Showing papers in "American Journal of Psychiatry in 2005"
TL;DR: Cellular adaptations in prefrontal glutamatergic innervation of the accumbens promote the compulsive character of drug seeking in addicts by decreasing the value of natural rewards, diminishing cognitive control (choice), and enhancing glutamatorgic drive in response to drug-associated stimuli.
Abstract: Objective: A primary behavioral pathology in drug addiction is the overpowering motivational strength and decreased ability to control the desire to obtain drugs. In this review the authors explore how advances in neurobiology are approaching an understanding of the cellular and circuitry underpinnings of addiction, and they describe the novel pharmacotherapeutic targets emerging from this understanding. Method: Findings from neuroimaging of addicts are integrated with cellular studies in animal models of drug seeking.
2,496 citations
TL;DR: The first consensus-based operational criteria for symptomatic remission in schizophrenia are based on distinct thresholds for reaching and maintaining improvement, as opposed to change criteria, allowing for alignment with traditional concepts of remission in both psychiatric and nonpsychiatric illness.
Abstract: New advances in the understanding of schizophrenia etiology, course, and treatment have increased interest on the part of patients, families, advocates, and professionals in the development of consensus-defined standards for clinical status and improvement, including illness remission and recovery As demonstrated in the area of mood disorders, such standards provide greater clarity around treatment goals, as well as an improved framework for the design and comparison of investigational trials and the subsequent evaluation of the effectiveness of interventions Unlike the approach to mood disorders, however, the novel application of the concept of standard outcome criteria to schizophrenia must reflect the wide heterogeneity of its long-term course and outcome, as well as the variable effects of different treatments on schizophrenia symptoms As an initial step in developing operational criteria, an expert working group reviewed available definitions and assessment instruments to provide a conceptual framework for symptomatic, functional, and cognitive domains in schizophrenia as they relate to remission of illness The first consensus-based operational criteria for symptomatic remission in schizophrenia are based on distinct thresholds for reaching and maintaining improvement, as opposed to change criteria, allowing for alignment with traditional concepts of remission in both psychiatric and nonpsychiatric illness This innovative approach for standardizing the definition for outcome in schizophrenia will require further examination of its validity and utility, as well as future refinement, particularly in relation to psychosocial and cognitive function and dysfunction These criteria should facilitate research and support a positive, longer-term approach to studying outcome in patients with schizophrenia
1,964 citations
TL;DR: The majority of patients treated with psychotherapy for PTSD in randomized trials recover or improve, rendering these approaches some of the most effective psychosocial treatments devised to date.
Abstract: Objective: The authors present a multidimensional meta-analysis of studies published between 1980 and 2003 on psychotherapy for PTSD. Method: Data on variables not previously meta-analyzed such as inclusion and exclusion criteria and rates, recovery and improvement rates, and follow-up data were examined. Results: Results suggest that psychotherapy for PTSD leads to a large initial improvement from baseline. More than half of patients who complete treatment with various forms of cognitive behavior therapy or eye movement desensitization and reprocessing improve. Reporting of metrics other than effect size provides a somewhat more nuanced account of outcome and generalizability. Conclusions: The majority of patients treated with psychotherapy for PTSD in randomized trials recover or improve, rendering these approaches some of the most effective psychosocial treatments devised to date. Several caveats, however, are important in applying these findings to patients treated in the community. Exclusion criteria and failure to address polysymptomatic presentations render generalizability to the population of PTSD patients indeterminate. The majority of patients posttreatment continue to have substantial residual symptoms, and follow-up data beyond very brief intervals have been largely absent. Future research intended to generalize to patients in practice should avoid exclusion criteria other than those a sensible clinician would impose in practice (e.g., schizophrenia), should avoid wait-list and other relatively inert control conditions, and should follow patients through at least 2 years.
1,674 citations
TL;DR: Shorter duration of untreated psychosis was associated with greater response to antipsychotic treatment, as measured by severity of global psychopathology, positive symptoms, negative symptoms, and functional outcomes.
