Buprenorphinerevolutionizes treatment for opiate dependence
A PUBl ICAT Ion oF The dePArTMenT
oF PSyCh IATry And PSyCholoGy
Insights2008
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
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
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 agonist-
antagonist, buprenorphine, which has significantly advanced the care of patients with chemi-
cal 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 ongo-
ing 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
dEar CollEagUEs
George e. Tesar, md
Chairman
2 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008
Buprenorphine revolutionizes treatment for opiate dependence
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 indicat-
ing 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 metha-
done 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 clin-
ics. Patients have been known to buy and sell metha-
done and other drugs to patients at or near methadone
clinics. The relative non-availability of psychiatric
services at these clinics likely contributes to their mar-
ginal 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 virtu-
ally impossible to overdose and die from a dose of
buprenorphine.
Also of alarming importance is that prescription opi-
ates are being abused by children, teenagers and the
elderly.
According to the Ohio Department of Alcohol and
Drug Addiction Services, young abusers of oxy-codone 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 num-ber of admissions for heroin abuse increased over-all 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 buprenor-
phine to treat dependent patients with this medica-
tion 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 treat-
ment 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
Since the mid-20th century, methadone was the only
legal pharmaceutical opiate for treatment of opiate
addiction. Methadone continues to be the tradi-
tional medication used at many treatment facilities.
Maintenance therapy supplied by methadone clinics
was instituted to relieve opiate addiction and with-
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
A d d i c T i o n
Gregory B. collins, md
ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 3
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 physi-
cians 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 improv-
ing treatment compliance and outcomes in opiate-
dependent patients.
Gregory B. Collins, MD, is head of Cleveland Clinic’s
Alcohol and Drug Recovery Center. His specialty inter-
ests include drug and alcohol rehabilitation, sports psy-
chiatry and executive counseling. He can be contacted at
216.444.2970 or [email protected].
Byron C. Leak, MD, is a research associate with
Cleveland Clinic’s Alcohol and Drug Recovery Center.
R EF E R E NC E S
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 buprenor-
phine 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 buprenorphine-
assisted relapse prevention treatment for heroin
dependence in Sweden: a randomized, placebo-
controlled trial. Lancet. 2003;361(9358):662-668.
6. Fudala PJ, Bridge TP, Herbert SA, et al. Office-based
treatment of opiate addiction with a sublingual-
tablet 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.
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-depen-
dent patients and Suboxone only in the outpatient set-
ting. 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 buprenor-
phine outpatient therapy on several factors, including
compliance, incorporation of self-help meetings, co-
morbid disorders and federal guidelines for prescrib-
ing 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-
A d d i c T i o n
0
50
100
150
200
250
Admissions
Buprenorp
hine
221
81
Total Admissions for opiate dependence and resulting Buprenophine Therapy
2006-2007
4 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology
presurgical Evaluation for Bariatric patients: Balancing science and Clinical Judgment
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 behav-
ioral 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-
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 popula-
tion that is at high risk for psychiatric co-morbidity.
Seventy percent of bariatric patients have a concur-
rent 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 mor-
bid 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 evalu-
ation 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 out-
come, 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-
By leslie J. heinberg, phd
Bariatric surgery is the most effective treatment for obesity.1 unlike standard diets that focus on altering ener-
gy balance, the permanent physiological changes that result from bariatric procedures yield significant weight-
loss maintenance and remission of most, if not all, of obesity-related co-morbidities.1
leslie J. heinberg, phd
B A r i A T r i c s
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
ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 5
didates, although they may receive recommenda-
tions 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 objec-
tive 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 [email protected].
R EF E R E NC E S
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.
B A r i A T r i c s
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 laparo-scopically, 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.
h o W B A r I A T r I C S U r G e r y W o r K S
6 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology
memory decline following temporal lobe resection for Intractable Epilepsy: the role of presurgical depression
*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 [email protected].
R EF E R E NC E S
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.
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 demon-
strate 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 presurgi-
cal 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 lobec-
tomy 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.
