1. Devereux Scales Of Mental Disorders Manual Muscles

1. Update supplement to diagnostic and statistical manual of mental disorders, fifth edition dsm-5 ® august 2015.
2. Muscle testing can be performed using manual strength testing, functional tests, and dynamometry. Manual muscle strength testing is one of the most commonly used form of muscle testing by practitioners.

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A 33-year-old male combat veteran came to the clinic for evaluation of snoring, apneas and daytime sleepiness. He was diagnosed with obstructive sleep apnea (OSA) at the age of 22, after he was witnessed to have apneas by other military veterans who were deployed with our patient while he was on active duty. His initial study had revealed an apnea-hypopnea index (AHI) of 16/hour and a respiratory disturbance index (RDI) of 19/h. At that time, due to active deployment overseas and personal preference, he chose to explore surgical options rather than positive airway pressure (PAP) therapy. He underwent a turbinate reduction and a nasal septoplasty. He did not have a repeat sleep study, but these surgeries helped improve his sleep symptoms significantly for several years following surgery.

However, about five years later, he began experiencing significant sleep symptoms. He had gained only 5 pounds since his initial sleep study. A repeat sleep study revealed an AHI of 20/h with an RDI of 24/h. At this time he underwent a PAP titration study, but unfortunately could not tolerate any mask interface on his face. He ascribed this inability to tolerate the mask due to claustrophobia and anxiety related to his posttraumatic stress disorder (PTSD). Since PAP therapy was not an option for this patient he was referred to oto-rhino-laryngology for consideration of surgical options. He underwent a repeat turbinate reduction which once more led to partial relief in his sleep symptoms following surgery. He again did not have a follow-up sleep study to assess the effect of surgery on the AHI.

Several years after his second surgery, his symptoms returned and he presented to our sleep clinic. He reported snoring, breathing pauses, unrefreshing sleep, hypertension, and daytime sleepiness. His Epworth Sleepiness Scale score was 13/24. He was distressed by frequent nocturnal awakenings and breathing pauses, and he believed these were increasing the nocturnal anxiety and nightmares. He had also gained about 15 pounds since his first sleep study. He was taking prazosin 5 mg to help reduce the frequency of his nightmares and alprazolam 0.5 mg as needed for relief of anxiety. In the clinic he agreed to undergo a repeat diagnostic sleep study, but strongly refused a PAP titration or PAP treatment. While he was not opposed to other surgical options, he was not very enthusiastic having additional upper airway surgery. On physical examination in the clinic he was found to have mild retrognathia, poor dentition (with only a few remaining teeth in each dental arch), an enlarged uvula, and a Mallampati score of 3. His weight was 221 pounds, neck circumference was 16 inches, and BMI was 30.90 kg/m². The remainder of the physical examination was unremarkable.

We discussed weight loss with the patient and ordered a full channel diagnostic polysomnogram. The results of this study are shown in Table 1. Hypopneas were scored based on the recommended hypopnea definition in the American Academy of Sleep Medicine scoring manual.¹

Based on the results of this study, the patient had significantly worsened sleep disordered breathing. He wanted treatment, but was firm on his decision to avoid PAP therapy and hesitant to undergo further surgery.

QUESTION: What other novel options are available to treat this patients' sleep apnea?

Devereux Scales Of Mental Disorders Manual Muscles

ANSWER: Treatment options include mask desensitization or oral pressure therapy.