Abstract: OBJECTIVE: The duration of untreated psychosis may influence response to treatment, reflecting a potentially malleable progressive pathological process. The authors reviewed the literature on the association of duration of untreated psychosis with symptom severity at first treatment contact and with treatment outcomes and conducted a meta-analysis examining these relationships. METHOD: English-language articles on duration of untreated psychosis published in peer-reviewed journals through July 2004 were reviewed. Studies that quantitatively assessed the duration of untreated psychosis; identified study subjects who met the criteria for nonaffective psychotic disorders at or close to first treatment; employed cross-sectional analyses of duration of untreated psychosis and of baseline symptoms, neurocognition, brain morphology, or functional measures or prospectively analyzed symptom change, response, or relapse; assessed psychopathology with clinician-rated instruments; and reported subjects’ diagnoses (a ...
1,182 citations
TL;DR: Findings of previous studies implicating migration as a risk factor for the development of schizophrenia and a quantitative index of the associated effect size are synthesized to suggest a role for psychosocial adversity in the etiology of schizophrenia.
Abstract: OBJECTIVE: The authors synthesize findings of previous studies implicating migration as a risk factor for the development of schizophrenia and provide a quantitative index of the associated effect size. METHOD: MEDLINE was searched for population-based incidence studies concerning migrants in English-language publications appearing between the years 1977 and 2003. Article bibliographies and an Australian database were cross-referenced. Studies were included if incidence reports provided numerators and denominators and if age correction was performed or could be performed by the authors. Relative risks for migrant groups were extracted or calculated for each study. Significant heterogeneity across studies indicated the need for a mixed-effects meta-analytic model. RESULTS: The mean weighted relative risk for developing schizophrenia among first-generation migrants (40 effect sizes) was 2.7 (95% confidence interval [CI]=2.3–3.2). A separate analysis performed for second-generation migrants (seven effect siz...
1,136 citations
1,106 citations
TL;DR: Voxel-based morphometry can be used as an exploratory whole-brain approach to identify abnormal brain regions in schizophrenia, which should then be validated by using region-of-interest analyses.
Abstract: OBJECTIVE: Voxel-based morphometry is a method for detecting group differences in the density or volume of brain matter. The authors reviewed the literature on use of voxel-based morphometry in schizophrenia imaging research to examine the capabilities of this method for clearly identifying specific structural differences in patients with schizophrenia, compared with healthy subjects. The authors looked for consistently reported results of relative deficits in gray and white matter in schizophrenia and evaluated voxel-based morphometry methods in order to propose a future strategy for using voxel-based morphometry in schizophrenia research. METHOD: The authors reviewed all voxel-based morphometry studies of schizophrenia that were published to May 2004 (15 studies). The studies included a total of 390 patients with a diagnosis of schizophrenia and 364 healthy volunteers. RESULTS: Gray and white matter deficits in patients with schizophrenia, relative to healthy comparison subjects, were reported in a tota...
1,095 citations
1,017 citations
TL;DR: The complex clinical presentation of OCD can be summarized with a few consistent, temporally stable symptom dimensions that can be understood as a spectrum of potentially overlapping syndromes that may coexist in any patient, be continuous with normal obsessive-compulsive phenomena, and extend beyond the traditional nosological boundaries of OCD.
Abstract: OBJECTIVE: Obsessive-compulsive disorder (OCD) is a clinically heterogeneous condition. This heterogeneity can reduce the power and obscure the findings from natural history studies to genome scans, neuroimaging, and clinical trials. The authors review the evidence supporting a multidimensional model of OCD. METHOD: Computerized and manual literature searches were performed to identify factor-analytic studies of obsessive-compulsive symptoms before data from disciplines that bear on the potential usefulness of these dimensions were considered. Selection criteria included the novelty and importance of studies and their relevance to outcomes of interest to well-informed mental health professionals. RESULTS: Twelve factor-analytic studies involving more than 2,000 patients were identified that consistently extracted at least four symptom dimensions: symmetry/ordering, hoarding, contamination/cleaning, and obsessions/checking. These dimensions were associated with distinct patterns of comorbidity, genetic tra...
950 citations
TL;DR: Verbal memory and processing speed and attention are potential targets for psychosocial interventions to improve outcome in schizophrenia, and cognition appears to explain less of the variance in outcome.
