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Insights - Cleveland Clinic

Buprenorphine

revolutionizes treatment for

opiate dependence

Also in This issue

evaluating patients for bariatric surgery

depression and epilepsy surgery

Anxiety and heart disease

Biofeedback for heart failure and insomnia

Bipolar disorder during pregnancy

Insights

A P U B l I C A T I o n o F T h e d e P A r T M e n T

oF PSyChIATry And PSyCholoGy

2008


in This issue

AddicTion

2 Buprenorphine revolutionizes Treatment for opiate dependence

BAriATrics

4 Presurgical evaluation for Bariatric Patients:

Balancing Science and Clinical Judgment

epilepsy

6 Memory decline Following Temporal lobe resection for Intractable epilepsy:

The role of Presurgical depression

heArT

8 Anxiety and heart disease

10 Biofeedback-Assisted Stress Management in the Treatment of heart Failure

sleep

12 Biofeedback: A Useful Tool for Psychophysiological Insomnia

Women’s heAlTh

13 Bipolar disorder during Pregnancy:

risk of recurrence

Also inside

14 Staff directory

19 Publications

22 Presentations

24 Current Clinical Trials

24 Upcoming Symposia


dEar CollEagUEs

George e. Tesar, md

Chairman

ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008

This issue of Insights features a sampling of clinical work and research performed by members

of the department of psychiatry and psychology within cleveland clinic’s neurological institute.

Their important work is a reflection of the growth of the department since joining the institute.

Those of you following our progress will recognize the increase in department membership. some

of this represents basic service consolidation. it also reflects an institution-wide recognition that

psychiatry is a key player on the general healthcare team.

Department members serving in the Bariatric and Metabolic Institute (Dr. Leslie Heinberg),

Epilepsy Center (Dr. Robyn Busch), Heart and Vascular Institute (Drs. Michael McKee, Christine

Moravec, Leo Pozuelo and Jianping Zhang), and Sleep Disorders Center (Dr. Kumar Budur)

provide excellent examples of our interdisciplinary teamwork.

Dr. Gregory Collins updates us on the important role of the partial opioid receptor agonistantagonist,

buprenorphine, which has significantly advanced the care of patients with chemical

dependency. The strong reputation of the Center for Drug and Alcohol Rehabilitation is

a distinctive feature of our department. It is one of several centers in the department that

provides primary psychiatric care to patients with mood disorders, chronic pain, chemical

dependency and psychiatric disorders of childhood and adolescence.

Recently recruited, Dr. Adele Viguera, known internationally for her clinical and investigative

work on perinatal management of bipolar disorder, shares an important example of her ongoing

work in this important area.

Finally, the summary of publications and presentations represents the department’s

continuing commitment to scholarship and academic advancement.

Thank you for taking the time to read this issue of Insights. We hope it provides you valuable

information not only about us, but also about progress in psychiatry and the behavioral

sciences.

Best wishes,

George E. Tesar, MD

Chairman

Department of Psychiatry and Psychology of the

Cleveland Clinic Neurological Institute


Gregory B. collins, md

Buprenorphine revolutionizes treatment for opiate dependence

Also of alarming importance is that prescription opiates

are being abused by children, teenagers and the

elderly.

According to the Ohio Department of Alcohol and

Drug Addiction Services, young abusers of oxycodone

have begun abusing heroin after they

can no longer obtain or afford oxycodone. Since

there is an increase in opiate addiction, including

heroin, it can be anticipated that the number of

people requiring detoxification and treatment will

increase as well. The Ohio Department of Alcohol

and Drug Addiction Services data indicate the number

of admissions for heroin abuse increased overall

about 8 percent from 2002 to 2003. 2

The introduction of buprenorphine

Fortunately, office-based opioid treatment with

buprenorphine has revolutionized treatment for

opiate-dependent patients. 3 The Drug Addiction

Treatment Act of 2000 and recent legislation have

allowed physicians who are registered for buprenorphine

to treat dependent patients with this medication

on an outpatient basis. These changes in the law

expanded access to treatment for opiate-dependent

patients and allow for treatment options to be tailored

to patients on an individual, confidential basis. 4

Treatment with buprenorphine results in higher treatment

retention rates, as a 12-month retention rate of

75 percent with concurrent psychological treatment

has shown. 5 Additionally, studies have shown a 35

percent to 67 percent decrease in opiate-positive urine

tests while on buprenorphine therapy. 3,6

The shortcomings of methadone

AddicTion

By gregory B. Collins, md, and Byron C. leak, md

The non-medical use of opiates has increased dramatically over the past few years. prescription opiates are now

the second most abused drugs in this country, behind marijuana. According to a 2005 report, there were 13.7

million users who indicated non-medical use of oxycodone in 2003. 1

Since the mid-20th century, methadone was the only

legal pharmaceutical opiate for treatment of opiate

addiction. Methadone continues to be the traditional

medication used at many treatment facilities.

Maintenance therapy supplied by methadone clinics

was instituted to relieve opiate addiction and with-

drawal, as well as to prevent drug-related criminal

activity.

However, several problems exist with methadone

therapy for opioid addiction. Methadone maintenance

generally requires a high daily dose for the prevention

of withdrawal symptoms. On average, patients require

60 mg to 120 mg per day of methadone, according to

the CDC Department of Health and Human Services.

Unfortunately, these high doses and the growing use

of methadone for pain management have resulted in

an FDA advisory released in November 2006 indicating

an increasing number of deaths from methadone.

These deaths often were due to cardiopulmonary

events such as prolonged QT syndrome, accidental

overdose and respiratory depression, and often occur

within the first 48 to 72 hours of therapy.

Other problems are the long waiting lists to enter into

methadone clinics, poor geographic access to clinics

and the length of treatment on methadone. A study in

2002 indicated that the average wait time for methadone

treatment was 10.6 weeks. 7

Currently, there are only 13 methadone clinics in Ohio.

Four other states have no certified methadone clinics

at all. Furthermore, there is a continuing problem with

diversion of methadone by patients at methadone clinics.

Patients have been known to buy and sell methadone

and other drugs to patients at or near methadone

clinics. The relative non-availability of psychiatric

services at these clinics likely contributes to their marginal

success.

Buprenorphine’s success

Buprenorphine has moved treatment from a daily

visit to a methadone clinic to a monthly visit to a

doctor’s office, with greater convenience and efficacy.

Buprenorphine, a partial agonist-antagonist, is a far

safer drug than methadone, a full agonist. It is virtually

impossible to overdose and die from a dose of

buprenorphine.

2 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008


In 2005, Cleveland Clinic’s Alcohol and Drug Recovery

Center (ADRC) adopted the use of buprenorphine

for opiate detox and maintenance. Several hundred

patients have been treated with the drug through the

ADRC. Most patients are slowly tapered down and off

the drug as outpatients and, after an initial induction

and intensive initial period of therapy, usually are

seen monthly. Patient satisfaction has been extremely

high with buprenorphine treatment. Many patients,

even with long-term opiate dependence, now are free

of illicit opiates, are living normal lives, and regard

buprenorphine as a miracle drug. Relapses have been

rare, as long as patients use the drug as prescribed

and continue to take it.

The ADRC uses buprenorphine in the form of Subutex

in the inpatient setting for treatment of opiate-dependent

patients and Suboxone only in the outpatient setting.

Methadone is used for opiate detoxification and

withdrawals in the inpatient setting only. The treating

physician makes the decision to place patients on

buprenorphine therapy or methadone therapy on an

individual basis. Patients are screened for buprenorphine

outpatient therapy on several factors, including

compliance, incorporation of self-help meetings, comorbid

disorders and federal guidelines for prescribing

buprenorphine. The figure shows patients treated

at Cleveland Clinic’s ADRC from 2006 to 2007 and

those placed on buprenorphine therapy.

In spite of the dramatic improvements in outcomes

from buprenorphine for opiate-dependent patients,

its use needs to be more widely adopted. The resis-

Total Admissions for opiate dependence

and resulting Buprenophine Therapy

250

200

150

100

50

0

Admissions

2006-2007

221

81

Buprenorphine

AddicTion

tance of treatment facilities and detoxification

centers to use buprenorphine for detoxification and

maintenance may be multifactorial, including rigid

adherence to a drug-free philosophy, too few physicians

registered for buprenorphine prescribing, the

cost of buprenorphine and the lack of treatment staff

and experience with buprenorphine. Buprenorphine,

nonetheless, is proving to be revolutionary by improving

treatment compliance and outcomes in opiatedependent

patients.

Gregory B. Collins, MD, is head of Cleveland Clinic’s

Alcohol and Drug Recovery Center. His specialty interests

include drug and alcohol rehabilitation, sports psychiatry

and executive counseling. He can be contacted at

216.444.2970 or colling@ccf.org.

