Damian McNamara

SAN JUAN, P.R. — People in intensive alcohol treatment programs are more abstinent if smoking cessation efforts are delayed by 6 months, according to a study.

Smoking is common among people with alcohol dependence, with an estimated 60%-90% prevalence. And because smoking causes a lot of morbidity and mortality in such patients, it is a “compelling issue to work on in recovery,” Anne Joseph, M.D., said at the annual meeting of the American Academy of Addiction Psychiatry.

Although the results of nonrandomized studies suggest that smoking cessation efforts during intensive alcohol treatment are better than doing nothing, these trials included small numbers of participants and demonstrated only a modest benefit to nicotine replacement in this population.

For a more definitive answer, Dr. Joseph and her colleagues performed a large, 18-month, randomized trial. They hypothesized that concurrent treatment would improve both smoking and alcohol abstinence outcomes (J. Stud. Alcohol 2004;65:681-91).

“Here comes the surprising, but unfortunate, news,” said Dr. Joseph of the department of medicine at the University of Minnesota, Minneapolis. Alcohol abstinence was better when the smoking intervention was delayed by 6 months, compared with addressing both concerns simultaneously.

There were significant differences in outcomes at 6, 12, and 18 months. At 6 months, 64% of the delayed intervention group achieved 30-day alcohol abstinence, compared with 51% of the concurrent group; at 12 months, success rates were 53% and 46%, and at 18 months the rates were 60% and 48%.

The researchers also assessed alcohol abstinence 6 months after initiation of the smoking intervention in each group. Fifty-six percent of the delayed group were abstinent from alcohol for 6 months, compared with 41% of the concurrent group. At 12 months, 6-month abstinence was 42% versus 33%, and at 18 months, the rates were 48% and 41%.

Why the delayed intervention group fared better is unknown. It may be that there is an interaction between smoking and alcohol interventions, confounded by a specific biologic or behavioral factor. It could also be that adding anything to alcohol treatment worsens outcome, said Dr. Joseph, also of Minneapolis Veterans Affairs Medical Center.

The investigators randomized 251 participants to concurrent alcohol and nicotine treatment and 248 to initial alcohol treatment followed by delayed smoking cessation treatment. The Timing of Alcohol and Smoking Cessation (TASC) trial included people from three residential, day, and outpatient rehabilitation programs in Minnesota offering 3-5 weeks of intensive intervention with aftercare.

The concurrent group completed the smoking intervention at 12 months and the delayed group completed it at 18 months. Participants were 21-75 years old, about two-thirds were male, and one-third had a high school education or less. They smoked at least five cigarettes per day, but most had significant nicotine dependence, indicated by an average score of 6 on the Fagerstrom Test for Nicotine Dependence. There were an average of three previous smoking quit attempts. About half reported alcohol abuse alone, the remainder had one, two, or three other substance abuse issues.

The smoking cessation intervention included behavioral treatment and nicotine replacement therapy (to avoid withdrawal effects). One hour of behavioral treatment at baseline was followed by three follow-up sessions either in person or via telephone.

SAN JUAN, P.R. — People in intensive alcohol treatment programs are more abstinent if smoking cessation efforts are delayed by 6 months, according to a study.

Smoking is common among people with alcohol dependence, with an estimated 60%-90% prevalence. And because smoking causes a lot of morbidity and mortality in such patients, it is a “compelling issue to work on in recovery,” Anne Joseph, M.D., said at the annual meeting of the American Academy of Addiction Psychiatry.

Although the results of nonrandomized studies suggest that smoking cessation efforts during intensive alcohol treatment are better than doing nothing, these trials included small numbers of participants and demonstrated only a modest benefit to nicotine replacement in this population.

For a more definitive answer, Dr. Joseph and her colleagues performed a large, 18-month, randomized trial. They hypothesized that concurrent treatment would improve both smoking and alcohol abstinence outcomes (J. Stud. Alcohol 2004;65:681-91).

“Here comes the surprising, but unfortunate, news,” said Dr. Joseph of the department of medicine at the University of Minnesota, Minneapolis. Alcohol abstinence was better when the smoking intervention was delayed by 6 months, compared with addressing both concerns simultaneously.

There were significant differences in outcomes at 6, 12, and 18 months. At 6 months, 64% of the delayed intervention group achieved 30-day alcohol abstinence, compared with 51% of the concurrent group; at 12 months, success rates were 53% and 46%, and at 18 months the rates were 60% and 48%.

The researchers also assessed alcohol abstinence 6 months after initiation of the smoking intervention in each group. Fifty-six percent of the delayed group were abstinent from alcohol for 6 months, compared with 41% of the concurrent group. At 12 months, 6-month abstinence was 42% versus 33%, and at 18 months, the rates were 48% and 41%.

Why the delayed intervention group fared better is unknown. It may be that there is an interaction between smoking and alcohol interventions, confounded by a specific biologic or behavioral factor. It could also be that adding anything to alcohol treatment worsens outcome, said Dr. Joseph, also of Minneapolis Veterans Affairs Medical Center.

The investigators randomized 251 participants to concurrent alcohol and nicotine treatment and 248 to initial alcohol treatment followed by delayed smoking cessation treatment. The Timing of Alcohol and Smoking Cessation (TASC) trial included people from three residential, day, and outpatient rehabilitation programs in Minnesota offering 3-5 weeks of intensive intervention with aftercare.

The concurrent group completed the smoking intervention at 12 months and the delayed group completed it at 18 months. Participants were 21-75 years old, about two-thirds were male, and one-third had a high school education or less. They smoked at least five cigarettes per day, but most had significant nicotine dependence, indicated by an average score of 6 on the Fagerstrom Test for Nicotine Dependence. There were an average of three previous smoking quit attempts. About half reported alcohol abuse alone, the remainder had one, two, or three other substance abuse issues.

The smoking cessation intervention included behavioral treatment and nicotine replacement therapy (to avoid withdrawal effects). One hour of behavioral treatment at baseline was followed by three follow-up sessions either in person or via telephone.

SAN JUAN, P.R. — People in intensive alcohol treatment programs are more abstinent if smoking cessation efforts are delayed by 6 months, according to a study.

Smoking is common among people with alcohol dependence, with an estimated 60%-90% prevalence. And because smoking causes a lot of morbidity and mortality in such patients, it is a “compelling issue to work on in recovery,” Anne Joseph, M.D., said at the annual meeting of the American Academy of Addiction Psychiatry.

Although the results of nonrandomized studies suggest that smoking cessation efforts during intensive alcohol treatment are better than doing nothing, these trials included small numbers of participants and demonstrated only a modest benefit to nicotine replacement in this population.

For a more definitive answer, Dr. Joseph and her colleagues performed a large, 18-month, randomized trial. They hypothesized that concurrent treatment would improve both smoking and alcohol abstinence outcomes (J. Stud. Alcohol 2004;65:681-91).

“Here comes the surprising, but unfortunate, news,” said Dr. Joseph of the department of medicine at the University of Minnesota, Minneapolis. Alcohol abstinence was better when the smoking intervention was delayed by 6 months, compared with addressing both concerns simultaneously.

There were significant differences in outcomes at 6, 12, and 18 months. At 6 months, 64% of the delayed intervention group achieved 30-day alcohol abstinence, compared with 51% of the concurrent group; at 12 months, success rates were 53% and 46%, and at 18 months the rates were 60% and 48%.

The researchers also assessed alcohol abstinence 6 months after initiation of the smoking intervention in each group. Fifty-six percent of the delayed group were abstinent from alcohol for 6 months, compared with 41% of the concurrent group. At 12 months, 6-month abstinence was 42% versus 33%, and at 18 months, the rates were 48% and 41%.

Why the delayed intervention group fared better is unknown. It may be that there is an interaction between smoking and alcohol interventions, confounded by a specific biologic or behavioral factor. It could also be that adding anything to alcohol treatment worsens outcome, said Dr. Joseph, also of Minneapolis Veterans Affairs Medical Center.

The investigators randomized 251 participants to concurrent alcohol and nicotine treatment and 248 to initial alcohol treatment followed by delayed smoking cessation treatment. The Timing of Alcohol and Smoking Cessation (TASC) trial included people from three residential, day, and outpatient rehabilitation programs in Minnesota offering 3-5 weeks of intensive intervention with aftercare.

The concurrent group completed the smoking intervention at 12 months and the delayed group completed it at 18 months. Participants were 21-75 years old, about two-thirds were male, and one-third had a high school education or less. They smoked at least five cigarettes per day, but most had significant nicotine dependence, indicated by an average score of 6 on the Fagerstrom Test for Nicotine Dependence. There were an average of three previous smoking quit attempts. About half reported alcohol abuse alone, the remainder had one, two, or three other substance abuse issues.

The smoking cessation intervention included behavioral treatment and nicotine replacement therapy (to avoid withdrawal effects). One hour of behavioral treatment at baseline was followed by three follow-up sessions either in person or via telephone.

MARCO ISLAND, FLA. — Semistructured group therapy improves mood state in HIV-positive men, which improves cortisol levels and immune function and thereby reduces viral load, Karl Goodkin, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Bereavement has long been known to be associated with immunosuppression and is also associated with increased mortality risk for surviving partners. The risk increases 40% for the first 6 months and 10-fold in the first year, the same time frame as observed decrements in the immune system, said Dr. Goodkin, professor of psychiatry and behavioral sciences, neurology, and psychology at the University of Miami.

In a randomized controlled trial, Dr. Goodkin and his colleagues compared the intervention with usual care in HIV-positive and HIV-negative gay men who had experienced a loss in the previous 6 months. Although effects of grief were similar, the two-tier group intervention decreased overall psychological stress—which improved mood and immune measures, including CD4 counts and viral loads—and reduced physician health visits, compared with the usual-care control group.

Participants attended a 90-minute session once weekly for 10 weeks. The groups consisted of 6-10 attendees and two professional coleaders. Enrollment was ongoing throughout the study. The first tier of the intervention fostered grief resolution; the second tier fostered stressor management, including identification of stressor impact and maladaptive behaviors. In addition to specific grief-related topics for each session, including past experiences of personal loss, reactions to surviving and implications for one's spirituality and mortality, non-bereavement-related stressor management was planned as a major focus of this unique group intervention, he said.

The usual-care group received any medical and psychosocial care that they had begun prior to initial assessment. Furthermore, they received four telephone calls during the 10-week intervention period to assess their clinical status. The total time for these calls was limited to 90 minutes over the 10-week period. Study staff avoided any therapeutic interactions during these calls and maintained a log documenting call content.

In the study, 166 participants (97 HIV-positive and 69 HIV-negative) completed the intervention or community usual-care group conditions. Participants were primarily in their late 30s, employed, and college educated. More than one-third were members of an ethnic minority.

The Stressor-Support-Coping model appears to have utility “with or without bereavement. We found increase in positive life events in HIV-positive men after the intervention. Social support increased in the intervention group and declined in controls,” Dr. Goodkin noted.

The investigators' theoretical model also predicts specific psychosocial treatment needs. If a person has a high life-stressor burden, stressor management would help. If a person has low social support, a social support group would be beneficial. Finally, if a participant demonstrated high passive maladaptive coping or low active coping, coping skills enhancement training would be helpful.

Evidence from the study suggests that increased serum cortisol from stress is associated with decreases in lymphocyte proliferation in response to the artificial stimulant phytohemagglutinin in HIV-positive men and women. This is a functional measure of immunity that tends to decrease before CD4 count, he said.

The intervention decreased overall psychological distress in HIV-negative men, compared with controls, according to scores on the Distress-Grief Composite Measure. However, the decreases in grief, specifically, were less prominent than those for distress or the composite of the two measures for both the HIV-positive and -negative men.

In terms of immune effects, HIV-positive people had a true increase in their lymphocyte proliferation response up to 2 years, and the intervention provided HIV-positive participants with a buffer against decreases in CD4 levels seen in controls. The decrement among HIV-positive participants was smaller, compared with HIV-negative groups, where there was a larger spread, Dr. Goodkin explained.

