antony fernandez - Academia.edu (original) (raw)

Papers by antony fernandez

Research paper thumbnail of Body mass index relates to males with posttraumatic stress disorder

Journal of the National Medical Association, 2006

We looked at the relationships among posttraumatic stress disorder (PTSD), body mass index (BMI) ... more We looked at the relationships among posttraumatic stress disorder (PTSD), body mass index (BMI) and socioeconomic status (SES) in a newly formed PTSD program at the Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, VA. We reviewed 265 records and then selected only black and white male veterans (n=252) for study. Variables were: 1) age, 2) decade of life, 3) height, 4) weight, 5) sex, 6) race, and 7) SES (estimated using priority group status). Low income is an important variable determining priority group status. About two-thirds of the veterans were in the age range of 50-59 years (Vietnam veterans). Their mean BMI was 30.2 +/- 5.6 kg/m2, and this value did not separate by race. Far exceeding national numbers, 84.1% of our veterans were either overweight or obese. Veterans in the lower priority groups had greater (p=0.029) BMIs than their counterparts in higher priority groups. The pervasiveness of overweight and obesity in our PTSD population was profound. Our o...

Research paper thumbnail of Posttraumatic Stress Disorder: Clinical Features, Pathophysiology, and Treatment

American Journal of Medicine, 2006

Posttraumatic stress disorder (PSTD), classified as an anxiety disorder, has become increasingly ... more Posttraumatic stress disorder (PSTD), classified as an anxiety disorder, has become increasingly important because of wars overseas, natural disasters, and domestic violence. After trauma exposes the victim to actual or threatened death or serious injury, 3 dimensions of PTSD unfold: (1) reexperiencing the event with distressing recollections, dreams, flashbacks, and/or psychologic and physical distress; (2) persistent avoidance of stimuli that might invite memories or experiences of the trauma; and (3) increased arousal. Traumatic events sufficient to produce PTSD in susceptible subjects may reach a lifetime prevalence of 50% to 90%. The actual lifetime prevalence of PTSD among US citizens is approximately 8%, with the clinical course driven by pathophysiologic changes in the amygdala and hippocampus. Comorbid depression and other anxiety disorders are common. General principles of treatment include the immediate management of PTSD symptoms and signs; management of any trauma-related comorbid conditions; nonpharmacologic interventions including cognitive behavioral treatment; and psychopharmacologic agents including antidepressants (selective serotonin reuptake inhibitors most commonly), antianxiety medications, mood stabilizing drugs, and antipsychotics. This review of PTSD will provide the reader with a clearer understanding of this condition, an increased capacity to recognize and treat this syndrome, and a greater appreciation for the role of the internist in PTSD.

Research paper thumbnail of Child and Adolescent Suicides in Virginia: 1987 to 2003

Journal of Child and Adolescent Psychopharmacology, 2005

The aim of this study was to better understand suicides in children and adolescents using records... more The aim of this study was to better understand suicides in children and adolescents using records from the Office of the Medical Examiner of Virginia from 1987 to 2003. Suicide accounted for 16.8% of unnatural deaths. Suicide rates were highest for Caucasians. Guns were the most common method of death for suicides, followed by hanging and poisoning. Poisoning other than carbon monoxide accounted for 7.8% of suicides, with tricyclic antidepressants (TCAs) the most identifiable poison. Female youths were 10 times more likely to die from TCAs than male youths, after adjusting for race and age. Guns and hanging were the principal methods of suicide. Among the antidepressants, TCAs have been the most common poisons used in suicide. Increasing age was a powerful determinant of suicide. Some patients may have stockpiled their TCAs for a while before their TCA overdose. Other suicide victims may have used TCA supplies from family members. Hence, some of the suicide victims may not have taken TCAs on a regular basis before committing suicide. Further exploration of TCA-induced suicidal thoughts is needed. Conclusions cannot be made at the time about the precise role that TCAs played in TCA-induced suicide reported in our study.

