S pneumoniae: eradicated in - Asociacion Medica de Puerto Rico

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B LETÍN
Asociación Médica de Puerto Rico
CONTENIDO
3 MENSAJE DEL PRESIDENTE
Rolance G. Chavier Roper, MD
Editorial
5 50 ANIVERSARIO DEPARTAMENTO DE PSIQUIATRIA ESCUELA DE MEDICINA – UNIVERSIDAD DE
PUERTO RICO
Lelis Nazario MD, Luz N. Colon Martí MD
Original articles/articulos originales
7 CYP2D6 GENOTYPES IN PUERTO RICAN PSYCHIATRY PATIENTS WITH INTOLERANCE OF ANTIDEPRESSANTS AND ANTIPSYCHOTICS
G M Gonzalez-Tejera, MD, S Corey PhD
13 EPIDEMIOLOGICAL PROFILE OF PSYCHIATRIC
CONSULTATIONS AT THE UNIVERSITY PEDIATRIC HOSPITAL
Myrangelisse Ríos Pelati MD, María del Mar Estremera MD, Karen
Martínez MD, Annette Pagán MD
18 JOB SATISFACTION OF A GROUP OF SURGICAL
AND NON-SURGICAL PHYSICIANS AT A HISPANIC
ACADEMIC MEDICAL CENTER, 2006-2007
Luz N. Colón-de Martí, MD , Linnette Rodríguez-Figueroa, MSc PhD
23 A SOCIO-DEMOGRAPHIC, PSYCHIATRY AND MEDICAL PROFILE OF INPATIENT SUICIDE ATTEMPTERS IN A PSYCHIATRY HOSPITAL OF PUERTO
RICO (AO)
Gabriel L. Martínez, MD, Raquel Herrero MD, Christine Fabelo MD,
Diana Diaz MD, Vilma McCarthy, MD.
31 ATTENTION DEFICIT HYPERACTIVITY DISORDER
IN FIVE SCHOOLS OF THE SAN JUAN METROPOLITAN AREA . ASSESSMENT OF TEACHER’S
KNOWLEDGE
Gloria González Tejera MD, Mari González PhD, Beatriz Ramírez MD,
Maralexis Rivera MD
36 MARITAL AND JOB SATISFACTION OF A GROUP
OF SURGICAL AND NON-SURGICAL PHYSICIANS
AT A HISPANIC ACADEMIC MEDICAL CENTER,
2006-2007
Luz N Colón-de Martí MD, Luis F Acevedo MD, Wayca R CéspedesGómez MD.
Portada
Don Victor Bernal y del Rio, MD
Review articles/articulos de resena
42 MANIFESTACIONES CLÍNICAS DEL TRASTORNO
DE DÉFICIT DE ATENCIÓN E HIPERACTIVIDAD
EN LA POBLACIÓN DE PUERTO RICO
Lelis L Nazario MD
45 CONFIDENCIALIDAD COMO RESPONSABILIDAD
ETICA Y DEBER LEGAL
Tamara Arroyo Cordero MD, JD
47 RISK OF SEROTONIN SYNDROME WITH COMPLEMENTARY AND ALTERNATIVE MEDICINES:
IMPORTANCE TO CHILD AND ADOLESCENT PSYCHIATRY
Gloria M. Suau MD*, Karen G. Martínez MD
51 ATYPICAL ANTIPSYCHOTICS IN THE MANAGEMENT OF BEHAVIORAL SYMPTOMS ASSOCIATED
WITH DEMENTIA: A REVIEW
Juan J González-Concepción, MD, Kenneth Geil, MD, Ivonne Z Jiménez-Velázquez, MD, FACP, Cristina Ramos-Romey, MD.
54 PRINCIPIOS BIOETICOS: LA PLANIFICACION
ADELANTADA
José Ramírez Rivera, MD, Jorge J. Ferrer, PhD
Case report/reporte de casos
59 SERTRALINE-INDUCED PANIC ATTACK
Nereida González-Berríos, MD
Historical articles/articulos de historia
61 HISTORIA DEL DEPARTAMENTO DE PSIQUIATRIA
Miguel González Manrique, MD
63 EL DR. BERNAL Y DEL RIO SIGUE PRODUCIENDO
Nestor J. Galarza, MD, DFAPA
BOLETIN - Asociación Médica de Puerto Rico
Ave. Fernández Juncos Núm. 1305
P.O.Box 9387 - SANTURCE, Puerto Rico 00908-9387
Tel.: (787) 721-6969 - Fax: (787) 724-5208
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Juan Laborde-Crocela en el Departamento de Informática de la
AMPR
E-mail: [email protected]
JUNTA DE DIRECTORES
Dr. Rolance G. Chavier Roper
Presidente
Dra. Ilsa Figueroa
Dr. Eduardo Rodríguez Vazquez
Presidente Distrito Este
Presidente Saliente
Dr. Gustavo Cedeño Quintero
Dr. Pedro Zayas Santos
Presidente Distrito Noreste
Secretario
Dr. Roberto Perez Nieves
Dr. Benigno López López
Presidente Distrito Sur
Tesorero
Dra. Hilda Ocasio Maldonado
Dra. Mildred R. Arché Matta
Vicepresidente
Presidente Distrito Central
Dr. Raúl Castellanos Bran
Dra. Wanda G. Velez Andujar
Vicepresidente
Presidente Consejo de Educación Medica
Dr. Raúl A. Yordán Rivera
Dr. José C. Román de Jesus
Vicepresidente
Presidente Consejo Ético Judicial
Dr. Arturo Arché Matta
Dr. Edgardo Rosario Burgos
Presidente Cámara Delegados
Presidente Consejo Relaciones y Servicios Públicos
Dr. Juan Rodríguez del Valle
Dr. Modesto Gonzalez del Rosario
Vicepresidente Cámara de Delegados
Presidente Consejo Servicios Médicos
Dr. Gonzalo González Liboy
Dr. Jaime M. Diaz Hernandez
Delegado AMA
Presidente Consejo Salud Pública y Bienestar Social
Dr. Rafael Fernández Feliberti
Dr. Rafael Fernández Soltero
Delegado Alterno AMA
Presidente Consejo Política Pública y Legislación
Dr. Ricardo Marrero Santiago
Dr. Rafael Fernández Feliberti
Delegado Alterno AMA
Presidente Comité Asesor Presidente
Dr. Julio de la Cruz
Presidente Comite de Finanzas
JUNTA EDITORA
Humberto Lugo Vicente, MD
Presidente
Luis Izquierdo Mora, MD
Juan Aranda Ramírez, MD
Melvin Bonilla Félix, MD
Francisco J. Muñiz Vázquez, MD
Carlos González Oppenheimer, MD
Walter Frontera, MD
Eduardo Santiago Delpin, MD
Mario. R. García Palmieri, MD
Francisco Joglar Pesquera, MD
Raúl Armstrong Mayoral, MD
Yocasta Brugal, MD
José Ginel Rodríguez, MD
3
MENSAJE DEL
PRESIDENTE
DE LA ASOCIACIÓN
MÉDICA DE
PUERTO RICO
Rolance G. Chavier-Roper, MD
Estimados Colegas lectores de la revista científica “Boletín”:
E
s un placer saludarles mediante este escrito.
El compromiso de la Asociación Médica de Puerto Rico
con la educación médica y la Academia esta hoy más
fuerte que nunca. Es por eso que me place presentarles
este nuevo número dedicado a la especialidad de Psiquiatría.
Como ustedes saben, el principal problema de
salud en Puerto Rico es la salud mental. En estos turbulentos tiempos que vivimos, los estresores a los que
se enfrenta nuestra sociedad son cada vez más agudos y
fuertes. Son de gran preo-cupación las estadísticas sobre
la violencia en todas sus manifestaciones. Una de las
más significativas es la tasa de suicidios durante este año;
que aún sólo en su séptimo mes al momento de escribir
esta reflexión ya sobrepasa el número de víctimas total
del año pasado.
La depresión, ansiedad y sentimientos de impotencia ante los problemas que nos aquejan requieren de la
más apremiante atención.
Es de gran importancia el facilitar el acceso del
paciente promedio al equipo multidisciplinario que atiende los problemas de salud mental. Nuestro actual sistema
de salud debe asegurarse de seguir preparando médicos
psiquiatras que puedan atender a nuestros pacientes con
desórdenes neuro-psiquiatricos con la misma intensidad
que se atienden otras condiciones médicas.
Esta edición, se la dedicamos a un gran profesor
de psiquiatría quien estuvo muy ligado a la Academia.
Se trata del Dr. Víctor Bernal y del Río, quien fue un
eminente psiquiatra seguidor de la filosofía Freudiana y
practicante de la psicoterapia. Muchos de los psiquiatras
de hoy día y médicos en general pasaron por sus manos y
aprendieron de sus técnicas.
Sé que van a disfrutar los artículos contenidos en
esta edición. Deseo agradecer a la Junta Editora por su
proficiente y esmerada labor que resulta en una publicación de excelencia y alta calidad.
Dr. Rolance G. Chavier Roper
Presidente,
Asociacion Médica de Puerto Rico
Boletín de la Asociación Médica de Puerto Rico - Volumen 101 - Núm. 1 Enero-Marzo 2009
(In vitro data; clinical significance unknown.
Full course of therapy is complete in 7 days.)1,2
n
ZYMAR® ophthalmic solution rapidly eradicates
key pathogens in vitro, including:
S aureus: eradicated in 15 minutes1,*
S epidermidis: eradicated in 30 minutes1,*
S pneumoniae: eradicated in 10 minutes2,*
H influenzae: eradicated in 5 minutes2,*
* Time to reach kill threshold. 10 CFU/mL is the lower limit of detection and is
indistinguishable from complete kill.
ZYMAR® ophthalmic solution is indicated for the treatment of bacterial conjunctivitis caused by susceptible strains
of the following organisms: Corynebacterium propinquum,† Staphylococcus aureus, Staphylococcus epidermidis,
Streptococcus mitis,† Streptococcus pneumoniae, and Haemophilus influenzae. (†Efficacy for this organism was studied
in fewer than 10 infections.)
Important Safety Information: NOT FOR INJECTION. ZYMAR® ophthalmic solution should not be injected
subconjunctivally, nor should it be introduced directly into the anterior chamber of the eye. As with other antiinfectives, prolonged use may result in overgrowth of nonsusceptible organisms, including fungi. If superinfection
occurs, discontinue use and institute alternative therapy. Patients should
be advised not to wear contact lenses if they have signs and symptoms of
bacterial conjunctivitis.
®
The most frequently reported adverse events occurring in approximately 5%
to 10% of the overall study population were conjunctival irritation, increased
lacrimation, keratitis, and papillary conjunctivitis.
Please see brief prescribing information on adjacent page.
1. O’Brien TP. Antimicrobial efficacy of ZYMAR® and Vigamox® against Staphylococcus species. Refract Eyecare Ophthalmol. 2003;7(12):15-18. 2. Novosad BD, Callegan MC.
Killing of Streptococcus pneumoniae, methicillin-resistant Staphylococcus aureus (MRSA), and Haemophilus influenzae ocular isolates by fourth-generation fluoroquinolones.
Poster presented at: 78th Annual Meeting of the Association for Research in Vision and Ophthalmology; April 30-May 4, 2006; Fort Lauderdale, FL.
©2009 Allergan, Inc., Irvine, CA 92612
www.allergan.com
® marks owned by Allergan, Inc.
ZYMAR® is licensed from Kyorin Pharmaceutical Co., Ltd., Tokyo, Japan.
APC50TC09
803807
5
RESUMEN
Editorial
El Departamento de Psiquiatría de la Escuela de Medicina de la Universidad de Puerto Rico
celebra su 50 Aniversario de fundado. Se describe
cual ha sido su misión a través de sus tres funciones cardinales: Adiestramiento, Servicio e Investigación. Sus programas de adiestramiento han preparado
aproximadamente 243 Psiquiatras y 65 Psiquiatras
de Niños y Adolescentes además de participar en la
educación de estudiantes de medicina y otras profesiones relacionadas a la salud durante esos años. Se
han ofrecido servicios clínicos de la más alta calidad
y se ha contribuido dentro del área de la investigación. Se describen las nuevas metas del Departamento dentro de las cuales está el Centro de Medicina
Psicosomática y Ansiedad (CEMPAS).
50 ANIVERSARIO
DEPARTAMENTO
DE
PSIQUIATRIA
ESCUELA DE MEDICINA
UNIVERSIDAD DE PUERTO RICO
E
l Departamento de Psiquiatría de la Escuela de Medicina de la UPR a través de los tiempos
ha asumido la misión de promover el desarrollo de estrategias innovadoras para contribuir a servir las necesidades de nuestro pueblo en el campo de la salud
mental. Esta misión se realiza a través de funciones
cardinales : el adiestramiento, el servicio y la investigación.
Lelis Nazario MD*
Luz N. Colon Martí MD**
* Directora del Departamento de Siquiatría y del Progra-
El Programa de adiestramiento en Psiquiatría ma de Psiquiatría de Niños y Adolescentes [email protected].
General tuvo su inicio en el año 1957 y tuvo su primera ** Directora Programa de Psiquiatría General <[email protected].
acreditación por el “Accreditation Council of Gradua- edu>. UPR Escuela de Medicina, Recinto de Ciencias Medicas.
te Medical Education “( ACGME) en el año 1958. Su
Dirección de los autores: Departamento de Psiquiatría, Reprimer Director de Adiestramiento lo fue el Dr. Juan Enrique Morales. En el año 1960 se graduó la primera cinto de Ciencias Medicas PO BOX 365067, San Juan, PR 00936.
clase de este programa. En el año 1965 se establece el
Programa de “Fellowship” de Psiquiatría de Niños y
Adolescentes siendo su primer Director el Dr. Alfredo
Figadero. El Dr. Jesús Infanzón Ochoteco fue el pricalidad a una población de múltiples y complejas necesidades y
mer Residente que completó esta sub-especialidad.
proveerle talleres óptimos de aprendizaje a nuestros residentes
Dentro del área de adiestramiento comparti- y estudiantes que cumplan con las exigencias impuestas por las
mos los logros de los programas de adiestramiento diferentes agencias de acreditación que nos rigen.
en Psiquiatría General y Psiquiatría de Niños y Adolescentes, cuya excelencia académica se evidencia a Nuestra tercera función principal ha sido el área de la
través de un historial distintivo por exitosos e ininte- investigación la cual ha estado evolucionando y transformánrrumpidos procesos de acreditación. De acuerdo a los dose extraordinariamente. Al presente el Departamento cuenta
datos disponibles aproximadamente 243 egresados con un excelente equipo de investigación el cual está abriendo
completaron su adiestramiento en nuestro programa paso para la excitante tarea de traducir los hallazgos investide adiestramiento de Psiquiatría General y 65 en el gativos al área clínica, lo que es conocido como “translational
de Psiquiatría de Niños y Adolescentes (Gráficas I-V). research”, específicamente en el área de ansiedad y extinción de
La calidad profesional de estos egresados se demues- respuestas de miedo.Nuestra meta más inmediata es establecer
tra a través de las múltiples aportaciones generadas a el Centro de Medicina Psicosomática y Ansiedad (CEMPAS).
través de los tiempos.
En este Centro continuaremos nuestra labor de investigación,
de ofrecer adiestramientos y servicios clínicos a pacientes con
Nuestra función departamental en el área de trastornos de ansiedad y aspectos emocionales de otras condiservicio ha cumplido dos propósitos principales: brin- ciones médicas. Esta excitante tarea la comparten la Facultad y
darle al pueblo de Puerto Rico servicios de la más alta Residentes dentro de un excelente equipo de trabajo.
6
Cada etapa vivida en nuestro desarrollo como
Departamento, ha sido una de grandes retos únicos e interesantes caracterizados por una gran pasión, compromiso
y fervor.
Número de Egresados
70
60
50
40
30
20
10
0
1960's
1970's
1980's
1990's 2000-08
5
3
Femeninas
Masculinos
# de Egresados
Gráfica IV:Distribución de Egresados del
Programa de Psiquiatría de Niños y
Adolescentes por Décadas y Géneros
11
11
7 7
3 3
2000-08
31
Femeninas
15
Masculinos
9
s
00
'
s
20
90
'
s
19
80
'
s
s
0
Gráfica V: Comparación Número de
Egresados de los programas de
Psiquiatría General y de Psiquiatría de
Niños y Adolescentes por Décadas
Décadas
78
1990's
Décadas
0
70
60
50
40
30
20
10
61
52
48
42
8
40
15
18
10
General
N/A
14
0
1960's
1970's
1980's
1990's 2000-08
Décadas
19
60
19 's
70
19 's
80
19 's
9
20 0's
00
-0
8
Número de
Egresados
10
17
10
19
14
5
15
10
5
0
20
10
8
10
1980's
37
32
29
25
30
19
15
38
40
19
Número de
Egresados
15
1970's
Gráfica II : Distribución de Egresados
del Programa de Psiquiatría General
por Décadas y Género
60
'
18
20
40
Décadas
Número de Egresados
Gráfica III: Distribución de Egresados
del Programa de Psiquiatría de Niños y
Adolescentes por Décadas
52
42
1960's
Caminamos hacia el futuro con el lema que nos
rige y nos ha caracterizado:
“A la vanguardia en educación, investigación y
servicio; comprometidos con la salud mental del pueblo
puertorriqueño”.
61
48
70
'
Nos sentimos honrados en proclamar que a través
de estos primeros cincuenta años de existencia, el Departamento de Psiquiatría de la Escuela de Medicina de la
Universidad de Puerto Rico ha cumplido cabalmente con
su responsabilidad, gracias a la incalculable aportación
de nuestros distinguidos fundadores, a los emprendedores ex-directores de departamento y de programas, a la
excelente facultad que día a día se esfuerza para hacer
realidad nuestras metas, a los residentes que confían su
formación en nosotros y nos ayudan con su compromiso de trabajo, al inestimable personal administrativo que
constituyen el armazón del edificio, a nuestros imponderables egresados y amigos en general.
Gráfica I :Distribución de Egresados
del Programa de Psiquiatría General
por Décadas
Décadas
ABSTRACT
The Department of Psychiatry of the University
of Puerto Rico was established 50 years ago. We describe
its mission and accomplishments in Education, Clinical
Services and Research. We are proud of our achievements
in preparing 243 General Psychiatrists and 65 Child /
Adolescent Psychiatrists as well as participating in the
education to medical students and other health related
disciplines. There have being other excellent contributions in Clinical Services and Research. The Department
will continue it’s commitment with the education of Residents and students and offering high quality clinical
services based on up-to date research. An example of that
is the establishment of the CEMPAS, an anxiety specialty
center with special interest in psychosomatic medicine.
7
Original Articles/Articulos Originales
ABSTRACT
The highly polymorphic enzyme cytochrome P450 2D6 metabolizes about 20% of all drugs,
including many antidepressants and antipsychotics.
Individuals with mutant CYP2D6 alleles may be at
increased risk for adverse drug reactions. We genotyped the CYP2D6 locus in 45 Puerto Rican psychiatry patients who had reported intolerance to antidepressants and/or antipsychotics. Three quarters
of the group had at least one mutant allele. Twentyone percent of the alleles had reduced activity, and
eighteen percent were inactive. Two patients could
not be genotyped by the microassay. Elevated basal metabolic index was common, except among
patients who were homozygous extensive metabolizers. Compared to other populations that have been
amply studied, Puerto Ricans may have relatively
fewer inactive alleles and relatively more reducedactivity alleles.
Index words: CYP2D6 genotype, Puerto Rico, antidepressant, antipsychotics
INTRODUCTION
A
dverse drug reactions rank among the leading causes of death in the United States, ahead of pulmonary disease, diabetes, HIV/AIDS, pneumonia and
accidents, according to Institute of Medicine data (1, 2).
Adverse drug reactions are more common among patients
who do not metabolize drugs normally, while treatment
failure may be more frequent in patients who metabolize
drugs unusually well (3). For most drugs, the first phase
of metabolism is handled by cytochrome P450, a family
of mixed function oxidases. Cytochrome CYP2D6, which
metabolizes 20-30% of therapeutic drugs including antidepressant and antipsychotic drugs and beta-blockers in
hypertension, is known to be encoded by a highly polymorphic gene (4).
CYP2D6 GENOTYPES
IN PUERTO RICAN
PSYCHIATRY
PATIENTS WITH
INTOLERANCE OF
ANTIDEPRESSANTS
AND
ANTIPSYCHOTICS
G M Gonzalez-Tejera, MD*
S Corey PhD*
From the *Department of Psychiatry, University
of Puerto Rico School of Medicine, and **Department of
Pharmacology and Toxicology, University of Puerto Rico
School of Medicine.
Address rerprints requests: Susan Corey, PhD,
Institute of Neurobiology, 201 Blvd del Valle, San Juan,
PR 00901. Email: [email protected]
two fully functional alleles. Some authors also recognize
the Intermediate Metabolizer (IM) phenotype in individuals with one reduced activity allele and one allele that
is not EM, i.e., inactive or decreased activity. At present 70 CYP2D6 alleles are recognized by
the Human Cytochrome P450 (CYP) Allele Nomenclature Committee (5, 6). The prevalence of variant CYP2D6
alleles varies among world populations (7). This fact is
acknowledged in the new Food & Drug Agency (FDA)
guidelines for clinical trials that recommend collection of
“ethnic and racial” data, since distinct subpopulations in
the USA respond differently to drugs (8).
The frequencies of mutant CYP2D6 allleles have
been studied in many European, Asian, Sub-Saharan and
North African populations (7). The metabolic capacities
of several populations are notable. For example, onefifth to one-third of Ethiopians and Saudi Arabians carry
gene duplications, making them ultra-rapid metabolizers.
Asian populations, on the other hand, have high frequencies of *10, a reduced activity allele. Europeans have the
highest frequencies of null and inactive alleles, such as
*4 and *5.
The metabolic capacity, phenotype, is predicted
by the number of active alleles. Hence, extensive metabolizers (EM) have at least one fully functional allele.
Poor metabolizers (PM) have two or more inactive alleles caused by gene deletion or harmful amino acid substitutions. Ultrarapid metabolizers (UM) have more than
Genetic frequencies are difficult to predict in New World
populations. For example, African Americans have higher frequencies of the *17 allele, a reduced activity allele, than many African populations (9). On the other hand,
Amerindians, a group that originally migrated from Asia,
have relatively low frequencies of *10, compared to the
8
high prevalence of *10 that characterizes most Asian
populations. Although numerous studies have examined
the CYP2D6 alleles in indigenous populations of Central
and South America (for example, 10), few general statements are possible, and populations appear to be widely
divergent.
Puerto Ricans are an admixed Caribbean population with genetic origins in European, African and Amerindian populations. Admixture began as early as 150709 with the introduction of African slaves to work with
Amerindian slaves in the gold mining enterprise (11).
Amerindians present in sixteenth century Puerto Rico included resident Tainos, as well as Amerindians brought
from Central and South America before slavery was prohibited for Amerindians in 1520. Caribbean Indians also
continued to raid the island during the early period of
the Spanish occupation (12). Although no ethnic Amerindians remain in Puerto Rico, Martinez-Cruzado has
estimated that more than 50% of Puerto Ricans carry
Amerindian mitochondrial markers (12).
Puerto Rico is a health disparity population in
terms of mental health disorders, diabetes mellitus, and
hypertension (13). Many antidepressants and antipsychotics, as well as beta blockers for hypertension are metabolized primarily by cytochrome P450. Therefore, it is
relevant to determine the metabolic capacity of Puerto
Ricans for these medications.
As a first step, we wanted to determine if there is
evidence that the distribution of CYP2D6 alleles among
Puerto Ricans is different from that already determined in
many European populations. We determined the CYP2D6
genotype in 45 Puerto Rican psychiatry patients using a
DNA microarray analysis. In order to identify the most
common inactive and poorly active alleles, we enriched
the gene pool by selecting patients who had adverse reactions or intolerance of antidepressants and antipsychotics
that are metabolized by CYP2D6. The results suggest
that European and African profiles are inadequate to determine the relative risk for adverse drug events in Puerto
Ricans.
MATERIALS AND METHODS
Patient recruiting. Inclusion criteria for participation in the study were (i) to be a native Puerto Rican,
at least 18 years old, with all parents and grandparents
born in Puerto Rico, (ii) ever having had an adverse drug
reaction related to atomoxetine or any antidepressant or
antipsychotic metabolized by cytochrome P450 2D6, (iii)
having no risk of suicide. Five non-qualifying individuals
with one grandparent born outside Puerto Rico were incorrectly included, but data are not presented. Qualifying
drugs included (antidepressants) amitriptyline, clomipramine, desipramine, imipramine, nortriptyline, paroxetine,
duloxetine, venlafaxine and (antipsychotics) haloperidol,
risperidol, thioridazine, chlorpromazine, perphenazine.
Bupropion, which inhibits cytochrome P450 2D6 was accepted only if used in combination with one of the above
(14).
Participants were recruited between March and
August 2008 from three general population groups: private patients who answered announcements in the press
or were referred by their psychiatrist (n=12), patients of a
metropolitan public mental health facility (n=18), and inpatients of the state psychiatry hospital (n =20). Detailed
income data were not obtained; nonetheless, patients of
the public mental health facilities are known to be medically indigent. Written informed consent was obtained
from all participants. Permission to access patients at the
public mental health clinics and hospitals was granted
by a research review board from ASSMCA, the Agency
for Mental Health and Against Addiction. This study was
approved by the Institutional Review Board of the University of Puerto Rico Medical Sciences Campus (San
Juan, Puerto Rico).
Genotyping. Peripheral blood was obtained from
all participants. Samples were maintained frozen at -20
oC for no longer than one month before being shipped
to Esoterix Laboratory (Research Triangle Park, North
Carolina). Laboratory personnel isolated leukocyte DNA
and performed the genotyping using the AmpliChip microarray (Roche Molecular Systems, Inc. and Affymetrix, Inc)(15). The AmpliChip is approved by the FDA
to determine genotypes for CYP2D6 and CYP2C19. The
twenty-seven CYP2D6 alleles that can be diagnosed include *1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, 17, 19, 20, 29,
35, 36, 40, 41, 1XN, 2XN, 4XN, 10XN, 17XN, 35XN,
41XN.
Personal information. After obtaining written informed consent, each participant was interviewed to obtain personal information to ensure qualification. Blood
pressure, height, weight and waist measurements were
obtained either from the patient’s record or by direct determination. The patient provided a list of medications
used during the period when the adverse events occurred.
Quantification of adverse effects. The UKU side
effects instrument (16) was administered by a boardcertified psychiatrist to quantify adverse events related
to antidepressants and antipsychotics metabolized by
CYP2D6. Patients were asked to rate the intensity of
their side effects on a scale of 0 to 3. Four categories of
side effects were evaluated: psychiatric, neurologic, autonomic and other.
RESULTS
Participants. The participants included forty-five
participants, all native Puerto Ricans, who had experienced adverse effects with antidepressants, antipsychotics
or atomoxetine and five controls. The ages were 42. 1 ±
15.5 years (mean ± SD) for the antipsychotic group and
43.8 ± 12.9 years for the antidepressant group. Seventyfour percent (n=37) were female, and twenty-six percent
(n=13) male.
Genotypes and predicted phenotypes. Phenotypes are assigned according to the following rule:
Extensive metabolizer, one or more fully active
alleles; Poor metabolizer, no active alleles; Intermediate
metabolizer, one inactive or null allele combined with either a null mutant or a reduced activity allele. The impact
of concurrent multiple drugs on the patient’s capacity to
metabolize them is not known at present.
9
Figure 1
A
20
The distribution of genotypes for all participants
is shown in Table I. Twenty-five percent were homozygous for an activity allele, suggesting that their intolerance was due to other factors. The data in Table II
compare the genotypes and predicted phenotypes in the
sub-group of Puerto Rican participants who reported intolerance of antidepressants, not psychotics, with a similar study conducted in Germany (3). Unlike the German
sample in which 29% were poor metabolizers and 2%
intermediate metabolizers, the Puerto Rican sub-group
had no poor metabolizers and 16.7% intermediate metabolizers.
18
Table 3 shows the genotypes and predicted phenotypes in participants with intolerance of antipsychotics. Since many of them reported difficulty with a single
drug, haloperidol, data are reported separated for all antipsychotics and haloperidol alone. The relative proportion of intermediate and poor metabolizers was lower in
this group, 11.2-11.6%, than in participants with intolerance of antidepressants, 16.7%.
The alleles present in two participants were not
among the 27 alleles tested. The list of alleles tested was
based on those commonly present in European, Asian
and African-American populations. Therefore, some relatively uncommon alleles are present in the Puerto Rican population.
Adverse effects. Height and body weight were
used to calculate the basal metabolic rate. According to
standard practice (ref), individuals with BMI greater than
or equal to 30 are considered obese, while individuals
with a BMI between 25 and 29.9 are overweight. In the
antidepressant subgroup (Table IV, A), all participants,
with the exception of the homogozygous EM, were either
overweight or obese. Fewer participants in the antipsychotic subgroup (Table IV, B) had elevated BMI, especially those with at least one fully active allele.
UKU analysis. Overall, side effects scores were
higher for participants taking the antipsychotic haloperidol than for those taking antidepressants. Figure 1 shows
a preliminary analysis of side effects grouped according
to genotype. Results for other antipsychotics are not
shown.
Psychiatric side effects include problems in concentration, memory, depression, tranquility, sleep and
apathy. Among participants taken antidepressants, psychiatric side effects were reported more by participants
with fully active CYP2D6 alleles. On the other hand, there may be a trend for reduced psychiatric side effects in
patients with fully active alleles among patients taking
haloperidol.
Neurologic side effects include dystonia, rigidity, hypokinesia or akinesia, tremors, akatisia, convulsion,
and paresthesias. Relatively high scores were reported by
all participants taking haloperidol, compared with those
taking antidepressants.
0
16
14
12
10
8
6
4
2
UK
O/I
O/E
I/E
E/E
B
20
18
16
14
12
10
8
6
4
2
0
UK
0/0
0/E
I/I
I/E
E/E
FIGURE LEGENDS
Fig. 1. UKU scores in patients with adverse reactions to all antidepressants (A) and haloperidol (B)
according to genotypes. The genotype is shown
along the X-axis. UK, unknown; 0, inactive allele;
I, allele with intermediate activity; E, allele with full
activity. The vertical bars show the average UKU
score for each of four categories of adverse events:
light dotted bar, psychiatric effects; dark dotted bar,
neurological side effects; horizontal stripes, autonomic side effects; slanted stripe, other.
10
Autonomic side effects include problems of accommodation, salivation, nausea and vomiting, diarrhea
and constipation, urination, polyuria and polydipsia, orthostatic hypotension, palpitation, and sweating. These
problems were scored higher by participants taking haloperidol than those taking antidepressants.
Other side effects include rash, photosensitivity,
changes in weight, menorrhagia, amenorrhea, galactorrhea, gynecomastia, changes in libido, erectile dysfunction
or difficulties in ejaculation or orgasm, and headache.
Problems were scored higher by patients taking haloperidol than those taking antidepressants.
The UKU analysis does not strongly support the idea
that reduced activity alleles are associated with adverse
events. Nonetheless, Fig. 1-B shows a trend to lower side
effect scores in the EE and EI groups. Data from a larger
group might provide greater support for the idea.
The absence of ultra-rapid metabolizers from
the adverse effects group was expected. Rau et al. (3)
found that ultra-rapid metabolism was a risk factor for
non-response to antidepressants, and absent from their
sub-group of patients with adverse effects.