DISCUSSION

PAP intolerance is a very common problem encountered in sleep clinics. Intolerance can be related to a number of issues including discomfort or poor fit of the mask interface. This leads to exploration of other options for treating patients with OSA. Our patient underwent nasal surgery on two occasions. Nasal surgery with turbinate reduction for treatment of OSA has been analyzed in a meta-analysis. This analysis showed that while this surgery was effective in reducing the severity of symptoms, the success rate after this surgery (defined as AHI improvement of more than 50% and a postoperative AHI ≤ 20 events/h) was only 16.7%. An observational study of the effects of nasal surgery on sleep apnea found that the combination of septoplasty and turbinate reduction was more effective than septoplasty alone. However, only 27% of patients undergoing both septoplasty and turbinate reduction had a postoperative drop in AHI to less than 20/h and/or a 50% reduction in AHI. Even though multiple alternatives are available for patients with mild obstructive sleep apnea, patients with more severe OSA have limited options as the most effective therapy to date is PAP.^, However, acceptance and adherence to PAP treatment remains much lower than desired.^,

In certain populations, particularly in veterans who have the posttraumatic stress disorder (PTSD), initiating PAP can be difficult.^, This is often due to anxiety or panic generated by an apparent constraint from a mask interface.^, PTSD is a common diagnosis in patients receiving care at VA medical centers. This diagnosis is made using the DSM-5 criteria¹² and scales such as the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5),¹³ which is considered a gold standard in PTSD assessment. This scale can additionally assess the severity of PTSD, which can help identify patient who are more predisposed to having claustrophobia. Anxiety-deconditioning therapy such as “mask desensitization” has been used for patients with intolerance to a mask interface. This entails getting patients comfortable with putting the mask on their face without using PAP, initially for short periods of time every day with a gradual increase in the time spent with the mask in place. Subsequently the patient uses the PAP with the mask during the non-sleeping hours and then gradually during the sleeping hours. This technique has been shown to be moderately successful in the general population. To our knowledge, there have been no studies or case reports of effectiveness of this therapy in military veterans.

Oral appliances, including mandibular advancement devices (MADs) and tongue retaining devices are other available options. MADs are constructed by dentists according to particular specifications of the patient's oral structures. Usual recommendations suggest that patient should have good dentition with at least 6–10 teeth in each arch for jaw advancement devices.¹⁵ Unfortunately our patient did not have adequate dentition for this type of treatment. Tongue retaining devices can still be used in edentulous patients or those with poor dentition, but they have been found to have a lower compliance rate and easily come out during the night. Surgical procedures such as uvulopharyngopalatoplasty (UPPP) or maxillary mandibular advancement (MMA) offer additional alternatives to PAP. Depending on the type of procedure and severity of sleep apnea, they carry a substantial failure rate in addition to being invasive, irreversible interventions. Hypoglossal nerve stimulation using a small stimulus generator (about the size of a pacemaker) placed beneath the skin on the upper chest, a breathing sensor lead, and a stimulation lead is another FDA approved treatment option available for patients who do not tolerate CPAP and have a BMI less than 32 kg/m². This treatment is currently available at a few VA medical centers. It works by electrical stimulation of the genioglossus muscle, the largest upper airway dilator muscle, causing tongue protrusion and stiffening of the anterior pharyngeal wall, and thereby relieving obstruction in the airway of OSA patients.

In recent years a novel treatment option called oral pressure therapy (OPT, Winx, Apnicure, Redwood, CA) has become available and is approved by the Federal Drug Administration for treatment of OSA. OPT works by applying a low level of suction via a mouthpiece which is placed between the teeth and over the patient's tongue (Figure 1). Suction retains the tongue and displaces the soft palate forward, away from the posterior pharyngeal wall maintaining an open upper airway while the patient is sleeping. MRI studies have shown that this device can lead to significant increase in the retropalatal airway space.¹⁸ The oral mouthpiece is attached by a tube running through the patient's lips to a bedside console delivering a controlled amount of suction. The console has the ability to record daily use on a data card (time with adequately applied level of suction). The interface is less cumbersome than needed for CPAP and may improve acceptance for some patients by avoiding a mask interface on the patient's face. A range of mouthpieces is available to fit a wide spectrum of dental arch sizes. Proper size is chosen based on a dental imprint after patients bite down on a wax wafer. Of note, only one molar in each quadrant is required for OPT. Patients with dentition inadequate for use of a mandibular retaining device may be treated with OPT. This treatment would also aid patients with OSA that have facial pain syndromes such as trigeminal neuralgia who cannot tolerate a mask on their face. On the other hand patients with bruxism are likely not good candidates for OPT, as the mouthpiece may be damaged.