By robyn m. Busch, phd
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
robyn m. Busch, phd
e p i l e p s y
ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 7
e p i l e p s y
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.
75
Pre-Surgery Post Surgery Pre-Surgery Post Surgery
Sta
nd
ard
Sco
re
80
85
90
95
left Temporal lobectomy right Temporal lobectomy
G e n e r A l M e M o r y S C o r e
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.
8 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology
anxiety and heart disease
Normative Aging Study, a large prospective study con-
ducted 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 cardio-
vascular morbidity and mortality. In the Women’s
Health Initiative Study, a six-month history of full-
blown 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 commu-
nity-dwelling elderly.6 These results were presented
at the 2008 American Psychosomatic Society annual
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 high-
er 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 per-
cent to 20 percent. Anxiety can present in many differ-
ent forms. There are several clinical subtypes of anxi-
ety 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 perspec-
tive, anxiety is a built-in alarm system to respond to
potential dangers in the environment, which has ben-
efited the human species for thousands of years. The
“fight or flight” response, coupled with activation of
the sympathetic nervous system and hypothalamus-
pituitary-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 sys-
tem, 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 vari-
ability), 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 anxi-
ety can be predictive of new onset of CHD. In the
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 coro-
nary heart disease (chd) among initially healthy people, as well as conferring increased morbidity and mortal-
ity in cardiac patients who subsequently get depressed.
h e A r T
leo pozuelo, md, FAcp
ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 9
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.
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 devel-
op 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, pri-
mary care psychiatry and medical student education. He
can be contacted at 216.445.3583 or [email protected].
Jianping Zhang, MD, PhD, is a resident with Cleveland
Clinic’s Department of Psychiatry and Psychology.
R EF E R E NC E S
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.
h e A r T
Adjusted survival curves in men, stratified on change pattern in anxiety scores over time.
Cum
Sur
viva
l
0.0
0.2
0.4
0.6
0.8
1.0
Survival Function for different Changes in Anxiety Scores
# Months from Time 1 to death
0.00 50.00 100.00 150.00 200.00
hazard ratio=1.00
hazard ratio=1.54 (p<0.05)hazard ratio=1.89 (p<0.01)
Median Survival in Months
n Stable group = 145.6 n down group = 95.1 n Up group = 76.3
1 0 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology
Biofeedback-assisted stress management in the treatment of heart failure
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. Biofeedback-
assisted 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
The physiological link between mental stress and car-
diovascular disease still needs to be fully elucidated,
but evidence favors a role of the sympathetic ner-
vous system in increasing cardiovascular reactivity,
enhancing platelet activation and contributing to the
development of both atherosclerotic plaque and life-
threatening 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; cop-
ing with new medications and their potential side
effects; and accepting the very real possibility of need-
ing 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 sympa-
thetic nervous system, activated in two ways, pumps
out catecholamines and activates adrenergic recep-
tors throughout the body. The end result is a worsen-
ing of the disease process and extreme energy deple-
tion 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.
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.
michael G. mcKee, phd
h e A r T
christine s. moravec, phd
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.
ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 11
S U G GE S T E D R E A DI NG
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 cardiovascu-
lar 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.
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 ten-
sion, 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 parasympa-
thetic nervous systems in a favorable direction will
result in enhanced quality of life, decreased symp-
toms 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 [email protected].
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
h e A r T
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.
1 2 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008
Biofeedback: a Useful tool for psychophysiological Insomnia
sessions. They reported sleeping better without medi-
cations. 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, para-
somnias, circadian rhythm sleep disorders and sleep/psy-
chiatry disorders. He can be contacted at 216.444.0915 or
Cleveland Clinic’s Sleep Disorders Center recently
has incorporated biofeedback therapy in its interdis-
ciplinary 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 activ-
ity). Brain activity is monitored with electroencepha-
logram (EEG). All of this information is displayed
for the patient, who then is instructed on how to
perform relaxation techniques such as deep breath-
ing, progressive muscle relaxation and meditation.