TABLE 1
DISCUSSION
The genotyping results suggest that the Puerto
Rican population may have fewer completely inactive
alleles and more intermediate activity alleles than the
German population studied by Rau et al. (3). It should be
noted that the German study used more stringent criteria
for qualifying drug intolerance as an adverse reaction. It
is possible that more poor metabolizers would have been
found in the Puerto Rican sample if a more stringent criterion had been employed.
On the other hand, European populations have
the highest frequency of poor metabolizers among world
populations (4). The Puerto Rican population is multiracial, with genetic influences from European, African and
Amerindian population groups. Many reduced activity
alleles have been detected in African groups, of which
the *17 allele is especially characteristic (17). At present,
no mutant alleles have been identified that might appear
to be characteristic of Amerindian populations.
Reduced activity alleles are more sensitive to
known potent inhibitors of cytochrome P450 2D6, such
as paroxetine, fluoxetine, sertraline and bupropion (18).
When added to a previously-established treatment regime, such inhibitors may cause plasma levels to rise, causing intolerance (19). Six of the study participants taking
antidepressants reported co-administration of bupropion
with other cytochrome P450 2D6 substrates. Antihistamines such as diphenhydramine and hydroxyzine are
also moderate inhibitors of cytochrome P450 2D6 (18),
and were reported to be co-administered with haloperidol. Whether the use of such combinations may influence
the frequency of reported intolerance is not known at present.
Overweight and obesity were very common in all
sectors of this sample, except among the extensive metabolizers. It is possible that extensive metabolism provides some protection against elevated basal metabolic index (BMI) by removing drug from plasma more rapidly
and diminishing the neurochemical signal that underlies
weight gain with psychotropics. Weight gain may not be
perceived as an adverse effect, despite its adverse impact
on many aspects of health. A larger study is needed to
test the association of weight gain with reduced activity
CYP2D6 alleles.
Distribution of predicted phenotypes in Puerto Rican psychiatry patients with adverse events during treatment with antipsychotics and/
or antidepressants.
Assigned
phenotype
Genotype
Frequency
PM
*0/*0
1 (2.5%)
Total PM
IM
*IM/*0
2 (5%)
*IM/*IM
1 (2.5%)
Total IM
EM
*EM/*EM
10 (25%)
*EM/*IM 13 (32.5%)
*EM/*O
11 (27.5%)
Total EM
34 (85%)
UM
*UM/X
0 (0%)
Unknown
Unknown
2 (5%)
2 (5%)
1 (2.5%)
3 (7.5%)
PM, poor metabolizer; IM, metabolizer; EM, extensive metabolizer;
UM, ultra-rapid metabolizer; 0, inactive or null allele; X, any allele.
REFERENCES
1.
Committee on Quality of Health Care in America: Institute
of Medicine. To err is human: building a safer health system. Washington, D.C.: National Academy Press; 2000.
2.
Lazarou J, Pomeranz BH Corey PN. Incidence of adverse drug reactions in hospitalized patients. JAMA 1998; 279, 12001205.
3.
Rau, T., Wohlleben, G., Wuttke, H., Theuerauf, N., Lunkenheimer, J., Lanczik, M., Eschenhagen, T. CYP2D6 genotype: Impact
on adverse effects and nonresponse during treatment with antidepressants- a pilot study. Clin Pharmacol Ther 2004; 75:386-393.
4.
Ingelman-Sundberg M. Human drug metabolising cytochrome P450 enzymes: properties and polymorphisms. Naunyn Schmiedebergs Arch Pharmacol. 2004 Jan;369(1):89-104.
5.
Solus JF, Arietta BJ, Harris JR, Sexton DP, Steward JQ,
McMunn C, Ihrie P, Mehall JM, Edwards TL, Dawson EP. Genetic
variation in eleven phase I drug metabolism genes in an ethnically
diverse population. Pharmacogenomics. 2004 Oct;5(7):895-931.
6.
CYP2D6 allele nomenclature [Internet]. Cytochrome P450
(CYP) Allele Nomenclature Committee. 2008 6 Jul. [cited 2008 23
Sep]; [about 11screens]. Available from: http://www.cypalleles.ki.se/
cyp2d6.htm
11
TABLE II
Antidepressants: Distribution of predicted phenotypes in Puerto Rican psychiatry patients with adverse events during treatment with antidepressants metabolized by cytochrome P450 2D6
Assigned
phenotype
Genotype
Puerto Rico
PM
*0/*0
0 (0%)
0 (0%)
IM
*IM/*0
2 (16.7%)
*IM/*IM
Total
2 (16.7%)
EM
*EM/*EM 1 (8.3%)
18 (64%)
*EM/*IM 2 (16.7%)
*EM/*O
6 (50%)
Total
9 (75%)
UM
*UM/X
0 (0%)
0 (0%)
Unknown
1 (8.3%)
1 (8.3%)
Germany (Ref #3)
8 (29%)
2 (7%)
0 (0%)
0 (0%)
Legend (Table II)
PM, poor metabolizer; IM, intermediate metabolizer; EM, extensive metabolizer; UM,
ultra-rapid metabolizer; 0, inactive or null allele; X, any allele.
TABLE III
Antipsychotics: Distribution of predicted phenotypes in Puerto Rican psychiatry patients with adverse events during treatment
Assigned phenotype Genotype
Haloperidol All antipsychotics
PM
IM
EM
UM
Unknown
1 (5.6%)
0 (0%)
1 (5.6%)
5.6%
6 (33.3%)
5 (27.8%)
4 (22.2%)
83.3%
0
1 (5.6%)
18
*0/*0
*IM/*0
*IM/*IM
Total IM
*EM/*EM
*EM/*IM
*EM/*O
Total EM
*UM/X
Unknown
Total
1 (3.9%)
1 (3.9%)
1 (3.9%)
2 (7.7%)
8 (30.8%)
8 (30.8%)
6 (23%)
22 (84.6%)
0
1 (3.9%)
26
Legend Table III
Patients reported being treated with either haloperidol as the principal antipsychotic (left
column) or other antipsychotic (right column) that is metabolized by cytochrome P450
2D6
12
TABLE IV
A. Antidepressants: Clinical data of patients with adverse effects related to antidepressants, according to assigned
phenotype
Genotype
Scores
*0/*0 *0/*IM
aBMI ³ 30
aBMI 25-29.9
2/2
Total BMI ³ 25
100%
*0/*EM
*IM/*IM
2/6
4/6
100%
*IM/EM
*EM/*EM
1 /2
1/2
100%
0/1
0/1
0%
Unknown
1/1
100%
B. Haloperidol: Clinical data of patients with adverse effects related to haloperidol, according to assigned phenotype
Genotype
Scores *0/*0 *0/*IM
BMI ³ 30
BMI 25-29.9
1/1
Total BMI ³ 25
100%
*0/*EM
*IM/*IM
1/5
1/1
2/5
60%
100%
*IM/EM
3/8
3/8
75%
*EM/*EM
5/11
3/11
73%
Unknown
1/1
100%
19.
Dayer P, Kronbach T, Eichelbaum M, Meyer UA. Enzyma7.
Xie, H-G., Kim, R.B., Wood, A.J.J., and Stein, C.M. Motic basis of the debrisoquine/sparteine-type genetic polymorphism of
lecular basis of ethnic differences in drug disposition and response.
drug oxidation. Characterization of bufuralol 1'-hydroxylation in liver
Annu Rev Pharmacol Toxicol. 2001., 815-850.
microsomes of in vivo phenotyped carriers of the genetic deficiency.
8.
Guidance for Industry. Collection of Race and Ethnicity
Biochem Pharmacol. 1987 Dec 1;36(23):4145-52.
Data in Clinical Trials (September 2005). http://www.fda.gov/cber/
gdlns/racethclin.htm
ACKNOWLEDGEMENTS
9.
Bradford LD. CYP2D6 allele frequency in European Caucasians, Asians, Africans and their descendants. Pharmacogenomics.
We gratefully acknowledge important suggestions from Dr.
2002 Mar;3(2):229-43.
José de Leon and Dr. Jorge Tamayo. Partially supported by an RCMI
10.
Bailliet G, Santos MR, Alfaro EL, Dipierri JE, Demarchi
Clinical Research Infrastructure Initiative award, 1P20RR11126,
DA, Carnese FR, Bianchi NO. Allele and genotype frequencies of
from the National Center for Research Resources, NIH.
metabolic genes in Native Americans from Argentina and Paraguay.
Mutat Res. 2007 Mar 5;627(2):171-7.
11.
Fernandez Mendez E. Las encomiendas y esclavitud de los
RESUMEN
indios de Puerto Rico 1508-1550. Rio Piedras: Editorial de la Universidad de Puerto Rico, 1975. 82 p.
12.
Martínez-Cruzado JC, Toro-Labrador G, Ho-Fung V, Esté
La enzima polimorfica P450 2D6 metabovez-Montero MA, Lobaina-Manzanet A, Padovani-Claudio DA, Sánliza alrededor del 20% de todos los medicamentos,
chez-Cruz H, Ortiz-Bermúdez P, Sánchez-Crespo A. Mitochondrial
incluyendo muchos antidepresivos y antipsicóticos.
DNA analysis reveals substantial Native American ancestry in Puerto
Rico.Hum Biol. 2001 Aug;73(4):491-511.
Las personas con alelos mutantes del CYP2D6 pue13.
Planning for Health Care Improvement for the People of
den tener un riesgo elevado en desarrollar reaccioPuerto Rico, Summary Report, Workshop University of Puerto Rico
nes adversas. Hicimos un estudio de genotipo del
and Vanderbilt Center for Better Health, August, 2008.
CYP2D6 en 45 pacientes puertorriqueños de siquia14.
Kotlyar M, Brauer LH, Tracy TS, Hatsukami DK, Hatría quienes habían reportado intolerancia de antiderris J, Bronars CA, Adson DE. Inhibition of CYP2D6 Activity by
Bupropion.J Clin Psychopharmacol. 2005;25(3):226-229.
presivos y/o antipsicóticos. Tres cuartos del grupo
15.
de Leon J, Susce MT, Murray-Carmichael E. The Amplitenían por lo menos un alelo mutante. Veintiún por
Chip CYP450 genotyping test: Integrating a new clinical tool. Mol
ciento de las alelos tenían actividad reducida, y dieDiagn Ther. 2006;10(3):135-51.
ciocho por ciento eran inactivos. No se podía deter16.
Lingjaerde O, Ahlfors UG, Bech P, Dencker SJ, Elgen K.
The UKU side effect rating scale. A new comprehensive rating scale
minar el genotipo de dos pacientes con el método
for psychotropic drugs and a cross-sectional study of side effects in
empleado. Aumento del índice basal metabólico era
neuroleptic-treated patients. Acta Psychiatr Scand Suppl. 1987;334:1común, excepto entre los pacientes quienes eran ho100.
mocigotos del los alelos funcionales. Comparados
17.
Gaedigk A, Bradford LD, Marcucci KA, Leeder JS. Unique
con otras poblaciones que han sido ampliamente
CYP2D6 activity distribution and genotype-phenotype discordance in
black Americans. Clin Pharmacol Ther. 2002;72:76-89
estudiado, los puertorriqueños parecen tener relati18.
Flockhart DA. Drug Interactions: Cytochrome P450 Drug
vamente pocos alelos inactivos y relativamente mas
Interaction Table. Indiana University School of Medicine (2007).
alelos de actividad reducida.
http://medicine.iupui.edu/flockhart/table.htm. Accessed 30 October
2008.
13
ABSTRACT
Background: Rates of
emotional and behavioral disorders are likely to be higher than
20% in children with chronic
illnesses. Research shows that
children with chronic diseases
have increase likelihood of psychiatric disorders.
Purpose/Method: We
reviewed the 2006 University
Pediatric Hospital consults generated to the Child and Adolescent Psychiatry Fellowship to
create an epidemiological profile.
Results: Of the 241
consults 51% were for male patients, with a peak at 16 years
old. Most consults were requested by Emergency Room.
Patients with malignancies,
neurological, and endocrinological conditions were more
frequently consulted. The most
frequent reason for consultation
was mood complaints. The most
frequent preliminary diagnosis
was Major Depressive Disorder
and Adjustment Disorder. Conclusions: The 2006
psychiatry consults at the University Pediatric Hospital consisted primarily in the request
for evaluation and treatment
of male or female adolescent
patients, who presented mood
symptoms in association with
neurological, malignancy or endocrine diagnosis.
EPIDEMIOLOGICAL PROFILE OF
PSYCHIATRY CONSULTATIONS
AT THE UNIVERSITY PEDIATRIC
HOSPITAL
Myrangelisse Ríos Pelati MD*
María del Mar Estremera MD*
Karen Martínez MD*
Annette Pagán MD*
* From the Department of Psychiatry, UPR School of Medicine, PR Health Science Center.
Address reprints requests: Myrangelisse Ríos Pelati MD, Department of Psychiatry, UPR School of Medicine, PR Health Science Center, PO Box 365067, San Juan Puerto
Rico 00936-5067. E-mail: < [email protected]>.
INTRODUCTION
C
onsultation-liaison psychiatry is the branch of psychiatry that specializes in the interface between other medical specialties and psychiatry, usually taking
place in a hospital or medical setting. The consultation-liaison consultant must have
an extensive clinical understanding of physical/neurological disorders and their relation to psychological/ psychiatric disturbances and ability to identify the social,
environmental, and cultural factors relevant to any psychiatric consultation.
The role of the child and adolescent consultation-liaison psychiatrist includes: the evaluation and treatment of developmental, behavioral, and psychological
problems as manifest in children, adolescents, and families in the medical setting (1);
awareness of the special psychiatric needs of this population in a pediatric setting,
particularly in children facing traumatic medical procedures and hospitalization; and
should be able to appreciate developmental and family issues as they apply to diagnosis and intervention (2). The identified client may be the child, the parent, or the
primary care provider.
The consultant must have an expertise in behavioral effects of medications,
noncompliance with treatment, treatment of chronic pain, reaction to acute and chroIndex words: psychiatry, con- nic medical illness, disorders of attachment, parent-infant relationship difficulties,
speech and language disorders, learning disabilities, psychiatric disorders specific to
sultation, children
childhood (3). The consultation-liaison consultant should have in-depth understanding of medical illness, general knowledge of procedures, medications, hospital routines, and outcomes for children
and adolescent patients. The consultation-liaison psychiatrist is also in charge of training the medical team to identify
psychiatric symptoms and to provide basic psychosocial support to those in need of it (4).
Emotional and behavioral problems have been found to affect 18%-20% of children in pediatric primary care
practices. Rates of emotional and behavioral disorders are likely to be higher than 20% in children with chronic illnesses
(5). Children with chronic diseases have increase likelihood of psychiatric disorders, especially if they have physical
disabilities.
In an epidemiological study of 11,699 children, aged 4-17, Gortmaker et. al. found that the odds of having emotional problems were higher if the child was younger, male, and had a single parent and low family income. Other studies
comparing children with different disease groups found that if disorders involved brain function, the child is more likely
to have persistent and severe emotional and behavioral problems (6). Social factors may either buffer or amplify child distress. If a child has chronic illness, his or her psychosocial
adjustment will be affected by the parent’s perception of the disease severity, parent control, visible impairment or frequency of pain.
Studies show that primary care physicians can recognize depression, anxiety, and somatization disorders in about
50% of the cases but even when those psychiatric disorders are properly recognized, it does not guarantee appropriate
treatment (7).
14
The involvement of a consulting psychiatrist appears to
be critical in improving patient outcomes in the primary
care setting.
In a study by Shaw et al. (2006), 144 pediatric
psychiatric consultation-liaison programs were surveyed
to understand their current practice. They found an average of 7.5 inpatient, 2.5 outpatient and 2.6 emergency
room consults per week. Reasons for consult of high-frequency included: adjustment to illness by both child and
parent, differential diagnosis of somatoform disorder,
suicide assessment, disruptive behavior, and medication
evaluation. Requests for evaluations of delirium and protocol evaluations for pre-transplant assessment were of
relatively low frequency (5).
The high rate of psychiatric illness that exists
in ambulatory, hospital, and long-term care settings is
poorly recognized and managed. This causes increased
financial costs and emotional pain, which often can be
decreased by behavioral interventions (8).
In a study by Wells et al. (1989), they found an
increased cost associated with co-morbid medical-psychiatric illness. They also found that there is a negative
impact of psychiatric illness on the functioning of medical patients, and that there is poor quality of psychiatric
care in the primary care setting (9).
Other studies found patients with depression incur twice the costs of non-depressed patients. The costs
associated with management of the depression are only a
fraction of these increased expenditures (10).
There is a need for the psychiatrists to evolve as
an expert diagnostician, psychopharmacologic expert,
systems coordinator, and consultant/supervisor for complex patients. The psychiatric physician is mandatory for
any mental health team within a medical setting (8).
To our knowledge, there have been no recent published papers that describe the epidemiological profile
of Psychiatric Consultations in a pediatric population in
Puerto Rico. It is important to describe the current status of pediatric Consultation-Liaison services in the hope
that these data would be useful for Child and Adolescent
Psychiatry Fellowship Program evaluation and planning
to improve patient quality of service.
We expected that the majority of requests for psychiatric services would come from the Oncology Service and that the most prevalent reasons for consultation
would be depressive and anxiety symptoms. We also
expected to find changes in the frequency of psychiatric
services request across the year.
METHODOLOGY
This research proposal was approved by the University of Puerto Rico Medical Sciences Campus Institutional Review Board. We reviewed all the University
Pediatric Hospital, at San Juan Medical Center, consults
to the Child and Adolescent Psychiatry Fellowship that
dated from January 1, 2006 to December 31, 2006.
The data obtained from each consult were organized in a data sheet that did not include any identifiers.
The information gathered includes sociodemographic information such as sex, age, and town of residence. It also
includes relevant information from the consults such as
consultant department, somatic medical diagnosis, reason for consultation to the psychiatric service, target of
consultation (patient, primary caregiver, or both), and psychiatric diagnostic impression.
RESULTS
There was a total of 241 consults in the 2006.
The data obtained reflects that the months with higher
frequency of consults during the 2006 were February
(29.1%) and November (10.8%). The data obtained reflects that the months with less frequency of consults
during the 2006 were October (5.8%), May (5.8%), and
April (6.2%).
In terms of gender, there was a 1:1 male to female ratio (51% male; 49% female). In the other hand,
it was found that most consulted patients were adolescents with a peak at 16 years old (15.3%) (Figure I). As
shown in Table I, it was also found that most of the consulted patients had their residence in the Metropolitan
Area (30.3%), followed by patients living in the North of
the Island (16.2%). There were 39 consults with missing
town of residence (16%).
Most consults during the 2006 were requested
by the Emergency Room Services (32.4%), followed by
consults from the General Pediatrics (28.2%), and Oncology services (13.3%)(Table II).
As shown in Figure II, most of the consulted
patients had a neurological or neurosurgery condition
(20.3%), followed by malignancies (15.4%), which not
include CNS malignancies (4.1%).
The 78.4% of the consults requested an evaluation of the hospitalized patient, 19.1% requested an evaluation of the primary caregiver, and 1.7% requested an
evaluation of both.
The most frequent reason for psychiatry consult
was mood complains (33.2%), followed by request for
patient or primary caregiver support (17%), and noncompliance with treatment (7.9%) (Figure III).
Finally, in terms of the most frequent preliminary
diagnosis of evaluated patients, 32.8% of patients were
described to have Major Depressive Disorder and 28.2%
of patients were described to have Adjustment Disorder.
Ninety two percent (92%) of the patients consulted received a psychiatric preliminary diagnosis.
DISCUSSION
In terms of the socio demographic data, our study
showed no difference in the frequency of consultations
between genders. Adolescents were more frequently consulted, being 16 years old the peak age. We did not find
any comparative data in our literature review to esta-
15
Figure I. Age Distribution of Psychiatry Consults
Age
Ag
e
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
1
1
1
2
9
12
9
5
0
17
11
5
5
16
28
19
37
33
10
6
6
7
5
10
15
20
25
30
35
40
Number of psychiatry consults
Number of psychiatry
consults
Table II. Number of Psychiatric Consults by Pediatric
Services
Pediatric Services Number of Consults Percent (%)
Nutritionist
1
0.4
Neuro surgery
2
0.8
NICU
3
1.2
Surgery
3
1.2
Orthopedics
5
2.1
Infectious Diseases
15
6.2
Nephrology
15
6.2
PICU
17
7.1
Oncology
32
13.3
General Pediatrics
68
28.2
Emergency Room
78
32.4
Table I. Distribution of Residence Towns among Patients
Consulted to Psychiatry
Area of Residence Number of Consults Percent (%)
North
39
16.2
South
13
5.4
West
15
6.2
East
24
10
Central
37
15.4
Metropolitan Area 73
30.3
Unavailable
16.2
39
Figure II. Medical Condition Requiring Hospitalization among Patients Consulted to Psychiatry
Primary condition for hospitalization
Other
Rheumatic
Cardio/Pulmonary
Social Situation
CNS malignancy
Psychiatric
Gastrointestinal
Infection
Renal
Trauma
Endocrine
Other malignancy
Neurological/neurosurgery
2
0
6
7
8
10
10
14
17
18
18
20
20
35
30
37
49
40
50
60
Number of psychiatry
Number of consults
psychiatry consults
16
Figure III. Primary Reason Stated for Psychiatry Consults
blish if this pattern is also found at other sites.
non-compliance with treatment.
It was not a surprise that even though the University Pediatric Hospital is one of the few tertiary hospitals in the island, and receives patients from all over the
country, the majority of the consulted patients were from
the Metropolitan Area, where it is located.
Our findings can be compared to those of Shaw et
al. in 2006, where he described that the reasons for consult of high-frequency in his study included Adjustment
to illness by both child and parent, differential diagnosis
of somatoform disorder, suicide assessment, disruptive
behavior, and medication evaluation(5) .
There were differences in the frequency of psychiatric
services request across the year but we could not identify
a definite pattern.
In contrast to our hypothesis in which we expected that the majority of requests for psychiatric services would come from the Oncology Service, our study
shows that most consults were requested by the Emergency Room or General Pediatric Services. This could
be explained by the fact that when patients arrive to the
hospital they are usually first evaluated by a primary care
physician, who screens for the need of further evaluation
and consultation to other medical specialties.
As described in other studies, which reported
that in disorders that involved brain function, the child
is more likely to have persistent and severe emotional
and behavioral problems; our data reflects that most of
the consulted patients had a neurological/neurosurgery
condition. It is important to point out that even though
the Oncology Service was not the most frequent consultant, we found that oncologic patients consults as a whole
(CNS malignancies and other malignancies subgroups)
were only surpass by neurological/neurosurgery conditions by two consults. Besides, a high number of consults
for these chronic conditions is consistent with our literature review where children with chronic diseases showed
an increase likelihood of psychiatric disorders.
As we proposed, the most frequent reason for
psychiatry consult was mood complains, followed by
request for patient or primary caregiver support and
Since most of the consulted patients received a psychiatric preliminary diagnosis we can conclude that the requested psychiatric services within pediatric subspecialties were justified. This contrast with literature findings
that postulate that primary care physicians can recognize
depression, anxiety, and somatization disorders in about
50% of the cases. Special attention should be given to
this fact since even when those psychiatric disorders are
properly recognized, it does not guarantee appropriate treatment (7). Further work is needed to determine if
more patients were in need of treatment and not consulted to the service.
Our role as consultation and liaison psychiatrist
is to continue to educate and sensitize hospital personnel
so that psychiatric conditions are recognized and adequately managed during pediatric hospitalization.
Finally, we can conclude that during 2006 the
experience of the child and adolescent psychiatry residents during the Consultation and Liaison rotation was
primarily in the evaluation and treatment of male or female adolescent patients, from the Metropolitan Area of
the island, who presented mood symptoms in association
with neurological, malignancy or endocrine diagnosis.
It is important to mention that since there were
multiple consultants evaluating patients during year
2006, we depended on documented information by the
evaluating physician and this could be considered a bias.
Another limitation is that the preliminary diagnosis was
not provided with the aid of a standardized diagnostic
tool. The missing residence town data could change the
resulting demographic profile in our population. On the
other hand, the obtained data describes the consultation
and liaison experience of the child and adolescent psychiatric service in a tertiary pediatric hospital in Puerto
Rico in the year 2006 and cannot be generalized to other
consultation and liaison psychiatric services or other calendar years.
Studies including the past psychiatric history of
consulted patients is needed to determine if consulted
patient had receive previous treatment or are being identified as in need for the first time during hospital stay.
Also, evaluation of the management and recommendations provided to the consulted patients is needed to study the general practices of the consultation and liaison
psychiatric services with hospitalized pediatric patients.
SUMMARY
Rates of emotional and behavioral disorders are
likely to be higher than 20% in children with chronic
illnesses. Research shows that children with chronic diseases have increase likelihood of psychiatric disorders.
We reviewed the 2006 University Pediatric Hospital consults generated to the Child and Adolescent Psychiatry
Fellowship to create an epidemiological profile. Of the
241 consults 51% were for male patients, with a peak
at 16 years old. Most consults were requested by Emergency Room. Patients with malignancies, neurological,
and endocrinological conditions were more frequently
consulted. The most frequent reason for consultation was
mood complaints. The most frequent preliminary diagnosis was Major Depressive Disorder and Adjustment Disorder. In conclusion, the 2006 psychiatry consults in the
University Pediatric Hospital consisted primarily in the
request for evaluation and treatment of male or female
adolescent patients, who presented mood symptoms in
association with neurological, malignancy or endocrine
diagnosis.
REFERENCES
1- Roberts MC, La Greca AM, Harper DC: Journal of Pediatric
Psychology: another stage of development. J Pediatr Psychol 1988;
13: 1–5.
2- Fritz GK, Mattison RE, Nurcombe B, et al.: Child and Adolescent Mental Health Consultation in Hospitals, Schools, and Courts.
Washington DC, American Psychiatric Press, 1993.
17
3- Bronheim H, Fulop G, Kunkel E, et al.: The Academy of Psychosomatic Medicine Practice Guidelines for Psychiatric Consultation in
the General Medical Setting. Psychosomatics 1998; 39: S8–S30.
4- Albuquerque V, Bruno P, Nogueira L, et al.: New Potential Clinical Indicators of Consultation–Liaison Psychiatry’s Effectiveness in
Brazilian General Hospitals. Psychosomatics 2008; 49: 29–38.
5- Shaw R, Wamboldt M, Bursch B, et al.: Practice Patterns in Pediatric Consultation Liaison Psychiatry A National Survey. Psychosomatics 2006; 47: 43–49.
6- Gortmaker S, Walker DK, Weitzman M, et al: Chronic conditions, socioeconomic risks, and behavioral problems in children and
adolescents. Pediatrics 1990; 3:267-276.
7- Kirmayer LJ, Robbins JM: Patients who somatize in primary
care: a longitudinal study of cognitive and social characteristics.
Psychol Med 1996; 26: 937–951.
8- Stoudemire A, Bronheim H, and Wise T: Why Guidelines for
Consultation-Liaison Psychiatry? Psychosomatics 1998; 39: S3-S7.
9- Wells KB, Stewart AL, Hays RD, et al.: The functioning and
well-being of depressed patients: results from the Medical Outcomes
Study. JAMA 1989; 262: 914–919.
10- Katon W, Von Korff M, Lin E, et al.: Collaborative management
to achieve treatment guidelines; Impact on depression in primary
care. JAMA 1995; 273: 1026–1031.
RESUMEN
Trasfondo: Los estudios demuestran que la
tasa de trastornos emocionales y de conducta es mayor
de 20% en niños con enfermedades crónicas por lo
que tienen mayor riesgo a presentar condiciones psiquiátricas. Propósito/Metodología: Para este estudio
se revisaron las consultas generadas en el año 2006 al
Programa de Psiquiatría de Niños y Adolescentes del
Hospital Universitario Pediátrico. Resultados: De las
241 consultas, 51% fueron de varones, predominantemente adolescentes. La mayoría de las consultas fueron
solicitadas por el Departamento de Emergencias. Las
condiciones más consultadas fueron las neurológicas,
malignidades y las endocrinológicas. El motivo más
frecuente de consulta fue quejas de estado de ánimo.
Los diagnósticos preliminares más frecuentes fueron
Trastorno Depresivo y Trastorno de Ajuste. Conclusión: En conclusión, la mayor parte de las consultas
generadas en el Hospital Pediátrico para el servicio
de Psiquiatría fueron para evaluación de adolescentes
de ambos sexos que presentaron síntomas de talante
asociados a condiciones neurológicas, malignidades o
endocrinas.
Asociese y Asocie
18
JOB SATISFACTION OF
A GROUP OF SURGICAL
AND NON-SURGICAL
PHYSICIANS AT A
HISPANIC ACADEMIC
MEDICAL CENTER,
2006-2007
Luz N. Colón-de Martí, MD *
Linnette Rodríguez-Figueroa, MSc PhD **
From the * University of Puerto Rico (UPR), School of Medicine
(SOM), Department of Psychiatry, and **University of Puerto Rico, Graduate School of Public Health, Department of Biostatistics and Epidemiology.
Request reprints to: Luz N. Colón-de Martí, MD, UPR-School
of Medicine, Department of Psychiatry, PO BOX 365067, San Juan, PR,
00936-5067. E-mail: <[email protected]>
INTRODUCTION
T
he ability to work and to love, a phrase often attributed to
Sigmund Freud, is considered by many as the hallmarks of mental wellness and functioning in our society. In other words, it is what defines
a healthy adult. Satisfaction of doing well at our job and the capacity
to love thus become the goals that we seek to achieve .But, what do we
mean by job satisfaction?
ABSTRACT
Background: Job satisfaction has
been associated with motivation, job involvement, job commitment, patient’s satisfaction, and quality of care. Physician’s
job satisfaction may improve retention and
performance in clinical practice, and maximize quality of services.
Methods: Job satisfaction was assessed in a group of non-resident surgical
and non-surgical married physicians of the
UPR SOM during the 2006-2007 academic
year. Job satisfaction was measured using
an 18-item scale.
Results: Ninety-two (n=92) physicians completed a self-administered
questionnaire for a response rate of 34.8%.
Almost all (90.0%) reported being satisfied
or very satisfied with their job. Satisfaction
was very high in both surgical and non-surgical physicians, and similar in both males and females. The physicians who were
most satisfied with their jobs were those
aged 35 or less, those who had completed
their residency/fellowship in the previous
10 years, those whose spouse was not a
physician, those who reported being previously married, and those who were not
active in their religion.
Conclusions: In this study, almost
all the physicians in both genders reported
being satisfied or very satisfied with their
job. The younger physicians, who are also
probably the same that completed their
residency/fellowship in the previous 10
years, were the most satisfied with their
jobs. Satisfaction was very high in both
the surgical and the non-surgical group.
The findings in this population differ from
other groups, particularly in the high level
of satisfaction among younger doctors and
the similar satisfaction levels among genders.
According to Locke (1), job satisfaction is a pleasurable or positive emotional state resulting from the appraisal of one’s job or job
experiences. For others, job satisfaction is an affective reaction to one’s
Keywords: job satisfaction, physician job
job or emotional response towards various facets of one’s job, or as an
satisfaction, hispanic physician
attitude towards one’s job (2, 3). Weiss suggests that we form attitudes
towards our jobs by taking into account our feelings, our beliefs, and our behaviors(4). In general, job satisfaction is simply how people feel about their jobs and different aspects of their jobs. It is the extent to which people like (satisfaction)
or dislike (dissatisfaction) their jobs (5).