Byron C. Leak, MD, is a research associate with

Cleveland Clinic’s Alcohol and Drug Recovery Center.

REFERENCES

1. National Survey on Drug Use and Health report,

2005. Available at: www.oas.samhsa.gov/2k4/

oxycodoneH/oxycodoneH.htm.

2. Ohio Department of Alcohol and Addiction Services

statistics. 2002-2003. Available at: www.usdoj.gov/

dea/pubs/states/ohio2004.html.

3. Moore B, et al. Primary care office-based buprenorphine

treatment: Comparison of heroin and

prescription opioid dependent patients. J Gen Intern

Med. 2007;22(4):527-530.

4. Fiellin DA, O’Connor, PG. Office-based treatment of

opioid dependent patients. NEJM. 2002;347(11):

817-823.

5. Kakko J, Svanborg KD, Kreek MJ, et al. One-year

retention and social function after buprenorphineassisted

relapse prevention treatment for heroin

dependence in Sweden: a randomized, placebocontrolled

trial. Lancet. 2003;361(9358):662-668.

6. Fudala PJ, Bridge TP, Herbert SA, et al. Office-based

treatment of opiate addiction with a sublingualtablet

formation of buprenorphine and naloxone.

NEJM. 2003;349(10):949-958.

7. Luty J. Geographical variations in substance misuse

services waiting times and methadone treatment of

opiate dependence in England and Wales. Psychiatr

Bull. 2002;26:447-448.

ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 3


leslie J. heinberg, phd

presurgical Evaluation for Bariatric patients:

Balancing science and Clinical Judgment

By leslie J. heinberg, phd

BAriATrics

Bariatric surgery is the most effective treatment for obesity. 1 unlike standard diets that focus on altering energy

balance, the permanent physiological changes that result from bariatric procedures yield significant weightloss

maintenance and remission of most, if not all, of obesity-related co-morbidities. 1

Although highly effective, bariatric surgery carries

significant risk and requires permanent lifestyle

change. Patients will need to adhere to a strict diet,

daily supplements, regular exercise and frequent

follow-ups in order to be successful. Determining the

appropriateness of candidates requires a balance of

empirically based decision-making and the “art” of

clinical judgment.

For example, adherence must occur in a population

that is at high risk for psychiatric co-morbidity.

Seventy percent of bariatric patients have a concurrent

Axis I disorder and 20 percent meet criteria for

Axis II pathology. 2 It is somewhat unclear whether the

co-morbidity is causal in the development of the morbid

obesity or whether it is secondary to, exacerbated

by or maintained by stigma, isolation and societal

prejudice.

Individuals interested in bariatric surgery often are

surprised to learn that almost all insurers require a

pre-surgical behavioral evaluation. For many, this is

their first-ever visit with a mental health professional

and they are understandably nervous. Conversely,

those with a long history of psychiatric care may have

concern that this history will disqualify them. Rather

than a “pass/fail test,” or a rubber stamp, our evaluation

focuses on eight domains (see table) that were

selected by Cleveland Clinic’s psychological team.

Our selection is based upon a thorough review of the

existing literature on psychosocial predictors of outcome,

as well as our many years of clinical expertise.

Each domain is graded on a five-point scale ranging

from poor to excellent. A summary assessment of

poor, guarded, fair, good or excellent is given at the

conclusion of the assessment. Many patients in lower

categories are given specific recommendations that

will improve their candidacy.

For example, about one-third of bariatric surgery

candidates (more in a tertiary care center like

Cleveland Clinic) meet criteria for binge eating dis-

8 doMAInS oF ASSeSSMenT

1. Capacity to consent

2. realistic nature

of expectations

3. Mental health

4. eating behaviors/disorders

5. Alcohol/substance use,

abuse, dependence

6. Social support

7. Adherence

8. Coping and stressors

order. 2 Although not a clear contra-indication for

surgery, patients with binge eating may not lose as

much weight and are at higher risk for weight regain.

Cleveland Clinic’s Bariatric Surgery Behavioral Health

Service offers a four-session binge eating group that

helps prepare such patients for surgery. Other behavioral

health groups we offer focus on reducing alcohol/

substance relapse risk and improving expectations

and behavioral adherence prior to and after surgery.

The use of a “grading” system and assessment across

many domains is essential in multi-disciplinary

assessments. Individuals considered poor (e.g., acute

psychosis, inpatient hospitalization or attempted

suicide within the last 12 months) generally are not

surgical candidates. Individuals who are fair, good

or excellent generally are considered surgical can-

4 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology


didates, although they may receive recommendations

from our team that are designed to improve

outcome. Most complicated are those patients who

are guarded. These individuals typically have both

significant psychological and medical risk factors.

Severe, life-threatening medical co-morbidities may

necessitate surgery despite significant psychological

risk. Conversely, significant psychological risk in the

absence of significant medical co-morbidities may be

rejected by the surgical team.

An interdisciplinary team effort combined with objective

ratings and sound clinical judgment has been

effective at Cleveland Clinic in balancing the medical

and psychological risks of patients who present for

bariatric surgery.

Leslie J. Heinberg, PhD, is a clinical psychologist and

Director of Behavioral Services for Cleveland Clinic’s

Bariatric and Metabolic Institute. She is also an

Associate Professor in the Cleveland Clinic Lerner

College of Medicine of Case Western Reserve University.

Her clinical and research interests are obesity, body

image and eating disorders. She can be contacted at

216.445.1986 or heinbel@ccf.org.

REFERENCES

1. Brethauer S, Chand B, Schauer PR. Risks and

benefits of bariatric surgery: current evidence.

Cleve Clin J Med. 2006;73:993-1007.

2. Kalarchian MA, Marcus MD. Bariatric surgery and

psychopathology. In: Mitchell JE and de Zwaan M

(Eds.). Bariatric Surgery: A Guide for Mental Health

Professionals. Routledge: New York, NY. 2005; 59-76.

BAriATrics

hoW BArIATrIC SUrGery WorKS

laparoscopic adjustable gastric

banding (illustrated above left) is

a restrictive procedure in which a

silicone band with an inflatable

inner collar is placed around the

upper stomach. the band is

connected to a port that is placed

in the subcutaneous tissue of the

abdominal wall. the inner diameter

of the band can be adjusted

according to weight loss by injecting

saline through the port.

this surgery is performed laparoscopically,

offering less surgical

trauma in the wound and to the

viscera, improved postoperative

pulmonary function and decreased

incidence of wound-related

complications. the procedure is

reversible and, if patients fail to

lose adequate weight, it can be

converted to a roux-en-y gastric

bypass.

roux-en-y gastric bypass (depicted

below left) is the most common

bariatric procedure performed in

the United states. It combines a

restrictive and a malabsorptive

procedure. a small (15-30 cc)

gastric pouch is created to restrict

food intake and a roux-en-y

gastrojejunostomy provides the mild

malabsorptive component.

at Cleveland Clinic, more than

95 percent of roux-en-y gastric

bypass procedures are performed

laparoscopically. this procedure

results in excellent long-term

weight reduction and resolution or

elimination of comorbidities.

ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 5


obyn m. Busch, phd

memory decline following temporal lobe resection for

Intractable Epilepsy: the role of presurgical depression

By robyn m. Busch, phd

epilepsy

depressive disorders are the most frequently observed psychiatric disturbances in patients with epilepsy. rates

of depression among patients with intractable epilepsy range from 20 percent to 55 percent, approximately 5

to 10 times greater than rates in the general population. 1-3

There is also a high prevalence of cognitive problems

in individuals with epilepsy. Several studies have

found that patients with temporal lobe epilepsy (TLE)

who report greater depressive symptoms demonstrate

reduced memory scores as compared with

patients who have fewer depressive symptoms,

particularly if seizures arise from the left temporal

lobe. This relationship also appears to hold after

anterior temporal lobe resection such that patients

with left TLE and emotional disturbance following

surgery demonstrate lower memory scores than

nondepressed left TLE patients and right TLE

patients. 4 However, no study had examined presurgical

depressed mood state as a moderator of change in

memory functioning following surgical intervention

for the treatment of medically intractable epilepsy.

This is an important issue given that presurgical

indicators can help to identify patients who are at risk

for memory decline following epilepsy surgery.

We recently completed a retrospective study to

evaluate mood state as a moderator of change in

memory abilities following temporal lobe resection

for the treatment of intractable epilepsy.* We found

that patients who underwent left temporal lobe

resections and who had depressed mood prior to

surgery demonstrated the largest declines on

measures of general and verbal memory after surgery

compared with left or right temporal lobectomy

patients without depression and right temporal lobectomy

patients with depression. The change in general

memory is depicted in the chart. These differences

could not be attributed to an increase in depressive

symptoms or to poorer seizure outcome after surgery.

