution for type-2 diabetes, gastric bypass surgery has opened a whole new understanding of the glucagon-like peptides and other intestinal polypeptides. It has opened the whole issue of possibly conducting non weight-loss metabolic surgery to put type-2 diabetes into remission in a small percent of type-2 diabetics who are of normal weight. It is now known that hyperlipidemia goes away quickly before weight loss, and obstructive sleep apnea, which is considered a physical obstruction of the trachea and upper airways when somebody is recumbent, goes away before the neck shrinks. Bariatric surgery has changed the whole paradigm of research. We are now seeing remissions of disease and now have to find out why and can it be achieved in a less  invasive fashion.

 

Do you think the dramatic reversal of metabolic syndrome is an enduring find?

Yes, it is enduring. I have had patients who have come to my clinic on 6–7 shots per day totalling 200–300 units of insulin. In just a couple of weeks after surgery, they are off of all medication. Some have been off of them for 10–15 years.

 

How many patients ultimately opt to have plastic surgery for redundant skin?

That is a socioeconomic issue. The younger the patient, the less they need to have plastic surgery, as it is likely they exercise more, have central obesity, and do not smoke. As for reconstructive surgery, the face is the most resilient part of the body. I have treated approximately 4,000 patients over the years, and one could count on his or her digits the number  of patients who have truly needed facial plastic surgery. Abdominoplasty involves the lower abdominal skin fold. If the resources were available, 60% to 70% of patients would benefit. Currently, there are two plastic surgery societies for the reconstruction of post-bariatric surgery patients. What they are able to accomplish is amazing, but such accomplishment is a matter of resources, not ability. It is about what people desire and what they can afford. Sometimes the abdominoplasty is covered by insurance. My record amount taken from the anterior abdominal wall was 80 pounds on a lady. Routinely, physicians will take 15–20 pounds off a patient’s lower abdominal panniculus; I consider that reconstructive. However, how the insurance companies handle it is a different matter. PP

 

Reference

1.    Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753-761.

 

Needs Assessment: As bariatric surgery becomes an increasingly popular option for improving the health of obese individuals, it is important to understand the range of psychosocial outcomes patients may experience.

Learning Objectives:
• Understand the purpose of pre-operative psychological evaluations
• Understand the psychosocial changes associated with bariatric surgery
• Identify the untoward psychosocial outcomes associated with surgery

Target Audience: Primary care physicians and psychiatrists.

CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.


Faculty Disclosure Policy Statement:
It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.

This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: June 23, 2008.

Drs. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest.

To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by August 1, 2010 to be eligible for credit. Release date: August 1, 2008. Termination date: August 31, 2010. The estimated time to complete all three articles and the posttest is 3 hours.

Primary Psychiatry. 2008;15(8):50-55

 

Dr. Sarwer is associate professor of psychology in the Psychiatry Department at the University of Pennsylvania School of Medicine (UPenn SOM) in Philadelphia, Pennsylvania and director of clinical services at its Center for Weight and Eating Disorders. Dr. Fabricatore is assistant professor of psychology in the Psychiatry Department at UPenn SOM and co-director of education at its Center for Weight and Eating Disorders. Dr. Jones-Corneille is instructor and clinician in the Psychiatry Department at UPenn SOM. Dr. Allison is assistant professor of psychology in the Psychiatry Department at UPenn SOM and co-director of education at its Center for Weight and Eating Disorders. Dr. Faulconbridge is research associate at UPenn SOM’s Center for Weight and Eating Disorders. Dr. Wadden is professor of psychology in the Psychiatry Department at UPenn SOM and director of its Center for Weight and Eating Disorders.

Disclosures: Dr. Sarwer is consultant to Ethicon Endo-Surgery and receives grant support from American Society of Metabolic and Bariatric Surgery, the American Society of Plastic Surgery, and the National Institutes of Health. Dr. Fabricatore is consultant to Merck and Pfizer and receives grant support from the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Jones-Corneille reports no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Allison receives grant support from the National Institutes of Health/National Center on Minority Health and Health Disparities. Dr. Faulconbridge reports no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Wadden receives grant support from the National Institutes of Health.

Please direct all correspondence to: David B. Sarwer, PhD, 3535 Market Street, Suite 3108, Philadelphia, PA 19104; Tel: 215-746-7182; Fax: 215-898-2878; E-mail: dsarwer@mail.med.upenn.edu.

 


 

 

Abstract

Over the past decade, bariatric surgery has grown in popularity as the most efficacious treatment for extreme obesity. During this time, there has also been increased research on the physical and psychosocial outcomes of the procedures. The vast majority of patients who undergo bariatric surgery experience improvements in morbidity and mortality, including improvements in several areas of psychological functioning. Unfortunately, a minority of patients appear to struggle with numerous psychological issues postoperatively. These include suboptimal weight loss, disordered eating, body image dissatisfaction, substance abuse, depression, and suicide. This article provides an overview of these untoward outcomes.

 

Introduction

Several comprehensive reviews of the literature1-6 on the psychosocial and behavioral aspects of bariatric surgery have been published. As summarized in these articles, people with extreme obesity who pursue bariatric surgery have high rates of psychopathology. Between 20% to 60% of patients have been characterized as suffering from an Axis I psychiatric disorder, the most common of which were mood and anxiety disorders. Smaller percentages have been diagnosed with substance abuse problems and personality disorders, both of which may impact surgical management and postoperative outcomes.

These findings must be viewed with some degree of caution. Many studies suffered from a range of methodologic problems, including reliance on small sample sizes, failure to use validated assessments of psychopathology, and absence of appropriate comparison groups. One recent study7 avoided some of these methodologic problems, yet confirmed an elevated prevalence of various psychiatric disorders in people seeking bariatric surgery. Among 288 bariatric surgery candidates who were assessed by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (the results of which were not shared with the surgical team), 38% received a current Axis I diagnosis and 66% were given a lifetime diagnosis. Current anxiety disorders were found in 24% of patients; 16% were found to have a mood disorder. Approximately 29% met criteria for a personality disorder.

Likely as a result of these studies, as well as for other reasons (including requirements from third party payers), the large majority of bariatric surgery programs in the United States require a mental health evaluation prior to surgery.8 While the focus of these evaluations is often on screening for psychopathology, the authors of this article suggest that the evaluations also have a psychoeducational focus. This focus includes an assessment of the behavioral and environmental factors that may have contributed to the development of extreme obesity as well as an assessment of the potential impact of these factors on the patient’s ability to make the necessary dietary and behavioral changes to experience an optimal postoperative outcome (DB Sarwer, PhD, unpublished material, 2008).9

Candidates for bariatric surgery often believe that the preoperative mental health evaluation is designed to “rule-out” patients for surgery. Thus, patients may be motivated to minimize psychological distress and present themselves in a favorable light during these evaluations.9,10 In reality, few patients are outright denied bariatric surgery based on the mental health evaluation.11-15 This typically occurs when the patient has significant, untreated psychopathology (including active substance abuse, active psychosis, bulimia nervosa, and severe uncontrolled depression) or exhibits a gross misunderstanding of the purpose of bariatric surgery. By contrast, the most common outcome of the preoperative evaluation, occurring in 70% to 90% of cases, is the unconditional recommendation to proceed with surgery.11-15

Patients who are not unconditionally recommended for surgery are typically asked to enter some additional mental health and/or dietary treatment for a period of time (eg, 3–6 months) and then return for re-evaluation. Upon re-evaluation, >50% of patients (but only 31% of males) were adherent to the recommendations of the mental health professional and, thus, were recommended for surgery.12

 

Psychosocial Outcomes Following Bariatric Surgery

The outcomes of bariatric surgery are, for the majority of patients, impressive. Within 12–18 months postoperatively, individuals typically lose 20% to 35% of initial body weight.16-19 The weight loss is associated with significant improvements in morbidity and mortality.16-26 Bariatric surgery is also associated with significant improvements in psychosocial status. Most psychosocial characteristics, including symptoms of depression and anxiety, health-related quality of life, self-esteem, and body image, improve dramatically in the first postoperative year.1-6 Many of these benefits appear to endure through the first 4 postoperative years. Longer-term psychosocial outcomes are largely unknown.

Similarly, the impact of bariatric surgery on formal psychopathology is unclear. In a review of the psychosocial literature, Herpertz and colleagues5 drew a thought-provoking conclusion. They suggested that psychosocial distress that is secondary to obesity, such as significant body image dissatisfaction or distress about weight-related limitations in functioning, may facilitate weight loss following surgery. In contrast, the presence of significant psychopathology that is independent from the degree of obesity, such as major depression, may inhibit patients’ ability to make the dietary and behavioral changes necessary for the most successful postoperative outcome possible.

While the majority of studies suggest that the psychosocial outcomes of bariatric surgery are largely positive, the authors of this article note that these investigations generally reported group outcomes and not changes for individual patients. The positive changes in psychosocial status are not universal. Just as some patients experience medical complications, some will also experience poor behavioral or psychological outcomes. (Sogg and colleagues27 discuss untoward psychological outcomes with regard to marital and sexual behavior, whereas the current article focuses on depression and suicide, suboptimal weight loss, disordered eating, body image dissatisfaction, and substance abuse.)

 

Depression and Suicide

Numerous studies have identified a relationship between depression, suicidality, and obesity. A large epidemiologic study28 found that obese women were significantly more likely to experience suicidal ideation and to make suicide attempts than their normal-weight counterparts. (Interestingly, obese men were less likely to report suicidal thoughts or behaviors than normal-weight men.) This study, however, did not take obesity severity into account. People with extreme obesity have been found to be 87% to 122% more likely to attempt suicide than people in the general population.29

Recently, Adams and colleagues25 examined mortality and causes of death over a mean of 7 years in 7,925 postoperative bariatric surgery patients and 7,925 non-patient controls who were matched for age, gender, and body mass index (BMI). All-cause mortality was significantly reduced in surgery patients compared to controls. However, nearly twice as many surgery patients (n=43) as controls (n=24) died by suicide. Although that difference was not statistically significant, the trend is both surprising and troubling.

Small case series have also documented suicides.30-32 Whereas the yearly suicide rate in the general population is 11.0 deaths per 100,000 people,33 Waters and colleagues,32 found three suicide deaths, over a 36-month period, in 157 bariatric surgery patients. Omalu and colleagues34 recently reported three suicides in the first 2 years following bariatric surgery. They noted that each of those patients had a history of severe depression before surgery that persisted postoperatively and despite maintaining weight losses of 25% to 41% of their initial weight.

Given the relationship between extreme obesity and suicide, and the generally salutary effects of bariatric surgery on psychological distress, reports of suicide after bariatric surgery are largely counterintuitive. In the absence of additional information on the relationship between bariatric surgery and suicide, these findings underscore the importance of ensuring that patients who have psychiatric disorders receive appropriate mental health assessment and treatment before and after bariatric surgery.

 

Suboptimal Weight Loss

Approximately 20% of people who undergo bariatric surgery fail to reach the typical postoperative weight loss or begin to regain large amounts of weight within the first few postoperative years.18,19 As seen in the Swedish Obese Subjects trial, both gastric banding and gastric bypass patients began to regain weight between the first and second postoperative years. At 10 years postoperatively, approximately 10% of patients who underwent gastric bypass and 25% of patients who underwent gastric banding failed to maintain at least a 5% reduction in initial weight. Suboptimal weight losses are typically attributed to poor adherence to the postoperative diet or a return of maladaptive eating behaviors, rather than to surgical factors.1-2,4

Numerous studies have found that adherence to the postoperative diet is poor (DB Sarwer, PhD, unpublished material, 2008).35,36 Caloric intake often increases significantly during the postoperative period (DB Sarwer, PhD, unpublished material, 2008).35,38 Participants in the Swedish Obese Subjects trial (the majority of whom underwent vertical gastric banding) consumed approximately 2,900 kcal/day prior to surgery.18 Intake decreased to approximately 1,500 kcal/day 6 months after surgery but increased to approximately 2,000 kcal/day 10 years later. This increased caloric intake likely contributed to weight regain these patients began to experience starting in the second postoperative year.

Bariatric surgery requires regular, if not life-long, follow up. Patients who undergo gastric bypass are recommended to return to the bariatric surgery program at least every 6 months in the first 2 postoperative years and annually thereafter.39 Adjustments of a gastric band can require follow-up appointments as regularly as every 4–6 weeks in the first postoperative year and quarterly through the first 3 postoperative years.40 These postoperative visits can be used not only to monitor patients’ weight loss (and overall psychosocial status) but to counsel patients on issues related to dietary adherence and eating behavior as well.41,42 Clinical reports have suggested that postoperative follow up with the bariatric surgery program is frequently suboptimal and can negatively impact weight loss, sometimes within the first postoperative year.42-45 In a recent report, only 40% of patients returned for each of their annual follow-up visits with the surgeon within the first 4 years of surgery. Those who returned for all of their annual follow-up visits lost significantly more weight than those patients who did not return; the latter regained weight between the first and third postoperative years.41

The direction of the relationship between postoperative follow up and weight loss is unknown. Did patients lose less weight because they lacked the support and care offered during follow-up visits, or did they fail to return because they were embarrassed over suboptimal weight loss? Clinicians are advised to prepare patients for the possibility of less-than-desired weight loss and weight regain when they counsel patients preoperatively and to normalize these outcomes should they occur postoperatively.

