Sherry Boschert

LAS VEGAS – Traditional techniques for anchoring cartilage grafts after Mohs surgery on the nose might be more complicated than necessary.

Well-known textbook descriptions of cartilage grafting for alar rim reconstruction involve harvesting a large piece of cartilage and securing the grafted cartilage with multiple sutures medially to the lower lateral cartilage and laterally to the periosteum of the piriform aperture of the maxilla.

This technique is appropriate for large defects that require reconstruction of the entire alar subunit, but is unnecessary for many of the smaller alar defects that commonly are encountered in Mohs surgery, Dr. Ravi S. Krishnan said.

"While this does produce nice results, I don't like it for two reasons," he said at the annual meeting of the American College of Mohs Surgery. "It requires a very large cartilage graft, and it often requires more effort than you sometimes need."

In his approach to performing a cartilage graft with a skin graft on top of it, he starts the conventional way by making some stab incisions on either side of the wound to create a pocket for the cartilage graft. What most surgeons would do next is to place either a figure-of-eight suture or some interrupted sutures to hold the graft in place.

"While these techniques are fine, I sometimes still have problems with them getting the cartilage graft flush against the alar remnant," noted Dr. Krishnan of Virginia Mason Medical Center, Seattle.

Instead, he starts suturing from inside the nose, pushing the suture through the nose behind the cartilage graft, then pulling it back through the cartilage graft and the nose, finally pulling inferiorly as the knot is tied. He repeats this process, so that there are two sutures anchoring the cartilage graft along the alar rim. These sutures are left in place for 2 weeks to allow some fibrosis to occur.

"The reason I like this technique is because it pulls the graft inferiorly so that it's perfectly flush against the alar rim remnant," he said. It also leaves more of the wound base exposed so that any overlying skin graft will be well perfused.

This is not necessarily a new technique, Dr. Krishnan said, but he could find no published description of it. It doesn't necessarily give better results, but it's easier to execute than are traditional methods, he added.

His techniques for anchoring cartilage grafts along the alar rim also work well with flaps including nasolabial transposition flaps, bilobed flaps, and interpolated paranasal flaps, resulting in good contour and symmetry and very acceptable results, he believes.

He typically follows these patients for 6 months after surgery, and while it's possible that the cartilage graft could shift after 6 months, "I doubt this would be the case."

One small drawback is that epithelium can start growing over the anchoring sutures during the 2 weeks that they are left in place, making them difficult to remove.

"Some people worry about infection, but I've never seen an infection with this technique," he added. All patients in his practice that receive cartilage grafts get perioperative antibiotics.

The advantages outweigh any potential drawbacks of the technique, in his opinion. It's easy to perform, and results are at least as good as those with more difficult techniques. His method precisely places the cartilage "exactly where you want it" along the alar rim, and apposes the cartilage graft to the mucosal lining, he said. When used in conjunction with a full-thickness skin graft, it allows the skin graft to come into contact with as much of the base of the wound as possible.

"It is important to remember that this technique is applicable only to smaller alar defects," he said. "For larger alar defects, using a large cartilage graft secured in the traditional manner is the preferred approach."

Dr. Krishnan said he has no relevant financial disclosures.

LAS VEGAS – Traditional techniques for anchoring cartilage grafts after Mohs surgery on the nose might be more complicated than necessary.

Well-known textbook descriptions of cartilage grafting for alar rim reconstruction involve harvesting a large piece of cartilage and securing the grafted cartilage with multiple sutures medially to the lower lateral cartilage and laterally to the periosteum of the piriform aperture of the maxilla.

This technique is appropriate for large defects that require reconstruction of the entire alar subunit, but is unnecessary for many of the smaller alar defects that commonly are encountered in Mohs surgery, Dr. Ravi S. Krishnan said.

"While this does produce nice results, I don't like it for two reasons," he said at the annual meeting of the American College of Mohs Surgery. "It requires a very large cartilage graft, and it often requires more effort than you sometimes need."

In his approach to performing a cartilage graft with a skin graft on top of it, he starts the conventional way by making some stab incisions on either side of the wound to create a pocket for the cartilage graft. What most surgeons would do next is to place either a figure-of-eight suture or some interrupted sutures to hold the graft in place.

"While these techniques are fine, I sometimes still have problems with them getting the cartilage graft flush against the alar remnant," noted Dr. Krishnan of Virginia Mason Medical Center, Seattle.

Instead, he starts suturing from inside the nose, pushing the suture through the nose behind the cartilage graft, then pulling it back through the cartilage graft and the nose, finally pulling inferiorly as the knot is tied. He repeats this process, so that there are two sutures anchoring the cartilage graft along the alar rim. These sutures are left in place for 2 weeks to allow some fibrosis to occur.

"The reason I like this technique is because it pulls the graft inferiorly so that it's perfectly flush against the alar rim remnant," he said. It also leaves more of the wound base exposed so that any overlying skin graft will be well perfused.

This is not necessarily a new technique, Dr. Krishnan said, but he could find no published description of it. It doesn't necessarily give better results, but it's easier to execute than are traditional methods, he added.

His techniques for anchoring cartilage grafts along the alar rim also work well with flaps including nasolabial transposition flaps, bilobed flaps, and interpolated paranasal flaps, resulting in good contour and symmetry and very acceptable results, he believes.

He typically follows these patients for 6 months after surgery, and while it's possible that the cartilage graft could shift after 6 months, "I doubt this would be the case."

One small drawback is that epithelium can start growing over the anchoring sutures during the 2 weeks that they are left in place, making them difficult to remove.

"Some people worry about infection, but I've never seen an infection with this technique," he added. All patients in his practice that receive cartilage grafts get perioperative antibiotics.

The advantages outweigh any potential drawbacks of the technique, in his opinion. It's easy to perform, and results are at least as good as those with more difficult techniques. His method precisely places the cartilage "exactly where you want it" along the alar rim, and apposes the cartilage graft to the mucosal lining, he said. When used in conjunction with a full-thickness skin graft, it allows the skin graft to come into contact with as much of the base of the wound as possible.

"It is important to remember that this technique is applicable only to smaller alar defects," he said. "For larger alar defects, using a large cartilage graft secured in the traditional manner is the preferred approach."

Dr. Krishnan said he has no relevant financial disclosures.

LAS VEGAS – Traditional techniques for anchoring cartilage grafts after Mohs surgery on the nose might be more complicated than necessary.

Well-known textbook descriptions of cartilage grafting for alar rim reconstruction involve harvesting a large piece of cartilage and securing the grafted cartilage with multiple sutures medially to the lower lateral cartilage and laterally to the periosteum of the piriform aperture of the maxilla.

This technique is appropriate for large defects that require reconstruction of the entire alar subunit, but is unnecessary for many of the smaller alar defects that commonly are encountered in Mohs surgery, Dr. Ravi S. Krishnan said.

"While this does produce nice results, I don't like it for two reasons," he said at the annual meeting of the American College of Mohs Surgery. "It requires a very large cartilage graft, and it often requires more effort than you sometimes need."

In his approach to performing a cartilage graft with a skin graft on top of it, he starts the conventional way by making some stab incisions on either side of the wound to create a pocket for the cartilage graft. What most surgeons would do next is to place either a figure-of-eight suture or some interrupted sutures to hold the graft in place.

"While these techniques are fine, I sometimes still have problems with them getting the cartilage graft flush against the alar remnant," noted Dr. Krishnan of Virginia Mason Medical Center, Seattle.

Instead, he starts suturing from inside the nose, pushing the suture through the nose behind the cartilage graft, then pulling it back through the cartilage graft and the nose, finally pulling inferiorly as the knot is tied. He repeats this process, so that there are two sutures anchoring the cartilage graft along the alar rim. These sutures are left in place for 2 weeks to allow some fibrosis to occur.

"The reason I like this technique is because it pulls the graft inferiorly so that it's perfectly flush against the alar rim remnant," he said. It also leaves more of the wound base exposed so that any overlying skin graft will be well perfused.

This is not necessarily a new technique, Dr. Krishnan said, but he could find no published description of it. It doesn't necessarily give better results, but it's easier to execute than are traditional methods, he added.

His techniques for anchoring cartilage grafts along the alar rim also work well with flaps including nasolabial transposition flaps, bilobed flaps, and interpolated paranasal flaps, resulting in good contour and symmetry and very acceptable results, he believes.

He typically follows these patients for 6 months after surgery, and while it's possible that the cartilage graft could shift after 6 months, "I doubt this would be the case."

One small drawback is that epithelium can start growing over the anchoring sutures during the 2 weeks that they are left in place, making them difficult to remove.

"Some people worry about infection, but I've never seen an infection with this technique," he added. All patients in his practice that receive cartilage grafts get perioperative antibiotics.

The advantages outweigh any potential drawbacks of the technique, in his opinion. It's easy to perform, and results are at least as good as those with more difficult techniques. His method precisely places the cartilage "exactly where you want it" along the alar rim, and apposes the cartilage graft to the mucosal lining, he said. When used in conjunction with a full-thickness skin graft, it allows the skin graft to come into contact with as much of the base of the wound as possible.

"It is important to remember that this technique is applicable only to smaller alar defects," he said. "For larger alar defects, using a large cartilage graft secured in the traditional manner is the preferred approach."

Dr. Krishnan said he has no relevant financial disclosures.

HONOLULU – The use of Internet-based cognitive-behavioral therapy could cure half of patients with internalizing mental disorders, including depression, social phobia, panic disorder, and generalized anxiety disorder, a review of data suggests.

Internalizing disorders account for half of mental disorders, Dr. Gavin P. Andrews said at the annual meeting of the American Psychiatric Association.

"A quarter of the burden of mental disorders is potentially removable by Internet-based cognitive-behavioral therapy" (CBT), said Dr. Andrews, professor of psychiatry at the University of New South Wales, Sydney, Australia. "If our profession could get a handle on effective treatment for internalizing disorders, we’d make a fundamental move forward."