These results suggest that depressed mood should be

taken into account when evaluating and providing

feedback to patients about the cognitive risks

associated with temporal lobectomy.

*This research was conducted in collaboration with Mario F. Dulay,

PhD, Kevin H. Kim, PhD, Jessica S. Chapin, PhD, Colleen Kalman,

BA, Richard I. Naugle, PhD, and Imad M. Najm, MD.

Robyn M. Busch, PhD, is a neuropsychologist with joint

appointments in Cleveland Clinic’s Epilepsy Center and

the Department of Psychiatry and Psychology. Fifty

percent of her time is devoted to research regarding

cognition and behavior in surgical epilepsy patients. The

remainder of Dr. Busch’s time is spent providing clinical

services to adults, primarily patients with epilepsy. She

can be contacted at 216.444.9042 or buschr@ccf.org.

REFERENCES

1. Hermann B, Seidenberg M, Bell B. Psychiatric

comorbidity in chronic epilepsy: identification,

consequences, and treatment of major depression.

Epilepsia. 2000;41:S31-S41.

2. Jacoby A, Baker GA, Steen N, et al. The clinical

course of epilepsy and its psychosocial correlates:

findings from a U.K. community study. Epilepsia.

1996;37:148-161.

3. Gilliam F, Kanner AM. Treatment of depressive

disorders in epilepsy patients. Epilepsy Behav.

2002;3:S2-S9.

4. Dulay MF, York MK, Soety EM et al. Memory,

emotional and vocational impairments before and

after anterior temporal lobectomy for complex

partial seizures. Epilepsia. 2006;47:1922-1930.

6 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology


Standard Score

95

90

85

80

75

GenerAl MeMory SCore

epilepsy

left Temporal lobectomy right Temporal lobectomy

Pre-Surgery Post Surgery Pre-Surgery Post Surgery

n non-depressed n depressed

Temporal lobe resection at a Glance: The coronal FlAir image (left) demonstrates prominent abnormal hyperintensity in the right hippocampal forma-

tion and mild volume loss typical of mesial temporal sclerosis. postoperatively (right), the anterior temporal lobe, amygdala and head and body of the

hippocampal formation have been resected in entirety.

Change in General Memory Score following

right temporal resection (right) and left

temporal resection (left) as a function of

depression group. For right temporal resection,

depressed mood is not associated with

memory performance as depressed and

non-depressed patients perform similarly

before and after surgery. For left temporal

resection, depressed patients perform more

poorly than non-depressed patients prior

to surgery, and memory scores decline for

depressed patients after surgery.

ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 7


leo pozuelo, md, FAcp

heArT

anxiety and heart disease

By leo pozuelo, md, faCp, and Jianping Zhang, md, phd

much attention has been paid to the connection between depression and coronary heart disease, both in the

research community and in the general population. depression is linked to increased risks of developing coronary

heart disease (chd) among initially healthy people, as well as conferring increased morbidity and mortality

in cardiac patients who subsequently get depressed.

In one of our prospective cohort studies, we found

that increasing depressive symptoms over time in an

elderly sample were associated with a 57 percent higher

risk of mortality. Compared with people who were

stable, those with increased depressive symptoms

died almost four years earlier. 1

In contrast, anxiety — another prevalent condition

in the population — has been less studied regarding

its relationship with heart disease. The prevalence of

anxiety disorders in the population is about 15 percent

to 20 percent. Anxiety can present in many different

forms. There are several clinical subtypes of anxiety

disorders, including panic disorder, social anxiety

disorder, generalized anxiety disorder, simple phobia,

obsessive-compulsive disorder and post-traumatic

stress disorder. Anxiety may be a normal reaction to

a stressful situation. From the evolutionary perspective,

anxiety is a built-in alarm system to respond to

potential dangers in the environment, which has benefited

the human species for thousands of years. The

“fight or flight” response, coupled with activation of

the sympathetic nervous system and hypothalamuspituitary-adrenal

system, allows an individual to get

ready for the potential threat.

However, in modern society, anxiety and the ancient

“fight or flight” response may be more maladaptive

and likely to be a “false alarm,” because in many

situations an individual needs a calm and rational

approach to cope with stress. Therefore, people with

chronically elevated anxiety, or an extremely high

level of anxiety, may over-drive their physiological system,

and put themselves at risk of developing health

problems. In fact, research has shown that anxiety

can lead to decreased vagal tone (i.e., heart rate variability),

increased blood cortisol levels and elevated

resting blood pressure and heart rate, all of which can

increase the risk of developing heart disease.

Several longitudinal studies have shown that anxiety

can be predictive of new onset of CHD. In the

Normative Aging Study, a large prospective study conducted

in the Boston area, higher levels of worry (an

important component of anxiety) were predictive of

increased risks of both myocardial infarction (MI) and

fatal CHD in male subjects at 20-year follow-up. 2 Men

reporting highest levels of worry had adjusted relative

risks of MI more than doubled (RR = 2.41) compared

with those with lowest levels of worry. Despite these

findings, we still tend to tell our patients (perhaps

erroneously) that panic attacks won’t kill them, to not

worry, “your heart is fine.” This especially plays out

in the emergency room, where the chest pain patient

is ruled out for myocardial damage, and panic and

anxiety is strongly suspected as the culprit of the chest

pain symptoms.

A very recent study supported the notion that panic

attacks may be an independent risk factor for cardiovascular

morbidity and mortality. In the Women’s

Health Initiative Study, a six-month history of fullblown

panic attacks was associated with three- to

four-fold increase in risks of CHD or stroke. 3

Anxiety also is relevant in clinical care for patients

with heart disease. Up to 10 percent of patients after

MI suffer from post-traumatic stress disorder, which

further interferes with treatment compliance and

leads to poor outcomes. 4 Many patients also have

high anxiety in anticipation of coronary artery bypass

grafting surgery (CABG). A recent study showed that

pre-operative anxiety was associated with higher post-

CABG mortality, whereas pre-operative depression

was not. 5 However, research in this area is still in its

early stages, and the relationship between anxiety and

CHD as well as mortality may be more complicated

than we expected.

Recently, we found in a prospective cohort study that

there were interesting gender differences in linking

anxiety to long-term mortality in a group of community-dwelling

elderly. 6 These results were presented

at the 2008 American Psychosomatic Society annual

8 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology


meeting in Baltimore. Increasing anxiety symptoms

over time were associated with a 42 percent higher

risk of all-cause mortality at the 15-year follow-up in

men, but not in women. In contrast, higher anxiety

levels at baseline were actually associated with lower

mortality in women, but not in men. A potential

explanation is that men and women deal with anxiety

differently, and that moderately higher anxiety in

women may motivate them to seek more healthcare,

which may result in early diagnosis and intervention

for certain illnesses, which, in turn, leads to lower

mortality. More research is needed to replicate the

finding and elucidate the potential mechanisms.

The relationship of depression, well established, and

now anxiety seems to be an important factor in the

management of cardiac patients. We need to screen

for these disorders more effectively, continue to study

the links that tie anxiety to cardiac disease, and develop

effective treatment strategies that can improve the

quality of life of the anxious and depressed cardiac

patient, as well as improve outcomes.

Leo Pozuelo, MD, FACP, is head of Cleveland Clinic’s

Consultation-Liaison Psychiatry Program. His specialty

interests include consultation-liaison psychiatry, primary

care psychiatry and medical student education. He

can be contacted at 216.445.3583 or pozuell@ccf.org.

Jianping Zhang, MD, PhD, is a resident with Cleveland

Clinic’s Department of Psychiatry and Psychology.

REFERENCES

1. Zhang J, Kahana B, Kahana E, Hu B, Pozuelo L.

Changes in depressive symptoms, not baseline

depression, predicted mortality in a sample of

community-dwelling elderly people. Paper

submitted for publication.

2. Kubzansky LD, Kawachi I, Spiro A, 3rd, Weiss ST,

Vokonas PS, Sparrow D. Is worrying bad for your

heart? A prospective study of worry and coronary

heart disease in the Normative Aging Study.

Circulation. February 18, 1997;95(4):818-824.

Cum Survival

1.0

0.8

0.6

0.4

0.2

0.0

heArT

Survival Function for different

Changes in Anxiety Scores

0.00 50.00 100.00 150.00 200.00

# Months from Time 1 to death

Adjusted survival curves in men, stratified on change pattern in anxiety

scores over time.

3. Smoller JW, Pollack MH, Wassertheil-Smoller S, et

al. Panic attacks and risk of incident cardiovascular

events among postmenopausal women in the

Women’s Health Initiative Observational Study.

Arch Gen Psychiatry. October 2007;64(10):1153-1160.

4. Wiedemar L, Schmid JP, Muller J, et al. Prevalence

and predictors of posttraumatic stress disorder in

patients with acute myocardial infarction. Heart

Lung. 2008;37(2):113-121.