Job satisfaction can be influenced by a variety of factors, including the quality of relationships with superiors,
supervisors, colleagues, and the degree of fulfillment at work, among others. The topic is important because of its implications for job-related variables. It has been found to be negatively related to absenteeism, turnover, and perceived
stress, but it has been positively correlated with motivation, job involvement and productivity, organizational citizenship
behavior, organizational commitment, life-satisfaction, and mental health (5,6). For some, job satisfaction is the most
influential determinant of the overall quality of life (7).Job satisfaction among physicians is considered a multidimensional issue. Determinants of physicians’ satisfaction include sociodemographic characteristics (age and sex), time since
graduation from medical school, medical specialty, and participation in administrative work, among others (8-10).
Why should we study physician’s job satisfaction? Because job satisfaction among physicians is associated with physicians health and wellbeing, as well as
with important aspects related to quality of care of the
patients and health care services (8, 9, 11-17). In other
words, knowing what affects a physician’s work satisfaction is important, not only for them but also for their
patients in general.
Crucial medical outcomes have been linked to
physician satisfaction, including prescribing behavior,
and patient adherence to medications and/or treatment (8,
13, 18,19). Physician dissatisfaction, on the other hand,
has been linked to riskier prescribing practices, to the
morale of health care workers and staff, to the quality of
care in general, and to patient satisfaction (12,15,18-21).
Physician job satisfaction is also relevant to the
role that many physicians have as supervisors and teachers of students in the health fields and residents since
the career choices of medical students and residents may
be influenced by stressed and dissatisfied teachers (22).
METHODS
Non –resident physicians involved in post graduate training programs of the University of Puerto Rico
School of Medicine (N=264) were invited to participate
.Among these, all legally married non-resident physicians were eligible to participate. Participants received
an information sheet with a brief description of the study, and a self-administered questionnaire. No indicators
that might identify the participant were included in this
cross-sectional survey. Participation was voluntary, and
all responses were kept anonymous and confidential.
The questionnaires were distributed in each training department and a sealed box was provided to each
department for the collection of the completed forms.
Investigators collected the completed forms weekly and
separated them into two envelopes labeled "surgical" and
"non-surgical" without any other specifiers. Surgical specialties included: anesthesiology, dermatology, ENT, general surgery, neurosurgery, OB/GYN, ophthalmology,
urology, and orthopedics. Non-surgical specialties comprised all other specialties not listed above.
Job satisfaction was measured using a questionnaire previously used in a Hispanic sample which measures job satisfaction considering many aspects of the
job. The instrument is a three- part questionnaire. Part II
measures job satisfaction. Content validity of the instrument was determined by a panel of experts. The Spanish
translation of the instrument was reviewed for validity.
Reliability was established by pilot testing the instrument. A test-retest procedure was used to determine the
coefficient of stability. The coefficient of stability for the
instrument was .70. Cronch’s alpha for Part I was .98 and
.75 for Part II. We used Part II which includes an 18- item
scale using a five-point Likert format that ranged from
“totally disagree” to “totally agree” (23). An additional
sheet with twelve questions regarding demographic characteristics was also used.
19
Data entry was performed using the Epi Info
version 6.04 software (Centers for Disease Control and
Prevention, 2001). The fidelity of data entry was verified
by re-entering all questionnaires. The data was analyzed
using SPSS (Statistical Package for the Social Sciences)
for Windows (version 11.01). The Chi-square (X2) and
Fisher Exact tests were used to determine the association
between job satisfaction and the variables under study.
Significance level was set to α=0.05.
RESULTS
Sociodemographic characteristics:
A total of 92 physicians completed the questionnaires. Most of the respondents (70.7%) were males,
about half (45.1%) were over age 50, and 55.4% had a
non-surgical specialty. Almost half (42.9%) of the physicians had completed their residency/fellowship over 20
years ago. Over half (51.6%) had been married for over
20 years and 88.0% did not report a previous marriage.
Most (62.0%) were not married to a physician and almost
all (91.3%) had children. Although 89.1% of the sample
reported having a religious affiliation (84.1% were catholics), only 55.6% considered themselves to be active
religious participants.
Job satisfaction:
Almost all the physicians (90.0%) reported being
satisfied or very satisfied with their job with 91.9% of
the males and 88.0% of the females reporting satisfaction
(Figure 1). The younger physicians were the most satisfied with their jobs with 93.3% of those aged 35 or less
reporting satisfaction (Figure 2). The 36-50 age group reported the highest percentage of undecided in regards to
satisfaction with their job (Figure 2). The group with the
highest percentage of job satisfaction was the group of
participants who had completed their residency/fellowship in the previous 10 years. Satisfaction was very high
in both study groups: 91.9 % of the surgical group and
90.0 % of the non-surgical group reported being satisfied
with their job (Figure 3). A higher proportion of participants whose spouse was not a physician reported to be
satisfied with their job (92.7%), when compared to those
whose spouse was a physician (87.5%).
All participants that reported being previously
married were satisfied with their job compared to only
89.7 % of those who had no previous marriages. Almost
all (97.1%) of the physicians that were not active in their
religion reported to be satisfied with their job compared
to only 85.7% of the ones that were active.
DISCUSSION
Although physicians have a job that is generally respected by society (has prestige or social standing),
their jobs involve great responsibility and many opportunities for stress (24).
20
Figure 1. Satisfaction with Job Scale by Gender
100
90
80
Percentage
The literature report findings about job related domains
which influence physician satisfaction. These include:
income (salary and overhead costs), relationships (with
patients, colleagues, nurses, and other staff), autonomy
(physician’s sense of control over his/her work as well
as his/her perceived ability to provide needed services
to patients) the domain of practice environment (practice
size, ownership, involvement with managed care, working hours, amount of personal time, etc.), and the domain of the broader market environment (managed care
penetration, and supply and organization of hospital and
physician services in the area) (25,26).
Physicians’ religious characteristics are diverse
and may differ in many ways from those of the general population (43). Their religious attributes may affect
patient care, too. Frank, et al. in their study of women
physicians, found that most of the participants reported
Protestantism (29.3%) and Catholicism (24.9%) as their
religious affiliation (44). In our study, 89.1% of the sample reported to have a religious affiliation (84.1% were
catholics). Nevertheless, when asked about active participation of their religious affiliation only 55.6 % considered themselves to be active religious participants. Almost
all (97.1%) of the physicians that were not active in
70
60
50
40
20
12.0
8.1
10
0
Undecided
Agrees/Totally Agrees
Feels Pretty Satisfied with Job
Figure 2. Satisfaction with Job Scale by Age
100
93.3
≤ 35 (n=15)
36-50 (n=33)
≥ 51 (n=38)
87.9
92.1
Percentage
80
60
40
20
12.1
6.7
7.9
0
Undecided
Agrees/Totally agrees
Figure 3. Satisfaction with Job Scale by Surgical Specialty
100
90
80
91.9
Surgical (n=37)
90.0
Non-surgical
(n=50)
70
Percentage
In regards to the job setting, Olarte surveyed a group of women psychiatrists (n=483, response
rate=55%) with academic affiliations/appointments. She
reported significantly more satisfaction with their current
work as a source of economic and personal rewards.
They also devoted more time to career related activities
than women without academic affiliation (42). In our
study, 88.0% of the female participants who were working at this academic center reported being satisfied with
their job compared to 91.9% of the male participants also
working at the same academic center.
88.0
30
Several studies present variance among racial and
ethnic subgroups regarding job satisfaction. In the study
of Glymour et al.(27), Hispanic physicians reported significantly higher job and career satisfaction compared to
white physicians .. Fletcher, in her study of minority physicians’ job satisfaction, found that Black/African American physicians were significantly less satisfied overall
when compared to any other cultural group (28).
Multiple studies have explored other selected aspects of physician job satisfaction and factors that can
affect it (13, 18, 29-32). One of them is the relationship between job satisfaction and gender, but results are
contradictory. For example, Bartol and Wortman (33),
Clark (34), Hodson (35), and Sloane and Williams (36)
reported higher level of satisfaction in women versus
men (33-36). However, Chiu, Shapiro and Stern reported
higher level in men (37, 38). Much of the research on job
satisfaction and gender has been conducted in the United
States (39). In most of 21 countries which reported job
satisfaction, women have been found less satisfied than
men. Great Britain and USA are the two countries where
females reported much higher job satisfaction levels than
men (40). In other countries like Spain, Romania, and
Bulgaria, gender does not seem to play a key role in job
satisfaction (41).
91.9
Males (n=62)
Females (n=25)
60
50
40
30
20
10
8.1
10.0
0
Undecided
Agrees/Totally agrees
their religion reported to be satisfied with their job compared to 85.7% of the ones that were active.
Regarding the relationship between job satisfaction and people’s education, there seems to be a common
trend that the higher the education level the higher the
degree of job satisfaction (41). We did not study this
relationship on this sample of surgical and non-surgical
physicians.
In some surveys, findings point to an increasing
job satisfaction with age; others indicate the opposite.
There are also others in which there is no clear connection between job satisfaction and age (41).
Al-Eisa et al., found a significant association between
overall satisfaction and physician age as well as number
of years worked (45). They evaluated the extent of job
satisfaction of primary health care physicians working
in the Capital Health region of Kuwait. They found an
overall satisfaction of 61.8%. Significantly, the higher
the age of the physician, as well as the number of years
worked, the higher the job satisfaction.
Branthwaite and Ross and Winefield and Anstey
found a significant association between overall satisfaction and physicians age as well as number of years worked, that is , older doctors were generally more satisfied
with their job than younger doctors (46,47). However in
our study, the group with the highest percentage of job
satisfaction was the group of participants that had completed their residency/fellowship training in the previous
10 years and those that were younger (93.3% of those age
35 or less reporting satisfaction). The 36-50 age group
reported the highest percentage of undecided in regards
to job satisfaction. This is an issue that requires special
attention considering that young physicians can impact
the future of the medical profession. There are researchers who think that the new practice arrangements increasingly available to physicians entering practice today
may offer more alternatives for young physicians to find
satisfying work arrangements (48).
CONCLUSIONS / RECOMMENDATIONS
In this study, almost all the physicians in both
genders reported being satisfied or very satisfied with
their job. The younger physicians, who are also probably the same that completed their residency/fellowship in
the previous 10 years, were the most satisfied with their
jobs. Satisfaction was very high in both the surgical and
the non-surgical group. A higher proportion of participants whose spouse was not a physician reported to be
satisfied with their job, when compared to those whose spouse was a physician. In addition, satisfaction was
higher among participants that reported being previously
married or that were not active in their religion. Our findings differ from other studies were males had reported
higher job satisfaction compared to females. They also
differ from other studies were the higher the age of the
physicians and the number of years worked, the higher
the job satisfaction.
Physician’s job satisfaction is important for
doctors themselves, their patients, and for other professionals that work closely with them. It has been linked
to patient care and health system outcomes. Highly-satisfied patients, coworkers, and physicians make their
work environment more attractive and efficient. Better
understanding of physician’s job satisfaction may improve performance in clinical practice and maximize quality
of services provided. Physician’s job satisfaction can be
measured using short self-administered questionnaires.
The questionnaires can also be used to monitor changes
in aspects related to their job satisfaction to prevent potentially damaging consequences.
Attention to physician’s job satisfaction may result in institutions to improve professional satisfaction
21
which will increase physicians’ retention and the amount
of physicians available to provide sufficient and efficient
health care. This is an important issue also for academic
institutions that would like to attract the best students
into Medicine.
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22
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RESUMEN:
La satisfacción con el trabajo se ha asociado a motivación, dedicación y compromiso con la
labor realizada. En el grupo de los profesionales
médicos se ha asociado también al cuidado ofrecido a pacientes, a las relaciones entre los profesionales que comparten ese cuidado y a la calidad
y satisfacción de los servicios recibidos. Este estudio evaluó la satisfacción con el trabajo de dos
grupos de facultativos casados: quirúrgicos y no
quirúrgicos trabajando en el centro académico de
la Escuela de Medicina de la UPR durante el periodo 2006-2007.El 90% de los participantes reportó estar satisfechos o muy satisfechos con su
trabajo. La satisfacción reportada fue alta en los
dos grupos pero no se encontró diferencias entre
los géneros. El grupo de médicos más jóvenes reportó mayor satisfacción. Estos hallazgos difieren
de otros grupos , particularmente en cuanto al nivel de satisfacción más alto reportado en los médicos más jóvenes y en que no hubo diferencias
significativas entre los géneros. La satisfacción
con el trabajo merece la atención de las instituciones que están comprometidas con mejorar la satisfacción profesional y la retención de su Facultad
como también con la satisfacción y la calidad de
los servicios clínicos ofrecidos. Así mismo debe
ser una prioridad para las instituciones académicas
que desean atraer los mejores candidatos a la profesión médica.
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23
ABSTRACT
Objectives: Describe the socio-demographic, medical, and psychiatric
profile of patients who attempted suicide in a psychiatric hospital of Puerto
Rico during the period of March 2005
to March 2007. Identify the methods
most frequently used; also days, time,
and observation level of the patient at
the time of the attempt.
Method: Inpatient suicidal attempts
in a state psychiatric hospital were
assessed from March 2005 to March
2007. Information was gathered from
the incident reports of the attempts
and the patients’ records.
Results: During the period of investigation a total of 44 suicidal attempts
were made by 31 inpatients. The majority of them being diagnosed with
psychotic (96.8%) and mood disorders (48.4%). The most commonly
used method was hanging (79.6%),
and the most commonly identified
precipitant was medical stressors such
as hallucinations or frustrations about
their psychiatric conditions.
Conclusion: Most of the results of
our study support previously published profiles for potential suicide attempters. Regarding prevention strategies, additional measures should be
established inside the wards in order
to reduce the risk of inpatients attempting suicide.
A SOCIO-DEMOGRAPHIC,
PSYCHIATRIC AND
MEDICAL PROFILE OF
INPATIENT SUICIDE
ATTEMPTERS
IN A PSYCHIATRIC
HOSPITAL OF
PUERTO RICO
Gabriel L. Martínez, MD*
Raquel Herrero MD*
Christine Fabelo MD*
Diana Diaz MD**
Vilma McCarthy, MD**
From the *General Psychiatry Residency Program, and **Department of Psychiatry, University of Puerto Rico School of Medicine.
Address reprints requests: Gabriel L. Martínez MD, Psychiatry
Department, Medical Science Campus, University of Puerto Rico. P.O. Box
365067 San Juan, PR 00936-5067. Email: <[email protected]>.
INTRODUCTION
T
here are approximately 30,000 suicides per year in the United
States, 5%-6% of which occur in hospitals (1). Suicide attempts and completed suicides represent a public health problem. The individual attempting suicide constitutes a distinct, but in many aspects similar population to
those who commit suicide (2). The estimates of life prevalence range from
0.7 to 5.9 attempts per 100,000 in a random sample of US adults (3).
On different studies depending on the length of the follow up from 6% to 27.5% of those who attempt suicide will ultimately die by suicide (1). In Puerto Rico vital statistics for the year 2000, the rate of death by suicide was 8.3%, with the
highest rate in the 35-39 age groups (4).
Keywords: Suicide attempts, inpatient, profile.
Psychiatric patients are known to have a higher suicide rate than the general population. The risk of suicide attempts is particularly high in psychiatric illness, and among hospital inpatients, especially among those with depression.
Thus the risk of suicide should be estimated in the first interview after admission to a psychiatric hospital (5). Early
recognition of suicidal behavior is of extreme importance for avoidance of this cause of death (6).
Inpatient suicides are a matter of concern in hospital psychiatry. For this reason patients at psychiatric wards who
are at risk of suicide should be identified. According to Deisenhammer, et al., 2000 the majority of patients who committed suicide inside the ward were diagnosed with either affective disorders (45.4%) or schizophrenia (27.3%) (7). Another
study indicated that suicide among inpatients was associated with severe psychopathological conditions, previous deliberate self harm, pre-admission and intra-admission suicidal thoughts, intra-admission suicide attempts, fluctuating suicidal
ideation, longer length of stay, greater number of ward transfers and prescription of a greater number of neuroleptics and
antidepressants (8).
24
It was also identified that either depressive symptoms or
extrapyramidal side effects (i.e. akathisia) during a hospitalization are major risk factors for committing suicide
(9). Another study, identified that for inpatients with schizophrenia, a history of parasuicide, or suicidal gesture,
was a risk factor for those with depression, it was suicidal
behavior on admission; and for patients with other diagnosis, it was violence during hospitalization (10).
Findings indicated that the frequency of suicidal behavior of psychiatric inpatients was 0.91% of total admissions, two thirds of the patients who attempted
suicide were diagnosed with schizophrenia or depression
(11). Patients suffering from depression, substance abuse, and personality disorders had a higher parasuicide
rate. Among these lasts, the ones diagnosed with bipolar
disorder-depressive episode had an extremely high parasuicide rate (11).
Suicidal and non suicidal psychiatric inpatients
have been differentiated in several studies. Suicidal patients showed the following traits: younger age, younger
age at the initial onset of depressive illness, more suicidal
attempts in the past, and a greater number of relatives
who committed suicide or made attempts (12). They were
more often single or divorced and had fewer children of
their own. Their psychopathology was characterized by
a more strongly developed syndrome of depression, hostility and apathy. On the other hand, it appeared that female suicide is much more frequent in the psychiatric inpatients’ group than in others (12). Psychiatric inpatients
used methods like jumping from high places, and hanging (9). This reflects that psychiatric inpatients use methods that are easily available (13). According to Dr. Liu,
most of the suicidal behavior of psychiatric in-patients
occurred in concealed places, and most of the patients
used non-violent methods. About half of the incidents
occurred during the evening shift and depressed patients
tended to attempt suicide during the night shift (11).
The information provided is based on studies
done in populations other than the Puerto Rican. The psychosocial, psychopathological, and social demographic
profile of suicide attempts in Puerto Rico has been mostly
studied in the non hospitalized adolescent population, but
not in the adult population, nor in the psychiatric ward
population. Studies that have been conducted about suicide behavior in adults in Puerto Rico are mostly about
completed suicide, but not about attempts and even so attempts in psychiatric wards. In our literature review little
was found about the methods used by suicide attempters
in psychiatric wards and none in the Puerto Rican psychiatric wards. This will be the first study that will review
the suicidal attempt methodology and the profile of those
who attempt suicide in a Puerto Rican adult’s psychiatric
hospital.
Efforts have been made for the prevention and
management of suicide attempts in psychiatric hospitals,
but not many efforts have been made to identify the demographic and clinical characteristics of Puerto Rican
patients from a public psychiatric hospital. This study
comes to fulfill the need of a comprehensive description
about the profile of this population.
The information obtained could be used in the development of measures to prevent these incidents in the future.
METHODS
This is a retrospective review of medical records
of patients who attempted suicide during a psychiatric
hospitalization at Puerto Rico State Psychiatric Hospital- Dr. Ramón Fernández Marina- during the period of
March 2005 to March 2007. Suicide attempts were chosen over completed suicides since the last suicide was
documented in 1998. The permissions from the respective governmental agency (ASSMCA), the IRB and the
Director of the Puerto Rico State Psychiatric HospitalDr. Ramón Fernández Marina were obtained.
As a standard procedure, the hospital’s protocol
requires that an incident report is completed for every
suicide attempt reported in each ward. We reviewed all
incident reports during the above mentioned period. A
total number of 44 incident reports were identified, but
since some patients attempted suicide more than once,
only 31 medical records were reviewed to obtain the information that was examined.
A code number was used to substitute the subjects’ record number in order to protect the patients’
identity. This information was kept safely at the principal
investigator office at University of Puerto Rico Medical
Sciences Campus in a safe cabinet where only he had
access. Informed consent was not required since this was
a retrospective study, the risks to the patients were minimal, and no direct contact was made with the subjects.
The subjects included were, male or female patients, 18 years old or older who attempted suicide during
a psychiatric hospitalization in the above mentioned period.
This state hospital has 157 beds distributed in 8 wards.
The hospital serves urban and rural Puerto Rican adults18 years old or older-, mostly indigents and persons using
the government health plan.
The obtained results were analyzed using means
and Chi Square.
RESULTS
Socio-Demographic Characteristics
A total of thirty-one (31) inpatients from the Psychiatric State Hospital in Puerto Rico attempted suicide
between March 2005 and March 2007. Table 1 presents
the socio-demographic characteristics of these patients.
Of the 31 inpatients, 15 were females and 16 were males.
Most (37.5%) of the males who attempted suicide were
30 years old or less compared to only 13.3% of women in
the same age range. Of the 31 inpatients who attempted
suicide 7 were over 45 years of age, with no significant
difference between genders in this age group (4 females
and 3 males).
25
26
Among the women who attempted suicide, the largest
number (4) was observed among those between the ages
of 36-40 and those over 45 years old (4). In terms of their
level of education, over half (56.7%) had not completed
high school, but 30% had some studies after high school.
More males than females were not high school graduates
(10 vs. 7); a higher proportion of females had more education (40.0% vs. 20.0%).
Of this inpatient group, most (61.3%) were
unemployed and 29.0% were disabled. Among this group
13 were Catholic (5 females and 8 males) and 12 were
Protestant (6 females and 6 males). The majority was never married (19); only 3 were married. A higher proportion of males were never married compared to females
(75.0% vs. 46.7%). Almost all females (80.0%) had offspring compared to only 18.7% of males. Almost all patients (80.7%) had a place to live, with no significant difference among genders. Of the social support identified,
45.2% of the sample identified their parents as their main
support with significantly more males (50.0%) than females (40.0%) identifying them as their support. Siblings
(32.0%) were also an important source of support. Only
four females (26.7%) and no males found support in their
partner. Most patients (61.3%) received 1-5 visits during
their hospitalization, but 35.5% did not receive any visits
during their stay in the hospital.
Psychiatric and Medical Characteristics
Psychiatric and medical characteristics of the
patients are presented in Table 2. The most common
psychiatric diagnoses of these patients were psychotic (96.8%) and mood (48.4%) disorders. Significantly
more females than males had a mood disorder diagnosis
(73.3% vs. 25.0%). Also, more females than males had
a personality disorder (20.0% vs. 6.3%), but this difference was not statistically significant. Males were more
likely to be diagnosed with substance disorder than females (18.8% vs. 6.7%), but this difference was also not
significant.
All patients in our study had a previous psychiatric treatment prior to admission. Most of them (38.7%)
had from one to four suicide attempts outside the hospital with no significant difference between genders.
Most used tobacco (45.2%), alcohol (29.0%), or cocaine
(25.8%). There was no reported history of use of barbiturates, hallucinogens or benzodiazepines. There were
no major differences between genders; except in tobacco
use where significantly more males reported it (68.3%
vs. 20.0 %). However, 25.0% of males and no females
reported cannabis use.
In relation to psychiatric medications during
hospitalization, 96.8% of our patients were using benzodiazepines. In addition, patients also had atypical antipsychotics (74.2%), mood stabilizers (58.1%), SSRIs
(41.9%), and typical antipsychotics (22.6%). The most
dramatic difference between male and females was in the
use of atypical antipsychotics with 86.7% of the females
using them compared to 62.5% of males; however, these
results were not statistically significant. Only one female
developed an extrapyramidal symptom (acute dystonia)
during hospitalization.
Most of the patients in our study (62.1%) had no
reported family history of psychiatric disorders or suicides (92.6%). In relation to medical conditions, 54.8%
of the population had reported some kind of a chronic
medical disease; only 9.7% reported any kind of physical
impairment.
The 31 patients under study had a total of 44 suicidal attempts inside the hospital during the study period
(see Table 3). Most of these episodes (68.2%) constituted
their first suicide attempt inside the hospital. In 54.6%
of the attempts the patients had reported suicidal ideation before the attempt, with a greater percentage of females (63.2%) reporting the ideation compared to males
(48.0%). In the case of the precipitants, patients reported medical reasons (63.6%) and interpersonal problems
(20.5%) as the most common factors.
Most (59.1%) of the attempts occurred while
the patients were at close level of observation, and the
most common methods used were hanging (79.6%) and
cutting wrists (18.2%); these attempts occurred mainly
during the afternoon (38.6%) and evening (40.9%).
DISCUSSION
The main objective of this study was to make a profile of
suicide attempters inside an inpatient psychiatric unit in
Puerto Rico. Our results present a description of who are
most likely to perform a suicide attempt inside in these
units, the reasons for doing it, and the methods used in
these attempts. Through a discussion of our results we
will be able to have a better understanding of this population and will be more able to prevent such attempts in
the future. Knowing which characteristics are shared by
suicide attempters will allow us to take measures in order
to protect their well being.
Our findings show that this group of inpatient
suicide attempters show very few significant differences
between genders. This contrasts with studies that have
found that suicide among females is much more frequent
in the psychiatric inpatients’ groups (9, 14). As expected, the majority of suicide attempters in our study were
either single, divorced, separated or a widower. These
findings concur with the study by Haug, et al., 1995. Our
findings show that the majority of male attempters had
no offspring. They also show that younger inpatient males presented more suicide attempts than older women
and males. This was also found in studies of inpatient
completed suicides where a gender difference between
number of offspring and age of attempters was seen, contrary to what was expected (7, 15). This aspect should
be further studied to establish if there is any difference
among genders.
Most of our patients reported belonging to a religion. In our culture, one would expect that religion would
be a protective factor. Further studies could examine if
religion acts as a risk or protective factor against suicide
and suicide attempts.
The majority of the suicide attempters were
unemployed or disabled, and most did not complete
27
28
high school. It might be that this population is at a higher risk of attempting and committing suicide since they
have less coping skills. A study suggested that this could
be related to the onset of the disease, the chronic nature
of the mental disease and the impairment it causes among
this population (16).
It is also known that having a poor social support
is another risk factor for attempting suicide (16). Most
of the group studied received support from their parents.
This could be expected in a group with a high number
of single, divorced, and widowers or had few offspring.
Our study shows that males identify more significantly
with their parents as supportive figures. Despite the social support identified upon admission, almost half of the
sample did not receive any visits while being hospitalized. The quality of the social support identified is not
known, thus it could represent an added stressor leading
to the suicide attempt. Further studies could evaluate the
importance and quality of the social support and how it
associates to the risk of attempting suicide.
As expected, most of those patients who attempted suicide in our study had a diagnosis of psychotic or a
mood disorder. These results are similar to previous studies (7, 11). Also, women had significantly higher proportion of mood diagnoses compared with men. Substance and personality disorder also affected our population,
although to a lower extent.
All patients in our study had prior psychiatric
treatment and many of them had more than one previous
suicide attempt outside the hospital. This agrees with
previous study (17), and with the previous knowledge
that psychiatric history and suicide attempts are a risk
factor for future suicidal behavior (16). History of substance use, which is a risk factor for suicidal behavior,
did not affect most of our patients. This could be related
to under-reporting of such use by the patients or by the
professionals in charge of writing the information in the
records.
In terms of pharmacotherapy, the great majority
of the patients in our study were receiving benzodiazepines, followed by atypical antipsychotics, mood stabilizers, SSRIs, and typical antipsychotics. This reflects that
the great majority of those who attempted suicide were
already on pharmacotherapy. The high use of benzodiazepines, atypical antipsychotics, and mood stabilizers
could reflect the high incidence of symptoms of anxiety,
psychosis, and poor impulse control. Interestingly, less
than half of the patients were on SSRIs, which could be
due to the fact that Bipolar disorder was included in the
mood disorders and this disorder, if in manic phase, is
usually not treated with antidepressants. The high use of
atypical antipsychotic and low use of typical antipsychotic could be the reason that just one patient developed an
extrapyramidal symptom (acute dystonia) during hospitalization. As identified by Dong, et al. extrapyramidal
side effects as a major risk factor for attempting suicide
(9).
Although psychiatric family history and family
history of suicides are risk factors for suicidal behavior
(16), most of the patients in our study did not have any.
Once again, this could be related to lack of reporting by
the patients or by the professionals in charge of the records. It is an aspect that should be followed up in further
studies.
Most of the patients had a chronic medical condition, which is also a major risk factor for attempting
suicide; but only few had a physical impairment, another
risk factor according to Kaplan and Saddock (16). Adequate treatment should be given to the medical conditions as part of their psychiatric treatment and prevention
of future suicidal attempts.
The 44 suicidal attempts inside the hospital were
done by 31 patients, which reflect the fact that some patients attempted suicide more than once. This result was
similar to a study (8) which indicated that suicide among
inpatients was associated with intra-admission suicidal
attempts. However, reporting suicidal ideation has been
named as an important risk factor for inpatient suicides
(7, 18). In our study, we found that males were less likely
to report their suicidal ideas prior to the attempt. This information is important since it appears that male patients
may have suicidal thoughts or ideations but not necessarily report them, which makes them more prone to having
the opportunity to make the attempt since the hospital
staff may not know their ideations.
About 35% of a sample of psychiatric inpatients
who were parasuicidal during hospitalization had motives to commit suicide that were attributable to their psychiatric illness, such as depressive hopelessness or a wish
to get rid of an unbearable hallucination (19). Individuals
who are already at risk for suicidal behavior may be at
increased risk for a suicide attempt when experiencing
command auditory hallucinations for suicide (20). In our
study, we had similar results since most of the patients
identified medical problems as the precipitant factor for
the attempt (for example, hallucinations and frustration
about having a psychiatric condition or about a specific
symptom). About 25% of the inpatient parasuicides were
related to conflicts patients had with significant others
outside the hospital and that 20% were related to interpersonal issues occurring on the unit itself (19). Similarly,
the second most common precipitant factor identified in
our sample was interpersonal problems, especially with
their primary support group, another patient, or personnel on the ward.
As in previous studies, the method most frequently used in our sample was hanging (7, 14, 21). This
correlates with the results seen in another study (13), reflecting that psychiatric inpatients use methods that are
easily available to them. The great majority of the hanging incidents were made with the bed sheets; the ones
that cut their wrists did it with objects found on the ward
or in their belongings. This emphasizes the fact that some
of the basic commodities that are available for the patient
may be potentially hazardous, thus the constant observation of high risk patients in essential. As stated in a study, the psychiatric units should be developed away from
readily available methods of suicide; and those inpatients
at high risk should be observed carefully to avoid absconding and suicide (8).
29
Although in over half of the attempts the patients
had reported suicidal ideations prior to the attempt, most
were at close observation. This may be due to the fact
that the psychiatric inpatients are not kept for many days
on constant 1:1 since it requires a reevaluation by a psychiatrist every 24 hours and constant supervision by a
staff member for that patient; in which case availability
of staff members may not be sufficient. According to Pitula, et al., constant observation was beneficial because it
contributed to their physical safety and restored hope for
the patients (22). It has been reported that the absence
of supportive interactions, frequent staff changes, and
lack of privacy adversely affected their experience (23).
However, most of the attempts in our study occurred
from noon to midnight. This was consistent with another
study (11) in which most of the suicidal attempts among
inpatients occurred during the evening and night shifts.
This occurrence may be related to decreased supervision
or fewer recreational activities during those hours. Suicide risk should be examined carefully in patients prior
to approving leave or changing the level of observation
particularly if they had fluctuating suicidal ideation (5).
30
While this study fulfills the need of a comprehensive description about the profile of psychiatric inpatient suicide attempters, it does have some limitations.
First, there was no control group so we cannot identify
the risk factors for inpatient suicide attempt, which could
be used in the development of measures to prevent these incidents in the future. Also the psychiatric hospital
where the study was conducted is a state hospital that is
responsible for inpatient care of more chronic psychiatric
patients, and may thus have more schizophrenic patients
with residual symptoms and potentially frequent psychotic exacerbations, a patient group at a particularly high
suicide risk as described by a previous study (7).