Internet-based CBT is a self-help program mediated through the Internet. The patient is in contact through e-mail with the person directing the therapy, which consists of psychoeducation and various exercises are completed online.

Dr. Andrews and his associates conducted a review of the literature and metaanalysis of data from 22 studies of Internet-based CBT involving 1,746 patients. The effect-size superiority over comparison groups was larger than the effect-size superiority traditionally seen for treatment of anxiety disorders using face-to-face CBT or selective serotonin reuptake inhibitors (SSRIs), compared with control groups, he said.

For each of the disorders (depression, social phobia, panic disorder, and generalized anxiety disorder), the number needed to treat with Internet-based CBT in order to show an effect was two (PLoS One 2010;5:e13196).

"Treat two people and one gets better. This is powerful treatment in psychiatry. It’s powerful treatment in medicine," said Dr. Andrews, who is a member of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group for the DSM-5.

The effects of Internet-based CBT appear to last, he added. Although the median follow-up time in the studies was approximately 6 months, some Swedish studies had 18-month follow-up data.

"There was no hint of relapse reported in any study, which is just foreign to my experience," he said. "Depression is supposed to be a relapsing and recurring disorder. What on earth is it doing just disappearing after someone does CBT over the Web? This is not what any of us were trained for."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

Dr. Andrews said the study was commissioned by the Journal of the American Medical Association, which declined to publish the results. He and his associates have now published 15 randomized, controlled trials, including approximately 1,500 people showing the effectiveness of Internet-based CBT, he said.

In a recent randomized, controlled study, Dr. Andrews and his associates tested the third iteration of transdiagnostic Internet-based CBT that they developed for patients with depression, social phobia, panic disorder, or generalized anxiety disorder. The study, recently published online in advance of print, compared 75 patients who underwent the clinician-guided Internet-based CBT or were on a waiting list for treatment. (Behav. Res. and Therapy 2011 [doi: 10.1016/j.brat.2011.03.007]). The effect-size superiority of the Internet-based CBT was 0.6 a measured on the Depression Anxiety Stress Scales, he said, roughly equivalent to effect sizes seen previously with face-to-face CBT or SSRI treatment. Measures of adherence showed that 76% of patients finished all eight of the Internet-based CBT lessons. Therapist guidance amounted to 70 minutes per patient by e-mail or phone over a 10-week period, on average. About 90% of patients said they would recommend the treatment to a friend.

In general, adherence to Internet-based CBT in Dr. Andrews’s studies averages around 75% of patients, "which is definitely better than what we see in our face-to-face clinics," he said. Data from approximately 1,300 Australian primary care physicians who are using Internet-based CBT with their patients suggest that the adherence rate is 54%. "Even 54% is extraordinarily good," Dr. Andrews said.

A separate analysis by Dr. Andrews and his associates suggests that the patients using Internet-based CBT are similar to patients seen in face-to-face CBT clinics. Among patients with depression, most are treatment experienced, with a history of multiple episodes of depression that began before age 20 years. "Those would not be easy cases," he said.

The simplicity, accessibility, and effectiveness of Internet-based CBT make it a powerful tool for treating internalizing mental disorders, but one that could downgrade the central role of the clinician in treating patients with these problems, he suggested. "You and I were trained that we were the key variable, and it offends me" to be usurped, he said facetiously.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

Dr. Andrews said he has no relevant conflicts of interest.

HONOLULU – The use of Internet-based cognitive-behavioral therapy could cure half of patients with internalizing mental disorders, including depression, social phobia, panic disorder, and generalized anxiety disorder, a review of data suggests.

Internalizing disorders account for half of mental disorders, Dr. Gavin P. Andrews said at the annual meeting of the American Psychiatric Association.

"A quarter of the burden of mental disorders is potentially removable by Internet-based cognitive-behavioral therapy" (CBT), said Dr. Andrews, professor of psychiatry at the University of New South Wales, Sydney, Australia. "If our profession could get a handle on effective treatment for internalizing disorders, we’d make a fundamental move forward."

Internet-based CBT is a self-help program mediated through the Internet. The patient is in contact through e-mail with the person directing the therapy, which consists of psychoeducation and various exercises are completed online.

Dr. Andrews and his associates conducted a review of the literature and metaanalysis of data from 22 studies of Internet-based CBT involving 1,746 patients. The effect-size superiority over comparison groups was larger than the effect-size superiority traditionally seen for treatment of anxiety disorders using face-to-face CBT or selective serotonin reuptake inhibitors (SSRIs), compared with control groups, he said.

For each of the disorders (depression, social phobia, panic disorder, and generalized anxiety disorder), the number needed to treat with Internet-based CBT in order to show an effect was two (PLoS One 2010;5:e13196).

"Treat two people and one gets better. This is powerful treatment in psychiatry. It’s powerful treatment in medicine," said Dr. Andrews, who is a member of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group for the DSM-5.

The effects of Internet-based CBT appear to last, he added. Although the median follow-up time in the studies was approximately 6 months, some Swedish studies had 18-month follow-up data.

"There was no hint of relapse reported in any study, which is just foreign to my experience," he said. "Depression is supposed to be a relapsing and recurring disorder. What on earth is it doing just disappearing after someone does CBT over the Web? This is not what any of us were trained for."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

Dr. Andrews said the study was commissioned by the Journal of the American Medical Association, which declined to publish the results. He and his associates have now published 15 randomized, controlled trials, including approximately 1,500 people showing the effectiveness of Internet-based CBT, he said.

In a recent randomized, controlled study, Dr. Andrews and his associates tested the third iteration of transdiagnostic Internet-based CBT that they developed for patients with depression, social phobia, panic disorder, or generalized anxiety disorder. The study, recently published online in advance of print, compared 75 patients who underwent the clinician-guided Internet-based CBT or were on a waiting list for treatment. (Behav. Res. and Therapy 2011 [doi: 10.1016/j.brat.2011.03.007]). The effect-size superiority of the Internet-based CBT was 0.6 a measured on the Depression Anxiety Stress Scales, he said, roughly equivalent to effect sizes seen previously with face-to-face CBT or SSRI treatment. Measures of adherence showed that 76% of patients finished all eight of the Internet-based CBT lessons. Therapist guidance amounted to 70 minutes per patient by e-mail or phone over a 10-week period, on average. About 90% of patients said they would recommend the treatment to a friend.

In general, adherence to Internet-based CBT in Dr. Andrews’s studies averages around 75% of patients, "which is definitely better than what we see in our face-to-face clinics," he said. Data from approximately 1,300 Australian primary care physicians who are using Internet-based CBT with their patients suggest that the adherence rate is 54%. "Even 54% is extraordinarily good," Dr. Andrews said.

A separate analysis by Dr. Andrews and his associates suggests that the patients using Internet-based CBT are similar to patients seen in face-to-face CBT clinics. Among patients with depression, most are treatment experienced, with a history of multiple episodes of depression that began before age 20 years. "Those would not be easy cases," he said.

The simplicity, accessibility, and effectiveness of Internet-based CBT make it a powerful tool for treating internalizing mental disorders, but one that could downgrade the central role of the clinician in treating patients with these problems, he suggested. "You and I were trained that we were the key variable, and it offends me" to be usurped, he said facetiously.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

Dr. Andrews said he has no relevant conflicts of interest.

HONOLULU – The use of Internet-based cognitive-behavioral therapy could cure half of patients with internalizing mental disorders, including depression, social phobia, panic disorder, and generalized anxiety disorder, a review of data suggests.

Internalizing disorders account for half of mental disorders, Dr. Gavin P. Andrews said at the annual meeting of the American Psychiatric Association.

"A quarter of the burden of mental disorders is potentially removable by Internet-based cognitive-behavioral therapy" (CBT), said Dr. Andrews, professor of psychiatry at the University of New South Wales, Sydney, Australia. "If our profession could get a handle on effective treatment for internalizing disorders, we’d make a fundamental move forward."

Internet-based CBT is a self-help program mediated through the Internet. The patient is in contact through e-mail with the person directing the therapy, which consists of psychoeducation and various exercises are completed online.

Dr. Andrews and his associates conducted a review of the literature and metaanalysis of data from 22 studies of Internet-based CBT involving 1,746 patients. The effect-size superiority over comparison groups was larger than the effect-size superiority traditionally seen for treatment of anxiety disorders using face-to-face CBT or selective serotonin reuptake inhibitors (SSRIs), compared with control groups, he said.

For each of the disorders (depression, social phobia, panic disorder, and generalized anxiety disorder), the number needed to treat with Internet-based CBT in order to show an effect was two (PLoS One 2010;5:e13196).

"Treat two people and one gets better. This is powerful treatment in psychiatry. It’s powerful treatment in medicine," said Dr. Andrews, who is a member of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group for the DSM-5.

The effects of Internet-based CBT appear to last, he added. Although the median follow-up time in the studies was approximately 6 months, some Swedish studies had 18-month follow-up data.

"There was no hint of relapse reported in any study, which is just foreign to my experience," he said. "Depression is supposed to be a relapsing and recurring disorder. What on earth is it doing just disappearing after someone does CBT over the Web? This is not what any of us were trained for."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

Dr. Andrews said the study was commissioned by the Journal of the American Medical Association, which declined to publish the results. He and his associates have now published 15 randomized, controlled trials, including approximately 1,500 people showing the effectiveness of Internet-based CBT, he said.

In a recent randomized, controlled study, Dr. Andrews and his associates tested the third iteration of transdiagnostic Internet-based CBT that they developed for patients with depression, social phobia, panic disorder, or generalized anxiety disorder. The study, recently published online in advance of print, compared 75 patients who underwent the clinician-guided Internet-based CBT or were on a waiting list for treatment. (Behav. Res. and Therapy 2011 [doi: 10.1016/j.brat.2011.03.007]). The effect-size superiority of the Internet-based CBT was 0.6 a measured on the Depression Anxiety Stress Scales, he said, roughly equivalent to effect sizes seen previously with face-to-face CBT or SSRI treatment. Measures of adherence showed that 76% of patients finished all eight of the Internet-based CBT lessons. Therapist guidance amounted to 70 minutes per patient by e-mail or phone over a 10-week period, on average. About 90% of patients said they would recommend the treatment to a friend.

