Long term treatment of severe obesity: four year follow up of results of combined behavioural modification programme.

A four year programme of treatment for severe obesity combining standard techniques such as behavioural modification, exercise, nutritional advice, and, in addition, readmission of patients who relapse has been developed. One hundred and seven subjects of both sexes were treated. Thirty nine had their jaws fixed from the start. After four years 104 out of 107 subjects were traced; 33 (31%) had left the programme. The mean loss of weight in the remaining 74 subjects was 11.7 kg (range -20 to 55.5): 14 had lost more than 20 kg, 35 had lost 5-20 kg, 17 had lost 0-5 kg, and eight were above their weight before treatment. The rate of dropping out in this study was lower than that generally reported. Our data suggest that combined behavioural modification used as a programme for reducing weight may result in a substantial loss of weight for several years even for severely obese subjects.     

Four years' experience of an interim secure unit.

An interim secure unit of 14 beds (Rainford Ward) at Rainhill Hospital has been functioning for four years. During that period 78 patients were referred and 39 were admitted from various sources. Of those admitted, 40% were women, all had committed dangerous acts, and the most common diagnosis was schizophrenia. Only seven patients have stayed for one year or more, and only one seems set to stay indefinitely. Patients discharged are followed up in roughly equal numbers by their catchment area psychiatric teams and by the regional forensic psychiatric service. The number of patients in the ward has settled to about 12 for a population of one million. The unit now functions unobtrusively in a large psychiatric hospital, has a high morale, has had few recruiting problems, and has suffered extremely few disturbing incidents.     

Psychiatric morbidity in patients with alcoholic liver disease.

Seventy one patients with alcoholic liver disease and an equal number with non-alcoholic liver disease were interviewed using the schedule for affective disorders and schizophrenia. Forty seven (66%) of the group with alcoholic liver disease had or had had psychiatric illnesses compared with 23 (32%) of the control group (p less than 0.001). Affective disorder, particularly major depression, neurotic disorders, and antisocial personality, were all more common among the patients with alcoholic liver disease than the controls. No patient had schizophrenia or other forms of psychosis. Among the patients with alcoholic liver disease 11 men (24%) and 14 women (54%) had an affective or a neurotic disorder that had antedated their heavy drinking, and 30 (77%) of those who had had such a problem at any time had symptoms at the time of interview. Abstinence from alcohol is essential for patients with severe alcoholic liver disease. In view of the high prevalence of psychiatric disorders in these patients psychiatric assessment is important to increase the patients'' likelihood of complying with such advice.     

Electroconvulsive therapy for manic state with mixed and psychotic features in a teenager with bipolar disorder and comorbid episodic obsessive–compulsive disorder: a case report

Background

Comorbidity of bipolar disorder and obsessive–compulsive disorder is common in adolescence. Obsessive–compulsive disorder symptoms may be episodic and secondary to alterations in mood, and display specific features. Management of pediatric bipolar disorder-obsessive–compulsive disorder is challenging, as pharmacotherapy of obsessive–compulsive disorder may induce or exacerbate manic episodes and there is limited evidence of treatment efficacy. Electroconvulsive therapy is sparsely used in children and adolescents, but is documented to be a safe and efficacious intervention in adults with bipolar disorder. In view of the severity of symptoms in juvenile mania, studies on treatment strategies are warranted. We report a case of an adolescent with bipolar disorder-obsessive–compulsive disorder who was successfully treated with electroconvulsive therapy during an episode of severe mania.

Case presentation

A 16-year-old girl of Middle East origin first presented to us with depressed mood, irritability, and increased obsessive–compulsive disorder symptoms, which were initially interpreted in the context of acute stress secondary to migration. She had been diagnosed with bipolar disorder and obsessive–compulsive disorder in her previous home country, but had difficulties in accounting for earlier psychiatric history. During hospitalization her mood switched to a manic state with mixed and psychotic features, at times showing aggression toward others. Interruption in her lithium treatment for a short period and possibly the introduction of an atypical antipsychotic could in part have been triggering factors. After 8 weeks of in-patient care and psychotropic drug trials, electroconvulsive therapy was initiated and administered every second or third day for 4 weeks, with marked positive response. No apparent side effects were reported.