(A) The general set up of the OPT machine showing the compact size of the console with less constraining interface. (B) Soft, rubberized mouthpiece, which is less cumbersome than the CPAP mask. (C) Cross section showing the placement of mouthpiece on the tongue increasing the retro-palatal space.

A multicenter study done in the past to investigate the effectiveness of OPT has shown that with the use of this therapy a clinically significant response (defined as treatment AHI ≤ 10/h and ≤ 50% of the control value) was seen in 20 of the 63 subjects evaluated. Median pre-intervention AHI was 27.5/h at the time of enrollment in to the study. With the use of OPT this was reduced to only a median of 13.4/h on the first treatment night, and 14.8/h on 28th treatment night of therapy. Adherence over 28-day periods was good with a mean usage of 6.0 ± 1.4 h use per night. Even though a clinically significant response in the AHI occurred in less than half of the study subjects, it was effective in some patients with both moderate (9/18) and severe (7/30) OSA. Exclusions to entry into the study included obesity (BMI > 40 kg/m²) and nasal obstruction. It is also important to note that a significant number of potential subjects were excluded due to inability to demonstrate an acceptable amount of sleep and duration of effective suction pressure on a screening night at home. A single-night feasibility study found that the number of awakenings and the percentage of sleep time spent in N1 sleep were significantly reduced while percentage of sleep time spent in N2, N3, and REM were significantly increased. OPT is generally well tolerated but initial side effects are commonly noted. In the feasibility study, device-related side effects were reported by 32% of the subjects, but 92% of the side effects were mild. The most common side effect in the multicenter study was oral tissue discomfort or irritation. A dry mouth and dental discomfort were also reported. In 43% of patients, side effects resolved with continued treatment.

To determine if OPT therapy will be effective in a particular patient, a treatment sleep study (Winx titration study) in which patient uses OPT instead of PAP is performed. The patient's respiratory events, oxygen desaturations, and sleep stages are recorded in usual fashion. The level of suction applied by the machine is automatic and set by a proprietary algorithm. The Winx titration study is used to document effectiveness and the ability to deliver suction during sleep. While mouthpiece size may be changed for comfort or the ability to deliver adequate suction, the level of pressure cannot be changed by the sleep technologist. A significant reduction in AHI to ≤ 10/h and patient's tolerance and relief of sleep symptoms can be a valuable guide to success with this treatment. Glasair iii for sale.

At the present time the availability of OPT is limited to a few durable medical equipment companies. Many third party payers are also not currently covering the cost of this therapy. However, the treatment is available in the VA Health Care System through the Prosthetics service and is currently available at a few centers as an additional treatment option for patients not able to use PAP therapy. Difficulties with providing OPT therapy include the need to have a number of different mouthpieces sizes on hand in the sleep center and developing proficiency in sizing patents for the proper mouthpiece. Since our patient had limited treatment options for his severe obstructive sleep apnea, a Winx titration study was performed to assess if this device would effectively treat his sleep apnea. The results of this study are shown in Table 2.

The patient liked this therapy and remarked that his sleep on this device was much better than usual. He was issued this therapy and he tolerated it well. During OPT, the user breathes exclusively through the nose, and, in the multicenter trial, one of the exclusion criteria was a peak nasal inspiratory flow rate of less than 75 L/minute. Our patient's two prior nasal airway surgeries may have increased the likelihood of good clinical outcome with OPT. Machine adherence data confirmed nightly use of the device with average use over five hours in the first month of treatment. He reported sustained relief from his sleep symptoms and his Epworth Sleepiness Scale score improved to 5/24 on follow-up.