5. Szekely A, Balog P, Benko E, et al. Anxiety predicts

mortality and morbidity after coronary artery and

valve surgery — a 4-year follow-up study. Psychosom

Med. 2007;69(7):625-631.

6. Zhang J, Kahana B, Kahana E, Hu B, Pozuelo L.

Gender difference prominent in linking anxiety to

long-term mortality among elderly. Paper presented

at: Annual Meeting of the American Psychosomatic

Society; March 2008; Baltimore, MD.

hazard ratio=1.00

Median Survival in Months

n Stable group = 145.6

n down group = 95.1

n Up group = 76.3

hazard ratio=1.54 (p


michael G. mcKee, phd

christine s. moravec, phd

heArT

Biofeedback-assisted stress management in the

treatment of heart failure

by michael g. mcKee, phd, and Christine s. moravec, phd

over the past 10 years, a wealth of studies has established that psychological stress, whether acute or chronic,

is an important risk factor for cardiovascular disease. studies estimate that psychological stress confers a risk

for the development or worsening of cardiovascular disease that is equal to the risk rendered by hypertension

or smoking.

The physiological link between mental stress and cardiovascular

disease still needs to be fully elucidated,

but evidence favors a role of the sympathetic nervous

system in increasing cardiovascular reactivity,

enhancing platelet activation and contributing to the

development of both atherosclerotic plaque and lifethreatening

arrhythmias.

Patients diagnosed with heart failure face a multitude

of uncertainties leading to mental stress. Incomplete

understanding of what the diagnosis means; concern

about rapidly evolving limitations in daily living; coping

with new medications and their potential side

effects; and accepting the very real possibility of needing

a pacemaker, a mechanical assist device or even

a transplant all contribute to chronic psychological

stress.

In heart failure patients, however, this psychological

stress and its biological consequences compound the

effects of an already over-active sympathetic nervous

system. In an unfortunate synergy, decreased cardiac

function activates the sympathetic nervous system in

a compensatory attempt to increase cardiac pumping

and end-organ perfusion, while mental stress elicits

the age-old “fight-or-flight” response, which served

our ancestors well in escaping physical stressors, but

is of little use in combating mental stress. The sympathetic

nervous system, activated in two ways, pumps

out catecholamines and activates adrenergic receptors

throughout the body. The end result is a worsening

of the disease process and extreme energy depletion

in the myocardium. Beta-blocking drugs, which

have only emerged as a treatment for heart failure in

the past few decades, counteract these deleterious

effects and improve symptoms.

In the population of patients with heart failure,

biofeedback-assisted stress management can serve as

a “physiologic beta blocker,” decreasing sympathetic

activation and also giving the patient a greater sense

of control over his or her physiology. Biofeedbackassisted

stress management involves a coupling

between routine techniques of stress management

(cognitive behavioral therapy, progressive muscle

relaxation, slow breathing, imagery) and physiological

measurements that allow the patient to actually see

the relationship between his or her degree of arousal

and blood pressure, heart rate, skin temperature or

muscle tension.

Patients are taught to recognize and understand the

relationship between their psychological stress level,

their ability to relax and the resulting changes in their

physiological measurements. Many patients learn for

the first time that their thought patterns can impact

their body. The feedback provided guides patients in

learning mastery of their own physiology. Over a series

example of a patient biofeedback screen. The therapist explains that the

signal coming from the patient’s trapezius muscles is displayed in green.

The goal is to get the green signal to decrease, indicating less muscle

tension. The therapist helps the patient to understand what types of

adjustments in breathing, relaxation and thinking will help to decrease

muscle tension.

10 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology


of 11 sessions, patients are taught to decrease the

activation of their sympathetic nervous system, with

resulting changes in their physiology.

One of our current studies is testing the effectiveness

of heart rate variability biofeedback in patients with a

new diagnosis of heart failure. Another of our current

studies is testing the ability of a more simple form of

biofeedback, using skin temperature and muscle tension,

in patients with end-stage heart failure awaiting

heart transplantation. In both cases, we hypothesize

that teaching the patients to decrease the activation

of their own sympathetic nervous system and to alter

the balance between sympathetic and parasympathetic

nervous systems in a favorable direction will

result in enhanced quality of life, decreased symptoms

and possibly biological changes in the markers

of heart failure progression.

These studies are funded by the American Heart

Association and the Cleveland Clinic Bakken Heart-

Brain Institute.

Michael G. McKee, PhD, is a psychologist with Cleveland

Clinic’s Department of Psychiatry and Psychology. His

specialty interests include psychotherapy, biofeedback,

stress management and life-span development issues. He

can be contacted at 216.444.5816 or mckeem@ccf.org.

Christine S. Moravec, PhD, is Associate Director

of the Bakken Heart-Brain Institute, and holds

appointments in Cleveland Clinic’s Department of

Cardiovascular Medicine and Center for Integrative

Medicine. Her specialty interests include heart failure,

left ventricular assist device support, intracellular

signaling, psychophysiology, stress and cardiovascular

disease, and autonomic nervous system activation in

heart failure. She can be contacted at 216.445.9949 or

moravec@ccf.org.

heArT

The patient uses the image on the screen to understand the relationship between what they are

thinking or feeling and the reaction of his or her body. We hypothesize that patients who have

good success with controlling their own reactivity will show clinical cardiovascular improvement.

SUGGESTED READING

Blumenthal JA, Sherwood A, Babyak MA, Watkins LL,

Waugh R, Georgiades A, Bacon SL, Hayano J, Coleman

RE, Hinderliter A. Effects of exercise and stress

management training on markers of cardiovascular

risk in patients with ischemic heart disease. JAMA.

2005;293:1626-1634.

Brotman DJ, Folden SH, Wittstein IS. The cardiovascular

toll of stress. Lancet. 2007;370:1089-1100.

Rozanski A, Blumenthal JA, Davidson KW, Saab PG,

Kubzansky L. The epidemiology, pathophysiology and

management of psychosocial risk factors in cardiac

practice: the emerging field of behavioral cardiology.

J Am Coll Cardiol. 2005;45:637-651.

ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 11


Kumar Budur, md

Biofeedback: a Useful tool for psychophysiological Insomnia

By Kumar Budur, md

sleep

everyone has occasional nights when racing thoughts and worries keep them awake, but persistent life stress

and anxiety can trigger insomnia that is disabling. psychophysiological insomnia accounts for about 15 percent

of the chronic insomnia seen at sleep disorders centers, and can be very difficult to treat. hypnotic medications,

typically the first line of treatment, have many limitations and often are ineffective.

Cleveland Clinic’s Sleep Disorders Center recently

has incorporated biofeedback therapy in its interdisciplinary

approach to this difficult problem. Novel

application of this tried-and-true technology helps

patients learn to relax — both at night and during the

day. We are one of just three centers offering this type

of approach to stress-and-anxiety-related insomnia in

the United States.

Biofeedback therapy involves the monitoring of body

functions that reflect tension and arousal (heart rate,

blood pressure, body temperature and muscle activity).

Brain activity is monitored with electroencephalogram

(EEG). All of this information is displayed

for the patient, who then is instructed on how to

perform relaxation techniques such as deep breathing,

progressive muscle relaxation and meditation.

The patient receives immediate feedback as to the

impact of relaxation on the multiple psychophysiologic

measures clearly displayed on monitors. Such a

quantitative display of progress encourages patients

to continue with the relaxation techniques, yielding

even greater results.

Patients are educated to continue these techniques

at home for maximum achievement of nighttime

restfulness. Since many are “night owls,” they also are

coached to readjust their body clocks to be less active

in the evening hours.

Although biofeedback therapy has long been used for

insomnia, research on its efficacy is limited and no

guidelines are available on patient characteristics, or

ideal number or type of sessions.

This prompted us to perform a retrospective chart

review of 30 patients with a primary diagnosis of psychophysiological

insomnia referred for biofeedbackbased

treatment. Seventy percent rated themselves

as “very much improved” or “improved” after three

sessions. They reported sleeping better without medications.

Patients with problems of somatized tension

responded best. Many also stated that relaxation

techniques helped them cope with daytime stress and

anxiety, allowing them, we believe, to overcome this

important component of the cycle of insomnia.

Kumar Budur, MD, is a psychiatrist and sleep specialist

with joint appointments in the Department of Psychiatry

and Psychology and Cleveland Clinic’s Sleep Disorders

Center. His specialty interests include insomnias, parasomnias,

circadian rhythm sleep disorders and sleep/psychiatry

disorders. He can be contacted at 216.444.0915 or

budurk@ccf.org.

