Staab, Jeffrey P.

Background Cardiovascular disease is linked to mental health conditions. Patients with cardiovascular disease and comorbid psychiatric illnesses such as major depressive disorder or generalized anxiety disorder often experience greater physical limitations and decreased overall health. Objective To determine if proactive psychiatric interventions improve staff satisfaction and patient outcomes, such as reducing length of stay and decreasing the 30-day readmission rate, for patients hospitalized on cardiac units with psychiatric comorbidities. Methods The implementation of a proactive psychiatric consultation-liaison service, which included proactive screening of psychiatric needs among patients hospitalized on cardiac units, targeted support for cardiovascular staff, and supportive interactions for patients. Results Comparison between preintervention and postintervention periods indicated a 21% reduction in the 30-day readmission rate for patients hospitalized on cardiac inpatient units with psychiatric comorbidities without adversely affecting hospital length of stay. Staff satisfaction significantly increased with the availability of psychiatric resources. Conclusion The implementation of a multi-disciplinary proactive psychiatric consultation-liaison service on inpatient cardiac units was associated with an increase in cardiovascular staff satisfaction with psychiatric services and a decrease in the 30-day readmission rate of patients with psychiatric comorbidities who were hospitalized for cardiovascular services without significantly affecting length of stay.

ABSTRACT Objective To derive precise estimates of anxiety and depressive disorder prevalence in patients with common vestibular disorders. Data Sources CINAHL, Cochrane Library, PubMed, PsycINFO, and SCOPUS. Review Methods This systematic review and meta‐analysis was reported per PRISMA guidelines. Outcomes included continuous measures (mean), proportions (%), and relative risks (RR) with 95% confidence intervals. Results Eighty‐five studies ( n = 764,403) examining anxiety, depression, and vestibular disorders in adults were included. Mean ages were 50.3 (vestibular) and 46.7 (control); females comprised 63.8% and 64.3%, respectively. Patients with vestibular disorders had significantly higher rates and risks of anxiety (31.4% vs. 8.3%, p < 0.0001; RR = 1.50, 95% CI: 1.1–2.0) and depression (28.3% vs. 4.7%, p < 0.0001; RR = 2.9, 95% CI: 1.8–4.4) than controls. Elevated rates were observed in benign paroxysmal positional vertigo (30.6%, 23.6%), Meniere's disease (47.0%, 43.1%), vestibular migraine (46.5%, 35.7%), and vestibular neuritis (19.4%, 20.7%) (all p < 0.0001). Episodic disorders showed higher prevalence than vestibular neuritis. Patients with unspecified peripheral vestibular disorders also had significantly higher anxiety (12.1%) and depression (13.2%) rates than controls. Meta‐regression revealed significant associations between Dizziness Handicap Inventory (DHI) scores and Hospital Anxiety and Depression Scale (HADS) anxiety and depression subscales. Conclusions This meta‐analysis offers the most precise prevalence and relative risk estimates of anxiety and depressive disorders in vestibular illness. The greater risk in episodic versus single‐event vestibular disorders may inform the understanding of vestibular–psychiatric comorbidity mechanisms.

Abstract Introduction Alice in Wonderland Syndrome (AIWS) is an uncommon condition manifesting visual and somatosensory disturbances in which patients may perceive objects, including their own bodies, as larger or smaller than they are. In adults, AIWS typically is associated with migraine and epilepsy but has been reported as an adverse effect of topiramate, which is used to treat both illnesses, making it difficult to ascertain whether illness or medication causes altered perceptions. Reported is a case of topiramate-associated AIWS, which adds to the limited reports published on this unique phenomenon. Case Report A 40-year-old woman admitted to a 3-week pain rehabilitation program to treat chronic migraine reported macrosomatognosia that she retrospectively recalled beginning during titration of topiramate. The symptoms of AIWS resolved after the topiramate was discontinued. An assessment with the Naranjo ADR Probability Scale indicated a possible association between topiramate and macrosomatognosia. Discussion In this patient with migraine, the onset of AIWS coincided with titration of topiramate, providing a clue that its emergence may have been an adverse drug reaction rather than the underlying illness. Consistent with previous reports, AIWS resolved shortly after topiramate was discontinued, lending credence to this conclusion. However, the mechanism of AIWS is unknown and may be multifactorial, leaving the possibility that migraine predisposed the patient to develop AIWS from topiramate. Conclusion The long association of AIWS with migraine and epilepsy makes it possible that cases caused by medications used to treat these illnesses, like topiramate, are underreported. Awareness of the temporal relationships between the course of illness and the timing of drug therapy can help guide the recognition of AIWS as a potential adverse event.

