Professional Documents
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Psychiatry
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CATEGORY 1
CME
3 4
I N
T H I S
2 0 1 4
N U M B E R
I S S U E
An Update on New Medications for the Treatment of Major Depressive Disorder . . . . . . .159
ASIM A. SHAH, MD; AND SANJAY J. MATHEW, MD
According to the World Health Organization, unipolar depression was the third most important cause of disease worldwide in 2004. The faculty of this lesson review available treatment options, describe unmet needs,
recommend augmentation strategies, and discuss some of the newer treatment options.
Untreated postpartum depression (PPD) poses a threat to the maternal-child bond and the well-being of the
entire family. Examine specific cultural factors and mental health help-seeking behaviors among these culturally diverse populations in an effort to improve PPD identification and treatment.
Sexual addiction, which is also known as hypersexual disorder, is associated with severe psychosocial problems and risk-taking behaviors. Although sexual addiction is not included in the Diagnostic and Statistical
Manual of Mental Disorders, several screening questionnaires have been developed for the diagnosis of sexual addiction or hypersexual disorder.
The addition of electronic health records provides opportunity for more rapid and comprehensive communication between patients primary and SUD care providers while promoting a collaborative care environment. Consider how to protect your patients information in this era of collaborative care while maintaining
rapid communication among healthcare providers.
This lesson provides readers with the clinical progression of the Ebola Virus Disease (EVD) as well as guidelines for management in the hospital setting. Readers will review the symptoms that present in the early, late,
and recovery phases of the disease as well as symptom management, and guidelines for protection of
healthcare providers and others who come into contact with individuals who have acquired the virus.
A HATHERLEIGH
CME JOURNAL
w w w . D i r e c t i o n s I n P s y c h i a t r y . c o m
Directions in Psychiatry
Senior Content Advisor
Leah J. Dickstein, MD, MS
Professor Emerita,
University of Louisville, Psychiatriy & Behavioral Sciences,
Louisville, KY; and Lecturer, Tufts University,
Medical Center, Psychiatry Dept., Boston, MA
Wendy Packman, JD
Pacific Graduate School of Psychology,
San Francisco, CA
Mark S. Gold, MD
University of Florida, Gainesville, FL
Alison Heru, MD
University of Colorado, Denver, CO
George Papakostas, MD
Massachusetts General Hospital, Boston, MA
Jimmie C. Holland, MD
Memorial Sloan-Kettering, Cancer Center,
NY, NY
Michael A. Schwartz, MD
University Hospitals of Cleveland,
Cleveland, OH
Hideo Hosaki, MD
Keio University, School of Medicine,
Tokyo, Japan
Peter C. Whybrow, MD
UCLA Department of Psychiatry and
Behavioral, Sciences, Los Angeles, CA
Philip Janicak, MD
Rush University, Chicago, IL.
Robert L. Williams, MD
Baylor College of Medicine, Houston, TX
Carl P. Malmquist, MD
University of Minnesota, Minneapolis, MN
Malkah T. Notman, MD,
The Cambridge Hospital, Cambridge, MA
Managing Editor
Stacy M. Powell, MS
Founding Editor
Frederic Flach, MD, KCHS, DFLAPA
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Directions in Psychiatry
Volume 34 Lessons 1115
CME Lesson 11
159
CME Lesson 12
Page
171
Page
185
Page
201
Page
215
CME Lesson 13
CME Lesson 14
CME Lesson 15
Faculty Disclosures:
Medication usage mentioned in the lessons for indications that are not approved by the FDA are listed on the title page of each
lesson if they exist.
Bindu Garapaty, PsyD:
Deepika Goyal, PhD, FNP:
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Howard Newville, PhD:
Asim A. Shah, MD:
James L. Sorenson, PhD:
Aviv Weinstein, PhD:
ACGME Competencies:
Patient Care that is compassionate, appropriate, and effective for the treatment of health problems
and the promotion of health.
Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g.
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best evidence or consensus recommendations to improve that care using follow-up assessments.
Lesson 11
Lesson 12
Lesson 13
Lesson 14
Lesson 15
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Utilize informatics
ACGME Competencies
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Medical knowledge
Practice-based learning and improvement
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Professionalism
System-based practice
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Professional standing
Commitment to lifelong learning
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Cognitive expertise
Performance in practice
Target Audience: The primary target audience for this program includes, but is not limited to: psychiatrists, primary care physicians, psychiatric nurses,
pharmacists, clinical psychologists, and social workers. Clinicians who have caseloads composed significantly of individuals with psychiatric disorders, and
comorbid medical illnesses will find this course particularly useful.
Duration of CME Status: Directions in Psychiatry begins May 1, 2014, and the preliminary expiration date is December 31, 2017. At that point, the
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Copyright 2014, THE HATHERLEIGH COMPANY, LTD. All rights reserved. No part of this publication may be reproduced in any form or by any means, except as
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and/or treatment mentioned herein. The names of medications are typically followed by TM or symbols, but these symbols are not stated in this publication.
Self-assessment Pre-test
Quetiapine
Aripiprazole
Risperidone
Both A & B
SelfAssessmentAnswerKey
13.D,14.B,15.C,16.B,17.D,18.D,19.B
17. If a clinician approaches an ethically uncomfortable and challenging situation, it is best to seek guidance from:
A. peers.
B. counselors.
C. professional associations.
D. All of the above
L003333
LESSON ABSTRACT: According to the World Health Organization, unipolar depression was the third most important
cause of disease worldwide in 2004. Unipolar depression was in eighth place in low-income countries, but at first place in
middle- and high-income countries.1 Despite it being such a common disorder, treatment options are not able to cure the
disease completely, and there are numerous unmet needs in the treatment of depression. In this continuing medical education
lesson, we will review the treatment options available to treat depression, describe unmet needs, recommend augmentation
strategies, and discuss new treatment options.
COMPETENCY AREAS: This lesson addresses the gap in knowledge of evidence-based practices for the treatment of
depression, including imminent and expert-based treatment options.
159
L003333 : An Update on New Medications for the Treatment of Major Depressive Disorder
Depression
According to the World Health Organization (WHO),
major depressive disorder (MDD) was the third most
important cause of disease burden worldwide in 2004.
Unipolar depression was in eighth place in low-income
countries, but at first place in middle- and high-income
countries.1 In a nationally representative face-to-face
household survey, 6.7% of adults in the United States
(US) experienced a major depressive episode in the
past 12 months.2 Significantly greater percentages of
lifetime major depression have been reported among
women (11.7%) than men (5.6%).3 Examining ethnic
differences reveals lifetime percentages of MDD of 6.5%
among Caucasians, 4.6% among African Americans, and
5.2% among Hispanics.4 According to the WHO, more
than 350 million people of all ages suffer from MDD
globally, and about 20 million of those live in the US.
Despite its prevalence and disease burden, treatment
options are not curative, and there remain numerous
unmet needs with respect to therapies, despite an abundance of antidepressant drug classes with varied receptor
profiles. While its use has diminished in recent years in
the US5 electroconvulsive therapy (ECT) is still considered
a more potent and rapid option for treating acute depressive episodes in medication-refractory patients.
The word placebo is derived from the Latin word
placere, which literally means to please.6,7 As MDD is
characterized by fluctuations in its course, spontaneous
improvements, and features distress as a key symptom,
it is not surprising that it is also a placebo-responsive
condition.8 The mean response rates for placebo in
antidepressant clinical trials ranges between 30% and
40%, 9,10 with a notable upward trend in placebo response
over the past several decades. Accordingly, across Phase
III registration trials performed for FDA approval, the
overall effect size for the acute efficacy of antidepressant
medications compared to placebo is relatively modest.6,10
While few would argue that antidepressants are beneficial in treating moderate to severe depression, arguments
have been made for treating mild depression with antidepressants.11 In an article published in the Journal of the
American Medical Association (JAMA)12 by Fournier et
al., the magnitude of benefit of antidepressant medication compared with placebo increases with the severity
of depression symptoms and may be minimal or nonexistent in patients with mild or moderate symptoms.
160
L003333 : An Update on New Medications for the Treatment of Major Depressive Disorder
L003333 : An Update on New Medications for the Treatment of Major Depressive Disorder
Trade Name
Alprazolam
Niravam, Xanax
Aripiprazole
Abilify
Bupropion
Citalopram
Celexa
Desvenlafaxine
Pristiq
Duloxetine
Cymbalta
Escitalopram
Lexapro
Fluoxetine
Prozac
Ketamine
Levomilnacipran
Fetzima
L-methylfolate
Deplin
Lurasidone
Latuda
Milnacipran
Savella
Mirtazapine
Olanzapine
Zyprexa
Paroxetine
Paxil
S-adenosyl-methionine
SAMe
Sertraline
Zoloft
Trazodone
Oleptro
Venlafaxine
Effexor
Vilazodone
Viibryd
Vortioxetine
Brintellix
162
L003333 : An Update on New Medications for the Treatment of Major Depressive Disorder
Depression can be a very devastating and crippling disease, and in most cases complete remission is not possible. While numerous medicinal options are available,
monotherapy may not always be sufficient, and combinations are used in these cases. In the last decade, no new
breakthrough treatments have made it to the market, and
the bulk of the treatment options depend on SSRI and
SNRI-related drugs. Further research is needed on drugs
that target glutamate, especially ketamine.
Conclusion
163
L003333 : An Update on New Medications for the Treatment of Major Depressive Disorder
References
1.
World Health Organization. The Global Burden of Disease: 2004 Update. Geneva, Switzerland: WHO Press, 2008.
2. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey
Replication. Arch Gen Psychiatry. 2005;62:617627.
3. Ford DE, Erlinger TP. Depression and C-reactive protein in US adults: Data from the third National Health and Nutrition Survey. Arch Intern Med. 2004;164:10101014.