12 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008

80%

70%

60%

50%

40%

30%

20%

10%

0%

Very Much Improved

Biofeedback for Insomnia:

After 3 Sessions

no Improvement


Adele c. Viguera, md, mph

Women’s heAlTh

Bipolar disorder during pregnancy: risk of recurrence

By adele C. viguera, md, mph

cleveland clinic’s center for the care and study of Women’s mental health integrates research into clinical

services. For more than a decade, this sub-specialty center has provided outpatient services including clinical

assessment, consultation and treatment for women presenting with a wide range of reproductive-associated

psychiatric syndromes. This includes premenstrual dysphoric disorder, antenatal mood disorders, postpartum

depression, and peri- and postmenopausal mood disturbance.

One area of particular research interest is bipolar

disorder and its course and management during

pregnancy and the postpartum period. In December

of 2007, colleagues and I published a landmark prospective

study in the American Journal of Psychiatry

examining the risk of recurrence among women with

a history of bipolar disorder that continued or discontinued

treatment with mood stabilizers during pregnancy.

1 We found that the overall risk of recurrence

during pregnancy was 71 percent. Women who discontinued

mood stabilizer treatment had a two-fold

greater recurrence risk and four-fold shorter time to

first recurrence compared with women who continued

mood stabilizers during pregnancy.

Additionally, the proportion of weeks ill during pregnancy

was five times greater among women who discontinued

mood stabilizer compared with women who

maintained mood stabilizer treatment. Most recurrences

were depressive or mixed states, and the majority

of episodes occurred during the first trimester.

These findings have important clinical implications

and suggest that recurrence risk can be reduced

markedly by continued mood stabilizer treatment.

Therefore, treatment planning for pregnant women

with bipolar disorder should consider not only the relative

risks of fetal exposure to mood stabilizers, but also

the high risk of recurrence and morbidity associated

with stopping maintenance mood stabilizer treatment.

Adele C Viguera, MD, MPH, is a psychiatrist with

Cleveland Clinic’s Department of Psychiatry and

Psychology. Her specialty interests are reproductive

related mood disorders including premenstrual dysphoric

disorder, perinatal mood disorders, menopause

and bipolar disorder and its course and management

during pregnancy and the postpartum period. She can

be contacted at 216.445.8245 or viguera@ccf.org.

REFERENCE

Viguera AC, Whitfield T, Baldessarini RJ, Newport

DJ, Stowe Z, Reminick A, Zurick A, Cohen LS. Risk of

recurrence in women with bipolar disorder during

pregnancy: prospective study of mood stabilizer discontinuation.

Am J Psychiatry. 2007;164(12):1817-1824.

SUGGESTED READING

Newport DJ, Stowe ZN, Viguera AC, Calamaras

MR, Juric S, Knight B, Pennell PB, Baldessarini RJ.

Lamotrigine in bipolar disorder: efficacy during pregnancy.

Bipolar Disord. 2008;10:432-436.

Viguera AC, Newport DJ, Ritchie J, Stowe ZN, Whitfield

TH, Mogielnicki J, Baldessarini RJ, Zurick A, Cohen

LS. Lithium in breastmilk and nursing infants: clinical

implications. Am J Psychiatry. 2007;164:342-345.

ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 13

Proportion Without recurrence

1.00

0.75

0.50

0.25

0.00

risk of recurrence in Pregnant Women

with Bipolar disorders Who Continued Versus

discontinued Any Mood Stabilizer

85%

Median time to recurrence > 40 weeks

(95% CI: indeterminate)

0 10 20 30 40

Weeks following Conception

n=89; Bipolar Type I and II

n Maintain (n=27) n discontinue (n=62)

37%

Median time to recurrence 9 weeks

(95% CI: 8-13 weeks)


psyChIatry aNd psyChology staff

George Tesar, md

Chairman, Department of Psychiatry

and Psychology

specialty Interests: emergency

psychiatry, anxiety and mood disorders,

consultation-liaison psychiatry,

neuropsychiatry, epilepsy psychiatry

216.445.6224 phone

216.445.0127 fax

susan Albers-Bowling, psyd

specialty Interests: depression, eating

disorders, women’s issues, weight loss,

mindful eating, relationships

330.287.4930 phone

330.264.2085 fax

Kathleen Ashton, phd

specialty Interests: weight

management, bariatric surgery

evaluation, binge eating disorder,

insomnia and sleep disorders, women’s

health, coping with chronic illness

216.444.3438 phone

216.444.8894 fax

scott Bea, psyd

specialty Interests: cognitive-behavioral

psychotherapy, treatment of anxiety disorders

including obsessive-compulsive disorder,

panic disorder and social anxiety disorder,

psychology of performance, motivational

speaking, psychocardiology

216.444.9036 phone

216.444.8894 fax

dana Brendza, psyd

specialty Interests: general outpatient

psychotherapy and personality assessment,

with special interest in health psychology (e.g.,

coping with medical illnesses, stress reduction,

headache management, coping with infertility)

and chronic depression

216.445.1319 phone

216.444.8894 fax

Karen Broer, phd

specialty Interests: general outpatient

psychotherapy, women’s issues, stress

management, lifespan developmental

issues, coping with chronic medical

illness, spiritually based interventions

216.444.0480 phone

216.444.8894 fax

Kumar Budur, md

specialty Interests: insomnias,

parasomnias, circadian rhythm sleep

disorders, sleep/psychiatry disorders

216.444.0915 phone

216.636.0090 fax

robyn Busch, phd

specialty Interests: epilepsy

neuropsychology, memory, executive

functioning, mood, genetics, prediction

of cognitive and mood outcome

following epilepsy surgery

216.444.9042 phone

216.444.4525 fax

Jessica chapin, phd

specialty Interests: neuropsychology,

adult epilepsy, memory, geriatrics

216.444.9044

216.444.9054 fax

Kathy coffman, md

specialty Interests: alcohol and drug

abuse in liver transplant patients,

delirium, immunomodulatory effects

of psychotropic drugs, CNs effects of

scleroderma and celiac disease

216.444.8832 phone

216.445.7032 fax

14 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008


psyChIatry aNd psyChology staff

Gregory collins, md

specialty Interests: drug and alcohol

rehabilitation, sports psychiatry,

executive counseling

216.444.2970 phone

216.445.3879 fax

edward covington, md

specialty Interests: chronic pain, pain

management

216.444.5964 phone

216.445.7000 fax

roman dale, md

specialty Interests: inpatient psychiatry,

mood disorders, psychopharmacology,

existential psychiatry

216.363.2473 phone

216.696.2885 fax

Beth dixon, psyd

specialty Interests: adult and older adult

clinical psychology, acute/chronic depression,

anxiety disorders, adjustment to chronic

illness and disability, stress management,

insomnia, difficult life transitions, coping with

grief and loss

440.899.5570 phone

440.899.5547 fax

Judy dodds, phd

specialty Interests: health psychology,

general adult psychology, such as

depression, anxiety disorders, stress

management, adjustment to issues of

daily living

440.878.2500 phone

440.878.3225 fax

Tatiana Falcone, md

specialty Interests: first episode psychosis,

epilepsy, the role of inflammation in schizophrenia,

research and education, child

psychiatry, consultation-liaison psychiatry

216.444.7459 phone

216.444.9054 fax

darlene Floden, phd

specialty Interests: neuropsychology,

deep brain stimulation, executive

function, neuroeconomics, parkinson’s

disease, fmrI

216.444.1298 phone

216.444.4525 fax

Kathleen Franco, md

specialty Interest: consultation-liaison

psychiatry

216.444.2671 phone

216.636.3206 fax

John p. Glazer, md

Head, Section of Child and Adolescent Psychiatry

Director, Pediatric Psychiatry Hospital

Consultation Service

specialty Interests: pediatric oncology, organ

transplantation, bioethics, delirium and intensive

care

216.445.1324 phone

216.444.9054 fax

lilian Gonsalves, md

Vice Chair for Psychiatry, Department

of Psychiatry and Psychology

specialty Interests: consultation

psychiatry, pain, women’s health

216.444.2197 phone

216.445.7032 fax

ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 15


psyChIatry aNd psyChology staff

shannon perkins, phd

specialty Interests: adult clinical

psychology including depression,

anxiety, weight management, stress

management, coping with chronic

illness and disability, and psychological

factors impacting physical health

440.878.2500 phone

440.878.3225 fax

Jennifer haut, phd

specialty Interest: neuropsychology

216.444.2454 phone

216.444.4525 fax

leslie heinberg, phd

specialty Interests: obesity, eating

disorders, body image, health

psychology

216.445.1986 phone

216.445.1586 fax

Karen Jacobs, do

specialty Interests: women’s issues,

transitional stages, add (hd), mood

and anxiety disorders, vNs, dBs

and tms

216.445.9345 phone

216.445.7032 fax

Joseph Janesz, phd, licdc

specialty Interests: chemical dependency,

executive coaching, organizational development

consulting, couples and group therapy, sports

counseling and psychotherapy

216.444.2199 phone

216.445.3879 fax

regina Josell, psyd

specialty Interests: anxiety disorders,

stress management and trauma

440.516.8691 phone

440.516.8695 fax

patricia Klaas, phd

specialty Interests: pediatric

neuropsychology, neurodevelopmental

disorders, epilepsy, head injury

216.444.2450 phone

216.444.4525 fax

steven Krause, phd, mBA

specialty Interests: management of

chronic pain and headache, coping

with chronic illness, depression and

anxiety, marital and family functioning,

organizational development

216.445.4462 phone

216.445.1696 fax

cynthia s. Kubu, phd, ABpp-cn

specialty Interests: neuropsychiatry;

