ABNORMAL LUNG CANCER SCREENING RESULTS

Will it motivate smokers to cease the habit?

Smokers who have more than one abnormal lung cancer screening may be more likely to quit than those who have normal ones.

Beginning in January 1999, researchers at the Mayo Clinic in Rochester, Minnesota, enrolled 926 current smokers and 594 former ones (N = 1,520) in a study, of whom 52% were male and 99% were white.

All of the participants were more than 50 years old, with a mean age of 59, in a range of 50 to 85 years. The subjects were people who were asymptomatic for lung cancer who either currently smoked cigarettes or formerly had (within the past 10 years), and with a longer than 20 pack-year history of the habit, for example one pack per day for 20 years, two packs per day for 10 years, and so on. People who had a history of cancer within the preceding five years (except those with nonmelanomatous skin carcinoma, cervical carcinoma in situ, and localized carcinoma of the prostate), those who were considered to be mentally incompetent or in unstable health that would prevent them from undergoing pulmonary resection (in the presence of congestive heart failure or disabling dyspnea, for example), and those who had serious illnesses and life expectancies of less than five years were excluded.

Each participant underwent a baseline, low-dose fast spiral chest computed tomographic (CT) scan and a baseline spirometric assessment and completed data sheets concerning his history of smoking (on which the date of cessation of the habit was included for former smokers). Then, for the next three years, each study subject underwent annual CT scans performed on a multislice spiral CT scanner. If an uncalcified nodule was detected, the subject was advised, whether a current or former smoker, to undergo interim follow-up in advance of the annual scan within either three or six months, depending on its size and characteristics. If an uncalcified nodule was not found, he was instructed to take the next annual examination.

Of the current smokers at baseline (n = 926), 57% had abnormal CT scan results at the baseline visit, 22% had such results at the second one, and 15% had them at the third. Among the 901 who returned for the first follow-up annual visit, 14% (129) said they abstained from smoking at that time, 22% (193 of 863) said they abstained at the second annual visit, and 24% (201 of 832) said they abstained at the third. Most significant, of the study subjects having abnormal scan results each of the three years, 41.9% said they abstained from smoking, compared with 28% of those having two abnormal results, 24.2% having one, and 19.8% having none.

Although the percentage of current smokers at baseline who said they abstained from smoking was consistent at each annual visit, of those who abstained at the first visit, 28% said they resumed the habit at the second one, and of those who said they abstained at the second one, 51% said they resumed the habit at the third.

The cost of annual CT scans of the lungs must be considered in conjunction with the possible benefit of a greater number of smokers who quit. Otherwise, health care providers should, of course, continue both to encourage abstinence in their patients who smoke and to provide education to those who request information on how to quit. -PWF

Townsend, CO, et al. Cancer 2005;103(10): 2154-62.

DONEPEZIL MAY DELAY ONSET OF ALZHEIMER DISEASE

Effect of first year of treatment in mild cognitive impairment.

There was a lower rate of progression to Alzheimer disease in the first year among patients who took the drug donepezil, rather than vitamin E or placebo, in treating mild cognitive impairment, according to a recently published study.

The participants who were enrolled in the five-year, double-blind study to receive 2,000 international units of vitamin E, a placebo, or donepezil 10 mg once daily, had been diagnosed with the amnesic subtype of mild cognitive impairment.

The vitamin E and placebo groups showed no significant difference in probable progression to Alzheimer disease during the three-year treatment period. Although there was an initial slowing of the development of symptoms among participants in the donepezil group, the number of participants in all three groups in whom symptoms progressed to Alzheimer disease did not significantly differ over the entire treatment period of three years. Additionally, during the treatment phase of the study there were no significant differences between the placebo group and the vitamin E group in the progression of mild cognitive impairment to Alzheimer disease.

The study participants who took donepezil suffered some adverse effects, including muscle cramps, gastrointestinal symptoms, and sleep disturbance. Moreover, patients and their families should be instructed that, although the drug may slow the progression to Alzheimer disease, its effectiveness in that regard was found to last only about one year. -PWF

Petersen RC, et al. N Engl J Med. 2005; 352(23):2439-41.

MEDICAL DIAGNOSIS CAN INDUCE DEPRESSIVE SYMPTOMS

Certain conditions are more likely to trigger them, and at different times.

Receiving a diagnosis of a medical condition and coping with it is difficult for most patients, yet some develop symptoms of depression after diagnosis while others don't. In a recently published study, researchers sought to determine the association between the diagnoses of seven conditions and the development of such symptoms.

To pursue the question, researchers used data from a sample obtained from the Health and Retirement Study, a national survey begun in 1992 to examine the relationship between health and retirement among enrollees during consecutive two-year intervals. The survey includes standard questions used to assess symptoms of depression according to the respondents' reported levels of energy, happiness, and sadness.