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Oquendo MA, Lizardi D, Greenwald S, Weissman MM, Mann JJ. Rates of lifetime suicide attempt and rates of lifetime major depression in different ethnic groups in the
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12. Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, Fawcett J. Antidepressant Drug Effects and Depression Severity: A Patient-Level
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17. Keller MB. Remission versus response: the new gold standard of antidepressant care. J Clin Psychiatry. 2004;65(Suppl. 4):5359.
18. Thase ME. Evaluating antidepressant therapies: remission as the optimal outcome. J Clin Psychiatry. 2003;64(Suppl. 13): 1825.
19. Fava M. Diagnosis and definition of treatment-resistant depression. Biological Psychiatry. 2003;53:649659.
20. Thase ME, Greenhouse JB, Frank E et al. Treatment of major depression with psychotherapy or psychotherapypharmacotherapy combinations. Arch Gen Psychiatry.
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21. Elhwuegi AS. Central monoamines and their role in major depression. Progress in Neuropsychopharmacology and Biological Psychiatry. 2004;28:435451
22. Hansen RA, Gartlehner G, Lohr KN, Gaynes BN, Carey TS. Efficacy and safety of second-generation antidepressants in the treatment of major depressive disorder. Annals
of Internal Medicine. 2005;143:415426.
23. Bauer M, Whybrow PC, Angst J, Versiani M, Moller HJ. World federation of societies of biological psychiatry (WFSBP) guidelines for biological treatment of unipolar
depressive disorders, Part 1: acute and continuation treatment of major depressive disorder. World Journal of Biological Psychiatry. 2002;3:543.
24. Mischoulon D, Nierenberg AA, Kizilbash L, Rosenbaum JF, Fava M. Strategies for managing depression refractory to selective serotonin reuptake inhibitor treatment: a
survey of clinicians. Canadian Journal of Psychiatry. 2000;45:476481.
25. Fredman SJ, Fava M, Kienke AS, White CN, Nierenberg AA, Rosenbaum JF. Partial response, nonresponse, and relapse with selective serotonin reuptake inhibitors in major
depression: a survey of current next-step practices. J Clin Psychiatry. 2000;61:403408.
26. Nelson JC. Treatment of antidepressant nonresponders: augmentation or switch? J Clin Psychiatry. 1998;59(Suppl. 15):3541.
27. Ros S, Agera L, De La Gndara J, Rojo JE, De Pedro JM. Potentiation strategies for treatment-resistant depression. Acta Psychiatrica Scandinavica. 2005;112(Suppl.
428):1424.
28. Fava M, Rush AJ. Current status of augmentation and combination treatments for major depressive disorder: a literature review and a proposal for a novel approach to
improve practice. Psychotherapy and Psychosomatics. 2006;75:139153.
29. Heninger GR, Charney DS, Sternberg DE. Lithium carbonate augmentation of antidepressant treatment. An effective prescription for treatment-refractory depression. Arch
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30. Kantor D, McNevin S, Leichner P, Harper D, Krenn M. The benefit of lithium carbonate adjunct in refractory depression fact or fiction? Canadian Journal of Psychiatry.
1986;31:416418.
31. Zusky PM, Biederman J, Rosenbaum JF, Manschreck TC, Gross CC, Weilberg JB, Gastfriend DR. Adjunct low dose lithium carbonate in treatment-resistant depression:
a placebo-controlled study. Journal of Clinical Psychopharmacology. 1988;8:120124.
32. Schopf J, Baumann P, Lemarchand T, Rey M. Treatment of endogenous depressions resistant to tricyclic antidepressants or related drugs by lithium addition. Results of a
placebo-controlled double-blind study. Pharmacopsychiatry. 1989;22;183187.
33. Browne M, Lapierre YD, Hrdina PD, Horn E. Lithium as an adjunct in the treatment of major depression. International Clinical Psychopharmacology. 1990;5:103110.
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34. Joffe RT, Singer W, Levitt AJ, MacDonald C. A placebo-controlled comparison of lithium and triiodothyronine augmentation of tricyclic antidepressants in unipolar
refractory depression. Archives of General Psychiatry. 1993;50:387393
35. Stein G, Bernadt M. Lithium augmentation therapy in tricyclic-resistant depression. A controlled trial using lithium in low and normal doses. British Journal of Psychiatry.
1993;162;634640.
36. Katona CL, Bou-Saleh MT, Harrison DA et al. Placebo-controlled trial of lithium augmentation of fluoxetine and lofepramine. British Journal of Psychiatry. 1995;166:8086.
37. Baumann P, Nil R, Souche A et al. A double-blind, placebo-controlled study of citalopram with and without lithium in the treatment of therapy-resistant depressive patients:
a clinical, pharmacokinetic, and pharmacogenetic investigation. J Clin Psychopharmacol. 1996;16:307314.
38. Januel D, Poirier MF, Dalche-Biree F, Dib M, Olie JP. Multicenter double-blind randomized parallel-group clinical trial of efficacy of the combination clomipramine
(150 mg/day) plus lithium carbonate (750 mg/day) versus clomipramine (150 mg/day) plus placebo in the treatment of unipolar major depression. Journal of Affective
Disorders. 2003;76:191200.
39. Bauer M, Bschor T, Kunz D, Berghofer A, Strohle A, Muller-Oerlinghausen B. Double-blind, placebo-controlled trial of the use of lithium to augment antidepressant
medication in continuation treatment of unipolar major depression. American Journal of Psychiatry. 2000;157:14291435.
40. Bauer M, Dopfmer S. Lithium augmentation in treatment-resistant depression: meta-analysis of placebo-controlled studies. J Clin Psychopharmacol. 1999;19:427434.
41. Fava M, Rosenbaum JF, McGrath PJ, Stewart JW, Amsterdam JD, Quitkin FM. Lithium and tricyclic augmentation of fluoxetine treatment for resistant major depression:
a double-blind, controlled study. American Journal of Psychiatry. 1994;151:13721374.
42. Fava M, Alpert J, Nierenberg A et al. Double-blind study of high-dose fluoxetine versus lithium or desipramine augmentation of fluoxetine in partial responders and
nonresponders to fluoxetine. J Clin Psychopharmacol. 2002;22:379387.
43. Aronson R, Offman HJ, Joffe RT, Naylor CD. Triiodothyronine augmentation in the treatment of refractory depression. A meta-analysis. Arch Gen Psychiatry.
1996;53:842848.
44. Blier P, Ward NM. Is there a role for 5-HT1A agonists in the treatment of depression? Biological Psychiatry. 2003;53:193203.
45. Ballesteros J, Callado LF. Effectiveness of pindolol plus serotonin uptake inhibitors in depression: a meta-analysis of early and late outcomes from randomised controlled
trials. J Affect Disord. 2004;79:137147.
46. Fawcett J, Kravitz HM, Zajecka JM, Schaff MR. CNS stimulant potentiation of monoamine oxidase inhibitors in treatment-refractory depression. J Clin Psychopharmacol.
1991;11:127132.
47. Feighner JP, Herbstein J, Damlouji N. Combined MAOI, TCA, and direct stimulant therapy of treatment-resistant depression. Journal of Clinical Psychiatry.
1985;46:206209.
48. Linet LS. Treatment of a refractory depression with a combination of fluoxetine and d-amphetamine. Am J Psychiatry. 1989;146:803804.
49. Masand PS, Anand VS, Tanquary JF. Psychostimulant augmentation of second generation antidepressants: a case series. Depress Anxiety. 1998;7:8991.
50. Metz A, Shader RI. Combination of fluoxetine with pemoline in the treatment of major depressive disorder. Int Clin Psychopharmacol. 1991;6:9396.
51. Stoll AL, Pillay SS, Diamond L, Workum SB, Cole JO. Methylphenidate augmentation of serotonin selective reuptake inhibitors: a case series. Journal of Clinical Psychiatry.
1996;57:7276.
52. Wharton RN, Perel JM, Dayton PG, Malitz S. A potential clinical use for methylphenidate with tricyclic antidepressants. Am J Psychiatry. 1971;127:16191625.
53. Menza MA, Kaufman KR, Castellanos A. Modafinil augmentation of antidepressant treatment in depression. Journal of Clinical Psychiatry. 2000;61:378381.
54. Abalan F. Primer in folic acid: folates and neuropsychiatry. Nutrition. 1999;15:595598.
55. Alpert JE, Mischoulon D, Nierenberg AA, Fava M. Nutrition and depression: focus on folate. Nutrition. 2000;16:544546.
56. Alpert JE, Mischoulon D, Rubenstein GE, Bottonari K, Nierenberg AA, Fava M. Folinic acid (Leucovorin) as an adjunctive treatment for SSRI-refractory depression. Ann
Clin Psychiatry. 2002;14:3338.
57. Coppen A, Bailey J. Enhancement of the antidepressant action of fluoxetine by folic acid: a randomised, placebo controlled trial. J Affect Disord. 2000;60:121130.
58. Rosenbaum JF, Fava M, Falk WE, Pollack MH, Cohen LS, Cohen BM, Zubenko GS. The antidepressant potential of oral S-adenosyl-l-methionine. Acta Psychiatrica
Scandinavica. 1990;81:432436.
59 Alpert JE, Papakostas G, Mischoulon D et al. S-adenosyl-L-methionine (SAMe) as an adjunct for resistant major depressive disorder: an open trial following partial or
nonresponse to selective serotonin reuptake inhibitors or venlafaxine. J Clin Psychopharmacol. 2004;24:661664.
60. Murrough JW, Iosifescu DV, Chang LC, Al Jurdi RK, Green CE, Perez AM, et al. Antidepressant efficacy of ketamine in treatment-resistant major depression: a two-site
randomized controlled trial. Am J Psychiatry. 2013;1;170(10):1134-42. doi:10.1176/appi.ajp. 2013.13030392.
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L003333 : An Update on New Medications for the Treatment of Major Depressive Disorder
L003333
Multiple-Choice Questions
41. According to the World Health Organization (WHO), major depressive disorder (MDD) was the
most important cause of disease burden worldwide in 2004.