In general, adherence to Internet-based CBT in Dr. Andrews’s studies averages around 75% of patients, "which is definitely better than what we see in our face-to-face clinics," he said. Data from approximately 1,300 Australian primary care physicians who are using Internet-based CBT with their patients suggest that the adherence rate is 54%. "Even 54% is extraordinarily good," Dr. Andrews said.

A separate analysis by Dr. Andrews and his associates suggests that the patients using Internet-based CBT are similar to patients seen in face-to-face CBT clinics. Among patients with depression, most are treatment experienced, with a history of multiple episodes of depression that began before age 20 years. "Those would not be easy cases," he said.

The simplicity, accessibility, and effectiveness of Internet-based CBT make it a powerful tool for treating internalizing mental disorders, but one that could downgrade the central role of the clinician in treating patients with these problems, he suggested. "You and I were trained that we were the key variable, and it offends me" to be usurped, he said facetiously.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

Dr. Andrews said he has no relevant conflicts of interest.

HONOLULU – Twenty minutes per day of either meditation or relaxation improved depression scores in family caregivers of people with dementia, but meditation seemed to provide additional benefits in a randomized, controlled pilot study in 39 caregivers.

Mental functioning and cognition scores improved significantly in the meditation group, compared with the relaxation group, Dr. Helen Lavretsky and Dr. Michael Irwin reported in a poster presentation at the annual meeting of the American Psychiatric Association. Both are professors of psychiatry and biobehavioral sciences at the University of California, Los Angeles.

The 23 caregivers in the meditation group averaged 61 years of age and the 16 caregivers in the relaxation group averaged 61 years of age. They had been caring for a family member with dementia for 5 years and 4 years, respectively. Participants in the relaxation group spent significantly more time per week in caregiving, averaging 63 hours vs. 48 in the meditation group. Hamilton Rating Scale–Depression (HAM-D) scores at baseline were 11.8 in the meditation group and 11.4 in the relaxation group.

Participants in the meditation group were trained in a yoga practice of meditation called Kirtan Kriya that involves chanting, breath work, and finger poses. Participants in the control group were asked to rest quietly while listening to relaxation recordings. Each group devoted 20 minutes per day to the activity for 8 weeks.

In both groups, devoting time each day to self-care was new to participants, all but two of whom were women, Dr. Lavretsky said in an interview.

HAM-D scores improved by 7 points in the meditation group and by 5 points in the relaxation group, a difference that was not statistically significant. The perceived burden of care improved in both groups, too.

In the meditation group, however, 52% showed at least a 50% improvement on the 36-item short form health survey (SF-36) global mental health score, compared with 19% in the relaxation group, which was a significant difference between groups.

Measures of cognition also improved significantly in the meditation group, compared with the control group. Mini-Mental Status Examination scores increased by 0.2 points in the meditation group and decreased by 0.9 points in the relaxation group. Times to complete the Trail Making Test (Part B), a measure of executive function, decreased by 11.2 seconds in the meditation group but increased by 9.9 seconds in the relaxation group.

Preliminary data from several other measures in the study suggest biological differences in outcomes, Dr. Lavretsky said. Intranuclear staining and flow cytometry showed that a significantly lower proportion of lymphocytes was positive for nuclear transcription factor–kappa beta (a protein complex that has been linked to chronic stress and inflammatory responses) in the meditation practitioners, compared with the control group. The meditation group also showed increased telomerase activity, compared with the relaxation group. Telomere length and telomerase activity are markers of biological age linking stress and disease, she said.

PET scan results suggested that improvements in cognition were associated with changes in regional brain metabolism in areas relevant for executive dysfunction and global cognition.

This and other studies suggest that meditation, tai chi, or other mind-body techniques seem to be helpful stress-reducing therapies for family caregivers of people with dementia, Dr. Lavretsky said.

A larger study is planned that also will compare the Kirtan Kriya form of meditation with aerobic exercise in stressed family caregivers of people with dementia, she said.

The Alzheimer’s Research and Prevention Foundation funded the study. Dr. Lavretsky is a certified yoga instructor who has practices the Kirtan Kriya form of meditation.

HONOLULU – Twenty minutes per day of either meditation or relaxation improved depression scores in family caregivers of people with dementia, but meditation seemed to provide additional benefits in a randomized, controlled pilot study in 39 caregivers.

Mental functioning and cognition scores improved significantly in the meditation group, compared with the relaxation group, Dr. Helen Lavretsky and Dr. Michael Irwin reported in a poster presentation at the annual meeting of the American Psychiatric Association. Both are professors of psychiatry and biobehavioral sciences at the University of California, Los Angeles.

The 23 caregivers in the meditation group averaged 61 years of age and the 16 caregivers in the relaxation group averaged 61 years of age. They had been caring for a family member with dementia for 5 years and 4 years, respectively. Participants in the relaxation group spent significantly more time per week in caregiving, averaging 63 hours vs. 48 in the meditation group. Hamilton Rating Scale–Depression (HAM-D) scores at baseline were 11.8 in the meditation group and 11.4 in the relaxation group.

Participants in the meditation group were trained in a yoga practice of meditation called Kirtan Kriya that involves chanting, breath work, and finger poses. Participants in the control group were asked to rest quietly while listening to relaxation recordings. Each group devoted 20 minutes per day to the activity for 8 weeks.

In both groups, devoting time each day to self-care was new to participants, all but two of whom were women, Dr. Lavretsky said in an interview.

HAM-D scores improved by 7 points in the meditation group and by 5 points in the relaxation group, a difference that was not statistically significant. The perceived burden of care improved in both groups, too.

In the meditation group, however, 52% showed at least a 50% improvement on the 36-item short form health survey (SF-36) global mental health score, compared with 19% in the relaxation group, which was a significant difference between groups.

Measures of cognition also improved significantly in the meditation group, compared with the control group. Mini-Mental Status Examination scores increased by 0.2 points in the meditation group and decreased by 0.9 points in the relaxation group. Times to complete the Trail Making Test (Part B), a measure of executive function, decreased by 11.2 seconds in the meditation group but increased by 9.9 seconds in the relaxation group.

Preliminary data from several other measures in the study suggest biological differences in outcomes, Dr. Lavretsky said. Intranuclear staining and flow cytometry showed that a significantly lower proportion of lymphocytes was positive for nuclear transcription factor–kappa beta (a protein complex that has been linked to chronic stress and inflammatory responses) in the meditation practitioners, compared with the control group. The meditation group also showed increased telomerase activity, compared with the relaxation group. Telomere length and telomerase activity are markers of biological age linking stress and disease, she said.

PET scan results suggested that improvements in cognition were associated with changes in regional brain metabolism in areas relevant for executive dysfunction and global cognition.

This and other studies suggest that meditation, tai chi, or other mind-body techniques seem to be helpful stress-reducing therapies for family caregivers of people with dementia, Dr. Lavretsky said.

A larger study is planned that also will compare the Kirtan Kriya form of meditation with aerobic exercise in stressed family caregivers of people with dementia, she said.

The Alzheimer’s Research and Prevention Foundation funded the study. Dr. Lavretsky is a certified yoga instructor who has practices the Kirtan Kriya form of meditation.

HONOLULU – Twenty minutes per day of either meditation or relaxation improved depression scores in family caregivers of people with dementia, but meditation seemed to provide additional benefits in a randomized, controlled pilot study in 39 caregivers.

Mental functioning and cognition scores improved significantly in the meditation group, compared with the relaxation group, Dr. Helen Lavretsky and Dr. Michael Irwin reported in a poster presentation at the annual meeting of the American Psychiatric Association. Both are professors of psychiatry and biobehavioral sciences at the University of California, Los Angeles.

The 23 caregivers in the meditation group averaged 61 years of age and the 16 caregivers in the relaxation group averaged 61 years of age. They had been caring for a family member with dementia for 5 years and 4 years, respectively. Participants in the relaxation group spent significantly more time per week in caregiving, averaging 63 hours vs. 48 in the meditation group. Hamilton Rating Scale–Depression (HAM-D) scores at baseline were 11.8 in the meditation group and 11.4 in the relaxation group.

Participants in the meditation group were trained in a yoga practice of meditation called Kirtan Kriya that involves chanting, breath work, and finger poses. Participants in the control group were asked to rest quietly while listening to relaxation recordings. Each group devoted 20 minutes per day to the activity for 8 weeks.

In both groups, devoting time each day to self-care was new to participants, all but two of whom were women, Dr. Lavretsky said in an interview.

HAM-D scores improved by 7 points in the meditation group and by 5 points in the relaxation group, a difference that was not statistically significant. The perceived burden of care improved in both groups, too.

In the meditation group, however, 52% showed at least a 50% improvement on the 36-item short form health survey (SF-36) global mental health score, compared with 19% in the relaxation group, which was a significant difference between groups.

Measures of cognition also improved significantly in the meditation group, compared with the control group. Mini-Mental Status Examination scores increased by 0.2 points in the meditation group and decreased by 0.9 points in the relaxation group. Times to complete the Trail Making Test (Part B), a measure of executive function, decreased by 11.2 seconds in the meditation group but increased by 9.9 seconds in the relaxation group.

Preliminary data from several other measures in the study suggest biological differences in outcomes, Dr. Lavretsky said. Intranuclear staining and flow cytometry showed that a significantly lower proportion of lymphocytes was positive for nuclear transcription factor–kappa beta (a protein complex that has been linked to chronic stress and inflammatory responses) in the meditation practitioners, compared with the control group. The meditation group also showed increased telomerase activity, compared with the relaxation group. Telomere length and telomerase activity are markers of biological age linking stress and disease, she said.