The researchers also looked for an effect at the physical health level. “There was a transition of the neuroendocrine changes to the immune level and, in turn, to the physical health level,”

All participants were asked to self-report physician health care visits in the 6 months prior to assessment; among HIV-positive participants, there was an increase in the control group that was not as great in the intervention group. Researchers found that the same pattern held true among HIV-negative individuals. There was increased health care utilization among control participants and a decrease among the intervention group. “We did not anticipate this. It indicated that this type of intervention is not only effective for improving the health of HIV-positive people but possibly for the entire population of people who lose a loved one,” he said.

Researchers were not able to analyze whether all health care visits were HIV or symptom related, an important caveat of the study. Another potential limitation was the difference in atmosphere between HIV-positive and HIV-negative group sessions. “HIV-positive groups talked more about concerns around their own mortality, but nonetheless it is important to note the consistency in findings across multiple domains, especially the physical domains,” Dr. Goodkin said.

“That suggests that if you improve mood state, you will improve cortisol, and you will improve immune function, which relates to improvements in viral load,” he said. The virology effect of the behavioral intervention was statistically significant, and Dr. Goodkin suggested that “it may ever be clinically significant, but we need to look at the latter effect on viral load seen in a subgroup over the long term in larger study groups.”

MARCO ISLAND, FLA. — Semistructured group therapy improves mood state in HIV-positive men, which improves cortisol levels and immune function and thereby reduces viral load, Karl Goodkin, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Bereavement has long been known to be associated with immunosuppression and is also associated with increased mortality risk for surviving partners. The risk increases 40% for the first 6 months and 10-fold in the first year, the same time frame as observed decrements in the immune system, said Dr. Goodkin, professor of psychiatry and behavioral sciences, neurology, and psychology at the University of Miami.

In a randomized controlled trial, Dr. Goodkin and his colleagues compared the intervention with usual care in HIV-positive and HIV-negative gay men who had experienced a loss in the previous 6 months. Although effects of grief were similar, the two-tier group intervention decreased overall psychological stress—which improved mood and immune measures, including CD4 counts and viral loads—and reduced physician health visits, compared with the usual-care control group.

Participants attended a 90-minute session once weekly for 10 weeks. The groups consisted of 6-10 attendees and two professional coleaders. Enrollment was ongoing throughout the study. The first tier of the intervention fostered grief resolution; the second tier fostered stressor management, including identification of stressor impact and maladaptive behaviors. In addition to specific grief-related topics for each session, including past experiences of personal loss, reactions to surviving and implications for one's spirituality and mortality, non-bereavement-related stressor management was planned as a major focus of this unique group intervention, he said.

The usual-care group received any medical and psychosocial care that they had begun prior to initial assessment. Furthermore, they received four telephone calls during the 10-week intervention period to assess their clinical status. The total time for these calls was limited to 90 minutes over the 10-week period. Study staff avoided any therapeutic interactions during these calls and maintained a log documenting call content.

In the study, 166 participants (97 HIV-positive and 69 HIV-negative) completed the intervention or community usual-care group conditions. Participants were primarily in their late 30s, employed, and college educated. More than one-third were members of an ethnic minority.

The Stressor-Support-Coping model appears to have utility “with or without bereavement. We found increase in positive life events in HIV-positive men after the intervention. Social support increased in the intervention group and declined in controls,” Dr. Goodkin noted.

The investigators' theoretical model also predicts specific psychosocial treatment needs. If a person has a high life-stressor burden, stressor management would help. If a person has low social support, a social support group would be beneficial. Finally, if a participant demonstrated high passive maladaptive coping or low active coping, coping skills enhancement training would be helpful.

Evidence from the study suggests that increased serum cortisol from stress is associated with decreases in lymphocyte proliferation in response to the artificial stimulant phytohemagglutinin in HIV-positive men and women. This is a functional measure of immunity that tends to decrease before CD4 count, he said.

The intervention decreased overall psychological distress in HIV-negative men, compared with controls, according to scores on the Distress-Grief Composite Measure. However, the decreases in grief, specifically, were less prominent than those for distress or the composite of the two measures for both the HIV-positive and -negative men.

In terms of immune effects, HIV-positive people had a true increase in their lymphocyte proliferation response up to 2 years, and the intervention provided HIV-positive participants with a buffer against decreases in CD4 levels seen in controls. The decrement among HIV-positive participants was smaller, compared with HIV-negative groups, where there was a larger spread, Dr. Goodkin explained.

The researchers also looked for an effect at the physical health level. “There was a transition of the neuroendocrine changes to the immune level and, in turn, to the physical health level,”

All participants were asked to self-report physician health care visits in the 6 months prior to assessment; among HIV-positive participants, there was an increase in the control group that was not as great in the intervention group. Researchers found that the same pattern held true among HIV-negative individuals. There was increased health care utilization among control participants and a decrease among the intervention group. “We did not anticipate this. It indicated that this type of intervention is not only effective for improving the health of HIV-positive people but possibly for the entire population of people who lose a loved one,” he said.

Researchers were not able to analyze whether all health care visits were HIV or symptom related, an important caveat of the study. Another potential limitation was the difference in atmosphere between HIV-positive and HIV-negative group sessions. “HIV-positive groups talked more about concerns around their own mortality, but nonetheless it is important to note the consistency in findings across multiple domains, especially the physical domains,” Dr. Goodkin said.

“That suggests that if you improve mood state, you will improve cortisol, and you will improve immune function, which relates to improvements in viral load,” he said. The virology effect of the behavioral intervention was statistically significant, and Dr. Goodkin suggested that “it may ever be clinically significant, but we need to look at the latter effect on viral load seen in a subgroup over the long term in larger study groups.”

MARCO ISLAND, FLA. — Semistructured group therapy improves mood state in HIV-positive men, which improves cortisol levels and immune function and thereby reduces viral load, Karl Goodkin, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Bereavement has long been known to be associated with immunosuppression and is also associated with increased mortality risk for surviving partners. The risk increases 40% for the first 6 months and 10-fold in the first year, the same time frame as observed decrements in the immune system, said Dr. Goodkin, professor of psychiatry and behavioral sciences, neurology, and psychology at the University of Miami.

In a randomized controlled trial, Dr. Goodkin and his colleagues compared the intervention with usual care in HIV-positive and HIV-negative gay men who had experienced a loss in the previous 6 months. Although effects of grief were similar, the two-tier group intervention decreased overall psychological stress—which improved mood and immune measures, including CD4 counts and viral loads—and reduced physician health visits, compared with the usual-care control group.

Participants attended a 90-minute session once weekly for 10 weeks. The groups consisted of 6-10 attendees and two professional coleaders. Enrollment was ongoing throughout the study. The first tier of the intervention fostered grief resolution; the second tier fostered stressor management, including identification of stressor impact and maladaptive behaviors. In addition to specific grief-related topics for each session, including past experiences of personal loss, reactions to surviving and implications for one's spirituality and mortality, non-bereavement-related stressor management was planned as a major focus of this unique group intervention, he said.

The usual-care group received any medical and psychosocial care that they had begun prior to initial assessment. Furthermore, they received four telephone calls during the 10-week intervention period to assess their clinical status. The total time for these calls was limited to 90 minutes over the 10-week period. Study staff avoided any therapeutic interactions during these calls and maintained a log documenting call content.

In the study, 166 participants (97 HIV-positive and 69 HIV-negative) completed the intervention or community usual-care group conditions. Participants were primarily in their late 30s, employed, and college educated. More than one-third were members of an ethnic minority.

The Stressor-Support-Coping model appears to have utility “with or without bereavement. We found increase in positive life events in HIV-positive men after the intervention. Social support increased in the intervention group and declined in controls,” Dr. Goodkin noted.

The investigators' theoretical model also predicts specific psychosocial treatment needs. If a person has a high life-stressor burden, stressor management would help. If a person has low social support, a social support group would be beneficial. Finally, if a participant demonstrated high passive maladaptive coping or low active coping, coping skills enhancement training would be helpful.

Evidence from the study suggests that increased serum cortisol from stress is associated with decreases in lymphocyte proliferation in response to the artificial stimulant phytohemagglutinin in HIV-positive men and women. This is a functional measure of immunity that tends to decrease before CD4 count, he said.

The intervention decreased overall psychological distress in HIV-negative men, compared with controls, according to scores on the Distress-Grief Composite Measure. However, the decreases in grief, specifically, were less prominent than those for distress or the composite of the two measures for both the HIV-positive and -negative men.

In terms of immune effects, HIV-positive people had a true increase in their lymphocyte proliferation response up to 2 years, and the intervention provided HIV-positive participants with a buffer against decreases in CD4 levels seen in controls. The decrement among HIV-positive participants was smaller, compared with HIV-negative groups, where there was a larger spread, Dr. Goodkin explained.

The researchers also looked for an effect at the physical health level. “There was a transition of the neuroendocrine changes to the immune level and, in turn, to the physical health level,”

All participants were asked to self-report physician health care visits in the 6 months prior to assessment; among HIV-positive participants, there was an increase in the control group that was not as great in the intervention group. Researchers found that the same pattern held true among HIV-negative individuals. There was increased health care utilization among control participants and a decrease among the intervention group. “We did not anticipate this. It indicated that this type of intervention is not only effective for improving the health of HIV-positive people but possibly for the entire population of people who lose a loved one,” he said.

Researchers were not able to analyze whether all health care visits were HIV or symptom related, an important caveat of the study. Another potential limitation was the difference in atmosphere between HIV-positive and HIV-negative group sessions. “HIV-positive groups talked more about concerns around their own mortality, but nonetheless it is important to note the consistency in findings across multiple domains, especially the physical domains,” Dr. Goodkin said.

“That suggests that if you improve mood state, you will improve cortisol, and you will improve immune function, which relates to improvements in viral load,” he said. The virology effect of the behavioral intervention was statistically significant, and Dr. Goodkin suggested that “it may ever be clinically significant, but we need to look at the latter effect on viral load seen in a subgroup over the long term in larger study groups.”

BAL HARBOUR, FLA. — Cognition declines in the years after a single stroke for a substantial minority of patients, according to a study presented at the annual meeting of the American Neuropsychiatric Association.

After the initial poststroke period, most experts would expect cognition to improve or remain static, according to the literature. However, some studies with a longer follow-up now suggest cognitive decline is possible after a single stroke, even in younger patients. The current research supports that finding and shows the utility of screening patients with the Mini Mental State Examination (MMSE).

The cognitive impairment due to stroke is not static. “Our findings suggest there is a subpopulation that continues to decline as they age,” Gregory Kellermeyer, M.D., said in an interview.

The investigators assessed 16 men and 10 women at least 1 year following a single known stroke. The mean follow-up was almost 6 years. Participants were relatively young with a mean age of 58 years. Pretreatment data for the stroke survivors came from a study of constraint-induced movement therapy for upper extremity motor impairment.

Cognitive deficits can occur independent of motor decline. The implication is that “even a single stroke may in some persons incite a progressive neurodegenerative process that preferentially affects cognition,” the investigators wrote.

There was possible cognitive impairment in 6 of 27 participants (22%) and definite cognitive impairment in 2 of 27 (7%). Possible cognitive impairment was defined as a greater than 1 standard deviation on the adjusted MMSE; definite cognitive impairment was defined as greater than 2 standard deviations.

“The Mini Mental State Examination is a possible way to identify this subpopulation,” said Dr. Kellermeyer, fourth year resident in psychiatry at the University of Colorado, Denver.

Patient age, gender, handedness, stroke laterality, and severity of motor impairments were not significantly associated with raw or adjusted MMSE results.

BAL HARBOUR, FLA. — Cognition declines in the years after a single stroke for a substantial minority of patients, according to a study presented at the annual meeting of the American Neuropsychiatric Association.

After the initial poststroke period, most experts would expect cognition to improve or remain static, according to the literature. However, some studies with a longer follow-up now suggest cognitive decline is possible after a single stroke, even in younger patients. The current research supports that finding and shows the utility of screening patients with the Mini Mental State Examination (MMSE).

The cognitive impairment due to stroke is not static. “Our findings suggest there is a subpopulation that continues to decline as they age,” Gregory Kellermeyer, M.D., said in an interview.

The investigators assessed 16 men and 10 women at least 1 year following a single known stroke. The mean follow-up was almost 6 years. Participants were relatively young with a mean age of 58 years. Pretreatment data for the stroke survivors came from a study of constraint-induced movement therapy for upper extremity motor impairment.