 

Malnutrition

A subset of bariatric surgery patients suffers from malnutrition. The most common and severe problems appear to be vitamin B12, iron, and folic acid deficiency.39 Calcium, vitamin D, and other vitamin deficiencies appear to be less common.39 Most cases of malnutrition among bariatric surgery patients appear to be responsive to improved dietary adherence or vitamin supplementation.39

 

Gastrointestinal Symptoms

Poor adherence to the postoperative diet may also result in gastrointestinal discomfort, including nausea, “plugging,” vomiting, and gastric dumping. “Plugging” has been described as the subjective experience of ingested food becoming lodged in the gastric pouch, which leads to pressure and/or pain in the chest.46 These symptoms typically follow over-consumption of pasta, bread, or dry meats, and were reported by 43% of gastric bypass patients years after surgery.46

One- to two-thirds of patients report postoperative vomiting.43,46 Although vomiting occurs most frequently during the first few postoperative months47 it may continue for several years postoperatively and may be associated with malnutrition.47 Patients may vomit reflexively due to food intolerance or may self-induce vomiting to relieve the discomfort associated with “plugging.” (Self-induced vomiting is not considered a sign of bulimia if it is not motivated by the desire to compensate for excessive caloric intake or by an excessive fear of weight gain.)

Gastric dumping, which occurs with the gastric bypass but not banding procedures, is a constellation of symptoms that can include nausea, flushing, bloating, faintness, fatigue, and severe diarrhea. It typically occurs following the consumption of foods high in sugar and/or fat. Dumping occurs in approximately 50% to 70% of gastric bypass patients.48,49 The aversiveness of dumping may be one factor that contributes to the weight-loss superiority of gastric bypass as compared to gastric banding.

 

Disordered Eating

Disordered eating, specifically binge eating and night eating, are thought to be relatively common among candidates for bariatric surgery. Binge-eating disorder (BED) is characterized by the consumption of an objectively large amount of food in a brief period of time (ie, 2 hours) with the patient’s report of subjective loss of control during the overeating episode.50-52 Night-eating syndrome (NES) is defined as a circadian delay in the pattern of eating, characterized by evening hyperphagia (ie, the consumption of ≥25% of total daily caloric intake after the evening meal) and/or ≥2 nocturnal ingestions (ie, waking during the sleep period to eat) per week. These criteria were recently modified and put forth as the official research criteria for the syndrome at the First International Night Eating Symposium (Minneapolis, Minnesota, April 26, 2008).

The rates of BED and NES among patients seeking bariatric surgery vary as a function of the methodology used to assess their presence.51,53-57 Using the Eating Disorder Examination, widely considered the “gold standard” for the assessment of eating pathology, 39% of gastric bypass candidates reported at least one binge eating episode per week during the prior 3 months.56 The prevalence of NES among bariatric surgery candidates has been estimated at 8% to 27% using questionnaire-based assessment methods.53,57 In contrast, a recent study by Allison and colleagues51 found that <5% of patients met full diagnostic criteria for BED and 2% to 9% for NES, when a questionnaire-based assessment was supplemented with additional interview questions.

Several studies have investigated the relationship between disordered eating prior to surgery and postoperative outcomes. Two studies found that while patients did not report any objective binge episodes postoperatively, a significant minority reported feelings of loss of control consistent with BED.58,59 Kalarchian and colleagues60 observed no binge episodes in the 4 months following surgery. However, 46% of patients have reported either objective or subjective binge eating at longer followup.61

Preoperative binge eating may be related to smaller weight losses or weight regain within the first 2 years after surgery.58,59,61 These suboptimal outcomes may be attributable not only to the binge eating but also the stretching of the gastric pouch, which would allow for increased energy intake over time.62 Individuals who engage in night eating before surgery have been found to continue the behavior postoperatively.57 At least one study has found that more frequent nocturnal eating following bariatric surgery was associated with greater BMI and lower satisfaction with surgery.63

 

Body Image Dissatisfaction

The massive weight loss seen with bariatric surgery is associated with significant improvements in body image.64-67 Unfortunately, some patients who lose large amounts of weight report residual body image dissatisfaction associated with loose, sagging skin of the breasts, abdomen, thighs, and arms. More than 66% of post-bariatric surgery patients considered the development of excess skin to be a negative consequence of surgery.69 This dissatisfaction likely motivates some individuals to seek plastic surgery to address these concerns.69

According to the American Society of Plastic Surgeons,70 in 2007, almost 67,000 patients underwent body contouring procedures after weight loss. The most common procedures were breast reduction and extended abdominoplasty/lower body life procedures. Little is known about the psychological aspects of the procedures.69,71 Studies of other cosmetic surgical procedures suggest that body image improves postoperatively.72-75 There is concern, however, that some patients who present for body contouring following bariatric surgery may be suffering from body dysmorphic disorder, which is seen in 5% to 15% of cosmetic surgery patients.72-75

 

Substance Abuse

Most studies that have examined the relationship between BMI and substance use disorders found lower rates of these disorders among obese individuals.76,77 Scott and colleagues,78 for example, found that the odds of an alcohol use disorder were 40% lower in obese versus normal weight individuals in the general US population. In a sample of bariatric surgery candidates, <2% met criteria for a current substance use disorder.7

Two concerns regarding postoperative substance use have become prominent in the mass media, if not in the scientific literature, namely, changes in alcohol metabolism and “addiction transfer.” To the knowledge of the authors of this article, no pre-postoperative comparisons of alcohol metabolism have been published. However, a comparison of Roux-en-Y gastric bypass (RYGB) patients (2 years postoperatively) and controls found that the former group had higher alcohol breath levels (0.08% vs. 0.05%) and took longer to return to 0 (108 minutes vs. 72 minutes), after consuming 5 ounces of red wine despite having a higher BMI.79 Similarly, Klockhoff and colleagues80 found a higher peak blood-alcohol concentration and a shorter time to reach peak levels among postoperative RYGB patients compared with age and BMI-matched controls. Based on these findings, as well as anecdotal reports, gastric bypass patients should be cautioned that they may experience the effects of alcohol quite differently following surgery.

“Addiction transfer” is a popular, mass media-created term that refers to the idea that patients who undergo bariatric surgery may develop addictions to substances, gambling, sex, and so forth to replace their preoperative “addiction” to food. The authors of this article hasten to point out that “addiction transfer” is not an accepted clinical or scientific term. The term and construct have several shortcomings, as detailed by Sogg.81 Chief among these is that the view of food as an addictive substance, or eating as an addictive behavior, is by no means supported by scientific consensus. Additionally, there is little support for the notion that a treated symptom (eg, compulsive eating) will resurface in a different form (eg, compulsive drinking or shopping) unless the psychological basis for the original problem is resolved.

Currently, there is no empirical evidence that bariatric surgery increases the risk of substance use or other addictive behaviors. Thus, “addiction transfer” cannot be considered a common outcome of bariatric surgery. It is, however, possible that bariatric surgery candidates are at increased risk of problematic substance use. Studies that have found an increased risk of death by suicide following bariatric surgery have also found an elevated risk of accidental death.25,34 It is not known how many of those accidental deaths were substance related.

 

Conclusion

Bariatric surgery is presently the most powerful tool to treat obesity. For the majority of patients, the surgical procedures produce sizable weight losses that are well maintained and are associated with significant improvements in mortality as well as physical and psychological comorbidities. Unfortunately, these impressive effects are not universal. Suboptimal outcomes are most often attributed to behavioral and psychological reasons rather than surgical ones.

Mental health professionals play a central role in the evaluation of candidates for bariatric surgery. Some also participate in patients’ postoperative care by running support groups or providing individual psychotherapy. Just as there is no standard of practice for conducting preoperative evaluations, there is no consensus regarding which postoperative mental health interventions are most appropriate and efficacious for optimizing surgical outcomes. It is intuitive, for instance, that cognitive-behavioral interventions would be useful for people struggling with disordered eating or body image disturbance postoperatively. However, there has been little, if any, empirical study in these areas or other areas of postoperative mental health care. The development and testing of postoperative interventions are important and logical “next steps” for researchers and practitioners who work with bariatric surgery patients. The anticipated growth of bariatric surgery in the coming years will provide ample opportunity to further consider the role of the mental health professional in the postoperative care of these individuals. PP

 

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63.    Latner JD, Wetzler S, Goodman ER, Glinski J. Gastric bypass in a low-income, inner-city population: eating disturbances and weight loss. Obes Res. 2004;12(6):956-961.
64.    Adami GF, Gandolfo P, Campostano A, Meneghelli A, Ravera G, Scopinaro N. Body image and body weight in obese patients. Int J Eat Disord. 1998;24(3):299-306
65.    Camps MA, Zervos E, Goode S, Rosemurgy AS. Impact of bariatric surgery on body image perception and sexuality in morbidly obese patients and their partners. Obes Surg. 1996;6(4):356-360.
66.    Dixon JB, Dixon ME, O’Brien PE. Body image: appearance orientation and evaluation in the severely obese. Changes with weight loss. Obes Surg. 2002;12(1):65-71.
67.    Neven K, Dymek M, leGrange D, Maasdam H, Boogerd AC, Alverdy J. The effects of Roux-en-Y gastric bypass surgery on body image. Obes Surg. 2002;12(2):265-269.
68.    Kinzl JF, Traweger C, Trefalt E, Biebl W. Psychosocial consequences of weight loss following gastric banding for morbid obesity. Obes Surg. 2003;13(1):105-110.
69.    Sarwer DB, Thompson JK, Mitchell JE, Rubin JP. Psychological considerations of the bariatric surgery patient interested in body contouring surgery. Plast Reconstr Surg. In Press.
70.    American Society of Plastic Surgeons. 2007 National Plastic Surgery Statistics. Arlington Heights, IL: ASPS; 2008.
71.    Sarwer DB, Fabricatore AN. Psychiatric considerations of the massive weight loss patient. Clin Plast Surg. 2008;35(1):1-10.
72.    Sarwer DB. The psychological aspects of cosmetic breast augmentation. Plast Reconstr Surg. 2007;120(7 suppl 1):110S-117S.
73.    Sarwer DB, Brown GK, Evans DL. Cosmetic breast augmentation and suicide. Am J Psychiatry. 2007;164(7):1006-1013.
74.    Sarwer DB, Crerand CE. Body image and cosmetic medical treatments. Body Image. 2004;1(1):99-111.
75.    Sarwer DB, Crerand CE. Body dysmorphic disorder and appearance enhancing medical treatments. Body Image. 2008;5(1):50-58.
76.    Kleiner KD, Gold MS, Frost-Pineda K, Lenz-Brunsman B, Perri MG, Jacobs WS. Body mass index and alcohol use. J Addict Dis. 2005;23(3):105-118.
77.    Simon GE, Von Korff M, Saunders K, et al. Association between obesity and psychiatric disorders in the US adult population. Arch Gen Psychiatry. 2006;63(7):824-830.
78.    Scott KM, Bruffaerts R, Simon GE, et al. Obesity and mental disorders in the general population: Results from the world mental health surveys. Int J Obes (Lond). 2008;32(1):192-200.
79.    Hagedorn JC, Encarnacion B, Brat GA, Morton JM. Does gastric bypass alter alcohol metabolism? Surg Obes Relat Dis. 2007;3(5):543-548.
80.    Klockhoff H, Naslund I, Jones AW. Faster absorption of ethanol and higher peak concentration in women after gastric bypass surgery. Br J Clin Pharmacol. 2002;54(6):587-591.
81.    Sogg S. Alcohol misuse after bariatric surgery: epiphenomenon or “Oprah” phenomenon? Surg Obes Relat Dis. 2007;3(3):366-368.

Psychiatric Dispatches

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Primary Psychiatry. 2008;15(8):21,24-26

 

Barriers Compromising Adherence to Positive Airway Pressure for Children with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is prevalent in 1% to 4% of the population. If untreated, it can lead to various ailments, including behavioral problems, neuropsychological deficits, and medical morbidity. Though there are effective treatments for OSA, such as tonsillectomy and adenoidectomy and positive airway pressure (PAP), not all children experience the benefits of or qualify for tonsillectomy and adenoidectomy. Further, pediatric patients undergoing PAP often have difficulty tolerating and being consistent with the procedure as prescribed. Kelly C. Byars, PsyD, CBSM, and colleagues evaluated adherence to PAP in the pediatric OSA population and found common barriers to adherence to the treatment.

The study involved a mostly male (72.7%) and white (61.4%) sample of 44 patients who were evaluated in the Accredited Sleep Center and Accredited Sleep Laboratory of the Academic Pediatric Medical Center in Cincinnati, Ohio. To qualify for the study, patients had to be ≤18 years of age (all patients were 5.37–16.13 years of age at time of diagnostic polysomnography) and experiencing PAP titration from January–December 2005. Each patient’s outpatient clinic notes were reviewed using the retrospective chart review (RCR) both prior to titration study and up through the year 2007. Scoring on the RCR was completed according to criteria from the American Academy of Sleep Medicine.