PET scan results suggested that improvements in cognition were associated with changes in regional brain metabolism in areas relevant for executive dysfunction and global cognition.

This and other studies suggest that meditation, tai chi, or other mind-body techniques seem to be helpful stress-reducing therapies for family caregivers of people with dementia, Dr. Lavretsky said.

A larger study is planned that also will compare the Kirtan Kriya form of meditation with aerobic exercise in stressed family caregivers of people with dementia, she said.

The Alzheimer’s Research and Prevention Foundation funded the study. Dr. Lavretsky is a certified yoga instructor who has practices the Kirtan Kriya form of meditation.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

HONOLULU – The stalking of physicians by patients is a real phenomenon, and physicians have not been trained how to handle it, a Canadian survey suggests.

Stalkers who target physicians are more likely to be females stalking males, the study found, while just the opposite is true for stalkers and their victims in the general population.

Stalking is defined as repeated acts that are experienced by the victim as intrusive, creating apprehension in the victim, and which can be understood by a reasonable fellow citizen to be grounds for becoming fearful, Dr. Gail E. Robinson said at the annual meeting of the American Psychiatric Association.

In the general Canadian population, 4%-9% of males and 9%-13% of females have been stalked, previous studies report. In total, 80% of offenders are male, and 75% of victims are female.

Dr. Robinson and her associates surveyed 3,159 physicians in Toronto, 37% of whom responded. They found that 177 (15%) of the 1,191 respondents had been stalked, including 11% of male respondents and 14% of female respondents, said Dr. Robinson, professor of psychiatry and obstetrics/gynecology at the University of Toronto.

The findings are consistent with previous reports suggesting that 6%-13% of health care workers have been stalked, said Dr. Robinson, who also is director of the university’s Program in Women’s Mental Health.

In the current survey, psychiatrists were the most likely to report being stalked, followed by ob.gyns., and then surgeons. Stalking was reported by 26% of psychiatrists, 16% of ob.gyns., and 16% of surgeons. Among solo practitioners, 15% reported being stalked, as did 8% of respondents in group practices.

The stalkers were patients in 67% of cases and ex-patients in 20%, with relatives, partners, or others making up the rest of the stalkers.

The toll on physician victims of stalking can be severe, yet 90% of survey respondents said they had received no education about identifying or managing stalking by patients before they were stalked.

Among physicians who had been stalked, 23% felt very or extremely embarrassed by it, which might be a factor that inhibits physicians from identifying and dealing with stalking, Dr. Robinson said. About 9% said the stalking made them very or extremely depressed, 45% felt very angry about it, and 5% said they felt very or extremely guilty.

Half of the victims said they were very or extremely frustrated by the stalking, 46% were very or extremely anxious, 40% were very or extremely frightened, 36% felt very or extremely out of control of the situation, 25% felt very or extremely helpless, and 7% felt hopeless.

Stalking also can lead to financial losses and loss of friends and freedom for the victim, she said.

Victims of stalking reported threatening behavior by the stalker in 11% of cases, vandalism in 2%, and physical harm in less than 1% of cases. Male physicians were more likely than females to report threats or harassment of family or friends by the stalkers. Male physicians were more likely than females to say that their stalkers were motivated by anger about their care, or because they were upset about an outcome.

Delusion motivated many of the stalkers, respondents said. Among physicians who said they had been stalked, 42% of women and 38% of men said the stalker was delusional.

Physicians – especially psychiatrists might have difficulty at first identifying a patient as a stalker rather than someone who is experiencing transference or some other problem that can be discussed and resolved relatively easily, Dr. Robinson said.

Victims in the survey reported warning signs of stalkers, which differed by sex. Half of male stalkers were described as "very demanding," 34% were said to be "easily angered," and 31% were described as delusional. For female stalkers, 49% were described as "very dependent," 31% showed interest in the physician’s personal life, and 28% professed love for the victim, respondents said.

Physicians can take precautions against stalking by setting clear boundaries with patients, including giving them an information sheet describing limits, Dr. Robinson said. Avoid listing private information in publicly accessible sites, and be careful what you leave out in your office or clinic, she added.

If you suspect a patient is showing prestalking or stalking behavior, restate clear boundaries in the physician-patient relationship. Clarify to the patient that there is no chance for any other kind of relationship. Consider reassessing the patient’s diagnosis, Dr. Robinson said.

Alert police about the problem early, and start recording calls and keeping any communications, she advised. Alert office staff, family, and friends about the problem. If the stalking persists, terminate your services to the patient, and do not initiate contact with the patient after the termination or respond to the patient’s attempts at contact.

Dr. Robinson said she has no relevant conflicts of interest.

SAN DIEGO – Few medical interventions both improve health and save money. Treating prediabetes with metformin is one of them, according to 10-year follow-up data from the Diabetes Prevention Program.

Intensive lifestyle intervention, the other treatment arm in the randomized, placebo-controlled Diabetes Prevention Program (DPP) study, did an even better job at improving health and quality of life, and at a favorable cost when compared with some common medical interventions for other diagnoses, Dr. William H. Herman and his associates reported at the annual scientific sessions of the American Diabetes Association.

Most of the costs for the placebo group in the ensuing decade were related to conversion of subjects’ prediabetes to diabetes, explained Dr. Herman, professor of medicine and epidemiology at the University of Michigan, Ann Arbor.

At baseline, all 3,234 participants in the DPP were nondiabetic, were overweight or obese, and had impaired glucose tolerance and an elevated fasting glucose level.

Metformin treatment (850 mg b.i.d.) reduced overall costs for medical care in those 10 years by $1,700 per person, and lifestyle intervention reduced those costs by $2,600 per person. After factoring in the costs of the interventions, the researchers found that metformin treatment produced a savings of $30 per patient compared with placebo over the 10 years.

The cost-saving benefits of metformin for people at high risk of diabetes puts this preventive intervention in a league with prenatal care, pediatric immunizations, and influenza vaccinations for people older than 65 years, Dr. Herman said. Only 1 in 10 medical interventions are cost-saving, he noted.

With the lifestyle intervention, overall costs were $1,500 per person greater than placebo, a price tag that puts lifestyle intervention for prediabetes in a league with some of the most widely accepted medical interventions when converted for comparison into quality-adjusted life-years gained.

In simple terms, the cost for a quality-adjusted life-year gained is the price "to buy 1 year of life in essentially perfect health," he explained.

In this study, the cost per quality-adjusted life-year gained with the intensive lifestyle intervention compared with the placebo group was $12,000. That $12,000 is on the low end of a $10,000-$50,000 range that’s widely accepted for medical interventions, including the use of beta-blockers after MI, the use of antihypertensive therapy for patients with very high diastolic blood pressure (greater than 105 mm Hg), or the use of statins for secondary prevention of cardiovascular disease in patients who’ve had an MI. Dialysis for end-stage renal disease costs $50,000-$100,000 per quality-adjusted life-year gained.

When the DPP results first came out, "The reaction in the medical community was, ‘This is great, but we don’t have the resources to implement it,’ " Dr. Herman said. Controversy continued due to conflicting results from analyses that modeled cost effectiveness over time based on the 3-year results of the DPP. The current study used real-life cost data collected prospectively for the study period and the following 7 years.

The results show that for patients with prediabetes, "metformin is cost saving. Intensive lifestyle intervention, though not cost saving, is extremely cost effective," Dr. Herman said. "It represents good value for the money."

The DPP’s lifestyle intervention aimed for a 7% reduction in body weight and 150 minutes per week of moderately intense physical activity, usually 30 minutes per day of brisk walking 5 days per week. Patients were asked to attend 16 sessions in a 6-month period for nutritional and exercise guidance and received ongoing follow-up with a case manager. After 3 years, the incidence of diabetes was 58% lower in the lifestyle intervention group and 31% lower with metformin compared with the placebo group (N. Engl. J. Med. 2002;346:393-403). The diabetes incidence was 5 cases per 100 person-years in the lifestyle group compared with 8 in the metformin group, and 11 in the placebo group.

During the next 7 years, patients in the metformin group were encouraged to continue the medication, and those in the lifestyle intervention group were offered a less intensive lifestyle intervention with fewer individual sessions. At the 10-year mark, the risk for developing diabetes was 34% less in the lifestyle intervention group and 18% less in the metformin group compared with the control group, Dr. Herman said. Quality of life was rated significantly higher in the metformin group compared with the placebo group, and significantly higher in the lifestyle intervention group compared with the metformin or placebo groups.

Implementation of a lifestyle intervention should be as simple as writing a prescription for a pill to prevent diabetes, Dr. Herman suggested. One way to build access to lifestyle interventions might be to locate them in cardiac rehabilitation centers, which already contain the facilities needed for exercise and other components of the intervention.

"Translating these findings into practice will reduce the development of type 2 diabetes, which has become one of the most common and costly diseases," Dr. Griffin P. Rodgers said in a statement released by the American Diabetes Association. Dr. Rodgers is director of the National Institute of Diabetes and Digestive and Kidney Diseases.

The costs of lifestyle intervention to prevent diabetes will decline over time, Dr. Herman said. The data suggest that the DPP’s intensive lifestyle intervention can be adapted into a less-expensive, but still effective, group-based model without having to reinvent everything, he added. Instead of 16 sessions in 6 months, patients may have a yearly session with a dietician.

Dr. Herman has been a consultant for McKinsey & Company.

SAN DIEGO – Few medical interventions both improve health and save money. Treating prediabetes with metformin is one of them, according to 10-year follow-up data from the Diabetes Prevention Program.

Intensive lifestyle intervention, the other treatment arm in the randomized, placebo-controlled Diabetes Prevention Program (DPP) study, did an even better job at improving health and quality of life, and at a favorable cost when compared with some common medical interventions for other diagnoses, Dr. William H. Herman and his associates reported at the annual scientific sessions of the American Diabetes Association.