SLEEP MEDICINE PEARLS

1. PAP treatment may be challenging in some patients with PTSD due to claustrophobia.

2. Mask desensitization therapy can be used to increase mask acceptance in motivated patients with claustrophobia.

3. Oral pressure therapy provides a treatment alternative for OSA patients with claustrophobia.

4. Effectiveness of OPT in a particular patient can be gauged by performing a sleep study while patient is using this device. Although OPT is effective in all severities of OSA, treatment is successful in less than half of the patients. Positive airway pressure is more reliably effective than OPT in patients with moderate to severe OSA. Long-term studies of adherence and effectiveness of OPT are not available.

5. OPT can be a treatment option for sleep apnea patients with poor dentition and those with claustrophobia. The effectiveness of OPT must be demonstrated by sleep monitoring.

DISCLOSURE STATEMENT

This was not an industry supported study. The authors have indicated no financial conflicts of interest.

ABBREVIATIONS

CITATION

Girdhar A, Berry RB, Ryals S, Beck E, Wagner M. A young man running out of treatment options. J Clin Sleep Med 2015;11(10)1239–1242.

REFERENCES

Abstract

We sought to evaluate the capacity of the Edinburgh Postnatal Depression Scale (EPDS) in discriminating mental disorders other than depression in pregnant women in northern Mexico. Three hundred pregnant women attending prenatal consultations in a public hospital in Durango City, Mexico submitted a validated EPDS and were examined for mental disorders other than depression using the Diagnostic and Statistical Manual of Mental Disorders - 4^th Ed. (DSM-IV) criteria. Sensitivity and specificity of cut-off points of the EPDS, and positive and negative predictive values were calculated. Of the 300 pregnant women studied, 21 had mental disorders other than depression by the DSM-IV criteria. The best EPDS score for screening mental disorders other than depression was 8/9. This threshold showed a sensitivity of 52.4%, a specificity of 67.0%, a positive predictive value of 11.5%, a negative predictive value of 95.4%, and an area under the curve of 0.643 (95% confidence interval: 0.52-0.76). The EPDS can be considered for screening mental disorders other than depression in Mexican pregnant women whenever a cut-off score of 8/9 is used. However, the tool showed small power to separate pregnant women with and without mental disorders other than depression.

Introduction

Mental disorders during pregnancy represent an important issue for gynecologists and psychiatrists. In addition, a clinical challenge for gynecologists is magnified when a pregnant woman suffering from a major mental disorder presents in labor. A number of mental disorders, other than depression, during pregnancy has been reported. In a recent systematic review, a high anxiety disorder prevalence in pregnancy was found. Other mental disorders that may occur in pregnancy include eating disorders,^, schizophrenia,^, bipolar disorder, personality disorders, psychosis,^, substance use disorders,^, and adjustment disorders.

The Edinburgh Postnatal Depression Scale (EPDS) has been used for screening depression in women during pregnancy and postnatally.^, However, very little is known about the performance of the EPDS for identifying mental disorders other than depression in pregnant women. In a recent study, pregnant women who scored higher than 11 in the EPDS were interviewed for psychiatric diagnosis and researchers found a number of mental disorders other than depression including bipolar disorder, anxiety disorders, obsessive-compulsive disorder, current substance abuse and other disorders. In a study of Vietnamese women in perinatal period, researchers validated the EPDS in detecting common mental disorders and found an optimal EPDS cut-off point of 3-4. The EPDS does not exclusively measure depression but it may also measure anxiety. In a study of prenatal depression in Australia, some women with positive EPDS were found to suffer from mental disorders other than depression including adjustment disorder, posttraumatic stress disorder, and borderline personality disorder.

The aim of the present study was to determine the validity of the EPDS in detecting mental disorders other than depression in a sample of pregnant women in the northern Mexican City of Durango, Mexico.