While adherence to the therapy ranged from complete rejection of the treatment to optimal usage, descriptive statistical results showed that most patients did not use PAP as required. In addition, it is important to note that most factors compromising adherence to PAP revolved around psychosocial issues.

These data indicate the need for behavioral sleep medicine practitioners in circumstances where children with OSA are using PAP therapy. Further research is still necessary for improved PAP adherence in pediatric OSA patients. (APSS 2008; Poster 0289). –ML

 

Changes in Sleep Pattern Often Occur in Military Personnel with Traumatic Brain Injury

Traumatic brain injury (TBI) is one of the most prevalent injuries suffered by members of the United States military. According to the Defense and Veterans Brain Injury Center, the military formerly diagnosed 2,121 cases of TBI between October 2001 and January 2007, though actual rates of such injury may be higher. In addition, due to the types of incidents causing brain injury, such as increased use of improvised explosive devices (IEDs) and mortar attacks, the rates of traumatic brain injury are similarly increasing. Data have shown that a majority of military personnel serving in Iraq and treated by a medical unit were injured due to IEDs or mortar attacks.

A common complaint of service men and women following TBI is change in sleep patterns. Despite this higher reporting of sleep complaints, few studies have investigated the link between TBI and sleep disturbance in service men and women or in the general population. Studies that have been conducted show that patients with brain injuries have reduced rapid eye movement (REM) sleep, disruptions in sleep architecture, and increased incidence of narcolepsy. Researchers in the Department of Neurology at the University of North Carolina in Chapel Hill sought to determine the link between sleep disturbance and TBI in a population of military personnel, whom the authors found would be at higher risk for changes in typical sleep patterns due to the nature of their injuries.

Peterson F. Giallanza, MD, and colleagues, studied sleep data from 35 marines (average age=23.4 years) who incurred brain injury and compared those findings with data from 21 participants (average age=24.2 years) who had no reported brain injury. The authors recorded a polysomnogram on every participant and studied standard sleep parameters, such as frequency of REM sleep. Nasal pressure and continuous end tidal carbon dioxide were also measured. All data were evaluated using American Academy of Sleep Medicine criteria.
The authors found that numerous patients with brain injury had higher measures on certain sleep indices, including total sleep and REM sleep time, than normal controls, which was a finding contrary to their hypothesis.

Among patients with TBI, 13 had a sleep efficiency of ≥95%; this result was found in two control patients. Evaluating latency to REM onset, eight patients with brain injury showed a latency period of <60 minutes and three patients had a latency period of <30 minutes. No control participants showed a latency period of <60 minutes. Regarding sleep onset REM periods (SOREMPs), Giallanza and colleagues found that 16 patients with TBI had ≥1 SOREMP during polysomnogram while only one control participant had ≥1 SOREMP. Eight TBI patients experienced ≥2 SOREMPs, and six of those patients had a mean sleep latency of <8 minutes. Among healthy participants, one had 2 SOREMPs.

The authors concluded that although these findings were contrary to earlier reports of decreased REM sleep in service men and women with TBI, they may be due to a higher sleep/wake dysregulation in combat veterans than in the general population. The authors added that such changes in sleep patterns may be a marker for a neurologic condition. Study limitations included lack of military controls and certain findings could be attributed to other disorders, such as sleep deprivation. (APSS 2008; Poster 0872). –CP

 

Insomnia Severity and Incidence of Comorbid Medical and Mental Illness

 In a large, community-based study, Khaled Sarsour, PhD, and colleagues assessed the severity of insomnia across a range of medical and psychiatric comorbid conditions and evaluated the effects of insomnia on daytime functioning across the severity spectrum. They used the Insomnia Severity Index (ISI) to determine symptom severity ratings of insomnia in the study. Ratings data were then compared with the number of independently reported medical and psychiatric comorbidities, and claims-based psychiatric and chronic medical conditions.

From a total of 2,292 enrollees (age range=18–80 years), all from a Midwest health plan, 1,181 were identified as having an insomnia-related claim, and the remaining 1,111 enrollees were chosen randomly. Mean age of the sample was 51.74 years (SD±14.3 years), 30.4% were male, and 87.1% lived in urban areas. Prevalence of subthreshold insomnia in this sample was 33.6%, according to the ISI. Prevalence rates of moderate and severe insomnia were 21.2% and 6%, respectively; 39.3% had no insomnia.

For subjects with severe insomnia, worry was the most severe comorbidity, with 91% experiencing it. Depression (79%), pain (70%), and sleep apnea (60%) were the next most prominent comorbidities. Less comorbidities were commensurate with decreasing insomnia severity in subjects with moderate and subthreshold insomnia. Similarly, subjects with severe insomnia reported the most difficulty initiating sleep (93%), difficulty maintaining sleep (97%), and early morning awakening (90%). Eighty-two percent reported all three symptoms.

Overall, for subjects with severe insomnia, the odds of having ≥1 psychiatric comorbidity and ≥1 chronic medical comorbidity are 5.26 and 2.22 times higher, respectively, compared to those with no insomnia. Aside from indicating that psychiatric and chronic medical comorbidities are strongly related to increased severity of insomnia, this study also provides an overview of the daytime effects of insomnia across all ranges of severity.

Funding for this research was provided by Eli Lilly. (APSS 2008; Poster 0724) –LS

 

Increased Probability of an Accident After Using Certain Insomnia Medications

In 2005, the National Sleep Foundation conducted a survey that found 54% of American adults endure at least one symptom of insomnia a few nights per week. Numerous treatments for insomnia can lead to next-day somnolence and possibly increased risk of accidental events. Alon Y. Avidan, MD, MPH, and colleagues of the Department of Neurology at the University of California in Los Angeles examined the risk of accidents in patients prescribed either a benzodiazepine receptor agonist or sedating antidepressant compared to that in patients prescribed a selective melatonin receptor agonist.

The researchers used a retrospective cohort analysis to compare the occurrence of accidental events in a commercial population with ≥9 months of health insurance eligibility data. Accidental events such as falls, open wounds, and motor vehicle accidents were distinguished from medical claims using External Causes of Injury codes from the International Classification of Diseases, 9th Revision. Patients initiated insomnia medication, including long-acting benzodiazepines (LABs; n=344,557), short-acting benzodiazepines (SABs; n=127,252), nonbenzodiazepines (nBzs; n=563,298), sedating antidepressants (n=175,564), and selective melatonin receptor agonists (n=132), and were evaluated over a 60-day period after initial prescription. During this time, probit models assessed the probability of an accidental event while proportional hazard models measured the time to an accidental event.

Results found that subjects taking an LAB, SAB, nBz, or sedating antidepressants experienced greater risk of an accidental event following treatment initiation than those taking a selective melatonin receptor agonist. Further, subjects taking a selective melatonin receptor agonist faced less time to an accidental event than those taking other insomnia medications.
The data indicated that there is apparent lower risk of accidental events in the selective melatonin receptor agonist cohort. However, this conclusion is limited, as the number of patients in this particular group was significantly smaller than those in the other treatment arrays. (APSS 2008; Poster 0776). –ML

 

Obstructive Sleep Apnea Patients at Increased Risk for Restless Legs Syndrome

Obstructive sleep apnea (OSA) and restless legs syndrome (RLS) are common conditions that patients often report negatively impact sleep and alter quality of life. Prior studies have shown that among patients who experience RLS symptoms—disruptive sensations in the legs and an urge to move during rest for relief—many report symptoms on multiple evenings per week, resulting in a high impact on quality of life. In addition, studies have shown that patients with OSA often have clinically significant RLS symptoms on multiple evenings per week. Nevertheless, there have been few studies examining the co-occurrence of RLS and OSA.

James M. Thompson, MD, of the Sleep Disorders Center of Lexington in Kentucky, and colleagues studied overnight polysomnography data from 357 adults (>18 years of age) with possible RLS and OSA or without the disorders to determine the prevalence and severity of both disorders in a patient population. Specifically, the authors sought to determine how often RLS co-occurs with OSA in patients with either condition.

All polysomnographs were conducted at two American Academy of Sleep Medicine-accredited community-based sleep centers. Patients were either referred for polysomnographs by sleep center physicians or other physicians, such as pulmonary specialists, to test for OSA or for continuous positive airway pressure titration.

Prior to the study beginning, included patients could have been diagnosed with and been receiving treatment for RLS as well as receiving treatment for other sleep conditions. Various questionnaires were also used to assess patients, including the Cambridge RLS questionnaire, the International Restless Legs Syndrome Scale (IRLS), the Epworth Sleepiness Scale, and the Sleep Disorders Center questionnaire that assesses rates of insomnia in the home.

Thompson and colleagues found that 319 patients had OSA, with 103 of those patients (32.3%) also experiencing RLS symptoms. Among patients with both OSA and RLS, 42 reported moderate RLS symptoms while a lower number of patients reported experiencing mild (IRLS score ≤10; n=31) or severe (IRLS score ≥20; n=30) RLS symptoms, according to the IRLS. In addition, 23% of all OSA patients reported RLS symptoms on ≥2 days per week. Patients with OSA and RLS also had latency to sleep times of >35 minutes, but those without RLS symptoms showed lower latency to sleep times (29.6 minutes).

The authors concluded that these findings show that RLS commonly co-occurs with OSA, as the prevalence rate of RLS (32.3%) is three times higher than the rate in the general population, according to prior studies. The rate of clinically significant RLS, as defined as an IRLS score of ≥20, is also three times higher in OSA patients than in the general population. Thus, the authors recommend that any patient presenting for polysomnography due to sleep disturbance be considered at risk for RLS, which can cause insomnia by increasing latency to sleep times. Thompson and colleagues suggest future reseach to determine the cause of the co-occurrence of RLS and OSA.

Funding for this research was provided by GlaxoSmithKline. (APSS 2008; Poster 0850). —CP

Indicators of Resilience to Effects of Sleep Deprivation in Adolescents

Approximately 50% of adolescents sleep <7 hours per school night and 16% sleep <6 hours, defying the optimal time of 9 hours. As a result of inadequate sleep, negative behavioral outcomes (eg, academic performance, mood difficulties, risk-taking behaviors) can affect teenagers’ long-term development. A small-sample study by Dean W. Beebe, PhD, ABPP-Cn, of the Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine in Ohio, and colleagues, examined potential indicators of resilience to effects of sleep deprivation in adolescents.

The 3-week study involved 19 teenagers (11 males; 8 females) 13.9–16.9 years of age. Participants were asked to neither nap nor drink caffeine Monday through Friday. Though they were allowed to self-select their bedtimes every Saturday and Sunday, the time at which they needed to arise for an 8:30 a.m. class (ie, “wake time”) was the same for all 3 weeks. Prior to sleep manipulation, the School Sleep Habits Survey was conducted to measure participants’ typical sleep duration on school nights and weekends. Four-item short forms of the fatigue and vigor subscales of the Profile of Mood States were given as well to determine how much participants thought sleep deprivation affected their mood. Experimental week 1 incorporated the sleep-restricted condition (ie, 6.5 hours in bed with lights out) and experimental week 2 employed the optimized sleep condition (ie, 10 hours in bed with lights out). As a resilience measure, participants rated their moods “over the past 2–3 days” every Saturday morning at the end of each experimental week. These scores reflected how much sleep deprivation actually affected their mood. Actual resilience scores were calculated as the difference between a participant’s mood rating for the optimized-sleep week and that of the sleep-restricted week. Actigraphs and nightly sleep diaries were collected every week to monitor adherence to the experimentally induced sleep manipulation.

Results revealed participants slept less and reported more fatigue in the sleep-restricted week than in the optimized-sleep week. Participants who thought they were more resilient to the effects of sleep deprivation slept less on school nights (P<.05) while those who showed greater actual resilience consistently slept less on weekends (P<.05) and showed no difference on school nights (P>0.8). Participants’ predictions concerning how vigorous they would feel during the experimental weeks were relatively accurate (P<.01), but predictions regarding levels of fatigue were not (P>0.5).

Though the data indicate a correlation between adolescents’ expectations of resilience to sleep restriction and their actual resilience and habitual sleep patterns, it is important to note that the study’s fatigue scores were reversed to show more resilience resulted in higher actual resilience scores. Future research should involve replication in larger samples and address different aspects, including attention and learning. It is also necessary to assess whether changes in sleep behaviors followed changes in beliefs about sleep and whether resilience is a stable trait.

Funding for this research was provided by the Cincinnati Children’s Hospital Medical Center in Ohio and the National Institutes of Health. (APSS 2008; Poster 0235) –ML

Posters were drawn from the 22nd Annual Meeting of the Associated Professional Sleep Societies, LLC (APSS; June 7–12, 2008, Baltimore, MD). Psychiatric dispatches is written by Michelisa Lanche, Carlos Perkins, Jr, and Lonnie Stoltzfoos.

e-mail: ns@mblcommunications.com

 

Dr. Sussman is editor of Primary Psychiatry and professor of psychiatry at the New York University School of Medicine in New York City.

Dr. Sussman reports no affiliation with or financial interest in any organization that may pose a conflict of interest.