Most of the costs for the placebo group in the ensuing decade were related to conversion of subjects’ prediabetes to diabetes, explained Dr. Herman, professor of medicine and epidemiology at the University of Michigan, Ann Arbor.

At baseline, all 3,234 participants in the DPP were nondiabetic, were overweight or obese, and had impaired glucose tolerance and an elevated fasting glucose level.

Metformin treatment (850 mg b.i.d.) reduced overall costs for medical care in those 10 years by $1,700 per person, and lifestyle intervention reduced those costs by $2,600 per person. After factoring in the costs of the interventions, the researchers found that metformin treatment produced a savings of $30 per patient compared with placebo over the 10 years.

The cost-saving benefits of metformin for people at high risk of diabetes puts this preventive intervention in a league with prenatal care, pediatric immunizations, and influenza vaccinations for people older than 65 years, Dr. Herman said. Only 1 in 10 medical interventions are cost-saving, he noted.

With the lifestyle intervention, overall costs were $1,500 per person greater than placebo, a price tag that puts lifestyle intervention for prediabetes in a league with some of the most widely accepted medical interventions when converted for comparison into quality-adjusted life-years gained.

In simple terms, the cost for a quality-adjusted life-year gained is the price "to buy 1 year of life in essentially perfect health," he explained.

In this study, the cost per quality-adjusted life-year gained with the intensive lifestyle intervention compared with the placebo group was $12,000. That $12,000 is on the low end of a $10,000-$50,000 range that’s widely accepted for medical interventions, including the use of beta-blockers after MI, the use of antihypertensive therapy for patients with very high diastolic blood pressure (greater than 105 mm Hg), or the use of statins for secondary prevention of cardiovascular disease in patients who’ve had an MI. Dialysis for end-stage renal disease costs $50,000-$100,000 per quality-adjusted life-year gained.

When the DPP results first came out, "The reaction in the medical community was, ‘This is great, but we don’t have the resources to implement it,’ " Dr. Herman said. Controversy continued due to conflicting results from analyses that modeled cost effectiveness over time based on the 3-year results of the DPP. The current study used real-life cost data collected prospectively for the study period and the following 7 years.

The results show that for patients with prediabetes, "metformin is cost saving. Intensive lifestyle intervention, though not cost saving, is extremely cost effective," Dr. Herman said. "It represents good value for the money."

The DPP’s lifestyle intervention aimed for a 7% reduction in body weight and 150 minutes per week of moderately intense physical activity, usually 30 minutes per day of brisk walking 5 days per week. Patients were asked to attend 16 sessions in a 6-month period for nutritional and exercise guidance and received ongoing follow-up with a case manager. After 3 years, the incidence of diabetes was 58% lower in the lifestyle intervention group and 31% lower with metformin compared with the placebo group (N. Engl. J. Med. 2002;346:393-403). The diabetes incidence was 5 cases per 100 person-years in the lifestyle group compared with 8 in the metformin group, and 11 in the placebo group.

During the next 7 years, patients in the metformin group were encouraged to continue the medication, and those in the lifestyle intervention group were offered a less intensive lifestyle intervention with fewer individual sessions. At the 10-year mark, the risk for developing diabetes was 34% less in the lifestyle intervention group and 18% less in the metformin group compared with the control group, Dr. Herman said. Quality of life was rated significantly higher in the metformin group compared with the placebo group, and significantly higher in the lifestyle intervention group compared with the metformin or placebo groups.

Implementation of a lifestyle intervention should be as simple as writing a prescription for a pill to prevent diabetes, Dr. Herman suggested. One way to build access to lifestyle interventions might be to locate them in cardiac rehabilitation centers, which already contain the facilities needed for exercise and other components of the intervention.

"Translating these findings into practice will reduce the development of type 2 diabetes, which has become one of the most common and costly diseases," Dr. Griffin P. Rodgers said in a statement released by the American Diabetes Association. Dr. Rodgers is director of the National Institute of Diabetes and Digestive and Kidney Diseases.

The costs of lifestyle intervention to prevent diabetes will decline over time, Dr. Herman said. The data suggest that the DPP’s intensive lifestyle intervention can be adapted into a less-expensive, but still effective, group-based model without having to reinvent everything, he added. Instead of 16 sessions in 6 months, patients may have a yearly session with a dietician.

Dr. Herman has been a consultant for McKinsey & Company.

SAN DIEGO – Few medical interventions both improve health and save money. Treating prediabetes with metformin is one of them, according to 10-year follow-up data from the Diabetes Prevention Program.

Intensive lifestyle intervention, the other treatment arm in the randomized, placebo-controlled Diabetes Prevention Program (DPP) study, did an even better job at improving health and quality of life, and at a favorable cost when compared with some common medical interventions for other diagnoses, Dr. William H. Herman and his associates reported at the annual scientific sessions of the American Diabetes Association.

Most of the costs for the placebo group in the ensuing decade were related to conversion of subjects’ prediabetes to diabetes, explained Dr. Herman, professor of medicine and epidemiology at the University of Michigan, Ann Arbor.

At baseline, all 3,234 participants in the DPP were nondiabetic, were overweight or obese, and had impaired glucose tolerance and an elevated fasting glucose level.

Metformin treatment (850 mg b.i.d.) reduced overall costs for medical care in those 10 years by $1,700 per person, and lifestyle intervention reduced those costs by $2,600 per person. After factoring in the costs of the interventions, the researchers found that metformin treatment produced a savings of $30 per patient compared with placebo over the 10 years.

The cost-saving benefits of metformin for people at high risk of diabetes puts this preventive intervention in a league with prenatal care, pediatric immunizations, and influenza vaccinations for people older than 65 years, Dr. Herman said. Only 1 in 10 medical interventions are cost-saving, he noted.

With the lifestyle intervention, overall costs were $1,500 per person greater than placebo, a price tag that puts lifestyle intervention for prediabetes in a league with some of the most widely accepted medical interventions when converted for comparison into quality-adjusted life-years gained.

In simple terms, the cost for a quality-adjusted life-year gained is the price "to buy 1 year of life in essentially perfect health," he explained.

In this study, the cost per quality-adjusted life-year gained with the intensive lifestyle intervention compared with the placebo group was $12,000. That $12,000 is on the low end of a $10,000-$50,000 range that’s widely accepted for medical interventions, including the use of beta-blockers after MI, the use of antihypertensive therapy for patients with very high diastolic blood pressure (greater than 105 mm Hg), or the use of statins for secondary prevention of cardiovascular disease in patients who’ve had an MI. Dialysis for end-stage renal disease costs $50,000-$100,000 per quality-adjusted life-year gained.

When the DPP results first came out, "The reaction in the medical community was, ‘This is great, but we don’t have the resources to implement it,’ " Dr. Herman said. Controversy continued due to conflicting results from analyses that modeled cost effectiveness over time based on the 3-year results of the DPP. The current study used real-life cost data collected prospectively for the study period and the following 7 years.

The results show that for patients with prediabetes, "metformin is cost saving. Intensive lifestyle intervention, though not cost saving, is extremely cost effective," Dr. Herman said. "It represents good value for the money."

The DPP’s lifestyle intervention aimed for a 7% reduction in body weight and 150 minutes per week of moderately intense physical activity, usually 30 minutes per day of brisk walking 5 days per week. Patients were asked to attend 16 sessions in a 6-month period for nutritional and exercise guidance and received ongoing follow-up with a case manager. After 3 years, the incidence of diabetes was 58% lower in the lifestyle intervention group and 31% lower with metformin compared with the placebo group (N. Engl. J. Med. 2002;346:393-403). The diabetes incidence was 5 cases per 100 person-years in the lifestyle group compared with 8 in the metformin group, and 11 in the placebo group.

During the next 7 years, patients in the metformin group were encouraged to continue the medication, and those in the lifestyle intervention group were offered a less intensive lifestyle intervention with fewer individual sessions. At the 10-year mark, the risk for developing diabetes was 34% less in the lifestyle intervention group and 18% less in the metformin group compared with the control group, Dr. Herman said. Quality of life was rated significantly higher in the metformin group compared with the placebo group, and significantly higher in the lifestyle intervention group compared with the metformin or placebo groups.

Implementation of a lifestyle intervention should be as simple as writing a prescription for a pill to prevent diabetes, Dr. Herman suggested. One way to build access to lifestyle interventions might be to locate them in cardiac rehabilitation centers, which already contain the facilities needed for exercise and other components of the intervention.

"Translating these findings into practice will reduce the development of type 2 diabetes, which has become one of the most common and costly diseases," Dr. Griffin P. Rodgers said in a statement released by the American Diabetes Association. Dr. Rodgers is director of the National Institute of Diabetes and Digestive and Kidney Diseases.

The costs of lifestyle intervention to prevent diabetes will decline over time, Dr. Herman said. The data suggest that the DPP’s intensive lifestyle intervention can be adapted into a less-expensive, but still effective, group-based model without having to reinvent everything, he added. Instead of 16 sessions in 6 months, patients may have a yearly session with a dietician.

Dr. Herman has been a consultant for McKinsey & Company.

SAN DIEGO – Few medical interventions both improve health and save money. Treating prediabetes with metformin is one of them, according to 10-year follow-up data from the Diabetes Prevention Program.

Intensive lifestyle intervention, the other treatment arm in the randomized, placebo-controlled Diabetes Prevention Program (DPP) study, did an even better job at improving health and quality of life, and at a favorable cost when compared with some common medical interventions for other diagnoses, Dr. William H. Herman and his associates reported at the annual scientific sessions of the American Diabetes Association.

Most of the costs for the placebo group in the ensuing decade were related to conversion of subjects’ prediabetes to diabetes, explained Dr. Herman, professor of medicine and epidemiology at the University of Michigan, Ann Arbor.

At baseline, all 3,234 participants in the DPP were nondiabetic, were overweight or obese, and had impaired glucose tolerance and an elevated fasting glucose level.