Also, data for our study was ascertained from a review
of medical records which depended on non-standardized
and variable quality of cases’ notes entry. Though we included all the attempts in the period of interest, the sample size was small and there were few statistically significant results. For future studies, it would be important
to increase the period studied in order to obtain a larger
sample. Also, to be able to assess the risks associated
with inpatient suicide attempts, we would need to include a control group.
In conclusion, most of the results of our study
support previously published profiles for potential suicide attempters (7, 9, 21, 24). Regarding prevention strategies, additional measures should be established inside the
wards in order to reduce the risk of inpatients attempting
suicide. Clinical suicide risk must be assessed and documented regularly in all patients admitted to the wards
despite diagnoses and reported suicidal ideation. Taking
this into account, treatment and level of observation can
be optimized as necessary, thus diminishing possible suicide behavior risk factors.
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Kaplan HI, Saddock BJ. Comprehensive Textbook of Psychiatry,
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Modestin J, Kamm A. Parasuicide in psychiatric inpatients: result
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Pitula CR, Cardell R. Suicidal In-Patients’ Experience of Constant
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ACKNOWLEDGEMENTS
This study was supported by the UPR School
of Medicine Endowed Health Services Research Center,
Grants 5S21MD000242 and 5S21MD000138, from the
National Center for Minority Health and Health Disparities, National Institutes of Health (NCMHD-NIH). Its
contents are sole the responsibility of the authors and do
not necessarily represent the official views of NCMHDNIH.
Linnette Rodríguez-Figueroa, MSc, PhD, Department of Biostatistics and Epidemiology, Graduated
School of Public Health, University of Puerto Rico.
Staff members of the Record Room, Puerto Rico
State Psychiatric Hospital- Dr. Ramón Fernández Marina
RESUMEN
Objetivos: Describir el perfil socio-demográfico, médico y psiquiátrico de pacientes con intentos
suicidas en el Hospital Psiquiátrico de Puerto Rico
durante el período comprendido entre marzo 2005 a
marzo 2007. Identificar los métodos usados con más
frecuencia; como también el día, la hora y nivel de
observación del paciente al momento del intento. Método: Los pacientes hospitalizados del Hospital Psiquiátrico Estatal, con intentos suicidas, fueron evaluados de marzo 2005 a marzo 2007. La información
fue recopilada de los reportes del incidente de estos
intentos y de los expedientes de dichos pacientes.
Resultados: Durante el período de investigación, un
total de 44 intentos de suicidios fueron reportados por
31 pacientes hospitalizados. La mayoría de los cuales fueron diagnosticados con trastornos psicóticos
(96.8%) y trastornos de ánimo (48.4%). El método
más comúnmente utilizado fue el de colgarse (79.6%);
y el precipitante más común identificado fueron los
estresores médicos, como lo son las alucinaciones o
frustraciones relacionadas a sus condiciones psiquiátricas. Conclusión: La mayor parte de los resultados
de nuestro estudio asemeja los perfiles publicados con
anterioridad para los intentos potenciales de suicidios.
Con respecto a las estrategias de prevención, deben
establecerse medidas adicionales dentro de las unidades para reducir el riesgo de los intentos suicidas en
los pacientes hospitalizados.
31
ABSTRACT
Objectives: The purpose of this study
was to explore the level of knowledge that a
group of Puerto Rican teachers have about Attention Deficit Hyperactivity Disorder (ADHD),
the most common psychiatric disorder in school
age children. Method: the design was descriptive experimental. One hundred thirty two school
teachers of five different schools (public and private) from the metropolitan area of San Juan participated in the study. Questionnaires administered included demographic data of participants;
29 true or false questions, (obtained from the
DSM-IV TR diagnostic criteria of ADHD and
other behavioral disorders); and five ‘vignettes’
of children with common behavioral problems
observed in the classroom. Logistic regression
was used in the analysis of data. Results: Thirty
five per cent of the teachers reported to have had
previous knowledge about ADHD. Seventy two
per cent (72) reported a low level of knowledge
about the disorder as reflected on the true/false section, while 60% were able to identify two
out of three vignettes of children with characteristics of ADHD. No statistically significant
correlation was found between teachers’ level
of knowledge and other variables studied (age,
gender, college where obtained the degree, years
of experience, the level they teach or previous
training obtained about ADHD). Discussion:
The findings evidence the limited information
and confusion that teachers have about ADHD.
A thorough revision of the curricular content
of teachers in training is recommended so that
they become knowledgeable about the common behavioral problems that commonly affect
children. Teachers’ observations are important
sources of information for child psychiatrists in
the process of evaluation and diagnosing children with ADHD. Therefore, is critical that teachers in the public and private sectors become
aware of these characteristics so they are able to
identify these children as early as possible.
ATTENTION DEFICIT
HYPERACTIVITY
DISORDER IN FIVE
SCHOOLS OF THE SAN
JUAN METROPOLITAN
AREA: ASSESMENT
OF TEACHER’S
KNOWLEDGE
Gloria González Tejera MD*
Mari González PhD*
Beatriz Ramírez MD*
Maralexis Rivera MD*
From the *Department of Psychiatry, UPR School of Medicine.
Address reprints requests: Gloria González Tejera, MD,
Departament of Psichiatry, UPR
PO Box 365067, San Juan PR 00936-5067. E-mail:
[email protected]
INTRODUCTION
A
ttention deficit hyperactivity disorder (ADHD) is
a common psychiatric diagnosis that affects 2-20 percent of
school grade children in the United States 1. It is more prevalent
in boys (8%) than in girls (3.3%) and most commonly affect
first-born boys. (2) The overall prevalence rate for ADHD in
Puerto Rico of youngsters 4 – 17 years old is 8.0 per cent, the
higher of all psychiatric disorders in this population (3) Children with ADHD are at higher risk to develop other disorders,
including the other two disruptive behavior disorders – oppositional defiant and conduct disorder (4 5). They are more
likely than non-ADHD children to experience poor academic achievement. ADHD is a clinical diagnosis, based on a
detailed history of a child’s early development and direct observation from parents and teachers. Most children with
ADHD present the core symptoms during elementary school years, consisting of developmentally inappropriate hyperactivity and impulsive behavior, and inattention which interferes with the child’s learning process. According to the DSMIV TR, (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revised) the symptoms have to be
present in two or more settings (for example school and home) for at least six months, and clear evidence of impairment
in social or academic functioning(6).
ADHD is the most common childhood psychiatric disorder also in other countries (7 8 9) but despite its popularity in the general public little is known about the knowledge that Puerto Rican teachers have concerning this disorder.
This is particularly important because child psychiatrists frequently use standardized rating scales to obtain information from the teachers’ about a child’s behavior at school. These scales provide helpful information to clinicians in the
process of evaluating a child with this disorder. Parents and teachers’ knowledge about the characteristics of ADHD in
children has been explored by other researchers (10 11 12 13). These studies demonstrated that the majority of teachers did
not receive adequate training on ADHD during their undergraduate education. A study which compared American and
Canadian teachers’ knowledge and
32
attitudes towards ADHD, indicated that both groups had
little in-service training about this condition and were not
aware of the educational implications of the disorder (14).
Another study comparing regular, and special education
teachers showed that basic knowledge about ADHD was
low for both groups (15). In Puerto Rico, two studies
about attitudes and knowledge of ADHD were conducted
in a general population (16 17), but no study has assessed teachers’ knowledge about the common manifestations of ADHD among Puerto Rican children.
The accuracy of teachers’ assessment on student’s
behavior is of special concern, because they have an important role in identifying and referring students to special education programs and psychological services (18
19 20). Behavioral problems in school can be predictors of academic failure, school dropout and delinquency.
Teachers are able to observe and interact with children
in a relatively standardized social environment; they are
also capable to observe their social skills and interaction
with other children. In addition, teachers may observe
and compare normal and deviant behaviors of children at
the same developmental level (21).
Teachers’ knowledge about the common behavioral problems that affect children and adolescents
is essential, particularly when the problem impairs the
child’s ability to learn or to relate with others. Considerable resources from private and public agencies, such as
the health department, social services, educational institutions and community groups are currently devoted to
the prevention and treatment of children and adolescents
with this diagnosis. However, lack of knowledge in the
general population and in the teachers yet hinders efforts
of early diagnosis and prompt intervention. Therefore,
in response to this need this study will examine the level
of knowledge that a group of Puerto Rican teachers have
about the characteristics of ADHD in children and adolescents.
METHODS
Subjects
The sample consisted of 132 schoolteachers, from
one private school (kinder to twelfth grade), two public
elementary schools, and two public high schools, from
the San Juan, (Puerto Rico) metropolitan area. There was
an overrepresentation of teachers who taught in public
school (69.7%) as opposed to private school (30.3%).
Measures and procedures
The teachers agreed to participate on a voluntary
basis and approval for the study was obtained from the
school principals. Special arrangements were scheduled
at each school to inform the teachers about the purpose
of the study, to discuss issues of confidentiality and to
administer the questionnaire. Five sessions (one at each
school) were held between the teachers and two child
psychiatry residents that administered the questionnaire
and supervised the process.
Data for this survey was obtained from participants’ selfreport questionnaires; 100% of the teachers completed the
questionnaires. The survey collected data of demographic characteristics and information relevant to their professional background which asked specifically whether
their training included information about ADHD. One
scale which consisted of 29 true-or-false questions was
developed to assess their knowledge about the condition
(ADHD) and other similar behavioral problems. These
questions were obtained from statements of the DSMIV TR diagnostic criteria of ADHD and other disruptive
behavioral disorders. For the analysis of the true-or-false
section, we chose eleven statements which corresponded positively to symptoms criteria of ADHD, combined
with eighteen statements of characteristics of other behavioral problems (i.e. ODD and CD), which corresponded
negatively to ADHD. We assigned a positive score for
the ADHD characteristics that were correctly identified
and a negative score to those that did not correspond to
ADHD characteristics. Each teacher’s score was obtained by subtracting the negative answers from the positive. A cut-off point of ‘6’ was considered as the lowest
score within the range of appropriate level of knowledge.
This figure was chosen based on the minimum number
of symptoms required for the diagnosis of ADHD, according to DSM IV. This score was then compared with
demographic and professional background data by using
logistic regression.
Another approach used to assess the teachers’
knowledge on ADHD included ‘vignettes’ representing
real life situations in the classroom of children and adolescents with common behavioral problems. Five vignettes were included; three of them had characteristics of
ADHD, one had conduct disorder and another had normal behavior. The teachers were asked to answer: ‘yes’,
‘no’ or ‘do not know’, when asked whether or not the
situation described corresponded to characteristics of an
ADHD child. The vignettes described common behavioral problems in children and adolescents that are likely to
be observed in a classroom setting. For example vignette
‘1’ presented a child with hyperactive-impulsive behavior
as the prominent manifestations. It reads as follows:
Pepito is 7 years old and is on second grade. His
teachers describe him as very active and verbal child. He
learns well and has good grades. The teachers have noticed that he gets easily distracted, particularly during Social Studies and occasionally does not complete his daily
work in Spanish. The home-room teacher complains that
Pepito talks too much; he frequently interrupts the class
and blurts out the answers without raising his hand. Pepito also leaves his sit and bothers his classmates. When
he is in the cafeteria, he has difficulty waiting his turn and
is not able to stay on line. During physical education,
Pepito is the most active child in his group; he makes
unnecessary noises and always wants to be the leader.
Vignette ‘2’ described a 10 year-old female with
prominent inattentive characteristics; vignette ‘3’ described a 14 year-old male mostly hyperactive, vignette ‘4’
described a 16-year old female with Conduct Disorder
(CD) and vignette ‘5’, a 9-year old female with ageappropriate behavior.
After each vignette, teachers were asked to check on the
best recommendations or action plan for each case. These responses were categorized as follows: ‘No need for
referral’, ‘Referral to school resources-school counselor
or social worker, ‘Referral for professional evaluation
-psychologist or child psychiatrist’, ‘talk to parents’,’
Don’t know’, ‘Any combination’ (of school resources
with professionals and/or parents) and ‘Non specific evaluation’. To assess the teachers’ knowledge we counted
the vignettes that were correctly identified and compared
these data with scores on the true/false test.
RESULTS
Teachers’ Characteristics
We administered the questionnaire to 132 teachers: 82% were females and 18% were males. The
mean age was 44 years. Seventy one percent (71%) of
all participants obtained their degree at the state university (UPR), while the rest from private universities. The
majority -73% completed a bachelors’ degree, while 26%
had a Masters’ degree, and 1% had a Ph.D. The years of
experience ranged from less than one year to 45. Among
the total sample, 37% were elementary school teachers,
16% were intermediate, 43% taught high-school level,
8% elementary and intermediate, and 9% intermediate
and high school. Using logistic regression, we compared every demographic variable with the teachers’ level
of knowledge (both scores, the true/false section and the
ratings of vignettes). We found no significant correlation
between any of them.
Teachers’ Knowledge
Thirty five percent (35%) of the teachers reported they received previous training about ADHD. The
majority –65% informed they were not formally trained,
but received conferences on the topic at the school setting where they worked.
Results of the true/false scale showed that only
27% of the teachers scored ‘6’ or more, while 72%, scored ‘5’ or less. The mean score obtained in this section
was 3.4. The characteristics of ADHD most commonly
identified were: “squirms in chair”, “difficulty awaiting
turns”, “often does not seem to listen”, “is often easily
distracted by extraneous stimuli”, “often does not follow through on instructions” and “fails to finish school
work”. The characteristics least likely associated with
the syndrome were: “often on the go” or “often acts as if
driven by a motor” and “is often forgetful in daily activities”.
On the other hand, the most common statements
that teachers wrongfully identified as characteristics of
ADHD which corresponded to other behavioral problems were: “constantly argues with adults’ (diagnostic
criteria for ODD) and ‘cruel with animals’ (diagnostic
criteria for CD). Thirty percent (30%) of the teachers
chose ODD characteristics as typical behavior of children with ADHD while 50% endorsed characteristics of
CD to ADHD.
33
Results of the vignettes’ section demonstrate that only
20% of the teachers could correctly identified the three
vignettes that described children with characteristics of
ADHD while 40% of the respondents identified at least
two of them. Vignette ‘1’ was the most easily identified.
The least easily identified, was vignette ‘2’- the 10 yearold girl with symptoms of inattention. Overall, teachers
from public schools were more likely to identify correctly
the characteristics of ADHD in vignette ‘1’ and ‘2’ than
private school teachers.
Regarding the recommendations or best action
plan, the most common response reported by the teachers
to vignette ‘1’ and ‘2’ was ‘Don’t know’; and for vignette
3, was ‘Non specific evaluation’.
DISCUSSION
Consistent with the literature, the findings of
this study confirmed the presence of some knowledge
gaps among a group of Puerto Rican teachers regarding
the identification of the most common characteristics of
ADHD in children and adolescents. Even though many
of the teachers were able to identify correctly the characteristics of inattention, hyperactivity and impulsivity;
the majority identified behavioral characteristics of other
diagnostic categories, like ODD and CD, as characteristics corresponding to ADHD. These findings suggest
that other factors like teachers’ attitudes, beliefs and perceptions of the disorder, which were not examined in this
study, could have influenced these results. For example,
the majority of the teachers were not able to identify correctly (vignette #2) the 10-year-old girl, with ADHD
predominantly inattentive subtype. For the majority of
the teachers, the profile of an ADHD child also included
characteristics of ODD and CD. Clinically, it is known
that ADHD with comorbid ODD and CD is the most severe form of the disorder. If teachers were more likely to
identify children with all three behavioral problems (that
is, the more severe cases) as those with ADHD, then is
highly probable that those children with the disorder that
are less severe may be overlooked by them. This result
also may suggest that teachers are more tolerant to mild
behavioral problems.
Moreover, females with the diagnosis, predominantly inattentive type are more likely to be unidentified,
as have been reported in the literature (22).
Even though the sample included special education teachers, the performance of this group was not compared with the rest of the teachers (‘regular’), so we were
not able to determine if the level of knowledge was higher for the special education teachers than for the group
of regular teachers.
We examined the results of the vignettes and
found that at least 60% of the teachers were able to identify correctly at least two of the three vignettes depicting
ADHD characteristics. We further evaluated the scores
they obtained in the true-or-false section and found no
correlation, but it is important to point out that the vignettes are not validated or standardized. This represents
one of the limitations in our study; therefore, validation
34
of additional vignettes is recommended.
Our findings are consistent with other studies
found in the literature that also examined teachers’
knowledge on ADHD (23 24). One study reported that
teacher’s claimed about four barriers they confronted in
the process of identifying children with ADHD; these
were: lack of time to address special interventions, lack
of training and knowledge, class size, and severity of the
problem ( 26).
We found that teachers were more likely to identify behavioral manifestations of hyperactivity and impulsivity since the latter tend to be more disruptive in
the classroom. In contrast, inattentive behaviors alone
tend not to be so disruptive and perhaps in crowded classrooms teachers overlook these children. In this study,
when teachers evaluated the case of a child with ADHD
inattentive type, only 19% of the participants informed
the child had ADHD. We speculate that cultural norms
regarding children’s behavior may play an important role
in the under identification of children with ADHD inattentive type. This area requires further research.
Previous work demonstrates that oppositional
behaviors produce a negative halo effect on ratings of
hyperactivity and inattention (26). This finding was also
evident in the case #4, depicting a female adolescent with
conduct disorder in which 67% of the teachers reported it
described ADHD characteristics. At least 33% of the teachers attributed more severe disruptive behaviors (ODD
and CD) to ADHD manifestations.
Almost all participants were unable to determine
an adequate action plan for the five situations depicted
on vignettes. The most common recommendations were:
Don’t know and non specific professional evaluation and
intervention with the student. Only 19% recommended
psychological or psychiatric evaluation and 34% would
make an intervention with the student.
This study showed the need to educate public and
private school teachers about the most common behavioral disorders affecting Puerto Rican children and adolescent, so they are more apt to identify them and refer them
for treatment.
CONCLUSIONS
Teachers are critical in early identification of
students with characteristics of ADHD. They have the
opportunity to observe students, describe their behaviors
and document their academic difficulties when present.
Given that many children with ADHD are commonly in
a regular classroom, regular schoolteachers should also
be trained during their professional development about
the behavioral problems in children, as well as the special education teachers are trained. Early diagnosis and
intervention allow ADHD children to adjust and succeed
at school and daily life.
The school system, public and private sectors should promote regular ‘in-trainings’ during
academic year about this critical diagnosis, not only for
the teachers but also for the parents of the children
they teach. .Parental lack of knowledge on behavioral and emotional problems affecting children and
adolescents, particularly Latino children has been
pointed out in the literature, as a barrier that prevents them from getting treatment (27 28). Schools
should develop ‘protocols’ that would help identify children with these problems; and, also to assist
them in making recommendations to the students’
parents, about the best action plan to be followed.
A network of mental health professionals in the
community – psychologist or child psychiatrist willing to provide the services may also be considered.
Early recognition and intervention of children with
ADHD, could significantly contribute to decrease
the rate of school dropouts, conduct disorder, substance abuse and delinquency.
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5- Biederman J, Faraone SV, Milberger S, et al. A prospective 4 year follow-up
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8- Gadow KD, Nolan EE, Litcher L, Carlson GA. Comparison of ADHD
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10- Kasten EF, Coury DL, Heron TJ. Educators’ knowledge and attitudes regarding stimulants in the treatment of attention deficit hyperactivity disorder. J
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12- Kwasman A, Tinsley BJ, Lepper HS.: Pediatricians’ knowledge and attitudes concerning diagnosis and treatment of attention deficit hyperactivity disorders: a national survey approach. Arch Paediatr Adolesc Med 1995;
149(11):1211-6.
13- Yang KN, Schaller JL, Parker R. Factor structures of Taiwanese teachers’ ratings of ADHD: a comparison with U.S. studies. J Learn Disab 2000;
33(1):72-82.
14- Jerome, Gordon Hustler, 1994 Jerome L, Gordon M, Hustler P. A comparison of American and Canadian teachers’knowledge and attitudes towards
ADHD. Can J Psychiatry 1994; 39(9):563-7.
15- Brook, Watemberg, Geva 2000
16- Bauermeister J.: Development of multivariate assessment scales for Puerto Rican children. Paper presented at the annual convention of the American
Psychological Association, Massachusetts, 1990
17- Bauermeister J et al.: Factor Analyses of teacher ratings of attention deficit
hyperactivity and oppositional defiant symptoms in children aged 4 through 13
years. J Clin Child Psychol 1992; 21(11): 27-34.
18- Bennet R et al.: Influence of behavior perceptions in gender on teachers’
judgment of students’ academic skills. J Educ Psychol 1993; 85: 347-356.
19- Huddley C: Comparing teachers and peers perception of aggression: an
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20- Ysseldyke JE. Generalizations from five years of research of assessment
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21- Edelbrock CS. The teacher version of the child behavior profile: boys ages
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25- Reid R. An analysis of teachers’ perceptions of ADHD. J Research Dev
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26- Stevens J, Quittner AL, Abikoff H. Factors influencing elementary school
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and Adolescent Psychiatry, 39, 841-849.
RESUMEN
Objetivo El propósito de este estudio fue
explorar el nivel de conocimiento que tienen los
maestros sobre el Trastorno de Déficit de Atención
e Hiperactividad (ADHD por sus siglas en inglés),
el diagnóstico psiquiátrico más común en niños.
Método El diseño fue descriptivo experimental. Se
administraron cuestionarios a 132 maestros de cinco escuelas del área metropolitana de San Juan. Los
mismos incluían datos demográficos; 29 preguntas
cierto o falso, (obtenidas de los criterios diagnósticos del DSM-IV del ADHD y otros problemas de
conducta); además, cinco ‘vignettes’ de niños con
diferentes conductas y/o situaciones para evaluar.
Se utilizó regresión logística para evaluar la posible
correlación entre los datos demográficos y el nivel
de conocimiento de los sujetos. Resultados Del total de la muestra, 35% de los maestros tuvo adiestramiento previo sobre el ADHD. Setenta y dos
(72) por ciento de los maestros tenían ‘poco’ conocimiento sobre la condición según reflejó la sección
de cierto o falso; mientras que 60% identificaron
dos de tres vignettes de niños con características
del ADHD. No hubo correlación estadísticamente
significativa entre el conocimiento de los maestros
y las demás variables que se estudiaron (edad, sexo,
universidad donde estudio, el grado académico obtenido, los años de experiencia, el nivel que enseña,
o adiestramiento previo sobre ADHD). Conclusión
Este estudio evidenció la falta de conocimiento y
confusión que tienen los maestros sobre el ADHD.
Se debe establecer como política pública, el entrenamiento y capacitación de éstos en los problemas
de conducta y/o e18mocionales que afectan comúnmente a los niños en edad escolar; ya que los maestros son un recurso importante en la identificación
temprana de condiciones como el ADHD.
SALA DE EMERGENCIA
El programa de radio de la Asociación Médica de Puerto Rico, moderado por su Presidente, el Dr. Rolance G. Chavier Roper.
Todos los jueves de 7pm a 8pm
36
MARITAL AND JOB
SATISFACTION
AMONG
NON-RESIDENT
PHYSICIANS AT
A HISPANIC
ACADEMIC MEDICAL
CENTER,
2006-2007
Luz N Colón-de Martí MD*
Luis F Acevedo MD*
Wayca R Céspedes-Gómez MD*
* From the Department of Psychiatry, UPR
School of Medicine, Puerto Rico Health Science Center.
Address reprints requests: Luz N Colón-de Martí
MD, Department of Psychiatry, UPR School of Medicine,
PO BOX 365067, San Juan, PR 00936. E-mail: <lncolon@
rcm.upr.edu>
ABSTRACT
Marital satisfaction has been previously associated with job satisfaction although few studies have
addressed this issue among Hispanic physicians. Marital and job satisfaction were assessed in a sample of
92 legally married non-residents physicians working
at a Hispanic Academic Medical Center during the
2006-2007 academic year. Marital satisfaction was
assessed using the Dyadic Adjustment Scale (DAS)
and job satisfaction was measured using a 18-item
scale. Response rate was 34.8%. Most (70.7%) of
the subjects were males. Forty- five percent (45.0%)
belonged to the surgical specialties group. The mean
scale value for marital satisfaction was found to be
in the average range. Almost all (88.7%) the participants reported being “satisfied “to “very satisfied”
with their job. Ninety percent (90.0%) of the surgical
specialists and 86.9% of the non-surgical specialists
reported being satisfied with their job. The percentage of participants that reported to be “very satisfied ”
with their job, was higher among the group of surgical specialists (23.3%) than among the non-surgical
specialists (13.0%) There was no significant relationship between marital satisfaction and job satisfaction. Also, no statistically significant difference
was observed in the level of marital satisfaction and
job satisfaction when surgical and non-surgical physicians were compared. The findings on marital satisfaction obtained in this sample were similar to those
observed in a previous study of resident physicians at
the same academic medical center.
Key Words: Physician’s satisfaction, marital satisfaction, job satisfaction, Hispanic Puerto Rico, academic center, non-resident physician’s satisfaction
INTRODUCTION
P
hysicians play several important roles in society. It is no surprise that the stressful nature of this profession
has an impact on their other roles, which themselves may be stressful enough to impact their professional role(s). The
medical literature has described the demanding nature of a physician’s job and how these constant demands may impact
family life, relationships, or even alter career paths (1-7). A stressful environment during one role may impact the level of
satisfaction during other roles. At the same time, difficulties in one role can be compensated by successful performance
in another (5).
Marital satisfaction has been previously associated with job satisfaction (6,8,9,). Lewis(8) found that physicians
who reported higher levels of marital satisfaction also reported higher levels of work satisfaction, lower levels of work
stress, and fewer psychiatric symptoms. Myers described how physicians with children found the challenges to be more
manageable and their joys were more intense when their primary relationship was happy (10). In Puerto Rico, Aponte
et al. (2006) studied a sample of resident physicians at the academic medical center used in the present study and found
marital satisfaction to be in the average range (11).
Job satisfaction among physicians is another important concern because it has been associated with physician’s
health and wellbeing, as well as with important aspects of patient’s care and costs of health services (2,4,5, 12-17). Job
satisfaction was not assessed in the previously mentioned study in this academic medical center.
This study examined marital and job satisfaction in a group of non-Resident Physicians working at a Hispanic
academic medical center. We explored the self-perceived job satisfaction in non-surgical and surgical physicians, and
studied if there was a relationship between job satisfaction and the level of marital satisfaction reported.
37
METHOD
A cross-sectional survey was conducted among
non-resident physicians of the University of Puerto RicoMedical Sciences Campus training departments during
the 2006-2007 academic year. Only those who were legally married were eligible to participate (N=264). Subjects
received written information with a brief description of
the study, a self-administered instrument, and an additional form with twelve (12) questions which addressed demographic data of participants. All forms were assigned a
number but no other indicators to identify the participant.
Participation in this study was voluntary and all forms
were kept anonymous and confidential. This notification
was included in the information sheet.
The forms were distributed in each department
with a sealed box where participants deposited their
forms upon completion. Investigators collected the
forms on a weekly basis and segregated them in one of
two envelopes labeled "Surgical" and "Non-surgical"
without any other specifiers. Surgical specialties included: anesthesiology, dermatology, ENT, general surgery,
neurosurgery, OB/GYN, ophthalmology, urology, and
orthopedics. Non-surgical specialties comprised all other
specialties not listed above. The segregation of forms in
these two categories was done to safeguard the identity
of participants by maintaining aggregate groups as large
as possible.
Marital satisfaction was evaluated using the Dyadic Adjustment Scale (DAS), a validated scale for marital satisfaction (18). This is a 32-item questionnaire that
measures satisfaction on four (4) distinct dimensions:
Dyadic Satisfaction (DS, which measures the amount of
tension in the relationship as well as the extent to which
the individual has considered ending the relationship),
Dyadic Cohesion (DCh, assesses the common interests
and activities shared by the couple), Dyadic Consensus
(DC, assesses the extent of agreement between partners
on matters important to the relationship), and Affectional Expression (AE, measures the individual’s satisfaction with the expression of affection and sex in the relationship). Results obtained with this questionnaire have
demonstrated to correlate with standardized measures
of marital satisfaction. Raw test scores were converted
to T-scores. T-scores have a mean or average of 50 and
a standard deviation of 10. The T-scores used with the
DAS are linear T-scores which are interpreted using the
guidelines provided (average range is 45-55). The scale also provides for individual subscale scores. Marital
Satisfaction was evaluated using the DAS interpretative
guidelines for T-scores as follows:
problem)
<34: Moderately atypical (Indicates significant
problem )
concern )
35-39: Mildly atypical (Indicates significant
40-44: Slightly atypical (Borderline: possible
45-55: Average (Typical score: no concern)
56-60 : Slightly atypical
61-65 : Mildly atypical
66-70 : Moderately atypical
>70 : Markedly atypical
Job satisfaction was measured using a questionnaire previously used in a Hispanic sample which measures job satisfaction considering many aspects of the
job (19). It uses a five-point Likert format where 1 (one)
represents “Completely Disagree” and 5 (five) represents
“Completely Agree.” Proportions were compared using
chi square and Fisher tests. Mean scores were compared
using T tests and ANOVA.
RESULTS
A total of 92 voluntary non-resident physicians
participated in the study for a response rate of 34.8%.
Most (70.7%) were males and from Non-surgical specialties group (55.4%). Only 16.5% were 35 years old or
less; most (45.1 %) were over 50 years old. Ninety one
percent of the sample had children. Over half (51.6 %)
had been married for over 20 years, and 62.0 % reported
that their spouse was not a physician. (See Table I)
Table I Distribution of Socio-Demographic Characteristics of Non-Resident Physicians,2006-2007
Characteristics
Gender
Male
Female
Age Group Years
≤35
36-50
>50
Years since
completing residency/ fellowship
≤ 10
11-20
>20
Type of Specialty
Surgical
Non-surgical
Frequency (N)
Proportion(%)
65
27
65
27
15
35
41
15
35
41
26
26
39
26
26
39
41
51
41
51
11
81
11
81
35
57
35
57
24
20
47
24
20
47
Previously Married
Yes
No
Previously Married
Yes
No
Years Married to
current spouse
≤ 10
11-20
>20
38
69
11
2
84.1
13.4
2.4
Active Religious
Participation
Yes
No
45
36
55.6
44.4
Marital Satisfaction:
Most (80.4%) of the physicians reported average to above average T-scores on Dyadic Adjustment Total Scale T-scores. Mean score was 50.51±9.86 which is
considered as within the average range (Figure 1).
Percentage (%)
Dyadic Adjustment T-scores
60
40
20
0
51
7.8 3.9
15.7 11.8
7.8
<35 35- 4039 44
45- 5655 60
2
0
61- 66- >70
65 70
T-scores
There were no significant differences in the
mean Dyadic Adjustment scores by specialty, gender,
age,, years since completing the residency, years married, previous marriages, spouse MD, having children
and having a religious affiliation.(Figure 2) However,
those who were catholic had a significantly lower mean
Dyadic Adjustment T-score (49.9±9.5) than those who
were from other religions (55.0±11.6)(Figure2, Table
II) Similar results were obtained for all Sub-scales . The
only significant difference was in the Dyadic Satisfaction
Scale where Catholics had a significantly lower score
(47.5±8.0) than others (55.6±2.9).