 


 

The clinical use of psychostimulants to treat attention-deficit/hyperactivity disorder (ADHD) is widespread, but the neural mechanisms responsible for their cognition-enhancing/behavioral-calming have never been adequately explained. This lack of clarity makes it more difficult to address criticisms that these drugs are not effective or are harmful. The fact is that stimulants are high on the list of controversial psychotropic medications. Apart from unanswered questions about how these drugs work, a major reason for concern about the use of drugs like amphetamines and methylphenidate is that they have a potential for diversion for recreational use, or some argue, may result in abuse among those who use them therapeutically. Another source of controversy is the fact that these agents are primarily used to treat children and adolescents with ADHD, a diagnosis that itself is actively questioned in the press. Most recently, there have been reports that influential researchers at Harvard Medical School may not have adequately disclosed the extent of their relationships with manufacturers of ADHD medications; these reports have raised additional questions about the validity of some studies that show very favorable risk-benefit profiles when these drugs are used to treat ADHD.1 Not being a specialist in child in adolescent psychiatry, nor having ever done research or consulted for a marketer of psychostimulants, I can only make observations based on my reading of the literature, reports from my patients, and accounts from patients’ family members.

The following are the basic benefits of stimulants. First, among hyperactive patients, the stimulants improve their ability to absorb and integrate information. They also become more focused and attentive. Second, when effective, drugs work rapidly, even within one day. A typical response is “I never thought this could be so easy.” The benefits are usually unmistakable. Last, there is an improvement in self esteem as a response to improved academic performance and a reduction in household tension that may have previously arisen from failure to do homework, reports of behavioral problems in school, and sloppiness at home.

Understanding how a drug works—demystifying its mechanism of action—can go a long way in overcoming excessive skepticism or antipathy to a psychotropic agent. It can also help in the development of more effective or better-tolerated medications. It may be helpful that researchers have made recent progress in explaining how these drugs work. Findings from research on rats that appeared in Biological Psychiatry,2 for example, suggest work by “fine-tuning” neuron activity in the prefrontal cortex, the part of the brain responsible for filtering out distractions and helping people to focus on tasks. University of Wisconsin-Madison researchers Devilbiss and Berridge2 report that methyphenidate “fine-tunes” neuronal activity in the prefrontal cortex. This is the brain region involved in attention, decision-making, and impulse control. Of particular interest  is that the medication had little or no effects on other areas of the brain.

To investigate, Devilbiss and Berridge2 attached tiny electrodes to individual neurons in the brains of normal rats and watched how different doses of the drug affected neuron activity. This is an important study because it seeks a more scientific explanation for the cognition-enhancing/behavioral-calming actions of these drugs.

The usual response to the question of “How do these drugs work?” has been to say that they raise brain activity of the catecholamine neurotransmitters, dopamine and norepinephrine. This study2 provides a more complex but more specific explanation. According to the authors, the study showed that cognition-enhancing doses of methylphenidate…

 

“…increase the magnitude of both excitatory and inhibitory responses of pre-frontal cortex [PFC] neurons while simultaneously reducing the duration of the inhibitory response. Low-dose methylphenidate also produced ‘gating,’ resulting in a larger number of PFC neurons responsive to CA1-subiculum input. Combined, these observations suggest that low-dose methylphenidate increases both the sensitivity of PFC neurons and the pool of responsive PFC neurons in a more complex manner than simply regulating the level of PFC excitability (ie, gain of neuronal activity), consistent with known actions of catecholamines on cortical neurons.”

A major concern about the use of stimulants is their potential for abuse. In May 2008, the American Journal of Psychiatry published an article3 that suggested there was little or no evidence that the use of stimulants to treat children increased subsequent risk of substance abuse. The study involved >100 young men 10 years after they had been diagnosed with ADHD. The investigators reported that their findings support the hypothesis that stimulant treatment does not increase the risk for subsequent substance use disorders.

In fact, ADHD drugs may be safer in terms of abuse potential and general medical health than the general public believes. Because of unwarranted reluctance to seek help for themselves or their children, many patients suffer needless frustration, poor self-esteem, and both academic and career difficulties. I hope that, as we learn more about the underlying neurobiology of ADHD and the mechanism-of-action of drugs that treat it manifestations, the idea of seeking treatment will become more prevalent and the types of treatment options will expand. PP

 

References

1.    Harris G, Carey B. Researchers fail to reveal full drug pay. New York Times. June 8, 2008. Available at: www.nytimes.com/2008/06/08/us/08conflict.html. Accessed July 21, 2008.
2.    Devilbiss DM, Berridge CW. Enhancing doses of methylphenidate preferentially increase prefrontal cortex neuronal responsiveness. Biol Psychiatry. 2008 Jun 26. [Epub ahead of print].
3.    Biederman J, Monuteaux MC, Spencer T, Wilens TE, Macpherson HA, Faraone SV. SStimulant therapy and risk for subsequent substance use disorders in male adults with ADHD: a naturalistic controlled 10-year follow-up study. Am J Psychiatry. 2008;165(5):597-603.

 

Ms. Anglin is the family health librarian at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders in New York City.

Disclosures: Ms. Anglin reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Carlita Anglin, MSInfoStds, Family Health Librarian, Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, Family Health Resource Center & Library, NYU Health Sciences Consumer Library, 160 E 32nd St, Medical Level, New York, NY 10016; Tel: 212-263-9958; Fax: 212-263-8410; E-mail: anglin@library.med.nyu.edu; Website: www.nyumc.org/hassenfeld.

 


 

 

Focus Points

• Consumer health information services in a pediatric hematology/oncology clinic provide an enriched psychosocial experience for patients and family members.
• A medical librarian can serve a vital role on a patient’s interdisciplinary care team.
• Patients and family members who are better informed about their diagnosis and treatment plan are more engaged in their own health care.
• An interdisciplinary pediatric hematology/oncology care team can work together to reduce patient information barriers and facilitate improved health literacy.

 

Abstract

A family health librarian and pediatric patient library can serve an important role as an interdisciplinary service line within a pediatric hematology/oncology outpatient clinic. Patients and families are offered an enhanced psychosocial experience during their clinic visit through patient library resources, programs, and services. As one aspect of integrated psychosocial support to patients and families, the patient library’s role in addressing issues in health literacy, patient education, consumers’ information styles, bibliotherapy, education and school readiness, online access to health information, and collection materials are described and discussed. The success of the Family Health Resource Center and Library at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders of New York University Langone Medical Center in New York City is owed largely to its integration within numerous psychosocial programs, an overall approach to holistic patient care within the clinic, and a personalized patient experience.

 

Introduction

The primary mission of the Family Health Resource Center and Library at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders (SDHCC) in New York City is to provide consumer health information that allows family members, patients, and others who care about them to understand their health condition and treatment path, be engaged in their own health care, and be informed during critical and difficult decision-making processes. The library is staffed by a professional librarian who provides services and programs that address issues in health literacy, patient education, educational enrichment, school readiness, research support, and psychosocial programming. This integrated service line contributes to the clinic’s emphasis on wellness and patient-centered care.

 

Background

SDHCC’s Family Health Resource Center and Library opened in the fall of 2006 through a generous start-up grant from the Citigroup Foundation. In the new clinic space the Family Health Resource Center and Library was envisioned as a program central to serving the mission of the clinic and as an integrated complement to existing programs such as therapeutic recreation activities, wellness services, psychology services, nutrition programming, patient education, and education initiatives. Members of the clinic’s leadership team, colleagues from the NYU Medical Center’s (NYUMC) Health Sciences Libraries, supporters from the Citigroup Foundation, and numerous other collaborators worked together to draft a vision for implementing educational programming through a new consumer health service line. Through a process of multi-disciplinary discussions and extensive reflection on the needs of patients and families, the Family Health Resource Center and Library was created to provide informational support to patients and their families during times of serious medical problems and illnesses.

 

Who Provides Professional Staffing for the Patient Library?

The Family Health Resource Center and Library is staffed by a professional medical librarian who holds a Master’s degree in information studies, a program of study that is recognized and accredited by the American Library Association. Additionally, the clinic’s Family Health Librarian has experience as a primary school teacher and holds special school library certification earned through a carefully prescribed program of study, field experience in a school library setting, and professional examinations. The clinic’s librarian also has special training and experience related to working with individuals in a healthcare setting and works to connect patients and families to quality information resources while making it clear that she is not qualified to interpret medical information or to give medical advice.

The Family Health Librarian is a faculty member of NYUMC’s Ehrman Medical Library where she, as other library faculty members, serves on various library-related committees and teams. As one of three medical librarians specializing in consumer health information services at NYUMC, the Family Health Librarian works closely with counterpart librarians from the adult cancer center and the main hospital. Each of NYUMC’s three consumer health librarians serves distinct audiences and populations, but they work as a team to accomplish common program goals related to patient-centered care and current issues in consumer health.

 

How are Library Services Integrated within the Clinic?

As a relatively small hematology and oncology outpatient clinic, the SDHCC provides a special, personalized patient-family experience. In this unique setting the Family Health Librarian is one of the multidisciplinary professionals serving on a patient’s care team. New patients and families are often introduced to the clinic’s librarian during an initial visit and clinic tour. The librarian participates in weekly medical and psychosocial rounds and contributes to psychosocial patient care planning. The librarian’s unique perspective and knowledge of families’ questions and struggles allow her to understand the personal world of the patients and their families1 and to bring that understanding to discussions related to patient care within clinic team meetings. The services of the Family Health Librarian are integrated into the multidisciplinary care team of all patients, both through the outpatient clinic experience as well as during any inpatient hospital stays. The personalized approach and librarian integration into patient care is important; in fact, research shows that clinical library services influence patient health outcomes and can save time for healthcare providers.2

 

What Library Programs and Services Support Families?

When a family is faced with the news of a child’s life-threatening illness or serious medical condition, all family members need support during this difficult time. Very often parents, grandparents, aunts, uncles, brothers, sisters, family friends, and even the patients seek information about diagnosis or treatment to help them come to terms with an illness or medical condition. At the SDHCC, the interdisciplinary care team works together to provide a wide range of resources and patient education materials for families as they adjust to the medical diagnosis of their loved one. The resources of the Family Health Resource Center and Library include access to specialized electronic and print-based health materials, professional medical literature searches, computer workstations, instructional assistance using searching and informational tools, reading materials for young children and the professional assistance of a medical librarian. Through these services and resources many patients and family members are able to “obtain, process, and understand the basic health information and services they need to make appropriate health decisions,”3 characteristics which commonly define health literacy.

 

How are Health Literacy Issues Addressed?

Health literacy is an important part of effectively engaging patients in their care; it is a fundamental part of patient and family centered care.3 More than the ability to merely decode health and medical language,4,5 health literacy requires complex skills and critical thinking; it refers to a person’s ability to understand and to act on information that directly affects his or her well being.3,6,7 It is also key to ensuring patient safety.8

Not surprisingly, many patients and families treated at the SDHCC clinic struggle with health literacy issues, as do 50% of the adult American population3 of varying educational and socioeconomic backgrounds. In order to provide the best possible care environment, clinic staff members work together to create opportunities for patients and family members to be engaged, informed, and active participants in their own care. The SDHCC families have interpretive language services available to them, translated patient education materials are provided with side-by-side English translations, written materials are created in jargon-free simplified language,9 a patient advocate helps struggling families navigate the health care maze, and families have the opportunity to work with the family health librarian for learning enrichment. Because of the small size of the clinic, interdisciplinary team members are able to identify patients, parents, or family members who have notable literacy and health literacy issues. Together the team is able to brainstorm possible solutions during psychosocial care plan meetings.

 

How is Patient Education Supported Through Interdisciplinary Work?

The SDHCC’s Family Health Resource Center and Library provides a centralized collection of materials that supports and assists members of a patient’s care team in educating patients, their family members, and their caregivers about disease and treatment information. Family members normally receive a packet of information about a patient’s medical condition and treatment plan from their physician or nurse practitioner at their initial visit; often the librarian plays a key role in this service by locating resources for the clinical staff. The Family Health Resource Center and Library also provides a place where patients and family members can turn for accurate, reliable patient information that complements the clinical visit. Patients and family members are able to improve their understanding about diagnosis and treatment and to be empowered to communicate better with their physician or healthcare provider.10

Having clearly written information about diagnosis or treatment makes it easier for families to digest the news of a serious medical condition during what is recognized as a naturally distressing event that interferes with a person’s ability to “absorb or remember information.”11 Research shows that a person’s capacity for remembering medical information during times of stress is challenged11; in fact, some estimates claim patients immediately forget 40% to 80% of what they are told by their doctors.12 Certainly, written patient education materials are most effective when they are presented in combination with other educational approaches such as a patient’s oral consultations with a physician or nurse educator.8 Patient education efforts at the SDHCC clinic employ this two-part written and oral approach, and, as much as possible, they are tailored to an individual’s learning and cognitive style.

 

What Influences a Person’s Information Style?