A. First
B. Third
C. Fourth
D. Tenth
42. The mean response rates for placebo in antidepressant clinical trials range between:
A. 30% to 40%
B. 10% to 20%
C. 50%
D. 0% to 5%
44. Ketamine is a:
A. GABA antagonist
B. NMDA receptor antagonist
C. Selective norepinephrine reuptake inhibitors
D. Opioid antagonist
167
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Notes
L003334
LESSON ABSTRACT: Untreated postpartum depression (PPD) poses a threat to the maternal-child bond and the well-being
of the entire family. With timely identification, women from diverse racial and ethnic backgrounds are easily treated, including
those of African American, Asian American, and Hispanic/Latina descent, who are less likely to self-report depressive symptoms,
thus delaying treatment. This lesson examines specific cultural factors and mental health help-seeking behaviors among these
culturally diverse populations in an effort to improve PPD identification and treatment. Evidence-based PPD screening questionnaires and treatment options will also be discussed.
COMPETENCY AREAS: This lesson helps clinicians to provide better patient-centered care to women by helping them
identify, respect, and care about patients differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health.
171
L003334 : Postpartum Depression Identification, Referral, and Treatment among Diverse Racial and Ethnic Groups
Introduction
Societal expectations often dictate that the birth of a new
baby should be a time of great joy and excitement for
new parents. However, the experiences of some parents
may not conform to such societal expectations. Parents
are often blindsided by the development of postpartum
mood disorders, including postpartum baby or maternity blues, postpartum depression (PPD), and postpartum
psychosis. Each of these affective mood disorders has a
unique presentation, a specific constellation of symptoms, and suggested treatment methodologies.
Of the three postpartum affective mood disorders,
maternity blues is the most common, affecting up to
84% of new mothers.1,2 Self-limiting in nature, the
symptoms including tearfulness, anxiety, and irritability,
present within the first 47 days postpartum and often
resolve without treatment.1 Symptoms that persist longer than 2 weeks or increase in severity are red flags and
reasons for prompt referral and further evaluation.
The rarest of the postpartum mood disorders,
postpartum psychosis, affects 1/1000 women.3 Symptoms include mood fluctuation, delusions, auditory
hallucinations, and insomnia, which present rapidly
after the infants birth.4 Postpartum psychosis requires
immediate inpatient psychiatric evaluation and treatment because this disorder may lead to suicide and
infanticide.5
Defined as a depressive episode occurring between
2 weeks and 12 months after childbirth, PPD affects 1
in 7 new mothers.6 The multiple risks to the mother,
infant, and whole family have been well documented.
When PPD is left untreated, the more serious risks
include disruption of the mother-infant bond,7 child
maltreatment,8 and infanticide.5 Although all postpartum mood disorders require diligent clinical assessment
and intervention, the focus of this lesson is on identifying and treating PPD.
According to 2013 United States (U.S.) Census
data,9 63% of the U.S. population self-identifies as white,
17% as Hispanic or Latino, 13% as African American,
and 5.3% as Asian American. Given these statistics, it
is not surprising that the majority of PPD research in
the United States to date has focused on PPD among
Caucasian women, with a lesser focus on minority
women, such as African American, Asian American,
172
L003334 : Postpartum Depression Identification, Referral, and Treatment among Diverse Racial and Ethnic Groups
Table 1:
Shifting the Multicultural Lens
African American
Asian
Hispanic
Black
Chicana/Latina
Psychosocial structure
patriarchal, education is
important, plays a role, respect
for elders is key
Ideologies of
health and healing
alternative practices,
yoga, meditation,
karmic philosophies
Emotional support
L003334 : Postpartum Depression Identification, Referral, and Treatment among Diverse Racial and Ethnic Groups
Postpartum Depression:
Screening and Referral
The effect of untreated PPD on the growth, development, and physical health of infants and children has
been well documented.31,32 Screening new mothers for
depressive symptoms has been shown to be cost-effective
in providing timely referral, diagnosis, and treatment,
all of which minimize the long-term effects of delayed/
undetected PPD.33 Given the detrimental effects of
Table 2:
Commonly Used Postpartum Depression Questionnaires
Characteristics
EPDS
PHQ-9
General purpose
Number of items
10 items
9 items
Symptom timeframe
previous week
previous 2 weeks
yes, both
yes, both
Range of scores
0-30
0-27
27
27
>10
>9
yes
yes
yes
yes
174
L003334 : Postpartum Depression Identification, Referral, and Treatment among Diverse Racial and Ethnic Groups
175
L003334 : Postpartum Depression Identification, Referral, and Treatment among Diverse Racial and Ethnic Groups
should consider the possible need to adjust medication dosages as the metabolic rate and other biological factors may differ between ethnic minority groups
compared with Caucasians.49 Since antidepressant
and therapy-based interventions are common first-line
treatment modalities for PPD, where feasible, clinicians
should consider alternative methods, such as yoga,50,51,52
which has been associated with improved maternal mental health outcomes. Strategies for promoting adequate
sleep53,54 and a robust social support network55 should
also be discussed with patients since the lack of both is
also associated with PPD.
Case Study 1
176
3.
Although Nina verbalizes no current
thoughts of harm to herself or others, her
EPDS score is 12/30 (cut-off score 10),
indicating that she has a high risk of developing PPD. The NP will refer Nina to a
psychiatrist/psychologist for further evaluation and treatment. The NP will also obtain routine lab tests to rule out anemia and
hypothyroidism, which may also contribute
to depressive symptoms.
Case Study 2
Shaundra is a 20-year-old African American
woman who presents to the postpartum clinic for her postpartum check-up at 8 weeks
because she was not able to keep a 6-week
appointment. She had a spontaneous vaginal
birth at 28 weeks gestation because of severe
pre-eclampsia and preterm labor. Her infant
weighed 2 pounds and 11 ounces at birth because of intrauterine growth restriction from
poorly controlled pre-eclampsia. The infant
boy is formula-fed and has been transferred to
a tertiary care center 4 hours from Shaundras
home in rural Georgia. He was hospitalized
until 38 days of life and has experienced many
health problems during his neonatal course,
including 2 readmissions to the local hospital
after initial discharge.
Shaundra works at a fast food restaurant, has
a high school education, and is covered by
Medicaid insurance. She lives with her mother, grandmother, and 4 younger siblings. She
has returned to work and has arranged that
L003334 : Postpartum Depression Identification, Referral, and Treatment among Diverse Racial and Ethnic Groups
3. The CNM should consult with her supervising physician to develop a treatment and
follow-up plan for Shaundra.
4. An emergency referral for immediate psychiatric evaluation and treatment must be
made since Shaundra has verbalized inability to take care of her infant and wanting to
run away.
5. Consider the use of telemental health services
for follow-up psychiatric appointments given Shaundras distance from the clinic and
the limited availability of in-person mental
health appointments.
6. Patient health counseling should focus on
self-care, including obtaining daily exercise,
getting enough sleep, and taking prescribed
medications (vitamins). Shaundra should
also be encouraged to enlist the help of her
social support network to lessen her depressive symptoms.
Answer: All of the above.
177
L003334 : Postpartum Depression Identification, Referral, and Treatment among Diverse Racial and Ethnic Groups
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21. Jesse DE, Dolbier CL, Blanchard A. Barriers to seeking help and treatment suggestions for prenatal depressive symptoms: Focus groups with rural low-income women. Issues
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26. Tewari N, Inman A, Sandhu, DS. South Asian Americans: Culture, concerns and therapeutic strategies. In: Iwamasa JMG, ed. Culturally Diverse Mental Health: The
Challenges of Research and Resistance (pp. 191-209). New York: Taylor & Francis Inc.; 2003.
27. Goyal D, Wang EJ, Shen J, Wong EC, Palaniappan, LP. Clinically identified postpartum depression in Asian American mothers. Journal of Obstetric, Gynecologic, and
Neonatal Nursing. 2012;41(3):408-416. doi:10.1111/j.1552-6909.2012.01352.x
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2007;77(2):231-242. doi:10.1037/0002-9432.77.2.231
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2006;8(4):377-385. doi:10.1007/s10903-006-9008-8
30. Kozhimannil KB, Trinacty CM, Busch, AB, Huskamp HA, Adams AS. Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatric
Services. 2011;62(6):619-625. doi:10.1176/appi.ps.62.6.619
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32. Siegenthaler E, Munder T, Egger M. Effect of preventive interventions in mentally ill parents on the mental health of the offspring: Systematic review and meta-analysis.
[Meta-Analysis Review]. Journal of the American Academy of Child & Adolescent Psychiatry. 2012;51(1): 8-17 e18. doi:10.1016/j.jaac.2011.10.018
33. Milgrom J, Mendelsohn J, Gemmill AW. Does postnatal depression screening work? Throwing out the bathwater, keeping the baby. J Affect Disord. 2011;132(3): 301-310.
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34. Earls MF. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010; 126(5):1032-1039. doi:10.1542/
peds.2010-2348
35. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. [Research Support, Non-U.S. Govt Validation Studies]. Journal of General
Internal Medicine. 2001;16(9):606-613.
36. Zubaran C, Schumacher M, Roxo MR, Foresti K. Screening tools for postpartum depression: Validity and cultural dimensions. African Journal of Psychiatry (Johannesbg).
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37. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry.
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38. Sidebottom AC, Harrison PA, Godecker A, Kim H. Validation of the patient health questionnaire (PHQ)-9 for prenatal depression screening. [Research Support, U.S.
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45. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
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48. Gonzalez HM, Tarraf W, West BT, Chan D, Miranda PY, Leong FT. Research article. Antidepressant use among Asians in the United States. Depress Anxiety. 201027(1):4655. doi:10.1002/da.20636
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50. Bershadsky S, Trumpfheller L, Kimble HB, Pipaloff D, Yim IS. The effect of prenatal Hatha yoga on affect, cortisol and depressive symptoms. Complementary Therapies in
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51. Marc I, Toureche N, Ernst E, Hodnett ED, Blanchet C, Dodin S. Njoya MM. Mind-body interventions during pregnancy for preventing or treating womens anxiety.