Metformin treatment (850 mg b.i.d.) reduced overall costs for medical care in those 10 years by $1,700 per person, and lifestyle intervention reduced those costs by $2,600 per person. After factoring in the costs of the interventions, the researchers found that metformin treatment produced a savings of $30 per patient compared with placebo over the 10 years.

The cost-saving benefits of metformin for people at high risk of diabetes puts this preventive intervention in a league with prenatal care, pediatric immunizations, and influenza vaccinations for people older than 65 years, Dr. Herman said. Only 1 in 10 medical interventions are cost-saving, he noted.

With the lifestyle intervention, overall costs were $1,500 per person greater than placebo, a price tag that puts lifestyle intervention for prediabetes in a league with some of the most widely accepted medical interventions when converted for comparison into quality-adjusted life-years gained.

In simple terms, the cost for a quality-adjusted life-year gained is the price "to buy 1 year of life in essentially perfect health," he explained.

In this study, the cost per quality-adjusted life-year gained with the intensive lifestyle intervention compared with the placebo group was $12,000. That $12,000 is on the low end of a $10,000-$50,000 range that’s widely accepted for medical interventions, including the use of beta-blockers after MI, the use of antihypertensive therapy for patients with very high diastolic blood pressure (greater than 105 mm Hg), or the use of statins for secondary prevention of cardiovascular disease in patients who’ve had an MI. Dialysis for end-stage renal disease costs $50,000-$100,000 per quality-adjusted life-year gained.

When the DPP results first came out, "The reaction in the medical community was, ‘This is great, but we don’t have the resources to implement it,’ " Dr. Herman said. Controversy continued due to conflicting results from analyses that modeled cost effectiveness over time based on the 3-year results of the DPP. The current study used real-life cost data collected prospectively for the study period and the following 7 years.

The results show that for patients with prediabetes, "metformin is cost saving. Intensive lifestyle intervention, though not cost saving, is extremely cost effective," Dr. Herman said. "It represents good value for the money."

The DPP’s lifestyle intervention aimed for a 7% reduction in body weight and 150 minutes per week of moderately intense physical activity, usually 30 minutes per day of brisk walking 5 days per week. Patients were asked to attend 16 sessions in a 6-month period for nutritional and exercise guidance and received ongoing follow-up with a case manager. After 3 years, the incidence of diabetes was 58% lower in the lifestyle intervention group and 31% lower with metformin compared with the placebo group (N. Engl. J. Med. 2002;346:393-403). The diabetes incidence was 5 cases per 100 person-years in the lifestyle group compared with 8 in the metformin group, and 11 in the placebo group.

During the next 7 years, patients in the metformin group were encouraged to continue the medication, and those in the lifestyle intervention group were offered a less intensive lifestyle intervention with fewer individual sessions. At the 10-year mark, the risk for developing diabetes was 34% less in the lifestyle intervention group and 18% less in the metformin group compared with the control group, Dr. Herman said. Quality of life was rated significantly higher in the metformin group compared with the placebo group, and significantly higher in the lifestyle intervention group compared with the metformin or placebo groups.

Implementation of a lifestyle intervention should be as simple as writing a prescription for a pill to prevent diabetes, Dr. Herman suggested. One way to build access to lifestyle interventions might be to locate them in cardiac rehabilitation centers, which already contain the facilities needed for exercise and other components of the intervention.

"Translating these findings into practice will reduce the development of type 2 diabetes, which has become one of the most common and costly diseases," Dr. Griffin P. Rodgers said in a statement released by the American Diabetes Association. Dr. Rodgers is director of the National Institute of Diabetes and Digestive and Kidney Diseases.

The costs of lifestyle intervention to prevent diabetes will decline over time, Dr. Herman said. The data suggest that the DPP’s intensive lifestyle intervention can be adapted into a less-expensive, but still effective, group-based model without having to reinvent everything, he added. Instead of 16 sessions in 6 months, patients may have a yearly session with a dietician.

Dr. Herman has been a consultant for McKinsey & Company.

SAN DIEGO – Few medical interventions both improve health and save money. Treating prediabetes with metformin is one of them, according to 10-year follow-up data from the Diabetes Prevention Program.

Intensive lifestyle intervention, the other treatment arm in the randomized, placebo-controlled Diabetes Prevention Program (DPP) study, did an even better job at improving health and quality of life, and at a favorable cost when compared with some common medical interventions for other diagnoses, Dr. William H. Herman and his associates reported at the annual scientific sessions of the American Diabetes Association.

Most of the costs for the placebo group in the ensuing decade were related to conversion of subjects’ prediabetes to diabetes, explained Dr. Herman, professor of medicine and epidemiology at the University of Michigan, Ann Arbor.

At baseline, all 3,234 participants in the DPP were nondiabetic, were overweight or obese, and had impaired glucose tolerance and an elevated fasting glucose level.

Metformin treatment (850 mg b.i.d.) reduced overall costs for medical care in those 10 years by $1,700 per person, and lifestyle intervention reduced those costs by $2,600 per person. After factoring in the costs of the interventions, the researchers found that metformin treatment produced a savings of $30 per patient compared with placebo over the 10 years.

The cost-saving benefits of metformin for people at high risk of diabetes puts this preventive intervention in a league with prenatal care, pediatric immunizations, and influenza vaccinations for people older than 65 years, Dr. Herman said. Only 1 in 10 medical interventions are cost-saving, he noted.

With the lifestyle intervention, overall costs were $1,500 per person greater than placebo, a price tag that puts lifestyle intervention for prediabetes in a league with some of the most widely accepted medical interventions when converted for comparison into quality-adjusted life-years gained.

In simple terms, the cost for a quality-adjusted life-year gained is the price "to buy 1 year of life in essentially perfect health," he explained.

In this study, the cost per quality-adjusted life-year gained with the intensive lifestyle intervention compared with the placebo group was $12,000. That $12,000 is on the low end of a $10,000-$50,000 range that’s widely accepted for medical interventions, including the use of beta-blockers after MI, the use of antihypertensive therapy for patients with very high diastolic blood pressure (greater than 105 mm Hg), or the use of statins for secondary prevention of cardiovascular disease in patients who’ve had an MI. Dialysis for end-stage renal disease costs $50,000-$100,000 per quality-adjusted life-year gained.

When the DPP results first came out, "The reaction in the medical community was, ‘This is great, but we don’t have the resources to implement it,’ " Dr. Herman said. Controversy continued due to conflicting results from analyses that modeled cost effectiveness over time based on the 3-year results of the DPP. The current study used real-life cost data collected prospectively for the study period and the following 7 years.

The results show that for patients with prediabetes, "metformin is cost saving. Intensive lifestyle intervention, though not cost saving, is extremely cost effective," Dr. Herman said. "It represents good value for the money."

The DPP’s lifestyle intervention aimed for a 7% reduction in body weight and 150 minutes per week of moderately intense physical activity, usually 30 minutes per day of brisk walking 5 days per week. Patients were asked to attend 16 sessions in a 6-month period for nutritional and exercise guidance and received ongoing follow-up with a case manager. After 3 years, the incidence of diabetes was 58% lower in the lifestyle intervention group and 31% lower with metformin compared with the placebo group (N. Engl. J. Med. 2002;346:393-403). The diabetes incidence was 5 cases per 100 person-years in the lifestyle group compared with 8 in the metformin group, and 11 in the placebo group.

During the next 7 years, patients in the metformin group were encouraged to continue the medication, and those in the lifestyle intervention group were offered a less intensive lifestyle intervention with fewer individual sessions. At the 10-year mark, the risk for developing diabetes was 34% less in the lifestyle intervention group and 18% less in the metformin group compared with the control group, Dr. Herman said. Quality of life was rated significantly higher in the metformin group compared with the placebo group, and significantly higher in the lifestyle intervention group compared with the metformin or placebo groups.

Implementation of a lifestyle intervention should be as simple as writing a prescription for a pill to prevent diabetes, Dr. Herman suggested. One way to build access to lifestyle interventions might be to locate them in cardiac rehabilitation centers, which already contain the facilities needed for exercise and other components of the intervention.

"Translating these findings into practice will reduce the development of type 2 diabetes, which has become one of the most common and costly diseases," Dr. Griffin P. Rodgers said in a statement released by the American Diabetes Association. Dr. Rodgers is director of the National Institute of Diabetes and Digestive and Kidney Diseases.

The costs of lifestyle intervention to prevent diabetes will decline over time, Dr. Herman said. The data suggest that the DPP’s intensive lifestyle intervention can be adapted into a less-expensive, but still effective, group-based model without having to reinvent everything, he added. Instead of 16 sessions in 6 months, patients may have a yearly session with a dietician.

Dr. Herman has been a consultant for McKinsey & Company.

SAN DIEGO – Few medical interventions both improve health and save money. Treating prediabetes with metformin is one of them, according to 10-year follow-up data from the Diabetes Prevention Program.

Intensive lifestyle intervention, the other treatment arm in the randomized, placebo-controlled Diabetes Prevention Program (DPP) study, did an even better job at improving health and quality of life, and at a favorable cost when compared with some common medical interventions for other diagnoses, Dr. William H. Herman and his associates reported at the annual scientific sessions of the American Diabetes Association.

Most of the costs for the placebo group in the ensuing decade were related to conversion of subjects’ prediabetes to diabetes, explained Dr. Herman, professor of medicine and epidemiology at the University of Michigan, Ann Arbor.

At baseline, all 3,234 participants in the DPP were nondiabetic, were overweight or obese, and had impaired glucose tolerance and an elevated fasting glucose level.

Metformin treatment (850 mg b.i.d.) reduced overall costs for medical care in those 10 years by $1,700 per person, and lifestyle intervention reduced those costs by $2,600 per person. After factoring in the costs of the interventions, the researchers found that metformin treatment produced a savings of $30 per patient compared with placebo over the 10 years.

The cost-saving benefits of metformin for people at high risk of diabetes puts this preventive intervention in a league with prenatal care, pediatric immunizations, and influenza vaccinations for people older than 65 years, Dr. Herman said. Only 1 in 10 medical interventions are cost-saving, he noted.