Research paper thumbnail of Posttraumatic Stress Disorder in Male Military Veterans With Comorbid Overweight and Obesity

The Primary Care Companion To The Journal of Clinical Psychiatry, 2006

Posttraumatic stress disorder (PTSD) is an important syndrome among military veterans. Little has... more Posttraumatic stress disorder (PTSD) is an important syndrome among military veterans. Little has been written about comorbid medical conditions of PTSD, particularly overweight and obesity. We focus on psychotropic and non-psychotropic drugs, their interactions, and metabolic issues most relevant to primary care physicians. Data from the recently constituted PTSD program at the Department of Veterans Affairs Medical Center in Richmond, Va., were retrospectively reviewed to assess the prevalence and severity of comorbid overweight and obesity in male veterans with PTSD. Also, our database allowed us to correlate various drugs used to treat hypertension, diabetes mellitus, and dyslipidemia with body mass index (BMI). The mean BMI of 157 veterans with PTSD (DSM-IV criteria) in this sample was in the obese range (30.3 ± 5.6 kg/m²). The number of drugs a given patient was taking for treatment of hypertension, diabetes mellitus, and dyslipidemia correlated with BMI. Psychotropic drugs associated with weight gain did not explain our findings. Overweight and obesity among our male veterans with PTSD strikingly exceeded national findings. The administration of psychotropic drugs associated with weight gain did not explain these findings. The number of medications used to treat hypertension, diabetes mellitus, and dyslipidemia correlated significantly with BMI. Rather than these medications explaining the high prevalence of overweight and obesity in our study population, obesity probably worsened these components of the metabolic syndrome, necessitating more aggressive treatment reflected in the high number of drugs prescribed.

Research paper thumbnail of Psychotropic Drug Considerations in Depressed Patients with Metabolic Disturbances

American Journal of Medicine, 2008

Depression, obesity, diabetes mellitus, and the metabolic syndrome are conditions commonly treate... more Depression, obesity, diabetes mellitus, and the metabolic syndrome are conditions commonly treated in primary care. The prevalence of each condition separately does not explain the frequency of their co-occurrence. Depression may lead to or exacerbate these endocrine and metabolic conditions. Conversely, these medical conditions may lead to or exacerbate depression. Psychotropic drugs that treat depression may increase appetite with resultant weight gain. Rarely, such agents may be associated with weight loss. We review the potential for psychotropic drugs to alter body weight and provide a figure as a guide to drug selection. Unless circumstances dictate otherwise, clinicians should select psychotropic drugs least likely to induce weight gain when treating depressed patients with obesity, diabetes mellitus, or the metabolic syndrome. Even drugs generally thought to be "weight neutral" may occasionally be associated with weight gain. Thus, alerting patients to this potential and due diligence form the cornerstone of weight management in the depressed patient.

Research paper thumbnail of Patient and direct-care staff body mass index in a state mental hospital: implications for management

Acta Psychiatrica Scandinavica, 2004

Research paper thumbnail of Proarrhythmic Risk with Antipsychotic and Antidepressant Drugs: Implications in the Elderly

Drugs & Aging, 2009

The quinidine-like effects of some antidepressant drugs (particularly tricyclic antidepressants) ... more The quinidine-like effects of some antidepressant drugs (particularly tricyclic antidepressants) and many antipsychotic drugs (particularly the phenothiazines) confound treatment of psychosis and depression in patients with major mental illness. This is especially true among elderly patients with existing risk factors for corrected QT (QTc) interval prolongation. We used PubMed, previously reported review articles and the extensive personal files of the authors to identify cases of subjects aged>or=60 years who developed QTc interval prolongation, polymorphic ventricular tachycardia (PVT)/torsade de pointes (TdP) and/or sudden cardiac death while taking antipsychotic or antidepressant drugs or a combination of these medications. We identified 37 patients who had taken, in total, 46 antipsychotic or antidepressant drugs. Our most striking finding was that almost four-fifths of our cases involved women. When the 14 critically ill subjects receiving haloperidol intravenously were excluded, 91.3% of our subjects were women. Almost three-quarters of our study subjects had cardiovascular disease. Intravenous administration of haloperidol in the critically ill and profoundly agitated elderly warrants particular comment. Of the 14 subjects in this category identified, six were men and eight were women. In 13 cases, the drug dose far exceeded the 2 mg necessary to produce an antipsychotic effect. These clinicians were using an agent to achieve sedation that usually requires very high doses in the critically ill and profoundly agitated elderly to achieve this effect. Inclusion criteria for our literature review required antipsychotic and/or antidepressant drug-induced QTc interval prolongation. Even so, our finding that 31 of our 37 subjects developed PVT is sobering. However, the reader should not conclude that drug-induced QTc interval prolongation is highly predictive of PVT or its TdP subtype. All of our study subjects had at least two risk factors for TdP, with age and sex being the most common. We included the rare case of a patient with congenital long QT syndrome who developed further lengthening of the QTc interval and TdP when prescribed an antidepressant drug well known to produce QTc interval prolongation. We conclude with recommendations for clinicians not expert in the specialty of cardiology to deal with the many questions raised in this review. Specifically, such clinicians treating elderly patients with antipsychotic and antidepressant drugs that may prolong the QTc interval should aggressively obtain a baseline ECG for elderly female patients with additional risk factors such as personal or family history of pre-syncope or syncope, electrolyte disturbances or cardiovascular disease. Elderly male patients are also subject to QTc interval prolongation when such risk factors are present. It is important that the clinicians themselves inspect ECGs. If the QT interval is more than half the RR interval, QTc interval prolongation is likely to be present. In such cases, a cardiology colleague interested in QTc interval issues and TdP should be asked to review the ECG. Finally, nothing in our recommendations replaces meticulous attention to US FDA guidelines in the package insert of each drug.