Cognitive deficits can occur independent of motor decline. The implication is that “even a single stroke may in some persons incite a progressive neurodegenerative process that preferentially affects cognition,” the investigators wrote.

There was possible cognitive impairment in 6 of 27 participants (22%) and definite cognitive impairment in 2 of 27 (7%). Possible cognitive impairment was defined as a greater than 1 standard deviation on the adjusted MMSE; definite cognitive impairment was defined as greater than 2 standard deviations.

“The Mini Mental State Examination is a possible way to identify this subpopulation,” said Dr. Kellermeyer, fourth year resident in psychiatry at the University of Colorado, Denver.

Patient age, gender, handedness, stroke laterality, and severity of motor impairments were not significantly associated with raw or adjusted MMSE results.

BAL HARBOUR, FLA. — Cognition declines in the years after a single stroke for a substantial minority of patients, according to a study presented at the annual meeting of the American Neuropsychiatric Association.

After the initial poststroke period, most experts would expect cognition to improve or remain static, according to the literature. However, some studies with a longer follow-up now suggest cognitive decline is possible after a single stroke, even in younger patients. The current research supports that finding and shows the utility of screening patients with the Mini Mental State Examination (MMSE).

The cognitive impairment due to stroke is not static. “Our findings suggest there is a subpopulation that continues to decline as they age,” Gregory Kellermeyer, M.D., said in an interview.

The investigators assessed 16 men and 10 women at least 1 year following a single known stroke. The mean follow-up was almost 6 years. Participants were relatively young with a mean age of 58 years. Pretreatment data for the stroke survivors came from a study of constraint-induced movement therapy for upper extremity motor impairment.

Cognitive deficits can occur independent of motor decline. The implication is that “even a single stroke may in some persons incite a progressive neurodegenerative process that preferentially affects cognition,” the investigators wrote.

There was possible cognitive impairment in 6 of 27 participants (22%) and definite cognitive impairment in 2 of 27 (7%). Possible cognitive impairment was defined as a greater than 1 standard deviation on the adjusted MMSE; definite cognitive impairment was defined as greater than 2 standard deviations.

“The Mini Mental State Examination is a possible way to identify this subpopulation,” said Dr. Kellermeyer, fourth year resident in psychiatry at the University of Colorado, Denver.

Patient age, gender, handedness, stroke laterality, and severity of motor impairments were not significantly associated with raw or adjusted MMSE results.

MIAMI BEACH — Lorena M. Siqueira, M.D., has a straightforward way of dealing with teenaged binge drinkers: Ask them their alcohol consumption, present the facts, and don't give lectures.

Nearly 14 million adults, or 1 in 13, in the United States abuse alcohol or are alcohol dependent, according to the National Institute on Alcohol Abuse and Alcoholism. Intervening with teens may make a long-term difference since more than 35% of adults with an alcohol problem say they were binge drinkers before age 19.

A binge can be defined as a self-destructive and unrestrained drinking bout, lasting at least a couple of days, at least once in the preceding 2 weeks. Binge drinking also can be defined as five or more alcoholic drinks in a row for males, or four or more drinks for females on a single occasion.

“We used to think the brain was fully formed by adolescence, but now we know it continues to develop into the early 20s. Exposure of a developing brain to alcohol may have long-lasting effects on intellectual capabilities,” said Dr. Siqueira, director of the division of adolescent medicine at Miami Children's Hospital.

Address binge drinking as early as possible, Dr. Siqueira advised. “Some children are already alcohol dependent when you see them. Some start as young as 9 or 10 years old,” she said at a pediatric update sponsored by the hospital.

Teenagers who binge drink are more likely to drive drunk, fight, carry a weapon, drop out of school, engage in risky sexual behavior, or use illicit drugs. Teenage binge drinking is “one of the strongest predictors of binge drinking through the college years.”

One role of the physician is to identify alcohol abuse. Blackouts, depression, sleep disorders, chronic abdominal pain, liver dysfunction, sexual dysfunction, and sexually transmitted infections (STIs) are common signs. For example, 60% of college women diagnosed with an STI were drunk at the time of acquiring the infection, Dr. Siqueira said.

Screen all children for use of alcohol, including beer, wine, and distilled spirits. Once a potential problem is identified, evaluate the extent of drinking. Ask questions about how many days they drink alcohol, how many drinks they have on those days, and whether there are times when they are unable to stop drinking once they start.

Almost every state allows minors to consent for care for drugs or alcohol without parental consent. If you do not have time or do not feel comfortable treating alcohol dependence, refer them, she suggested.

“The best way to get [children] to change, rather than lecturing to them, is to present them with as many facts as you can,” Dr. Siqueira said. If a patient refuses to admit to having an issue with alcohol, ask the patient to define when it will become a problem. Some will say alcohol would be a problem if their grades dropped, for example.

“Appeal to their vanity,” Dr. Siqueira said. “Tell them drinking gives them bad breath and makes them gain weight.”

Recommended tools and resources for physicians include the CRAFFT (mnemonic) screen for alcohol use (Arch. Pediatr. Adolesc. Med. 1999;153:591-6), the National Council on Alcoholism and Drug Dependence (www.ncadd.orgwww.niaaa.nih.gov

Resources for patients and parents include Alateen (www.alateen.orgwww.niaaa.nih.gov/publications/makediff.htmwww.jointogether.org

MIAMI BEACH — Lorena M. Siqueira, M.D., has a straightforward way of dealing with teenaged binge drinkers: Ask them their alcohol consumption, present the facts, and don't give lectures.

Nearly 14 million adults, or 1 in 13, in the United States abuse alcohol or are alcohol dependent, according to the National Institute on Alcohol Abuse and Alcoholism. Intervening with teens may make a long-term difference since more than 35% of adults with an alcohol problem say they were binge drinkers before age 19.

A binge can be defined as a self-destructive and unrestrained drinking bout, lasting at least a couple of days, at least once in the preceding 2 weeks. Binge drinking also can be defined as five or more alcoholic drinks in a row for males, or four or more drinks for females on a single occasion.

“We used to think the brain was fully formed by adolescence, but now we know it continues to develop into the early 20s. Exposure of a developing brain to alcohol may have long-lasting effects on intellectual capabilities,” said Dr. Siqueira, director of the division of adolescent medicine at Miami Children's Hospital.

Address binge drinking as early as possible, Dr. Siqueira advised. “Some children are already alcohol dependent when you see them. Some start as young as 9 or 10 years old,” she said at a pediatric update sponsored by the hospital.

Teenagers who binge drink are more likely to drive drunk, fight, carry a weapon, drop out of school, engage in risky sexual behavior, or use illicit drugs. Teenage binge drinking is “one of the strongest predictors of binge drinking through the college years.”

One role of the physician is to identify alcohol abuse. Blackouts, depression, sleep disorders, chronic abdominal pain, liver dysfunction, sexual dysfunction, and sexually transmitted infections (STIs) are common signs. For example, 60% of college women diagnosed with an STI were drunk at the time of acquiring the infection, Dr. Siqueira said.

Screen all children for use of alcohol, including beer, wine, and distilled spirits. Once a potential problem is identified, evaluate the extent of drinking. Ask questions about how many days they drink alcohol, how many drinks they have on those days, and whether there are times when they are unable to stop drinking once they start.

Almost every state allows minors to consent for care for drugs or alcohol without parental consent. If you do not have time or do not feel comfortable treating alcohol dependence, refer them, she suggested.

“The best way to get [children] to change, rather than lecturing to them, is to present them with as many facts as you can,” Dr. Siqueira said. If a patient refuses to admit to having an issue with alcohol, ask the patient to define when it will become a problem. Some will say alcohol would be a problem if their grades dropped, for example.

“Appeal to their vanity,” Dr. Siqueira said. “Tell them drinking gives them bad breath and makes them gain weight.”

Recommended tools and resources for physicians include the CRAFFT (mnemonic) screen for alcohol use (Arch. Pediatr. Adolesc. Med. 1999;153:591-6), the National Council on Alcoholism and Drug Dependence (www.ncadd.orgwww.niaaa.nih.gov

Resources for patients and parents include Alateen (www.alateen.orgwww.niaaa.nih.gov/publications/makediff.htmwww.jointogether.org

MIAMI BEACH — Lorena M. Siqueira, M.D., has a straightforward way of dealing with teenaged binge drinkers: Ask them their alcohol consumption, present the facts, and don't give lectures.

Nearly 14 million adults, or 1 in 13, in the United States abuse alcohol or are alcohol dependent, according to the National Institute on Alcohol Abuse and Alcoholism. Intervening with teens may make a long-term difference since more than 35% of adults with an alcohol problem say they were binge drinkers before age 19.

A binge can be defined as a self-destructive and unrestrained drinking bout, lasting at least a couple of days, at least once in the preceding 2 weeks. Binge drinking also can be defined as five or more alcoholic drinks in a row for males, or four or more drinks for females on a single occasion.

“We used to think the brain was fully formed by adolescence, but now we know it continues to develop into the early 20s. Exposure of a developing brain to alcohol may have long-lasting effects on intellectual capabilities,” said Dr. Siqueira, director of the division of adolescent medicine at Miami Children's Hospital.

Address binge drinking as early as possible, Dr. Siqueira advised. “Some children are already alcohol dependent when you see them. Some start as young as 9 or 10 years old,” she said at a pediatric update sponsored by the hospital.

Teenagers who binge drink are more likely to drive drunk, fight, carry a weapon, drop out of school, engage in risky sexual behavior, or use illicit drugs. Teenage binge drinking is “one of the strongest predictors of binge drinking through the college years.”

One role of the physician is to identify alcohol abuse. Blackouts, depression, sleep disorders, chronic abdominal pain, liver dysfunction, sexual dysfunction, and sexually transmitted infections (STIs) are common signs. For example, 60% of college women diagnosed with an STI were drunk at the time of acquiring the infection, Dr. Siqueira said.

Screen all children for use of alcohol, including beer, wine, and distilled spirits. Once a potential problem is identified, evaluate the extent of drinking. Ask questions about how many days they drink alcohol, how many drinks they have on those days, and whether there are times when they are unable to stop drinking once they start.

Almost every state allows minors to consent for care for drugs or alcohol without parental consent. If you do not have time or do not feel comfortable treating alcohol dependence, refer them, she suggested.

“The best way to get [children] to change, rather than lecturing to them, is to present them with as many facts as you can,” Dr. Siqueira said. If a patient refuses to admit to having an issue with alcohol, ask the patient to define when it will become a problem. Some will say alcohol would be a problem if their grades dropped, for example.

“Appeal to their vanity,” Dr. Siqueira said. “Tell them drinking gives them bad breath and makes them gain weight.”

Recommended tools and resources for physicians include the CRAFFT (mnemonic) screen for alcohol use (Arch. Pediatr. Adolesc. Med. 1999;153:591-6), the National Council on Alcoholism and Drug Dependence (www.ncadd.orgwww.niaaa.nih.gov

Resources for patients and parents include Alateen (www.alateen.orgwww.niaaa.nih.gov/publications/makediff.htmwww.jointogether.org

FORT MYERS, FLA. – Psychiatrists should not cast the sole vote on whether someone is a suitable candidate for organ transplantation, panel members agreed during a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

“There is no other area of psychiatry where you might be involved in a decision as to whether a patient gets a lifesaving procedure or not. How comfortable do you feel with this?” asked Catherine C. Crone, M.D., of Georgetown University, Washington.

Psychiatrists contribute to transplantation teams in many different ways. Most often, psychiatrists assist in the total evaluation and treatment of a given patient, including direct psychotherapy. Some psychiatrists consult, and others are full team members. Some psychiatrists vote on potential candidates, while others do not.

“Transplant psychiatrists multitask,” Dr. Crone said. Other duties include development of psychosocial selection criteria for the program, assessment of living donors, and treatment of waiting-list patients, transplant recipients, and family members.

Psychiatrists should consider themselves integral team members who maintain their own identity. “It is important not to be viewed by the team as an outsider. Although we work with surgeons and internists, we are not competing with them,” she said.

“It is unfortunate if you work in a system where you are asked to be the sole gatekeeper,” said Owen S. Surman, M.D., of Harvard Medical School, Boston. For example, a surgeon might approach the transplant psychiatrist and simply ask “Yay or nay?” about a candidate. Dr. Crone suggested providing additional information about the patient. “Try to pull [surgeons] in some by giving them context. Humanize that patient by giving the considerations on either side of the decision.”