neuropsychological assessment

in the neurosurgical treatment for

epilepsy, movement, psychiatric and

neurobehavioral disorders; dementia;

neuroethics

216.445.6848 phone

216.444.4525 fax

donald malone Jr., md

specialty Interests: psychopharmacology,

mood disorders anxiety

disorders, neuromodulation

216.444.5817 phone

216.445.7032 fax

16 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008


psyChIatry aNd psyChology staff

michael mcKee, phd

specialty Interests: psychotherapy,

stress management, life span

developmental problems

216.444.5816 phone

216.444.8894 fax

scott meit, psyd, mBA

specialty Interests: primary care

health psychology, executive health,

organizational development, psychooncology,

geropsychology, facial

allografts

216.444.3148 phone

216-444-8894 fax

Gene morris, phd

specialty Interests: individual therapy,

relationship couples and family therapy,

depressive disorders, trauma, anxiety disorders

330.287.4907 phone

330.264.8184 fax

david muzina, md

Director, Center for Mood Disorders

Treatment and Research

specialty Interests: neuropsychiatric illness,

depression, bipolar disorder, neuroimaging

and behavioral health, clinical research

216.444.5810 phone

216.445.7032 fax

richard naugle, phd

specialty Interests: neuropsychological

assessment, dementia, stroke, epilepsy,

language disorders, memory loss

216.444.7748 phone

216.444.4525 fax

mayur pandya, do

specialty Interests: neurobehavioral

disorders in parkinson’s disease and

other movement disorders, adult

psychiatry

216.445.5585 phone

216.636.5683 fax

michael parsons, phd

specialty Interests: memory and

memory disorders, functional brain

imaging, dementia, movement and

movement disorders

216.445.3322 phone

216.444.4525 fax

leo pozuelo, md

specialty Interests: consultation-liaison

psychiatry, heart-brain medicine,

primary care psychology, medical

student education

216.445.3583 phone

216.445.7032 fax

Kathleen Quinn, md

specialty Interests: adhd, anxiety

disorders and autistic spectrum

disorders

216.444.5950 phone

216.444.9054 fax

Ted raddell, phd

specialty Interests: trauma recovery,

mood and anxiety disorders, health

psychology, marital therapy, stress

management, parenting issues,

co-dependency

216.839.3900 phone

216.839.3910 fax

ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 17


psyChIatry aNd psyChology staff

Judith scheman, phd

Program Director, Chronic Pain

Rehabilitation Program

specialty Interest: chronic pain

rehabilitation

216.444.2875 phone

216.445.7000 fax

isabel schuermeyer, md

specialty Interest: adult psychiatry

216.444.5965 phone

216.445.7032 fax

Jean simmons, phd

specialty Interests: coping with chronic

illness, mind/body wellness, women’s

health, eating disorders, sleep disorders

and smoking cessation

440.516.8690 phone

440.516.8695 fax

Barry simon, do

specialty Interests: crisis management

and inpatient psychiatry

216.445.1954 phone

216.444.9054 fax

catherine stenroos, phd

specialty Interests: coping with chronic

illness, anxiety disorders, international

and domestic adoption issues, smoking

cessation, women’s health issues

216.986.4000 phone

216.986.4923 fax

david streem, md

specialty Interests: chemical

dependency rehabilitation, drug testing,

medical problems related to addiction,

smoking cessation

216.444.5815 phone

216.445.3879 fax

Adele Viguera, md

specialty Interests: women’s mental

health research

216.445.8245 phone

216.445.7032 fax

John Vitkus, phd

specialty Interests: anxiety, depression,

bereavement, interpersonal processes

and relationship stress, women’s

mental health, trauma recovery

440.519.6800 phone

440.519.3004 fax

cynthia White, psyd

specialty Interests: anxiety, depression,

stress-related medical problems,

coping with chronic illness, mind/body

wellness

440.899.5555 phone

440.899.5547 fax

Amy Windover, phd

specialty Interests: health psychology

including bariatric surgery evaluation,

weight management, smoking

cessation and coping with chronic

medical illness

216.444.3673 phone

216.636.1863 fax

18 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008


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Carroll BT, Goforth hW, Thomas C, Ahuja n, Mcdaniel WW, Kraus MF,

Spiegel dr, Franco Kn, Pozuelo l, Munoz C. review of adjunctive

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Coffman Kl. The debate about marijuana usage in transplant candidates:

recent medical evidence on marijuana health effects. Current Opinion

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Collins GB, McAllister MS, Ford dB. Patient-provider e-mail communication

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2007;26(2):45-52.

Collins GB, McAllister MS. Buprenorphine maintenance: a new treatment

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2007 May;25(2):539-566.

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Culbert TP, Banez GA. Integrative approaches to childhood constipation

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denelsky Gy. Stop Smoking NOW!: The Rewarding Journey to a

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Falcone T, Sidhu n. Psychiatry. In: rolston ddK, nielsen C, eds.

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2007;27(2):99-112.

Kudel I, edwards rr, Kozachik S, Block BM, Agarwal S, heinberg lJ,

haythornthwaite J, raja Sn. Predictors and consequences of multiple

persistent postmastectomy pains. J Pain Symptom Manage. 2007

dec;34(6):619-627.

lewandowski W, Morris r, draucker CB, risko J. Chronic pain and the

family: theory-driven treatment approaches. Issues Ment Health Nurs.

2007 Sep;28(9):1019-1044.

Mathews M, Muzina dJ. Atypical antipsychotics: new drugs, new challenges.

Cleve Clin J Med. 2007 Aug;74(8):597-606.

Mehta A, Franco K. Forced medications to restore adjudicative competency.

Am J Forensic Psychiatry. 2008;29(1):5-17.

Meit SS, Fitzpatrick KM, Selby JB. domestic violence, elder mistreatment,

intimate partner violence, child abuse, and sexual assault. In: rakel

re, ed. Textbook of Family Medicine. 7th ed. Philadelphia: Saunders

elsevier; 2007:47-66.

Meit SS, Borges nJ, early lA. Personality profiles of incoming male and

female medical students: results of a multi-site 9-year study. Medical

Education Online [electronic resource]. 2007;12(7):1-6.

Muzina dJ, Colangelo e, Manning JS, Calabrese Jr. differentiating bipolar

disorder from depression in primary care. Cleve Clin J Med. 2007

Feb;74(2):89-105.

Muzina dJ. Bipolar spectrum disorder: differential diagnosis and treatment.

Prim Care. 2007 Sep;34(3):521-550.

Muzina dJ, Kemp de, McIntyre rS. differentiating bipolar disorders

from major depressive disorders: treatment implications. Ann Clin

Psychiatry. 2007 oct;19(4):305-312.

Muzina dJ, Momah C, eudicone JM, Pikalov A, McQuade rd, Marcus

rn, Sanchez r, Carlson BX. Aripiprazole monotherapy in patients

with rapid-cycling bipolar I disorder: an analysis from a long-term,

double-blind, placebo-controlled study. Int J Clin Pract. 2008

May;62(5):679-687.

20 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008


2007 –2008 pUBlICatIoNs

of thE dEpartmENt of psyChIatry aNd psyChology

newport dJ, Calamaras Mr, deVane Cl, donovan J, Beach AJ, Winn S,

Knight BT, Gibson BB, Viguera AC, owens MJ, nemeroff CB, Stowe

Zn. Atypical antipsychotic administration during late pregnancy:

placental passage and obstetrical outcomes. Am J Psychiatry. 2007

Aug;164(8):1214-1220.

Pandya M, Pozuelo l, Malone d. electroconvulsive therapy: what the

internist needs to know. Cleve Clin J Med. 2007 Sep;74(9):679-685.

Pearson Kh, nonacs rM, Viguera AC, heller Vl, Petrillo lF, Brandes M,

hennen J, Cohen lS. Birth outcomes following prenatal exposure to

antidepressants. J Clin Psychiatry. 2007 Aug;68(8):1284-1289.

Pinto AM, heinberg lJ, Coughlin JW, Fava Jl, Guarda AS. The eating

disorder recovery Self-efficacy Questionnaire (edrSQ): Change

with treatment and prediction of outcome. Eat Behav. 2008

Apr;9(2):143-153.