Percentage (%)
Dyadic Adjustment T-scores of
Surgical and Non-surgical physicians
60
40
20
0
Surgical
Non-surgical
<34
3539
4044
4555
5660
T-scores
6165
>66
Specialty
Surgical
Non-surgical
50.9
49.7
9.3
9.6
0.553
Gender
Male
Female
50.6
49.4
10.0
8.1
0.580
Age Group
≤35
36-50
>50
52.6
49.1
50.1
7.5
9.6
9.9
0.494
Years married
0-10 years
11-20
21+
50.4
50.3
50.8
9.5
9.9
8.4
0.975
Previous marriages
Yes
No
47.3
50.6
4.4
1.0
0 .330
Spouse Physician
Yes
No
51.5
49.5
8.0
10.1
0.356
Have Children
Yes
No
50.1
51.5
9.8
5.5
0 697
50.2
49.9
55.0
50.3
9.5
9.5
11.6
9.5
0.986
0.238
52.1
48.7
8.5
9.3
0.198
Religious Affiliation
Yes
Catholic
Other
No
Active participant of religious affiliation
Yes
No
pvalue
Religious Affiliation
Catholic
Protestant
Other
Standard
Deviation
91.3
8.7
Mean
84
8
TABLE II : Mean Dyadic Adjustment T-scores of nonresident physicians, 2006-2007
Variables
Have any children
Yes
No
39
Mean Sub-scales T–scores for Dyadic Cohesion, Affectional Expression, Dyadic Satisfaction and Dyadic Consensus all yielded average to above average T-scores.(Figure 3; Table III )
Dyadic Adjustment Sub-Scales Mean T-Scores
of Non-Resident Physicians, 2006-07*
* Mean ± standard deviation
Table III Distribution of Mean Dyadic Adjustment Sub-scales T- Scores of Non-Resident Physicians by Specialty, 20062007
Specialty
Total
Non-surgical
Surgical
(‾x ±s)
Scales
(‾x ±s)
(‾x±s)
Dyadic Cohesion
57.7±12.9
58.0±7.3
57.8±10.7
Affectional Expression
49.8±11.8
52.0±8.3
50.8±10.3
Dyadic Satisfaction
47.8±9.7
48.7±5.9
48.2±8.2
Dyadic Consensus
48.3±10.3
48.2±7.9
48.3±9.2
Dyadic Adjustment
50.3±11.5
50.8±7.6
50.5±9.9
Almost all (90.2%) of the non-resident physicians reported Dyadic Cohesion Subscale (which assesses common
interests and activities shared by the couple ) T-score average or above.
Job Satisfaction: Almost 90 % ( 88.7%) of participants who completed all required forms reported being “Very
Satisfied ” to “Satisfied ” with their job. Ninety percentage of the Surgical specialists reported to be “Satisfied “to “Very
Satisfied “compared to 86.9% of the Non-Surgical specialists group. More Surgical specialists (23.3%) reported being
“Very Satisfied” with their job compared to 13.0% of the Non-Surgical specialists ( See Table IV ).
Table IV: Overall Job Satisfaction of Non-resident Physicians at the UPR- MSC 2006-2007 by type of specialty
Level of Job satisfaction
Dissatisfied
Satisfied
Very Satisfied
Specialty
Specialty Surgical
N(%) 3 (10.0%)
20(66.7 %)
7 (23.3%)
Non-surgical N(%)
3 (13.0%)
17(73.9%)
3 (13.0%)
Total
N (%)
6 (11.3 %)
37 (69.8 %)
10 (18.9 %)
40
DISCUSSION
The literature on physician’s satisfaction includes
findings of physicians who report higher levels of marital
satisfaction and also higher levels of family competence,
higher levels of work satisfaction, lower levels of work
stress and fewer psychiatric symptoms. Physicians and
Dentists who reported high levels of satisfaction in one
important area of life, also have the tendency to report
high levels of satisfaction in other areas of life and fewer
psychiatric symptoms. (8)
Crucial medical outcomes have been linked to
physician satisfaction, too. Among these the literature revised include: prescribing behavior, patient adherence to
medications (20); physician turnover (17,3); morale of
health care workers/staff, and quality of care in general
(15,16). Mechanic (21) understands that physician satisfaction matters also for patient’s care and what factors
influence it since professional dissatisfaction may have
damaging consequences for patients.
Among the outcomes included we also found
patient satisfaction (13) quality of care (12,14,15,16,22)
and burnout of physicians which is an expensive and
unfortunate outcome (23).Physician satisfaction is also
relevant for the education and career choices of medical
students and residents (24).
Research has also found a positive relationship
between physician satisfaction and patient satisfaction
with the medical encounter. It’s also probable that physician satisfaction affects the morale of health care workers
and office staff who work close to physicians (23).
Lewis(8) found that 85% of physicians and their
spouses appeared to be pleased with their marriages, providing information to disprove the widely held belief that
physicians are more prone to dysfunctional and unsatisfactory marital relationships. In this study approximately
80% of participants reported average to above average
mean T-Scores on the Dyadic Adjustment Scale which is
a validated scale for marital satisfaction (18).
Dual physician relationships have been found
to be another area of interest that can involve rewards
and conflicts.(25). Sobecks, Justice, Hinze, et al (1999),
found that marriage to another physician had distinct benefits for both men and women, including more frequent
enjoyment from shared work interests and higher family
incomes ( 26).Smith, Boulger and Beattie (2002), explored the dual-physician marriages, too (9).They found that
most responders felt the advantages of being married to
another physician outweighed the disadvantages. Among
the advantages they mentioned more interests and values
to share as well as support for the stresses of their careers.
It is interesting that although in our sample only approximate 1/3 of our participants have physician spouses; the
mean T-score obtained in the Dyadic Cohesion subscale
(which assesses common interests and activities shared
by the couple) was the highest.
We wanted to assess job satisfaction in this sample and to find out if there was an association with their
marital satisfaction as well. Almost 90 % (88. 7%) of
participants reported to be “Satisfied” to “Very satisfied”
with their job which is also a high percent of the participants. Although we did not find a direct association between marital satisfaction and job satisfaction; there are
studies in which physicians who reported higher levels
of marital satisfaction also reported higher levels of work
satisfaction (8).
CONCLUSIONS
The marital satisfaction of this group of Non-Resident Physicians of a Hispanic academic medical center
was found to be average to above average. Most of the
Surgical (90%) and Non-surgical (86.7% ) specialists
that participated in the study reported satisfaction with
their job. The percentage of participants that reported to
be “Very Satisfied” with their job was higher among the
group of Surgical specialists (23.3%). than among the
Non-Surgical specialists group (13%) There was not a
significant difference in overall marital and job satisfaction between these Surgical and Non-Surgical group of
Non-Residents physicians. Although we did not find an
association between marital satisfaction and job satisfaction; our findings are not compatible with the belief that
physicians are discontent with their job or have unsatisfactory marriages.
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TA: Is the professional satisfaction of general internists associated with
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Warde CE, Moonsinghe K, Allen W, Gelberg L: Marital and
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Williams ES, Konrad TR, Scheckher DP) .Understanding
physician’s intentions to withdraw from practice:the role of job satisfaction
, job stress, mental and physical health. Health Care Manage Rev. Aspen
Publishers.2001; 26:7-19.
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Lewis JM, Barnhart FD, Nace EP, Carson DI, Howard BL:
Marital satisfaction in the lives of physicians. Bull Menninger Clin 1993;
57(4):458-65.
9.
Smith C, Boulger J, Beattie K: Exploring the Dual –Physician
Marriage. Minnesota Medicine 2002; 85(3): 39-43.
10.
.Myers MF: Doctors and divorce. When medicine, marriage, and
motherhood don't mix. Med Econ 1998; 75(10):100-2, 105, 109-110.
11.
Aponte V, Franco GA, Vicente MC :Marital satisfaction of resident physicians at the University of Puerto Rico. ( 2006, Unpublished Data ).
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Barr D : The Effects of Organizational Structure on Primary Care
Outcomes under Managed Care. Annals of Internal Medicine1995;122(5):
353-359.
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Davis D, Collins KS, Schoen C, Morris C: Choice matters: enrollees' views of their health plans:Health Affairs 1995;14,(2):99-112.
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DiMatteo MR, Sherbourne C, Hays RD, et al:Physicians Characteristics influence patient’s adherence to medical treatment; Results from the
medical outcome study. Health Psychology 1993;12 (2):93-102.
15.
Grol R, Mokkink H, Smits A et al :Work satisfaction of general
practitioners and the quality of patient care. Fam Pract 1985; 2(3):128–135.
16.
Kassirer JP: Doctor Discontent. N Engl J Med1998;339:1543.
17.
Kerr EA, Hays RD, Mittman BS et al:Primary Care Physicians
satisfaction with quality of care in California capitated medical groups.
JAMA1997;278(4):308-312 .
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18.
Spanier, G. B. (1986, 1989): Dyadic Adjustment Scale. North
Tonawanda, NY: Multi-Health Systems, Inc.
19.
Padilla, D :Job satisfaction of vocational teachers of Puerto Rico.
Unpublished Doctoral dissertation, The Ohio State University, Columbus.
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Melville A: Job satisfaction in general practice: implications for
prescribing.
Soc Sci Med 1980;14: 495-499.
21.
Mechanic D :Physician Discontent: Challenges and Opportunities.
JAMA 2003; 290:941-946.
22.
Grumbach K, M.D., Osmond D, Vranizan K, et al: Primary Care
Physicians' Experience of Financial Incentives in Managed-Care Systems.
N. Engl J Med 1998; 339:1516-1521.
23.
Murray A, Montgomery JE, Chang H et al :Doctor discontent: a
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McMurray JE, Schwarts MD, Genero NP, Linzer M:The Attractiveness of Internal Medicine: A Qualitative Analysis of the Experiences of
Female and Male Medical Students. Annals of Internal Medicine1993; 119:
812-818.
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Schrager S, Kolan A, Dottl SL: Is that your pager or mine: a
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Sobecks NW, Justice AC, Hinze S , et al :When doctors marry
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Acknowledgements
This study was supported by the UPR School
of Medicine Endowed Health Services Research Center,
Grant 5S21MD000242, from the National Center for Minority Health and Health Disparities, NIH. Its contents
are sole the responsibility of the authors and do not necessarily represent the official views of NCMHD-NIH.
Special thanks to David Padilla Vélez, PhD, Cynthia Rivera, MT (ASCP), MPH, José Vega, PhD, Gloria González Tejera, MD and Linnette Rodríguez- Figueroa, PhD
for their collaboration.
RESUMEN
Se evaluó la percepción de la satisfacción
marital y del trabajo en un grupo de Médicos, NoResidentes legalmente casados, pertenecientes a
especialidades quirúrgicas y no-quirúrgicas trabajando en un centro médico académico hispano
durante el periodo 2006-2007. Se trató de explorar
si había una relación entre la satisfacción marital
y con su trabajo La satisfacción marital que se
reportó está en promedio o sobre el promedio de
acuerdo a la escala utilizada (Dyadic Adjustment
Scale). Estos hallazgos son similares a los reportados en otro estudio sobre la satisfacción marital
reportada por Médicos Residentes en este mismo
centro. La gran mayoría (97%) de los participantes
reportaron estar “Satisfechos ”o “Muy satisfechos”
con su trabajo. No se encontró asociación entre la
satisfacción marital y la satisfacción con el trabajo reportadas por este grupo. No hubo diferencia
significativa entre los Médicos pertenecientes a
especialidades quirúrgicas y los que pertenecían
a especialidades no-quirúrgicas en cuanto a la satisfacción marital y con el trabajo en general.
La Asociación Médica de Puerto Rico
renta sus lujosos salones y oficinas
para actividades o uso continuo
Precios módicos
Excelente ubicacion
Amplio predio para estacionamiento
Informes: Sra. María Laureano, (787) 721-6969
42
RESUMEN
Review Articles/Articulos de Reseña
MANIFESTACIONES CLINICAS DEL TRASTORNO DE
DEFICIT DE ATENCION E
HIPERACTIVIDAD EN LA
POBLACION
DE PUERTO RICO
Lelis L Nazario MD*
dicas.
*Directora, Departamento de Psiquiatría, UPR, Recinto de Ciencias Mé-
Direccion del autor: Lelis Nazario MD, Departamento de Psiquiatría,
Recinto de Ciencias Medicas PO BOX 365067, San Juan, PR 00936. E-mail: [email protected]
El Trastorno de Déficit de
Atención e Hiperactividad (TDAH)
es el trastorno psiquiátrico más
frecuentemente diagnosticado en
niños con una presentación que se
extiende a través del ciclo de vida.
Aquellos niños con síntomas activos que no son detectados, ni tratados tempranamente, están a riesgo
de múltiples problemas incluyendo
abuso de sustancias, delincuencia
y pobres relaciones interpersonales, entre otros. En este artículo se
presenta data clínica relacionada al
TDAH obtenida en estudios realizados con nuestra población, comparándola con data de la población
estadounidense, incluyendo prevalencia, diferencias por género,
correlaciones clínicas y sus implicaciones incluyendo datos sobre
intervenciones existentes. Al revisar la literatura, podemos concluir
que necesitamos aunar esfuerzo
para mejorar la detección temprana
y el tratamiento de esta condición.
Palabras indices: trastorno, deficit,
atencion, hiperactividad, Puerto
Rico
INTRODUCCION
E
l Trastorno de Déficit de Atención e Hiperactividad (TDAH) es la condición psiquiátrica más
comúnmente diagnosticada en niños. Su presentación
usualmente se extiende a través del ciclo de vida, de lo
cual la literatura reporta que un 80% de los casos continúan con síntomas presentes durante la adolescencia
y un 65% durante la adultez1. La mayoría de los casos
identificados son referidos a tratamiento entre las edades de 6-9 años, periodo en el que los niños comienzan
su proceso formativo en la escuela. Aquellos niños con
síntomas de TDAH que no son detectados a tiempo o no
son referidos a un tratamiento adecuado están a riesgo
de graves consecuencias. Según estudios realizados, estadísticas informan que un 52% de estos casos presentan
con un historial de abuso/dependencia a drogas y/o alcohol durante la adultez; 43% de los varones con hiperactividad y conducta agresiva son arrestados por fechorías
a la edad de 16 años; un 75% presenta problemas en sus
relaciones interpersonales y un 35% nunca acaba la escuela1. Es por esto que se reconoce la gran importancia
de detección e intervención adecuada temprana.
Canino et al (2004)2 utilizó una muestra representativa de la Isla para realizar un estudio de prevalencia
de trastornos psiquiátricos en Puerto Rico durante el periodo de 1999-2000. La muestra incluía niños y adolescentes entre las edades de 4-17 años. Entre los instrumentos
metodológicos que se utilizaron se encontraban el DISCIV (“Diagnostic Interview Schedule for Children Version
IV”) y el PIC-GAS (“Lay version of the Children's Global Assessment Scale”) para identificar criterios diagnósticos y medida de disfunción. Los resultados en nuestra
población reflejaron un 8% de prevalencia, comparando
con la prevalencia en Estados Unidos y otras partes del
mundo. Este fue el trastorno de mayor prevalencia en
esta población.
Utilizando la misma muestra, Bauermeister et al
(2007)3 establecieron diferencias en la presentación del
TDAH por género. Entre los hallazgos se reportó que los
varones de la muestra eran diagnosticados el doble de
las veces que las féminas (10.3% vs. 4.7%). Estos también tendían a presentar mayor problemas en las escuelas, siendo sujetos a un mayor número de suspensiones
y expulsiones. Por otro lado, las féminas tenían menos
probabilidades de recibir tratamiento con medicamentos,
lo cual no se encontró asociación con actitudes negativas
hacia la medicación. Estudiando las co-morbilidades del
trastorno por subtipos (combinado, primordialmente inatento, o primordialmente hiperactivo), se observó que
los varones con TDAH tipo combinado estaban más a
riesgo de sufrir depresión y las féminas con TDAH tipo
inatento estaban más a riegos de presentar con trastornos
de ansiedad. A pesar de estas diferencias, hay un número
43
de variables que representan factores de riesgo tanto para
los varones como para las féminas incluyendo el nivel de
carga para la familia, la presencia de disciplina negativa,
la calidad entre la relación entre padres e hijos y los patrones de co-morbilidad.
Las implicaciones clínicas de sus hallazgos según reportadas son varias e importantes para considerar
al momento de evaluación y elaboración de un plan de
tratamiento comprensivo. Si tomamos en cuenta las diferencias entre tipos de ADHD como fueron presentadas,
hay que mantener en mente y diagnosticar las diferentes
co-morbilidades que pueden estar asociadas y que necesitan tratamiento conjunto. A pesar de las diferencias
al momento de ser diagnosticados, tanto varones como
hembras presentan riesgos y secuelas similares. No se
reflejan diferencias por género en cuanto a prognosis
y respuesta a tratamiento. Por lo tanto, las féminas, las
cuales presentan con similar nivel de disfunción que los
varones, podrían beneficiarse de detección temprana y
referido inmediato a tratamiento. Por otro lado, es importante desarrollar programas de intervención para varones
que puedan prevenir el mayor número de suspensiones y
expulsiones a las que son sometidos.
En otro artículo científico que continua utilizando la misma muestra comparando con una muestra
clínica, Bauermeister et al (2007)4 reportan diferentes
correlatos clínicos significativos del TDAH. Utilizando
la muestra clínica, encontraron una prevalencia de 26.2%
de TDAH, también similar a la de Estados Unidos. La
prevalencia fue mayor en varones tanto en la muestra de
la comunidad como en la clínica. A su vez, los niños con
TDAH en la muestra clínica presentaron mayor número
de co-morbilidades asociadas. Entre las co-morbilidades
más significativamente asociadas se encontraban el trastorno de Oposición y Desafío además de los diferentes
trastornos de ansiedad y afectivos. La presencia de comorbilidades a su vez se asocia con un nivel mayor de
disfunción. A pesar de las similitudes identificadas entre
nuestra población y la de Estados Unidos, se encontró
una tasa menor de co-morbilidad entre TDAH y Trastorno de Conducta en nuestra muestra. Los autores exponen que la menor prevalencia de Trastorno de Conducta
podría deberse a relaciones familiares más significativas
con un mayor apoyo social entre nuestra población.
Los hallazgos de este grupo enfatizan el nivel tan
significativo de disfunción social que presentan estos pacientes y por ende nuevamente la importancia de detección temprana y referido a tratamiento. Cuando se tomó
en cuenta la familia de los niños con TDAH, se demostró
que los cuidadores primarios percibían mayor carga por
el cuidado de estos niños, peores relaciones paterno-filiares y reporte de disciplina negativa que las familias de
niños sin el diagnóstico. Por tanto, el tratamiento debe
estar dirigido a cubrir las necesidades individuales de
cada niño y su familia tomando en consideración diferentes aspectos incluyendo las relaciones entre los padres
y los niños, las prácticas de crianza, la carga familiar asociada, los patrones de sueño, problemas de lenguaje y la
presencia de ayudas y servicios adecuados en la escuela
entre otros.
Jensen et al, (1999)5 utilizaron data de la encuesta epidemiológica realizada por el estudio MECA (“Methods for the Epidemiology of Child and Adolescent Mental Disorders”) para investigar las preocupaciones que
surgieron en cuanto al aumento en diagnóstico de TDAH
y la posible sobre medicación de los niños. De la muestra
obtenida de cuatro comunidades de los Estados Unidos
(Atlanta, Georgia; New Haven, Connecticut; Westchester, New York; y San Juan, Puerto Rico) investigaron la
frecuencia del diagnóstico, el alcance de prescripción de
medicamentos y la provisión de otros servicios. Utilizando los criterios del DSM-III-R (“Diagnostic Statistic Manual Version III Revised”) encontraron que un 5.1% de
niños cumplían con el diagnóstico. De esta muestra, sólo
el 12.5% habían recibido tratamiento con estimulantes en
un periodo de 12 meses antes del estudio, de los cuales
el 85% eran recetados por sus médicos primarios. Esto es
sumamente significativo y preocupante cuando tomamos
en consideración toda la evidencia científica existente
probando la eficacia de los estimulantes en el tratamiento de esta condición y todo el efecto positivo que tiene
en mejorar sintomatología, funcionalidad y evitar otras
adversidades asociadas como las previamente mencionadas. Un grupo mínimo recibió medicamentos sin cumplir
con los criterios diagnósticos, aún así presentaban con
problemas significativos de disfunción por lo cual se entendió que los medicamentos estaban justificados.
En cuanto a otro tipo de intervenciones el estudio
reveló que sólo una cuarta parte de estos niños recibieron
algún servicio especial o ayuda de la escuela y aproximadamente sólo una tercera parte habían recibido alguna
intervención de tratamiento psicosocial. Del grupo que
recibió algún tipo de tratamiento especializado en salud
mental, sólo el 3% había estado en tratamiento con un
psiquiatra, un 12% con sicólogos y el resto era tratado
por consejeros, trabajadores sociales u otros. Comparando las cuatro comunidades, los niños en PR fueron los
que recibieron significativamente menos servicios o tipos
de tratamiento de cualquier tipo.
Utilizando este estudio de base y la muestra del
estudio epidemiológico de Canino et al., Bauermeister y
su grupo6 encontraron que de los niños diagnosticados
con TDAH, un 7% recibió tratamiento con estimulantes
en el último año previo a la entrevista, de los cuales sólo
el 3.6% continuaban con el tratamiento al momento de la
entrevista. Estos hallazgos no estuvieron asociados a seguros médicos ni a barreras socioeconómicas. Los varones fueron más medicados que las féminas (10:1). Menos
de una cuarta parte de los niños con TDAH recibieron
algún tipo de servicio en alguna facilidad de salud mental
o por profesionales, incluyendo terapia individual o de
familia, manejo de caso o evaluación y/o pruebas psicológicas. Adicionalmente, sólo una cuarta parte de estos
niños estaban recibiendo algún tipo de ayuda o servicio
en la escuela
Considerando los estudios realizados en nuestra
población podemos concluir que estamos lejos de cumplir con los estándares de práctica establecidos para esta
condición. Es necesario educar y alertar a nuestra población sobre las necesidades de estos niños, las consecuencias de la pobre detección y el tratamiento que se puede
44
ofrecer para mitigar los daños. Necesitamos realizar más
estudios específicos dirigidos a entender las dificultades
y barreras que enfrenta nuestra población para llegar al
tratamiento efectivo.
REFERENCIAS
1.
Dulcan MK, Benson RS. AACAP Official Action. Summary of
the practice parameters for the assessment and treatment of children, adolescents, and adults with ADHD. J Am Acad Child Adolesc Psychiatry. 1997;
36(9):1311-7.
2.
Canino G, et al. The DSM-IV Rates of Child and Adolescent Disorders in Puerto Rico. Arc Gen Psychiatry. 2004; 61:85-93.
3.
Bauermeister JJ, et al. ADHD and gender: are risks and sequela of
ADHD the same for boys and girls? Journal of Child Psychology and Psychiatry. 2007; 48(8):831-839.
4.
Bauermeister JJ, et al. ADHD Correlates, Comorbidity, and Impairment in Community and Treated Samples of Children and Adolescents. J
Abnorm Child Psychol. 2007; 35:883-898.
5.
Jensen PS, et al. Are stimulants overprescribed? Treatment of
ADHD in four U.S. communities. J Am Acad Child Adolesc Psychiatry.
1999; 38(7):797-804.
6.
Bauermeister JJ, et al. Stimulant and Psychosocial Treatment of
ADHD in Latino/Hispanic Children. J Am Acad Adolesc Psychiatry. 2003;
42(7):851-855.
ABSTRACT
Attention deficit and hyperactivity disorders are among the most common psychiatric disorder in children. In a great number of cases, its
presentation is manifested throughout the life cycle.
There are serious consequences when this disorder
is not detected early or effectively treated, including
substance abuse, delinquent behavior, and poor interpersonal relationships among many others. This
article reviews clinical data from scientific studies
among our population and compares findings with
national data, including prevalence, clinical differences by genre, clinical correlations and its implications, as well as evidence in treatment options.
General findings are alarming as there is poor detection and less than optimal treatment offered to
our population
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45
RESUMEN
El artículo analiza el reto que
representa para los profesionales de
la salud guardar la confidencialidad
de los pacientes ante la incesante demanda de la globalización de la información. Discute la importancia que la
confidencialidad tiene para la relación
médico-paciente y cómo ésta es protegida por el gobierno. Identifica áreas
vulnerables en la protección de la confidencialidad, específicamente en el área
de la psiquiatría. Finalmente, invita a
analizar el beneficio de la divulgación
de la información frente a la amenaza
que muchas veces esto representa para
la relación terapéutica.
Palabras índices: confidencialidad, ética, deber, legal
CONFIDENCIALIDAD
COMO
RESPONSABILIDAD ETICA
Y DEBER LEGAL
Tamara Arroyo Cordero MD, JD*
* Del Departamento de Psiquiatria de la Universidad de Puerto
Rico, Escuela de Medicina.
Direccion autor: Tamara Arroyo Cordero MD, JD, Departamento de Psiquiatría, Recinto de Ciencias Medicas PO BOX 365067, San
Juan, PR 00936. Email: <[email protected]>
L
a confidencialidad es una de las primeras
obligaciones del médico con su paciente. La misma,
consagrada en el juramento de Hipócrates 1, es protegida
con celo tanto por las guías de la Sociedad Americana de
Psiquiatría 2 como por el sistema judicial 3.
Las confidencias que hace un paciente a su médico, así como la información concerniente al diagnóstico y
tratamiento de las condiciones del mismo, representan información privilegiada que no debe divulgarse a terceras
personas. Sin embargo, la modernización de la medicina,
así como la creciente tendencia de los sistemas de salud a
proveer servicios integrados, ha traído nuevos retos para
la protección de tan importante privilegio. Es así como
día tras día, la información de los pacientes es rescatada
por aseguradoras, comités de utilización, inspectores de
acreditación, investigadores biomédicos, y aún por agencias del sistema judicial, muchas veces con propósitos
que no se relacionan al bienestar médico del paciente.
Ante nuestro deber de honrar la promesa de confidencialidad que se deposita en la relación médico-paciente es
menester, no sólo atender la responsabilidad ética, sino
también conocer la obligación judicial que impone tener
el más estricto cuidado al divulgar la información provista como parte de la relación médico-paciente.
En el campo de la psiquiatría, particularmente, el
asunto de la protección de la confidencialidad cobra gran
importancia. Ser un paciente psiquiátrico trae consigo un
prejuicio social muchas veces insalvable, y esto, sumado
a que la relación terapéutica misma se fundamenta en la
1 “(…) Guardaré silencio sobre todo aquello que en mi profesión, o
fuera de ella, oiga o vea en la vida de los hombres que no deba ser
público, manteniendo estas cosas de manera que no se pueda hablar
de ellas (…)”
confianza, convierte a la confidencialidad en la “piedra
angular de la ética en la psiquiatría” 4. Sin embargo, conociendo la capacidad atenuada de gran parte de nuestros pacientes para tomar decisiones en su tratamiento,
y atendiendo a la necesidad de comprometer a familiares, cuidadores y tutores con el cumplimiento del mismo,
diariamente tenemos que decidir si debemos compartir
alguna información sobre nuestros pacientes en nombre
de su bienestar.
Esta área gris se intensifica en casos de poblaciones especiales como lo son los pacientes psiquiátricos geriátricos y menores de edad. En ambos casos, al manejo
de los pacientes usualmente se integran familiares a los
que se les comparte información del diagnóstico y
tratamiento del paciente, rompiéndose así el consagrado
privilegio. Las recomendaciones provistas por la Socie2 “ (…)” A physician shall respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient
confidences within the constrains of the law ” Ethics Primer of the
American Psychiatric Association, p.86
3 Regla 26 (B) de Evidencia, 32 L.P.R.A. Ap. IV R. 26(B): “Sujeto
a lo dispuesto en esta regla, el paciente, sea o no parte en el pleito o
acción, tiene el privilegio de rehusar revelar, y de impedir que otro
revele, una comunicación confidencial entre el paciente y el médico
si el paciente o el médico razonablemente creían que la comunicación
era necesaria para permitir al médico diagnosticar o ayudarle en un
diagnóstico de la condición del paciente o para prescribir o dar tratamiento a la misma. El privilegio puede ser invocado no sólo por su
poseedor, el paciente, sino también por una persona autorizada para
invocarlo en beneficio del paciente, o por el médico a quien se hizo
la comunicación confidencial, si éste lo invoca a nombre de y para
beneficio del paciente.
4 Ethics Primer of the American Psychiatric Association, p.16.
46
dad Americana de Psiquiatría para casos como los descritos no son claras: “el asunto de la confidencialidad debe
ser discutido en el comienzo de la relación terapéutica”
5 y “cada situación debe examinarse caso a caso” 6. La
dicotomía entre el paternalismo clásico y la autonomía
del paciente renace, y el asunto de proteger la confidencialidad se matiza con decisiones basadas en lo que el terapeuta piensa que representa el bienestar de su paciente,
más no necesariamente lo que el paciente entiende que
es lo mejor para él/ella. ¿Debe conocer el padre del adolescente el deseo de su hijo de comenzar a estar sexualmente activo?… ¿debe conocer el tutor de un anciano
que ha sido asignado por la corte su diagnóstico psiquiátrico, aún cuando éste no es parte de su familia?… El
terapeuta debe, evitando toda contratransferencia, tomar
decisiones éticamente válidas a la luz de los intereses del
paciente y la protección de la sociedad.i
En cuanto a la utilización de información confidencial por parte de terceros, el Estado recientemente ha establecido un estándar de cuidado para manejar
información de los pacientes mediante la implantación
de la Ley HIPPA (Health Insurance Portability and Accountability Act, 1996). La misma impone penalidades
civiles de hasta $25,000.00 y penalidades criminales de
hasta $250,000.00 con el tiempo de encarcelamiento correspondiente al que, violando la confidencialidad del
paciente, utilice o divulgue su información 7. Esta ley
promete la protección de la información confidencial,
particularmente a la luz de los nuevos sistemas de salud
integrados, donde un promedio de 150 personas (enfermeras/os, técnicos/as de rayos x, oficiales de utilización,
personal médico etc.) tienen acceso al expediente médico
durante el transcurso de una hospitalización 8.
Existen excepciones a la protección de la confidencialidad del paciente psiquiátrico. Estas incluyen
el deber de informar cuando un paciente puede hacerse
daño, cuando se sospecha que el paciente es víctima de
abuso y cuando el paciente amenaza con hacerle daño a
terceras personas 9. Sobre este último particular se expresó el Tribunal en Tarasoff v Regents of the University of
California 10. En este caso, un psiquiatra falló en avisar
a las autoridades que su paciente, Poddar, en reiteradas
ocasiones le había manifestado la intención de matar a
su novia. Cuando finalmente Poddar la asesinó, el Tribunal de California declaró que “el terapista de un paciente
mental tiene el deber de cuidado razonable de avisar del
peligro causado por la condición psiquiátrica de su paciente a terceras personas posiblemente afectadas”. Esta
decisión ha sido reiterada por varios tribunales estatales.
Queda claro cómo la obligación de proteger la
confidencialidad del paciente no es asunto sencillo. Muchas veces la privacidad médica debe competir con las
metas de mejorar la salud del paciente y proteger la salud
pública. Ante el surgimiento de iniciativas que proponen
7 Furrow, B. and colleagues. Health Law, Cases, Materials and Problems. 5th Edition. 2004. p. 348.
sistemas electrónicos interconectados de expedientes
médicos, así como almacenamiento de información genética, nos vemos enfrentándonos a nuevos retos para la
protección de la confidencialidad. Existe una necesidad
de establecer un balance. Es imperativo reconocer que el
derecho individual muchas veces cede ante el colectivo,
sin embargo, en la divulgación de información, el nivel
del posible daño que se cause al paciente muchas veces
compara negativamente con la necesidad que pretende
tener la sociedad de la información sobre el mismo. La
relación terapéutica no debería sacrificarse si el beneficio
de romper el privilegio de la confidencialidad no es claro
y convincente.