Objectives: Examining the effect of demographics and social vulnerability on diagnosis and management of patients with vestibular and balance disorders. Design: Retrospective review of a database of patients presenting with vestibular symptoms to a multidisciplinary tertiary vestibular clinic between January and October 2021. Main outcomes included odds ratios of final diagnosis, treatment response, time to presentation by demographic variable, insurance status, residence, and social vulnerability factors according to the 2018 Centers for Disease Control Social Vulnerability Index. Results: Five hundred thirty-six patients with definitive vestibular diagnoses and treatment outcome data were included. Mean age at presentation was 60.4 ± 16.5 years. Women (n = 389, 72.6%) outnumbered men (n = 147, 27.4%). Most patients self-identified as White (n = 440, 82.1%) and non-Hispanic (n = 521, 97.2%). Overall, 17.4% of participants belonged to a minority group. Socioeconomic status, household composition, geographic location, and insurance status were associated with patient diagnoses received. Patients from the lowest socioeconomic class were more likely to be diagnosed with Meniere’s disease. In addition, patients with private insurance were more likely to be diagnosed with Meniere disease or vestibular migraine than those with Medicare insurance. Geographic distance greater than 60 miles from the clinic was associated with a higher likelihood to present >90 days since initial symptom onset. Housing and transportation vulnerabilities were associated with decreased treatment response. Conclusions: Diagnostic classification, time to presentation, and treatment outcomes differed according to demographic and social vulnerability factors. There was no single unifying theme among vulnerabilities, but the results of this study offer preliminary data to design future investigations on regional and national levels to understand and mitigate the effects of social vulnerability factors on access to specialty vestibular care and outcomes of treatment.

Abstract Background Despite 40 years of evidence supporting psychosocial interventions as a component of comprehensive cancer care, patients continue to report vast unmet psychosocial needs and distress. Cognitive behavioral therapies for cancer distress (CBT-C) are the most rigorously tested class of psychosocial interventions for cancer care. Purpose To report clinical effectiveness outcomes of cancer-related distress and self-efficacy following implementation of best-evidence CBT-C, adapted for a real-world, billable practice setting. Methods Patients who completed group-delivered, CBT-C (10 intervention hours, 5 sessions) in the practice setting were invited to enroll in a research study to document cancer distress across the year following CBT-C. Participants (n = 65) were primarily middle-aged (mean 50.5 years, 17% were young adults ≤40 years), female, and White. Analyses utilized mixed linear models with intent-to-treat procedures. Given group delivery and social skills training content within CBT-C, social self-efficacy was assessed as a potential treatment mechanism. Results Distress decreased across the year following CBT-C (mean score change of 20 points for YAs, 6 points for non-YAs), with statistically significant age x time effects. Within-person improvements in social self-efficacy scores were related to reductions in cancer distress, including distress subscales of intrusive thoughts, avoidant coping, and hyperarousal. The model explained 76.6% of the total variance in cancer distress. Conclusions This study demonstrates the effective translation of CBT-C from controlled research trials to the practice setting. CBT-C effectiveness within a mixed-cancer population and relatively rural region of the US is also supported. CBT-C can be effectively translated to the practice settings for which it is intended.