Materials and Methods

Pregnant women studied

Pregnant women attended a public hospital (Mothers and Children’s Hospital of the Secretary of Health) in Durango City, Mexico were studied from January to December 2013. As a strategy to enroll participants, pregnant women were invited to participate in the study when attending their prenatal consultations. A simple random sampling was used for the selection of participants. Inclusion criteria for enrollment of participant in the study were: i) pregnant women within their 1-9 month of pregnancy; ii) of any occupation; iii) who voluntarily accepted to participate. Age and socioeconomic status were not restrictive criteria for enrollment. In total, 300 women were enrolled in the study. The mean age of participants was 23.39±8.0 years old (range 13-45 years). Participants were evaluated once within their 2-9 months (median: 7 months) of pregnancy. Of the 300 pregnant women studied, 126 (42.0%) were in their first pregnancy and 174 (58.0%) were in their 2-8 pregnancy.

Edinburgh Postnatal DepressionScale version used

We used the Spanish translated EPDS version previously validated in pregnant women in Mexico.^, To assess the presence of mental disorders other than depression, all participants completed the self-administered EPDS and were interviewed by a psychiatrist. Diagnosis of mental disorders was based on the Diagnostic and Statistical Manual of Mental Disorders - 4^th Ed. (DSM-IV) criteria.²³ Participants submitted the EPDS and had the psychiatric interview in the same day. EPDS scores obtained by the pregnant women were not revealed to the psychiatrist who interviewed them. In addition, the gynecologist who submitted the EPDS and the psychiatrist who interviewed the pregnant women did not perform the data analysis in this study.

Statistical analysis

Analysis of data was performed with software SPSS version 15.0. Sensitivity, specificity, and positive and negative predictive values of the EPDS were calculated. The optimal cut-off score of the EPDS for detecting mental disorders in pregnant women was obtained by drawing a receiver operating characteristic curve.

Ethical aspects

This study was approved by the institutional ethical committee of the Mothers and Children’s Hospital of the Secretary of Health in Durango City, Mexico. The aims and procedures of the study were explained to all participants, and a written informed consent was obtained from all of them.

Results

Of the 300 pregnant women studied, 21 (7.0%) had mental disorders other than depression according to the DSM-IV criteria. The psychiatric diagnosis in these 21 pregnant women were: adjustment disorder in 14, grief disorder in three, anxiety in two, obsessive-compulsive disorder in one, and personality disorder in one. Table 1 shows the results of sensitivity and specificity for different EPDS scores found in the 300 pregnant women.

Table 1.

Sensitivity and specificity of the Edinburgh Postnatal Depression Scale (EPDS) at different thresholds as compared with Diagnostic and Statistical Manual of Mental Disorders-4th ed. results for mental disorders other than depression in pregnant women.

Receiver operating characteristic curve showed that an EPDS cut-off of 8/9 had the best sensitivity and specificity in the pregnant women studied (Figure 1). This cut-off means that an EPDS score of 8 or greater would be more appropriate for identifying women with mental disorders other than depression. At this threshold, we found a sensitivity of 52.4% and a specificity of 67.0%. The area under the curve was 0.643 (95% confidence interval: 0.52-0.76). Increasing the threshold to 9/10 the sensitivity was reduced to 47.7% but the specificity increased to 70.3%. Whereas lowering the threshold to 7/8 the sensitivity increased to 57.1% but the specificity was reduced to 60.9%. Of the 21 women with mental disorders other than depression by the DSM-IV criteria, 12 were positive and nine negative in the EPDS. While of the 279 women without mental disorders other than depression by the DSM-IV criteria, 187 were negative and 92 positive in the EPDS. Therefore, a positive predictive value of 11.5% and a negative predictive value of 95.4% for the EPDS were obtained. Women with mental disorders other than depression were treated with psychotherapy.

Receiver operating characteristic curve for mental disorders in pregnant women as measured by the Edinburgh Postnatal Depression Scale (EPDS). Optimal performance of the EPDS in these women was found at 8/9 cut-off point.