Research paper thumbnail of Posttraumatic Stress Disorder and Body Mass Index in Military Veterans: The Richmond Experience

Stress, Trauma, and Crisis: An International Journal, 2006

Military veterans suffering from Posttraumatic Stress Disorder (PTSD) often have comorbid conditi... more Military veterans suffering from Posttraumatic Stress Disorder (PTSD) often have comorbid conditions including obesity. They may become disabled either from these comorbid conditions or from PTSD (or from both). Service-connected disability (SCD) is a concept employed by both the Department of Defense and the Department of Veterans Affairs to identify and compensate military veterans with such disabilities. SCD could serve as a measure of the functional impact of PTSD and comorbid obesity and other medical conditions. We reviewed the database of the recently constituted PTSD program at Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, Virginia. Variables assessed included 1) age, 2) decade of life, 3) height, 4) weight, 5) sex, 6) race, 7) employment status, 8) presence or absence of comorbid psychiatric conditions, 9) presence or absence of comorbid medical conditions, and 10) degree of disability. From the height and weight measurements, we calculated body mass index (BMI). We used SCD to estimate degree of disability in terms of total disability (total SCD) and disability ascribed to PTSD (PTSD-SCD). Results indicated that the mean BMI of the study population was 30.3±5.7 kg/m2. This value was consistent with the current definition of obesity. 83.8% of our study population was either overweight or obese. This rate exceeded the US general population level of 64.5%. SCD and comorbid medical conditions had statistically significant relationships with obesity. Race was almost a statistically significant predictor of obesity. Decade of life, employment status and presence/absence of comorbid psychiatric condition did not separate the obese veteran from the non-obese veteran. Analysis of variance (ANOVA) revealed statistical significant differences in BMI (df = 4, F = 2.921, p = 0.022)among various levels of SCD suggesting a threshold effect. PTSD-related SCD, however, did not have a significant relationship with BMI. The prevalence of overweight and obesity among our sample of veterans with PTSD exceeded current U.S. population rates. Comorbid medical conditions may predispose veterans with PTSD to obesity. SCD had a significant relationship with BMI in that there was a threshold effect in which 30% or greater SCD identified veterans with obesity. The cross-sectional nature of the study and the absence of control populations limit the conclusions that may be drawn from our study. Clearly, more definitive studies are needed with much larger study populations.

Research paper thumbnail of Cardiovascular side effects of newer antidepressants

We review the cardiovascular effects of newer antidepressants. Although further studies are warra... more We review the cardiovascular effects of newer antidepressants. Although further studies are warranted, the safety of the selective serotonin reuptake inhibitors and the serotonin norepinephrine reuptake inhibitors on patients with comorbid cardiac conditions is impressive. Newer antidepressants should be considered as first-line agents for the treatment of depression in patients with and without cardiovascular disease.

Research paper thumbnail of Toxicology Findings in Child and Adolescent Suicides in Virginia

The Primary Care Companion To The Journal of Clinical Psychiatry, 2006

In a follow-up report of child and adolescent suicides in Virginia, we describe postmortem toxico... more In a follow-up report of child and adolescent suicides in Virginia, we describe postmortem toxicology findings in a subset of these youths. We analyzed "unnatural" deaths from Virginia's Office of the Chief Medical Examiner for 1987 to 2003. There were 2818 unnatural deaths in children and adolescents. We grouped unnatural deaths as accidents, homicides, and suicides. Toxicology records were available for 753 cases, of which 732 were black or white youths. There were no age differences among suicide victims and accident or homicide victims. Whites were more likely than blacks to die by accident and suicide. White females were more likely than black females to commit suicide. Black males were more likely than white males to suffer homicide. For all unexpected deaths, antidepressants were more commonly found among whites than blacks. Suicide by poisoning occurred more commonly among whites. Recreational drugs were more commonly found among blacks than whites. Suicide by gun occurred more commonly among blacks. Antidepressants were found in 39 black and white suicide victims. Anti-depressants (all tricyclic antidepressants) were causally related in 17 cases of suicide by poisoning. No other antidepressants were found in lethal levels in suicide by poisoning. Selective serotonin reuptake inhibitors (SSRIs)/venlafaxine appeared more commonly in the suicides (p < .0001) than in accidents or homicides. For suicides, SSRIs appeared no more commonly in poisoning than in gun or hanging deaths (p = .695). Antidepressants appeared more commonly among youths committing suicide than those dying by accident or homicide. SSRIs did not appear more commonly among youths committing suicide by poisoning than those committing suicide by gun or hanging. Because our data are descriptive, they are subject to over-interpretation. Cause-effect inferences should not be drawn.