Abstract: Objective: The relationship between cognition and outcome in people with schizophrenia has been established in studies that, for the most part, examined chronic patients and were cross-sectional in design. The purpose of this study was to analyze the relationships between neurocognitive variables assessed at illness onset and functional outcome in a longitudinal design. An additional area of interest was whether the severity of negative symptoms would predict outcome independently from neurocognitive variables or whether there would be an overlap in their predictive power. Method: The authors administered a comprehensive cognitive battery and clinical assessments to 99 subjects who were in their first episode of illness and analyzed the relationship of cognition and symptom severity at intake with community outcome after an average follow-up period of 7 years. Results: Verbal memory, processing speed and attention, and the severity of negative symptoms at intake were related to subsequent outcome. Global psychosocial functioning was predicted by negative symptoms and attention. Verbal memory was the significant predictor of the degree of impairment in recreational activities. Impairment in relationships was predicted by negative symptoms and memory, whereas attention and negative symptoms were predictive of work performance. There was an overlap in the variance in outcome explained by cognitive variables and negative symptoms. Conclusions: Verbal memory and processing speed and attention are potential targets for psychosocial interventions to improve outcome. Results from cross-sectional or chronic patient studies do not necessarily correspond to the findings of this prospective first-episode study in which cognition appears to explain less of the variance in outcome.
877 citations
TL;DR: The anxiety disorders are depicted as insidious, with a chronic clinical course, low rates of recovery, and relatively high probabilities of recurrence, and the presence of particular comorbid psychiatric disorders significantly lowered the likelihood of recovery from anxiety disorders and increased thelihood of their recurrence.
Abstract: OBJECTIVE: The authors sought to observe the long-term clinical course of anxiety disorders over 12 years and to examine the influence of comorbid psychiatric disorders on recovery from or recurrence of panic disorder, generalized anxiety disorder, and social phobia. METHOD: Data were drawn from the Harvard/Brown Anxiety Disorders Research Program, a prospective, naturalistic, longitudinal, multicenter study of adults with a current or past history of anxiety disorders. Probabilities of recovery and recurrence were calculated by using standard survival analysis methods. Proportional hazards regression analyses with time-varying covariates were conducted to determine risk ratios for possible comorbid psychiatric predictors of recovery and recurrence. RESULTS: Survival analyses revealed an overall chronic course for the majority of the anxiety disorders. Social phobia had the smallest probability of recovery after 12 years of follow-up. Moreover, patients who had prospectively observed recovery from their i...
TL;DR: Subjects with affective or anxiety disorders who enter clinical trials have significant quality-of-life impairment, although the degree of dysfunction varies, and diagnostic-specific symptom measures explained only a small proportion of the variance in quality of life.
Abstract: Results: The proportion of patients with clinically severe impairment (two or more standard deviations below the community norm) in quality of life varied with different diagnoses: major depressive disorder (63%), chronic/double depression (85%), dysthymic disorder (56%), panic disorder (20%), OCD (26%), social phobia (21%), premenstrual dysphoric disorder (31%), and PTSD (59%). Regression analyses conducted for each disorder suggested that illness-specific symptom scales were significantly associated with baseline quality of life but explained only a small to modest proportion of the variance in Quality of Life Enjoyment and Satisfaction Questionnaire scores. Conclusions: Subjects with affective or anxiety disorders who enter clinical trials have significant quality-of-life impairment, although the degree of dysfunction varies. Diagnostic-specific symptom measures explained only a small proportion of the variance in quality of life, suggesting that an individual’s perception of quality of life is an additional factor that should be part of a complete assessment.
TL;DR: Intensive exposure and ritual prevention may be superior to clomipramine and, by implication, to monotherapy with the other SRIs and their combination are all efficacious treatments for OCD.
Abstract: OBJECTIVE: The purpose of the study was to test the relative and combined efficacy of clomipramine and exposure and ritual prevention in the treatment of obsessive-compulsive disorder (OCD) in adults. Serotonin reuptake inhibitors (SRIs) and cognitive behavior therapy by exposure and ritual prevention are both established treatments for OCD, yet their relative and combined efficacy have not been demonstrated conclusively. METHOD: A double-blind, randomized, placebo-controlled trial comparing exposure and ritual prevention, clomipramine, their combination (exposure and ritual prevention plus clomipramine), and pill placebo was conducted at one center expert in pharmacotherapy, another with expertise in exposure and ritual prevention, and a third with expertise in both modalities. Participants were adult outpatients (N=122 entrants) with OCD. Interventions included intensive exposure and ritual prevention for 4 weeks, followed by eight weekly maintenance sessions, and/or clomipramine administered for 12 wee...