“One of the things I find extremely helpful is to tell stories about patients. Sometimes there are fascinating family stories, occupational stories, or things that they have done that make them people and not just cases,” Dr. Surman said.

If a candidate has behavioral or psychiatric issues, the psychiatrist effectively becomes the gatekeeper in many instances. “If you think in good conscience you cannot recommend someone, state that,” said Steven A. Epstein, M.D., professor and chair of psychiatry at Georgetown.

Use the term “risk assessment” when discussing a patient with other doctors. “Other physicians are familiar with looking at medical issues using that term,” said Curley L. Bonds, M.D., director of the consultation-evaluation psychiatry service at the University of California, Los Angeles.

A meeting attendee asked if psychiatric consultation with transplant patients improves postoperative recovery or long-term outcome. “There are no good data. But we have fairly compelling anecdotal data,” Donald L. Rosenstein, M.D., replied.

Cite whatever data you can to back your decision, Dr. Bonds suggested. “In California there have been lawsuits because we denied someone, and they go to another center and get listed.”

Despite a transplant team's best efforts at candidate screening, results are not guaranteed. “On retrospect, transplanting some people turns out to be a bad idea, and we should have listened to our gut,” said Dr. Rosenstein, deputy clinical director of the National Institute of Mental Health, Bethesda, Md.

On the other hand, “we see people who benefit from transplant whom we never would have expected to benefit,” Dr. Surman said.

One audience member asked about absolute psychiatric contraindications to transplantation. “The only absolute contraindications are circumstances–such as active psychosis, delusional depression, or active substance abuse–that impact an ability to give informed consent,” Dr. Rosenstein said. “Obviously, certain behaviors get you a lot closer to an absolute contraindication.”

FORT MYERS, FLA. – Psychiatrists should not cast the sole vote on whether someone is a suitable candidate for organ transplantation, panel members agreed during a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

“There is no other area of psychiatry where you might be involved in a decision as to whether a patient gets a lifesaving procedure or not. How comfortable do you feel with this?” asked Catherine C. Crone, M.D., of Georgetown University, Washington.

Psychiatrists contribute to transplantation teams in many different ways. Most often, psychiatrists assist in the total evaluation and treatment of a given patient, including direct psychotherapy. Some psychiatrists consult, and others are full team members. Some psychiatrists vote on potential candidates, while others do not.

“Transplant psychiatrists multitask,” Dr. Crone said. Other duties include development of psychosocial selection criteria for the program, assessment of living donors, and treatment of waiting-list patients, transplant recipients, and family members.

Psychiatrists should consider themselves integral team members who maintain their own identity. “It is important not to be viewed by the team as an outsider. Although we work with surgeons and internists, we are not competing with them,” she said.

“It is unfortunate if you work in a system where you are asked to be the sole gatekeeper,” said Owen S. Surman, M.D., of Harvard Medical School, Boston. For example, a surgeon might approach the transplant psychiatrist and simply ask “Yay or nay?” about a candidate. Dr. Crone suggested providing additional information about the patient. “Try to pull [surgeons] in some by giving them context. Humanize that patient by giving the considerations on either side of the decision.”

“One of the things I find extremely helpful is to tell stories about patients. Sometimes there are fascinating family stories, occupational stories, or things that they have done that make them people and not just cases,” Dr. Surman said.

If a candidate has behavioral or psychiatric issues, the psychiatrist effectively becomes the gatekeeper in many instances. “If you think in good conscience you cannot recommend someone, state that,” said Steven A. Epstein, M.D., professor and chair of psychiatry at Georgetown.

Use the term “risk assessment” when discussing a patient with other doctors. “Other physicians are familiar with looking at medical issues using that term,” said Curley L. Bonds, M.D., director of the consultation-evaluation psychiatry service at the University of California, Los Angeles.

A meeting attendee asked if psychiatric consultation with transplant patients improves postoperative recovery or long-term outcome. “There are no good data. But we have fairly compelling anecdotal data,” Donald L. Rosenstein, M.D., replied.

Cite whatever data you can to back your decision, Dr. Bonds suggested. “In California there have been lawsuits because we denied someone, and they go to another center and get listed.”

Despite a transplant team's best efforts at candidate screening, results are not guaranteed. “On retrospect, transplanting some people turns out to be a bad idea, and we should have listened to our gut,” said Dr. Rosenstein, deputy clinical director of the National Institute of Mental Health, Bethesda, Md.

On the other hand, “we see people who benefit from transplant whom we never would have expected to benefit,” Dr. Surman said.

One audience member asked about absolute psychiatric contraindications to transplantation. “The only absolute contraindications are circumstances–such as active psychosis, delusional depression, or active substance abuse–that impact an ability to give informed consent,” Dr. Rosenstein said. “Obviously, certain behaviors get you a lot closer to an absolute contraindication.”

FORT MYERS, FLA. – Psychiatrists should not cast the sole vote on whether someone is a suitable candidate for organ transplantation, panel members agreed during a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

“There is no other area of psychiatry where you might be involved in a decision as to whether a patient gets a lifesaving procedure or not. How comfortable do you feel with this?” asked Catherine C. Crone, M.D., of Georgetown University, Washington.

Psychiatrists contribute to transplantation teams in many different ways. Most often, psychiatrists assist in the total evaluation and treatment of a given patient, including direct psychotherapy. Some psychiatrists consult, and others are full team members. Some psychiatrists vote on potential candidates, while others do not.

“Transplant psychiatrists multitask,” Dr. Crone said. Other duties include development of psychosocial selection criteria for the program, assessment of living donors, and treatment of waiting-list patients, transplant recipients, and family members.

Psychiatrists should consider themselves integral team members who maintain their own identity. “It is important not to be viewed by the team as an outsider. Although we work with surgeons and internists, we are not competing with them,” she said.

“It is unfortunate if you work in a system where you are asked to be the sole gatekeeper,” said Owen S. Surman, M.D., of Harvard Medical School, Boston. For example, a surgeon might approach the transplant psychiatrist and simply ask “Yay or nay?” about a candidate. Dr. Crone suggested providing additional information about the patient. “Try to pull [surgeons] in some by giving them context. Humanize that patient by giving the considerations on either side of the decision.”

“One of the things I find extremely helpful is to tell stories about patients. Sometimes there are fascinating family stories, occupational stories, or things that they have done that make them people and not just cases,” Dr. Surman said.

If a candidate has behavioral or psychiatric issues, the psychiatrist effectively becomes the gatekeeper in many instances. “If you think in good conscience you cannot recommend someone, state that,” said Steven A. Epstein, M.D., professor and chair of psychiatry at Georgetown.

Use the term “risk assessment” when discussing a patient with other doctors. “Other physicians are familiar with looking at medical issues using that term,” said Curley L. Bonds, M.D., director of the consultation-evaluation psychiatry service at the University of California, Los Angeles.

A meeting attendee asked if psychiatric consultation with transplant patients improves postoperative recovery or long-term outcome. “There are no good data. But we have fairly compelling anecdotal data,” Donald L. Rosenstein, M.D., replied.

Cite whatever data you can to back your decision, Dr. Bonds suggested. “In California there have been lawsuits because we denied someone, and they go to another center and get listed.”

Despite a transplant team's best efforts at candidate screening, results are not guaranteed. “On retrospect, transplanting some people turns out to be a bad idea, and we should have listened to our gut,” said Dr. Rosenstein, deputy clinical director of the National Institute of Mental Health, Bethesda, Md.

On the other hand, “we see people who benefit from transplant whom we never would have expected to benefit,” Dr. Surman said.

One audience member asked about absolute psychiatric contraindications to transplantation. “The only absolute contraindications are circumstances–such as active psychosis, delusional depression, or active substance abuse–that impact an ability to give informed consent,” Dr. Rosenstein said. “Obviously, certain behaviors get you a lot closer to an absolute contraindication.”

SAN JUAN, P.R. – People in intensive alcohol treatment programs are more abstinent if smoking cessation efforts are delayed by 6 months, according to a study.

Smoking is common among people with alcohol dependence, with an estimated 60%-90% prevalence. And because smoking causes a lot of morbidity and mortality in such patients, it is a “compelling issue to work on in recovery,” Anne Joseph, M.D., said at the annual meeting of the American Academy of Addiction Psychiatry.

Although the results of nonrandomized studies suggest that smoking cessation efforts during intensive alcohol treatment are better than doing nothing, these trials included small numbers of participants and demonstrated only a modest benefit to nicotine replacement in this population.

For a more definitive answer, Dr. Joseph and her colleagues performed a large, 18-month, randomized trial. They hypothesized that concurrent treatment would improve both smoking and alcohol abstinence outcomes (J. Stud. Alcohol 2004;65:681-91).

“Here comes the surprising, but unfortunate, news,” said Dr. Joseph of the department of medicine at the University of Minnesota, Minneapolis. Alcohol abstinence was better when the smoking intervention was delayed by 6 months, compared with addressing both concerns simultaneously.

There were significant differences in outcomes at 6, 12, and 18 months. At 6 months, 64% of the delayed intervention group achieved 30-day alcohol abstinence, compared with 51% of the concurrent group; at 12 months, success rates were 53% and 46%, and at 18 months the rates were 60% and 48%.

The researchers also assessed alcohol abstinence 6 months after initiation of the smoking intervention in each group. Fifty-six percent of the delayed group were abstinent for alcohol for 6 months, compared with 41% of the concurrent group. At 12 months, 6-month abstinence was 42% versus 33%, and at 18 months, the rates were 48% and 41%.

Based on these findings, “delayed smoking cessation should be offered,” Dr. Joseph said.

Why the delayed intervention group fared better is unknown. It may be that there is an interaction between smoking and alcohol interventions, confounded by a specific biologic or behavioral factor. It could also be that adding anything to alcohol treatment worsens outcome, said Dr. Joseph, also of Minneapolis Veterans Affairs Medical Center.

The investigators randomized 251 participants to concurrent alcohol and nicotine treatment and 248 to initial alcohol treatment followed by delayed smoking cessation treatment. The Timing of Alcohol and Smoking Cessation (TASC) trial included people from three residential, day, and outpatient rehabilitation programs in Minnesota offering 3-5 weeks of intensive intervention with aftercare.

The concurrent group completed the smoking intervention at 12 months and the delayed group completed it at 18 months. Participants were 21-75 years old, about two-thirds were male, and one-third had a high school education or less. They smoked at least five cigarettes per day, but most had significant nicotine dependence, indicated by an average score of 6 on the Fagerstrom Test for Nicotine Dependence. There were an average of three previous smoking quit attempts. About half reported alcohol abuse alone, the remainder had one, two, or three other substance abuse issues.

The smoking cessation intervention included behavioral treatment and nicotine replacement therapy (to avoid withdrawal effects). One hour of behavioral treatment at baseline was followed by three follow-up sessions either in person or via telephone.

SAN JUAN, P.R. – People in intensive alcohol treatment programs are more abstinent if smoking cessation efforts are delayed by 6 months, according to a study.

Smoking is common among people with alcohol dependence, with an estimated 60%-90% prevalence. And because smoking causes a lot of morbidity and mortality in such patients, it is a “compelling issue to work on in recovery,” Anne Joseph, M.D., said at the annual meeting of the American Academy of Addiction Psychiatry.

Although the results of nonrandomized studies suggest that smoking cessation efforts during intensive alcohol treatment are better than doing nothing, these trials included small numbers of participants and demonstrated only a modest benefit to nicotine replacement in this population.

For a more definitive answer, Dr. Joseph and her colleagues performed a large, 18-month, randomized trial. They hypothesized that concurrent treatment would improve both smoking and alcohol abstinence outcomes (J. Stud. Alcohol 2004;65:681-91).

“Here comes the surprising, but unfortunate, news,” said Dr. Joseph of the department of medicine at the University of Minnesota, Minneapolis. Alcohol abstinence was better when the smoking intervention was delayed by 6 months, compared with addressing both concerns simultaneously.

There were significant differences in outcomes at 6, 12, and 18 months. At 6 months, 64% of the delayed intervention group achieved 30-day alcohol abstinence, compared with 51% of the concurrent group; at 12 months, success rates were 53% and 46%, and at 18 months the rates were 60% and 48%.