REFERENCIAS
1. Juramento de Hipócrates. www.smu.org.uy/publicaciones/libros/laetica/
nor-hipocr.htm. Última revisión 10/27/08.
2. American Psychiatric Association. 2007. Ethics Primer of the American
Psychiatric Association. p.86
3. Reglas de Evidencia de Puerto Rico. 32 L.P.R.A. Ap. IV R. 26(B)
Psychiatric Association. p. 24
7. Furrow, B. and colleagues. Health Law, Cases, Materials and Problems. 5th
Edition. 2004. p. 348.
8. Furrow, B. and colleagues. Health Law, Cases, Materials and Problems. 5th
Edition. 2004. p. 336.
Psychiatric Association. p.17.
10. arasoff v Regents of the University of California. 17Cal.3d425, 131 CalRptr.14,551 P.2d 334 (1976).
ABSTRACT
The article analyzes the challenge that
the health professionals encounter when trying
to protect their patient’s confidentiality, considering the increasing demand for globalization of
the information. It discusses the importance that
confidentiality has for the therapeutic alliance and
how the government has protected it throughout
time. It identifies weak areas in the protection of
confidentiality, especially in the psychiatry field.
Finally, it invites the reader to consider the real
benefits of sharing patient’s information when deciding whether to brake or not the patient’s confidentiality.
8 Furrow, B. and colleagues. Health Law, Cases, Materials and
Problems. 5th Edition. 2004. p. 336.
9 Ethics Primer of the American Psychiatric Association, p.17
10 17Cal.3d425, 131 CalRptr.14,551 P.2d 334 (1976).
47
RISK OF SEROTONIN SYNDROME
WITH COMPLEMENTARY AND
ALTERNATIVE MEDICINES:
IMPORTANCE TO CHILD AND
ADOLESCENT PSYCHIATRY
Gloria M. Suau MD*
Karen G. Martínez MD*
* From the University of Puerto Rico, Department of Psychiatry, San Juan, Puerto Rico.
Address reprints requests: Dr. Gloria M. Suau, UPR-Department of Psychiatry P.O. BOX 365067, San Juan, PR
00936-5067. Email: [email protected].
INTRODUCTION
C
omplementary and alternative medicines
(CAM) use poses a real challenge to psychiatrists given
their availability and their frequent use among patients.
Different studies have documented the increasing use of
CAM over the last decade, especially in distressed individuals with symptoms of anxiety and depression. The popularity that complementary medicine has gained has led
to frequent appearance of new products. Some patients
prefer using “natural remedies” than using conventional
prescribed medications since they believed that “natural” implies no side effects or adverse reactions. Others
prefer using natural remedies since they may be easier
to purchase directly at pharmacies or health stores. The
use of the internet enables patients to educate themselves about diseases and initiate treatment without direct
physician supervision. Due to the availability and easy
access to these medications, many people frequently use
them to treat their medical conditions.
Woodward survey’s demonstrated the potential
for herbal remedies and homeopathic products to produce adverse reactions or drug interactions and showed the
scope for potential for confusion with those arising from
conventional medicines (1). There is a need for greater awareness that adverse reactions, apparently due to a
conventional medicine, might in reality be due to a herbal
medicine or a drug interaction between a herbal medicine and a conventional drug, particularly when a health
professional is unaware of the extent of a patient’s selfmedication with alternative therapies(1).
The truth is that the risks of using herbal remedies, considered “natural” should not be disregarded, as
some have serious side effects and some interact and influence conventional medical therapeutics(2). The effect
may be pharmacokinetic by altering absorption or metabolism, and may be pharmacodynamic, by changing the
final effect of the drug (2). For example, St. John’s Wort,
an antidepressant herbal remedy, may pharmacodynamically interact with specific serotonin reuptake inhibitors
causing a serotonin syndrome(2).
Serotonin syndrome is a potentially dangerous
syndrome characterizes by changes in autonomic, neuromotor, and cognitive-behavioral function triggered by
increases in serotonergic stimulation (3). Some of these
symptoms are diarrhea, bloating, and abdominal cramping; some of the neurological symptoms are dysarthria,
myoclonus, incoordination and tremulousness. It is also
characterizes by tachycardia, changes in blood pressure,
confusion, disorientation, hallucinations, diaphoresis, elevated temperature and hyperreflexia. Over the last years,
the SSRI’s have emerged as an excellent pharmacotherapy option for depressive and anxiety symptoms. As the
list of serotonergic agents grows each year, recognizing
potentially dangerous drug combinations is critical to our
patient safety (3). Any drug or combination that increases serotonin can, in theory, cause serotonin syndrome
(3). The incidence of serotonin syndrome is unknown.
Some experts say that it may be under-reported because
some physicians fail to recognize the symptoms or
48
ABSTRACT
OBJECTIVES: Evaluate how child and adolescent psychiatrists rate themselves regarding their
knowledge and clinical skills in assessing interactions between non-prescribed complementary and
alternative medicines (CAM) and prescribed medications. METHODOLOGY: A brief questionnaire
about the practice of asking patients about CAM
use was given to child and adolescent psychiatrists.
RESULTS: The questionnaire was completed by 20
child and adolescent psychiatrists. Only 35% of the
sample stated that they always asked about CAM use
although 55% stated that they aware of the importance of prescribed drug interactions with CAM. Of the
sample, 90% stated that they could recognize serotonin syndrome, but only 65% answered correctly to
the description of the syndrome. Given a list of possible CAM that could interact with prescribed drugs
to produce serotonin syndrome, only 10% identified
all the drugs correctly. CONCLUSION: CAM training should be included in training programs and in
continued education curriculums for practicing child
psychiatrists.
Index words: serotonin, complementary, alternative,
medicine, child adolescent
because some doctors simply are unaware of the combinations of drugs that can trigger this condition. Despite
the potential consequences of serotonin syndrome, it is
not clear if all physicians are aware of the syndrome. Serotonin syndrome is definitely a diagnostic challenge since the list of drugs that can trigger a serotonin syndrome
goes from prescription medications and over-the-counter
medications to recreational and herbal remedies.
There is also evidence which suggests that folate
may be a useful adjunct to antidepressant treatment by
being a cofactor in the synthesis of neurotransmitters in
the brain, such as serotonin (4). In 2000, Coppen and
Bailey in a randomized placebo controlled trial, concluded that folic acid greatly improved the antidepressant
action of fluoxetine (4). Brocardo et al. demonstrated in
mice that a sub-effective dose of folic acid produced a
synergistic antidepressant-like effect (5). If folic acid
produces a synergistic effect and enhances the action of
fluoxetine, then, this combination of a conventional medication and a dietary supplement could produce a serotonin syndrome.
Psychiatrists should be able to recognize and
be aware of the potential drug interactions that can be
caused by the combination of herbal supplements and
conventional medications. Psychiatrists require an upto-date working knowledge of CAM since our patients
need education and orientation about the possible drug
interactions of these agents with conventional medicines.
Avoiding potentially dangerous drug combinations, monitoring patients carefully and identifying and treating
serotonin syndrome early can minimize its morbidity and
mortality (3).
Because the onset and progression of serotonin syndrome
are rapid, prompt action may be needed to avoid potentially life-threatening consequences. By becoming more
knowledgeable about the risks and benefits of nutritional
supplements, psychiatrists can assist patients in making
informed choices and avoiding unnecessary harm. This
particular interest in CAM and its role in child and adolescent psychiatry arose due to a very challenging case
that is described below. This clinical case and the research required for its adequate management, led to the
production of a brief survey that evaluated the perceived knowledge of child and adolescent psychiatrists in
evaluating CAM use in their patients and in identifying
CAM-prescribed drug interactions that could cause serotonin syndrome.
METHODOLOGY
A brief questionnaire about the practice of asking
patients about CAM use was given to child and adolescent psychiatrists. The survey had no identifying data
and did not ask for any information that could be used
to identify the psychiatrist in their practice. The survey
was completed by the child and adolescent psychiatrists
who belong to the Puerto Rico Chapter of the American
Academy of Child and Adolescent Psychiatry. All psychiatrists of the association were given the survey at the
association meeting and completed it if they wished to
participate. The questionnaire included questions regarding how psychiatrists evaluate CAM use in their clinical
practice, their awareness of CAM-prescribed drug interactions and their ability to identify serotonin syndrome
with its possible cause by a CAM drug.
CLINICAL CASE
XX was a 16 year old female patient who was on
her senior year of high school and lived with her parents
and siblings in the metropolitan area. XX was evaluated
during an inpatient hospitalization from March 6 to March
14, 2003. She had been receiving ambulatory psychiatric
treatment for the past 4 months due to Anorexia Nervosa.
XX had been treated with Prozac 20mg daily. XX had
one prior psychiatric hospitalization and was brought on
March 6, 2003 to First Hospital Panamericano due to psychotic symptoms. Patient was taken on March 4, 2003
to Hospital San Pablo due to fever, diarrhea, nausea, confusion, tremors, and disorientation. Parents reported that
a Brain MRI, an abdominal CT scan, an upper GI series,
CBC, U/A, and a metabolic panel were done. All tests
were normal. Patient was discharged from the hospital
and referred to her psychiatrist, who recommended a
psychiatric hospitalization to stabilize acute symptoms.
Upon evaluation, XX was presenting symptoms such as
psychomotor agitation, disorganized behavior, disorganized speech, visual and auditory hallucinations, delusion
of religious content, anxiety, irritability and insomnia.
Parents reported that symptoms started about 4 days prior
to admission. Parents deny any history of prior episodes
like this one before. XX’s psychiatrist indicated that this
was her first psychotic episode. There is no history of
suicidal/homicidal gestures or attempts. There is no history of illicit drugs, alcohol or tobacco use.
49
PAST PSYCHIATRY HISTORY
XX started psychiatric treatment about four
months ago due to symptoms of excessive weight loss
(60 pounds), intense fear of gaining weight, body image distortion, refusal to eat, absence of menstrual cycles
and irritability. XX was also using laxatives, diuretics
and exercising excessively in order to lose weight. XX
was on a strict diet basically eating only vegetables and
Special K cereal. XX was hospitalized on November 3,
2002 in First Hospital Panamericano with a diagnosis of
Anorexia Nervosa. XX also presented depressive symptoms such as sad mood, difficulty falling asleep, social
isolation and decreased concentration for which she was
started on Prozac 10mg. XX was discharged from the
hospital on November 6, 2002. Patient then continued
ambulatory psychiatric treatment and Eating Disorders
support groups. Prozac was optimized to 20mg daily.
MEDICAL HISTORY
There is history of dermatitis. Also, there is past
history of pneumonia in October 2001 and chicken pox.
There is no history of hospitalizations, allergies, surgeries, trauma, loss of consciousness, or seizures. Patient
reports taking vitamins and dietary supplements.
FAMILY HISTORY
There is family history of diabetes mellitus and
hypertension in maternal grandfather. There is no history
of psychiatric treatment in the family.
during the interview. XX presented with delusions of religious content. During the interview, there was evidence
of auditory and visual hallucinations. XX seems to be
responding to internal stimuli. Patient was alert, but disoriented in time and place. There was also evidence of
poor concentration and attention. XX had no insight and
poor judgment.
GENERAL MEDICAL SCREENING AND LABORATORY EVALUATI0N
VITALS SIGNS ADMISSION DATE: BP=80/60;
P=68/min; T=35.2 ̊C; R=14/min; Weight=85 POUNDS;
Height=5 feet and 1.5 inches
VITALS SIGNS DISCHARGE DATE: BP=100/70;
P=74/min; R=18/min; Weight=91pounds;
BRAIN MRI= normal; UPPER GI SERIES: normal; ABDOMINAL CT SCAN: normal; PREGNANCY TEST:
negative; URINE TOXICOLOGY: negative; SERUM
TOXICOLOGY: negative for amphetamines, barbitures,
cannabis, cocaine, opioids, and PCP;
THYROID FUNCTION TEST: within normal limits;
SEDIMENTATION RATE: within normal limits; COMPLETE METABOLIC PANEL: Bun= 6 ¯, Total proteins= 6.2 ¯; CBC: Hgb= 11.1 ¯, Hematocrit=32.9 ¯,
MCV=102.8
MCH=34.7 , FOLATE LEVELS: 25.9 , VITAMIN B12
LEVELS: 712
SOCIAL HISTORY
CLINICAL OUTCOME
XX was in 12th grade and had always been a
good student with excellent grades (all A’s). XX likes
listening to music, watching TV, going to the movies and
talking on the phone with her friends. Her passion is
painting and had been taking art classes for the past years.
Her parents describe her as a very sweet, nice, friendly,
loving girl although somewhat shy. XX’s parents report
that XX has many friends at school but usually stays at
home during the weekends.
In addition to her psychotropic medicines, XX
was taking vitamins to supplement her poor caloric intake. She was taking an over-the-counter medicine described in its label as “a powerful combination of vitamins,
herbs, minerals, and electrolytes”. It contained many
ingredients, including Guarana fruit extract, Ginkgo biloba, Ginger root powder, Ginseng powder, Bee pollen,
Gotu Kola Herb, Lecithin, Rose hip powder, Folic acid,
Magnesium, Selenium, Copper, and Chloride, among
others. The effect of this CAM was explained by the
manufacturer as “it works because the alkaloids that are
naturally present in the potent Select Herbs, encourage
the release of essential neurotransmitters into the blood
stream and the CNS”. Neither the parents nor the patient
had thought or asked about possible interactions of this
supplement and her prescribed medicines. The clinical
presentation of this patient could have been caused by a
synergistic effect of the high amount of folic acid in the
CAM enhancing the action of fluoxetine and thus causing
a serotonin syndrome. XX was treated with antipsychotic medications and benzodiazepine to treat agitation and
psychotic symptoms. After a week, symptoms started to
resolve and patient was discharged home and continued
ambulatory treatment.
DEVELOPMENTAL HISTORY
Parents reported that XX had a normal and adequate development. Parents also indicated that XX started walking and talking about 1 year of age. There is no
history of sexual abuse. XX denies any history of sexual
relationships.
MENTAL STATUS EXAMINATION
This is a 16 year old female patient who looks
younger than her chronological age, thin, disheveled,
wearing casual clothing, with poor eye contact, not cooperative, and with severe psychomotor agitation. XX was
not spontaneous and used a high volume of voice. Mood
could not be evaluated. Affect was labile. Patient was
illogical, irrelevant and incoherent. No flight of ideas,
pressured speech, loosening of associations or echolalia
noted. Suicidal or homicidal ideas could not be evaluated
RESULTS
This clinical case demonstrates the importan-
50
ce of considering CAM interactions with psychiatric medications when evaluating children and adolescents. For
this reason, a survey questionnaire regarding knowledge
and use of CAM was given and completed by 20 child
and adolescent psychiatrists in Puerto Rico. Only 35% of
the sample stated that they always asked about CAM use
although 55% stated that they aware of the importance
of prescribed drug interactions with CAM. In terms of
taking a formal course on CAM or interactions, only 20%
of the child and adolescent psychiatrist stated having
taken these courses. Of the sample, 90% stated that they
could recognize serotonin syndrome, but only 65% answered correctly to the description of the syndrome. Given a list of possible CAM that could interact with prescribed drugs to produce serotonin syndrome, only 10%
identified all the drugs correctly. Of the 26% of CAM
drugs that could cause serotonin syndrome, the mean for
correctly identified drugs was 10. Only 4 persons were
able to correctly identify folic acid as a possible cause of
serotonin syndrome.
CONCLUSIONS
Our study shows that our sample of child and
adolescent psychiatrists in Puerto Rico rarely take into
consideration the role of CAM in their clinical practice.
Few child psychiatrists (35%) routinely ask for CAM
use in their evaluations and only 55% stated that they
understood the CAM-prescribed drugs interactions were
important. It is also interesting to note that only 20% of
the sample had ever taken a formal course on CAM. In
terms of knowledge regarding serotonin syndrome, some
child psychiatrists were not able to correctly identify a
clinical description of the condition and only 4 subjects
were able to state that folic acid was a possible agent
that interacts to cause serotonin syndrome. These results
show that there is a great need for formal training in the
evaluation of CAM use in children and adolescents in
psychiatric treatment. In particular, child and adolescent
psychiatrists need to be aware of the potential for CAMprescribed drug interactions, especially as a possible cause of serotonin syndrome. Adverse drug reactions are
one of the most frequent causes of medical malpractice
claims against psychiatrists and of non-compliance with
psychotropic medications. If child and adolescent psychiatrists increase their understanding of the important
role of CAM use and its side effects with prescribed
Searching
Medical
Tools?
medications, treatment outcomes could greatly improve.
We propose that formal CAM training should be included in training programs and in continued education curriculums for practicing child psychiatrists.
REFERENCES
1.
Woodward KN. The potential impact of the use of homeopathic and
herbal remedies on monitoring the safety of prescription products. Hum Exp
Toxicol. 2005; 24(5):219-33.
2.
Goldstein LH, Elias M, Berkovitch M, Golik A. The risks of combining medicine and herbal remedies. Harefuah. 2006; 145(9):670-6.
3.
Sternbach H. Serotonin syndrome: How to avoid, identify & treat
dangerous drug interactions. Current Psychiatry. 2003; 2(5):14-24.
4.
Woodward KN. The potential impact of the use of homeopathic and
herbal remedies on monitoring the safety of prescription products. Hum Exp
Toxicol. 2005; 24(5):219-33.
5.
Coppen A, Bailey J. Enhancement of the antidepressant action of
fluoxetine by folic acid: a randomized, placebo controlled trial. Journal of
affective disorders. 2002; 60(2):297-98.
RESUMEN
OBJETIVO: Explorar cómo psiquiatras de niños y
adolescentes describen el conocimiento y la experiencia clínica para reconocer interacciones entre
medicinas alternativas o complementarias (CAM) y
medicinas recetadas.
METODOLOGIA: Un cuestionario breve acerca de
la evaluación de uso de CAM en pacientes le fue entregado a psiquiatras.
RESULTADOS: El cuestionario fue completado por
20 psiquiatras. Sólo 35% expresó que siempre preguntan acerca del uso de CAM a sus pacientes a pesar de que 55% contestó que están conscientes de la
importancia de las interacciones. Dentro esta muestra, 90% expresaron poder reconocer el síndrome serotonérgico, pero sólo 65% identificó correctamente
la descripción del síndrome. En una lista de posibles
CAM que pueden interaccionar con medicinas recetadas para producir el síndrome serotonérgico, solo
10% identificaron todas las drogas correctamente.
CONCLUSION: Enseñanza en CAM debe ser incluido en programas de entrenamiento y en cursos
de educación continua para psiquiatras de niños y
adolescentes.
we got them!
En la AMPR nos hemos propuesto brindarle a nuestros
profesionales todas las herramientas informáticas imprescindibles en la actualidad para el eficiente ejercicio de la
medicina. Por esto encontrará desde información actualizada hasta software gratuito. Aproveche este recurso único, visite nuestra página y conviértala en su portal médico
preferido.
www.asociacionmedicapr.org
51
ABSTRACT
Dementia is characterized by a progressive deterioration of memory and cognitive
function that occurs mostly in the
elderly population. In the United
States nearly 4.5 million people
suffers dementia. Behavioral
and psychological symptoms of
dementia (BPSD) are defined as
agitation, delusions, hallucinations, anxiety, and aggressiveness
in patients diagnosed with this
condition. One of the most useful
therapeutic approaches for behavioral symptoms is antipsychotic medications, though there is
no ill-established evidence about
their efficacy. This article review
possible benefits as well as side
effects of these drugs. A detailed
orientation about antipsychotic
side effects and risks should be
given to patients and caregivers,
to obtain an appropriate and informed consent decision.
Key Words: Use of antipsychotics /Dementia / Elderly / Nursing
Homes
ATYPICAL ANTIPSYCHOTICS IN
THE MANAGEMENT OF
BEHAVIORAL SYMPTOMS
ASSOCIATED WITH DEMENTIA
Juan J González-Concepción, MD*
Kenneth Geil, MD**
Ivonne Z Jiménez-Velázquez, MD, FACP*
Cristina Ramos-Romey, MD*.
From the *Internal Medicine Department, Geriatric Medicine Program, University of Puerto Rico Medical Sciences Campus, San Juan, PR, and the **Veterans
Healthcare Center, Geriatrics and Extended Care, San Juan, PR.
Address reprints to: Juan J. González-Concepción, MD, Department of Medicine, Geriatric Medicine Program, PO Box 365067, San Juan, PR 00936-5067. Email - <[email protected]>
D
ementia is characterized by a progressive deterioration of memory and cognitive function that
occurs mostly in the elderly population. Alzheimer’s disease (AD) affects approximately 5% of patients over 65
years old and 40% of those over 85. In the United States
about 4.5 millions of people have dementia. The number
of cases is expected to increase dramatically in the near
future due to increase in life expectancy. Alzheimer’s
disease is the most common cause of dementia (about 60
to 80% of cases), followed by vascular dementia (10 to
20%), and Parkinson’s disease (5%).
Behavioral and psychological symptoms of dementia (BPSD) are defined as agitation, delusions, hallucinations, anxiety, and aggressiveness. According to
different authors they may occur in about 60 to 80% of
patients with Alzheimer's disease or other referred illnesses precipitating nursing home placement (1, 2). BPSD
are recognized as one of the most common causes of institutionalization among the elderly.
These symptoms are most likely to be evident in
the advanced stages of the disease and they may occur at
any stage. There are several modalities of treatment that
have been used in nursing homes around the world to
ameliorate symptoms. One of the most useful therapeutic
approaches for behavioral symptoms is antipsychotic
medications. Nevertheless, there is no well-established
evidence about their efficacy. It is still unclear if antipsy-
chotics improve behavior or provide a chemical restraint
to the affected patient (3).
The cause of psychotic disturbances is not clearly
understood, although neurotransmitters such as serotonin, dopamine, and noradrenalin have all been implicated
in the pathophysiology of psychosis in patients with dementia. A post mortem study revealed decreased serotonin levels in some areas of the brain of patients with AD
with history of psychotic behaviors, compared to patients
without psychosis (4). However, these findings have not
been confirmed by other studies. In another postmortem
study increased levels of noradrenalin were associated
with psychotic behaviors, but this relationship is still under investigation (4). In vitro and in vivo studies provides
inconsistent evidence to link psychotic symptoms with
serotonergic and dopaminergic dysfunction (4).
In view of the lack of evidence of the cause of
BPSD, the treatment of behavioral and psychological
symptoms of dementia has been a challenge for clinicians that provide medical care to affected patients. The
atypical antipsychotics are often prescribed to treat those
symptoms, though concerns have been raised that atypical antipsychotics may increase the risk of adverse cerebrovascular events, including stroke among elderly with
BPSD (1, 5, 6).
Several studies have demonstrated an increase
52
in cerebrovascular events and mortality among elderly
patients using atypical antipsychotics. However, conventional antipsychotics had a 35% greater mortality risk due
to fatal outpatient cardiac events, pneumonia, and stroke
compared to patients who were prescribed atypical antipsychotics (6). Studies related with the risk of death and
cerebrovascular events (CVAE) associated with the use
of antipsychotics, did not evaluate pre-morbid medical
conditions, such as cardiovascular disease, diabetes and
hypertension prior to treatment (6). These co-morbidities
are very important considering that elderly patients are
more likely to have these medical conditions, which can
place them at risk of CVAE, and death.
A meta-analysis performed by Haupt et al, showed that
risperidone had no significant increase in mortality
(4.0%, vs. 3.1%) when compared to placebo, but has a
small but significant increase in cerebrovascular adverse
events (3.8% vs. 1.5%). These events did not increase
with higher risperidone doses (1).
There are other side effects of antipsychotic
medications such as extra pyramidal effects, somnolence, falls, syncope, hematomas, and increased risk of
urinary tract infection that can also worsen their already
frail medical condition. Extra pyramidal effects are the
most common side effect of antipsychotics, although less
common among atypical antipsychotics. Risperidone,
olanzapine, aripiprazole, and quetiapine are used more
frequently than other antipsychotics. Therefore more studies have been conducted regarding their efficacy in the
treatment of BPSD (7).
Atypical antipsychotics have been shown to improve psychosis in elderly patients with dementia. If the
patient is at risk of self-harm or might place others at
risk due to psychosis, a low dose of antipsychotics can
be started. A study performed by Fossey, et al (2006),
analyzing the use of neuroleptics in 12 different nursing
homes in London, found that psychological and/or environmental management allowed staff to reduce significantly the use of antipsychotics (average reduction of
19.1%) among residents in a 12 month period. They did
not find an increase in agitation or aggressiveness in this
group. This study demonstrated that training the nursing
home staff about behavioral management techniques will
decrease the use of neuroleptics without worsening the
behavioral symptoms associated to dementia.
The frequency of EPS was found higher in several studies performed with risperidone compared to
others (3, 7). However, the risk of EPS is still latent in
all atypical antipsychotics, although with less frequency than conventional antipsychotic medications such as
haloperidol (7). A case report presented by Dr. Cheng
in Psychiatry and Neurosciences (2002), demonstrated
acute onset of extra pyramidal effects in an 80 year old
patient taking donezepil on the second day after starting
risperidone 1 mg/ day. These symptoms improved in one
week after discontinuing risperidone and starting olanzapine 2.5 mg/day. There is evidence that there of increased
risk of EPS when risperidone and donezepil are combined
(8). Compared to other atypical antipsychotics, risperidone seems to be more associated with tardive dyskinesia
(3).
A meta-analysis performed by Schneider and colleagues evaluated fifteen trials in patients with dementia
and antipsychotic use, found that somnolence is associated with all atypical antipsychotic medications (7). Aripiprazole and olanzapine have a mild increase in risk. This
is clinically relevant since some elderly patients spend
more time in bed increasing the risk of infections, incontinence, and cardiopulmonary events. This effect may
also increases the risk of falls due to dizziness and gait
problems associated with somnolence. Similar studies
comparing the effect of atypical antipsychotics in patients
with BPSD have shown an increase risk of abnormal gait
among patients using olanzapine and risperidone. This
effect was not increased by quetiapine (7).
Risperidone is the only atypical antipsychotic
that is currently approved for treatment of one or more
symptoms of BPSD in more than 30 countries (1). No
atypical antipsychotics are approved by the FDA for
treatment of BPS or psychosis of Alzheimer’s disease.
The use of anticholinesterase inhibitors in demented patients is not clearly stated in the reviewed
studies. This is clinically significant since recent studies
have shown some degree of benefit in the treatment of
BPSD with acetyl cholinesterase inhibitors, such as donezepil and rivastigmine (10).
Polypharmacy in the elderly is of great concern
and has gained special attention among health care professionals dealing with demented patients. The decrease
in hepatic metabolism and renal clearance, in addition
to multiple medications, places the elderly at higher risk
of side effects related to drug-drug interactions. Before considering antipsychotics in the elderly patients a
cautious examination of drug interaction and toxic metabolites should be performed to avoid intoxications or
exacerbation of side effects, especially if they are using
medications for dyslipidemia, hypertension, diabetes and
cardiac disease (12). The nutritional status must also be
considered since many medications bind to plasma proteins; therefore if the patient has hypoalbuminemia the
level of these medications will be increased.
Atypical antipsychotics have been widely used
among nursing home residents with behavioral symptoms
related to dementia. However, they are not FDA approved for this use, and could have potential medico-legal
implications. Therefore a detailed mental examination,
drug metabolism and interactions should be performed
before prescribing them. If the patient is using anticholinesterase medications, such as donezepil, rivastigmine or galantamine, the dose should be optimized before
considering antipsychotics. Memantine might be added
to the treatment since also improves behavioral symptoms in patients with dementia according to the literature
reviewed (3,10). The training and support of care home
staff reduced antipsychotic use in residents with dementia in nursing homes without worsening behavioral
symptoms (11). The physician should consider all other
non-pharmacological alternatives before starting antipsychotics.
We strongly recommend a detailed mental examination, using a validated scale such as Mini-mental
status examination (MMSE), Mini-cog and/or Geriatric
Depression scale, prior to considering antipsychotics.
These scales may help in determining if the behavioral
symptoms are related to cognitive dysfunction or undiagnosed depression. depression in the elderly is sometimes
not recognized due to atypical symptoms that can mimic a systemic illness instead of mood changes. Patients
with severe behavioral symptoms such as agitation and
aggressiveness, have greater benefit from antipsychotics
than patients with milder symptoms. Memantine therapy
alone or combined with donezepil may also reduce these
symptoms (10). Before considering antipsychotics, cholinesterase inhibitors and/ or Namenda should be prescribed and optimized.
We also recommend to start a low dose of atypical antipsychotics such as quetiapine, olanzapine, or aripripazole, that have been more studied, if the patient has
not responded to anticholinesterase inhibitors and environmental changes. Clinical improvement should be expected within 10 to 14 weeks, then medication should be
discontinued and other approaches could be reconsidered
(7). The goal is to use antipsychotics for a short period
of time, then wean off. Trials should be done every 10 to
12 weeks. As with other medications in elderly people,
the rule ‘”start low & go slow“ is important to avoid side
effects and interactions.
An interdisciplinary group including an occupational therapist, a recreational therapist and a psychologist can minimize the use of antipsychotics as per evidenced in the study performed by Fossey and colleagues
in the United Kingdom (11). Yet, this modality requires
a trained staff in behavioral management techniques, and
a compromised attitude among nursing home staff. These interventions have an economic impact in the nursing
home, which may elevate the costs of these institutions.
A detailed orientation about antipsychotics’ side
effects and risks should be given to the patient and caregiver, to take the appropriate decision in conjunction.
Important aspects such as risk of cerebrovascular events,
increased mortality, drug interactions, further cognitive
impairment, metabolic syndrome, edema, increase risk
of infections, somnolence, and extrapyramidal effects
should be considered and fully explained to the patient’s
caregiver or legal tutor before considering antipsychotics.
REFERENCES
1. Haupt, M., Cruz, A., Jeste, D. (2006) Mortality in Elderly Dementia Patients Treated With Risperidone. Journal of Clinical Psychopharmacology;
Vol. 26; No. 6; 566-570.
2. Slachevsky, A., Fuentes, P. (2005) Síntomas psicológicos y conductuales
asociados a demencias: actualización terapéutica. Revista Médica, Chile; 133:
1242-1251.
53
3. Daiello, L. (2007) Atypical Antipsycotics for the Treatment of DementiaRelated Behaviors: An Update. Advances in Pharmacology; Vol. 90; No.6;
191-194.
4. Rojas-Fernández, C.; Allen, D.; (2001) Pharmacotherapy of Behavioral and
Psychological Symptoms of Dementia: Time for a Different Paradigm? Pharmacotherapy 21(1):74-102.
5. Gill, S., Rochon, P., Herrmann, N., et al (2005) Atypical antipsychotic drugs
and risk of ischaemic stroke: population based retrospective cohort study.
BMJ; 330;445-450.
6. Percudani, M., Barbui, C., Fortino, I., et al (2005) Second-Generation Antipsychotic and Risk of Cerebrovascular Accidents in the Elderly. Journal of
Clinical Psychopharmacology; Vol. 25; No. 5; 468-470.