Research paper thumbnail of Posttraumatic stress disorder and body mass index in military veterans

Progress in Neuro-psychopharmacology & Biological Psychiatry, 2006

Introduction: Current management of posttraumatic stress disorder (PTSD) focuses on the psychiatr... more Introduction: Current management of posttraumatic stress disorder (PTSD) focuses on the psychiatric parameters of this condition. Little has been written about co-morbid overweight and obesity in PTSD. Methods: We used the database of the recently constituted PTSD program at the Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, Virginia to assess and better understand the prevalence and severity of overweight and obesity among military veterans with PTSD. Variables assessed included age, decade of life, height, weight, sex, race, and severity and chronicity of PTSD. We used PTSD CheckList-Military Version (PCL-M) to assess current complaints and service-connected disability (SCD) to estimate the long-term severity of PTSD. Results: Of the 221 male veterans extracted from our PTSD database for purposes of this study, 144 (65.2%) were in the age range of 50 to 59 years consistent with Vietnam veterans dominating our study population. Their mean body mass index (BMI) was 30.2 ± 5.8 kg/m 2 placing the typical veteran in the obese range. Far exceeding the current US population rate of 64.5%, 82.8% of our study population was either overweight or obese. Our sample had BMI measurements greater than those reported for non-PTSD veterans and also BMI measurements reported in the literature for veterans with PTSD. Current (PCL-M) and long-term (SCD) markers of PTSD did not relate to obesity. Conclusions: The prevalence of overweight and obesity among our veterans with PTSD far exceeded current US population findings and those of other veteran groups with and without PTSD. PTSD symptoms, whether assessed acutely or chronically, did not explain our findings. Prospective studies of PTSD and comorbidity are needed using larger study populations to better understand the relationships among PTSD, stress, and obesity.

Research paper thumbnail of Posttraumatic Stress Disorder in Male Military Veterans With Comorbid Overweight and Obesity: Psychotropic, Antihypertensive, and Metabolic Medications

Little has been written about comorbid medical conditions of PTSD, particularly overweight and ob... more Little has been written about comorbid medical conditions of PTSD, particularly overweight and obesity. We focus on psychotropic and non-psychotropic drugs, their interactions, and metabolic issues most relevant to primary care physicians.

Research paper thumbnail of Posttraumatic stress disorder as a risk factor for obesity among male military veterans

Acta Psychiatrica Scandinavica, 2007

Objective: Obesity is a significant public health problem in the United States, particularly amo... more Objective: Obesity is a significant public health problem in the United States, particularly among military veterans with multiple risk factors. Heretofore, posttraumatic stress disorder (PTSD) has not clearly been identified as a risk factor for this condition.Method: We accessed both a national and local database of PTSD veterans.Results: Body mass index (BMI) was greater (P < 0.0001) among male military veterans (n = 1819) with PTSD (29.28 ± 6.09 kg/m2) than those veterans (n = 44 959) without PTSD (27.61 ± 5.99 kg/m2) in a sample of randomly selected veterans from the national database. In the local database of male military veterans with PTSD, mean BMI was in the obese range (30.00 ± 5.65) and did not vary by decade of life (P = 0.242).Conclusion: Posttraumatic stress disorder may be a risk factor for overweight and obesity among male military veterans.

Research paper thumbnail of Toxicology Findings in Child and Adolescent Suicides in Virginia: 1987-2003

Research paper thumbnail of Clinical monitoring and management of the metabolic syndrome in patients receiving atypical antipsychotic medications

Primary Care Diabetes, 2009

Please cite this article in press as: M. Hasnain, et al., Clinical monitoring and management of t... more Please cite this article in press as: M. Hasnain, et al., Clinical monitoring and management of the metabolic syndrome in patients receiving atypical antipsychotic medications, Prim.