The researchers also assessed alcohol abstinence 6 months after initiation of the smoking intervention in each group. Fifty-six percent of the delayed group were abstinent for alcohol for 6 months, compared with 41% of the concurrent group. At 12 months, 6-month abstinence was 42% versus 33%, and at 18 months, the rates were 48% and 41%.

Based on these findings, “delayed smoking cessation should be offered,” Dr. Joseph said.

Why the delayed intervention group fared better is unknown. It may be that there is an interaction between smoking and alcohol interventions, confounded by a specific biologic or behavioral factor. It could also be that adding anything to alcohol treatment worsens outcome, said Dr. Joseph, also of Minneapolis Veterans Affairs Medical Center.

The investigators randomized 251 participants to concurrent alcohol and nicotine treatment and 248 to initial alcohol treatment followed by delayed smoking cessation treatment. The Timing of Alcohol and Smoking Cessation (TASC) trial included people from three residential, day, and outpatient rehabilitation programs in Minnesota offering 3-5 weeks of intensive intervention with aftercare.

The concurrent group completed the smoking intervention at 12 months and the delayed group completed it at 18 months. Participants were 21-75 years old, about two-thirds were male, and one-third had a high school education or less. They smoked at least five cigarettes per day, but most had significant nicotine dependence, indicated by an average score of 6 on the Fagerstrom Test for Nicotine Dependence. There were an average of three previous smoking quit attempts. About half reported alcohol abuse alone, the remainder had one, two, or three other substance abuse issues.

The smoking cessation intervention included behavioral treatment and nicotine replacement therapy (to avoid withdrawal effects). One hour of behavioral treatment at baseline was followed by three follow-up sessions either in person or via telephone.

SAN JUAN, P.R. – People in intensive alcohol treatment programs are more abstinent if smoking cessation efforts are delayed by 6 months, according to a study.

Smoking is common among people with alcohol dependence, with an estimated 60%-90% prevalence. And because smoking causes a lot of morbidity and mortality in such patients, it is a “compelling issue to work on in recovery,” Anne Joseph, M.D., said at the annual meeting of the American Academy of Addiction Psychiatry.

Although the results of nonrandomized studies suggest that smoking cessation efforts during intensive alcohol treatment are better than doing nothing, these trials included small numbers of participants and demonstrated only a modest benefit to nicotine replacement in this population.

For a more definitive answer, Dr. Joseph and her colleagues performed a large, 18-month, randomized trial. They hypothesized that concurrent treatment would improve both smoking and alcohol abstinence outcomes (J. Stud. Alcohol 2004;65:681-91).

“Here comes the surprising, but unfortunate, news,” said Dr. Joseph of the department of medicine at the University of Minnesota, Minneapolis. Alcohol abstinence was better when the smoking intervention was delayed by 6 months, compared with addressing both concerns simultaneously.

There were significant differences in outcomes at 6, 12, and 18 months. At 6 months, 64% of the delayed intervention group achieved 30-day alcohol abstinence, compared with 51% of the concurrent group; at 12 months, success rates were 53% and 46%, and at 18 months the rates were 60% and 48%.

The researchers also assessed alcohol abstinence 6 months after initiation of the smoking intervention in each group. Fifty-six percent of the delayed group were abstinent for alcohol for 6 months, compared with 41% of the concurrent group. At 12 months, 6-month abstinence was 42% versus 33%, and at 18 months, the rates were 48% and 41%.

Based on these findings, “delayed smoking cessation should be offered,” Dr. Joseph said.

Why the delayed intervention group fared better is unknown. It may be that there is an interaction between smoking and alcohol interventions, confounded by a specific biologic or behavioral factor. It could also be that adding anything to alcohol treatment worsens outcome, said Dr. Joseph, also of Minneapolis Veterans Affairs Medical Center.

The investigators randomized 251 participants to concurrent alcohol and nicotine treatment and 248 to initial alcohol treatment followed by delayed smoking cessation treatment. The Timing of Alcohol and Smoking Cessation (TASC) trial included people from three residential, day, and outpatient rehabilitation programs in Minnesota offering 3-5 weeks of intensive intervention with aftercare.

The concurrent group completed the smoking intervention at 12 months and the delayed group completed it at 18 months. Participants were 21-75 years old, about two-thirds were male, and one-third had a high school education or less. They smoked at least five cigarettes per day, but most had significant nicotine dependence, indicated by an average score of 6 on the Fagerstrom Test for Nicotine Dependence. There were an average of three previous smoking quit attempts. About half reported alcohol abuse alone, the remainder had one, two, or three other substance abuse issues.

The smoking cessation intervention included behavioral treatment and nicotine replacement therapy (to avoid withdrawal effects). One hour of behavioral treatment at baseline was followed by three follow-up sessions either in person or via telephone.

ORLANDO, FLA. – Nearly 20% of children and adolescents have a neuropsychiatric diagnosis at the time they are diagnosed with type 2 diabetes, according to a retrospective study presented at the annual scientific sessions of the American Diabetes Association.

“Adolescents with neuropsychiatric disease and other risk factors may have a higher risk for glucose intolerance or type 2 diabetes, and may benefit from screening,” Lorraine E. Levitt Katz, M.D., said. “The risk of type 2 diabetes may be greatest for obese children on atypical antipsychotics.”

The relationship between neuropsychiatric illness and type 2 diabetes is not completely clear and is likely multifactorial. Weight gain, caused by neuropsychiatric illness or antipsychotic medication, may play a role; obesity is a risk factor for type 2 diabetes in children and adolescents. Neuropsychiatric illness may promote a sedentary lifestyle, another factor associated with weight gain. Some medications may cause hyperglycemia through insulin resistance or effects on beta cells. Other risk factors for pediatric type 2 diabetes include family history, ethnicity, and female gender, said Dr. Levitt Katz, a pediatric endocrinologist at the Children's Hospital of Philadelphia.

“At [Children's Hospital of Philadelphia], we've seen an increase in new type 2 diabetes cases. The number has increased steadily each year, up to 55 in 2002,” said Dr. Levitt Katz, also of the University of Pennsylvania.

She and her colleagues reviewed the charts of 237 children and adolescents newly diagnosed with type 2 diabetes, to determine the prevalence of neuropsychiatric illness. They identified 46 such patients (19%). Diagnoses included depression, behavioral disorders (including attention-deficit hyperactivity disorder), mental retardation, autism, and developmental delay.

“A large number of pediatric patients with type 2 diabetes have neuropsychiatric disease,” Dr. Levitt Katz said. Pediatric endocrinologists diagnosed most of the diabetes in the study population, but primary care physicians diagnosed some patients. The study findings may not even reflect the true prevalence. “We would argue our data are an underestimation of neuropsychiatric illness among children with diabetes.”

Depression was the leading diagnosis (13 patients). A meeting attendee asked whether preexisting depression interferes with a patient's motivation regarding diabetes. “It's an enormous challenge that will require creative thinking to address,” Dr. Levitt Katz said. Although the study focused on neuropsychiatric illness at the time of diagnosis, she added that there is also depression after diagnosis and a large number of undiagnosed disorders.

Investigators next looked at patient demographics for any factors that might be more strongly associated with neuropsychiatric illness. For example, they compared body mass index (BMI) z scores between diabetics with a neuropsychiatric condition and those without. “We did not find statistically significant differences in BMI, unlike we expected,” she said.

Neither gender nor age at diabetes diagnosis was associated with a higher prevalence of neuropsychiatric illness. There was a trend toward a difference by ethnicity. The patient population included children who were African American (67%), Caucasian (24%), Asian Pacific (6%), and other (3%). “We found the African American population in the affected group was overrepresented at 79%, but it was not significantly different,” Dr. Levitt Katz said.

The large number of comorbid conditions was a limitation of the study. In addition, the frequency of neuropsychiatric disease was not studied in a comparable pediatric population without diabetes.

The researchers looked for an association between the number of antipsychotics and diabetes. They found that 37.5% of children taking antipsychotics were on one agent and 27.5% were on two agents, but there was no correlation. Dr. Levitt Katz said, “We were somewhat surprised by these results; we initially thought type 2 diabetes was associated with psychiatric medications.”

Twenty patients were taking mood stabilizers and eight were taking selective serotonin reuptake inhibitors. There were 17 patients on atypical antipsychotics, most commonly risperidone (Risperdal) and olanzapine (Zyprexa). The atypical agents were prescribed for a wide range of diagnoses, including behavioral problems, bipolar disorder, schizophrenia, depression, and seizure disorder secondary to head trauma. Dr. Levitt Katz said, “This suggests there may be a lot of off-label use of these antipsychotics in children.”

In February 2004, a consensus conference was held on antipsychotics, obesity, and diabetes. Recommendations that emerged from that meeting include performing a risk-benefit assessment before starting medications, tracking BMI and waist circumference, doing a baseline screening for diabetes, and monitoring patients regularly.

ORLANDO, FLA. – Nearly 20% of children and adolescents have a neuropsychiatric diagnosis at the time they are diagnosed with type 2 diabetes, according to a retrospective study presented at the annual scientific sessions of the American Diabetes Association.

“Adolescents with neuropsychiatric disease and other risk factors may have a higher risk for glucose intolerance or type 2 diabetes, and may benefit from screening,” Lorraine E. Levitt Katz, M.D., said. “The risk of type 2 diabetes may be greatest for obese children on atypical antipsychotics.”

The relationship between neuropsychiatric illness and type 2 diabetes is not completely clear and is likely multifactorial. Weight gain, caused by neuropsychiatric illness or antipsychotic medication, may play a role; obesity is a risk factor for type 2 diabetes in children and adolescents. Neuropsychiatric illness may promote a sedentary lifestyle, another factor associated with weight gain. Some medications may cause hyperglycemia through insulin resistance or effects on beta cells. Other risk factors for pediatric type 2 diabetes include family history, ethnicity, and female gender, said Dr. Levitt Katz, a pediatric endocrinologist at the Children's Hospital of Philadelphia.

“At [Children's Hospital of Philadelphia], we've seen an increase in new type 2 diabetes cases. The number has increased steadily each year, up to 55 in 2002,” said Dr. Levitt Katz, also of the University of Pennsylvania.

She and her colleagues reviewed the charts of 237 children and adolescents newly diagnosed with type 2 diabetes, to determine the prevalence of neuropsychiatric illness. They identified 46 such patients (19%). Diagnoses included depression, behavioral disorders (including attention-deficit hyperactivity disorder), mental retardation, autism, and developmental delay.

“A large number of pediatric patients with type 2 diabetes have neuropsychiatric disease,” Dr. Levitt Katz said. Pediatric endocrinologists diagnosed most of the diabetes in the study population, but primary care physicians diagnosed some patients. The study findings may not even reflect the true prevalence. “We would argue our data are an underestimation of neuropsychiatric illness among children with diabetes.”

Depression was the leading diagnosis (13 patients). A meeting attendee asked whether preexisting depression interferes with a patient's motivation regarding diabetes. “It's an enormous challenge that will require creative thinking to address,” Dr. Levitt Katz said. Although the study focused on neuropsychiatric illness at the time of diagnosis, she added that there is also depression after diagnosis and a large number of undiagnosed disorders.

Investigators next looked at patient demographics for any factors that might be more strongly associated with neuropsychiatric illness. For example, they compared body mass index (BMI) z scores between diabetics with a neuropsychiatric condition and those without. “We did not find statistically significant differences in BMI, unlike we expected,” she said.

Neither gender nor age at diabetes diagnosis was associated with a higher prevalence of neuropsychiatric illness. There was a trend toward a difference by ethnicity. The patient population included children who were African American (67%), Caucasian (24%), Asian Pacific (6%), and other (3%). “We found the African American population in the affected group was overrepresented at 79%, but it was not significantly different,” Dr. Levitt Katz said.

The large number of comorbid conditions was a limitation of the study. In addition, the frequency of neuropsychiatric disease was not studied in a comparable pediatric population without diabetes.

The researchers looked for an association between the number of antipsychotics and diabetes. They found that 37.5% of children taking antipsychotics were on one agent and 27.5% were on two agents, but there was no correlation. Dr. Levitt Katz said, “We were somewhat surprised by these results; we initially thought type 2 diabetes was associated with psychiatric medications.”