7. Schneider, L., Dagerman, K. Insel, P. (2006) Efficacy and Adverse Effects
of Atypical Antipsychotics for Dementia: Meta-Analysis of Randomized, Placebo- Controlled Trials. American Journal of Geriatric Psychiatry 14:3; 191210.
8. Magnuson TM, Keller BK; Burke WJ; (1998): Extrapyramidal side effects
in a patient treated with risperidone plus donezepil. American Journal of Psychiatry: 155;1458-1459.
9. Hsing-Cheng, L., Shih-Ku, L., Sing-Ming, S. (2002) Extrapyramidal sideeffect due to drug combination of risperidone and donepezil. Psychiatry and
Clinical Neurosciences; 56, 479.
10. Apostolova, L., Cummings, J. (2007) Psychiatric Manifestations in Dementia. Continuum Lifelong Learning Neurology; 13(2); 165-179.\
11. Fossey, J., Ballard, C., Juszczak, E., et al ( 2006) Effects of enhanced
psychosocial care on antipsychotic use in nursing home residents with severe
dementia: cluster randomized trial. BMJ; 332;756-761.
12. Katona, C. (2001) Psychotropics and drug interactions in the elderly patient. International Journal of Geriatric Psychiatry;16: S86-S90.
13. Hartikainen, S., Rahkonen, T., Kautiainen, H., Sulkava, R. (2003) Use of
psycotropics among home-dwelling nondemented and demented elderly. International Journal of Geriatric Psychiatry; 18; 1135-1141.
14. Holmquist, IB.,Svensson, B. & Höglund, P. (2003)Psychotropic drugs in
nursing- and old-age homes: relationships between needs of care and mental
health status. Springer-Verlag.
15. Hosia-Randell, H., Pitkälä, K. (2005) Use of Psychotropic Drugs in Elderly Nursing Home Residents with and without Dementia in Helsinki, Finland. Drugs Aging; 22(9): 793-800.
RESUMEN
La demencia se caracteriza por el deterioro
progresivo de la memoria y otras funciones cognoscitivas que ocurre principalmente en la población envejeciente. En Estados Unidos aproximadamente 4.
5 millones de personas tienen demencia. Los síntomas de comportamiento y cambios psicológicos que
ocurren asociados a esta condición son la agitación,
delusiones, alucinaciones, ansiedad y agresividad en
pacientes que padecen de esta condición. Uno de los
tratamientos más útiles para los síntomas de comportamiento son los medicamentos antipsicóticos. Sin
embargo, no hay evidencia establecida sobre su efectividad. Este artículo discute los posibles efectos beneficiosos al igual que perjudiciales que pueden producir. Una orientación detallada sobre los posibles
efectos secundarios y riesgos que pueden producir los
antipsicóticos debe proveerse tanto al paciente como
al cuidador, para tomar la decisión más apropiada en
conjunto.
Obtenga Créditos de
Educación Médica Continua
Jornadas Científicas - Boletín de la AMPR - Web Site
Gratis para
Asociados
54
RESUMEN
PRINCIPIOS BIOETICOS:
LA PLANIFICACION Y
LAS DIRECTRICES
ADELANTADAS
PUERTORRIQUEÑAS
José Ramírez Rivera, MD, MACP*
Jorge J. Ferrer, PhD**
*Catedrático de Medicina, Universidad Central del Caribe,
Bayamón, PR, Director de Investigaciones Clínicas, Hospital de la
Concepción, San Germán, PR y Catedrático de Medicina de la Universidad de Puerto Rico.**Catedrático de Humanidades, Universidad de
Puerto Rico, Mayagüez, PR.
Comunicaciones: José Ramírez Rivera, MD. MACP. Summit Hills 1657 Calle Adams - San Juan, PR 0920-4361 ramirez.r629@
gmail.com
Los principios libertadores de autonomía
personal y justicia personalizada que se establecieron firmemente y se difundieron rápidamente
en la emergente democracia americana de los
siglos 18 y 19 promovieron el desarrollo de la
Bioética en los Estados Unidos. El Respeto por
la Autonomía, Beneficencia, No Maleficencia y
Justicia promueven la elaboración de directrices
anticipadas y la designación de un mandatario
para hacer decisiones médicas cuando el paciente
ya no tiene la capacidad de hacerlas. Las directrices anticipadas pueden redactarse y juramentarse
con la ayuda de un abogado. También pueden redactarse legalmente en la oficina de un médico o
en el hospital ante un médico y dos testigos “idóneos” (personas que no puedan beneficiarse de la
muerte del paciente y no estén involucradas en su
cuidado). Presentamos un modelo de directrices
anticipadas adecuado para usarse en las oficinas
de los médicos y en los hospitales. Éste cumple
con los requisitos de la ley de Puerto Rico 160
de noviembre 2001 y armoniza con los de la ley
federal de Autodeterminación de Paciente, ley
que se hizo efectiva en el 1991. El documento
también contiene recomendaciones válidas con
relación a la donación de órganos. Discutimos
los fundamentos bioéticos para que se haga este
documento. Sugerimos que a las aseguradoras de
planes de salud les convendría económicamente
compensar a los médicos por el procedimiento de
hacer este documento; evitaría, en muchos casos,
los gastos excesivos de admisiones inapropiadas
a cuidados intensivos al final de la vida.
Palabras clave: planificación adelantada, directrices adelantadas, testamento vital.
INTRODUCCION
E
n los escritos hipocráticos estaba establecido que el médico debía laborar de forma “intensa, persistente, inteligente y responsable” en beneficio del paciente
(1). Cuando la naturaleza o la severidad de la enfermedad
sobrepasaban sus capacidades, el profesional debía continuar el apoyo al paciente, descontinuando, sin embargo,
sus esfuerzos curativos. Con la llegada de las técnicas de
reanimación y el desarrollo del ventilador mecánico, a
mediados del siglo XX, cobró auge la dedicación hipocrática a la preservación de la vida junto con una nueva
y perniciosa creencia. Según ésta, el triunfo del buen médico estaba en prevenir la muerte usando todas las tecnologías emergentes y la virtuosidad diagnóstica y técnica
de los especialistas en cada órgano (2). El médico moderno abandonó la tradicional aceptación de límites. Fuera
del contexto de las corrientes políticas y sociales del liberalismo, no percibió la obligación de orientar plenamente
a los pacientes acerca de las alternativas terapéuticas y de
tener en cuenta los deseos, valores y metas del paciente a
la hora de tomar las decisiones clínicas (3,4). El médico
moderno, en su afán por preservar la vida, no está realmente obteniendo un consentimiento informado.
Si leemos los documentos fundamentales del desarrollo de la cultura norteamericana-- la Declaración
de Independencia, la Constitución y la Declaración de
Derechos—nos percatamos por qué el consentimiento informado adquirió prioridad en los Estados Unidos. Basta
analizar una escena de una de las tradicionales películas
de vaqueros para vislumbrar dos principios morales fundamentales respetados por esa nueva cultura: la autonomía personalista y la justicia personalizada.
Todos sabían que el hombre bueno esperaba
algo. Al oír los cascos de un caballo deja la barra, sale
de la cantina con un portazo y se dirige con seguridad y
aplomo por el medio de la calle principal del pueblo, en
dirección del jinete que desmontaba. Sin mediar palabra
le descargó sus dos revólveres en el pecho al asesino de
su hermano. Mientras el sheriff y su ayudante-- sin comentarios-- recogían el cadáver, él regresó a darse un
trago antes de retirarse. Ya los parroquianos habían regresado al juego de naipes o a la barra y cuchicheaban
en voz baja. Al salir algunos se le acercaron para darle
un apretón de manos y un espaldarazo. Se había portado
como un buen norteamericano: con autonomía personalista y justicia personalizada.
Estos dos principios del novel experimento político norteamericano los identificó de varias formas el
pensador e historiador francés Alexis de Tocqueville en
su obra Democracy in America (1835 y 1840): “Libre de
las cadenas previamente impuestas por sistemas de clases o por hombres, el espíritu humano sería sólidamente
(.y solamente) limitado por la voluntad imperante de la
mayoría (5). Este es el substrato que lleva al desarrollo
de una nueva disciplina en los Estados Unidos para la
cual Van Rensselaer Potter acuño en el 1970 el título de
“bioética”(6).
Una de las corrientes principales de esta bioética
se basa en 4 principios generales, a los que a menudo se
les identifica como el Mantra de Georgetown: Respeto
por la Autonomía, Beneficencia, No Maleficencia y Justicia. Pero el consentimiento informado que hace posible
el ejercicio de la autonomía requiere conocer el carácter
de las personas, sus experiencias pasadas y su trasfondo
cultural. Hay variaciones en valores y costumbres entre hombres, mujeres, clases sociales, origines étnicos y
creencias religiosas.
Los historiales que ordinariamente obtenemos
son totalmente insuficientes para atender los pacientes al
final de la vida No sabemos cómo la enfermedad ha afectado al paciente como persona ni cómo él o ella percibe
como se afectará su vida futura. No solemos auscultar
qué tratamientos o métodos de diagnóstico o qué consultas el paciente cree apropiadas o inapropiadas en sus
circunstancias. No preguntamos sobres sus necesidades
espirituales ni cómo le podemos ayudar al respecto. No
ofrecemos orientación verbal y escrita profesional para
que considere las virtudes de definir y documentar como
quiere ser atendido(a) cuando sus días estén contados y
cuando haya perdido la capacidad para hacer decisiones
armónicas con sus valores y sus metas.
Presentamos un modelo de directrices adelantadas que incluye un testamento vital, la designación de
un mandatario y una determinación sobre la donación
de órganos. Este modelo puede usarse en un consultorio
médico o cuando el paciente es admitido a un hospital.
El documento cumple con los requisitos de la ley 160
de Puerto Rico, del 17 de noviembre de 2001(7) y es una
respuesta adecuada a algunas de las exigencias de la ley
federal de la Libre Determinación del Paciente (Patient
Self Determination Act) que entró en vigor el 1 de diciembre de 1991, exigencias que al presente se cumplen
en nuestros hospitales de forma generalmente inefectiva.
Para facilitar su duplicación lo colocamos como un apéndice a este artículo.
Comentario
1. La planificación anticipada y el respeto por la autonomía personal
El testamento vital y el documento designando
un mandatario son elementos integrantes de un proceso
de comunicación mucho más amplio, al que llamamos
55
planificación anticipada del cuidado médico (PA). Entendemos que la PA es el proceso de comunicación que
se da entre una persona (paciente) y los profesionales de
la salud que le asisten. Entre estos profesionales, el lugar más importante lo ocupa el médico de cabecera del
paciente. Estas conversaciones deben ocurrir temprano,
preferiblemente en el consultorio, aún antes de identificar
una enfermedad con el potencial de complicaciones; no
debe esperarse a cuando la muerte es ya inminente.
El fundamento ético y jurídico se encuentra en el
reconocimiento y protección de la dignidad personal del
paciente y del fundamental derecho a la autonomía que
de ella se deriva. La pérdida de la capacidad decisoria no
anula el derecho fundamental a la autodeterminación. Un
documentado proceso de PA que incluya directrices anticipadas es un instrumento ético y jurídico que también
sirve como apoyo moral y protección legal a los profesionales de la salud que acompañan a los pacientes en la fase
final de sus biografías.
El principio de respeto por la autonomía tiene
que conjugarse con otros principios fundamentales como
la no-maleficencia y la justicia, siendo este último el principio rector del orden social desde la antigüedad clásica.
El respeto por la autonomía, dentro de sus justos límites,
tanbien es una exigencia de la justicia en una sociedad
moderna y democrática. Esa compaginación del respeto a
la autonomía con la justicia lo hemos recogido en el neologismo “justicia personalizada”, que hemos adelantado
en la introducción de este artículo.
2. El ejercicio de la autonomía al final de la vida.
La muerte es un dato biológico inevitable. En el
ser humano también es un dato antropológico y social.
A diferencia de otros seres, los humanos sabemos que
hemos de morir. A menudo sabemos cuándo estamos
muriendo. Tanto el fallecimiento propio como el de las
personas que amamos plantea innumerables preguntas y
suscita multitud de sentimientos, no pocas veces encontrados entre sí: dolor, rebeldía, alivio, esperanza... Cada
cultura tiene sus costumbres y rituales para vivir la muerte propia y ajena. Así como hay una cultura de la vida,
cada civilización también tiene una cultura de la muerte.
Para nuestros fines basta mencionar dos factores
de nuestra cultura de la muerte. El primero de ellos es la
“medicalización del proceso de muerte”. Aunque la mayor parte de las personas aseguran que desearían morir en
sus casas, rodeados por sus familiares, en los países desarrollados la mayor parte de las muertes ocurren en los
hospitales. El proceso de morir, sobre todo en las unidades de cuidados intensivos, lleva muchas veces a lo que
se llama “obstinación terapéutica”. A menudo se aplican
medidas heroicas, que imponen al paciente unas cargas
desproporcionadas, inarmónicas con su proyecto de vida.
Los movimientos que abogan por el derecho a la eutanasia y al suicidio con asistencia médica nacen, al menos en
parte, como una reivindicación de la autonomía personal
y de la justicia personalizada ante lo que se percibe como
el control indebido del proceso de morir por parte de las
instituciones médicas.
56
El segundo factor que queremos destacar es la
negación cultural de la muerte. El tema de la muerte se
evita, incluso en el seno de las familias. Se prefiere no
pensar en la muerte propia o en la de los seres queridos.
No obstante, la muerte sigue y seguirá siendo un dato
inexorable. Por tanto es mejor enfrentarla y preparase
adecuadamente. La PA es un instrumento para humanizar el proceso de morir. Es la salvaguarda del principio
ético y jurídico del derecho al ejercicio de la autonomía y
a una justicia personalizada.
3. Los interlocutores.
El protagonista del proceso es el propio paciente.
Junto al protagonista hay otros interlocutores. El primero
de ellos es el médico. Frecuentemente le toca al médico
iniciar la conversación sobre la PA. Él tiene los conocimientos científicos y clínicos esenciales para educar
acerca del diagnóstico, pronóstico y las posibles alternativas terapéuticas. Además es el aliado del enfermo y es a
menudo el portero que controla el acceso a la mayor parte
de los servicios.
Pero suele ser necesario incluir a otras personas
en la conversación. En primer lugar, a los seres queridos
del paciente y al mandatario. Son ellos los que probablemente van acompañarlo más de cerca en su proceso
de enfermedad y muerte. También puede ser necesario
la participación de otros interlocutores en el proceso: el
trabajador social, el psicólogo, el notario y, en el caso
de pacientes con creencias religiosas, los acompañantes
espirituales de la propia tradición.
4. Los beneficios de la planificación.
Los interlocutores principales de este proceso
derivan múltiples beneficios del mismo. Al protagonista
le sirve para enfrentar con realismo su futuro. Lo educa
sobre lo que puede esperar que ocurra en la etapa final de
su biografía. También le permite ganar un cierto sentido
de control sobre esa etapa final al darle la oportunidad
para expresar sus preferencias y designar a las personas
que lo van a representar, cuando él ya no pueda tomar
sus propias decisiones. El proceso da a los allegados del
enfermo la tranquilidad de conocer los deseos de su ser
querido. Los prepara, psicológica y espiritualmente, para
el difícil trance de la separación. Al médico le da la seguridad de estar actuando en conformidad con los valores
y preferencias de su paciente. La planificación anticipada
disminuye las probabilidades de conflictos y malentendidos y minimiza los riesgos de futuras complicaciones
médico-legales.
5. ¿Por qué no se pone en práctica la planificación
con mayor empeño y regularidad en el día a día de la
práctica médica en Puerto Rico?
Parece haber dos razones de peso. En primer lugar, recordemos que son los médicos los que deberían
iniciar la conversación con sus pacientes. Esto se hace
en el consultorio, quizá amplificando los datos de un impreso educativo. Existen estudios que demuestran que la
planificación adelantada se hace con más éxito cuando es
un tópico recurrente, en múltiples visitas. La entrega de
material educativo sin que éste se discuta es relativamente inefectiva (8). La verdad es que muchos médicos
no se sienten cómodos tratando con sus pacientes temas
propios del final de la vida. Temen que el paciente se
asuste, que piense que está peor de lo que en realidad
está o que deduzca que el médico no va a hacer todos
los esfuerzos necesarios para que salga con éxito de una
situación crítica. Estos son temores infundados. En un estudio reciente en un hospital comunitario de Connecticut,
de 136 pacientes, 133 (98%) se mostraron dispuestos a
discutir los temas de reanimación y ventilación artificial.
El 82% identificó la información recibida como útil (9).
Los médicos puertorriqueños pertenecen al mismo medio
cultural que pertenecemos todos. Por lo tanto, se sienten
tan incómodos con el tema de la mortalidad como sus
pacientes y los familiares de éstos. Pero esa incomodidad
debe ceder ante un imperativo profesional: tomar decisiones con relación a estos temas sin haber auscultado
los deseos del paciente es una mala práctica profesional.
Esperar la llegada de una enfermedad seria que
precipite una hospitalización para abordar el tema del final de la vida es cortejar el fracaso: solo el 41% de 253
pacientes admitidos a un hospital comunitario puertorriqueño estaban mentalmente capacitados en las primeras
72 horas después de la admisión para hacer este trámite (10). Para sorpresa de muchos, de los 100 pacientes
consecutivos con la capacidad y la disponibilidad para
responder a la encuesta, el 63% no aceptaría reanimación y 73% no aceptaría intubación si una recuperación
completa no fuese probable. En una encuesta similar de
922 profesionales de la salud de cinco hospitales puertorriqueños, la respuesta fue aún más conservadora que la
de los pacientes: el 82% de los varones y el 91% de las
mujeres no aceptaría reanimación y el 81% de los varones y un 90% de las mujeres no aceptaría intubación
si una pérdida importante de la función física o mental
fuese probable (11). Nuestra práctica intuitiva actual no
refleja estas observaciones.
El segundo obstáculo importante es el tiempo limitado que el médico tiene destinado para cada consulta:
las aseguradoras no pagan por el tiempo necesario para
tener una conversación (o varias) con los pacientes y sus
familiares acerca del final de la vida.
Si queremos humanizar la práctica médica necesitamos revisar como hacer mejor uso del tiempo del
médico. Aunque algunas de las funciones podrían delegarse a otros profesionales, la responsabilidad principal
de iniciar la conversación, de informar al paciente, y de
obtener un consentimiento informado, recae inevitablemente sobre sus hombros. En un futuro cercano esperamos ver que las aseguradoras, interesadas estrictamente
en reducir sus desembolsos, paguen por la ejecución de
directrices anticipadas como un procedimiento equivalente a una primera visita. Es sorprendente que las aseguradoras no se hayan percatado aún de las economías
substanciales que pueden surgir cuando un paciente con
una enfermedad terminal exhibe un testamento vital .al
entrar al hospital. Un documento que prohíba intervenciones tales como intubación o admisión a la sala de tratamientos intensivos haría la admisión miles de dólares
menos costosa.
6. La limitación del esfuerzo terapéutico: perspectiva
ética.
La limitación de esfuerzo terapéutico se encuentra firmemente enraizada en la tradición médica. También ha sido aceptada por la tradición de la ética teológica
cristiana occidental (12). Los teólogos católicos desarrollaron una elaborada doctrina sobre los medios ordinarios y extraordinarios para conservar la vida. Los medios
ordinarios eran considerados obligatorios, mientras que
los extraordinarios eran opcionales. Para que un medio
para sostener y prolongar la vida física fuese tenido por
ordinario (=obligatorio) era necesario que cumpliese con
dos requisitos: 1) que ofreciese una esperanza razonable
de recuperar la salud o de prolongar la vida; 2) que no
fuese desproporcionadamente oneroso para el paciente
(13, 14,15). Por lo tanto, según esta doctrina, no todo tratamiento que pudiese prolongar la vida física del enfermo
sería moralmente obligatorio. Tratamientos que imponen
al paciente una carga desproporcionada son opcionales
y pueden no iniciarse o incluso retirarse una vez hayan
sido iniciados. En nuestro sistema legal, la voluntad del
paciente es prácticamente soberana para rechazar tratamientos no deseados, aunque no lo sea para requerirlos.
Proponemos la planificación adelantada, las directrices
anticipadas y la designación de un mandatario para la
salud como instrumentos útiles para brindar a nuestros
pacientes un cuidado médico que armoniza nuestras capacidades profesionales con el proyecto de vida del paciente.
REFERENCIAS
1. Petersen W.F. Hippocratic Wisdom. Charles C. Thomas: Publisher, 1946
page. xv.
2. Ramírez-Rivera J., First relieve Suffering. Bol As Med PR., 1985; 77:
101-103.
3. Ramírez-Rivera J., No resucitemos a los muertos. Bol As Med PR., 1992;
83:473-475.
4. ecker N.S., Knowing when to stop: The Limits of Medicine. Hastings
Center Report 1991; 21:5-8.
5. Alexis de Tocqueville. Democracy in America, trans. Gerald E. Bevan
(New York, Penguin Putnam Press, 2003) pag. 278.
6. Potter V.R., Bioethics, the science of survival. Persp Biol Med 1970;
14:127-153.
7. Ley de declaración previa de voluntad sobre tratamiento médico en caso
de sufrir una condición de salud terminal o estado vegetativo persistente. Ley
núm. 160 del 17 de noviembre de 2001. Lexjuris de Puerto Rico.
8. Ramsaroop S.D., Reid M.C., Adelman R.D. Completing an advanced directive in the primary care setting: What do we need for success? J Am Geriatr
Soc. 2007; 55:277-83.
9. Nicolasora N., Pannala R., Mountantonakis S., Shanmugan B., DeGirolamo A, et al. If asked, hospitalized patients will choose whether to receive
life-sustaining therapies. J Hosp Med 2006; 1: 161-7.
10. Ramírez-Rivera J., Jaume-Anselmi F., Martínez M. Cardiopulmonary
resuscitation: What patients say. Bol As Med PR. 1990; 82: 119-24.
11. Ramírez-Rivera J., Velázquez I., Jaume-Anselmi F. Cardiopulmonary resuscitation: Personal choices of physicians and nurses. Bol As Med PR. 1992;
84: 139-43.
12. Cf. Álvarez J.C. Limitación del esfuerzo terapéutico in Elizari F.J. (Op.
citp., 245-301).
13. Cf. Ferrer J.J. Deber y deliberación (Mayagüez, Centro de Publicaciones
Académicas de la Universidad de Puerto Rico en Mayagüez, 2004) Pág. 341362.
14. ID., Medical Care at the End of Life (Washington, DC: Georgetown University Press, 2006) page 1-11.
15. Wildes K. Ordinary and extraordinary means. Theological Studies. 1996;
57:505-507.
Apéndice
Modelo de Directrices Adelantadas Puertorriqueñas
La Ley 160 de Puerto Rico, promulgada el 17 de
noviembre de 2001, reconoce el derecho de toda persona
57
mayor de edad, en pleno uso de sus facultades mentales,
a declarar previamente su voluntad sobre el tipo de tratamiento médico que desea recibir en caso de sufrir una
condición de salud en fase irreversible. La mencionada ley concede al paciente el derecho a dejar directrices
adelantadas, y designar un mandatario para que tome
decisiones respecto de su salud cuando el paciente no
pueda ya tomarlas por sí mismo(a). La ley federal de la
Libre Determinación del Paciente, efectiva desde el 1 de
diciembre de 1991, exige que todas las instituciones que
atiendan pacientes que reciban el beneficio de medicare,
les provean a estos un documento que les facilite declarar
su voluntad con relación a los servicios médicos que desean o no desean recibir y la designación de un mandatario que los represente cuando ellos ya no puedan expresar
sus propias preferencias.
•
No importa cuan de saludable usted se sienta, ni
cuan joven usted sea, es recomendable que usted escriba,
firme y estipule voluntariamente sus directrices adelantadas y designe un mandatario que tome decisiones sobre
el cuidado de su salud cuando usted ya no lo pueda hacer.
•
Este derecho civil puede ejecutarse ante un notario previo a ser admitido(a) en una institución de servicios de salud. Es, responsabilidad suya o de sus allegados notificar a los médicos y a la institución la existencia
de esta declaración y, asimismo, entregarles copias del
documento. En adición a lo anterior, la ley permite que
usted haga sus directrices adelantadas y designación de
mandatario en presencia de un médico y de dos testigos
adultos que no sean sus herederos ni participen en su
cuidado directo. Estas directrices pueden ejecutarse en
la oficina del médico o cuando usted es admitido al hospital. Usted retendrá el control de su tratamiento médico mientras tenga la capacidad de tomar decisiones: Las
directrices adelantadas y la designación de mandatario
pueden ser “revocadas por usted en cualquier momento
mediante expresión escrita u oral a esos efectos”
He aquí un ejemplo de directrices adelantadas y
designación de mandatario que llena los requisitos de la
Ley de Puerto Rico y que puede hacerse en un consultorio médico o en el hospital:
II Directrices Adelantadas:
Yo, (nombre completo en letra de molde), en pleno uso
de mis facultades mentales, presto esta declaración como
un mandato a cumplirse en caso de que quede permanentemente incapacitado(a) para participar en decisiones
respecto a mi asistencia médica. Estas instrucciones sólo
entrarán en vigor si yo: 1) tuviese una condición terminal, 2) estuviese permanentemente inconsciente o 3)
estuviese consciente pero con daño cerebral irreversible,
y sin posibilidad de recobrar la facultad para tomar decisiones y expresar mis deseos. Estas instrucciones reflejan mi decisión firme de rehusar tratamientos médicos
desproporcionados. De ser víctima de una enfermedad
terminal, sin una expectativa razonable de recuperación,
instruyo a mi médico de cabecera a descontinuar o a no
prestarme tratamientos médicos desproporcionados que
irracionalmente prolonguen el proceso de morir. En caso
de no tener una expectativa de recuperación, mi atención
médica debe limitarse a medidas que mejoren mi bienestar,
58
que alivien el dolor y el sufrimiento, incluyendo el momento cuando se descontinúe el tratamiento.
Se inician los cuidados médicos que se rehúsan
específicamente:
Reanimación Cardiopulmonar (CPR) – Procedimiento que restaura el movimiento del corazón
cuando los latidos se detienen y que provee respiración
artificial cuando cesa el mecanismo de la respiración.
(INICIALES)
Respiración Mecánica – Se utiliza una máquina
llamada ventilador o respirador para ayudar al pulmón en
su función respiratoria cuando ésta es inadecuada.
(INICIALES)
(INICIALES)
Diálisis
(INICIALES)
Transfusiones de sangre
(INICIALES)
Antibióticos
Otros cuidados médicos que se rehúsan (letra de
imprenta) _____________________________
(INICIALES)
III. Designación del Mandatario
Habrá otras decisiones médicas importantes que
no se pueden anticipar. Por eso la ley 160 de 2001 también contempla la designación de un mandatario que
tome decisiones sobre aceptación o rechazo de tratamientos armónicas con sus deseos y preferencias cuando
ya usted le sea imposible comunicarse.
Del declarante no designar un mandatario “se
considerará mandatario al pariente mayor de edad más
próximo, según el orden sucesoral establecido en el Código Civil de Puerto Rico, según enmendado, teniendo el
primer rango el cónyuge del declarante”.
Designo a ( ) quien conoce bien mis valores,
para que vigile el documento de las instrucciones sobre el
final de mi vida y tome otras decisiones que el/ella crea
apropiadas, sobre la aceptación o rechazo de tratamientos
sugeridos. Su dirección es: ( ) Teléfonos: ( ) Residencia ( ) Celular: ( )
Certifico que:
( ) Le notifiqué su designación
( ) Le notificaré su designación.
En caso de que a este mandatario le fuera imposible servir, designo alternativamente a ( ) a que haga esta función.
Su dirección es: ( ) Teléfonos: ( ) Residencia ( ) Celular ( )
Certifico que:
( ) Le notifiqué su designación
( ) Le notificaré su designación.
IV Donación de órganos:
( ) No deseo donar mis órganos, tejidos u ojos.
Después de mí muerte deseo donar:
( ) Cualquier órgano, tejido u ojos que pudiesen ser útiles.
( ) Solamente los siguientes órganos o tejidos: ( )
Es mi deseo que después de mi muerte se mantengan las
medidas de sostén necesarias para que mis órganos mantengan la viabilidad que los hace útiles. Entiendo que mis
herederos no son responsables por gastos asociados a mi
donación de órganos o tejidos.
Nombre del Paciente/Firma/Fecha y hora
Nombre del Testigo/Firma/Fecha y hora
Nombre del Testigo/Firma/Fecha y hora
Nombre del médico/Firma del médico/Fecha y hora/
Núm. de licencia
V. Responsabilidad institucional (cuando se hace en
un hospital)
Yo, (Nombre en letra de molde) del Departamento de( )
me he asegurado que sus decisiones se hayan hecho parte
de su expediente clínico.
Firma / Fecha y hora
Nota. Ya que estos documentos son en efecto consentimientos informados, es recomendable que éstos sean
explicados por un profesional de la salud.
ABSTRACT
The libertarian principles of Personal
Autonomy and Personalized Justice which grew
mightily in the rapidly spreading young American
democracy in the 18th and 19th centuries led to the
development of Bioethics in the United States. The
bioethical principles of Respect for Autonomy, Beneficence, non-Maleficence and Justice support the
elaboration of advance directives (living will and
the designation of a proxy to attend health matters)
for when the patient is no longer capable to make
health decisions. Advance directives can be drafted
and signed in Puerto Rico with the help of a lawyer.
They can also be legally prepared in a doctor’s office or in a hospital if witnessed by a doctor and two
persons who will not benefit from the patient’s demise or are directly involved in his/her care). We
present a model for advance directives which may
be executed in a doctor’s office or a hospital. The
model fulfills the legal requirements of Puerto Rico
Law 160 which became effective November 2001.
It also fulfills requirements of the Patients Self-Determination Act that became effective in 1991.The
document also contains standard options for organ
donations. We discuss the fundamental bioethical
principles which have given root to the development of the advance directives. We suggest that it
may be economically advantageous to health insurance carriers to compensate physicians who help
their patients in the execution of a valid document.
The existence of this document may help prevent
the large expenses associated with inappropriate
admissions to intensive care of patients at the endof-life.
59
Case Report/Reporte de Casos
ABSTRACT
Selective Serotonin Reuptake Inhibitors
are the treatment of choice for depression and
anxiety disorders due to its tolerability, safety
and side effects profile. However, with the current and frequent use of these medications in
patients with these disorders, new side effects
have been reported. This case report describes
the development of panic attacks in a 24 yearold-female patient with depressive and anxiety
symptoms, and no previous predisposing history
for panic attacks.
Key words: sertraline, side-effects, panic
attacks
SERTRALINE-INDUCED
PANIC ATTACK
Nereida González-Berríos, MD *
* From the Department of Psychiatry, UPR School of Medicine, Medical Science Campus.