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52. Muzik M, Hamilton SE, Rosenblum LK, Waxler E, Hadi Z. Mindfulness yoga during pregnancy for psychiatrically at-risk women: Preliminary results from a pilot feasibility
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53. Goyal D, Gay C, Lee K. Fragmented maternal sleep is more strongly correlated with depressive symptoms than infant temperament at three months postpartum. Archives
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54. Goyal D, Gay CL, Lee KA. Patterns of sleep disruption and depressive symptoms in new mothers. [Research Support, N.I.H., Extramural Research Support, Non-U.S.
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55. Beck CT. Predictors of postpartum depression: An update. Nurs Res. 2001;50(5): 275-285.
56. Lee KA, Gay CL. Can modifications to the bedroom environment improve the sleep of new parents? Two randomized controlled trials. [Randomized Controlled Trial
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L003334 : Postpartum Depression Identication, Referral, and Treatment among Diverse Racial and Ethnic Groups
L003334 : Postpartum Depression Identication, Referral, and Treatment among Diverse Racial and Ethnic Groups
L003334
L003334
Multiple-Choice Questions
Multiple-Choice Questions
45. Which of the following statements are correct regarding the selection of a postpartum depression
screening tool for diverse populations?
45. Which of the following statements are correct regarding the selection of a postpartum depression
screening tool for diverse populations?
A. Neither the EPDS nor the PHQ9 is validated for use in diverse populations.
A. Neither the EPDS nor the PHQ9 is validated for use in diverse populations.
B. The EPDS and the PHQ9 are validated for use in diverse populations.
B. The EPDS and the PHQ9 are validated for use in diverse populations.
46. When should a patient be referred for a further mental health evaluation?
46. When should a patient be referred for a further mental health evaluation?
47. What cut-off score on the (GLQEXUJK3RVWQDWDO'HSUHVVLRQ6FDOH would prompt you to refer your
patient for further evaluation?
47. What cut-off score on the (GLQEXUJK3RVWQDWDO'HSUHVVLRQ6FDOH would prompt you to refer your
patient for further evaluation?
A. 6
A. 6
B. 4
B. 4
C. 11
C. 11
D. 8
D. 8
:KDWDUHWKHGLDJQRVWLFJXLGHOLQHVIRU33'EDVHGRQWKHQHZ'LDJQRVWLFDQG6WDWLVWLFDO0DQXDO
of Mental Disorders (DSM-5)"'LDJQRVLVVKRXOGEHEDVHGRQZKLFKRIWKHIROORZLQJ"
:KDWDUHWKHGLDJQRVWLFJXLGHOLQHVIRU33'EDVHGRQWKHQHZ'LDJQRVWLFDQG6WDWLVWLFDO0DQXDO
of Mental Disorders (DSM-5)"'LDJQRVLVVKRXOGEHEDVHGRQZKLFKRIWKHIROORZLQJ"
B. Symptom onset during the pregnancy as well as in the 4 weeks following delivery
B. Symptom onset during the pregnancy as well as in the 4 weeks following delivery
181
181
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Notes
L003335
COMPETENCY AREAS: This lesson addresses the gap in learning in the area of sexual addiction or hypersexual disorder,
including diagnosis, assessment, prevalence, comorbidity, cognitive-behavioral and neurobiological mechanisms, and psychological and pharmacological treatment. Many clinicians lack understanding of how to adequately diagnose and treat sexual addiction or hypersexual disorder, which often goes underreported by patients. Pharmacological treatment with SSRIs together with
cognitive-behavior therapy may be useful for treating sexual addiction. Upon the conclusion of this lesson, readers will have a
better understanding of sexual addiction or hypersexual disorder and its diagnosis and treatment.
185
L003335 : Sexual Addiction or Hypersexual Disorder: Clinical Implications for Assessment and Treatment
Introduction
History of Sexual Addiction and
Its Treatment:
Sexual addiction, which is also known as hypersexual
disorder, is associated with severe psychosocial problems and risk-taking behaviors.1-3 Various terms have
been used to name the condition, including sexual
compulsivity, sexual impulsivity,4 out-of-control
sexual behavior,5 sexual addiction, and hypersexual
behavior.6-7
In 1812, U.S. physician Benjamin Rush documented
in his book Medical Inquiries and Observations Upon the
Diseases of the Mind the case of a person with excessive
sexual appetite which caused him great psychological
distress.8 In 1886, German psychiatrist Dr. Richard von
Krafft-Ebbing argued that pathological sexuality is a
psychiatric illness that results in an impulsive series of
sexual enjoyment resulting in legal, moral, and psychological problems.9
In the mid-1970s, British psychologist Dr. Jim Orford
suggested that hypersexuality should be included in the
spectrum of addictive disorders. He argued that hypersexuality is similar to excessive drinking and gambling
in that hypersexuality is an excessive appetitive behavior
that does not have psychoactive drugs as an object.10 He
described the behavior as a maladaptive pattern of use
and impaired control of a behavior that was associated
with adverse consequences.10 Several problems with the
dependence model of sex were discussed by Orford and
Carnes,10-11 notably that it is difficult to separate normal
and abnormal sexual behavior, it is difficult to determine
when loss of control occurs, and it is difficult to assess the
role of culture in this model.
In his 2001 best-selling book, Out of the Shadows:
Understanding Sexual Addiction, Carnes described
sexual addiction as a psychopathological condition of
excessive sexual behavior.12 A distinct approach was proposed by Mick and Hollander, who argued that sexual
addiction can be conceptualized as a disorder on the
impulsive-compulsive spectrum.4 According to this view,
impulsivity and compulsivity coexist. First, an impulsive
component (pleasure, arousal, or gratification) initiates
the cycle, and then a compulsive component leads to the
persistence of the behavior.4
186
L003335 : Sexual Addiction or Hypersexual Disorder: Clinical Implications for Assessment and Treatment
Table 1:
Goodmans Proposed Sexual Addiction Diagnostic Criteria20
A maladaptive pattern of sexual behavior leading to clinically significant impairment or distress as manifested by 3 (or
more) of the following and occurring at any time in the same 12-month period:
1. Tolerance, as defined by either of the following:
(a) A need for a markedly increased amount or intensity of sexual behavior to achieve the desired effect.
(b) Markedly diminished effect with continued involvement in sexual behavior at the same level of intensity.
2. Withdrawal, as manifested by either of the following:
(a) Characteristic psychophysiological withdrawal syndromes of physiologically described changes and/or psychologically described
changes upon discontinuation of the sexual behavior.
(b) The same (or a closely related) sexual behavior is engaged in to relieve or avoid withdrawal symptoms.
3. The sexual behavior is often engaged in over a longer period, in greater quantity, or at a higher level of intensity than was intended.
4. There is a persistent desire or unsuccessful effort to cut down or control the sexual behavior.
5. A great deal of time is spent in activities necessary to prepare for the sexual behavior, to engage in the behavior, or to recover from
its effects.
6. Important social, occupational, or recreational activities are given up or reduced because of the sexual behavior.
7. The sexual behavior continues despite knowledge of a persistent or recurrent physical or psychological problem that is likely to have
been caused or exacerbated by the behavior.
Table 2:
Kafkas Proposed Hypersexual Disorder Diagnostic Criteria21
A. Over a period of at least 6 consecutive months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors in association
with 4 or more of the following 5 criteria:
1. Excessive time consumed by sexual fantasies and urges and by planning for and engaging in sexual behavior.
2. Repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression,
boredom, irritability).
3. Repetitively engaging in sexual fantasies, urges, or behaviors in response to stressful life events.
4. Repetitive but unsuccessful efforts to control or significantly reduce the sexual fantasies, urges, and behaviors.
5. Repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others.
B. There is clinically significant personal distress or impairment in social occupational or other important areas of functioning associated
with the frequency and intensity of the sexual fantasies, urges, and behaviors.
C. These sexual fantasies, urges, and behaviors are not due to direct physiological effects of exogenous substances (e.g., abuse of drugs or
medications) or to manic episodes.
D. The person is at least 18 years of age.
Specify if: masturbation, pornography, sexual behavior with consenting adults, cybersex, telephone sex, strip clubs.
Specify if in remission: no distress, impairment, or recurring behavior and in an uncontrolled environment, and state duration of remission in
months in a controlled environment.