Research paper thumbnail of Body mass index relates to males with posttraumatic stress disorder

Journal of the National Medical Association, 2006

We looked at the relationships among posttraumatic stress disorder (PTSD), body mass index (BMI) ... more We looked at the relationships among posttraumatic stress disorder (PTSD), body mass index (BMI) and socioeconomic status (SES) in a newly formed PTSD program at the Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, VA. We reviewed 265 records and then selected only black and white male veterans (n=252) for study. Variables were: 1) age, 2) decade of life, 3) height, 4) weight, 5) sex, 6) race, and 7) SES (estimated using priority group status). Low income is an important variable determining priority group status. About two-thirds of the veterans were in the age range of 50-59 years (Vietnam veterans). Their mean BMI was 30.2 +/- 5.6 kg/m2, and this value did not separate by race. Far exceeding national numbers, 84.1% of our veterans were either overweight or obese. Veterans in the lower priority groups had greater (p=0.029) BMIs than their counterparts in higher priority groups. The pervasiveness of overweight and obesity in our PTSD population was profound. Our o...

Research paper thumbnail of Posttraumatic Stress Disorder: Clinical Features, Pathophysiology, and Treatment

American Journal of Medicine, 2006

Posttraumatic stress disorder (PSTD), classified as an anxiety disorder, has become increasingly ... more Posttraumatic stress disorder (PSTD), classified as an anxiety disorder, has become increasingly important because of wars overseas, natural disasters, and domestic violence. After trauma exposes the victim to actual or threatened death or serious injury, 3 dimensions of PTSD unfold: (1) reexperiencing the event with distressing recollections, dreams, flashbacks, and/or psychologic and physical distress; (2) persistent avoidance of stimuli that might invite memories or experiences of the trauma; and (3) increased arousal. Traumatic events sufficient to produce PTSD in susceptible subjects may reach a lifetime prevalence of 50% to 90%. The actual lifetime prevalence of PTSD among US citizens is approximately 8%, with the clinical course driven by pathophysiologic changes in the amygdala and hippocampus. Comorbid depression and other anxiety disorders are common. General principles of treatment include the immediate management of PTSD symptoms and signs; management of any trauma-related comorbid conditions; nonpharmacologic interventions including cognitive behavioral treatment; and psychopharmacologic agents including antidepressants (selective serotonin reuptake inhibitors most commonly), antianxiety medications, mood stabilizing drugs, and antipsychotics. This review of PTSD will provide the reader with a clearer understanding of this condition, an increased capacity to recognize and treat this syndrome, and a greater appreciation for the role of the internist in PTSD.

Research paper thumbnail of Child and Adolescent Suicides in Virginia: 1987 to 2003

Journal of Child and Adolescent Psychopharmacology, 2005

The aim of this study was to better understand suicides in children and adolescents using records... more The aim of this study was to better understand suicides in children and adolescents using records from the Office of the Medical Examiner of Virginia from 1987 to 2003. Suicide accounted for 16.8% of unnatural deaths. Suicide rates were highest for Caucasians. Guns were the most common method of death for suicides, followed by hanging and poisoning. Poisoning other than carbon monoxide accounted for 7.8% of suicides, with tricyclic antidepressants (TCAs) the most identifiable poison. Female youths were 10 times more likely to die from TCAs than male youths, after adjusting for race and age. Guns and hanging were the principal methods of suicide. Among the antidepressants, TCAs have been the most common poisons used in suicide. Increasing age was a powerful determinant of suicide. Some patients may have stockpiled their TCAs for a while before their TCA overdose. Other suicide victims may have used TCA supplies from family members. Hence, some of the suicide victims may not have taken TCAs on a regular basis before committing suicide. Further exploration of TCA-induced suicidal thoughts is needed. Conclusions cannot be made at the time about the precise role that TCAs played in TCA-induced suicide reported in our study.