Data concerning more than 8,387 of the 12,652 patients represented in the survey were used in the analysis, the eligibility criteria for the final sample of subjects being an age of 51 to 61 years and an absence of significant depressive symptoms at the outset of the study. The seven medical conditions that are included in the survey were included in the analysis--cancer (excepting minor skin cancer), hypertension, cronic lung disease (including bronchitis and emphysema but not asthma), diabetes, stroke, arthritis (or rheumatism), and heart disease (including heart attack, coronary heart disease, angina, and congestive heart failure). The survey enrollees incorporated into the analysis sample had been followed from 1992 until 2000, until the first reported episode of depression, the enrollee's death, or loss to follow-up. At the end of each two-year interval, the subjects had been interviewed and asked for an evaluation of their health, including any new medical diagnoses received during the preceding period.

During the follow-up period at least one of the seven medical conditions had been diagnosed among half of the sample subjects, and 16% of the sample subjects manifested significant depressive symptoms. A diagnosis of cancer was found to be three times more likely to induce depressive symptoms in the subsequent two years than was no such diagnosis; a significant association between a diagnosis of lung disease and depressive symptoms during that period was also identified. Patients diagnosed with arthritis were more likely to develop depressive symptoms, but the onset occurred two to four years later. After a diagnosis of heart disease, patients were at higher risk for the development of depressive symptoms for a longer period of time, even through the last interval ending a full eight years later. A diagnosis of stroke, hypertension, or diabetes was not found to be significantly associated with depressive symptoms during the study period.

The researchers maintain that screening patients who are at high risk for depression for its symptoms could help to prevent symptom progression and facilitate early treatment. -AK

Polsky D, et al. Arch Intern Med (2005);165(11):1260-6.

ANTIPSYCHOTIC MEDICATION

Is it being misused?

Since the 1990s, a class of prescription medications known as the "atypical" or "second-generation" antipsychotics has become widely used in the treatment of certain psychiatric conditions, including dementia, schizophrenia, and delusional disorder. They have been shown to cause fewer extrapyramidal adverse effects than do "typical" or "conventional" antipsychotic medications, and are less likely to be associated with tardive dyskinesia-a neurologic syndrome characterized by repetitive, involuntary movements such as grimacing, tongue protrusion, rapid blinking, and smacking of lips.

In 1987 the Federal Nursing Home Reform Act was passed as part of the Omnibus Budget Reconciliation Act, creating a set of standards for the care provided to nursing home residents, including prescription guidelines pertaining to antipsychotics. Although the guidelines are updated regularly, there has been little current information on whether they are being observed in common daily practice.

A recently published study reveals that more than a quarter of the 2.5 million Medicare beneficiaries residing in nursing homes (27.6%) received antipsychotics in 2000 and 2001, a significant increase from 12.2% in 1998. However, prescription practices were not always in compliance with recommended guidelines-more than half of the residents who were taking antipsychotics received doses that exceeded the maximal recommended ones (more common with conventional than with atypical antipsychotics); were administered more than one such medication for the same condition; or received the medication for conditions for which antipsychotics are not indicated, including memory problems, unaggressive behavioral problems, and depression without psychotic features.

In another study, researchers discovered that among 5,275 patients hospitalized with mental illness between April and June of 2003, 4,961 had received antipsychotics, most commonly atypical ones. It also was discovered that while the use of some antipsychotics had decreased (particularly, conventional ones), the use of others, particularly olanzapine (Zyprexa) and quetiapine (Seroquel), both atypical, had increased greatly-about 73% of the patients were receiving olanzapine (in comparison with 49.5% in 1997), and nearly 56% were receiving quetiapine (compared with 10% in 1997), both in excessive doses. In addition, the researchers pointed out that, because an estimated third of hospitalized psychiatric patients commonly receive more than one antipsychotic medication (without compensatory dosing adjustment), there may be more patients receiving unnecessarily high doses of antipsychotics than the consideration of the use of antipsychotic monotherapy in that population would seem to indicate.

Much regarding the effect of antipsychotic medications on the quality of life remains unknown. Researchers in another study conducted a literature review of studies that investigated the relationship between treatment with antipsychotics and the quality of life among patients with dementia. They found that while atypical medications are preferable to conventional ones in this population, they still must be administered with great caution because their efficacy tends to be modest while their adverse side effects often are considerable.

Last, a group of researchers recently conducted a survey among 48 experts (geriatric psychiatrists and family physicians) on the use of antipsychotics in adults 65 years of age and older. After analyzing the responses, the researchers accordingly compiled prescription guidelines pertaining to the medications; determined which conditions are unlikely to respond to treatment with them (panic disorder, generalized anxiety disorder, nonpsychotic major depression, hypochondriasis, neuropathic pain, severe nausea, motion sickness, irritability, hostility, and sleep disturbance in the absence of a major psychiatric syndrome); outlined appropriate indications for their use; and formulated recommendations concerning the choice of antipsychotic for different conditions. A detailed copy of these guidelines can be found at http://www.psychiatrist.com/supplenet/v65s02/index.htm. -DS

Alexopoulos GS, et al. J Clin Psychiatry 2004;65(Suppl 2):5-20; Ballard CG, Margallo-Lana ML. J Clin Psychiatry 2004;6(Suppl 11):23-8; Briesacher BA, et al. Arch Intern Med 2005;165(11):1280-5; Citrome L, et al. J Clin Psychopharmacol 2005;25(4):388-91.