As information seeker’s parents and family members at the clinic are representative of the larger population, people have different learning styles, tolerances for quantities of information, coping strategies, and levels of interest in being informed.11 Numerous factors can affect a person’s interest in receiving health information and his or her ability to process it. Educational levels, literacy levels, cultural beliefs, presentation styles of health professionals, individual personality characteristics, and experiencing distress all affect a person’s unique informational style.11 By working with a librarian, parents are able to access accurate and reliable information that makes sense to them. A librarian can also help parents and family members gain confidence in communicating during medical appointments.10

Parents, family members, and patients alike benefit from their library experience on numerous levels. For some, being better informed about the latest advances in medical research gives a family satisfaction and an informed approach to treatment choices that is known as “evidence-based patient choice.”8 For others, additional information may ensure they are more compliant with medications and treatment regimens. Still others gain personal confidence and a vocabulary that allow them to communicate better with their physicians. Recently, one mother asked the Family Health Librarian for help accessing medical articles she could present to her daughter’s physician because she said, “I want our doctor to know that I have intelligence.”

 

How Does a Patient Library Help Consumers Seeking Information On the Internet?

Understandably there are physician concerns about patients getting medical information on the Internet.13 Certainly, families facing a devastating illness or medical problem can easily find themselves intrigued by the promise of a miraculous cure that might seem available online. Often it can be difficult for even the well-educated and sophisticated consumer to discern reliable health sources from those of shrewd advertisers representing products for sale. Because so many people are seeking health information online, it is important to empower patients with resources and skills to ensure they are getting correct and reliable information. The Family Health Librarian works with patients and family members to connect them with trustworthy information and to show them strategies for critically evaluating online health information.

Although all new patients and families are given educational materials and information about community support resources by their care team, many parents and older patients engage in self-directed inquiry often even before their relationship with the SDHCC begins. The Pew Internet and American Life Project has estimated that eight out of every ten Internet users have looked for health information online.14 In households with Internet access among people with a chronic illness or disability, such numbers are even higher.15 Many of the center’s parents are very sophisticated Internet users. They often approach medical research as a way of coping with their child’s illness or a way of making order out of a chaotic process. These parents are able to find reassurance and support by connecting to specialized medical literature resources, by accessing full-text articles, by improving their PubMed searching skills through tutorials with the librarian, and learning about trustworthy consumer Websites such as MedlinePlus. However, other parents and families may not have computers at home and may be unskilled at accessing online information. For them, the SDHCC library is a place where they have access to computers and where they can hone basic computing skills.

 

How is a Patient Library Collection Built?

In order to build a collection that ably serves the needs of the entire clinic population, the Family Health Librarian identifies and purchases high quality health resources that are written in accessible language on a wide variety of childhood cancers, blood disorders, and vascular anomalies. Many of the print materials available as booklets or brochures are procured from well-respected national health or professional organizations such as the American Academy of Pediatrics, the Association of Pediatric Hematology-Oncology Nurses, the Leukemia and Lymphoma Society or the National Cancer Institute. As part of NYUMC, the Family Health Resource Center and Library shares a wealth of resources from the larger medical center and university communities. Often parents and staff benefit from personalized instruction about specialized databases of academic medical literature and electronic resources that are available through the NYU Health Sciences Libraries. The clinic’s library retains basic medical textbooks, medical dictionaries, and drug manuals to serve as reference materials to medical and nursing staff as well as interested parents.

The SDHCC’s collection also reflects the diversity of the clinic’s patient population and the importance of providing informational help for the psychosocial needs of families facing serious medical diagnoses. Respect for different cultural sensitivities and practices is paramount, as parents and family members of all cultural backgrounds come to the SDHCC library looking for information that can help them handle difficult emotional and parenting situations that arise during the sustained family stress of managing the care for a seriously ill child. The materials held in the library aim to serve the unique heterogeneous needs of all SDHCC patients and families, which is a special challenge in New York City. The clinic’s library serves families representing a wide range of nationalities, religious backgrounds, educational levels, languages spoken, and cultural practices. Young patients influence the library’s collection development policy by making requests. For example, two young school age male patients recently approached the librarian separately to suggest more picture books for leisure reading should be available in Russian and Chinese languages.

 

What is the Role of Bibliotherapy and Therapeutic Books for Children?

As expected, most often the information seekers served by the Family Health Resource Center and Library are a patient’s parents. Parents look for information related to their child’s diagnosis and treatment, but there are often numerous unexpected turns in the lines of inquiry. Frequently, parents ask the clinic librarian for information about how to address sensitive issues and questions raised by other young children in the family or by a child’s classmates and friends. Topics such as dealing with a serious medical problem, facing fears related to the medical environment, handling bullies or teasing by peers,16 or discussing death are just some of the specialized topics addressed in therapeutic picture books held in the collection. Very often these specialized books are written by psychologists who have special expertise in working with young children. The books interweave storylines and imaginative illustrations that help children internalize a story’s message; in some instances readers can practice cognitive skill-building through the story process by drawing on the experiences and problem solving skills of a story’s characters.

Parents have reported to the Family Health Librarian that through the experience of reading therapeutic picture books with their children, many important conversations occur. As with other kinds of reading, children find comfort in stories that mirror their personal experience. After identifying with a story’s main character and drawing correlations to their lives, children are able to experience emotional catharsis and ultimately gain deeper insight into their own personal psychosocial experience.16 Parents are able to discuss sensitive topics indirectly by asking their children questions about the reading material and the experiences of a story’s characters. During the experience of reading, parents and children are able to spend important time together that facilitates bonding and supports healthy habits for child development. Bibliotherapy, the process of reading for therapeutic value, is an important part of the healing process for many young patients facing illness, disability, or psychosocial challenges to help them process their feelings.16-20

 

How Does the Library Support Family Literacy and School Readiness?

Family reading and encouragement for early literacy are also emphasized through the clinic’s Reach Out and Read (ROR) program, which is managed through the Family Health Resource Center and Library by the Family Health Librarian. ROR is a national program in which physicians and healthcare providers encourage reading and early literacy among children who are 6 months to 5 years of age. During staged visits that correspond to childhood developmental milestones, patients receive a developmentally appropriate book that is theirs to keep. At the same time, parents receive literacy guidance, modeling, and encouragement from the medical provider who underscores the importance of daily reading to young children.21 For example, healthcare providers give their patients personalized “prescriptions” to read. These interactions are important, not only for the benefit of the young patient but very often they offer encouragement to parents who are non-native speakers of English or who are struggling with their reading abilities. This program is popular among patients and their parents, but it is also a favorite among the physicians and nurse practitioners who are able to have a meaningful non-medical encounter with patients during the ROR interaction.

The SDHCC’s patient library is a natural fit for Reach Out and Read programming. Because the clinic serves a large Medicaid and Medicaid-health maintenance organization population, it meets the ROR program goal of targeting at-risk and underserved families during well-child visits at a time when the SDHCC serves their primary care needs. The ROR program model complements the clinic’s approach to care because it employs an interdisciplinary approach22 to personal wellness and family and child resilience.

 

Conclusion

The SDHCC’s Family Health Resource Center and Library provides a unique and interdisciplinary service line and programming within the clinic. As one psychosocial component of the SDHCC care team, library services are a vital part of actualizing the clinic’s mission to provide patient and family-centered care. SDHCC’s Family Health Resource Center and Library provides programming and services to enhance the educational experiences of patients and family members, address issues in health literacy, improve patient and physician communication, support patient education, assist parents in having conversations with their children, support family literacy, and reflect individual learning styles. A strength of the Family Health Resource Center and Library program, as with all clinic services, is that families receive very personalized attention and care.

Visiting the library can be a very normalizing experience for many patients and their family members. For example, some patients and siblings make a point of visiting the library during every clinic visit. This familiar and pleasant experience reminds them of visits to their school or public library. Patients, siblings, family members, and caregivers seek out the library, not only for information, resources, homework help, research assistance, and help searching the Internet but also for a quiet place away from the bustling activity of the clinic and the playroom areas. For many of the SDHCC patients and families, visiting the library is a conscious choice. PP

 

References

1.    Zipperer L, Gillaspy M, Goeltz R. Facilitating patient centeredness through information work: seeing librarians as guests in the lives of patients. Journal of Hospital Librarianship. 2005;5(3):1-15.
2.    Weightman AL, Williamson J. The value and impact of information provided through library services for patient care: a systematic review. Health Info Libr J. 2005;22(1):4-25.
3.    Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. What is health literacy? In: Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004:31-58.
4.    Larson L. Health literacy: how are your patients reading you? Trustee. 2007;60(5)8-12.
5.    Muro A. What is health literacy? Health and Literacy Special Collection from National Institute for Literacy LINCS Project. Available at: www.lincs.worlded.org/muro.htm. Accessed May 23, 2008.
6.    Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America’s adults: results from the 2003 national assessment of adult literacy (NCES 2006-483). U.S. Department of Education. Washington, DC: National Center for Education Statistics; 2006.
7.    U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000. Available at: www.healthypeople.gov/Document/. Accessed May 23, 2008.
8.    Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. BMJ. 2007;335(7609):24-27.
9.    Aldridge MD. Writing and designing readable patient education materials. Nephrol Nurs J. 2004;31(4):373-377.
10.    Ochillo M, Auflick PA. Health literacy and consumers: empowering patients. Journal of Hospital Librarianship. 2005;5(2):57-64.
11.    Harris KA. The informational needs of patients with cancer and their families. Cancer Pract. 1998;6(1):39-46.
12.    Kessels RP. Patients’ memory for medical information. J R Soc Med. 2003;96(5):219-222.
13.    Shaw J, Baker M. “Expert patient”–dream or nightmare? BMJ. 2004;328(7442):723-724.
14.    Pew Internet & American Life Project. (2005) Health information online. Available at: www.pewinternet.org/PPF/r/156/report_display.asp. Accessed May 23, 2008.
15.    Ayers SL, Kronenfeld JJ. Chronic illness and health-seeking information on the Internet. Health (London). 2007;11(3):327-347.
16.    Gregory KE, Vessey JA. Bibliotherapy: a strategy to help students with bullying. J Sch Nurs. 2004;20(3):127-133.
17.    Amer K. Bibliotherapy: using fiction to help children in two populations discuss feelings. Pediatr Nurs. 1999;25(1):91-95.
18.    Burke RV, Kuhn BR, Peterson JL. Brief report: a “storybook” ending to children’s bedtime problems – the use of a rewarding social story to reduce bedtime resistance and frequent night waking. J Pediatr Psychol. 2004;29(5):389-396.
19.    Shechtman Z. Bibliotherapy: an indirect approach to treatment of childhood aggression. Child Psychiatry Hum Dev. 1999;30(1):39-53.
20.    Tolin DF. Case study: bibliotherapy and extinction treatment of obsessive-compulsive disorder in a 5-year-old boy. J Am Acad Child Adolesc Psychiatry. 2001;40(9):1111-1114.
21.    Reach Out and Read National Center website. Available at: www.reachoutandread.org.Accessed May 23, 2008.
22.    Bailey R, Louis RK. Reach out and read: promoting pediatric literacy guidance though a transdisciplinary team. J Health Care Poor Underserved. 2005;16(2):225-230.

 

Needs Assessment: This article aims to educate others who are less familiar with the psychosocial care needs of pediatric hematology/oncology populations. The article provides a description of multidisciplinary collaborations within the same program in contrast to services accessible to this population via outside referrals.

Learning Objectives:
• List issues that arise for children with chronic illness.
• Understand the steps required for organizing a multidisciplinary approach to psychosocial care.
• Ask questions about how children and families can be best served in outpatient clinics.

Target Audience: Primary care physicians and psychiatrists.


CME Accreditation Statement:
This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.


Credit Designation:
The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.

This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: June 4, 2008.

Drs. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest.

To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by July 1, 2010 to be eligible for credit. Release date: July 1, 2008. Termination date: July 31, 2010. The estimated time to complete all three articles and the posttest is 3 hours.

Primary Psychiatry. 2008;15(7):63-67

 

Dr. Cruz-Arrieta is senior psychologist and clinical assistant professor in both the Departments of Child & Adolescent Psychiatry and Pediatrics at the New York University (NYU) School of Medicine in New York City. Ms. Weinshank is licensed clinical social worker in the Social Work Department at NYU Langone Medical Center.
Disclosure: The authors report no affiliation with or financial interest in any organization that might pose a conflict of interest.

Please direct all correspondence to: Eduvigis Cruz-Arrieta, PhD, Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, 160 E 32nd St, Second Floor, New York, NY 10016; Tel: 212-263-9925; Fax: 212-263-8410; E-mail: Eduvigis.cruz-arrieta@nyumc.org.

 


 

 

Abstract

Scientific advances that lead to early detection and treatment of childhood illnesses once fatal to most children have contributed to higher survival rates. This article outlines a model used at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders for providing outpatient cancer and hematology treatments facilitated and supported by allied health professionals. Coping is sometimes compromised by biopsychosocial factors present in the lives of patients prior to illness. Allied health professionals help patients and families cope by providing a supportive environment for the child with a chronic illness and his or her family. A multidisciplinary team approach is illustrated in this article. The authors describe the process of creating a pathway toward holistic care for all patients, from designing tools that integrate basic information about each patient ‘“in context’’ to how this is accomplished. Two case examples of collaboration between disciplines are provided. Finally, ideas on the need for research that demonstrates the benefits of psychosocial interventions and the need for dissemination of information about what works within the pediatric, allied health, and mental health professions are offered.