With the lifestyle intervention, overall costs were $1,500 per person greater than placebo, a price tag that puts lifestyle intervention for prediabetes in a league with some of the most widely accepted medical interventions when converted for comparison into quality-adjusted life-years gained.

In simple terms, the cost for a quality-adjusted life-year gained is the price "to buy 1 year of life in essentially perfect health," he explained.

In this study, the cost per quality-adjusted life-year gained with the intensive lifestyle intervention compared with the placebo group was $12,000. That $12,000 is on the low end of a $10,000-$50,000 range that’s widely accepted for medical interventions, including the use of beta-blockers after MI, the use of antihypertensive therapy for patients with very high diastolic blood pressure (greater than 105 mm Hg), or the use of statins for secondary prevention of cardiovascular disease in patients who’ve had an MI. Dialysis for end-stage renal disease costs $50,000-$100,000 per quality-adjusted life-year gained.

When the DPP results first came out, "The reaction in the medical community was, ‘This is great, but we don’t have the resources to implement it,’ " Dr. Herman said. Controversy continued due to conflicting results from analyses that modeled cost effectiveness over time based on the 3-year results of the DPP. The current study used real-life cost data collected prospectively for the study period and the following 7 years.

The results show that for patients with prediabetes, "metformin is cost saving. Intensive lifestyle intervention, though not cost saving, is extremely cost effective," Dr. Herman said. "It represents good value for the money."

The DPP’s lifestyle intervention aimed for a 7% reduction in body weight and 150 minutes per week of moderately intense physical activity, usually 30 minutes per day of brisk walking 5 days per week. Patients were asked to attend 16 sessions in a 6-month period for nutritional and exercise guidance and received ongoing follow-up with a case manager. After 3 years, the incidence of diabetes was 58% lower in the lifestyle intervention group and 31% lower with metformin compared with the placebo group (N. Engl. J. Med. 2002;346:393-403). The diabetes incidence was 5 cases per 100 person-years in the lifestyle group compared with 8 in the metformin group, and 11 in the placebo group.

During the next 7 years, patients in the metformin group were encouraged to continue the medication, and those in the lifestyle intervention group were offered a less intensive lifestyle intervention with fewer individual sessions. At the 10-year mark, the risk for developing diabetes was 34% less in the lifestyle intervention group and 18% less in the metformin group compared with the control group, Dr. Herman said. Quality of life was rated significantly higher in the metformin group compared with the placebo group, and significantly higher in the lifestyle intervention group compared with the metformin or placebo groups.

Implementation of a lifestyle intervention should be as simple as writing a prescription for a pill to prevent diabetes, Dr. Herman suggested. One way to build access to lifestyle interventions might be to locate them in cardiac rehabilitation centers, which already contain the facilities needed for exercise and other components of the intervention.

"Translating these findings into practice will reduce the development of type 2 diabetes, which has become one of the most common and costly diseases," Dr. Griffin P. Rodgers said in a statement released by the American Diabetes Association. Dr. Rodgers is director of the National Institute of Diabetes and Digestive and Kidney Diseases.

The costs of lifestyle intervention to prevent diabetes will decline over time, Dr. Herman said. The data suggest that the DPP’s intensive lifestyle intervention can be adapted into a less-expensive, but still effective, group-based model without having to reinvent everything, he added. Instead of 16 sessions in 6 months, patients may have a yearly session with a dietician.

Dr. Herman has been a consultant for McKinsey & Company.

SAN DIEGO – Significant increases in adiposity and insulin resistance quickly became apparent in a 12-week study of low-dose antipsychotics to treat mainly nonpsychotic disorders in 144 children.

Newer, “atypical” antipsychotics increasingly are being used to treat mood and disruptive behavior disorders in children, Dr. John W. Newcomer said at the annual meeting of the American Diabetes Association.

“It’s a topic of increasing concern in a number of state Medicaid” systems, he said. Concerns have been generated in part by data showing premature mortality in people with mental disorders that’s related primarily to cardiovascular disease but also to cardiometabolic risk.

Children in the open-label study were randomized to flexibly dosed treatment with risperidone, olanzapine, or aripiprazole. It was their first use of antipsychotics.

These were “very low doses,” he emphasized. “These are not doses that would be used to treat a psychotic disorder,” said Dr. Newcomer, who led the study while at Washington University, St. Louis. He now is a professor of psychiatry and behavioral sciences at the University of Miami.

The 5-year Metabolic Effects of Antipsychotics in Children (MEAC) study targeted symptoms of aggression and irritability in patients aged 6-18 years. “Typically, they had been suspended from school,” he said.

The main primary diagnosis was treatment-refractory attention deficit hyperactivity disorder (ADHD) in 57% of patients. “This is what clinicians are using these drugs for in this type of public-sector population – kids who fail two or three courses of stimulants who then are looking for some other treatment.”

Other main diagnoses included oppositional defiant disorder in 22%, pervasive developmental disorder in 6%, bipolar disorder in 4%, and major depression in 3%. Smaller proportions of patients were diagnosed with other mood disorders, Asperger’s syndrome, autism, obsessive-compulsive disorder, or Tourette’s syndrome.

Mean doses were 1 mg/day in the 49 patients on risperidone, 6.3 mg/day in the 46 patients on olanzapine, and 6 mg/day in the 49 patients on aripiprazole. Approximately half of patients also were on stable doses of stimulants for ADHD.

Total body percentage of adiposity increased 2.4% after 12 weeks on antipsychotics – slightly less than a standard deviation, and a highly significant change, Dr. Newcomer and his associates reported. Mean total fat increased 2.3 kg, they added.

The percentage body fat increased the most in the youngest children. Greater changes were seen with olanzapine than with risperidone or aripiprazole. About a fourth of patients on risperidone or aripiprazole showed little change in body fat, but three-quarters on those drugs and nearly all patients on olanzapine showed increases.

Whole-body insulin sensitivity decreased approximately from 8 mg/kg per minute to 7 mg/kg per minute, a significant reduction. Olanzapine produced the greatest reduction in whole-body insulin sensitivity.

Importantly, scores for irritability and aggression improved in all groups, he added.

“I’m not a child psychiatrist. I was not terribly sympathetic to this at the beginning” of clinicians’ use of antipsychotics for these indications, said Dr. Newcomer, who chaired the Drug Utilization Review Board for Missouri Medicaid for 14 years. “But I was educated by the psychiatric outcome. There was really profound psychiatric symptom improvement, with kids going back to school and [behaving differently],” he said. The psychiatric response was similar among treatment groups in the study.

As early as 6 weeks after starting therapy, significant changes could be seen on adiposity. Children with the biggest changes in body fat showed effects within the first month of treatment.

Height, weight, waist circumference, body mass index, and BMI percentile were measured at all visits. At baseline and at 12 weeks, investigators performed dual-energy x-ray absorptiometry (DEXA) scans and MRI to assess changes in adiposity, hyperinsulinemic euglycemic clamp with isotopomers to assess changes in insulin sensitivity, plasma sampling (such as oral glucose tolerance test or measuring fasting glucose and lipids), ECG, and psychiatric ratings. At the 6-week follow-up, patients underwent DEXA, oral glucose tolerance testing, and lab measures of fasting status.

A previous nonrandomized study of 272 antipsychotic-naive children and adolescents reported weight gains of 4-8 kg and increases in BMI percentile for patients taking any of four atypical antipsychotics for a median of 11 weeks, compared with a control group (JAMA 2009;302:1811-2).

The study’s design raised concern that the effects could be larger than reported, however, because overweight or obese children were assigned to drugs considered to have the lowest risk for weight gain, Dr. Newcomer said.

In a post-hoc analysis, Dr. Newcomer showed that at the start of the current study, the children had similar rates of overweight or obesity as did children in the general population, but rates were higher in the cohort by the end of the study. The rate of overweight or obese children in the cohort increased from about 33% to 48%.

“I’m personally skeptical about the idea that it’s the psychiatric disorders themselves that are the metabolic challenge, rather than the treatment being the primary effect,” he said.

Medicaid data suggest that 43% of prescriptions for atypical antipsychotics are for indications that are not backed by evidence justifying use, he said. Visits to U.S. physicians that included prescriptions for antipsychotics to patients aged 20 years or younger more than doubled between 1997 and 2002, to a rate greater than 1,400 per 100,000 visits, a separate study reported (Arch Gen. Psych. 2006;63-681).

The National Institutes of Health funded the study. Dr. Newcomer has been a consultant for or received grants from Janssen Pharmaceuticals Inc., Pfizer Inc. , AstraZeneca, Bristol-Myers Squibb, Otsuka Pharmaceutical Co. Ltd., Schering/Merck, Vivus Inc., Obecure Ltd., Biovail Corp., Lundbeck A/S, Sanofi, and Dainippon Sumitomo Pharma Co. Ltd./Sepracor Inc.

SAN DIEGO – Significant increases in adiposity and insulin resistance quickly became apparent in a 12-week study of low-dose antipsychotics to treat mainly nonpsychotic disorders in 144 children.

Newer, “atypical” antipsychotics increasingly are being used to treat mood and disruptive behavior disorders in children, Dr. John W. Newcomer said at the annual meeting of the American Diabetes Association.

“It’s a topic of increasing concern in a number of state Medicaid” systems, he said. Concerns have been generated in part by data showing premature mortality in people with mental disorders that’s related primarily to cardiovascular disease but also to cardiometabolic risk.

Children in the open-label study were randomized to flexibly dosed treatment with risperidone, olanzapine, or aripiprazole. It was their first use of antipsychotics.

These were “very low doses,” he emphasized. “These are not doses that would be used to treat a psychotic disorder,” said Dr. Newcomer, who led the study while at Washington University, St. Louis. He now is a professor of psychiatry and behavioral sciences at the University of Miami.