187
L003335 : Sexual Addiction or Hypersexual Disorder: Clinical Implications for Assessment and Treatment
or the adverse consequences of the disorder. The psychometric qualities of the existing measures are generally
low, and further validation studies are required. The primary concerns for and limitations regarding the existing
measures include (a) the absence of valid cut-off criteria
to identify sexual addiction; (b) a lack of generalizability
(e.g., some instruments have been used only in very specific samples, such as men who have sex with men); and
(c) variance in reliability, response format (dimensional
versus categorical responses), and factorial structures.3
Carnes created one of the first instruments for assessing sexual addictionthe Sexual Addiction Screening
Test (SAST).26 The SAST is composed of 25 items that
measure symptoms of sexual addiction, mostly geared
toward heterosexual men. The Cronbachs alpha coefficients for the total score of the SAST range from 0.85 to
0.95. The SAST discriminated between male sex addicts
and non-addicts,26 and it was related to other measures
of sexual addiction.27-28 Carnes has also developed two
other versions: the WSAST (the SAST for women)29 and
the GSAST (the SAST for men who have sex with men
[MSM]).30 A new version of the SAST, the SAST-R,31
was developed, and it applies to heterosexual men and
women and MSM. Recently, Carnes and colleagues also
created the PATHOS, a short instrument that assesses
sexual addiction. The PATHOS has 6 items to preoccupation, shame, treatment-seeking, hurting others, outof-control behavior, and sadness.32
Kalichman and Rompa developed the Sexual Compulsivity Scale (SCS), which is a 10-item questionnaire
that assesses sexual compulsive behavior, sexual preoccupations, and intrusive sexual-related thoughts.33 A
cut-off score of 24 or higher has been used to indicate
problems with sexual addiction. The SCS displays good
psychometric properties with Cronbachs alpha coefficients ranging from 0.59 to 0.92.26 The SCS has a good
convergent validity and relates to other measures of
sexual addiction.33 The SCS also has good discriminant
validity, and is unrelated to ethnicity,34-35 education, and
income.34 Miner et al reported that the SCS predicted
the practice of engaging in unprotected sex, a large number of sexual partners, the use of cocaine in HIV-positive
men, and high frequency of sex-seeking behavior on the
Internet.36
188
Prevalence Rates
To date, no large epidemiological studies of sexual
addiction have been conducted using standardized diagnostic criteria.7,37 However, some studies have estimated
the prevalence of sexual addiction to be between 3%
and 6% of the general population.38-41 The occurrence
rates of sexual addiction vary in the literature depending
on characteristics examined such as gender, sexual orientation, age, and the diagnostic criteria implemented
in the study. The prevalence of sexual addiction-related
disorders ranges from 3% to 16.8%.42-45 In a Swedish
sample of 2,450 participants from the general population, Langstrm and Hanson estimated that 12%
of men and 6.8% of women present with hypersexuality.46 The researchers found that 5% to 10% of
the most sexually active respondents reported higher
levels of co-occurring addictions, risk-taking behaviors, distress, and psychiatric symptoms, suggesting
a subgroup of the most sexually active who may have
psychosocial impairments.46 Traeen et al47 specifically
investigated pornography dependence in the adult Norwegian male population, and found that 1% of their
sample masturbated to ejaculation twice or more per day
while viewing pornography. Laumann et al48 reported
that 7.6% of American men (n = 1320; ages 1859)
engaged in partnered sex 4 or more times/week for at
least 1 year, and 1.2% of the men masturbated more
than once/day during the year leading up to the survey.
Higher rates have been suggested in specific populations,
such as sexual offenders, patients with HIV,49 and people
with hypersexual disorders and paraphilias.50 The evidence suggests that men have a higher prevalence of
sexual addictions than women; the estimated ratio of
sexual addictions is between 3 and 5 men for every
1 woman.51-53 The dissimilar prevalence rates reported
can at least partially be attributed to the use of different classification criteria along with the use of different
screening instruments and/or cut-off criteria.
Psychiatric Comorbidity
The adverse consequences of sexual addiction are similar to the consequences of other addictive disorders.54
Other direct risks are associated with unprotected and
anonymous sexual encounters, such as HIV/AIDS,
L003335 : Sexual Addiction or Hypersexual Disorder: Clinical Implications for Assessment and Treatment
other sexually transmitted diseases, and unwanted pregnancy.12,51-52 Hypersexual men and women also engage
in tobacco use, alcohol, and illicit drug abuse.55-56
Among men, gambling is prevalent.7 Other psychiatric comorbidities include mood disorders, depression, anxiety,55,57 social anxiety, dysthymia, attention
deficit hyperactivity disorder,4,37,58 affect dysregulation,59 and posttraumatic stress disorder.60 Finally,
some studies find that sexual addiction is associated
with or in response to dysphoric affects or stressful
life events.61-64
The co-occurrence of sexual addiction and other
addictions suggest that these disorders share etiological
mechanisms, such as neurobiological and psychosocial
factors (e.g., personality traits, cognitive deficits, or
bias).65 Carnes66 reported that the majority of a sample of
1603 sex addicts reported a lifetime prevalence of other
addictive and abusive behaviors such as substance abuse,
gambling, or eating disorders. Finally, a study of pathological gamblers67 found that 19.6% of the subjects also
met the criteria for compulsive sexual behavior (CSB). The
majority of the subjects who met the criteria for both
disorders reported that CSB had preceded their gambling
problems.
Behavioral Characteristics of
Sexual Addiction
Sexual addiction or hypersexual disorder includes various
types of problematic behaviors.37,54,68 Coleman and colleagues classified seven subtypes of impulsive-compulsive
sexual behavior: compulsive cruising and multiple
partners, compulsive fixation on an unattainable
partner, compulsive masturbation, compulsive use
of erotica, compulsive use of the Internet for sexual
purposes, multiple compulsive love relationships, and
compulsive sexuality in a relationship.69 Behavioral
symptoms may also include engaging in risky sexual
activities, paying for sexual services, and resisting
behavioral changes to avert HIV risk.69-72 Bancroft57
suggested that 2 types of sexual behavior are especially likely to become out of control: masturbation
and the new and exceedingly important development
of the sexual use of the Internet. A growing number
of men and women use the Internet for sexual purposes.
L003335 : Sexual Addiction or Hypersexual Disorder: Clinical Implications for Assessment and Treatment
Associated Psychobiological
Mechanisms
The sexual addictive process is described by Goodman
as an interaction of impairments in three functional systems: motivation-reward, affect regulation, and behavioral inhibition.65 Brain imaging studies of human sexual
behavior in normal subjects and subjects with sexual
disorders used positron emission tomography (PET) and
functional magnetic resonance imaging (fMRI) to identify
brain mechanisms that underlie responses to visual sexual stimuli. These studies have demonstrated that visual
sexual stimuli are associated with the activation of the
brains reward mechanisms, including the limbic and
paralimbic regions (the anterior cingulate gyrus and the
orbitofrontal cortex) and the striatum (the head of the
caudate nucleus and putamen). These regions contain
dopaminergic (DA) projections that are an important
part of the brain reward network. Gender effects were
found, with men showing significantly greater amygdala
activation, which perhaps reflects differences in how men
and women process sexual signals.92 Amygdala activation
in men characterizes the appetitive phase of sexual
behavior, whereas ejaculation, which characterizes the
consummatory phase of sexual behavior in men, is
associated with a decrease in amygdala activity.93
Further brain imaging studies of human subjects
during sexual arousal suggest that the frontal areas of
the brain may exert control and exercise reason over the
posterior reward centers.94-95 Brain scan studies of sexual
dimorphism may help us understand the differences
between men and women, particularly when it comes to
sexual acting-out. For instance, a sexual activity-related
PET study demonstrated that male arousal was more
often associated with activation of the visual cortices of
the braineven when the subjects eyes were closed.96
Female arousal was associated with stronger activity
in the left dorsal frontoparietal regions, including the
premotor and posterior parietal areas.97 During orgasm,
male and female brain functioning appears similar with
activation in the anterior lobe of the cerebellar vermis
and deep cerebellar nuclei and deactivations in the left
ventromedial and orbitofrontal cortex. Although promising and intriguing, todays PET and fMRI studies do
not yet provide any clinical guidance in treating sexual
addiction.2
190
Treatment
Pharmacological Treatment:
Currently, there is a lack of consensus and empirical
research on sexual addiction/hypersexual disorders, and
clear diagnostic criteria are needed to test the efficacy
of psychological and pharmacological treatments in
controlled studies. However, similar to other behavioral
addictions (e.g., pathological gambling and compulsive
buying), the appropriate treatment of sexual addiction
should include a combination of pharmacological and
psychological approaches.3,107
Pharmacological treatments have limited evidence
of success. To date, no large double-blind clinical trials
have been conducted in patients with sexual addiction/
hypersexual disorders. One small, 12-week randomized
trial showed an effect of selective serotonin reuptake
inhibitors (SSRIs; escitalopram 2060 mg) on sexual desire, sexual drive, frequency of masturbation,
and pornography use.108 Escitalopram (Lexapro) has
L003335 : Sexual Addiction or Hypersexual Disorder: Clinical Implications for Assessment and Treatment
Psychological Treatment:
Motivational interviewing, cognitive-behavior therapy,
and couples and family therapy have been shown to be
efficient for treating several forms of drug and behavioral
addiction.115-117 Behavioral therapies may be associated
with reductions in substance use and may have effects
on cognitive control, impulsivity, motivation, and
attention and related brain mechanisms.118 Group-based
treatments can also be used.119 Although Sex Addicts
Anonymous is not affiliated with any other organization,
the basic principles of the group are found in the 12 steps
and 12 traditions of Alcoholics Anonymous. Treatment
consists of approaches that have been used for substance
addiction such as group and individual therapy, motivational interviewing, cognitive-behavioral techniques,
relapse prevention, insight-oriented therapy, and family
therapy. In the United States, numerous inpatient and
outpatient treatment centers use an addiction model
to treat sexual compulsivity and addiction. Carnes has
developed a task-centered approach program with a series
of operationalized workbooks appropriate for treating
sexual addiction patients.120
Conclusion
Sexual addiction or hypersexual disorder involves powerful sexual urges together with lack of control of these
urges and preoccupation or an obsession with sexual
behavior. Sexually addicted patients lack control of this
activity, which has long-term harmful consequences
functionally and socially, as well as economically. Several
screening questionnaires have been created specifically
to assess the proposed diagnostic criteria for hypersexual
disorder and are likely to be the best choice of measures
if the researcher or clinician is looking for a brief instrument. According to Womack,25 a thorough assessment of
hypersexual behavior includes (a) a self-report measure
of general symptoms, (b) a self-report measure of consequences, (c) a clinical interview, and (d) an objective
assessment of sexual behavior.
The neurobiological and psychological mechanisms of sexual addiction are under investigation, and
currently, there is no validated pharmacological or
psychological treatment for this disorder. The absence
of validated treatment is at least partly because sexual
addiction is not clearly defined and diagnosed as a clinical disorder; instead, it is a construct that covers many
different types of problematic sexual behaviors. Due to
this diversity, Kor et al.121 concluded that despite many
similarities between the features of hypersexual behavior
and substance-related disorders, the research on hypersexual disorder at this time is in its infancy and much
remains to be learned before it can be definitively characterized as an addiction. Rosenberg et al.2 anticipated
that as psychiatric research improves our understanding,
studies will support the existence of sexual addiction and
related disorders as painful and serious disorders. Hopefully, future research will be able to integrate the different types of problematic sexual behavior into a clinically
defined disorder.