 

Introduction

The Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders (SDHCC) of New York University Langone Medical Center functions both as a day hospital and an outpatient medical facility for children with cancer and blood disorders. It provides modern medical treatments facilitated and supported by allied health professionals. The last 30 years have witnessed scientific advances that led to earlier detection and treatment of childhood illnesses once fatal for most children. For example, the 5-year survival rate in pediatric cancer is approximately 80%, resulting in a continuously growing population of childhood cancer survivors. Data collected in the last 10 years shows ≥270,000 survivors of childhood cancer in the United States. One in 1,000 individuals is a childhood cancer survivor. Demographics of the childhood cancer survivors in the US show that while 33% of these survivors are <20 years of age, 46% are 20–40 years of age, and an additional 18% are >40 years of age.1

Children affected with blood disorders such as sickle cell anemia are transitioning into longer, productive lives with significantly less impairment than before thanks to transfusion and oral medication therapies. However, despite the development of promising future cures through procedures such as bone marrow transplants and gene therapies, inadequate attention to psychological, social, and interpersonal functioning is still present.2 Along with these changes, the need for supportive services (ie, nursing and medical teams) for children, families, and caregivers coping with a chronic, life-threatening illness have evolved in specialized ways to further them.3 In the 1990s, changes in health care led to a reduction of available psychosocial services because they were perceived as expensive and “less essential than other evaluations and interventions.”4

Most people who experience a chronic and/or life-threatening disease cope adequately with the stressors it brings. However, this is not an easy task. For a smaller number of patients and families, their coping is compromised by biopsychosocial factors present in their lives prior to the illness (eg, financial difficulties, psychological disorders). Child life, creative arts therapies, family health librarian, pastoral care, psychology, recreation and rehabilitation therapies, and social work, along with the newly integrated complementary therapies, including mind/body techniques such as aromatherapy, acupuncture/acupressure, dance-movement therapies, herbalism, hypnotherapy, therapy massage, music, Reiki, and yoga, now offer tools and support focused on the needs of ill children and survivors of childhood diseases. These therapeutic activities provide children with age-appropriate ways to identify and discuss numerous feelings associated with treatment.4

The SDHCC’s allied health professional staff, comprised by the disciplines outlined above, is dedicated to providing a positive, nurturing, and supportive environment for children with a chronic illness and their families. This psychosocial team focuses on helping children gain and maintain developmental skills during their illness, hospitalization, and treatment.4 At the SDHCC, the family health librarian is a member of the psychosocial team that participates in clinical discussions. This is anchored in the understanding of these professionals’ contribution to the therapeutic needs of patients and families via their input, selection, and recommendations of bibliotherapy resources. Similarly, pastoral care services that address the spiritual and religious needs of patients and families are a core component of the group’s work (S. Harding, personal communication, August 2007).

Both the quality of patients and parents’ perception of the support received and their individual reactions at the time of diagnosis determines the experience at different stages of medical treatment. It colors their transition out of treatment. The authors believe that a multidisciplinary team approach3,5-7 is essential, as they describe the process of creating a pathway toward holistic care for all patients from the designing of tools that integrate basic information about each patient “in context” to how they accomplish this. Two examples of collaboration between disciplines are offered. The authors hope that these practices lead to well-adjusted survivors of childhood cancer.4

 

Pathway

In an effort to fine-tune the available therapeutic offerings, as well as keep a finger on the pulse of the team’s professional interests and potential contributions, periodic meetings focusing on program planning were organized with administrative leadership. A survey that combined feedback from parents and staff was designed and conducted, and its results were compiled by a social work trainee. The results were incorporated into an in-service presentation for all staff to assist with program planning. How patients and their families moved from the point of diagnosis to participation in active treatment was reviewed.

 

Assessment

The SDHCC’s social workers obtained various tools already in use in similar local hospital settings. One model was selected and adapted for the author’s purposes in a series of multidisciplinary reviews. The authors examined its ease of use, whether it built-in basic relevant information regarding each child, its cultural relevancy, and the inclusion of all professionals needed for child-in-context services. The clinic’s manager consulted with hospital administration concerning the viability of the document draft and the protocol for approval.

 

The Process of Meeting New Patients

The tool adaptation was followed with a review of communication pathways, starting from the moment patients enter the medical center’s system to their first visit to the clinic (Table 1).

 

The psychosocial rounds forum is a meeting in which high-risk issues are identified from the initial interview and impressions and concerns are articulated. The main objectives are to design a multidisciplinary care plan for patients and caregivers, discuss in greater detail relevant psychosocial/behavioral health issues, prepare to follow up with those issues by presenting them at our Interdisciplinary Medical Rounds, and address urgent issues or emergencies. In addition, this meeting serves as a forum for program planning and administrative problem-solving related to services provided to patients.

The standard procedure for case discussions begins with soliciting patients’ names and topics from all medical/psychosocial staff in advance to generate a list for discussion. Urgent issues are addressed first, followed by newly diagnosed patients and a review of ongoing cases. For new patients, a care plan is designed. For existing patients, the care plan is periodically reviewed.

A summary of the discussion is shared with all faculty and staff in medical rounds. The patient’s chart, psychosocial assessment form (excerpted in Table 2), and psychosocial treatment planning form (excerpted in Table 3) are used to guide the psychosocial discussion.

 

 

 

This form is completed by the social workers after completing three meetings with a new patient and his or her family. Table 2 contains examples of basic psychosocial information included in the form. The information collected is shared with the team. When a patient is referred to other disciplines, this is noted in the “professional collaboration” section. The form is stored in the patients’ medical record. From there on, all pertinent allied healthcare providers document psychosocial interventions in the progress notes section of the medical record.

Table 3 shows a section of the treatment planning form used to organize the psychosocial care plan. Not shown are the list of all disciplines available to work with each child and the short- as well as long-term goals section. This form is brought to the psychosocial rounds and used as part of the treatment planning for the patient. After the initial psychosocial assessment is discussed, the patient is referred to other disciplines if not previously done. The date of the referral is noted, and the form is filed in the patients’ medical record. As each team member meets with the patient or after interventions are completed, these are noted and dated in the form. A full progress note is then added to medical record explaining the intervention.

Patients’ care can be brought up by any staff member whenever issues arise. The following cases, concerning Linnea and Beth, provide a general view of how these routine procedures work.

 

Case Examples

Case 1: Linnea

Linnea, a 7-year-old female recently diagnosed with medulloblastoma, was left visually impaired after having emergency brain surgery prior to beginning treatment. Her vision loss was not discovered until after she began her chemotherapy and radiation protocol. Linnea presented as a shy, quiet child who did not interact much with psychosocial or medical staff. Her mother was constantly tearful but was not forthcoming in discussing these feelings with staff. The psychosocial team was introduced to Linnea and her mother with the goal of ameliorating the crisis of a diagnosis of pediatric brain cancer and the medical crisis of losing part of her vision. Linnea responded well to social work and art therapy staff. Ongoing sessions were arranged where Linnea could produce artwork that helped her express her feelings regarding her diagnosis. Linnea also used imaginative play therapy to cope with painful medical procedures and long hours of receiving chemotherapy. (A general description of these interventions can be found elsewhere.)8

Linnea’s mother met with the psychologist who assisted her in understanding how to help her daughter and other members of the family during this difficult time. In addition, the psychologist helped her figure out the extent of Linnea’s vision difficulties prior to her diagnosis. Linnea’s mother had expressed some guilt about whether there had been signs no one had noticed. Linnea’s decreased appetite and weight loss were also discussed, and her participation in creating a simple, palatable menu was encouraged. Various members of the team also worked with Linnea’s 8-year-old brother, Mike, who has a love of theatre and music. The music therapist succeeded in introducing music as the modality in which he could express his feelings surrounding his sister’s illness. This shows how easily psychosocial care extends to the whole family unit when the patient’s treatment is provided in context and services are available to address the different needs of its members.

Midway through Linnea’s treatment, eating issues became a concern. The psychosocial team was consulted again. The psychologist met with her mother to assess the reasons for Linnea’s appetite issues and to monitor possible mood changes secondary to her medical conditions. Consultations with the inpatient unit team and a consultation/liaison pediatric psychiatrist followed. Linnea’s social worker began to engage her in an age-appropriate manner in order to better understand why she was not eating. A plan to restructure Linnea’s meal times with parental assistance was devised and, in this way, the placement of a feeding tube was avoided. This was a temporary solution as the team is still trying to find out the best way to help her. The medical and psychosocial teams continue to collaborate to support this family through their battle with pediatric cancer.

 

Case 2: Beth

Beth is 8 years of age and was recently diagnosed with acute lymphocytic leukemia. Beth lives with her parents in a New York suburb. Her grandmother, who was her primary caregiver, also lives near the family. There were initial identified issues, including conflict within the family regarding caregiving and Beth’s anxiety toward medical procedures. Beth’s social worker spent time speaking with both the parents and the grandmother reviewing caregiving details. Beth’s mother had previously worked long hours and the grandmother had cared for her. Since diagnosis, the mother had stopped working and began to care for Beth full time. Role changes are often seen in families due to a medical diagnosis, as priorities change for all members of the family when faced with life-threatening circumstances. The mother expressed guilt over her not being able to spend time with Beth prior to her diagnosis. The grandmother felt distant from the family now that the mother was increasingly active with Beth’s daily care.

Team members directly working with the family assisted with creating a schedule for Beth’s care with which all members felt comfortable. They addressed the mother’s feelings of guilt and helped the grandmother feel comfortable with the new limitations on her caregiving role. The psychologist worked with them on basic parenting strategies such as relaxation techniques to decrease Beth’s anxieties. In addition, the expertise of Beth’s nurse for identifying medication strategies was incorporated to help the patient manage her anxieties before spinal taps in the event that non-pharmacologic strategies were not enough.

Both the music and art therapists contributed to Beth’s care by providing a multimodal intervention to calm her medical procedures anxieties. Family issues that are still impacting Beth’s treatment experience in the clinic continued to be addressed with the help of the team’s psychologist on an “as-needed” basis.

 

Conclusion

Psychosocial issues related to the treatment of pediatric illness have been given more attention in recent years.5,9-11 The authors believe that their interdisciplinary team model allows for the most comprehensive psychosocial care of patients and their families. They attempt to identify issues at an early stage and coordinate psychosocial care in a manner that alleviates some of the stressors associated with pediatric illnesses. Their team aims to enhance the quality of life of all patients and families treated at SDHCC.

Future directions of this effort include conducting research to demonstrate the benefits of psychosocial interventions. More information is needed on the existing benefits of the services provided formally and informally at the facility. Who benefits from what? Which interventions are prioritized by the families? Requesting and incorporating feedback from each family on how they and their child benefited from various psychosocial interventions will help refine the work.

The authors intend to compile a psychosocial care manual based on the practice model as well as that of other centers in the US and abroad. Its goal is to provide a map to make the provision of modern medical treatments facilitated and supported by allied health professionals an essential part of any center’s mission. Such models have been designed before3 but are not readily available; others require updated information on how to provide services that fit the needs of families living in complex social contexts with cultural, financial, political, educational, and spiritual12 challenges that are part of living with cancer and other chronic childhood diseases. This manual will offer basic principles of psychosocial care, as well as general interventions that can be implemented by different disciplines either collaboratively or individually. It will also include specialized modules for patients and families at higher risk of having more difficulties with the experience of diagnosis and treatment. Dissemination of information about what works for the authors within the pediatric, allied health, and mental health professions will follow. The poet Maya Angelou said, “Children’s talent to endure stems from their ignorance of alternatives.”13 Primary care physicians can help them endure less and cope more successfully by their knowing what works and creating better alternatives. PP

 

References

1. Bhatia S. Cancer survivorship–pediatric issues. Hematology Am Soc Hematol Educ Program. 2005;507-515.
2. Edwards CL, Scales MT, Loughlin C, et al. A brief review of the pathophysiology, associated pain, and psychosocial issues in sickle cell disease. Int J Behav Med. 2005;12(3):171-179.
3. Kusch M, Labouvie H, Ladisch V, Fleischhack G, Bode U. Structuring psychosocial care in pediatric oncology. Patient Educ Couns. 2000;40(3):231-245.
4. Kazak AE, Cant MC, Jensen MM, et al. Identifying psychosocial risk indicative of subsequent resource use in families of newly diagnosed pediatric oncology patients. J Clin Oncol. 2003;21(17):3220-3225.
5. Hicks MD, Lavender R. Psychosocial practice trends in pediatric oncology. J Pediatr Oncol Nurs. 2001; 18(4):143-153.
6. Creagan ET. Psychosocial issues in oncologic practice. Mayo Clin Proc. 1993;68(2):161-167.
7. Kaufman KL, Harbeck C, Olson R, Nitschke R. The availability of psychosocial interventions to children with cancer and their families. Child Health Care. 1992;21(1):21-25.
8. Nesbitt LL, Tabatt-Haussmann K. The role of the creative arts therapies in the treatment of pediatric hematology and oncology patients. Primary Psychiatry. 2008;15(7):56-58,61-62.
9. Mitchell W, Clarke S, Sloper P. Survey of psychosocial support provided by UK paediatric oncology centres. Arch Dis Child. 2005;90(8):796-800.
10. Waters EB, Wake MA, Hesketh KD, Ashley DM, Smibert E. Health-related quality of life of children with acute lymphoblastic leukaemia: comparisons and correlations between parent and clinician reports. Int J Cancer. 2003;103(4):514-518.
11. Ljungman G, McGrath PJ, Cooper E, et al. Psychosocial needs of families with a child with cancer. J Pediatr Hematol Oncol. 2003;25(3):223-231.
12. Harrison MO, Edwards CL, Koenig HG, Bosworth HB, Decastro L, Wood M. Religiosity/spirituality and pain in patients with sickle cell disease. J Nerv Ment Dis. 2005;193(4):250-257.
13. Angelou M. I Know Why the Caged Bird Sings. 1st ed. New York, NY: Random House; 1969.