The patient receives immediate feedback as to the
impact of relaxation on the multiple psychophysi-
ologic 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 psy-
chophysiological insomnia referred for biofeedback-
based treatment. Seventy percent rated themselves
as “very much improved” or “improved” after three
By Kumar Budur, md
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 medica-
tions, typically the first line of treatment, have many limitations and often are ineffective.
Kumar Budur, md
s l e e p
0%
10%
20%
30%
40%
50%
60%
70%
80%
Biofeedback for Insomnia: After 3 Sessions
Very Much Im
proved
no Improv
ement
ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 13
W o m e n ’ s h e A l T h
Bipolar disorder during pregnancy: risk of recurrence
R EF E R E NC E
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 dis-
continuation. Am J Psychiatry. 2007;164(12):1817-1824.
S U G GE S T E D R E A DI NG
Newport DJ, Stowe ZN, Viguera AC, Calamaras
MR, Juric S, Knight B, Pennell PB, Baldessarini RJ.
Lamotrigine in bipolar disorder: efficacy during preg-
nancy. 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: clini-
cal implications. Am J Psychiatry. 2007;164:342-345.
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 pro-
spective study in the American Journal of Psychiatry
examining the risk of recurrence among women with
a history of bipolar disorder that continued or discon-
tinued treatment with mood stabilizers during preg-
nancy.1 We found that the overall risk of recurrence
during pregnancy was 71 percent. Women who dis-
continued mood stabilizer treatment had a two-fold
greater recurrence risk and four-fold shorter time to
first recurrence compared with women who contin-
ued mood stabilizers during pregnancy.
Additionally, the proportion of weeks ill during preg-
nancy was five times greater among women who dis-
continued mood stabilizer compared with women who
maintained mood stabilizer treatment. Most recur-
rences were depressive or mixed states, and the major-
ity 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 rela-
tive 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 dys-
phoric 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 [email protected].
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.
Adele c. Viguera, md, mph
0.00
0.25
0.50
0.75
1.00
0 10 20 30 40
risk of recurrence in Pregnant Women with Bipolar disorders Who Continued Versus
discontinued Any Mood Stabilizer
Median time to recurrence > 40 weeks (95% CI: indeterminate)
Weeks following Conception
Pro
port
ion
With
out
rec
urre
nce
Median time to recurrence 9 weeks (95% CI: 8-13 weeks)
37%
85%
n=89; Bipolar Type I and II
n Maintain (n=27) n discontinue (n=62)
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
psyChIatry aNd psyChology staff
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
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
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
1 4 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008
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
Jessica chapin, phd
specialty Interests: neuropsychology, adult epilepsy, memory, geriatrics
216.444.9044 216.444.9054 fax
psyChIatry aNd psyChology staff
darlene Floden, phd
specialty Interests: neuropsychology, deep brain stimulation, executive function, neuroeconomics, parkinson’s disease, fmrI
216.444.1298 phone 216.444.4525 fax
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
Tatiana Falcone, md
specialty Interests: first episode psychosis, epilepsy, the role of inflammation in schizo- phrenia, research and education, child psychiatry, consultation-liaison psychiatry
216.444.7459 phone 216.444.9054 fax
ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 15
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
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
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
Kathleen Franco, md
specialty Interest: consultation-liaison psychiatry
216.444.2671 phone 216.636.3206 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
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: psychopharma-cology, mood disorders anxiety disorders, neuromodulation
216.444.5817 phone 216.445.7032 fax
psyChIatry aNd psyChology staff
1 6 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008
regina Josell, psyd
specialty Interests: anxiety disorders, stress management and trauma
440.516.8691 phone 440.516.8695 fax
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
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, psycho-oncology, 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
ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 17
psyChIatry aNd psyChology staff
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
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
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
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
psyChIatry aNd psyChology staff
1 8 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008
isabel schuermeyer, md
specialty Interest: adult psychiatry
216.444.5965 phone 216.445.7032 fax
Barry simon, do
specialty Interests: crisis management and inpatient psychiatry
216.445.1954 phone 216.444.9054 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
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
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
Judith scheman, phd
Program Director, Chronic Pain Rehabilitation Program
specialty Interest: chronic pain rehabilitation
216.444.2875 phone 216.445.7000 fax
ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 19
2007 –2008 pUBlICatIoNs
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Muzina dJ, Colangelo e, Manning JS, Calabrese Jr. differentiating bipo-lar disorder from depression in primary care. Cleve Clin J Med. 2007 Feb;74(2):89-105.