Research paper thumbnail of Posttraumatic Stress Disorder in Male Military Veterans With Comorbid Overweight and Obesity

The Primary Care Companion To The Journal of Clinical Psychiatry, 2006

Posttraumatic stress disorder (PTSD) is an important syndrome among military veterans. Little has... more Posttraumatic stress disorder (PTSD) is an important syndrome among military veterans. Little has been written about comorbid medical conditions of PTSD, particularly overweight and obesity. We focus on psychotropic and non-psychotropic drugs, their interactions, and metabolic issues most relevant to primary care physicians. Data from the recently constituted PTSD program at the Department of Veterans Affairs Medical Center in Richmond, Va., were retrospectively reviewed to assess the prevalence and severity of comorbid overweight and obesity in male veterans with PTSD. Also, our database allowed us to correlate various drugs used to treat hypertension, diabetes mellitus, and dyslipidemia with body mass index (BMI). The mean BMI of 157 veterans with PTSD (DSM-IV criteria) in this sample was in the obese range (30.3 ± 5.6 kg/m²). The number of drugs a given patient was taking for treatment of hypertension, diabetes mellitus, and dyslipidemia correlated with BMI. Psychotropic drugs associated with weight gain did not explain our findings. Overweight and obesity among our male veterans with PTSD strikingly exceeded national findings. The administration of psychotropic drugs associated with weight gain did not explain these findings. The number of medications used to treat hypertension, diabetes mellitus, and dyslipidemia correlated significantly with BMI. Rather than these medications explaining the high prevalence of overweight and obesity in our study population, obesity probably worsened these components of the metabolic syndrome, necessitating more aggressive treatment reflected in the high number of drugs prescribed.

Research paper thumbnail of Psychotropic Drug Considerations in Depressed Patients with Metabolic Disturbances

American Journal of Medicine, 2008

Depression, obesity, diabetes mellitus, and the metabolic syndrome are conditions commonly treate... more Depression, obesity, diabetes mellitus, and the metabolic syndrome are conditions commonly treated in primary care. The prevalence of each condition separately does not explain the frequency of their co-occurrence. Depression may lead to or exacerbate these endocrine and metabolic conditions. Conversely, these medical conditions may lead to or exacerbate depression. Psychotropic drugs that treat depression may increase appetite with resultant weight gain. Rarely, such agents may be associated with weight loss. We review the potential for psychotropic drugs to alter body weight and provide a figure as a guide to drug selection. Unless circumstances dictate otherwise, clinicians should select psychotropic drugs least likely to induce weight gain when treating depressed patients with obesity, diabetes mellitus, or the metabolic syndrome. Even drugs generally thought to be "weight neutral" may occasionally be associated with weight gain. Thus, alerting patients to this potential and due diligence form the cornerstone of weight management in the depressed patient.

Research paper thumbnail of Patient and direct-care staff body mass index in a state mental hospital: implications for management

Acta Psychiatrica Scandinavica, 2004

Research paper thumbnail of Proarrhythmic Risk with Antipsychotic and Antidepressant Drugs: Implications in the Elderly

Drugs & Aging, 2009

The quinidine-like effects of some antidepressant drugs (particularly tricyclic antidepressants) ... more The quinidine-like effects of some antidepressant drugs (particularly tricyclic antidepressants) and many antipsychotic drugs (particularly the phenothiazines) confound treatment of psychosis and depression in patients with major mental illness. This is especially true among elderly patients with existing risk factors for corrected QT (QTc) interval prolongation. We used PubMed, previously reported review articles and the extensive personal files of the authors to identify cases of subjects aged&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or=60 years who developed QTc interval prolongation, polymorphic ventricular tachycardia (PVT)/torsade de pointes (TdP) and/or sudden cardiac death while taking antipsychotic or antidepressant drugs or a combination of these medications. We identified 37 patients who had taken, in total, 46 antipsychotic or antidepressant drugs. Our most striking finding was that almost four-fifths of our cases involved women. When the 14 critically ill subjects receiving haloperidol intravenously were excluded, 91.3% of our subjects were women. Almost three-quarters of our study subjects had cardiovascular disease. Intravenous administration of haloperidol in the critically ill and profoundly agitated elderly warrants particular comment. Of the 14 subjects in this category identified, six were men and eight were women. In 13 cases, the drug dose far exceeded the 2 mg necessary to produce an antipsychotic effect. These clinicians were using an agent to achieve sedation that usually requires very high doses in the critically ill and profoundly agitated elderly to achieve this effect. Inclusion criteria for our literature review required antipsychotic and/or antidepressant drug-induced QTc interval prolongation. Even so, our finding that 31 of our 37 subjects developed PVT is sobering. However, the reader should not conclude that drug-induced QTc interval prolongation is highly predictive of PVT or its TdP subtype. All of our study subjects had at least two risk factors for TdP, with age and sex being the most common. We included the rare case of a patient with congenital long QT syndrome who developed further lengthening of the QTc interval and TdP when prescribed an antidepressant drug well known to produce QTc interval prolongation. We conclude with recommendations for clinicians not expert in the specialty of cardiology to deal with the many questions raised in this review. Specifically, such clinicians treating elderly patients with antipsychotic and antidepressant drugs that may prolong the QTc interval should aggressively obtain a baseline ECG for elderly female patients with additional risk factors such as personal or family history of pre-syncope or syncope, electrolyte disturbances or cardiovascular disease. Elderly male patients are also subject to QTc interval prolongation when such risk factors are present. It is important that the clinicians themselves inspect ECGs. If the QT interval is more than half the RR interval, QTc interval prolongation is likely to be present. In such cases, a cardiology colleague interested in QTc interval issues and TdP should be asked to review the ECG. Finally, nothing in our recommendations replaces meticulous attention to US FDA guidelines in the package insert of each drug.