 

Needs Assessment: This article aims to educate others on the application of a pill-swallowing training protocol for children with cancer. It describes the main points of the training and the role of adequate parental training via brief vignettes.

Learning Objectives:
• Describe general issues with pill-swallowing training for young children.
• List helpful suggestions for parents of children learning how to swallow pills.
• Understand the role of parents in their children’s learning this skill.

Target Audience: Primary care physicians and psychiatrists.


CME Accreditation Statement:
This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

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This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: June 4, 2008.

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To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by July 1, 2010 to be eligible for credit. Release date: July 1, 2008. Termination date: July 31, 2010. The estimated time to complete all three articles and the posttest is 3 hours.

Primary Psychiatry. 2008;15(7):49-53

 

Dr. Cruz-Arrieta is senior psychologist and clinical assistant professor in both the Departments of Child & Adolescent Psychiatry and Pediatrics at New York University School of Medicine in New York City.

Disclosure: Dr. Cruz-Arrieta reports no affiliation with or financial interest in any organization that may pose a conflict of interest.

Please direct all correspondence to: Eduvigis Cruz-Arrieta, PhD, Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, 160 E 32nd St, Second Floor, New York, NY 10016; Tel: 212-263-9925; Fax: 212-263-8410; E-mail: Eduvigis.cruz-arrieta@nyumc.org.

 


 

 

Abstract

The use of behavioral techniques such as shaping and differential attention used to teach children ≥18 months of age how to swallow pills is well documented. However, there is a lack of data on the capacity of children of various ages to ingest pills. Pediatric cancer patients as young as 3 years of age must learn to take pills in order to benefit from alternative treatments for their conditions due to difficulties in drinking liquid formulations or requiring medication only available in pill form. Parents are trained on how to hide medication in foods, but they are not coached on how to teach their children to take pills. The stress of pediatric cancer and its effect on caregivers makes this a priority. This article provides guidelines on how to do this.

 

Introduction

The use of well-known behavioral techniques such as shaping and differential attention used to teach children ≥18 months of age how to swallow pills has been documented extensively.1-7 There is a lack of data on the capacity of children of various ages to ingest pills. One recent study showed that the majority of children 6–11 years of age say they can successfully swallow small tablets.8 The majority of the literature has further developed from the research and treatment of young pediatric AIDS patients who needed help learning how to take several pills per day indefinitely as part of the long-term management of HIV. At the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders of New York University Langone Medical Center, the need for patients as young as 3 years of age to learn how to take pills in order to benefit from alternative treatments for their conditions was identified. Some children were rejecting liquid formulations due to its bitter taste. This prompted both medical staff members and parents to seek other ways to provide the medicine. Other children required medication only available in pill form. Although parents can be advised to hide medication in palatable foods, some are uncomfortable with this strategy, especially if their child notices this. Most deny it to the child and report feeling “bad” for “tricking” him or her. As children are perceptive, they sense when “something is up” as one parent described it. This sometimes increases the child’s resistance to participating in other medical procedures. Given the stressful nature of pediatric cancer and its effect on caregivers, finding less stressful alternatives to caring for their children is always a priority.

 

Treatment Goals and Method

The treatment goals include increasing children’s self-efficacy in one aspect of their treatment by applying something they already know how to do (eg, “swallowing”) to their medical regimen at will, shortening the time spent taking medication by introducing a simple, fast way of ingesting it, reducing the need for coercive methods for administering medication by teaching parents how to present medication to their children, and providing age-appropriate psycho-education on why, when, and how children take medicine. This article reviews the author and colleagues’ experience teaching this skill to pediatric cancer patients. It illustrates modifications necessary when working with pre-schoolers with cancer in acute need to begin oral chemotherapy through case examples. Additional emphasis on role modeling and attention to cultural sensitivity as it applies to the interaction between patients and therapists of different ethnic and cultural backgrounds will be noted.

Various research studies document the use of candy and chunks of ice3,7 for this training. Cruz-Arrieta and colleagues believe that a method that distinguishes between eating candy and taking medicines aligns with the goal of sending a cohesive message about best practices to parents, despite anecdotal reports about successful use of candy (eg, “Tic Tac” mints, mini M&Ms, jelly beans) for this purpose in non-clinical settings.

The authors adopted the pill training protocol designed by Czyzewski from the Texas Children’s Hospital (D. Czyzewski, personal communication, June 2007). This spells out the presentation of placebos of increasing size, after demonstrating proper posture and pill swallowing technique, while providing no further attention to protests or distractions. Czyzewski and colleagues10 have produced two training videos designed to demonstrate proper training techniques as well as suggestions for common problems during and after the training.12,13 Modeling their tools after this material, the authors organized pill boxes using sugar-free, odorless, flavorless, gluten-free, and kosher placebos that ranged in size from size 4 (38–44 mg) to 00 (93–105 mg). None of the medications currently administered to the patients exceed a size 2 (57–65 mg). Regardless, the trainers practiced taking all placebo sizes to be able to compare and answer such questions from parents. In addition, the psychologist/trainer selected what to say beforehand and practiced a basic script to become comfortable with the information provided to the parents and their children during the session.

Six children (four boys and two girls) 3–5 years of age were referred by either the nurse practitioners and physicians working with the families or by the parents themselves. Five of these patients had brain tumor diagnoses and one had leukemia. As all of the children were from a different cultural and racial background than the trainer, questions relevant to the children’s family background were answered to accommodate parental requests when appropriate (eg, “my son cannot eat anything that is not kosher”). For example, a staff recreational therapist was asked to join the training session with the psychologist to increase the level of comfort for a boy 5 years of age with vision problems who responds very well in the presence of the recreational therapist but withdraws from unfamiliar people. The recreational therapist took turns taking placebo, modeling the behavior for the child. Another patient required that the psychologist discuss commonly used parenting strategies in the mother’s country of origin (eg, instructing the child to do something in a stern tone of voice to command respect) versus mainstream American practices (eg, instructing the child in a neutral tone) pertinent to handling the child’s potential medication refusal.

The psychologist met with each child’s parents before beginning the child’s training to review the plan and discuss how they can supplement their child’s learning of the skill using positive behavioral techniques. For example, they were instructed to reinforce approximations of successful pill swallowing while withdrawing attention for avoidance, whining, gagging, and vomiting behaviors.14 The psychologist encouraged parents to model pill-taking behavior at home as part of their morning routine by taking their multivitamins or any other medication within view of their child. Emphasis on keeping this as low key as possible was made. A tip sheet based on Czyzewski’s instructions (D Czyzewski, personal communication, June 2007) given to the parents at the end of the consultation is shown in the Table.

 

In general, all parents voiced disbelief about children’s ability to swallow pills and their child’s ability in particular. Parents with stronger opinions mentioned their “child is too young,” the pills are too big,” or the child “is stubborn.” These parents experienced more difficulties in maintaining their child’s newly acquired behavior at home.

 

Case 1: K.S.

At 5 years of age, K.S., a brain tumor patient, had a history of medication refusal and difficulties with medical procedures such as intravenous placements. Coercion was used to make him drink liquid medication at least once prior to referral for pill-swallowing training. The child required structured play time (ie, listening to a story about children with illness) in the psychology office before he was able to separate from his mother for the training. Despite a brief episode of gagging and some regurgitation, he learned to swallow pills on his first visit. Following two successful courses of oral medication that required five pills in a row over a 3-week period, K.S. reverted to his medication refusal behaviors. He attended a second training session after which he regained his skill. However, his parents remained anxious about his ability to do this at home, and shortly after he began to refuse again. Additional parental consultations were offered during a time off from treatment to assist them with resuming their giving pills to the patient.

K.S.’s statements concerning his not having to take pills (“I do not have to do this”) followed by his refusing all parental attempts to convince him to accept his pills were the most striking features of the interaction. He convinced his parents of their inability to make him do what he did “not have to.” The work continues as of the time of writing this report.

 

Case 2: S.D.

The parents of S.D., a 5-year-old boy, also expressed doubts about his ability to learn pill taking given his tendency to get “nervous easily.” Upon meeting S.D., it was evident that he tended to talk himself into feeling “scared,” as he repeatedly mentioned this to the psychologist on the way to the office. On his third visit, he was able to take three placebos and shared his newly learned skill with his father. He began his oral chemotherapy pills the next day and did not have any difficulties with his medication schedule for 6 months.

 

Case 3: S.N.

S.N., another 5-year-old brain tumor patient, was referred by her neuro-oncologist. She was identified as having some developmental delays. Her family needed additional guidance regarding the training, as she was perceived as “too young” for it. She was easily engaged by the psychologist; she separated easily from her mother and completed the training faster than anticipated (ie, 5 minutes into the presentation of the task). S.N. quickly demonstrated it for her mother who had originally been skeptical of her child’s achievement due to the ease in which the girl mastered the task. A follow-up after 6 months since training indicated no relapses in her ability and willingness to take pills.

 

Case 4: C.A.

C.A., a 9-year-old boy, was seen after completing a second round of treatment, post-relapse, for a brain tumor. He successfully learned to take pills under a psychologist’s supervision using Tic-Tacs but was not able to resume taking any medication in pill form due to intense gagging each time he tried. In addition, C.A. had a history of being extremely controlling of his environment as well as showing signs of hyperactivity and inattentiveness. C.A. refused to cooperate, citing increased anxiety at the thought of engaging in pill taking. Additional anxiety-reducing techniques that he previously learned to assist him during magnetic response imaging scans and radiation therapy were offered without success. He complained about wanting to be “retrained” with candy. The training was canceled after one session rather than risking an increase of his refusal behaviors that could prevent future training. Family issues and changes in the family structure took precedence over pill taking training, particularly since C.A. had finished treatment and was now on long-term follow-up.

 

Case 5: E.L.

E.L. is a very bright girl who was 32 months old at the time of her training. Her parents expressed multiple questions regarding her age, the size of her throat (she is petite for her age), the protocol, how to implement the pill-taking schedule at home, and what to do if she did not learn. They were somewhat surprised and reassured after she successfully swallowed a size-2 placebo in two brief visits. After this, the parents wanted to “practice” at home with more placebos. Concerns about practice failure with overanxious parents led to the psychologist discouraging the parents, beyond the general guidelines listed in the learning tip sheet, from doing any practice in the home. They succeeded in presenting the medication to their daughter on the first night of treatment. E.L. took the medication as prescribed. On the second day, she gagged after tasting the bitterness of the medication, as it dissolved in her mouth. Parents’ efforts were not successful and E.L. resumed taking the rest of the doses in liquid form. E.L. informed the psychologist that she will try this again when she turns “four.”

 

Case 6: O.B.

O.B., a 5-year-old leukemia patient, was referred for training soon after his diagnosis. The family provided a history of learning problems, parenting issues, and anxiety. However, only anxiety was mildly evident in O.B.’s overt behavior. These were considered factors working against maintaining his anxiety low and keeping motivation high enough to learn and practice pill taking on a regular basis. O.B. participated in the training after some initial difficulty separating from his mother to do so. His parents succeeded at having O.B. take pills 2 nights in a row, followed by refusal and vomiting as well as another parent training session in person (without the patient present) to review basic troubleshooting strategies for home and offer additional support to decrease parental anxiety over the procedure. Two weeks later, O.B. spontaneously reported mastering his new skill when greeted by the trainer in the clinic’s hallway. Three months later, he still takes pills successfully and uses empty placebo caps to consolidate several smaller tablets into one dose.

 

Discussion

The examples briefly described here emphasize the importance of proper parental preparation for pill-taking training prior to attempting to teach the child. While maintaining a “matter-of-fact” attitude about medical procedures; offering brief, age-appropriate explanations for why their kids need to take medicine; modeling the behavior for their child without pressure to perform; and keeping their own nervousness in check, parents of young children with cancer can better incorporate pills into their children’s treatment. However, even after a successful training, children may dislike the taste of some medications. This may be addressed by using strategies such as placing a bitter tablet inside a flavorless capsule to help maintain the newly acquired skills of these children. The literature points to a combination of skill deficit, anxiety, and lack of motivation as factors related to pill swallowing difficulties. The author and colleagues’ experience with the cases briefly presented here showed that when training was not successful, this could be partially explained by pre-existing risk factors associated with poor success rates. These include a history of negative experiences associated with pill taking such as coercion; oppositional or controlling tendencies; anxiety; strong food preferences (eg, “picky eaters”); or a perception of a sense of urgency and desirability of quick learning to the child coming from parents and staff. The importance of a comprehensive pre-training interview with parents and medical staff as a strategy to plan how to teach the skills best while reducing anxieties and increasing motivation in both the child and the parents cannot be stressed enough.