Discussion

Very little is known about the capacity of the EPDS to detect mental disorders other than depression in general and in pregnant women in particular. Women with high EPDS do not always have depression. It is not clear whether EPDS scores correlate with mental disorders other than depression in pregnant women in Mexico. Therefore, the present study was aimed to determine the validity of the EPDS for detecting pregnant women with mental disorders other than depression in Durango City, Mexico. This assessment is an important initial step towards the possible use of the EPDS for screening mental disorders other than depression. A validated EPDS can be useful for detecting women with mental disorders other than depression who need further examination by a psychiatrist. In this study, the EPDS showed a poor accuracy to separate women into those with and without mental disorders other than depression. The 0.643 area under the receiver operating characteristic curve found indicates a poor accuracy of the test. The more appropriated cut-off score to separate women with and without mental disorders other than depression was 8/9. This cut-off had low sensitivity (52.4%) and specificity (67.0%). In addition, the screening tool evaluated had a low positive predictive value (11.5%). In contrast, the EPDS had good negative predictive value (95.4%). Altogether, results suggest that the EPDS may identify only a small fraction of pregnant women suffering from mental disorders other than depression. The low (52.4%) sensitivity of the instrument found indicates that the screening tool does not detect almost half of the women suffering from mental disorders other than depression. On the other hand, the 67.0% specificity of the instrument found indicates that two thirds of the women considered as not having mental disorders other than depression are correctly identified as true negative cases. In this study, every possible mental disorder other than depression was studied. We found cases of adjustment disorder, grief disorder, anxiety, obsessive-compulsive disorder, and personality disorder. However, these mental illnesses were the only disorders present in the sample of women examined during the study period. It is unclear whether other mental illnesses not found in this study could be identified by the EPDS in pregnant women in Mexico. In a recent study in Iceland, researchers found that the use of the EPDS in the second trimester of pregnancy identified an important number of women with mental disorders other than depression including eating disorders, obsessive-compulsive disorder, and bipolar disorder. In the Icelandic study, only women who scored above 11 in the EPDS were further examined by a psychiatric diagnostic interview. The findings in the Icelandic study points toward the importance of further clinical examination of women with high EPDS scores for the likelihood of having mental disorders other than depression. In a similar study of pregnant women with positive scores on the EPDS in Australia, researchers also found women with mental disorders other than depression including adjustment disorder, posttraumatic stress disorder and borderline personality disorder. In contrast, in the present validation study pregnant women with both high and low EPDS scores were studied. We found that women suffering from mental disorders other than depression might have high or low EPDS scores. Even with the use of the more appropriated EPDS cut-off point (8/9) found in the study, nearly half of the women with mental disorders other than depression scored below the cut-off threshold. In a study of women in the perinatal period in Vietnam, the EPDS was found suitable for screening common mental disorders when a 3/4 cut-off point was used. This cut-off point is rather low and certainly contributes in the sensibility of the test. In the present study, a 3/4 cut-off point would improve the sensitivity to 76.2% but the specificity would fall down to 29.7%. However, this low cut-off point means that most of the women tested would result positive for the screening. Difference in the EPDS cut-off points, obtained among the studies, indicates that the same cut-off score of this tool cannot be generalizable worldwide. Results also stress the need to validate the EPDS instrument in the countries where this tool is intended to be used. Differences in cultures and frequencies of certain mental illnesses among countries might influence the scores of the EPDS. The EPDS is known to identify anxiety too.^, In our study, there was a limited number of pregnant women with anxiety. The small number of women with mental disorders other than depression in the present study might have contributed for a small discrimination power of the EPDS. Further studies with a larger sample size to assess the discrimination power of the EPDS are needed. The instrument validated in this study may help to identify current mental illnesses other than depression in pregnant women. However, it is unclear whether these mental disorders can persist or disappear during pregnancy. Only repeat testing of the EPDS during pregnancy may help to differentiate between a transient and enduring disease as shown in a recent study.

Conclusions

We conclude that an 8/9 cut-off score of the EPDS was the more appropriated to screen mental disorders other than depression in pregnant women in Durango, Mexico. However, this tool had a small power to discriminate pregnant women with and without mental disorders other than depression. Our results points towards a need for further researches to elucidate the capacity of the EPDS in the detection of mental disorders other than depression in pregnant women.

Funding Statement

Funding: The study was supported by Juárez University of Durango State, Mexico.

References