Conclusions

This case demonstrates the need for a detailed medical history, taking special note of periodicity and character of obsessive–compulsive disorder symptoms, in adolescents with mood disorders. When treating culturally diverse patients, extra consideration should be taken. Special concerns in the pharmacological treatment to avoid the patient’s condition from worsening must be addressed, including giving priority to mood stabilization before obsessive–compulsive disorder symptoms. There are potential benefits in considering electroconvulsive therapy in young patients with severe mania where first-line treatment options have failed.

     

A Randomized Trial of Lifestyle Modification and Taranabant for Maintaining Weight Loss Achieved With a Low‐Calorie Diet

Improving the maintenance of weight loss remains a critical challenge for obesity researchers. The present 1‐year, randomized, placebo‐controlled trial evaluated the safety and efficacy of weight maintenance counseling combined with either placebo or the cannabinoid‐1 receptor inverse agonist, taranabant, for sustaining prior weight loss achieved on a low‐calorie diet (LCD). Seven hundred eighty‐four individuals who had lost ≥6% of body weight during six initial weeks of treatment with an 800 kcal/day liquid LCD were randomly assigned to placebo or once‐daily taranabant in doses of 0.5, 1, or 2 mg. All participants were provided monthly, on‐site behavioral weight maintenance counseling, as well as monthly phone calls. The primary end point was change in body weight from randomization to week 52. The randomized participants lost an average of 9.6 kg (9.5% of initial weight) during the 6‐week LCD. The model‐adjusted mean change in body weight during the subsequent 1 year was +1.7 kg for placebo, compared with ?0.1, ?0.6, and ?1.2 kg for the taranabant 0.5, 1, and 2 mg doses, respectively (all P values ≤0.007 vs. placebo). The incidences of psychiatric‐related adverse events, including irritability, were higher for taranabant 1 and 2 mg vs. placebo (P ≤ 0.038). In addition to reporting data on the safety and efficacy of taranabant, this study provides a method for studying the combination of lifestyle modification and pharmacotherapy for weight maintenance after diet‐induced weight loss.     

Neuroimaging of psychiatric and pedopsychiatric disorders

Over the last two decades, imaging techniques have allowed to establish the cerebral neurophysiologic correlates of psychiatric disorders and have highlighted the impact of psychopathologic events, therapeutic drugs, addictions, on the growth and plasticity of brain. In this review, we intend to illustrate how neuroimaging has improved our knowledge of such alterations in brain maturation (schizophrenia, autistic disorders), fronto-limbic (depressive syndromes) or fronto-striatal (compulsive disorders) regions in psychiatric illnesses, but also in psychopharmacology, or pedopsychiatry. Statistically significant alterations in the structure and/or function of brain are detected in all psychiatric disorders and these are often detectable already during childhood or teenage. Furthermore, neuroimaging has allowed to underline the importance of cerebral networks specific to each disorder, but also to uncover those which are common to different diseases provided that they share common clinical or cognitive features. Besides their value in basic research, neuroimaging findings have been key in changing the perception that society has of these diseases which contributed to their therapeutic approach.     

Treatment of Hypothalamic Obesity with Caffeine and Ephedrine

ObjectiveTo investigate the hypothesis that the peripheral actions of caffeine and ephedrine to increase sympathetic tone and metabolic rate and to preserve lean tissue will cause weight loss in patients with hypothalamic obesity.MethodsWe present 3 case studies of consecutive patients who presented with hypothalamic obesity and were treated with caffeine (200 mg) and ephedrine hydrochloride (25 mg) 3 times a day.ResultsAll patients were gaining weight at the time of initial assessment. The first patient lost 8% to 9% of her body weight and maintained that loss for the subsequent 2 years. The second patient lost 18.8% of her body weight and was maintaining a 9.5% weight loss after 6 years. The third patient lost 14% of her body weight during a 6- month period and gradually returned to her baseline weight during a period of 5 years, after which she was referred for bariatric surgical treatment.ConclusionThese 3 patients with hypothalamic obesity, who had been steadily gaining weight, lost a mean of 13.9% of their body weight, and 2 of them maintained weight loss for a period of years. Thus, caffeine and ephedrine appeared to halt weight gain and maintain a clinically significant weight loss in 2 of our 3 patients. A randomized clinical trial to confirm these findings would be appropriate but difficult because of the rarity of this disorder. (Endocr Pract. 2008;14:697-703)     

Indomethacin increases plasma lithium.