 

Conclusion

There is a need to further study the usefulness of teaching pill-swallowing skills to both parents and medical staff as well as training children with cancer. A formal clinical trial evaluating the success of this approach in the pediatric oncology setting is needed in order to provide a more comprehensive way of determining success rates using this approach.

Providing psycho-education to parents and medical staff on pill swallowing training principles and techniques ensures that all adults communicate a consistent message to the child (“you can do it,” “this is easy,” and “we are here to teach you how”). Their children will become confident and competent participants in their own medical treatment if given the proper tools. PP

 

References

1.    Babbitt RL, Parrish JM, Brierley PE, Kohr MA. Teaching developmentally disabled children with chronic illness to swallow prescribed capsules. J Dev Behav Pediatr. 1991;12(4):229-235.
2.    Pelco LE, Kissel RC, Parrish JM, Miltenberger RG. Behavioral management of oral medication administration difficulties among children: a review of literature with case illustrations. J Dev Behav Pediatr. 1987;8(2):90-96.
3.    Walco GA. A behavioral treatment for difficulty in swallowing pills. J Behav Ther Exp Psychiatry. 1986;17(2):127-128.
4.    Funk MJ, Mullins LL, Olson RA. Teaching children to swallow pills: a case study. Child Health Care. 1984;13:20-23.
5.    Dahlquist LM, Blount RL. Teaching a six-year-old girl to swallow pills. J Behav Ther Exp Psychiatry. 1984;15(2):171-173.
6.    Sallows GO. Behavioral treatment of swallowing difficulty. J Behav Ther Exp Psychiatry. 1980;11:45-47.
7.    Wright L, Woodcock JM, Scott R. Conditioning children when refusal of oral medication is life threatening. Pediatrics. 1969;44(6):969-972.
8.    Meltzer EO, Welch MJ, Ostrom NK. Pill swallowing ability and training in children 6 to 11 years of age. Clin Pediatr (Phila). 2006;45(8):725-733.
9.    Garvie PA, Lensing S, Rai SN. Efficacy of a pill-swallowing training intervention to improve antiretroviral medication adherence in pediatric patients with HIV/AIDS. Pediatrics. 2007;119(4):893-899.
10.    Czyzewski DI, Runyan RD, Lopez MA, Calles NR. Teaching and maintaining pill-swallowing in HIV-infected children. AIDS Reader. 2000;10(2):88-95.
11.    Czyzewski D. Teaching Pill Swallowing [videotape]. Houston, TX: Texas Children’s Hospital & Genentech; 2004.
12.     Baylor International Pediatric AIDS Initiative. Teaching and Reinforcing Essential Skills for Taking Important Medications [videotape]. Houston, TX: Baylor College of Medicine; 1998.
13.    LaGrone RG. Hypnobehavioral therapy to reduce gag and emesis with a 10-year-old pill swallower. Am J Clin Hypn. 1993;36(2):132-136.

 

Dr. Kennedy is professor in the Department of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine, and director of the Division of Geriatric Psychiatry at Montefiore Medical Center in the Bronx, New York.

Disclosure: Dr. Kennedy has received research support or honoraria from AstraZeneca, Eli Lilly, Forest, Janssen, Myriad, and Pfizer.

Please direct all correspondence to: Gary J. Kennedy, MD, Director, Department of Geriatric Psychiatry, MMC, 111 East 210th St, Klau One, Bronx, NY 10467; Tel: 718-920-4236; Fax: 718-920-6538; E-mail: gjkennedy@msn.com.

 


 

The evidence base supporting the treatment of psychotic depression among older adults is scant. Although the consensus regarding the best therapeutic opinion favors electroconvulsive therapy, most patients, their families, and practitioners will exhaust medication alternatives first. Recent preliminary reports from the Study of the Pharmacotherapy of Psychotic Depression  (STOP-PD) suggest a 12-week program of combined antidepressant and antipsychotic pharmacotherapy may achieve remission rates as high as 60%.

The recognition of psychotic depression, more appropriately described as delusional depression, has particular relevance to primary care physicians. Patients with psychotic depression have sustained irrational beliefs (delusions) associated with depressed mood that are often plausible. Psychotic depression should be suspected when the irrational belief focuses on somatic symptoms or around fears of a serious physical condition when there is no medical evidence identified to support the belief despite adequate examinations. Patients with somatic delusions visit multiple specialists and obtain repeated testing to identify problems they “know” exist rather than for the purpose of seeking relief from persistent somatic “worries.” The careful assessment of depressed patients to determine whether their concerns are plausible would presumably reduce the 25% rate at which the presence of delusions associated with major depressive disorder (MDD) is not recognized.1

However, due to the obsessional yet plausible quality of the delusion, obsessive-compulsive disorder (OCD) may be a reasonable possibility. The difference between obsessive rumination and delusional thinking can be difficult to distinguish.2 Body dysmorphic disorder (BDD) with psychosis, which is characterized by an irrational belief that one’s physique is seriously flawed despite obvious evidence to the contrary, may also complicate the diagnostic consideration. Hypochondriasis is a common feature of delusional depression misdirecting the diagnostician to a somatoform rather than a mood disorder. The distinction is important because BDD responds to monotherapy with a selective serotonin reuptake inhibitor.3 Difficulty concentrating, deficits in executive function, and subjective complaints of impaired cognition suggestive of dementia are frequently seen. The occurrence of depression with hallucinations but not delusions in older adults suggests structural brain diseases, bipolar disorder, or schizoaffective disorder. In addition, other symptoms of MDD may not be so prominent or severe, further distracting the practitioner from the correct diagnosis. Differentiating schizoaffective disorder from psychotic depression may also be difficult because the distinguishing the sequence of symptom emergence, which is the presence of psychosis prior to depression, is unreliable.4  

When psychosis complicates MDD the evidence directing choice of pharmacotherapy for older adults is scant but emerging. Mulsant and colleagues5 randomized 52 patients with a mean age of 72 experiencing a major depressive episode with psychotic features to nortriptyline plus perphenazine or nortriptyline plus placebo. All were openly treated with nortriptyline initially with the dose titrated to between 50–150 ng/mL (target=100 ng/mL). For patients not responding within 2 weeks, placebo (n=19) or perphenazile (n=17) in randomized double-blind protocol were then administered. The placebo or perphenazine doses were then titrated to a maximum dose of 24 mg/day until either a therapeutic response or extrapyramidal side effects occurred. The mean dose of perphenazine was 18.9 mg/day. At a mean duration of 9 weeks for combined therapy, only 50% of people receiving nortriptyline plus perphenazine and 44% receiving nortriptyline plus placebo achieved a categorical response. Similarly, there were no statistically significant differences between the two groups’ depression severity as measured by the Hamilton Rating Scale for Depression (HAM-D) or the psychoticism subscale of the Brief Psychiatric Inventory. Although the response rate among those with a Mini-Mental State Examination (MINI) score of ≥27 was twice that of those with a score below, the difference was not significant. Of the 36 patients randomized, only five achieved the target dose of perphenazine while only 30 completed the protocol.

Mulsant and colleagues5 concluded that the mediocre response rates did not favorably weigh against the potential toxicity of a tricyclic antidepressant combined with typical antipsychotic. They also speculated that the brief period of treatment and insipient dementia might account for the poor results. They concluded that newer agents either singly or in combination might be used but that electroconvulsive therapy (ECT) should be offered promptly if the patient failed to respond. ECT is effective for depression complicated by psychosis.6 It is often considered the treatment of choice due to poor response rates or adverse events associated with monotherapy or combined therapy with an antidepressant and antipsychotic.7 Yet, few patients or their family members will consider ECT without having exhausted alternatives. The need for reliable predictors of successful pharmacotherapy is thus critical for patients, their families, and their physicians.

The multi-site STOP-PD was designed to have sufficient participants with an extended age range to address numerous limitations of prior studies.7 To approach diagnostic precision, the investigators excluded people with OCD, BDD, and dementia, even if they met criteria for psychotic depression, as well as those with schizoaffective disorder (psychosis over a 2-week period free of depression). Participants were stratified by age such that the number of patients 18–59 years of age equaled the number of patients ≥60 years of age, in order to examine the effect of age on treatment responsiveness as well as tolerance. Executive cognitive dysfunction was to be measured with the Initiation Perseveration subtest of the Mattis Dementia Rating Scale and the Stoop Color Word Test. The MINI was used as a global measure of cognitive impairment associated with depression rather than as an exclusion criterion for suspected dementia. The hypothesis to be tested was the relationship between global impairment generally and executive dysfunction specifically as a predictor of poor response to treatment. 

A 12-week acute phase of treatment was to be followed by a 12-week stabilization phase extending the period of treatment considerably longer than prior studies. In the acute phase, participants were randomized to olanzapine plus placebo or sertraline plus olanzapine. Outcome measures for the acute phase included non-remission, partial remission, and full remission. Partial remission required a 30% reduction to a threshold score no higher than 17 from the baseline HAM-D. Full remission was defined by a score of <10 on the HAM-D. Both remission categories required an absence of hallucinations and delusions. For the subsequent 12 weeks of the stabilization phase, partial responders who had received sertraline plus olanzapine were randomized to augmentation with lithium or placebo. Partial responders who had initially been given placebo plus olanzapine received augmentation with sertraline plus placebo lithium. This allowed for a comparison of the benefits of adding lithium when a partial remission occurred for people previously treated with combined sertraline plus olanzapine compared to the addition of sertraline for those treated previously with olanzapine only.

The dosing protocol started with sertraline 50 mg each morning and/or olanzapine 5 mg each evening. Doses were escalated every 3–7 days up to 15 mg olanzapine and/or 150 mg sertraline depending on response and tolerability. If after 2 weeks the patient remained symptomatic, sertraline could be increased to 200 mg and olanzapine to 20 mg. When doses were reduced due to intolerance and the patients remained symptomatic, they were re-challenged with the higher dose at a later date. Remission was achieved in 40% of all patients randomized and 67% of those completing the study who received a combination of sertraline and olanzapine over 12 weeks. The average age of participants was 72 years but remission rates were comparable for those above and below 60 years of age. Remission rates with combination therapy were substantially and significantly better than with sertraline alone. The average end-of-study daily doses of were approximately 150 mg of sertraline and >12 mg of olanzapine.9 Weight gain was a frequent side effect and more prevalent among the younger participants. The effects of any physical illness and cognitive impairment have yet to be determined. In addition, the benefits, if any, of augmenting therapy with lithium have yet to be reported.  More importantly, the profile of people least likely to respond or to tolerate this course of pharmacotherapy and who should be offered ECT early rather than later remains to be determined.

A 90-day treatment period for patients given a combination of sertraline and olanzapine offered substantially better prognosis than previously observed. Therefore, while ECT remains an effective treatment option for late-life psychotic depression, intensive combination of antipsychotic and antidepressant pharmacotherapy may be an effective initial strategy. PP

 

References

1. Andreescu C, Mulsant BH, Peasley-Miklus C, et al. Persisting low use of antipsychotics in the treatment of major depressive disorder with psychotic features. J Clin Psychiatry. 2007;68(2):194-200.
2. DeBattista C, Lembke A. Challenges in differentiating and diagnosing psychotic depression: phenomenology and the pursuit of optimal treatment. Primary Psychiatry. 2008;15(4):59-64.
3. Phillips KA. Psychosis in body dysmorphic disorder. J Psychiatr Res. 2004;38(1):63-72.
4. Rothschild AJ, Mulsant BH, Meyers BS, Flint AJ. Challenges in differentiating and diagnosing psychotic depression. Psychiatric Ann. 2006;36(1):40-46.
5. Mulsant BH, Sweet RA, Rosen J, et al. A double-blind, randomized comparison of nortriptyline plus perphenazine versus nortriptyline plus placebo in the treatment of psychotic depression. J Clin Psychiatry. 2001;62(8):597-604.
6. Practice guideline for treatment of patients with major depressive disorder (revision). American Psychiatric Association. Am J Psychiatry. 2000;157(4 suppl):1-45.
7. Meyers BS, Klimstra SA, Gabriele M, et al. Continuation treatment of delusional depression in older adults. Am J Psychiatry. 2001;9(4):415-422.
8. Meyers BS, Peasly-Miklus C, Flint AJ, Mulsant BH, Rothschild AJ. Methodological issues in designing a randomized controlled trial for psychotic depression: the STOP-PD study. Psychiatric Ann. 2006;36(1):57-64.
9. Meyers BS, Peasly-Miklus C, Flint AJ, Mulsant BH, Rothschild AJ, Whyte E. Efficacy and tolerability of pharmacotherapy for psychotic depression: age effects. Paper presented at: the Annual Scientific Meeting of the American Association for Geriatric Psychiatry; March 15, 2008; Miami, FL.