191
L003335 : Sexual Addiction or Hypersexual Disorder: Clinical Implications for Assessment and Treatment
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L003335
Multiple-Choice Questions
49. According to the lesson, all of the following statements regarding sexual addiction or hypersexual
disorder are true, except:
A. Sexual addiction, or hypersexual disorder, is often associated with risk-taking behavior and psychosocial
problems.
B. The proposed diagnosis of hypersexual disorder requires the presence of dependence, tolerance, and
withdrawal.
C. Hypersexual disorder has been associated with compulsivity, impulsivity, emotional dysregulation, and
stress proneness.
D. Hypersexual disorder is repetitively engaging in sexual fantasies, urges, and behavior in response to dysphoric
mood states (e.g., anxiety, depression, boredom, irritability).
50. Which of the following psychiatric disorders has not been frequently described as related to hypersexual disorder?
A. Depression
B. Anxiety
C. Attention and hyperactivity disorder
D. Schizophrenia
51. Hypersexual disorder has been shown to be related to all of the following, except:
A. increased activity of the dopamine reward areas to visual sexual stimuli.
B. increased impulsivity and risk-taking behavior.
C. shared comorbidity with pathological gambling.
D. there is higher prevalence of hypersexual disorder in women than men.
52. Which of the following medications has not been shown to be useful in treatment for hypersexual
disorder?
A. Escitalopram, a selective serotonin reuptake inhibitor
B. Naltrexone, an opiate antagonist
C. Topiramate, an anticonvulsant medication
D. Risperidol, an antipsychotic
197
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Notes
L903336
KEY WORDS: Electronic Health Records Substance Use Disorders Treatment Patient Confidentiality
LEARNING OBJECTIVES: Clinicians will review the current policies regarding patient confidentiality issues and substance
use disorder (SUD) treatment. Readers will consider how to protect their patients in this era of collaborative care while
maintaining rapid communication among healthcare providers. As this lesson discusses substance use disorders, the implications
can be considered among other medical conditions.
LESSON ABSTRACT: Practitioners in federally-assisted substance use disorder (SUD) treatment programs are faced with
increasingly complex decisions when addressing patient confidentiality issues. Recent policy changes, intended to make
treatment more available and accessible, are having an impact on delivery of SUD treatment in the United States. The addition
of electronic health records provides opportunity for more rapid and comprehensive communication between patients primary
and SUD care providers while promoting a collaborative care environment. This shift toward collaborative care is complicated
by the special protections that SUD documentation receives in SUD treatment programs, which vary depending on what
care is provided and the setting where the patient is treated. This lesson explores the special protections for substance abuse
documentation, discrepancies in treatment documentation, ways to deal with these issues in clinical practice, and the need for
more knowledge about how to harmonize treatment in the SUD and primary care systems.
COMPETENCY AREAS: This lesson addresses the issue of ethical decision making for clinicians working in substance use
disorder treatment programs. With the recent changes in policies that make substance use disorder treatment more available and
the rise in the use of electronic health records to facilitate collaboration, clinicians often face questions regarding the protections
for substance use disorder documentation, the involvement of the legal system, and the involvement of other parties in the
treatment program. Upon completion of this lesson, readers will have a better understanding of the recent policy changes
regarding substance use disorder treatment and will provide clinicians with a better understanding of ethical practice regarding
collaboration and consultation.
201
L903336 : Confidentiality Protections Versus Collaborative Care in the Treatment of Substance Use Disorders
Introduction
Increasingly, substance use assessment and treatment is
occurring in health care settings such as primary care
clinics, emergency departments, and trauma units.
Furthermore, many health care settings have adopted or
plan to adopt the use of electronic health records (EHRs),
a change that can facilitate the integration of substance
use disorder (SUD) treatment with other forms of health
care. Thus, the landscape of SUD treatment has shifted
in recent years. At the same time, current regulations for
SUD treatment confidentiality have not been updated,
despite the number of changes in how and where SUD
is delivered. In this paper, the authors provide a summary of recent legislative and policy changes, the reasons
for confidentiality protections, review the degree that
substance abuse treatment documentation is protected
in different environments, and suggest several directions
for maintaining confidentiality while promoting coordination of care.
L903336 : Confidentiality Protections Versus Collaborative Care in the Treatment of Substance Use Disorders
HIPAA Regulations:
As years passed, additional legislation was adopted
to further ensure patient privacy. In 1996, the United
States Congress passed the Health Information Portability and Accountability Act (HIPAA), which contains a
privacy rule that restricts the spread of Protected Health
Information (PHI). HIPAA regulates PHI held by covered entities, such as health plans, health care clearinghouses, and health care providers. HIPAA was written
for direct transfers of electronic information between
providers, rather than networks streamlining information.10 Some view HIPAA as restricting the necessary
transfer of data and needing improvements to facilitate
smoother communication10-12 whereas others suggest
that the HIPAA Privacy Rule should be augmented with
new federal regulations.13
Modifications have been proposed to address some
of the privacy issues with 42 CFR Part 2 and HIPAA.
For example, the Patient Protection Coalition, a
group aiming to reform 42 CFR Part 2, has suggested
permitting disclosures of demographic information,
diagnosis, medications, laboratory results, and current
and past treatment providers to ensure patient safety.
Additionally, they support enhancing patient protections
regarding discrimination based on having received SUD
treatment and strengthening legal ramifications for
unauthorized disclosures of information.14
Federal privacy laws are further complicated with
the advent of electronic medical records.15 Federal
privacy laws were written before the development of
electronic medical records, when all records were kept
in paper form, rendering some parts of these laws
obsolete and other parts in opposition to the electronic
changeover.16 Various groups insist on maintaining
the strict protections in 42 CFR Part 217 whereas others argue for a reform of the current confidentiality
protections.18
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L903336 : Confidentiality Protections Versus Collaborative Care in the Treatment of Substance Use Disorders
Confidentiality Protections in
Current Practice:
Practitioners ask as we move toward an era where medications are increasingly being prescribed for SUD, are
the current protections potentially harmful to patients?
Providers of patients who are prescribed naltrexone,
buprenorphine, or methadone may need this information in order to accurately treat their patients. While
the 42 CFR Part 2 guidelines indicate that patient
information may be disclosed in medical emergency
situations, preventing a potentially fatal drug interaction
does not necessitate a disclosure if there is not an immediate medical emergency.25 A study by Walley et al.26
found that 59% of the opioid patients on methadone
maintenance therapy (MMT) were also prescribed
medications with a potentially harmful interaction
with their MMT. In fact, 19% of the patients were
prescribed three or more medications that could
potentially interact with MMT. Currently, the patient
must serve as the intermediary between their SUD and
healthcare providers or sign an authorization of release
of information for each of their particular providers.
As a result failure to share patient-specific information
across providers promotes uncoordinated and sometimes
unsafe care.27, p716
L903336 : Confidentiality Protections Versus Collaborative Care in the Treatment of Substance Use Disorders
Table 1:
SUD Documentation in Specialty and General Medical Setting
Specialty SUD Provider in Federally-assisted SUD Program
Documentation
Patient is asked about his alcohol and drug use as part of a visit to
an emergency room for a traumatic injury. Patient indicates his injury
occurred while intoxicated and voices concern about drinking.
L903336 : Confidentiality Protections Versus Collaborative Care in the Treatment of Substance Use Disorders
has specific information on the confidentiality requirements for physicians who are providing office-based opioid addiction treatment. The TIP also includes a sample
consent form to release information protected by 42 CFR
Part 2.31 Additionally the Legal Action Center (LAC) can
be an excellent resource, available online at http://www.
lac.org/. LAC is a non-profit law and policy organization
that seeks to fight discrimination against individuals with
addictions, HIV/AIDS or criminal records. They provide
on-line courses available both in basic and advanced
issues concerning confidentiality, as well as brochures,
sample forms for physicians and treatment programs,
and policy analyses, including a paper on confidentiality
of alcohol and drug records in the 21st Century.
Seek Guidance
When a provider approaches an uncomfortable situation it is wise to seek guidance. Counselors, peers,
clinical supervisors, physicians, and licensed professionals at the SUD treatment program are essential for
support, and professional associations can be helpful.
For example the NAADAC, the National Association for
Addiction Professionals (http://www.naadac.org/), offers
webinar trainings, one of which is Compliance with
Ethical Standards for Drug, Alcohol and Addictions
Counselors. We stress that the specific guidelines may
be changing constantly as new information emerges. For
example, earlier in this paper we mentioned that in July
2010 CSAT released a Frequently Asked Questions
paper (http://www.samhsa.gov/HealthPrivacy/docs /EHRFAQs.pdf). The paper was initially drafted by the LAC.
Enos32 documents the many points of controversy about
this document, and a month later SAMHSA sponsored
a stakeholders meeting to air different viewpoints and
clarify the FAQs. We also emphasize the importance of
206
Implement
At the clinic level, update guidelines for your patients,
staff, and referral sources, and if guidelines do not exist, it
may be wise to develop them. Examples of such guidelines
are available from the CSAT TIPS and TAPS mentioned
above, or they may be available locally or through the
single state agency that is responsible for SUD treatment.
Seek Feedback
Obtaining feedback from those affected is an obvious
suggestion, but feedback often happens only when
something has gone wrong. Encourage quality assurance
studies to understand what is working and why. Encourage research to understand how serious specific issues are
in your setting. As an example of the utility of research,
Salomon et al.33 surveyed psychiatric clinicians who had
recently switched to an electronic health record system
and found the majority opinion was that open therapeutic
communications were not interfered with. On the other
hand, once they were using the electronic health record
system the majority was less willing to record highly confidential information. In short, the clinicians indicated
that the system worked but they were more cautious than
before about recording sensitive information.