TL;DR: The rate of reported pervasive developmental disorders has increased, and the authors found a rate of 62.6 per 10,000 in a previous study of preschoolers in Stafford, U.K, suggesting a stable incidence.
Abstract: OBJECTIVE: The rate of reported pervasive developmental disorders has increased, and the authors found a rate of 62.6 per 10,000 in a previous study of preschoolers in Stafford, U.K. They conducted another survey in 2002 to estimate the prevalence in children in a later birth cohort and to compare it to previous findings from the same area. METHOD: Screening for developmental problems included 10,903 children ages 4.0 to 6.0 years who were living in a Midlands town on the survey date. Children with symptoms suggestive of pervasive developmental disorders were intensively assessed by a multidisciplinary team using standardized diagnostic interviews, psychometric tests, and medical workups. RESULTS: Sixty-four children (85.9% boys) were diagnosed with pervasive developmental disorders. The prevalence was 58.7 per 10,000, with a 95% confidence interval (CI) of 45.2–74.9, for all pervasive developmental disorders, 22.0 per 10,000 (95% CI=14.1–32.7) for autistic disorder, and 36.7 per 10,000 (95% CI=26.2–49.9)...
TL;DR: Evidence at the molecular, cellular, systems, behavioral, and computational levels of analysis is converging to suggest the view that addiction represents a pathological usurpation of the neural mechanisms of learning and memory that under normal circumstances serve to shape survival behaviors related to the pursuit of rewards and the cues that predict them.
Abstract: If neurobiology is ultimately to contribute to the development of successful treatments for drug addiction, researchers must discover the molecular mechanisms by which drug-seeking behaviors are consolidated into compulsive use, the mechanisms that underlie the long persistence of relapse risk, and the mechanisms by which drug-associated cues come to control behavior. Evidence at the molecular, cellular, systems, behavioral, and computational levels of analysis is converging to suggest the view that addiction represents a pathological usurpation of the neural mechanisms of learning and memory that under normal circumstances serve to shape survival behaviors related to the pursuit of rewards and the cues that predict them. The author summarizes the converging evidence in this area and highlights key questions that remain.
TL;DR: This analysis of randomized, controlled trials suggests that bright light treatment and dawn simulation for seasonal affective disorder and bright light for nonseasonal depression are efficacious, with effect sizes equivalent to those in most antidepressant pharmacotherapy trials.
Abstract: Objective: The purpose of this study was to assess the evidence base for the efficacy of light therapy in treating mood disorders. Method: The authors systematically searched PubMed (January 1975 to July 2003) to identify randomized, controlled trials of light therapy for mood disorders that fulfilled predefined criteria. These articles were abstracted, and data were synthesized by disease and intervention category. Results: Only 13% of the studies met the inclusion criteria. Meta-analyses revealed that a significant reduction in depression symptom severity was associated with bright light treatment (eight studies, having an effect size of 0.84 and 95% confidence interval [CI] of 0.60 to 1.08) and dawn simulation in seasonal affective disorder (five studies; effect size=0.73, 95% CI=0.37 to 1.08) and with bright light treatment in nonseasonal depression (three studies; effect size=0.53, 95% CI=0.18 to 0.89). Bright light as an adjunct to antidepressant pharmacotherapy for nonseasonal depression was not effective (five studies; effect size= –0.01, 95% CI=–0.36 to 0.34). Conclusions: Many reports of the efficacy of light therapy are not based on rigorous study designs. This analysis of randomized, controlled trials suggests that bright light treatment and dawn simulation for seasonal affective disorder and bright light for nonseasonal depression are efficacious, with effect sizes equivalent to those in most antidepressant pharmacotherapy trials. Adopting standard approaches to light therapy’s specific issues (e.g., defining parameters of active versus placebo conditions) and incorporating rigorous designs (e.g., adequate group sizes, randomized assignment) are necessary to evaluate light therapy for mood disorders. (Am J Psychiatry 2005; 162:656–662) T he development of light therapy in psychiatry is closely intertwined with the original description of the syndrome of seasonal affective disorder. Two decades ago, Rosenthal and colleagues (1) described a series of patients with histories of recurrent depressions that developed in the fall or winter and spontaneously remitted during the following spring or summer. Their initial report also included preliminary findings indicating that bright artificial light, administered in a manner that would in essence extend the photoperiod, was more effective than dim light in treating seasonal affective disorder. The article presented an underlying hypothesis about the pathophysiology of the syndrome (i.e., depressogenic effects of melatonin), which in turn shaped the selection of treatment parameters: the intensity, duration, and timing of bright light exposure were designed to suppress the release of melatonin and lengthen the photoperiod. Both seasonal affective disorder and bright light therapy quickly captured considerable attention, both in the scientific community and with the general public. Several research groups launched clinical trial programs, and soon this experimental treatment was extended to other conditions, including nonseasonal mood disorders, Alz
TL;DR: Quetiapine monotherapy is efficacious and well tolerated for the treatment of bipolar depression and demonstrated statistically significant improvement in Montgomery-Asberg Depression Rating Scale total scores compared with placebo from week 1 onward.