The 5-year Metabolic Effects of Antipsychotics in Children (MEAC) study targeted symptoms of aggression and irritability in patients aged 6-18 years. “Typically, they had been suspended from school,” he said.

The main primary diagnosis was treatment-refractory attention deficit hyperactivity disorder (ADHD) in 57% of patients. “This is what clinicians are using these drugs for in this type of public-sector population – kids who fail two or three courses of stimulants who then are looking for some other treatment.”

Other main diagnoses included oppositional defiant disorder in 22%, pervasive developmental disorder in 6%, bipolar disorder in 4%, and major depression in 3%. Smaller proportions of patients were diagnosed with other mood disorders, Asperger’s syndrome, autism, obsessive-compulsive disorder, or Tourette’s syndrome.

Mean doses were 1 mg/day in the 49 patients on risperidone, 6.3 mg/day in the 46 patients on olanzapine, and 6 mg/day in the 49 patients on aripiprazole. Approximately half of patients also were on stable doses of stimulants for ADHD.

Total body percentage of adiposity increased 2.4% after 12 weeks on antipsychotics – slightly less than a standard deviation, and a highly significant change, Dr. Newcomer and his associates reported. Mean total fat increased 2.3 kg, they added.

The percentage body fat increased the most in the youngest children. Greater changes were seen with olanzapine than with risperidone or aripiprazole. About a fourth of patients on risperidone or aripiprazole showed little change in body fat, but three-quarters on those drugs and nearly all patients on olanzapine showed increases.

Whole-body insulin sensitivity decreased approximately from 8 mg/kg per minute to 7 mg/kg per minute, a significant reduction. Olanzapine produced the greatest reduction in whole-body insulin sensitivity.

Importantly, scores for irritability and aggression improved in all groups, he added.

“I’m not a child psychiatrist. I was not terribly sympathetic to this at the beginning” of clinicians’ use of antipsychotics for these indications, said Dr. Newcomer, who chaired the Drug Utilization Review Board for Missouri Medicaid for 14 years. “But I was educated by the psychiatric outcome. There was really profound psychiatric symptom improvement, with kids going back to school and [behaving differently],” he said. The psychiatric response was similar among treatment groups in the study.

As early as 6 weeks after starting therapy, significant changes could be seen on adiposity. Children with the biggest changes in body fat showed effects within the first month of treatment.

Height, weight, waist circumference, body mass index, and BMI percentile were measured at all visits. At baseline and at 12 weeks, investigators performed dual-energy x-ray absorptiometry (DEXA) scans and MRI to assess changes in adiposity, hyperinsulinemic euglycemic clamp with isotopomers to assess changes in insulin sensitivity, plasma sampling (such as oral glucose tolerance test or measuring fasting glucose and lipids), ECG, and psychiatric ratings. At the 6-week follow-up, patients underwent DEXA, oral glucose tolerance testing, and lab measures of fasting status.

A previous nonrandomized study of 272 antipsychotic-naive children and adolescents reported weight gains of 4-8 kg and increases in BMI percentile for patients taking any of four atypical antipsychotics for a median of 11 weeks, compared with a control group (JAMA 2009;302:1811-2).

The study’s design raised concern that the effects could be larger than reported, however, because overweight or obese children were assigned to drugs considered to have the lowest risk for weight gain, Dr. Newcomer said.

In a post-hoc analysis, Dr. Newcomer showed that at the start of the current study, the children had similar rates of overweight or obesity as did children in the general population, but rates were higher in the cohort by the end of the study. The rate of overweight or obese children in the cohort increased from about 33% to 48%.

“I’m personally skeptical about the idea that it’s the psychiatric disorders themselves that are the metabolic challenge, rather than the treatment being the primary effect,” he said.

Medicaid data suggest that 43% of prescriptions for atypical antipsychotics are for indications that are not backed by evidence justifying use, he said. Visits to U.S. physicians that included prescriptions for antipsychotics to patients aged 20 years or younger more than doubled between 1997 and 2002, to a rate greater than 1,400 per 100,000 visits, a separate study reported (Arch Gen. Psych. 2006;63-681).

The National Institutes of Health funded the study. Dr. Newcomer has been a consultant for or received grants from Janssen Pharmaceuticals Inc., Pfizer Inc. , AstraZeneca, Bristol-Myers Squibb, Otsuka Pharmaceutical Co. Ltd., Schering/Merck, Vivus Inc., Obecure Ltd., Biovail Corp., Lundbeck A/S, Sanofi, and Dainippon Sumitomo Pharma Co. Ltd./Sepracor Inc.

SAN DIEGO – Significant increases in adiposity and insulin resistance quickly became apparent in a 12-week study of low-dose antipsychotics to treat mainly nonpsychotic disorders in 144 children.

Newer, “atypical” antipsychotics increasingly are being used to treat mood and disruptive behavior disorders in children, Dr. John W. Newcomer said at the annual meeting of the American Diabetes Association.

“It’s a topic of increasing concern in a number of state Medicaid” systems, he said. Concerns have been generated in part by data showing premature mortality in people with mental disorders that’s related primarily to cardiovascular disease but also to cardiometabolic risk.

Children in the open-label study were randomized to flexibly dosed treatment with risperidone, olanzapine, or aripiprazole. It was their first use of antipsychotics.

These were “very low doses,” he emphasized. “These are not doses that would be used to treat a psychotic disorder,” said Dr. Newcomer, who led the study while at Washington University, St. Louis. He now is a professor of psychiatry and behavioral sciences at the University of Miami.

The 5-year Metabolic Effects of Antipsychotics in Children (MEAC) study targeted symptoms of aggression and irritability in patients aged 6-18 years. “Typically, they had been suspended from school,” he said.

The main primary diagnosis was treatment-refractory attention deficit hyperactivity disorder (ADHD) in 57% of patients. “This is what clinicians are using these drugs for in this type of public-sector population – kids who fail two or three courses of stimulants who then are looking for some other treatment.”

Other main diagnoses included oppositional defiant disorder in 22%, pervasive developmental disorder in 6%, bipolar disorder in 4%, and major depression in 3%. Smaller proportions of patients were diagnosed with other mood disorders, Asperger’s syndrome, autism, obsessive-compulsive disorder, or Tourette’s syndrome.

Mean doses were 1 mg/day in the 49 patients on risperidone, 6.3 mg/day in the 46 patients on olanzapine, and 6 mg/day in the 49 patients on aripiprazole. Approximately half of patients also were on stable doses of stimulants for ADHD.

Total body percentage of adiposity increased 2.4% after 12 weeks on antipsychotics – slightly less than a standard deviation, and a highly significant change, Dr. Newcomer and his associates reported. Mean total fat increased 2.3 kg, they added.

The percentage body fat increased the most in the youngest children. Greater changes were seen with olanzapine than with risperidone or aripiprazole. About a fourth of patients on risperidone or aripiprazole showed little change in body fat, but three-quarters on those drugs and nearly all patients on olanzapine showed increases.

Whole-body insulin sensitivity decreased approximately from 8 mg/kg per minute to 7 mg/kg per minute, a significant reduction. Olanzapine produced the greatest reduction in whole-body insulin sensitivity.

Importantly, scores for irritability and aggression improved in all groups, he added.

“I’m not a child psychiatrist. I was not terribly sympathetic to this at the beginning” of clinicians’ use of antipsychotics for these indications, said Dr. Newcomer, who chaired the Drug Utilization Review Board for Missouri Medicaid for 14 years. “But I was educated by the psychiatric outcome. There was really profound psychiatric symptom improvement, with kids going back to school and [behaving differently],” he said. The psychiatric response was similar among treatment groups in the study.

As early as 6 weeks after starting therapy, significant changes could be seen on adiposity. Children with the biggest changes in body fat showed effects within the first month of treatment.

Height, weight, waist circumference, body mass index, and BMI percentile were measured at all visits. At baseline and at 12 weeks, investigators performed dual-energy x-ray absorptiometry (DEXA) scans and MRI to assess changes in adiposity, hyperinsulinemic euglycemic clamp with isotopomers to assess changes in insulin sensitivity, plasma sampling (such as oral glucose tolerance test or measuring fasting glucose and lipids), ECG, and psychiatric ratings. At the 6-week follow-up, patients underwent DEXA, oral glucose tolerance testing, and lab measures of fasting status.

A previous nonrandomized study of 272 antipsychotic-naive children and adolescents reported weight gains of 4-8 kg and increases in BMI percentile for patients taking any of four atypical antipsychotics for a median of 11 weeks, compared with a control group (JAMA 2009;302:1811-2).

The study’s design raised concern that the effects could be larger than reported, however, because overweight or obese children were assigned to drugs considered to have the lowest risk for weight gain, Dr. Newcomer said.

In a post-hoc analysis, Dr. Newcomer showed that at the start of the current study, the children had similar rates of overweight or obesity as did children in the general population, but rates were higher in the cohort by the end of the study. The rate of overweight or obese children in the cohort increased from about 33% to 48%.

“I’m personally skeptical about the idea that it’s the psychiatric disorders themselves that are the metabolic challenge, rather than the treatment being the primary effect,” he said.

Medicaid data suggest that 43% of prescriptions for atypical antipsychotics are for indications that are not backed by evidence justifying use, he said. Visits to U.S. physicians that included prescriptions for antipsychotics to patients aged 20 years or younger more than doubled between 1997 and 2002, to a rate greater than 1,400 per 100,000 visits, a separate study reported (Arch Gen. Psych. 2006;63-681).

The National Institutes of Health funded the study. Dr. Newcomer has been a consultant for or received grants from Janssen Pharmaceuticals Inc., Pfizer Inc. , AstraZeneca, Bristol-Myers Squibb, Otsuka Pharmaceutical Co. Ltd., Schering/Merck, Vivus Inc., Obecure Ltd., Biovail Corp., Lundbeck A/S, Sanofi, and Dainippon Sumitomo Pharma Co. Ltd./Sepracor Inc.