Pozuelo l, Whinney CM, locala J. Preoperative psychiatric evaluation

and perioperative management of patients with psychiatric disorders.

In: Williams MV, ed. Comprehensive Hospital Medicine: an Evidence

Based Approach. Philadelphia, PA: Saunders elsevier; 2007:863-870.

redgrave GW, Coughlin JW, heinberg lJ, Guarda AS. First-degree relative

history of alcoholism in eating disorder inpatients: relationship to eating

and substance use psychopathology. Eat Behav. 2007 Jan;8(1):15-22.

rezai Ar, Machado AG, deogaonkar M, Azmi h, Kubu C, Boulis nM.

Surgery for movement disorders. Neurosurgery. 2008 Feb;62(Suppl

2):ShC809-ShC838 .

Schauer P, Ashton K. Addictions after bariatric surgery: examining risks

and prevention. OH Magazine. 2007 Sep-oct;(1):48.

Taban M, naugle rI, lee MS. Transient homonymous hemianopia and

positive visual phenomena in patients with nonketotic hyperglycemia.

Arch Ophthalmol. 2007 Jun;125(6):845-847.

Tesar Ge. Whither hospital and academic psychiatry? Psychiatr Clin North

Am. 2008 Mar;31(1):27-42.

Toledo-Pereyra lh, Cozzi e, Coffman K. editorial introductions. Current

Opinion in Organ Transplantation. 2008 Apr;13(2):vii-viii.

Varkula M, dale r. Acute dystonic reaction after initiating aripiprazole

monotherapy in a 20-year-old man. J Clin Psychopharmacol. 2008

Apr;28(2):245-247.

Viguera AC, Koukopoulos A, Muzina dJ, Baldessarini rJ. Teratogenicity

and anticonvulsants: lessons from neurology to psychiatry. J Clin

Psychiatry. 2007;68 Suppl 9:29-33.

Viguera AC, Whitfield T, Baldessarini rJ, newport dJ, Stowe Z, reminick

A, Zurick A, Cohen lS. risk of recurrence in women with bipolar disorder

during pregnancy: prospective study of mood stabilizer discontinuation.

Am J Psychiatry. 2007 dec;164(12):1817-1824.

Viguera AC, newport dJ, ritchie J, Stowe Z, Whitfield T, Mogielnicki

J, Baldessarini rJ, Zurick A, Cohen lS. lithium in breast milk

and nursing infants: clinical implications. Am J Psychiatry. 2007

Feb;164(2):342-345.

Vitaliano P, echeverria d, Shelkey M, Zhang J, Scanlan J. A cognitive

psychophysiological model to predict functional decline in

chronically stressed older adults. J Clin Psychol Med Settings. 2007

Sep;14(3):177-190.

Whinney CM, Pozuelo l, locala J. evaluation and management of

medical patients with psychiatric disorders. In: Williams MV, ed.

Comprehensive Hospital Medicine: an Evidence Based Approach.

Philadelphia, PA: Saunders elsevier; 2007:851-862.

Xia G, Gajwani P, Muzina dJ, Kemp de, Gao K, Ganocy SJ, Calabrese

Jr. Treatment-emergent mania in unipolar and bipolar depression:

focus on repetitive transcranial magnetic stimulation. Int J

Neuropsychopharmacol. 2008 Feb;11(1):119-130.

ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 21


2007 –2008 prEsENtatIoNs

of thE dEpartmENt of psyChIatry aNd psyChology

Ashton K, drerup M. efficacy of a four-session cognitive behavioral group

intervention for binge eating among bariatric surgery candidates.

Presented at: Society of Behavioral Medicine 2007 Annual Meeting and

Scientific Sessions; March 24, 2007; Washington, dC.

Belzile CJ, Chapin JS, haut JS, Klaas PA, Busch rM. The family pictures

subtest of the children’s memory scale: a measure of visual and verbal

memory in pediatric patients with intractable temporal lobe epilepsy.

Poster presented at: the 36th Annual International neuropsychological

Society Meeting; February, 2008; Waikoloa, hawaii.

Belzile CJ, Chapin JS, naugle rI, Busch rM. Victoria symptom

validity test performance is related to IQ scores in patients with

medically intractable epilepsy. Poster presented at: the American

neuropsychiatric Association 19th Annual Meeting; March, 2008;

Savannah, Georgia.

Belzile CJ, Klaas PA, haut JS, Busch rM, dulay MF, Wyllie e.

Postoperative behavior problems in children with temporal lobe

epilepsy. Poster presented at: the 36th Annual International

neuropsychological Society Meeting; February, 2008; Waikoloa,

hawaii.

Budur K. oxygen desaturations in sleep apnea: mean oxygen saturation

vs. percent time spent below 90 percent vs. nadir oxygen saturation.

What is important in the determination of edS? Presented at: Annual

Sleep Meeting, SleeP 2008; June 2-7, 2008; Baltimore, Md.

Budur K, novak B, Sliwinski J, et al. Biofeedback in patients with psychophysiological

insomnia. Poster presented at: Annual Sleep Meeting,

SleeP 2008; June 2-7, 2008; Baltimore, Md.

Buetefisch C, Parsons M, haut M, Goldstein S, Whiting d, oh M. Safety

and efficacy of deep brain stimulation in mildly demented Parkinson

disease patients. A multiple case study. Poster presented at: the Annual

Meeting of the Movement disorders Society; 2008; Chicago, Ill.

Chapin JS, Busch rM, Janigro d, Tilelli CQ, lineweaver TT, dougherty

M, naugle rI, diaz-Arrastia r, najm IM. APoe ε4 is associated with

increased percentage monocytes in patients with longstanding epilepsy.

Poster presented at: the American epilepsy Society Meeting; december,

2007; Philadelphia, Pa.

Collins GB, yared JP, McAllister, Adury K, hanuschock r. A

Multidisciplinary Approach to Identification and Management of

Cardiothoracic Surgical Patients at risk for Alcohol Withdrawal.

Presented at: the American Academy of Addiction Psychiatry 18th

Annual Meeting; november 29, 2007; Coronado, Calif.

Coughlin JW, redgrave, GW, heinberg lJ, Klick B, Guarda AS. Predictors

of premature drop-out from hospitalization in underweight patients with

eating disorders. Poster presented at: the annual meeting of the eating

disorders research Society; 2007; Pittsburgh, Pa.

Falcone, T. Psychosis in epilepsy. Poster presented at: American epilepsy

Society; december 3, 2007; Philadelphia, Pa.

Falcone T, rothermundt M, Franco K, Janigro d. Psychosis inflammation

and the brain. Presented at: the Annual Meeting of the American

Psychological Association; May 8, 2008; Washington, d.C.

Floden d, rezai Ar, Walter Bl, Kubu CS. Patients with pre-operative

cognitive impairment show disproportionate cognitive slowing following

dBS for treatment of Parkinson disease. Presented at: 36th Annual

Meeting of the International neuropsychological Society; February

2008; Waikoloa, hawaii.

Frank dl, Klecka Me, Kiffer JF, henrickson hC, McKee MG, Moravec CS.

Biofeedback-assisted stress management training to reverse myocardial

remodeling in patients with end-stage heart failure. Presented at: the

heart-Brain Summit; June 4, 2008; Cleveland, ohio.

Ferguson l, Burns J, Scheman J, Covington e. Treatment outcomes of

a multidisciplinary chronic nonmalignant pain rehabilitation program:

the examination of the differences between patients based on disability

income status. Poster presented at: the American Pain Society 27th

Annual Scientific Meeting; May 8-10, 2008; Tampa, Fla.

Ibrahim S, Bae C, Budur K. PhQ-9 as an outcome instrument in patients

with sleep apnea. Poster presented at: Annual Sleep Meeting, SleeP

2008; June 2-7, 2008; Baltimore, Md.

Kalman C, haut J, Klaas P, Tuxhorn I, Busch rM. Anxiety is related to

memory performance in children with intractable left temporal lobe

epilepsy. Poster presented at: the American epilepsy Society Meeting;

december, 2007; Philadelphia, Pa.

Klaas, PA, haut JS, Chapin JS, Busch rM. Memory change following

temporal lobectomy in children. Poster presented at: the 36th Annual

International neuropsychological Society Meeting; February 2008;

Waikoloa, hawaii.

Klecka Me, Frank dl, Kiffer JF, henrickson hC, Moravec CS, McKee MG.

heart rate variability biofeedback in the treatment of early heart failure.

Presented at: the heart-Brain Summit; Cleveland, ohio; June 4, 2008.

Kubu C, Greenberg B, Malone d, rasmussen S, Friehs G, Machado A,

rezai A. Cognitive effects of dBS in the ventral striatum in patients

with severe major depression and obsessive-compulsive disorder.