The effects of indomethacin on plasma lithium concentrations and renal lithium clearance were investigated in three psychiatric patients and four normal volunteers. After steady-state plasma lithium concentrations had been reached, the subjects received indomethacin placebo for three to seven days, indomethacin (50 mg thrice daily) for seven days, and placebo again for three to seven days. Indomethacin increased plasma lithium concentrations by 59% in the psychiatric patients and 30% in the volunteers. Renal lithium clearance was reduced by indomethacin by 31% in the group as a whole, and prostaglandin synthesis, determined by measuring the major metabolite of PGE2 with mass spectrometry, was reduced by 55%. These results show that indomethacin reduces renal lithium clearance to an extent which may be clinically important. They also suggest that the renal clearance may be affected by a prostaglandin-dependent mechanism, possibly located in the distal tubule.     

A New Look at Bimedial Prefrontal Leukotomy

Forty-four selected patients with “hard core” functional psychiatric illness were treated by bimedial prefrontal leukotomy, in which only the medial half of the prefrontal white matter of both frontal lobes was divided. This operation differs from the conventional or “standard” leukotomy which divides the entire prefrontal white matter. There were six patients with personality disorders, 25 psychoneurotics, 12 schizophrenics, and one with involutional melancholia. Forty-two of the 44 patients had thorough psychiatric follow-up, ranging from one to seven years postoperatively. They were assessed clinically and also on a point-rating scale of assessment.Seventy-six per cent of these patients had excellent or satisfactory outcomes. The most striking benefit was decrease in anxiety and tension.Modified leukotomy is a safe and effective method of reducing the symptoms of excessive tension, anxiety, fear or depression in patients with a variety of illnesses, including anxiety neurosis, phobic psychoneurosis, obsessional neurosis, neurotic or psychotic depressive reactions and schizophrenia. The operation should be considered in such neurotic, personality and psychotic illnesses when medical treatment has failed.     

Detection of an unbalanced translocation (4;14) in a mildly retarded father and son by flow cytometry

Summary A child with impaired intelligence, minor dysmorphisms, obesity and genital hypoplasia was found to have an apparently balanced translocation, 46,XY,t(4;14)(q12;q13), following cytogenetic analysis. The same rearrangement was also detected in the child's father, who had similar phenotypic abnormalities to his son. Detailed study of flow karyotypes produced from lymphoblastoid cell lines established that in both patients the translocation was in fact unbalanced with approximately 11 million base pairs of DNA (corresponding to about 6.0% of chromosome 4 or 11.0% of chromosome 14) being lost.     

The Effect of Obesity and Cardiometabolic Risk Factors on Expenditures and Productivity in the United States

Objective: To examine the effect of obesity and cardiometabolic risk factors on medical expenditures and missed work days. Methods and Procedures: The 2000 and 2002 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the US population, was used to estimate the marginal effect of obesity (BMI ≥ 30) on annual per‐person medical expenditures and missed work days for patients with diabetes, dyslipidemia, or hypertension using multivariate regression methods controlling for age, sex, race, ethnicity, education, income, insurance, and smoking status. Maximum Likelihood Heckman Selection with Smearing retransformation was used to assess medical expenditures, and Negative Binomial regression was used for missed work days. Results: Normal weight individuals with diabetes, dyslipidemia, or hypertension had significantly greater medical expenditures than those without the respective condition ($6,006 (5,124–6,887), $4,760 (4,102–5,417), $3,911 (3,345–4,476)) and obesity significantly exacerbated this effect ($7,986 (7,397–8,574), $7,636 (7,072–8,200), $6,197 (5,745–6,649); $2007; all P < 0.05). In addition, diabetes, dyslipidemia, and hypertension resulted in greater missed work days (3.1 (0.94–6.21), 3.2 (0.42–7.91), 1.4 (0.0–3.52)) (all P < 0.05 except hypertension), which resulted in greater lost productivity ($433, $451, $199) and obesity significantly exacerbated the deleterious effect on work days (8.7 (4.44–15.2), 5.5 (2.18–10.5), 4.5 (2.92–6.34)) and lost productivity ($1,217, $763, $622) (all P < 0.05). In addition, medical expenditures increased for increasing weight category and increasing number of risk factors. Discussion: Obesity significantly exacerbates the deleterious effect of diabetes, dyslipidemia, and hypertension on medical expenditures and productivity loss in the United States. Obesity is preventable and public health efforts need to be undertaken to prevent its alarming increase in order to reduce the incidence and effect of cardiometabolic risk factors.     