Twenty patients were taking mood stabilizers and eight were taking selective serotonin reuptake inhibitors. There were 17 patients on atypical antipsychotics, most commonly risperidone (Risperdal) and olanzapine (Zyprexa). The atypical agents were prescribed for a wide range of diagnoses, including behavioral problems, bipolar disorder, schizophrenia, depression, and seizure disorder secondary to head trauma. Dr. Levitt Katz said, “This suggests there may be a lot of off-label use of these antipsychotics in children.”

In February 2004, a consensus conference was held on antipsychotics, obesity, and diabetes. Recommendations that emerged from that meeting include performing a risk-benefit assessment before starting medications, tracking BMI and waist circumference, doing a baseline screening for diabetes, and monitoring patients regularly.

ORLANDO, FLA. – Nearly 20% of children and adolescents have a neuropsychiatric diagnosis at the time they are diagnosed with type 2 diabetes, according to a retrospective study presented at the annual scientific sessions of the American Diabetes Association.

“Adolescents with neuropsychiatric disease and other risk factors may have a higher risk for glucose intolerance or type 2 diabetes, and may benefit from screening,” Lorraine E. Levitt Katz, M.D., said. “The risk of type 2 diabetes may be greatest for obese children on atypical antipsychotics.”

The relationship between neuropsychiatric illness and type 2 diabetes is not completely clear and is likely multifactorial. Weight gain, caused by neuropsychiatric illness or antipsychotic medication, may play a role; obesity is a risk factor for type 2 diabetes in children and adolescents. Neuropsychiatric illness may promote a sedentary lifestyle, another factor associated with weight gain. Some medications may cause hyperglycemia through insulin resistance or effects on beta cells. Other risk factors for pediatric type 2 diabetes include family history, ethnicity, and female gender, said Dr. Levitt Katz, a pediatric endocrinologist at the Children's Hospital of Philadelphia.

“At [Children's Hospital of Philadelphia], we've seen an increase in new type 2 diabetes cases. The number has increased steadily each year, up to 55 in 2002,” said Dr. Levitt Katz, also of the University of Pennsylvania.

She and her colleagues reviewed the charts of 237 children and adolescents newly diagnosed with type 2 diabetes, to determine the prevalence of neuropsychiatric illness. They identified 46 such patients (19%). Diagnoses included depression, behavioral disorders (including attention-deficit hyperactivity disorder), mental retardation, autism, and developmental delay.

“A large number of pediatric patients with type 2 diabetes have neuropsychiatric disease,” Dr. Levitt Katz said. Pediatric endocrinologists diagnosed most of the diabetes in the study population, but primary care physicians diagnosed some patients. The study findings may not even reflect the true prevalence. “We would argue our data are an underestimation of neuropsychiatric illness among children with diabetes.”

Depression was the leading diagnosis (13 patients). A meeting attendee asked whether preexisting depression interferes with a patient's motivation regarding diabetes. “It's an enormous challenge that will require creative thinking to address,” Dr. Levitt Katz said. Although the study focused on neuropsychiatric illness at the time of diagnosis, she added that there is also depression after diagnosis and a large number of undiagnosed disorders.

Investigators next looked at patient demographics for any factors that might be more strongly associated with neuropsychiatric illness. For example, they compared body mass index (BMI) z scores between diabetics with a neuropsychiatric condition and those without. “We did not find statistically significant differences in BMI, unlike we expected,” she said.

Neither gender nor age at diabetes diagnosis was associated with a higher prevalence of neuropsychiatric illness. There was a trend toward a difference by ethnicity. The patient population included children who were African American (67%), Caucasian (24%), Asian Pacific (6%), and other (3%). “We found the African American population in the affected group was overrepresented at 79%, but it was not significantly different,” Dr. Levitt Katz said.

The large number of comorbid conditions was a limitation of the study. In addition, the frequency of neuropsychiatric disease was not studied in a comparable pediatric population without diabetes.

The researchers looked for an association between the number of antipsychotics and diabetes. They found that 37.5% of children taking antipsychotics were on one agent and 27.5% were on two agents, but there was no correlation. Dr. Levitt Katz said, “We were somewhat surprised by these results; we initially thought type 2 diabetes was associated with psychiatric medications.”

Twenty patients were taking mood stabilizers and eight were taking selective serotonin reuptake inhibitors. There were 17 patients on atypical antipsychotics, most commonly risperidone (Risperdal) and olanzapine (Zyprexa). The atypical agents were prescribed for a wide range of diagnoses, including behavioral problems, bipolar disorder, schizophrenia, depression, and seizure disorder secondary to head trauma. Dr. Levitt Katz said, “This suggests there may be a lot of off-label use of these antipsychotics in children.”

In February 2004, a consensus conference was held on antipsychotics, obesity, and diabetes. Recommendations that emerged from that meeting include performing a risk-benefit assessment before starting medications, tracking BMI and waist circumference, doing a baseline screening for diabetes, and monitoring patients regularly.

MIAMI BEACH – Physicians can help teenagers who binge drink by asking about alcohol consumption, presenting the facts, and not giving lectures, Lorena M. Siqueira, M.D., said at a pediatric update sponsored by Miami Children's Hospital.

There are nearly 14 million adults, or 1 in 13, in the United States who abuse alcohol or who are alcohol dependent, according to the National Institute on Alcohol Abuse and Alcoholism. Physicians may be able to make a long-term difference since more than 35% of adults with an alcohol problem say they were binge drinkers before age 19.

A binge can be defined as a self-destructive and unrestrained drinking bout, lasting at least a couple of days, at least once in the preceding 2 weeks. Binge drinking also can be defined as five or more alcoholic drinks in a row for males, or four or more drinks for females on a single occasion. This is approximately the number of drinks that causes an average size person to reach the blood alcohol concentration of 0.10%, which is the limit most states set for driving under influence of an impairing substance.

“We used to think the brain was fully formed by adolescence, but now we know it continues to develop into the early 20s. Exposure of a developing brain to alcohol may have long-lasting effects on intellectual capabilities,” said Dr. Siqueira, director of the division of adolescent medicine at Miami Children's Hospital.

Address binge drinking as early as possible, Dr. Siqueira advised. “Some children are already alcohol dependent when you see them. Some start as young as 9 or 10 years old.”

Teenagers who binge drink are more likely to drive drunk, fight, carry a weapon, drop out of school, engage in risky sexual behavior, or use illicit drugs. Teenage binge drinking is “one of the strongest predictors of binge drinking through the college years.”

One role of the physician is to identify alcohol abuse. Blackouts, depression, sleep disorders, chronic abdominal pain, liver dysfunction, sexual dysfunction, and sexually transmitted infections (STIs) are common signs. For example, 60% of college women diagnosed with an STI were drunk at the time of acquiring the infection, Dr. Siqueira said.

Screen all children for use of alcohol, including beer, wine, and distilled spirits. Once a potential problem is identified, evaluate the extent of drinking. Ask questions about how many days they drink alcohol, how many drinks they have on those days, and whether there are times when they are unable to stop drinking once they start.

Almost every state allows minors to consent to care for drugs or alcohol without parental consent. If you do not have time or do not feel comfortable treating alcohol dependence, refer them, Dr. Siqueira suggested.

“The best way to get [children] to change, rather than lecturing to them, is to present them with as many facts as you can,” Dr. Siqueira said. If a patient refuses to admit to having an issue with alcohol, ask the patient to define when it will become a problem. Some will say alcohol would be a problem if their grades dropped, for example.

“Appeal to their vanity,” Dr. Siqueira said. “Tell them drinking gives them bad breath and makes them gain weight.”

Recommended tools and resources for physicians include the CRAFFT (mnemonic) screen for alcohol use (Arch. Pediatr. Adolesc. Med. 1999;153:591-6), the National Council on Alcoholism and Drug Dependence (www.ncadd.orgwww.niaaa.nih.gov

Resources that are available for patients and parents include Alateen (www.alateen.orgwww.niaaa.nih.gov/publications/makediff.htmwww.jointogether.org

MIAMI BEACH – Physicians can help teenagers who binge drink by asking about alcohol consumption, presenting the facts, and not giving lectures, Lorena M. Siqueira, M.D., said at a pediatric update sponsored by Miami Children's Hospital.

There are nearly 14 million adults, or 1 in 13, in the United States who abuse alcohol or who are alcohol dependent, according to the National Institute on Alcohol Abuse and Alcoholism. Physicians may be able to make a long-term difference since more than 35% of adults with an alcohol problem say they were binge drinkers before age 19.

A binge can be defined as a self-destructive and unrestrained drinking bout, lasting at least a couple of days, at least once in the preceding 2 weeks. Binge drinking also can be defined as five or more alcoholic drinks in a row for males, or four or more drinks for females on a single occasion. This is approximately the number of drinks that causes an average size person to reach the blood alcohol concentration of 0.10%, which is the limit most states set for driving under influence of an impairing substance.

“We used to think the brain was fully formed by adolescence, but now we know it continues to develop into the early 20s. Exposure of a developing brain to alcohol may have long-lasting effects on intellectual capabilities,” said Dr. Siqueira, director of the division of adolescent medicine at Miami Children's Hospital.

Address binge drinking as early as possible, Dr. Siqueira advised. “Some children are already alcohol dependent when you see them. Some start as young as 9 or 10 years old.”

Teenagers who binge drink are more likely to drive drunk, fight, carry a weapon, drop out of school, engage in risky sexual behavior, or use illicit drugs. Teenage binge drinking is “one of the strongest predictors of binge drinking through the college years.”

One role of the physician is to identify alcohol abuse. Blackouts, depression, sleep disorders, chronic abdominal pain, liver dysfunction, sexual dysfunction, and sexually transmitted infections (STIs) are common signs. For example, 60% of college women diagnosed with an STI were drunk at the time of acquiring the infection, Dr. Siqueira said.

Screen all children for use of alcohol, including beer, wine, and distilled spirits. Once a potential problem is identified, evaluate the extent of drinking. Ask questions about how many days they drink alcohol, how many drinks they have on those days, and whether there are times when they are unable to stop drinking once they start.

Almost every state allows minors to consent to care for drugs or alcohol without parental consent. If you do not have time or do not feel comfortable treating alcohol dependence, refer them, Dr. Siqueira suggested.

“The best way to get [children] to change, rather than lecturing to them, is to present them with as many facts as you can,” Dr. Siqueira said. If a patient refuses to admit to having an issue with alcohol, ask the patient to define when it will become a problem. Some will say alcohol would be a problem if their grades dropped, for example.

“Appeal to their vanity,” Dr. Siqueira said. “Tell them drinking gives them bad breath and makes them gain weight.”

Recommended tools and resources for physicians include the CRAFFT (mnemonic) screen for alcohol use (Arch. Pediatr. Adolesc. Med. 1999;153:591-6), the National Council on Alcoholism and Drug Dependence (www.ncadd.orgwww.niaaa.nih.gov

Resources that are available for patients and parents include Alateen (www.alateen.orgwww.niaaa.nih.gov/publications/makediff.htmwww.jointogether.org

MIAMI BEACH – Physicians can help teenagers who binge drink by asking about alcohol consumption, presenting the facts, and not giving lectures, Lorena M. Siqueira, M.D., said at a pediatric update sponsored by Miami Children's Hospital.

There are nearly 14 million adults, or 1 in 13, in the United States who abuse alcohol or who are alcohol dependent, according to the National Institute on Alcohol Abuse and Alcoholism. Physicians may be able to make a long-term difference since more than 35% of adults with an alcohol problem say they were binge drinkers before age 19.

A binge can be defined as a self-destructive and unrestrained drinking bout, lasting at least a couple of days, at least once in the preceding 2 weeks. Binge drinking also can be defined as five or more alcoholic drinks in a row for males, or four or more drinks for females on a single occasion. This is approximately the number of drinks that causes an average size person to reach the blood alcohol concentration of 0.10%, which is the limit most states set for driving under influence of an impairing substance.

“We used to think the brain was fully formed by adolescence, but now we know it continues to develop into the early 20s. Exposure of a developing brain to alcohol may have long-lasting effects on intellectual capabilities,” said Dr. Siqueira, director of the division of adolescent medicine at Miami Children's Hospital.