Address reprints requests: Nereida González, MD - PO
BOX 146, Barceloneta, PR 00617. E-mail: <[email protected]>
INTRODUCTION
CASE REPORT
ood and anxiety disorders constitute the
most common groups of psychiatric disorders (1). Their
treatment includes different modalities that are divided
in psycho- and pharmacotherapy. When pharmacotherapy is considered, those medications approved by the
FDA are the preferred ones and, among them, are the Selective Serotonin Reuptake Inhibitors (SSRIs) (1). These
agents have become the first choice in treatment due to
their better-tolerated adverse effects. Among these adverse effects are: sexual dysfunction, headache, insomnia or
sedation, seizures, extrapyramidal symptoms, sweating,
and anxiety, which have been described for Fluoxetine,
Paroxetine and Escitalopram. However, the incidence of
panic attacks has not been completely described in the
textbooks as an adverse effect (1). This particular adverse effect is thought to be the result of the acute stimulation of 2A and 2C receptors in the projection from
raphe to limbic cortex (6). SSRIs have less activity in
other neurotransmitter receptors compared to older antidepressants (such as TCAs and MAOIs) and, therefore,
have less systemic side effects, which make them the first
choice for pharmacotherapy. Sertraline, in these instances, is described as a weaker inhibitor of norepinephrine
and dopamine reuptake that could explain, at some point,
the incidence of panic attacks in patients using this medication. Norepinephrine and serotonin have both been
associated to the development of anxiety symptoms (1).
The logical explanation for this is that there is an increased turnover of serotonin as a response to acute stress,
while norepinephrine produces physiological symptoms
experienced in panic attacks. Several case reports and
studies have stressed out the incidence of panic attacks
with several SSRIs such as fluoxetine (2), paroxetine (3)
as well as with sertraline (4, 5). These case reports described a diverse patient population with no similarities
among them. Patients in these reports varied from a 21
y/o male with no previous psychiatric diagnosis to a 62
y/o female with multiple medical conditions and multiple
drug treatments. In this case report, the onset of a panic attack will be described in a female patient who was
diagnosed with Major Depressive Disorder and a Personality Disorder.
This is the case of a 24-year-old woman with a
diagnosis of Major Depressive Disorder: single episode,
moderate, with atypical features, without psychotic features that also met diagnostic criteria for dependent personality disorder. She didn’t have a previous history of
psychiatric disorders or any medical condition. During
her initial visit, she mentioned that she was feeling “really
sad” and that she felt depressed, anxious, with low selfesteem, low energy, increased appetite, hypersomnolence, and poor concentration. Patient also developed death
wishes that began when her problems with her boyfriend
started. She also described herself as dependent, and incapable of living alone. She admitted having difficulties
making decisions by herself, had difficulties expressing
disagreement with her partners, and usually sought another relationship as a source of support when a close relationship ended. Patient also denied any allergies or any
medication use (nor herbal supplements). A general laboratory workup was ordered, including thyroid function
tests, and all values were within normal limits. Patient
was started on Zoloft 50 mg daily and a follow-up visit was scheduled. Patient came to her next appointment
(one week later) on time and complained of abdominal
discomfort during the first two days of treatment. However, this discomfort disappeared and patient felt less depressed than before treatment. Her anxiety symptoms did
not show a significant improvement, but medication was
left on 50 mg in order to give it more time to work appropriately. A new appointment was given to the patient for
the next week and she was instructed to monitor side
effects and current symptoms. The patient came to the
clinics five days prior to her appointment (approximately
9 days after starting the medication) referring that she
was not tolerating the medication. She looked concerned
and was breathing rapidly. Patient was evaluated and began saying that she had an anxiety attack. This episode
occurred while she was in a classroom taking a seminar.
She mentioned that she began to feel like fainting, with
shortness of breath, chest pain, palpitations, inability to
move or think calmly and sweating. Patient felt that something was going to happen to her and had to leave the
classroom immediately. At that moment she decided to
M
60
come to the clinics for a reevaluation of her medication.
Zoloft was discontinued immediately and patient was
started on Lexapro 10 mg. She did not experience another panic attack after discontinuing Sertraline and her
symptoms responded well to Lexapro.
DISCUSSION
The incidence of panic attacks in patients taking
SSRIs has been documented in several case reports (2-5).
However, there are not any controlled clinical trials that
can elicit a clear etiology, explanation or predisposing
factor that can be related to this specific adverse effect.
In previous written case reports, there are not any similarities among the patients described in them. A possible
explanation for the wide variety in the type of patients
described is the molecular diversity found among the
SSRI group which also contribute to different side effects
depending in which antidepressant is used. The specific
individual response of each patient, given the circumstances to which they were exposed, is another contributing factor for this diversity. All these factors contribute
to the difference in responses and tolerability. Possible
explanations for the development of panic attacks while
using SSRIs have been mentioned. One of these theories
is mentioned in two case reports previously published (4,
5). It describes the existence of a biphasic response in
which there is an increased in anxiety and panic attacks
followed by a gradual amelioration of symptoms. This is
possibly due to the stimulation of hypersensitive postsynaptic serotonin receptors with a subsequent compensatory down regulation response.
The description of these case reports help us to
be aware of the possibility of this peculiar adverse effect
with medications that are supposed to be approved for
the treatment of the same adverse effect they are causing.
However, no current reports or studies about this matter
H.I.T.
HEALTH
INFORMATION
TECHNOLOGY
were found. Most of the case reports found were written in the 90’s (2,3,4) with only one case report written
on 2000 (4). This case report addresses the relevance of
promoting more organized and controlled clinical studies, which could bring a clear explanation for the development of this adverse effect. Research in this area
could also contribute to the early identification of specific
predisposing factors such as multiple drug use, previous
diagnoses of anxiety disorders or personality disorders.
REFERENCES:
1. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry, 10th edition. Lippincott, Williams &
Williams. 2007. 528, 581-595.
2. Altshuler LL. Fluoxetine-associated panic attacks. J Clin Psychopharm.
1994; 14: 433–434.
3. Ballenger JC, Wheadon DE, Steiner M, Bushnell W, Gergel IP.Doubleblind, fixed-dose, placebo-controlled study of Paroxetine in the treatment of
panic disorder. Am J Psychiatry 1998; 155: 36–42.
4. Catalano G, Hakala SM, Catalano MC. Sertraline-induced Panic Attacks
Clin. Neuropharmacol., Vol. 23, No. 3, 2000. 164-168.
5. Zinner SH. Panic Attacks Precipitated by Sertraline. The American Journal
of Psychiatry; Jan 1994; 151, 1; 147.
6. Stahl S.M. Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 2nd Ed. Cambridge University. 2000. 230-235.
RESUMEN
Los Inhibidores Selectivos de Receptores de
Serotonina (ISRSs) son el tratamiento de predilección para los trastornos de ansiedad y depresión debido a su tolerabilidad, seguridad y perfil de efectos
secundarios. Sin embargo, el uso actual y frecuente
de estos medicamentos ha traído a su vez el hallazgo
de nuevos efectos secundarios. Este artículo describe el desarrollo de un ataque de pánico como efecto
secundario al uso de sertralina en una joven mujer
de 24 años de edad. Dicha paciente llegó a nuestras
clínicas con síntomas depresivos y de ansiedad, y no
tenía un historial previo de ataques de pánico.
55ava CONVENCION
ANUAL
DEL DISTRITO ESTE
ADVENTURE OF THE SEAS
SABADOS 31 DE OCTUBRE Y 7 DE
NOVIEMBRE 2009 - 1 a 4 PM
20 al 27 de setiembre
de 2009
2 Jornadas de 3 horas credito cada una, orientadas a profesionales de salud y personal auxiliar,
en informacion y entrenamiento para uso de tec
nologia informatica en aplicaciones medicas.
Programa Científico orientado a Medicos Primarios, Medicos Generalistas, Medicos
de Familia, Especialistas de
todas las Especialidades.
Los cursos abarcarán desde temas básicos de
computacion general hasta aplicaciones como eprescribing y registros electronicos de salud.
Consulte y regístrese en nuestro web site :
para recibir mas informacion
Puerto Rico Medical Association - East District
(787) 750-1670 / 249-2704 / 409-4891
[email protected]
[email protected]
61
Historical Articles/Articulos de Historia
HISTORIA DEL DESARROLLO
DEL DEPARTAMENTO DE PSIQUIATRIA
DE LA UNIVERSIDAD DE PUERTO RICO,
RECINTO DE CIENCIAS MÉDICAS
Miguel González Manrique, MD*
* Catedrático-Departamento de Psiquiatría. UPR Escuela de Medicina,
Recinto de Ciencias Médicas.
Dirección del autor: Departamento de Psiquiatría, Recinto de Ciencias
Medicas PO BOX 365067, San Juan, PR 00936.
N
uestro origen respondió a la necesidad de
enseñarles psiquiatría a estudiantes de medicina de tercer
y cuarto año de la Universidad de Puerto Rico durante su
pasantía clínica en el antiguo Hospital Municipal de San
Juan, hoy Museo de Arte de Puerto Rico. Funcionábamos como la “Sección” del Departamento de Medicina
Interna de nuestra recién fundada Escuela de Medicina.
Allí se desarrolló la primera Clínica de Psiquiatría Ambulatoria para Adultos y de Niños y Adolescentes. En el
1958 nos convertimos en el Departamento de Psiquiatría
siendo su primer Director el Dr. Juan A. Rosselló y su
Director del Programa de Adiestramiento el Dr. Juan E.
Morales.
Pronto unimos esfuerzos con el Departamento
de Salud, creando y desarrollando el Programa de Salud Mental en Puerto Rico ubicado en el Edificio A del
Hospital Estatal de Psiquiatría. Nuestra primera clase de
residentes se graduó en el 1960. En el 1956 establecimos
la sub-especialidad de Psiquiatría de Niños y Adolescentes. Ambos programas han sido acreditados por el ACGME ininterrumpidamente hasta el presente. Esta fue una
etapa “germinativa” desarrollando noveles estrategias de
servicios psiquiátricos, el equipo interdisciplinario y comunitario como modelo; aprobación de propuestas educativas y de investigación, enseñanza de psiquiatría en
nuestra Escuela y la primera acreditación del Hospital
Estatal de Psiquiatría.
En el 1972 el Departamento de Salud desarrolló
la Secretaría Auxiliar de Salud Mental y asume la dirección y administración de sus servicios. El Departamento
de Psiquiatría se traslada al 9no. Piso del recién construido Recinto de Ciencias Médicas aportando el modelo
biopsicosocial al nuevo currículo de Medicina. Nos integramos a las otras especialidades médicas en el Hospital Universitario y desarrollamos nuestra Clínica de Servicios Ambulatoria para Adultos en el 9no. Piso del RCM
y el “Fellowship” de Psiquiatría de Niños y Adolescentes
en el Hospital Universitario Pediátrico. Ampliamos nuestra afiliación con el Hospital de Veteranos convirtiéndose
este en nuestro Taller Clínico Primario para estudiantes
y residentes. Comenzó el proyecto de Investigación en
Epidemiología Psiquiátrica en Puerto Rico.
En los 90 se inicia el nuevo modelo de prestación
de servicios médicos y de Salud Mental (Reforma). El
Hospital de la U.P.R. en Carolina se convierte en nuestro
taller clínico primario y añadimos la diversificación de
otros talleres clínicos como los hospitales psiquiátricos
privados, Centro de Trauma en Centro Médico, los Servicios Médicos Universitarios de la U.P.R. en Río Piedras,
otra vez el Hospital Estatal de Psiquiatría (32 años más
tarde) y el nuevo Centro de Investigación “Fear Learning
Laboratory” en nuestro Recinto de Ciencias Médicas.
Al celebrar nuestro cincuentenario, nos sentimos
orgullosos de nuestros logros; .los cuales han contribuido
al desarrollo de la psiquiatría moderna y al cuidado de la
salud mental en Puerto Rico. Nuestro futuro está comprometido con la promoción del profesionalismo y el humanismo en la formación médica de nuestros estudiantes
y residentes.
Basic Topics in Pain Management
Saturday,
September 26th, 2009
Amphitheater 6th floor RCM
8:00 Welcome and Introduction - Luis Baerga, MD
8:10
Pain Pathophysiology - Jan Kraemer, MD
8:30
Pain Evaluation and Assessment - Marimie Rodriguez, MD
9:00
Pain Pharmacology for the Primary Doctor - Luis Baerga, MD
9:30 Opioid Prescription and Federal Guidelines - Jan Kraemer, MD
10:30 Low back pain and Sciatica - Luis Baerga, MD
11:00 Neck Pain and Headaches - Liza Hernandez, MD
11:30 Case Presentations- Moderator Luis Baerga, MD
12:15
Lunch (on your own)
1:00
Neuropathic Pain Syndromesand CRPS- Linka Matos, MD
1:30
Interventional and Implantable Therapies - Francisco Lebrón, MD
2:30
Pain Management in Cancer Patients - Dorian López, MD
3:00
Case Presentations 2 - Moderator: Francisco Lebrón, MD
3:45 Questions
For registration information:
Department of Physical Medicine
Rehabilitation & Sports Medicine
Office A-204 - Medical Sciences Campus
Phone: (787) 751-9625
El Dr. Bernal y
del Rio, MD
sigue produciendo.
63
Nestor Jose Galarza Diaz, MD, DFAPA
http://www.njgalarza.blogspot.com
Esta reseña bilingüe tiene un fin educativo y
otro honorífico para nuestro Caballero de la
Triste Figura e inmensa personalidad.
V
íctor Bernal y Del Río nació en 1917. Se
adiestró como joven persona en San Sebastián del
Pepino y luego como médico y ginecólogo y psicoanalista en Portugal y Nueva York. El decia, en varios idiomas,“Thoughts have no consequences, acts
do… Thoughts represent wishes…Wishes have no
limits, no dimensions, time schedules, dates, no compassion nor justice”. A Freudian psychoanalyst, Dr
Bernal addressed and practiced all kinds of defense
mechanisms with a narcissistic trend. Charismatic is
his best description as a teacher and mentor. Having
met him seems to help a person understand the basic
psychology of the unconscious and the subconscious.
Just remembering him you can imagine, notice or see
narcissism, projection, displacement, denial, introjections, altruism. The educational motive of the professor is still here, posthumously in the hundreds of
well-trained physicians of the Puerto Rico Institute of
Psychiatry. Having met him you can also learn about
psychopathology and about the psychology of the
psychoanalyst.
Because of his 51 years as a member of the
American Psychiatric Association you can imagine
Don Victor standing with one foot in organized and
academic Psychiatry, and one foot in his unrelenting
support of the mentally ill, with his longstanding support of the National Alliance for Mental Illness in
Puerto Rico. If you read his short story The Alchemist for the third millennium you cannot avoid to rehash the theme of the elegant psychotic nationalist in
Puerto Rico, remindful of Don Quixote, the epic story
from Spain. Reading it reminds me how un-disabling
a delusion can be and how a person can survive, thrive and continue to weave his life around a fixed idea
about himself and his mission. Also how others, including the family, laugh at the deluded. Was this meant
to address present day stigmatization of the mentally
ill? Read more of Bernal y del Rio and his only book
Y. Bernalerias Y. Literatura de lo absurdo at http://
njgalarza.blogspot.com/2007_01_01_archive.html.
Don Victor partially died in San Juan on December
28, 2006. Partly he is here.
IMPORTANT TREATMENT CONSIDERATIONS
PRISTIQ 50-mg Extended-Release Tablets are indicated for the treatment
of major depressive disorder in adults.
WARNING: SUICIDALITY AND ANTIDEPRESSANT DRUGS
Antidepressants increased the risk compared to placebo of suicidal
thinking and behavior (suicidality) in children, adolescents, and young
adults in short-term studies of Major Depressive Disorder (MDD) and
other psychiatric disorders. Anyone considering the use of PRISTIQ
or any other antidepressant in a child, adolescent, or young adult must
balance this risk with the clinical need. Short-term studies did not
show an increase in the risk of suicidality with antidepressants
compared to placebo in adults beyond age 24; there was a reduction
in risk with antidepressants compared to placebo in adults aged 65 and
older. Depression and certain other psychiatric disorders are themselves
associated with increases in the risk of suicide. Patients of all ages
who are started on antidepressant therapy should be monitored
appropriately and observed closely for clinical worsening, suicidality,
or unusual changes in behavior. Families and caregivers should be
advised of the need for close observation and communication with
the prescriber. PRISTIQ is not approved for use in pediatric patients.
Contraindications
• PRISTIQ is contraindicated in patients with a known hypersensitivity
to PRISTIQ or venlafaxine.
• PRISTIQ must not be used concomitantly with an MAOI or within
14 days of stopping an MAOI. Allow 7 days after stopping PRISTIQ
before starting an MAOI.
Warnings and Precautions
• All patients treated with antidepressants should be monitored
appropriately and observed closely for clinical worsening, suicidality,
and unusual changes in behavior, especially during the first few
months of treatment and when changing the dose. Consider
changing the therapeutic regimen, including possibly discontinuing
the medication, in patients whose depression is persistently worse
or includes symptoms of anxiety, agitation, panic attacks, insomnia,
irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania,
mania,or suicidality that are severe, abrupt in onset, or were not part
of the patient’s presenting symptoms. Families and caregivers of
patients being treated with antidepressants should be alerted about
the need to monitor patients.
• Development of a potentially life-threatening serotonin syndrome or
Neuroleptic Malignant Syndrome-like reactions have been reported
with SNRIs and SSRIs alone, including PRISTIQ treatment, but
particularly with concomitant use of serotonergic drugs, including
triptans, with drugs that impair the metabolism of serotonin (including
MAOIs), or with antipsychotics or other dopamine antagonists. If
concomitant use with a triptan is clinically warranted, careful
observation of the patient is advised, particularly during treatment
initiation and dose increases. Concomitant use of PRISTIQ with
serotonin precursors is not recommended.
• Patients receiving PRISTIQ should have regular monitoring of blood
pressure since sustained increases in blood pressure were observed
in clinical studies. Pre-existing hypertension should be controlled
before starting PRISTIQ. Caution should be exercised in treating
patients with pre-existing hypertension or other underlying conditions
that might be compromised by increases in blood pressure. Cases of
elevated blood pressure requiring immediate treatment have been
reported. For patients who experience a sustained increase in blood
pressure, either dose reduction or discontinuation should be considered.
For the treatment of adults
with major depressive disorder
The start is just the
beginning
It’s not just about starting your adult patients
with MDD on therapy; it’s about helping them
toward their treatment goals. Patients should
be periodically reassessed to determine the
need for continued treatment.1
PRISTIQ 50 mg:
• SNRI therapy with efficacy proven in 8-week clinical studies
• One recommended therapeutic dose from the start
• Discontinuation rate due to adverse events comparable
to placebo in 8-week clinical studies1
• SSRIs and SNRIs, including PRISTIQ, may increase the risk of
bleeding events. Concomitant use of aspirin, NSAIDs, warfarin, and
other anticoagulants may add to this risk.
• Mydriasis has been reported in association with PRISTIQ; therefore,
patients with raised intraocular pressure or those at risk of acute
narrow-angle glaucoma (angle-closure glaucoma) should be monitored.
• PRISTIQ is not approved for use in bipolar depression. Prior to
initiating treatment with an antidepressant, patients should be
adequately screened to determine the risk of bipolar disorder.
• As with all antidepressants, PRISTIQ should be used cautiously in
patients with a history or family history of mania or hypomania, or
with a history of seizure disorder.
• Caution is advised in administering PRISTIQ to patients with cardiovascular,
cerebrovascular, or lipid metabolism disorders. Increases in blood
pressure and small increases in heart rate were observed in clinical
studies with PRISTIQ. PRISTIQ has not been evaluated systematically
in patients with a recent history of myocardial infarction, unstable heart
disease, uncontrolled hypertension, or cerebrovascular disease.
• Dose-related elevations in fasting serum total cholesterol, LDL (low
density lipoprotein) cholesterol, and triglycerides were observed in
clinical studies. Measurement of serum lipids should be considered
during PRISTIQ treatment.
• On discontinuation, adverse events, some of which may be serious,
have been reported with PRISTIQ and other SSRIs and SNRIs. Abrupt
discontinuation of PRISTIQ has been associated with the appearance
of new symptoms. Patients should be monitored for symptoms when
discontinuing treatment. A gradual reduction in dose (by giving
50 mg of PRISTIQ less frequently) rather than abrupt cessation is
recommended whenever possible.
• Dosage adjustment (50 mg every other day) is necessary in patients
with severe renal impairment or end-stage renal disease (ESRD). The
dose should not be escalated in patients with moderate or severe renal
impairment or ESRD.
• Products containing desvenlafaxine and products containing venlafaxine
should not be used concomitantly with PRISTIQ.
• Hyponatremia may occur as a result of treatment with SSRIs and
SNRIs, including PRISTIQ. Discontinuation of PRISTIQ should be
considered in patients with symptomatic hyponatremia.
• Interstitial lung disease and eosinophilic pneumonia associated
with venlafaxine (the parent drug of PRISTIQ) therapy have been
rarely reported.
Adverse Reactions
• The most commonly observed adverse reactions in patients taking
PRISTIQ vs placebo for MDD in short-term fixed-dose premarketing
studies (incidence ≥5% and twice the rate of placebo in the 50-mg
dose group) were nausea (22% vs 10%), dizziness (13% vs 5%),
hyperhidrosis (10% vs 4%), constipation (9% vs 4%), and decreased
appetite (5% vs 2%).
Reference: 1. Pristiq® (desvenlafaxine) Prescribing Information, Wyeth Pharmaceuticals Inc.
Please see brief summary of Prescribing Information
on adjacent pages.
For more information on PRISTIQ, please visit www.PristiqHCP.com.
© 2009, Wyeth Pharmaceuticals Inc.
Philadelphia, PA 19101 254222-01
La Asociación Médica
en carrera hacia el futuro
•
•
•
•
•
•
Mayor participación en las decisiones
comunitarias.
Compromiso con la práctica eficiente.
Servicios de alta tecnología para nuestros profesionales de salud.
Clinicas de salud gratuitas para nuestro
Pueblo.
Grandes novedades para educación
continua on-line.
Health Information Technology a su
disposición.
El asma tiene dos causas principales. Tratar
ambas con ADVAIR ayuda a prevenir los síntomas.
®
1. Constricción de las vías respiratorias
2. Inflamación
Si sus síntomas siguen repitiéndose, podría ser que su
medicamento de control trate sólo una de las causas principales.
Ayuda a prevenir los síntomas. Trata ambas causas.™
Pregunte a su médico si ADVAIR es adecuado para usted. Para más información, llame al 1-800-646-6644 o visite www.ADVAIR.com
Información importante sobre ADVAIR DISKUS. ADVAIR, disponible con receta, no remplaza los inhaladores de acción rápida para los síntomas
repentinos y no debe usarse más de dos veces al día. ADVAIR es para personas que siguen teniendo síntomas mientras reciben otro medicamento de
control del asma o que necesitan dos medicamentos de control. ADVAIR contiene salmeterol. En pacientes de asma, los medicamentos como el salmeterol
pueden aumentar las probabilidades de muerte relacionada con el asma. ADVAIR no es para personas que tengan el asma bien controlada con otros
medicamentos de control.
Hable con el médico sobre los riesgos y beneficios de tratarse el asma con ADVAIR. No use ADVAIR con beta2-agonistas de acción prolongada por ninguna
razón. Si usa ADVAIR, debe visitar a su médico si el asma no mejora o empeora. Informe a su médico si tiene una condición cardiaca o alta presión. Algunas
personas pueden experimentar un aumento de la presión arterial, la frecuencia cardiaca o cambios en el ritmo cardiaco. ADVAIR es para pacientes de 4
años o más. El ADVAIR DISKUS 100/50 es para pacientes de 4 a 11 años que tienen síntomas de asma mientras reciben un corticosteroide inhalado.
Véase información importante sobre ADVAIR en la próxima página.
Le exhortamos a informar efectos secundarios negativos de medicamentos recetados a la FDA.
Visite www.fda.gov/medwatch o llame al 1-800-FDA-1088.
B LETÍN
ASOCIACIÓN MÉDICA DE PUERTO RICO
El “Boletín” acepta para su publicación artículos relativos a medicina y cirugía
y las ciencias afines. ¡Igualmente acepta artículos especiales y correspondencia
que pudiera ser de interés general para la profesión médica. Se urge a los
autores se esfuercen en perseguir claridad, brevedad, e ir a lo pertinente en sus
manuscritos, no importa el tema o formato del manuscrito.
El artículo, si se aceptara, será con la condición de que se publicara únicamente
en la revista. Para facilitar la labor de revisión de la junta Editora y la del
impresor, se requiere de los autores que sigan las siguientes instrucciones:
• Manuscrito
El manuscrito completo, incluyendo las leyendas y referencias deberán estar
escritos en maquinilla a doble espacio; por un sólo lado de cada página,
en TRIPLICADO y con amplio margen (ARTÍCULO DEBERÁ SER
ACOMPAÑADO POR UN “CD”). En página separada deberá incluirse lo
siguiente: título, nombre de autor(es) y su grado (ej.: MD, FACP), ciudad
donde se hizo el trabajo, el hospital o institución académica, patrocinadores
del estudio, y si un artículo ha sido leído en alguna reunión o congreso, así
debe hacerse constar como una nota al calce.
El manuscrito debe comenzar con una breve introducción en la cual se
especifique el propósito del mismo. Las secciones principales (como por
ejemplo: materiales y métodos) deben identificarse con un encabezamiento en
letras mayúsculas.
Artículos referentes a resultados de estudios clínicos o investigaciones
de laboratorio deben organizarse bajo los siguientes encabezamientos:
introducción, Materiales y Métodos, Resultados, Discusión, Resumen (en
español e inglés), Reconocimiento y Referencias.
Artículos referentes a estudios de casos aislados deben organizarse en la siguiente
forma: Introducción, Materiales y Métodos si es aplicable,Observaciones
del Caso, Discusión, Resumen (en español e inglés), Reconocimientos y
Referencias.
• Nomenclatura
Deben usarse los nombres genéricos de los medicamentos. Podrán usarse
también los nombres comerciales, entre paréntesis, si así se desea se usará con
preferencia el sistema métrico de pesos y medidas.
• Tablas
Las tablas deben aparecer en hojas separadas. Estas deben incluir el título, y
el número de la tabla debe estar en romano. Los símbolos de unidades deben
limitarse al encabezamiento de las columnas. Se deben omitir líneas verticales
en la tabla. Se usará en las tablas el mismo idioma en el cual está escrito el
artículo. Deben limitarse las tablas a solo aquellas que contribuyan al mejor
entendimiento del manuscrito.
• Ilustraciones
Las fotografías y microfotografías se someterán como copias en papel de
lustre, sin montar o en transparencias. En el reverso de la figura debe aparecer
el número de la figura (arábigo) y el autor. Debe indicarse la parte superior de
la ilustración.
• Resumen
Un abstracto no mayor de 150 palabras debe acompañar los manuscritos.
Debe incluir los puntos principales que ilustren la substancia del artículo y la
exposición del problema, métodos, resultados y conclusiones.
• Referencias
Las referencias deben ir numeradas sucesivamente de acuerdo a su aparición en
el texto. Los números deben aparecer en paréntesis al nivel de la línea u oración.
Al final de cada artículo las referencias deben aparecer en el orden numérico en
que se citan en el texto. Deben utilizarse solamente las abreviaturas para títulos
de revistas científicas según indicadas en el “Cumulative Index Medicus" que
publica la Asociación Médica Americana.
Las referencias deben seguir el patrón que se describe a continuación.
1. Para artículos de revistas: Apellido(s) e iniciales del nombre del autor(es),
título del artículo, nombre de la revista, año, volumen, páginas. Por ejemplo:
Villavicencio R: Soplos inocentes en pediatría, Bol Asoc Méd P Rico 198 1;
73: 479-87. Si hay más de 7 autores, incluir los primeros 3 y añadir et al.
2. Para citación de libros donde el autor(es) del capítulo citado es a su vez el
(los) editor(es): Apellido(s) e iniciales del autor(es), título del libro, número
de edición, ciudad, casa editora, año y página. Por ejemplo: Keith JD, Rowe
RD, Vlad P: Heart disease in infancy and childhood, 3d. Ed., New York,
MacMillan, 1978: 789
3. Para citación de libros donde el editor(es) no es el autor(es) del capítulo
citado se añade el autor(es) del capítulo y el título del mismo. Por ejemplo:
Olley PM: Cardiac arrythmias; In: Keith ID, Rowe RD, Vlad P Eds. Heart
disease in infancy and childhood,
3d Ed., New York, MacMillan, 1978: 275-301
• Cartas al Editor
Se publicarán a discreción de la Junta Editora. Deben estar escritas en
maquinilla a doble espacio, no deben ser mayores de 500 palabras, ni incluir
más de cinco referencias.
(ARTÍCULO DEBERÁ SER ACOMPAÑADO POR UN “CD”)* Estas
“Instrucciones para los Autores` son de acuerdo a las normas establecidas por
el Comité Internacional de Editores de Revistas Médicas en sus `Requisitos
Uniformes para Manuscritos Sometidos a Revistas Bio-Médicas".
• Instrucciones para los Autores*
• Instructions to Authors*
The “Buletín” will accept for publication contributions relating to the various
areas of medicine, surgery and allied medical sciences. Special articles and
correspondence on subjects of general interest to physicians will also be
accepted. All material is accepted with the understanding that is to be published
solely in this journal.
All authors are urged to seek clarity, brevity, and pertinence in the manuscripts
regardless of subject or format.
In order to facilitate review of the article by the Editorial Board and the work
of the printer, the authors must conform with the following instructions:
• Manuscripts
The entire manuscript, including legends and references should be typewritten
double spaced in TRIPLICATE with ample margins (ARTICLES SHOULD
BE ACCOMPANIED WITH A ”CD”). A separate title page should include
the following: title, authors and their degrees (e.g. MD, FACP), city where
the work was done, hospital or academic institutions, acknowledgments of
financial sponsors, and if the paper has been at a meeting the place and date
should be given.
The manuscripts should start with a brief introductory paragraph or paragraphs
which should state its purpose. The main sections (for example, Materials and
Methods) should be identified by heading in capital letters.
Articles reporting the results of clinical studies or laboratory investigation
should be organized under the following headings: Introduction, Materials and
Methods, Result if indicated, Discussion, Summary in English and Spanish,
Acknowledgments if any, and References.
• Nomenclature
Generic names of drugs should be used; trade names my also be given
in parenthesis, if desired, metric units of measurement should be used
preferentially.
• Tables
These should be typed on separate sheets with the title and table number
(Roman) centered. Symbol for units should be confined lo the column headings.
Vertical lines should be omitted. The language used in the tables must be the
same as that of the article. Include only those tables which will enhance the
understanding of the article. They should supplement, not duplicate the text.
• Illustrations
Photographs and photomicrographs should be submitted as glossy prints
(unmounted) or slides. They should be labeled in the back with the name of the
authors and figure number (Arabic) and the top should be indicated. Legend to
the figures should be typed on separate sheet.
• Summary
An abstract not longer than 150 words should accompany all articles. It must
include the main points that present the core of the article and the exposition of
the problem, method, results, and conclusions.
• References
These should be numbered serially as they appear in the text. The number
should be enclosed in parenthesis on the line or writing and not as superscript,
numbers. At the end of the article references should be listed in the numerical
order in which they are first cited in the text. The titles of journals should be
abbreviated according to the style used in the "Cumulative Index Medicus"
published by the American Medical Association. The correct forms of
references are as given below:
1. For periodicals: Surname and initials of author(s), title of article, name of
journal, year, volume, pages. For example: Villavicencio R.: Soplos inocentes
en pediatría. Bol Asoc Med P Rico 198 1; 73: 479 87. If there are more than 7
authors list only 3 and add et al.
2. For books when the authors of the cited chapter is at the same time the
editor: Surname and initials of author(s), title, edition, city, publishing house,
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Introducing the ﬁrst new molecule in analgesia in over 25 years for the relief
of moderate to severe acute pain in patients 18 years of age or older
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S pneumoniae: eradicated in - Asociacion Medica de Puerto Rico

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