Research paper thumbnail of Posttraumatic Stress Disorder and Body Mass Index in Military Veterans: The Richmond Experience

Stress, Trauma, and Crisis: An International Journal, 2006

Military veterans suffering from Posttraumatic Stress Disorder (PTSD) often have comorbid conditi... more Military veterans suffering from Posttraumatic Stress Disorder (PTSD) often have comorbid conditions including obesity. They may become disabled either from these comorbid conditions or from PTSD (or from both). Service-connected disability (SCD) is a concept employed by both the Department of Defense and the Department of Veterans Affairs to identify and compensate military veterans with such disabilities. SCD could serve as a measure of the functional impact of PTSD and comorbid obesity and other medical conditions. We reviewed the database of the recently constituted PTSD program at Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, Virginia. Variables assessed included 1) age, 2) decade of life, 3) height, 4) weight, 5) sex, 6) race, 7) employment status, 8) presence or absence of comorbid psychiatric conditions, 9) presence or absence of comorbid medical conditions, and 10) degree of disability. From the height and weight measurements, we calculated body mass index (BMI). We used SCD to estimate degree of disability in terms of total disability (total SCD) and disability ascribed to PTSD (PTSD-SCD). Results indicated that the mean BMI of the study population was 30.3±5.7 kg/m2. This value was consistent with the current definition of obesity. 83.8% of our study population was either overweight or obese. This rate exceeded the US general population level of 64.5%. SCD and comorbid medical conditions had statistically significant relationships with obesity. Race was almost a statistically significant predictor of obesity. Decade of life, employment status and presence/absence of comorbid psychiatric condition did not separate the obese veteran from the non-obese veteran. Analysis of variance (ANOVA) revealed statistical significant differences in BMI (df = 4, F = 2.921, p = 0.022)among various levels of SCD suggesting a threshold effect. PTSD-related SCD, however, did not have a significant relationship with BMI. The prevalence of overweight and obesity among our sample of veterans with PTSD exceeded current U.S. population rates. Comorbid medical conditions may predispose veterans with PTSD to obesity. SCD had a significant relationship with BMI in that there was a threshold effect in which 30% or greater SCD identified veterans with obesity. The cross-sectional nature of the study and the absence of control populations limit the conclusions that may be drawn from our study. Clearly, more definitive studies are needed with much larger study populations.

Research paper thumbnail of Cardiovascular side effects of newer antidepressants

We review the cardiovascular effects of newer antidepressants. Although further studies are warra... more We review the cardiovascular effects of newer antidepressants. Although further studies are warranted, the safety of the selective serotonin reuptake inhibitors and the serotonin norepinephrine reuptake inhibitors on patients with comorbid cardiac conditions is impressive. Newer antidepressants should be considered as first-line agents for the treatment of depression in patients with and without cardiovascular disease.

Research paper thumbnail of Toxicology Findings in Child and Adolescent Suicides in Virginia

The Primary Care Companion To The Journal of Clinical Psychiatry, 2006

In a follow-up report of child and adolescent suicides in Virginia, we describe postmortem toxico... more In a follow-up report of child and adolescent suicides in Virginia, we describe postmortem toxicology findings in a subset of these youths. We analyzed &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;unnatural&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; deaths from Virginia&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Office of the Chief Medical Examiner for 1987 to 2003. There were 2818 unnatural deaths in children and adolescents. We grouped unnatural deaths as accidents, homicides, and suicides. Toxicology records were available for 753 cases, of which 732 were black or white youths. There were no age differences among suicide victims and accident or homicide victims. Whites were more likely than blacks to die by accident and suicide. White females were more likely than black females to commit suicide. Black males were more likely than white males to suffer homicide. For all unexpected deaths, antidepressants were more commonly found among whites than blacks. Suicide by poisoning occurred more commonly among whites. Recreational drugs were more commonly found among blacks than whites. Suicide by gun occurred more commonly among blacks. Antidepressants were found in 39 black and white suicide victims. Anti-depressants (all tricyclic antidepressants) were causally related in 17 cases of suicide by poisoning. No other antidepressants were found in lethal levels in suicide by poisoning. Selective serotonin reuptake inhibitors (SSRIs)/venlafaxine appeared more commonly in the suicides (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001) than in accidents or homicides. For suicides, SSRIs appeared no more commonly in poisoning than in gun or hanging deaths (p = .695). Antidepressants appeared more commonly among youths committing suicide than those dying by accident or homicide. SSRIs did not appear more commonly among youths committing suicide by poisoning than those committing suicide by gun or hanging. Because our data are descriptive, they are subject to over-interpretation. Cause-effect inferences should not be drawn.