Abstract: OBJECTIVE: There is a major unmet need for effective options in the treatment of bipolar depression. METHOD: Five hundred forty-two outpatients with bipolar I (N=360) or II (N=182) disorder experiencing a major depressive episode (DSM-IV) were randomly assigned to 8 weeks of quetiapine (600 or 300 mg/day) or placebo. The primary efficacy measure was mean change from baseline to week 8 in the Montgomery-Asberg Depression Rating Scale total score. Additional efficacy assessments included the Hamilton Depression Rating Scale, Clinical Global Impression of severity and improvement, Hamilton Anxiety Rating Scale, Pittsburgh Sleep Quality Index, and Quality of Life Enjoyment and Satisfaction Questionnaire. RESULTS: Quetiapine at either dose demonstrated statistically significant improvement in Montgomery-Asberg Depression Rating Scale total scores compared with placebo from week 1 onward. The proportions of patients meeting response criteria (≥50% Montgomery-Asberg Depression Rating Scale score improvement) at ...
TL;DR: Examination of the frequency of DSM-IV personality disorders in a patient group and the comorbidity among them found avoidant, borderline, and obsessive-compulsive personality disorder were the most frequent specific diagnoses.
Abstract: OBJECTIVE: The largest clinical epidemiological surveys of personality disorders have been based on unstructured clinical evaluations. However, several recent studies have questioned the accuracy and thoroughness of clinical diagnostic interviews; consequently, clinical epidemiological studies, like community-based studies, should be based on standardized evaluations. The Rhode Island Methods to Improve Diagnostic Assessment and Services project is one of the largest clinical epidemiological studies to use semistructured interviews to assess a wide range of psychiatric disorders conducted in general clinical outpatient practice. In the present report, the authors examined the frequency of DSM-IV personality disorders in a patient group and the comorbidity among them. METHOD: Eight hundred fifty-nine psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality upon presentation for treatment. RESULTS: Slightly less than one-third of the patients were diagnosed with one of t...
TL;DR: Findings support the hypothesis that the limbic system, in particular the hippocampus, may be involved in the pathophysiology of pediatric bipolar disorder.
Abstract: Background: Youths with bipolar disorder are ideal for studying illness pathophysiology given their early presentation, lack of extended treatment, and high genetic loading. Adult bipolar disorder MRI studies have focused increasingly on limbic structures and the thalamus because of their role in mood and cognition. On the basis of adult studies, the authors hypothesized a priori that youths with bipolar disorder would have amygdalar, hippocampal, and thalamic volume abnormalities. METHOD: Forty-three youths 6–16 years of age with DSM-IV bipolar disorder (23 male, 20 female) and 20 healthy comparison subjects (12 male, eight female) similar in age and sex underwent structured and clinical interviews, neurological examination, and cognitive testing. Differences in limbic and thalamic brain volumes, on the logarithmic scale, were tested using a two-way (diagnosis and sex) univariate analysis of variance, with total cerebral volume and age controlled. RESULTS: The subjects with bipolar disorder had smaller h...
TL;DR: The results highlight the importance in a suicide prevention strategy of early intervention after an episode of self-harm, and the importance of attention to physical illness, alcohol problems, and living circumstances, in treating female patients.
Abstract: OBJECTIVE: The purposes of this study were to estimate suicide rates up to 4 years after a deliberate self-harm episode, to investigate time-period effects on the suicide rate over the follow-up period, and to examine potential sociodemographic and clinical predictors of suicide within this cohort. METHOD: This prospective cohort study included 7,968 deliberate self-harm attendees at the emergency departments of four hospital trusts in the neighboring cities of Manchester and Salford, in northwest England, between September 1, 1997, and August 31, 2001. Suicide rates and standardized mortality ratios (SMRs) for the cohort were calculated. Potential risk factors were investigated by using Cox’s proportional hazards models. RESULTS: Sixty suicides occurred in the cohort during the follow-up period. An approximately 30-fold increase in risk of suicide, compared with the general population, was observed for the whole cohort. The SMR was substantially higher for female patients than for male patients. Suicide ...