Muzina dJ. Bipolar spectrum disorder: differential diagnosis and treat-ment. 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.
ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 21
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 disor-der during pregnancy: prospective study of mood stabilizer discontinua-tion. 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 cogni-tive 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 depres-sion: focus on repetitive transcranial magnetic stimulation. Int J Neuropsychopharmacol. 2008 Feb;11(1):119-130.
2 2 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008
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 psy-chophysiological 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 inflamma-tion 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 follow-ing 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.
2007 –2008 prEsENtatIoNs
of thE dEpartmENt of psyChIatry aNd psyChology
2007 –2008 prEsENtatIoNs
of thE dEpartmENt of psyChIatry aNd psyChology
ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 23
loue S, Mendez n, heaphy e, heinberg,lJ. Sexual identity, sexual behav-ior 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 path-ways activated by deep brain stimulation for neuropsychiatric disor-ders. Presented at: American Society for Stereotactic and Functional neurosurgery Biannual Meeting; June 2008; Vancouver, Canada.
Malone d. deep brain stimulation for treatment-refractory psychiatric dis-orders. 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 emerg-ing 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 cap-sule/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 sta-bilizer 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 pri-mary 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: long-term 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 experi-ence. Presented at: American Association of neurological Surgeons’ Annual Meeting; April, 2008; Chicago, Ill.
Windover AK, Isaacson Jh, Pien lC, Bierer SB, Taylor C. Advanced com-munication 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.
2 4 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology 2008
SeleCT
ClInICAl TrIAlS
MO OD DI S OR DER S P S YCHOPH A R M AC OL O G Y
U N I T (M DPU)
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.
PR I NCI PA L I N V E S T IG AT OR
David Muzina, MD
C ON TAC T
Elisa Colangelo, 216.445.7168
BI P OL A R DI S OR DER I N PR E GN A NC Y A N D
P O S T PA R T U M PER IOD : PR EDIC T OR S OF MOR BI DI T Y
Prospective study to delineate the clinical, psychosocial and
pharmacologic predictors of BPD recurrence during pregnancy.
PR I NCI PA L I N V E S T IG AT OR
Adele Viguera, MD
C ON TAC T
Elisa Colangelo, 216.445.7168
N EU ROPH Y SIOL O G Y OF BI P OL A R DEPR E S SION
Study to determine functional and neurochemical changes in
the ALN of patients with bipolar depression.
PR I NCI PA L I N V E S T IG AT OR
David Muzina, MD
C ON TAC T
Elisa Colangelo, 216.445.7168
UPCoMInG
SyMPoSIA
September 10–12, 2008 OBE SI T Y SU M M I T 2 0 0 8
InterContinental Hotel & Bank of America Conference Center Cleveland, Ohio
For more information, visit clevelandclinicmeded.org or call 800.238.6750.
October 30–31, 2008 T R AU M AT IC BR A I N I N J U RY
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 DI S OR DE R S Y M P O SI U M
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.
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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It does not provide a complete overview
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© The Cleveland Clinic Foundation 2008
This fall, Cleveland Clinic is introducing the future of healthcare with the opening of the Sydell and Arnold Miller Family Pavilion and the Glickman Tower.
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 for their care.
With 278 private patient rooms, more than 90 ICU beds and a combined total of nearly 200 exam rooms and more than 90 procedure rooms, patients will have faster access to Cleveland Clinic cardiac and urological services.
For details, including a virtual tour, please visit meetthebuildings.com.
I n T r o d U C I n G
The FUTUre oF heAlThCAre
Innovative new
buildings improve patient
access, experience.
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