Keep Learning
At the individual level, keep up to date as guidelines
change. A 2009 CSAT TIP entitled Clinical Supervision
and Professional Development of the Substance Abuse Counselor may be helpful (TIP 52).21 At the program and
Conclusions
This [lesson] explored protecting confidentiality in
SUD treatment programs in the light of changes that
have occurred recently in the policies and regulations.
L903336 : Confidentiality Protections Versus Collaborative Care in the Treatment of Substance Use Disorders
207
L903336 : Confidentiality Protections Versus Collaborative Care in the Treatment of Substance Use Disorders
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14. Patient Protection Coalition. A proposal to promote coordination of care and to strengthen patient protections under the federal alcohol and drug abuse confidentiality law.
2010. Available at http://www.law.virginia.edu/pdf/faculty/bonnie_patientprotection.pdf, accessed (December 18, 2012)
15. McCarty D, McConnell KJ, Schmidt LA. Priorities for policy research on treatments for alcohol and drug use disorders. J Subst Abus Treat. 2010;39(2):8795. doi:
10.1016/j.jsat.2010.05.003.
16. Connors B, Leipold J. The 42 CFR Part 2 and NHIN Conundrum. Behavioral Healthcare. 2009;29(7):5253.
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28. Undem T. Consumers and health information technology: A national survey. 2010. Accessed http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/
PDF%20ConsumersHealthInfoTechnologyNationalSurvey.pdf on December 18, 2012.
29. King TE, Jr, Wheeler MB. Medical management of underserved patients: Principles, practice, and populations. New York: McGraw-Hill; 2007.
30. Center for Substance Abuse Treatment. Confidentiality of patient records for alcohol and other drug programs. Technical Assistance Protocol (TAP) Series 16. NCADI
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31. Center for Substance Abuse Treatment. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. Treatment Improvement Protocol (TIP) Series
40. DHHS Publication No. (SMA) 043939. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004.
32. Enos G. SAMHSA document on confidentiality regulations raises further questions. 2010. Available at http://www.jointogether.org/news/ features/2010/samhsadocument-on.html, accessed March 8, 2011.
33. Salomon RM, Blackford JU, Rosenbloom ST, Seidel S, Clayton EW, Dilts DM, Finder SG. Openness of patients reporting with use of electronic records: Psychiatric
clinicians views. JAmerican Med Inf Assoc. 2009;17:5460
Hatherleighs Note: Additional typeface treatment was added to text for emphasis along with title page information, CME, and Best Practices which were not part of the original article.
Competing interests
The authors declare that they have no competing interests.
Authors contributions
JKM drafted Confidentiality protections in current practice, Integration of SUD treatment and healthcare, and edited the manuscript. Together, JKM and SEL drafted Table 1. HN drafted
parts of The advance of electronic health records, Why confidentiality laws and HIPAA regulations. SEL drafted parts of The advance of electronic health records, Why confidentiality laws and
HIPAA regulations. JLS drafted Why Confidentiality Laws, Solving a clinical conundrum and Conclusions and edited the manuscript. All authors read and approved the final manuscript.
Acknowledgements
Supported in part by NIH/NIDA and NIH/NIMH Grants P50DA09253 (PI=Joseph Guydish; joseph.guydish@ ucsf.edu), U10DA015815 (PI=James Sorensen; james.sorensen@ucsf.edu),
R01DA020781 (PI=Carmen Masson; carmen.masson@ucsf.edu), R21DA020369 (PI=James Sorensen), T32DA07250 (PI=James Sorensen), T32MH018261 (PI Patricia Arean; patricia.
arean@ucsf.edu), F32DA0324465 (PI=Howard Newville; howard.newville@ucsf.edu) and the Robert Wood Johnson Foundation (Dr. Sorensen).
The authors acknowledge and support the above funding sources we recognize that the views presented in this manuscript are that of the authors and not of the funding sources.
Authors contributions
JKM drafted Confidentiality protections in current practice, Integration of SUD treatment and healthcare, and edited the manuscript. Together, JKM and SEL drafted Table 1. HN drafted
parts of The advance of electronic health records, Why confidentiality laws and HIPAA regulations. SEL drafted parts of The advance of electronic health records, Why confidentiality laws and
HIPAA regulations. JLS drafted Why Confidentiality Laws, Solving a clinical conundrum and Conclusions and edited the manuscript. All authors read and approved the final manuscript.
Acknowledgements
Supported in part by NIH/NIDA and NIH/NIMH Grants P50DA09253 (PI=Joseph Guydish; joseph.guydish @ucsf.edu), U10DA015815 (PI=James Sorensen; james.sorensen@ucsf.edu),
R01DA020781 (PI=Carmen Masson; carmen.masson@ucsf.edu), R21DA020369 (PI=James Sorensen), T32DA07250 (PI=James Sorensen), T32MH018261 (PI Patricia Arean; patricia.
arean@ucsf.edu), F32DA0324465 (PI=Howard Newville; howard.newville@ucsf.edu) and the Robert Wood Johnson Foundation (Dr. Sorensen).
The authors acknowledge and support the above funding sources we recognize that the views presented in this manuscript are that of the authors and not of the funding sources.
Copyright 2013 Manuel et al.; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work is properly cited.
210
L903336 : Confidentiality Protections Versus Collaborative Care in the Treatment of Substance Use Disorders
L903336
Multiple-Choice Questions
53. The increase in the use of electronic medical records is due in large part to:
A. the invention and increased use of mobile computing technology, allowing doctors to send records with
greater ease.
B. expectations on the part of the patient that doctors should be able to access all information in their medical
history quickly and efficiently.
C. increased funding in the 2009 economic stimulus package providing for the modernization of electronic
health record-keeping systems.
D. the need for doctors to have easier access to information so that patients can be seen at a faster rate,
compensating for increased demand.
54. What is the purpose of the confidentiality laws detailed in 42 CRF Part Two?
A. To provide patients seeking mental health care protections above and beyond HIPAA
B. To prevent police from using medical records to arrest patients seeking help for substance abuse
C. To remind clinicians of their ethical responsibilities regarding confidentiality
D. To aid law enforcement in the event a criminal defendant makes a mental health-related defense
55. According to a study by Walley et al., what percentage of patients on methadone maintenance therapy
were prescribed a drug with a potentially harmful interaction?
A. 59%
B. 32%
C. 6%
D. 79%
56. According to the lesson, why is it important to understand why the confidentiality laws exist and why
the context of these laws is changing?
A. To protect the patient autonomy
B. To be able to reconcile ones ethical concerns within the boundaries of the law
C. To be certain about what information is protected by confidentiality
D. All of the above
211
The information presented herein is based upon the content in the associated CMElesson. If you have comments or feedback about this page,
please send your feedback via email to: editorial@hatherleighpress.com and reference the ID number under the title to which you are referring.
We will review your commentary, which may be used for publication.
The material in this journal is not a substitute for seeking the attention of a licensed health or medical clinician. These materials were created for professional education
purposes only and are not the express opinion of The Hatherleigh Company, Ltd.
Notes
L903337
LESSON ABSTRACT: In response to the Ebola public health emergency, the American Hospital Association (AHA) has
provided an Ebola education package for CME providers. This package contains information that the American Hospital
Association believes would be useful to healthcare providers and institutions right now, including this FAQ. For more recent
updates, readers should refer to the Centers for Disease Control and Prevention (CDC) or other cited sources on the day they
access this information to get the most current information or version that may now be available.a
COMPETENCY AREAS: This lesson provides healthcare providers with current information released by the American
Hospital Association regarding the presentation of the Ebola virus and how to manage presenting symptoms. This lesson also
provides informatics for systematic controls in the hospital setting.
215
Table 1:
DISEASE PROGRESSION
Table 2:
CLINICAL EVIDENCE
CARE COMPONENT
CLINICAL MANAGEMENT
Disease Pathophysiology4
Research suggests the virus first infects dendritic cells, disabling immune system, and then attacks
the vascular system, causing hemorrhage, hypotension and shock. The virus also affects the liver
(impacting coagulation proteins), the adrenal gland (affecting steroid synthesis for blood pressure
stabilization) and the gastrointestinal tract (diarrhea).
Hemodynamic
Support1,2,5-7
Hypotension/Shock: Aggressive IV fluid resuscitation resembling the approach to the septic shock
patient is identified by the CDC as one of three interventions that impact mortality through
observation and case series. Base fluid selection (Lactated Ringers or Normal Saline) on patient
electrolyte status. One animal study examined supplemental fluid resuscitation of infected,
hypotensive rhesus macaques, which resulted in improved renal parameters. Hydrocortisone may
be considered to support viral disruption in steroid synthesis.
Hypotension/shock,
hemorrhage/DIC
216
Maintain adequate oxygenation (titrate to SpO2 >90%). To protect the airway and/or treat
multisystem organ failure, standard mechanical ventilation practices should be followed with the
addition of HEPA filtration of airflow gases. Methods of non-invasive ventilation are not ideal due
to increased potential for aspiration and infection transmission. Additional measures including
placement of ventilated patients in a negative pressure room, use of video/optical laryngoscopy
for intubation, use of rapid sequence intubation with neuromuscular blockade, and use of a
ventilator-patient monitoring system interface to minimize entry into the patient room should be
considered.1-2,6-8
Table 3:
CLINICAL EVIDENCE
CARE COMPONENT
CLINICAL MANAGEMENT
Treat fever with acetaminophen (avoid aspirin and NSAIDs due to antiplatelet activity). Identify any
additional sources of infection and treat with appropriate empiric antimicrobials. If sepsis develops,
administer broad-spectrum IV antibiotics within 1 hour and follow Sur viving Sepsis Early Goal Directed
Therapy (EGDT). Antiviral and antimalarial agents are not efficacious for Zaire Ebola virus. Consider
passive immunotherapy early in disease course by transfusing whole blood or plasma donated from a
convalescent patient.