Address binge drinking as early as possible, Dr. Siqueira advised. “Some children are already alcohol dependent when you see them. Some start as young as 9 or 10 years old.”

Teenagers who binge drink are more likely to drive drunk, fight, carry a weapon, drop out of school, engage in risky sexual behavior, or use illicit drugs. Teenage binge drinking is “one of the strongest predictors of binge drinking through the college years.”

One role of the physician is to identify alcohol abuse. Blackouts, depression, sleep disorders, chronic abdominal pain, liver dysfunction, sexual dysfunction, and sexually transmitted infections (STIs) are common signs. For example, 60% of college women diagnosed with an STI were drunk at the time of acquiring the infection, Dr. Siqueira said.

Screen all children for use of alcohol, including beer, wine, and distilled spirits. Once a potential problem is identified, evaluate the extent of drinking. Ask questions about how many days they drink alcohol, how many drinks they have on those days, and whether there are times when they are unable to stop drinking once they start.

Almost every state allows minors to consent to care for drugs or alcohol without parental consent. If you do not have time or do not feel comfortable treating alcohol dependence, refer them, Dr. Siqueira suggested.

“The best way to get [children] to change, rather than lecturing to them, is to present them with as many facts as you can,” Dr. Siqueira said. If a patient refuses to admit to having an issue with alcohol, ask the patient to define when it will become a problem. Some will say alcohol would be a problem if their grades dropped, for example.

“Appeal to their vanity,” Dr. Siqueira said. “Tell them drinking gives them bad breath and makes them gain weight.”

Recommended tools and resources for physicians include the CRAFFT (mnemonic) screen for alcohol use (Arch. Pediatr. Adolesc. Med. 1999;153:591-6), the National Council on Alcoholism and Drug Dependence (www.ncadd.orgwww.niaaa.nih.gov

Resources that are available for patients and parents include Alateen (www.alateen.orgwww.niaaa.nih.gov/publications/makediff.htmwww.jointogether.org

MIAMI BEACH — Demanding cosmetic dermatology patients who are never satisfied might have underlying psychiatric conditions to identify and treat, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

In addition to body dysmorphic disorder, "difficult" cosmetic patients can have narcissistic personality disorder or histrionic personality disorder, or they can be "self-destructive deniers," said Eva C. Ritvo, M.D. Also possible are mood disorders, anxiety disorders, and substance abuse issues.

Certain red flags can help identify such patients. Dermatologists should be wary of people with unrealistic expectations or a history of numerous procedures. Other warning signs include routinely complaining about previous procedures or other providers, calling or visiting an office excessively, or spending money they do not have for cosmetic enhancement.

Take a careful history, get to know the patient, and be explicit about the plan and expected results, suggested Dr. Ritvo, chief of the department of psychiatry at Mount Sinai Medical Center, Miami Beach.

Take before and after photographs, and have the patient sign a written contract, she added.

"Think like a shrink," Dr. Ritvo said. Dermatologists should be aware of their reactions and check the emotions that arise when they deal with challenging patients, Dr. Ritvo suggested.

If possible, use the "24-hour rule." If a patient calls a few days after a procedure to complain about the outcome, tell him or her to come in the next day to discuss any concerns, Dr. Ritvo said. This delay allows a physician time to approach the patient more objectively and not act on impulse.

Dr. Ritvo highlighted some common underlying psychiatric conditions in these patients:

▸ Body dysmorphic disorder. Patients with this disorder become preoccupied with an imaginary defect in their appearance or excessively concerned with a slight anomaly. The preoccupation causes significant distress or impairs functioning. The disorder usually begins during adolescence, and diagnosis often takes years. Contrary to the common perception, Dr. Ritvo said, the disorder is equally prevalent in women and men.

Do not perform inappropriate procedures in these patients, Dr. Ritvo emphasized. Instead, refer them to a mental health professional. She suggested that you say, "I would like you to see a colleague of mine before we proceed."

▸ Narcissistic personality disorder. Patients with this disorder are grandiose, seek admiration, and have fragile self-esteem. They can be preoccupied with fantasies of personal beauty, and although frequently dissatisfied, continuously return to the cosmetic dermatologist's office.

"These patients are the entitled demanders," Dr. Ritvo said. They might call and demand an immediate appointment because their botulinum toxin type A is wearing off, for example.

Do not attack them, and never disparage their feelings. Instead, acknowledge their right to good health care, and try to restore their sense of control, Dr. Ritvo suggested. Involve the person's family. Review realistic expectations, and set limits. If you refer them, make sure you document the reason carefully, she suggested.

▸ Histrionic personality disorder. Patients with histrionic personality disorder have a pervasive pattern of excessive emotionality and attention seeking. Some display inappropriate, sexually seductive behaviors. Others refer to doctors by their first names. Make the diagnosis, communicate clearly and carefully, and review expectations, Dr. Ritvo suggested. Document everything, and stay alert for shifting moods in these patients.

▸ Self-destructive deniers. These patients include smokers, drinkers, sun abusers, skin pickers, and drug seekers, Dr. Ritvo said. They are noncompliant, at a high risk for complications, and generally "out of control."

Avoid being judgmental or punitive, Dr. Ritvo suggested. Remember the disease model for addiction. Set clear, realistic goals with the patient, and do not be seduced by their stories. Do not perform unnecessary cosmetic procedures, and consider a psychiatric consultation.

MIAMI BEACH — Demanding cosmetic dermatology patients who are never satisfied might have underlying psychiatric conditions to identify and treat, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

In addition to body dysmorphic disorder, "difficult" cosmetic patients can have narcissistic personality disorder or histrionic personality disorder, or they can be "self-destructive deniers," said Eva C. Ritvo, M.D. Also possible are mood disorders, anxiety disorders, and substance abuse issues.

Certain red flags can help identify such patients. Dermatologists should be wary of people with unrealistic expectations or a history of numerous procedures. Other warning signs include routinely complaining about previous procedures or other providers, calling or visiting an office excessively, or spending money they do not have for cosmetic enhancement.

Take a careful history, get to know the patient, and be explicit about the plan and expected results, suggested Dr. Ritvo, chief of the department of psychiatry at Mount Sinai Medical Center, Miami Beach.

Take before and after photographs, and have the patient sign a written contract, she added.

"Think like a shrink," Dr. Ritvo said. Dermatologists should be aware of their reactions and check the emotions that arise when they deal with challenging patients, Dr. Ritvo suggested.

If possible, use the "24-hour rule." If a patient calls a few days after a procedure to complain about the outcome, tell him or her to come in the next day to discuss any concerns, Dr. Ritvo said. This delay allows a physician time to approach the patient more objectively and not act on impulse.

Dr. Ritvo highlighted some common underlying psychiatric conditions in these patients:

▸ Body dysmorphic disorder. Patients with this disorder become preoccupied with an imaginary defect in their appearance or excessively concerned with a slight anomaly. The preoccupation causes significant distress or impairs functioning. The disorder usually begins during adolescence, and diagnosis often takes years. Contrary to the common perception, Dr. Ritvo said, the disorder is equally prevalent in women and men.

Do not perform inappropriate procedures in these patients, Dr. Ritvo emphasized. Instead, refer them to a mental health professional. She suggested that you say, "I would like you to see a colleague of mine before we proceed."

▸ Narcissistic personality disorder. Patients with this disorder are grandiose, seek admiration, and have fragile self-esteem. They can be preoccupied with fantasies of personal beauty, and although frequently dissatisfied, continuously return to the cosmetic dermatologist's office.

"These patients are the entitled demanders," Dr. Ritvo said. They might call and demand an immediate appointment because their botulinum toxin type A is wearing off, for example.

Do not attack them, and never disparage their feelings. Instead, acknowledge their right to good health care, and try to restore their sense of control, Dr. Ritvo suggested. Involve the person's family. Review realistic expectations, and set limits. If you refer them, make sure you document the reason carefully, she suggested.

▸ Histrionic personality disorder. Patients with histrionic personality disorder have a pervasive pattern of excessive emotionality and attention seeking. Some display inappropriate, sexually seductive behaviors. Others refer to doctors by their first names. Make the diagnosis, communicate clearly and carefully, and review expectations, Dr. Ritvo suggested. Document everything, and stay alert for shifting moods in these patients.

▸ Self-destructive deniers. These patients include smokers, drinkers, sun abusers, skin pickers, and drug seekers, Dr. Ritvo said. They are noncompliant, at a high risk for complications, and generally "out of control."

Avoid being judgmental or punitive, Dr. Ritvo suggested. Remember the disease model for addiction. Set clear, realistic goals with the patient, and do not be seduced by their stories. Do not perform unnecessary cosmetic procedures, and consider a psychiatric consultation.

MIAMI BEACH — Demanding cosmetic dermatology patients who are never satisfied might have underlying psychiatric conditions to identify and treat, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

In addition to body dysmorphic disorder, "difficult" cosmetic patients can have narcissistic personality disorder or histrionic personality disorder, or they can be "self-destructive deniers," said Eva C. Ritvo, M.D. Also possible are mood disorders, anxiety disorders, and substance abuse issues.

Certain red flags can help identify such patients. Dermatologists should be wary of people with unrealistic expectations or a history of numerous procedures. Other warning signs include routinely complaining about previous procedures or other providers, calling or visiting an office excessively, or spending money they do not have for cosmetic enhancement.

Take a careful history, get to know the patient, and be explicit about the plan and expected results, suggested Dr. Ritvo, chief of the department of psychiatry at Mount Sinai Medical Center, Miami Beach.

Take before and after photographs, and have the patient sign a written contract, she added.

"Think like a shrink," Dr. Ritvo said. Dermatologists should be aware of their reactions and check the emotions that arise when they deal with challenging patients, Dr. Ritvo suggested.

If possible, use the "24-hour rule." If a patient calls a few days after a procedure to complain about the outcome, tell him or her to come in the next day to discuss any concerns, Dr. Ritvo said. This delay allows a physician time to approach the patient more objectively and not act on impulse.

Dr. Ritvo highlighted some common underlying psychiatric conditions in these patients:

▸ Body dysmorphic disorder. Patients with this disorder become preoccupied with an imaginary defect in their appearance or excessively concerned with a slight anomaly. The preoccupation causes significant distress or impairs functioning. The disorder usually begins during adolescence, and diagnosis often takes years. Contrary to the common perception, Dr. Ritvo said, the disorder is equally prevalent in women and men.

Do not perform inappropriate procedures in these patients, Dr. Ritvo emphasized. Instead, refer them to a mental health professional. She suggested that you say, "I would like you to see a colleague of mine before we proceed."

▸ Narcissistic personality disorder. Patients with this disorder are grandiose, seek admiration, and have fragile self-esteem. They can be preoccupied with fantasies of personal beauty, and although frequently dissatisfied, continuously return to the cosmetic dermatologist's office.

"These patients are the entitled demanders," Dr. Ritvo said. They might call and demand an immediate appointment because their botulinum toxin type A is wearing off, for example.

Do not attack them, and never disparage their feelings. Instead, acknowledge their right to good health care, and try to restore their sense of control, Dr. Ritvo suggested. Involve the person's family. Review realistic expectations, and set limits. If you refer them, make sure you document the reason carefully, she suggested.

▸ Histrionic personality disorder. Patients with histrionic personality disorder have a pervasive pattern of excessive emotionality and attention seeking. Some display inappropriate, sexually seductive behaviors. Others refer to doctors by their first names. Make the diagnosis, communicate clearly and carefully, and review expectations, Dr. Ritvo suggested. Document everything, and stay alert for shifting moods in these patients.

▸ Self-destructive deniers. These patients include smokers, drinkers, sun abusers, skin pickers, and drug seekers, Dr. Ritvo said. They are noncompliant, at a high risk for complications, and generally "out of control."

Avoid being judgmental or punitive, Dr. Ritvo suggested. Remember the disease model for addiction. Set clear, realistic goals with the patient, and do not be seduced by their stories. Do not perform unnecessary cosmetic procedures, and consider a psychiatric consultation.

MIAMI BEACH — Although most U.S. dermatologists have limited experience with poly-L-lactic acid, this filler can be used successfully to correct lipoatrophy, Susan H. Weinkle, M.D., said at a seminar sponsored by the Skin Disease and Education Foundation.