TL;DR: Only behavior management therapies, specific types of caregiver and residential care staff education, and possibly cognitive stimulation appear to have lasting effectiveness for the management of dementia-associated neuropsychiatric symptoms.
Abstract: OBJECTIVE: The authors systematically reviewed the literature on psychological approaches to treating the neuropsychiatric symptoms of dementia. METHOD: Reports of studies that examined effects of any therapy derived from a psychological approach that satisfied prespecified criteria were reviewed. Data were extracted, the quality of each study was rated, and an overall rating was given to each study by using the Oxford Centre for Evidence-Based Medicine criteria. RESULTS: A total of 1,632 studies were identified, and 162 satisfied the inclusion criteria for the review. Specific types of psychoeducation for caregivers about managing neuropsychiatric symptoms were effective treatments whose benefits lasted for months, but other caregiver interventions were not. Behavioral management techniques that are centered on individual patients’ behavior or on caregiver behavior had similar benefits, as did cognitive stimulation. Music therapy and Snoezelen, and possibly sensory stimulation, were useful during the tre...
TL;DR: Lithium is effective in the prevention of suicide, deliberate self-harm, and death from all causes in patients with mood disorders, according to the Cochrane Collaboration.
Abstract: Objective: Observational studies suggest that long-term lithium treatment has a strong antisuicidal effect in mood disorders, but it is uncertain whether this association is a genuine therapeutic effect or is due to confounding factors in nonrandomized studies. The authors conducted a systematic review and meta-analysis of randomized trials to investigate the effect of lithium, compared to placebo and other active treatments, on the risk of suicide, deliberate self-harm, and all-cause mortality in patients with mood disorder. Method: The data source was the Cochrane Collaboration Depression, Anxiety
TL;DR: The study shows that abnormal brain activation during inhibitory challenge in ADHD is specific to the disorder, since it persists when medication history and performance discrepancies are excluded.
Abstract: Objective: Patients with attention deficit hyperactivity disorder (ADHD) and a medication history have shown abnormal brain activation in prefrontal and striatal brain regions during cognitive challenge. Previous findings have been confounded, however, by potential long-term effects of stimulant medication exposure and group discrepancies in task performance. The aim of this study was to investigate whether medication-naive adolescents with ADHD would still show abnormal brain activation in prefrontal brain regions during motor response inhibition in a task designed to control for intergroup performance discrepancies. Method: Rapid, event-related functional magnetic resonance imaging was used to compare brain activation in 16 medication-naive ADHD adolescents and 21 IQ-, age-, and sex-matched healthy comparison volunteers during a challenging, idiosyncratically adjusted task that required withholding of a triggered motor response. The design, which manipulated task parameters to force each subject to fail on 50% of trials, ensured that subjects worked at the edge of their own inhibitory performance, thereby controlling for intersubject and intergroup performance discrepancies and furthermore allowing for investigation of differences in brain activation related to inhibition and inhibition failure. Results: Medication-naive adolescents with ADHD showed significantly reduced brain activation in the right inferior prefrontal cortex during successful motor response inhibition and in the precuneus and posterior cingulate gyrus during inhibition failure, both of which correlated with behavioral scores of ADHD. Conclusions: The study shows that abnormal brain activation during inhibitory challenge in ADHD is specific to the disorder, since it persists when medication history and performance discrepancies are excluded.
TL;DR: Homelessness is a serious problem among patients with severe mental illness and interventions focusing on potentially modifiable factors such as substance use disorders and a lack of Medicaid need to be studied in this population.