Research paper thumbnail of Posttraumatic stress disorder and body mass index in military veterans

Progress in Neuro-psychopharmacology & Biological Psychiatry, 2006

Introduction: Current management of posttraumatic stress disorder (PTSD) focuses on the psychiatr... more Introduction: Current management of posttraumatic stress disorder (PTSD) focuses on the psychiatric parameters of this condition. Little has been written about co-morbid overweight and obesity in PTSD. Methods: We used the database of the recently constituted PTSD program at the Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, Virginia to assess and better understand the prevalence and severity of overweight and obesity among military veterans with PTSD. Variables assessed included age, decade of life, height, weight, sex, race, and severity and chronicity of PTSD. We used PTSD CheckList-Military Version (PCL-M) to assess current complaints and service-connected disability (SCD) to estimate the long-term severity of PTSD. Results: Of the 221 male veterans extracted from our PTSD database for purposes of this study, 144 (65.2%) were in the age range of 50 to 59 years consistent with Vietnam veterans dominating our study population. Their mean body mass index (BMI) was 30.2 ± 5.8 kg/m 2 placing the typical veteran in the obese range. Far exceeding the current US population rate of 64.5%, 82.8% of our study population was either overweight or obese. Our sample had BMI measurements greater than those reported for non-PTSD veterans and also BMI measurements reported in the literature for veterans with PTSD. Current (PCL-M) and long-term (SCD) markers of PTSD did not relate to obesity. Conclusions: The prevalence of overweight and obesity among our veterans with PTSD far exceeded current US population findings and those of other veteran groups with and without PTSD. PTSD symptoms, whether assessed acutely or chronically, did not explain our findings. Prospective studies of PTSD and comorbidity are needed using larger study populations to better understand the relationships among PTSD, stress, and obesity.

Research paper thumbnail of Posttraumatic Stress Disorder in Male Military Veterans With Comorbid Overweight and Obesity: Psychotropic, Antihypertensive, and Metabolic Medications

Little has been written about comorbid medical conditions of PTSD, particularly overweight and ob... more Little has been written about comorbid medical conditions of PTSD, particularly overweight and obesity. We focus on psychotropic and non-psychotropic drugs, their interactions, and metabolic issues most relevant to primary care physicians.

Research paper thumbnail of Posttraumatic stress disorder as a risk factor for obesity among male military veterans

Acta Psychiatrica Scandinavica, 2007

Objective: Obesity is a significant public health problem in the United States, particularly amo... more Objective: Obesity is a significant public health problem in the United States, particularly among military veterans with multiple risk factors. Heretofore, posttraumatic stress disorder (PTSD) has not clearly been identified as a risk factor for this condition.Method: We accessed both a national and local database of PTSD veterans.Results: Body mass index (BMI) was greater (P < 0.0001) among male military veterans (n = 1819) with PTSD (29.28 ± 6.09 kg/m2) than those veterans (n = 44 959) without PTSD (27.61 ± 5.99 kg/m2) in a sample of randomly selected veterans from the national database. In the local database of male military veterans with PTSD, mean BMI was in the obese range (30.00 ± 5.65) and did not vary by decade of life (P = 0.242).Conclusion: Posttraumatic stress disorder may be a risk factor for overweight and obesity among male military veterans.

Research paper thumbnail of Toxicology Findings in Child and Adolescent Suicides in Virginia: 1987-2003

Research paper thumbnail of Clinical monitoring and management of the metabolic syndrome in patients receiving atypical antipsychotic medications

Primary Care Diabetes, 2009

Please cite this article in press as: M. Hasnain, et al., Clinical monitoring and management of t... more Please cite this article in press as: M. Hasnain, et al., Clinical monitoring and management of the metabolic syndrome in patients receiving atypical antipsychotic medications, Prim.