In 2007, the Bárány Society embarked on a project to establish definitions of vestibular syndromes and disorders based on best available evidence, referred to as the International Classification of Vestibular Disorders (ICVD). Since then, numerous publications providing consensus-driven diagnostic criteria for vestibular symptoms, syndromes, and disorders have been published. Here, we reflect on the rationale for developing the ICVD as well as its subsequent achievements, challenges, and outlook. In this summary of the work of the ICVD to date, the authors will focus on practical aspects to help improve the utility and applicability of these diagnostic criteria moving forward.

ImportanceVestibular migraine has no established treatments.ObjectiveTo test the efficacy of rizatriptan for treating vestibular migraine attacks.Design, Setting, and ParticipantsThis double-blind, randomized clinical trial of rizatriptan vs placebo was conducted from December 2014 through July 2020 (data analyses in 2021 and sensitivity analyses in 2022 and 2024) at 2 tertiary neurotologic centers. Adults with vestibular migraine were included.InterventionAll participants underwent prospective observation to confirm diagnosis and illness activity and were then randomized in a 2:1 ratio to receive rizatriptan 10 mg or placebo to treat up to 3 vestibular migraine attacks per participant.Main Outcomes and MeasuresParticipants rated symptoms as absent, mild, moderate, or severe at scheduled intervals. Primary outcomes were the percentage of attacks with reductions in vertigo and unsteadiness/dizziness from moderate or severe to absent or mild at 1 hour. Secondary outcomes were the percentage of attacks with complete resolution of vestibular symptoms at 1 hour; reductions in headache and associated symptoms at 1 hour; use of rescue medications after 1 hour; reductions in vestibular, headache, and associated symptoms at 24 hours without rescue medications; treatment satisfaction and quality of life at 48 hours; and rates of serious adverse effects and discontinuation due to adverse effects.ResultsOf 222 total participants (mean [SD] age, 42.3 [11.7] years; 70.7% were women), 134 (60.4%) with active illness treated 307 attacks. Efficacy was tested using 240 attacks with vestibular symptoms rated as moderate or severe when participants took study drug. At 1 hour, rizatriptan did not differ from placebo for reducing vertigo (73/151 [48.3%] vs 50/88 [56.8%] attacks; odds ratio [OR], 0.71 [95% CI, 0.42-1.21]), unsteadiness/dizziness (29/151 [19.2%] vs 11/89 [12.4%] attacks; OR, 1.69 [95% CI, 0.80-3.57]), or any secondary outcomes. Similar percentages of participants in rizatriptan and placebo groups (26.4% for both groups) added rescue remedies after 1 hour. At 24 hours, rizatriptan had medium effects over placebo for unsteadiness/dizziness (OR, 2.65) and motion sensitivity (OR, 3.58). Post hoc analyses of all treated attacks found a medium effect favoring rizatriptan for headache and photophobia or phonophobia at 24 hours. Treatment satisfaction was equivocal. Quality of life was mixed. No participants experienced serious adverse effects or discontinued treatment for adverse effects.Conclusions and RelevanceIn this study, rizatriptan was ineffective at 1 hour for treating vestibular migraine attacks and had limited benefit on symptoms at 24 hours. Findings do not support using rizatriptan for vestibular migraine attacks.Trial RegistrationClinicalTrials.gov Identifier: NCT02447991