Renal: Advanced stage may lead to impaired kidney function, increased creatinine and BUN, and
decreased urine output. Renal failure has been repor ted in fatal cases. Patients may experience
persistent oliguria, hematuria and proteinuria despite IV fluid resuscitation. Repor ts of peritoneal and
hemodialysis show no consistent correlation on sur vivability, and transmission risk to healthcare workers
should be considered. Hepatic: Patients demonstrate impaired liver function, hepatomegaly and elevated
liver enzymes (ALT/AST), but severity is lower than that seen in hepatitis A/B or yellow fever. One study
showed AST was several times higher than ALT in fatal cases.
Pain Management2,14-16
Treat mild pain with acetaminophen and moderate to severe pain with opioids. Avoid diclofenac,
ibuprofen and other NSAIDS due to antiplatelet activity; avoid tramadol due to seizure activity. The
management of pain resembling the approach to a critically ill patient with potential multi-organ failure
should be followed due to high risk of renal and hepatic failure.
Monitor the patient for confusion, anxiety and seizures. Treat anxiety and seizures with benzodiazepines.
Avoid the use of other medications that may reduce seizure threshold. Late in the disease progression,
monitor neurologic status for increased intracranial pressure and intracranial hemorrhage.
Provide rehydration therapy to prevent volume depletion. Correct abnormal electrolytes. Proton pump
inhibitors should be administered for dyspepsia and gastrointestinal bleed prophylaxis. Administer
antiemetics for nausea/vomiting. Monitor for dehydration.
Sur vivability2,3
Dependent upon access to basic care and patient immune status. Current West Africa Ebola strain has
repor ted 70% mor tality rate (October 14, 2014).
Recover y2,13
Recover y (weeks to months) is highly dependent on suppor tive care and immunologic response of
patient. Men can still transmit Ebola virus through semen for up to 3 months so abstinence is
encouraged during this time. Once fully recovered, patients are no longer able to transmit the virus.
Development of antibodies last at least 10 years but it is unknown if this confers lifelong immunity or
if infection with other strains is possible. Acute complications include: generalized weakness, weight
loss, headache, sensor y distor tion, migrator y ar thralgias, skin sloughing, alopecia, and persistent anemia.
Uveitis and orchitis can occur weeks after illness, and virus can persist in aqueous humor and semen.
Experimental Therapies2,4
No experimental vaccines or antiviral medications have been fully tested for safety or efficacy. ZMapp
(Mapp Biopharmaceutical, Inc.), is an experimental treatment of three monoclonal antibodies that bind
to viral protein. All available doses have been distributed at this time. Several experimental vaccines and
treatments in animal models show promise.
217
Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. World Health Organization. World Health Organization ,
2014. April 2014. Level 3
2.
Ebola (Ebola Virus Disease). Centers for Disease Control and Prevention website http://www.cdc.gov/vhf/ebola/. Updated October 3, 2014. Accessed October 16, 2014.
3.
WHO finds 70 percent Ebola mortality rate. Aljazeera.com Aljazeera America, 15 Oct 2014. Web. 16 Oct 2014.
4.
Ansari AA. Clinical features and pathobiology of Ebola virusinfection J Autoimmun 2014 Sep 23. Doi: 10.1016/j.jaut/2014.09.001. [Epub ahead of print] Level 3
5.
Kortepeter MG, Salwer JV, Hensley LE, et al. Real-time monitoring of cardiovascular function in rhesus macaques infected with Zaire ebolavirus. J Infect Dis 2011 Nov;204
Suppl 3:S1000-10. Animal study
Level 3
6.
Clark DV, Jahrling PB, Lawler JV. Clinical management of filovirus-infected patients. Viruses. 2012; 4, 1668-1686. Level 3
7.
Tan DX, Korkmaz A, Reiter RG, Manchester LC. Ebola virus disease: potential use of melatonin as treatment. J Pineal Res. 2014 Sep 27. doi: 10.1111/jpi.12186. [Epub
ahead of print] Level 3
8.
Ebola Clinical Care Guidelines: a guide for clinicians in Canada. http://www.ammi.ca/media/69846/Ebola%20Clinical%20Care%20Guidelines %202%20Sep%202014.
pdf. Updated August 29, 2014. Accessed October 16, 2014. Level 3
9.
Feldmann H, Geisbert TW. Ebola haemorrhagic fever. The Lancet. 2011;377(9768):849-62. Level 3
10.
Fowler RA, Fletcher T, Fischer WA, 2nd, Lamontagne F, Jacob S, Brett-Major D, et al. Caring for critically ill patients with ebola virus disease. Perspectives from west Africa.
Am J Respir Crit Care Med. 2014;190(7):733-7. Level 3
11.
Mupapa K, Massamba M, Kibadi K, Kuvala K, Bwaka, et al. Treatment of ebola hemorrhagic fever with blood transfusion from convalescent patients. J Infect Dis. 1999;
179(Suppl 1):S18-23. Level 2
12.
Roddy P, Colebunders R, Jeffs B, et al. Filovirus hemorrhagic fever outbreak case management: a review of current and future treatment options. Infect Disease. 2011; 204:
S791-S795. Level 3
13.
Kortepeter MG, Bausch DG, Bray M. Basic clinical and laboratory features of filoviral hemorrhagic fever. Infect Disease. 2011; 204: S810-S816. Level 3
14.
WHO: IMAI District Clinician Manual: Hospital Care for Adolescents and Adults- Guidelines for the Management of Common Illnesses with Limited Resources, 2011.
Available at http://apps.who.int/iris/bitstream/10665/ 77751/1/9789241548281_ Vol1_eng.pdf. Level 3
15.
Sprecher A. Filovirus haemorrhagic fever guidelines. Mdecins Sans Frontires Belgium 2013. (in draft) Level 3
16.
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care
Med 2013; 41:263. Level 3
219
L903337
Multiple-Choice Questions
57. What is the first part of ones body attacked by the Ebola virus?
A. The adrenal system
B. Vascular system causing hemorrhage
C. Immune system by infecting dendritic cells
D. Gastrointestinal tract causing diarrhea
58. To manage pain in patients with Ebola Virus Disease (EVD), clinicians should:
A. administer NSAIDS such as ibuprofen.
B. avoid tramadol due to potential seizure activity.
C. administer aspirin.
D. None of the above
59. Which of the following medications is recommended to provide neurological support to patients
with EVD who experience anxiety, confusion, and seizures?
A. Benzodiazepines
B. Opioids
C. Selective serotonin reuptake inhibitors
D. Selective norepinephrine reuptake inhibitors
60. For patients who fully recover from the Ebola viral infection:
A. patients have immunity to all known strains of the Ebola virus.
B. individuals develop antibodies for a lifetime.
C. men can still transmit the virus through semen for up to 3 months.
D. None of the above
221
Are U.S. hospitals ready to care for patients with Ebola virus disease (EVD)?
Yes any U.S. hospital that is following CDCs infection control recommendations and can isolate a patient in a
private room is capable of safely managing a patient with EVD. CDC recommends that U.S. hospitals isolate the
patient in a private room and implement standard, contact, and droplet precautions.
The information presented herein is based upon the content in the associated CMElesson. If you have comments or feedback about this page,
please send your feedback via email to: editorial@hatherleighpress.com and reference the ID number under the title to which you are referring.
We will review your commentary, which may be used for publication.
The material in this journal is not a substitute for seeking the attention of a licensed health or medical clinician. These materials were created for professional education
purposes only and are not the express opinion of The Hatherleigh Company, Ltd.
What should U.S. hospitals do if they have a patient with suspect EVD?
Early recognition is critical for infection control. Healthcare providers should be alert for and evaluate any patients
suspected of having EVD who have (see EVD case definition):
1. A fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe
headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage;
AND
2. Risk factors within the past 3 weeks before the onset of symptoms, such as contact with blood or other body fluids
of a patient known to have or suspected to have EVD; residence inor travel toan area where EVD transmission is
active; or direct handling of bats or nonhuman primates from disease-endemic areas. Malaria diagnostics should also
be a part of initial testing because it is the most common cause of febrile illness in persons with a travel history to the
affected countries.
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Restrict visitors: Avoid entry of visitors into the patients room. Exceptions may be considered on a case by case basis
for those who are essential for the patients wellbeing. A logbook should be kept to document all persons entering the
patients room. See CDCs infection control guidance on procedures for monitoring, managing, and training of visitors.
Avoid aerosol-generating procedures: Avoid aerosol-generating procedures. If performing these procedures, PPE
should include respiratory protection (N95 or higher filtering facepiece respirator) and the procedure should be
performed in an airborne infection isolation room.
Implement environmental infection control measures: Diligent environmental cleaning and disinfection and safe
handling of potentially contaminated materials is of paramount importance, as blood, sweat, vomit, feces, urine and
other body secretions represent potentially infectious materials should be done following hospital protocols.
Why do responders in Africa wear so much personal protective equipment (that can
include full body suits) for this Ebola outbreak when CDC says hospitals here could
safely manage the care of an Ebola patient without a full body suit?
There are important differences between providing care or performing public health tasks in Africa versus in a U.S.
hospital.
In field medical settings, additional PPE may be necessary to protect healthcare workers. In some places in Africa,
workers may not have the ability to prepare for potential exposures. For example, in some places, care may be provided
in clinics with limited resources (e.g., no running water, no climate control, no floors, inadequate medical supplies),
and workers could be in those areas for several hours with a number of Ebola infected patients. Additionally, certain
job responsibilities and tasks, such as attending to dead bodies, may also require different PPE than what is used when
providing care for infected patients in a hospital.
Content source:
Centers for Disease Control and Prevention
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
Division of High-Consequence Pathogens and Pathology (DHCPP)
Viral Special Pathogens Branch (VSPB)
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