Proper reconstitution, technique, and patient education were among the practical tips Dr. Weinkle presented for preparation of both the product and the patient.

Poly-L-lactic acid (Sculptra, Dermik Laboratories), which is indicated for restoration and/or correction of lipoatrophy in people with human immunodeficiency virus, was fast-tracked and approved by the Food and Drug Administration in August. Some physicians have been using the filler off label to restore volume to the aging face.

"Both the HIV and aging patients develop lipodystrophy, a loss of fat and a loss of volume. Our colleagues in plastic surgery think the way to deal with this is to pull and stretch. We want to volumize and fill," said Dr. Weinkle, a dermatologist in private practice in Bradenton, Fla., who is on the advisory boards for Galderma, Procter & Gamble, and Dermik.

Poly-L-lactic acid (PLLA) is not a site-specific wrinkle filler; it's a "global volume sculptor," Dr. Weinkle said. It returns desired contours by smoothing wrinkles and folds from the inside out. The product stimulates a patient's own fibroblasts to produce collagen. "We're not just filling a wrinkle, we're revolumizing from within," she said during a live patient demonstration.

The filler material is freeze dried. Reconstitution with 5 mL sterile water or 4 mL sterile water and 1 mL lidocaine with epinephrine is recommended. Reconstitution with only 3 mL is possible, but this formulation should be reserved for experienced injectors who are treating the most severe cases, Dr. Weinkle said.

Do not shake the vial during or immediately after reconstitution. Set it aside for at least 2 hours. "I like to hydrate it the night before," she added. Shake firmly just prior to injection.

Unlike some fillers, PLLA does not require an allergic skin test, and refrigeration is not needed. But because it has only a limited shelf life once reconstituted, PLLA can be a costly option if patients cancel or miss an appointment. Some physicians are requiring patients to prepay the estimated $800-$1,000 for each vial.

"The cost across the U.S. varies a lot. If the patient does not show up, you have 72 hours to use it. If you have some left, give it to your office staff, if suitable. Your office staff is your best marketer," she said.

Prepare the area with a topical anesthetic such as Betacaine Plus. Injections should be deeper than the dermis and placed 0.5 to 1 cm apart. Inject 0.1 mL to 0.2 mL at each site. Dr. Weinkle suggested using an 18G BD Luer Lock 1-cc syringe. She injects bevel up and massages the area after every three to four injections.

It is important to undercorrect rather than overcorrect, she noted. "I usually inject a half cc on either side of the face to start and have them return in a month."

Patients must be told to expect little immediate gratification, Dr. Weinkle said. "Think of this as a staged procedure, like Mohs surgery. It typically takes three to five monthly treatment sessions to yield desired results. Uninformed patients are likely to call a few days after the initial session—once the swelling has gone down—and say, 'I paid you so much and I have nothing,'" she said.

Dr. Weinkle likes to see patients every 4 weeks, which allows adequate time to gauge the results. "Then you can fine-tune it," she said. "As a physician you need an aesthetic eye. Next time I may think I need some more volumizing in a different area to get a little more lift."

The effect lasts 18-24 months, and PLLA is not permanent. Other fillers last 4-6 months.

Unlike collagen, injection of PLLA should stop as the needle is withdrawn, before the needle tip returns to the skin's surface. "I was injected myself 5 days ago, and I have some bruising from not using enough pressure," Dr. Weinkle said.

Another caveat is to inject PLLA rapidly to avoid clogging of the needle. If a clog does occur, it is necessary to change the needle. "There is a learning curve, but this is so easy," Dr. Weinkle said.

"Some patients will experience some minor discomfort and should be forewarned," Dr. Weinkle said. Most adverse events are technique dependent, such as the bruising. Also, if PLLA is injected too superficially, nodules can result.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

PLLA for lipodystrophy volumizes and fills, thus restoring volume to the aging face.

After three sessions and half a vial of PLLA, there is significant improvement in volume and decrease in the nasolabial fold. Photos courtesy Dr. Susan H. Weinkle

MIAMI BEACH — Although most U.S. dermatologists have limited experience with poly-L-lactic acid, this filler can be used successfully to correct lipoatrophy, Susan H. Weinkle, M.D., said at a seminar sponsored by the Skin Disease and Education Foundation.

Proper reconstitution, technique, and patient education were among the practical tips Dr. Weinkle presented for preparation of both the product and the patient.

Poly-L-lactic acid (Sculptra, Dermik Laboratories), which is indicated for restoration and/or correction of lipoatrophy in people with human immunodeficiency virus, was fast-tracked and approved by the Food and Drug Administration in August. Some physicians have been using the filler off label to restore volume to the aging face.

"Both the HIV and aging patients develop lipodystrophy, a loss of fat and a loss of volume. Our colleagues in plastic surgery think the way to deal with this is to pull and stretch. We want to volumize and fill," said Dr. Weinkle, a dermatologist in private practice in Bradenton, Fla., who is on the advisory boards for Galderma, Procter & Gamble, and Dermik.

Poly-L-lactic acid (PLLA) is not a site-specific wrinkle filler; it's a "global volume sculptor," Dr. Weinkle said. It returns desired contours by smoothing wrinkles and folds from the inside out. The product stimulates a patient's own fibroblasts to produce collagen. "We're not just filling a wrinkle, we're revolumizing from within," she said during a live patient demonstration.

The filler material is freeze dried. Reconstitution with 5 mL sterile water or 4 mL sterile water and 1 mL lidocaine with epinephrine is recommended. Reconstitution with only 3 mL is possible, but this formulation should be reserved for experienced injectors who are treating the most severe cases, Dr. Weinkle said.

Do not shake the vial during or immediately after reconstitution. Set it aside for at least 2 hours. "I like to hydrate it the night before," she added. Shake firmly just prior to injection.

Unlike some fillers, PLLA does not require an allergic skin test, and refrigeration is not needed. But because it has only a limited shelf life once reconstituted, PLLA can be a costly option if patients cancel or miss an appointment. Some physicians are requiring patients to prepay the estimated $800-$1,000 for each vial.

"The cost across the U.S. varies a lot. If the patient does not show up, you have 72 hours to use it. If you have some left, give it to your office staff, if suitable. Your office staff is your best marketer," she said.

Prepare the area with a topical anesthetic such as Betacaine Plus. Injections should be deeper than the dermis and placed 0.5 to 1 cm apart. Inject 0.1 mL to 0.2 mL at each site. Dr. Weinkle suggested using an 18G BD Luer Lock 1-cc syringe. She injects bevel up and massages the area after every three to four injections.

It is important to undercorrect rather than overcorrect, she noted. "I usually inject a half cc on either side of the face to start and have them return in a month."

Patients must be told to expect little immediate gratification, Dr. Weinkle said. "Think of this as a staged procedure, like Mohs surgery. It typically takes three to five monthly treatment sessions to yield desired results. Uninformed patients are likely to call a few days after the initial session—once the swelling has gone down—and say, 'I paid you so much and I have nothing,'" she said.

Dr. Weinkle likes to see patients every 4 weeks, which allows adequate time to gauge the results. "Then you can fine-tune it," she said. "As a physician you need an aesthetic eye. Next time I may think I need some more volumizing in a different area to get a little more lift."

The effect lasts 18-24 months, and PLLA is not permanent. Other fillers last 4-6 months.

Unlike collagen, injection of PLLA should stop as the needle is withdrawn, before the needle tip returns to the skin's surface. "I was injected myself 5 days ago, and I have some bruising from not using enough pressure," Dr. Weinkle said.

Another caveat is to inject PLLA rapidly to avoid clogging of the needle. If a clog does occur, it is necessary to change the needle. "There is a learning curve, but this is so easy," Dr. Weinkle said.

"Some patients will experience some minor discomfort and should be forewarned," Dr. Weinkle said. Most adverse events are technique dependent, such as the bruising. Also, if PLLA is injected too superficially, nodules can result.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

PLLA for lipodystrophy volumizes and fills, thus restoring volume to the aging face.

After three sessions and half a vial of PLLA, there is significant improvement in volume and decrease in the nasolabial fold. Photos courtesy Dr. Susan H. Weinkle

MIAMI BEACH — Although most U.S. dermatologists have limited experience with poly-L-lactic acid, this filler can be used successfully to correct lipoatrophy, Susan H. Weinkle, M.D., said at a seminar sponsored by the Skin Disease and Education Foundation.

Proper reconstitution, technique, and patient education were among the practical tips Dr. Weinkle presented for preparation of both the product and the patient.

Poly-L-lactic acid (Sculptra, Dermik Laboratories), which is indicated for restoration and/or correction of lipoatrophy in people with human immunodeficiency virus, was fast-tracked and approved by the Food and Drug Administration in August. Some physicians have been using the filler off label to restore volume to the aging face.

"Both the HIV and aging patients develop lipodystrophy, a loss of fat and a loss of volume. Our colleagues in plastic surgery think the way to deal with this is to pull and stretch. We want to volumize and fill," said Dr. Weinkle, a dermatologist in private practice in Bradenton, Fla., who is on the advisory boards for Galderma, Procter & Gamble, and Dermik.

Poly-L-lactic acid (PLLA) is not a site-specific wrinkle filler; it's a "global volume sculptor," Dr. Weinkle said. It returns desired contours by smoothing wrinkles and folds from the inside out. The product stimulates a patient's own fibroblasts to produce collagen. "We're not just filling a wrinkle, we're revolumizing from within," she said during a live patient demonstration.

The filler material is freeze dried. Reconstitution with 5 mL sterile water or 4 mL sterile water and 1 mL lidocaine with epinephrine is recommended. Reconstitution with only 3 mL is possible, but this formulation should be reserved for experienced injectors who are treating the most severe cases, Dr. Weinkle said.

Do not shake the vial during or immediately after reconstitution. Set it aside for at least 2 hours. "I like to hydrate it the night before," she added. Shake firmly just prior to injection.

Unlike some fillers, PLLA does not require an allergic skin test, and refrigeration is not needed. But because it has only a limited shelf life once reconstituted, PLLA can be a costly option if patients cancel or miss an appointment. Some physicians are requiring patients to prepay the estimated $800-$1,000 for each vial.

"The cost across the U.S. varies a lot. If the patient does not show up, you have 72 hours to use it. If you have some left, give it to your office staff, if suitable. Your office staff is your best marketer," she said.

Prepare the area with a topical anesthetic such as Betacaine Plus. Injections should be deeper than the dermis and placed 0.5 to 1 cm apart. Inject 0.1 mL to 0.2 mL at each site. Dr. Weinkle suggested using an 18G BD Luer Lock 1-cc syringe. She injects bevel up and massages the area after every three to four injections.

It is important to undercorrect rather than overcorrect, she noted. "I usually inject a half cc on either side of the face to start and have them return in a month."

Patients must be told to expect little immediate gratification, Dr. Weinkle said. "Think of this as a staged procedure, like Mohs surgery. It typically takes three to five monthly treatment sessions to yield desired results. Uninformed patients are likely to call a few days after the initial session—once the swelling has gone down—and say, 'I paid you so much and I have nothing,'" she said.

Dr. Weinkle likes to see patients every 4 weeks, which allows adequate time to gauge the results. "Then you can fine-tune it," she said. "As a physician you need an aesthetic eye. Next time I may think I need some more volumizing in a different area to get a little more lift."

The effect lasts 18-24 months, and PLLA is not permanent. Other fillers last 4-6 months.

Unlike collagen, injection of PLLA should stop as the needle is withdrawn, before the needle tip returns to the skin's surface. "I was injected myself 5 days ago, and I have some bruising from not using enough pressure," Dr. Weinkle said.

Another caveat is to inject PLLA rapidly to avoid clogging of the needle. If a clog does occur, it is necessary to change the needle. "There is a learning curve, but this is so easy," Dr. Weinkle said.

"Some patients will experience some minor discomfort and should be forewarned," Dr. Weinkle said. Most adverse events are technique dependent, such as the bruising. Also, if PLLA is injected too superficially, nodules can result.

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PLLA for lipodystrophy volumizes and fills, thus restoring volume to the aging face.

After three sessions and half a vial of PLLA, there is significant improvement in volume and decrease in the nasolabial fold. Photos courtesy Dr. Susan H. Weinkle