Abstract Motion of the visual field can alter postural sway and cause illusions of self-motion. The relative perceptual sensitivity of self-motion versus visual field motion induced by virtual reality (VR) stimulation and whether observable sway differs based on perceptual task is unknown. Methods to quantify sway perception while concurrently measuring sway do not exist. We measured head sway and motion perception (self or world) in healthy adults who stood with feet together wearing a VR headset while experiencing adaptive staircases of virtual sinusoidal pitch rotation about the ankle axis. In separate conditions of randomly ordered blocks, subjects were asked to indicate (yes/no) if the room moved (regardless of perceived postural sway) or if their postural sway increased (regardless of perceived room motion). Head sway area was measured by tracking movement of the VR headset. Yes/No responses were fit with psychometric curves to determine points of subjective equality (PSEs) for room motion and postural sway. PSEs were compared between conditions. Effects of motion perception (binary responses) on head sway area before, during, and after visual stimulation were examined. The mean PSE for room motion (0.42 degrees) was significantly lower than for postural sway (2.02 degrees) [t(1,18) = 4.4714, p = 0.00029]. Head sway area was significantly larger during (z = 11.53, p < 0.001) and after (z = 5.09, p < 0.001) visual stimulation only when participants perceived increased postural sway. Nearly 5-fold greater amplitudes of oscillating VR visual stimuli were required to induce perceptions of altered self-versus visual field motion. Observed head sway during visual motion was only linked to perceptual responses when participants focused internally on self-motion, not externally on room motion.

AbstractObjectiveTo assess relations between Ménière's disease and suicidality, measured by suicidal ideation, suicidal behaviors, and death by suicide.Data SourcesCINAHL, Cochrane Library, PubMed, PsycINFO, and SCOPUS databases were searched from inception through July 2, 2024.Review MethodsObservational studies related to suicidality in patients with Ménière's disease were included. Non‐English language papers, editorials, and studies on vestibular disorders not specified as Ménière's disease were excluded. The Risk Of Bias In Nonrandomized Studies‐of Exposure tool was used for cohort and qualitative studies, and the Joanna Briggs Institute critical appraisal checklist was used for case‐control studies.ResultsFour studies (n = 168,566) were included in our review. Two cohort studies found significantly increased adjusted hazard ratios of 2.1 (95% CI: 2.0‐2.2) for death by suicide and 7.6 (95% CI: 4.4‐13.3) for suicidal behaviors, respectively, in patients with Ménière's disease compared to the control population after their diagnosis. However, a case‐control study found no significant difference in the prevalence of suicidal ideation or behaviors prior to the date of diagnosis in patients with Ménière's disease compared to the control population (0.9% vs 0.8%; P = .44). In addition, one patient with Ménière's disease expressed suicidal ideation in the qualitative study.ConclusionPatients may experience variable responses to Ménière's disease. Thus, otolaryngologists should be mindful of the potential for suicidality in patients with Ménière's disease.

Abstract Background Persistent postural‐perceptual dizziness (PPPD) is a chronic functional vestibular disorder that is a potential sequela of traumatic brain injury (TBI). Currently, little is known about how patients with TBI associated PPPD respond to typical PPPD treatment modalities. Objective To investigate the prevalence of TBI as a precipitant for PPPD and assess outcomes of usual treatment. Design Retrospective cohort study. Setting Electronic medical records from a tertiary care center. Participants Patients ≥18 years of age diagnosed with PPPD secondary to TBI between January 2015 and December 2022 who underwent 6 months of treatment with at least one return clinic visit. Interventions Not applicable. Main Outcome Measure(s) Patients' best clinical global impression‐improvement scale (CGI‐I) score following 6 months of treatment were collected and then compared with previously published literature, with CGI‐I scores of 1 or 2 (indicating the patient was “very much” or “much” improved, respectively) considered treatment responders. Results In total, 134 (8.9%) of 1503 patients had a TBI as the triggering event for PPPD. The mean age of this cohort was 47.6 years with most of these cases occurring after a mild TBI (85.8%). The proportion of females with post‐TBI PPPD (58.2%) was significantly lower than the proportion with PPPD due to all causes ( p < .037). The most common treatment prescribed was vestibular therapy (82.2%), and 53.3% of patients were considered treatment responders after 6 months. Patients with TBI‐induced PPPD had a significantly worse mean CGI‐I score (2.49 ± 1.1) when compared to prior literature (1.71 ± 0.83) ( p < .001). Conclusions This study found a 9% prevalence of PPPD following TBI in the largest cohort studied to date. Patients who developed PPPD following TBI did not respond as well to standard treatments as patients with other causes of the disorder, and thus may require closer clinical follow‐up to assess treatment efficacy.