DYNAMICS AND MANAGEMENT OF SELF-INDUCED ERUPTIONS

Self-induced eruptions are always expressions of an emotionally disturbed person. They cover a wide variety of injuries and include aggravation of preexisting dermatoses, neurotic excoriations, mucocutaneous changes from compulsive movements, factitial dermatitis and trichotillomania. The emotional disturbances in such patients range from mild psychoneuroses to severe psychoses. Attention should be focused primarily on the emotional disturbance. The management of psychotic patients is the domain of the psychiatrist. But those unsuitable for psychiatric care and persons with mild psychoneuroses—who fortunately constitute the majority among patients with self-inflicted eruptions—should remain with their dermatologist or general physician and get from him effective supportive psychotherapy in addition to such treatment for the self-induced damage to the skin as may be indicated.     

How Physician Obesity Specialists Use Drugs to Treat Obesity

Specialist physicians may have prescribing habits that are different from nonspecialist physicians. Little is known about the prescribing habits of physicians specializing in the treatment of obesity. An anonymous survey was given to the physician members of the American Society of Bariatric Physicians (ASBP). There was a 35% response rate (266 physicians) to the questionnaire that was represented nationally. Almost all prescribed medications and all of them recommended phentermine. The average maximal dose of phentermine was above that approved in the package insert, and these physicians disagreed with the National Institutes of Health (NIH) Obesity Treatment Guidelines. Phendimetrazine, metformin, and phentermine plus l ‐5‐hydroxytryptophan (5‐HTP) with carbidopa were all used more frequently than either orlistat or sibutramine. The combination of sibutramine and orlistat as well as 5‐HTP/carbidopa were prescribed by 14 and 20%, respectively. As 5‐HTP‐carbidopa was a combination not previously reported for the treatment of obesity, a retrospective chart review was performed in a single obesity practice, which may not be representative. Twenty‐two subjects had a 16% weight loss with phentermine over 6 months and an additional 1% weight loss with the addition of 5‐HTP/carbidopa for an additional 6 months. One subject who started on 5‐HTP/carbidopa alone lost 24.4% of initial body weight over 6 months. This questionnaire revealed that 20% of the obesity specialists responding to the survey used phentermine plus of 5‐HTP/carbidopa, an unreported combination. A controlled, randomized, clinical trial to evaluate the safety and efficacy of this combination in treating obesity should be considered.     

UNDERGRADUATE PSYCHIATRIC EDUCATION—Senior Medical Students Study Patients with the Clinical Team

A course in psychiatry for senior medical students, designed to give all members of the class some direct experience, particularly in therapeutic interviewing as well as in total psychiatric study of patients by the clinically integrated work of medical specialists, psychiatric social workers, and clinical psychologists in collaboration with psychotherapeutically trained and experienced psychiatrists is conducted in the following manner: A third of the class, about 25 students, is divided into four sections of six or seven members, and each section attends five hours one forenoon a week for approximately three months. Each student, after an initial demonstration interview by the instructor, sees weekly the same two clinic patients alone, for 45-minute individual interviews, followed by a one and a half hour supervisory session. After this a 50-minute seminar or treatment review conference is followed by a similar period for writing records of interviews and summaries of the therapeutic work. Of four seminars, two are conducted by the psychiatric faculty, and one each by the social worker and the psychologist. Each student reads a written summary of all his interviews with one patient for discussion by his colleagues in the section and by the faculty from all three disciplines.     

Insulin Secretion in Hypothalamic Obesity: Diurnal Variation and the Effect of Naloxone

This paper has tested the hypothesis that patients with hypothalamic obesity have altered mechanisms controlling insulin secretion when compared to obese patients without hypothalamic injury. Fasting glucose and insulin values were significantly higher in the morning than in the afternoon in the six control obese patients, but there was no diurnal difference in the six patients with hypothalamic obesity (n=6). The control obese subjects showed a diurnal variation in glucose-stimulated insulin secretion, whereas the patients with hypothalamic obesity did not, suggesting that hypothalamic injury had destroyed diurnal rhythms. Naloxone, an opioid antagonist, acutely suppressed fasting insulin in the six patients with essential obesity but had little effect on fasting insulin in the three patients with hypothalamic obesity or in five normal-weight controls. Naloxone increased insulin sensitivity in the obese control patients, but did not affect either insulin secretion or insulin sensitivity in patients with hypothalamic obesity or in normal weight subjects. Our results support the conclusion that hypothalamic obesity disrupts diurnal rhythms, with the suggestion that opioid peptides affect insulin secretion differently in patients with essential obesity as compared to normal weight subjects or those with hypothalamic obesity.     

