August 2012

Vol. 24. No. 3


Slowing down to reflect on our work and the future of health care

For most of us, work never stops. There are patients to see, meetings to attend, and problems to solve. Yet, we all need time to relax and contemplate our lives, and summer vacation is the time for that. Life slows down and work sometimes takes a back seat as we spend time with family and friends relaxing around the house, at the beach, or in the mountains. This is a time away from meetings, and a time to think, take stock, and plan for the future. The US Supreme Court upheld the Affordable Care Act (also known as “Obamacare”), and from the sidelines I am anxiously watching the next steps. Will individual states stonewall or fall into line? Will individuals gain access to affordable insurance? Who will take care of these newly insured people? Will people seek earlier preventive care, and have less need for urgent care? How will these benefits impact our psychiatric patients? Only time will tell…



Body dysmorphic disorder and eating disorders in elite professional female ballet dancers

Antonio Leandro Nascimento, MD | Juliano Victor Luna, MD | Leonardo F. Fontenelle , MD, PhD

BACKGROUND: Our objective is to report the prevalence and the clinical features associated with body dysmorphic disorder (BDD) and eating disorders (ED) in a group of elite Brazilian professional female ballet dancers.

METHODS: Thirty-five elite Brazilian professional female ballet dancers were invited to participate in the study and 19 agreed to be assessed. Individuals were evaluated with a series of instruments, including the Mini International Neuropsychiatric Interview supplemented by the somatoform and eating disorders modules of the Structured Clinical Interview for DSM-IV disorders, the Bulimic Investigatory Test, and the Beck Depression Inventory.

RESULTS: Three dancers (15.78%) had a lifetime diagnosis of anorexia nervosa (restrictive subtype) and 2 others (10.52%) presented a current diagnosis of BDD. No individuals had current or lifetime bulimia nervosa. Results could not be ascribed to comorbid major depression or increased severity of depression.

CONCLUSION: The lifetime prevalence of BDD and ED among elite professional female ballet dancers was higher than the general population. High standards of beauty, public body exposure, and repeated exposure to mirrors in the rehearsal rooms may contribute to the development of body image disorders in this sample.


Does the diagnosis of multiple Axis II disorders have clinical significance?

Mark Zimmerman, MD | Janine N. Galione, BS | Iwona Chelminski, PhD | Diane Young, PhD | Kristy Dalrymple, PhD | Theresa A. Morgan, MPhil

BACKGROUND: A stated goal of the DSM-5 Work Group on Personality and Personality Disorders (PDs) has been to reduce the high rate of comorbidity among PDs. Few studies have examined whether the diagnosis of multiple PDs has clinical significance. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we tested the hypothesis that patients with >1 DSM-IV PD would have more severe forms of psychopathology than patients who were diagnosed with only 1 DSM-IV PD.

METHODS: A total of 2,150 psychiatric outpatients were evaluated with semi-structured diagnostic interviews for DSM-IV Axis I and Axis II disorders and measures of psychosocial morbidity.

RESULTS: For 8 of the 10 PDs, the majority of patients had at least 1 additional PD, although at least 20% of patients diagnosed with each PD were diagnosed with only 1 PD. Compared with patients with 1 PD, patients with ≥2 PDs had significantly more psychosocial morbidity.

CONCLUSIONS: The co-occurrence of PDs conveys clinically significant information. Moreover, despite high levels of comorbidity, each PD also existed as a stand-alone entity. These findings raise questions about the DSM-5 Work Group’s emphasis on reducing comorbidity in Axis II.


Risk factors for delirium in patients undergoing hematopoietic stem cell transplantation

Michelle T. Weckmann, MS, MD | Roger Gingrich, MD | James A. Mills, MS | Larry Hook, MD | Leigh J. Beglinger, PhD

BACKGROUND: Delirium is common after hematopoietic stem cell transplantation (HSCT) and is associated with increased morbidity and mortality. Early recognition and treatment have been shown to improve long-term outcomes. We sought to investigate the relationship between potential risk factors and the development of delirium following HSCT.

METHODS: Fifty-four inpatients admitted for HSCT were assessed prospectively for delirium every 2 to 3 days during their inpatient stay using standardized delirium and neuropsychological measures. Self reports of medical history, medical records, and neurocognitive and psychiatric assessments were used to identify risk factors. Both pre- and post-HSCT risk factors were examined.

RESULTS: Delirium incidence was 35% and occurred with highest frequency in the 2 weeks following transplant. The only pre-transplantation risk factor was lower oxygen saturation (P = .003). Post-transplantation risk factors for delirium included higher creatinine (P < .0001), higher blood urea nitrogen levels (P = .005), lower creatinine clearance (P = .0006), lower oxygen saturation (P = .001), lower hemoglobin (P = .04), and lower albumin (P = .03). There was no observed association with level of cognitive performance, transplant type, disease severity, medical comorbidity index, age, or conditioning regimen.

CONCLUSIONS: Routine laboratory values can assist in the identification of high-risk patients before delirium onset to improve early detection and treatment of delirium after HSCT.



The effects of mirtazapine on sleep in patients with major depressive disorder

Christian R. Dolder, PharmD | Michele A. Nelson, MD | Cameron A. Iler, PharmD

BACKGROUND: Mirtazapine is a commonly used antidepressant with a wellknown ability to produce sedation. At the same time, its sleep-promoting effects in patients with major depressive disorder (MDD) are relatively unclear. The purpose of this article is to provide clinicians with a detailed review of mirtazapine’s sleep effects in patients with MDD.

METHODS: A literature search was conducted for studies involving mirtazapine in depressed patients that specifically assessed sleep.

RESULTS: Twenty-three studies met criteria and were included in this review. Of the 15 studies that included a general assessment of sleep, all noted improvement from baseline with mirtazapine. Twelve of the 23 trials were randomized, blinded, and controlled. Mirtazapine was superior to placebo but did not clearly differentiate itself from other antidepressants, with the exception of venlafaxine. Eight studies used detailed measures of sleep and consistently reported that mirtazapine produced significant improvement in sleep efficiency, total sleep time, and sleep quality. Few investigations combined detailed assessments of sleep along with a comparator antidepressant.

CONCLUSION: Mirtazapine is an antidepressant with sleep-promoting effects significantly greater than placebo, similar to tricyclic antidepressants, and somewhat similar to a particular serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. These effects must be balanced with mirtazapine’s ability to cause sedation-related side effects.