Presented at: Society for Biological Psychiatry Annual Meeting; May,

2008; Washington, d.C.

22 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008


2007 –2008 prEsENtatIoNs

of thE dEpartmENt of psyChIatry aNd psyChology

loue S, Mendez n, heaphy e, heinberg,lJ. Sexual identity, sexual behavior

and hIV risk in a sample of African-American men who have sex

with men. Paper presented at: the Annual Meeting of the Society for

the Scientific Study of Sexuality; 2008; Cleveland, ohio.

lujan Jl, Chaturvedi A, Malone d, rezai Ar, McIntyre CC. Axonal pathways

activated by deep brain stimulation for neuropsychiatric disorders.

Presented at: American Society for Stereotactic and Functional

neurosurgery Biannual Meeting; June 2008; Vancouver, Canada.

Malone d. deep brain stimulation for treatment-refractory psychiatric disorders.

Presented at: the Annual Meeting of the Psychiatric research

Society; February, 2008; Salt lake City, Utah.

Malone d. Practical issues in providing clinical dBS for patients with

severe oCd. Presented at: Association for Convulsive Therapy Annual

Meeting, May 2008; Washington, d.C.

Malone d. Surgery for psychiatric disorders: current treatment and emerging

applications. Presented at: Congress of neurological Surgeons

Annual Meeting. September 2007; Chicago, Ill.

Malone d, haber S, Machado A, Prayson r, Boongird A, rezai A. Autopsy

findings in a patient receiving deep brain stimulation of the ventral capsule/ventral

striatum. Presented at: the Annual Meeting of the American

Association of neurological Surgeons; April, 2008; Chicago, Ill.

Malone dA, rowney r, hagan-Sowell J. Aripiprazole augmentation of

serotonin reuptake inhibitor-refractory obsessive-compulsive disorder.

Presented at: American Psychiatric Association Annual Meeting; May,

2008; Washington, d.C.

Mathews M, Greenberg B, dougherty d, rezai A, Carpenter l, Kubu C,

Malone d. Change in suicidal ideation in patients undergoing dBS

for depression. Presented at: American Society for Stereotactic and

Functional neurosurgery Biannual Meeting; June, 2008; Vancouver,

Canada.

Murphy M, Chapin JS, Kubu CS. Impulse control disorder behaviors are

frequent in Pd dBS candidates and unrelated to medication status.

Poster presented at: the 36th Annual International neuropsychological

Society Meeting; February, 2008; Waikoloa, hawaii.

Muzina d, Momah Cn, eudicone J, Pikalov A, McQuade rd, Marcus rn,

Sanchez r, Carlson BX. Aripiprazole monotherapy in a subpopulation

with rapid cycling bipolar I disorder: an analysis from a long-term,

double-blind, placebo-controlled study. Presented at the: International

Conference on Bipolar disorders; June, 2008; Pittsburgh Pa.

Muzina dJ, Ganocy S, Khalife S, Gao K, Kemp d, Bachtel MB, Colangelo

e, Conroy C, Bilali S, Calabrese Jr. A double-blind, placebo-controlled

study of divalproex extended-release in newly diagnosed mood stabilizer

naïve patients with acute bipolar I or II depression. Presented at: the

American Psychiatric Association Annual Meeting; May 3-8, 2008;

Washington, d.C.

Muzina dJ, Ganocy S, Khalife S, Gao K, Kemp d, Bachtel MB, Colangelo

e, Conroy C, Bilali S, Calabrese Jr. A double-blind, placebo-controlled

study of divalproex extended-release in newly diagnosed mood stabilizer

naïve patients with acute bipolar I or II depression. Presented

at: the nCdeU 2008: new research Approaches for Mental health

Interventions; May 27-30, 2008; Phoenix, Ariz.

Parsons M, Boling W, lancaster M, Kraszpulski M. Correlating fMrI

and neuronavigation: demonstration of a “whole hand” area in primary

motor cortex. Presented at: the 35th Annual Meeting of the

International neuropsychological Society; February, 2008; Waikoloa,

hawaii.

Quinn K, leatherberry Jd, Fromm l. risk management in child/adolescent

psychiatry. Presented at: the Annual Meeting of the American Academy

of Psychiatry and the law; october, 2007; Miami, Fla.

redgrave GW, Coughlin, JW, heinberg lJ, Mason S, Guarda AS.

Vegetarianism is associated with longer length of stay among eating

disorder inpatients. Poster presented at: the Annual Meeting of the

eating disorders research Society; 2007; Pittsburgh, Pa.

rezai A, Malone d, dougherty d, Friehs G, eskandar e, Machado A,

Kubu C, Carpenter l, Tyrka A, Malloy P, Salloway S, rauch S, Price l,

rasmussen S. deep brain stimulation for treatment of depression: longterm

outcomes from a prospective multicenter trial. Presented at: the

American Association of neurological Surgeons’ Annual Meeting; April,

2008; Chicago, Ill.

rezai Ar, Gabriels l, Greenberg B, Malone d, Friehs G, Foote K,

Machado A, okun M, Shapira n, Cosyns P, Kubu C, Malloy P, Salloway

S, Goodman W. deep brain stimulation of the ventral internal capsule/

ventral striatum for obsessive-compulsive disorder: world-wide experience.

Presented at: American Association of neurological Surgeons’

Annual Meeting; April, 2008; Chicago, Ill.

Windover AK, Isaacson Jh, Pien lC, Bierer SB, Taylor C. Advanced communication

skills training: a method to sustain and enhance medical

student communication skills. Poster presented at: the International

Conference on Communication in healthcare; october 9-12, 2007;

Charleston, S.C.

Zaharna M, Budur K, Sowell J, Gonsalves l. Suicide in patients with

depression and sleep problems. Poster presented at: Annual Sleep

Meeting, SleeP 2008; June 2-7, 2008; Baltimore, Md.

ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 23


SeleCT

ClInICAl TrIAlS

MOOD DISORDERS PSYCHOPHARMACOLOGY

UNIT (MDPU)

Long-term, observational, multicenter patient outcome registry

created to collect data from patient care in the Mood Disorders

Psychopharmacology Unit for the scientific study of the causes,

treatments and illness course for primary mood disorders.

PRINCIPAL INVESTIGATOR

David Muzina, MD

CONTACT

Elisa Colangelo, 216.445.7168

BI P OL A R DI S OR DER I N PR E GNA NC Y A N D

POSTPARTUM PERIOD: PREDICTORS OF MORBIDITY

Prospective study to delineate the clinical, psychosocial and

pharmacologic predictors of BPD recurrence during pregnancy.

PRINCIPAL INVESTIGATOR

Adele Viguera, MD

CONTACT

Elisa Colangelo, 216.445.7168

NEUROPHYSIOLOGY OF BIPOLAR DEPRESSION

Study to determine functional and neurochemical changes in

the ALN of patients with bipolar depression.

PRINCIPAL INVESTIGATOR

David Muzina, MD

CONTACT

Elisa Colangelo, 216.445.7168

UPCoMInG

SyMPoSIA

September 10–12, 2008

OBESITY SUMMIT 2008

InterContinental Hotel & Bank of America

Conference Center

Cleveland, Ohio

For more information, visit clevelandclinicmeded.org

or call 800.238.6750.

October 30–31, 2008

TRAUMATIC BRAIN INJURY

InterContinental Hotel & Bank of America

Conference Center

Cleveland, Ohio

For more information, visit

clevelandclinic.org/neuroscience/CME or contact

Martha Tobin at 800.223.2273, ext. 53449.

November 21, 2008

3R D A N N UA L P O S T T R AU M AT IC S T R E S S

DISORDER SYMPOSIUM

InterContinental Hotel & Bank of America

Conference Center

Cleveland, Ohio

For more information, visit

clevelandclinic.org/neuroscience/CME or contact

Brigid Ring at 800.223.2273, ext. 50754.

24 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008


Insights | 2008

George Tesar, Md

Medical Editor

Christine Coolick

Managing Editor

Chip Valleriano

Art Director

Insights is written for physicians

and should be relied upon for

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InTrodUCInG

T h e F U T U r e

oF heAlThCAre

Innovative new

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This fall, Cleveland Clinic is introducing the future of healthcare with the opening of the Sydell and

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These buildings, which represent the largest construction and philanthropy project in Cleveland Clinic

history, embody the pioneering spirit and commitment to quality that define Cleveland Clinic. These

structures are a tangible expression of institutes, our new model of care that organizes patient services

by organ and disease.

At 1 million square feet, the Miller Family Pavilion is the country’s largest single-use facility for heart

and vascular care. The 12-story Glickman Tower, new home to the Glickman Urological & Kidney

Institute, is the tallest building on Cleveland Clinic’s main campus. Both will help us improve patient

experience by increasing our capacity and by consolidating services, so patients can stay in one location

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