Which neuroses need specialist care?

In order to differentiate the neurotic patient who both needs and responds to psychiatric care from the majority of neurotic patients, who do not need this, carefully matched pairs of neurotic patients being treated at psychiatric and nonpsychiatric clinics in Montreal were followed up for 1 year. Improvement was substantial regardless of treatment, and the psychiatrically treated, on the whole, improved only slightly more than the others. However, one type of patient improved greatly under psychiatric care while improving almost not at all without it--introverts who considered themselves unhealthy but found life manageable, had avoided taking time off work or using anxiolytic drugs and appeared to handle their frustrations without repressing their irritation or losing self-control. It is suggested that it is mainly this type of neurotic that should receive specialist referral.     

Gastric Bypass in a Low‐Income,Inner‐City Population: Eating Disturbances and Weight Loss

Objective: To examine the prevalence of eating disturbances and psychiatric disorders among extremely obese patients before and after gastric bypass surgery and to examine the relationship between these disturbances and weight outcomes. Research Methods and Procedures: Sixty‐five women patients (ages 19 to 67) with a mean BMI of 54.1 were assessed by semistructured psychiatric interview before surgery and by telephone interview after surgery (mean follow‐up: 16.4 months) to determine psychiatric status, eating disturbances, and weight and health‐related variables. Results: Patients lost a mean of 71% of their excess BMI, with significantly poorer weight loss outcomes among African Americans. Psychiatric disorders remained prevalent before (37%) and after (41%) surgery. In contrast, binge eating disorder dropped from 48% to 0%. Psychiatric diagnosis did not affect weight outcomes. Instead, more frequent preoperative binge eating, along with greater initial BMI, follow‐up length, and postoperative exercise, predicted greater BMI loss. Postsurgical health behaviors (exercise and smoking) and nocturnal eating episodes were also linked to weight loss. Exercise frequency increased and smoking frequency tended to decrease after surgery. Discussion: These findings indicated that eating and psychiatric disturbances did not inhibit weight loss after gastric bypass and should not contraindicate surgery. Prior binge eating, eliminated after surgery, predicted BMI loss and, thus, may have previously been a maintaining factor in the obesity of these patients. The association between health behaviors and outcome suggests possible targets for intervention to improve surgical results. Poorer outcomes among African Americans indicate that these patients should be closely monitored and supported after surgery.     

Treatment in England of Canadian Patients Addicted to Narcotic Drugs

The method of treatment and the results obtained from the treatment of 50 Canadian patients addicted to narcotic drugs who went to England are recorded. These patients were first stabilized on the minimal dose of narcotic drug which permitted them to work, and to acquire security and self-respect. Then, after psychiatric treatment dealing with the basic problem of their personality disorder, complete withdrawal treatment of the narcotic drug was undertaken.Nine of 10 patients aged between 20 and 30, of good social and cultural background, have been relieved of dependence on drugs for over two years.The other 40 patients came from a different background. Nearly all had been imprisoned for drug offences and they had come to England to obtain treatment and to avoid further prison sentences in Canada.The 31 patients whose prison sentences had been directly connected with drug offences are working steadily and leading an apparently normal life.The remaining nine patients had been convicted of criminal acts before becoming addicted to narcotic drugs and, with two exceptions, the results of their treatment compare unfavourably with the other patients, seven having been convicted and imprisoned in London.     

Rapid Estimation of Thyroid Function by Photomotography

The usefulness of photomotographic determination of the duration of the ankle reflex in the diagnosis of thyroid dysfunction was studied. Diagnoses by photomotography and I¹³¹ uptake were in accord in 28 normals (260-380 milliseconds), 14 hypothyroid (390-600) and 21 hyperthyroid patients (160-250). Euthyroid reflex duration did not vary in 141 healthy persons when considered in terms of race, sex, age and pregnancy. In 172 patients, psychiatric or neuromuscular illness, heart failure, fever or several drugs had no effect. Hyperthyroidism was erroneously diagnosed in seven euthyroid subjects; there were no false hypothyroid values. Photomotography is helpful in the diagnosis of thyroid dysfunction, especially hypothyroidism.