Abstract: OBJECTIVE: The authors examined the prevalence of and risk factors for homelessness among all patients treated for serious mental illnesses in a large public mental health system in a 1-year period. The use of public mental health services among homeless persons was also examined. METHOD: The study included 10,340 persons treated for schizophrenia, bipolar disorder, or major depression in the San Diego County Adult Mental Health Services over a 1-year period (1999–2000). Analytic methods that adjusted for potentially confounding variables were used. Multivariate logistic regression analyses were used to calculate odds ratios for the factors associated with homelessness, including age, gender, ethnicity, substance use disorder, Medicaid insurance, psychiatric diagnosis, and level of functioning. Similarly, odds ratios were computed for utilization of mental health services by homeless versus not-homeless patients. RESULTS: The prevalence of homelessness was 15%. Homelessness was associated with male gender...
TL;DR: Impulsive-aggressive personality disorders and alcohol abuse/dependence were two independent predictors of suicide in major depression, and impulsive and aggressive behaviors seem to underlie these risk factors.
Abstract: Objective: Major depression is a major risk factor for suicide. However, not all individuals with major depression commit suicide. Impulsive and aggressive behaviors have been proposed as risk factors for suicide, but it remains unclear whether their effect on the risk of suicide is at least partly explained by axis I disorders commonly associated with suicide, such as major depression. With a case-control design, a comparison of the level of impulsive and aggressive behaviors and the prevalence of associated psychopathology was carried out with control for the presence of primary psychopathology. Method: One hundred and four male suicide completers who died during an episode of major depression and 74 living depressed male comparison subjects were investigated with proxy-based interviews by using structured diagnostic instruments and personality trait assessments. Results: The authors found that current (6-month prevalence) alcohol abuse/dependence, current drug abuse/dependence, and cluster B personality disorders increased the risk of suicide in individuals with major depression. Also, higher levels of impulsivity and aggression were associated with suicide. An analysis by age showed that these risk factors were more specific to younger suicide victims (ages 18–40). A multivariate analysis indicated that current alcohol abuse/dependence and cluster B personality disorder were two independent predictors of suicide. Conclusions: Impulsive-aggressive personality disorders and alcohol abuse/dependence were two independent predictors of suicide in major depression, and impulsive and aggressive behaviors seem to underlie these risk factors. A developmental hypothesis of suicidal behavior, with impulsive and aggressive behaviors as the starting point, is discussed.
TL;DR: The authors discuss the neurobiological interface between substance use Disorders and other psychiatric disorders with an emphasis on emerging data concerning four psychiatric disorders that commonly co-occur with substance use disorders: depression/mood disorders, posttraumatic stress disorder, attention deficit hyperactivity disorder, and schizophrenia.
Abstract: The high rate of co-occurrence of substance use disorders and other psychiatric disorders is well established. The population of people with co-occurring disorders is heterogeneous, and the prevalence of comorbidity differs by diagnostic group. One of the overarching issues in the area of comorbidity is the nature of the connection between psychiatric disorders and substance use disorders. The rapid development of technical advances in the neurosciences has led to a better understanding of the molecular biology, neurotransmitter systems, and neural circuitry involved in mental illness and substance use disorders. The authors discuss the neurobiological interface between substance use disorders and other psychiatric disorders with an emphasis on emerging data concerning four psychiatric disorders that commonly co-occur with substance use disorders: depression/mood disorders, posttraumatic stress disorder, attention deficit hyperactivity disorder, and schizophrenia. Better understanding of the connection between substance use disorders and psychiatric disorders could have a profound effect on prevention and treatment.
TL;DR: Significant racial/ethnic group differences in likelihood of receiving any mental health service and, specifically, formal outpatient services were found after the effects of potentially confounding variables were controlled.
Abstract: OBJECTIVE: Racial and ethnic disparities in mental health service use have been identified as a major public health problem. However, the extent to which these disparities may be accounted for by other confounding sociodemographic or clinical predictors of service use (e.g., family income, functional impairment, caregiver strain) is relatively unexplored, especially for youth services. The goal of this study was to test for racial/ethnic disparities in use of a variety of outpatient, inpatient, and informal mental health services among high-risk youths, with the effects of other predictive factors controlled. METHOD: Participants were 1,256 youths ages 6–18 years who received services in a large, publicly funded system of care (including the child welfare, juvenile justice, special education, alcohol and drug abuse, and mental health service sectors). Youths and caregivers were interviewed with established measures of mental health service use, psychiatric diagnoses, functional impairment, caregiver strai...
TL;DR: Impaired decision making, possibly due to emotional dysfunction, may be a neuropsychological risk factor for suicidal behavior.
Abstract: Objective: The understanding of suicidal behavior is incomplete. The stress-diathesis model suggests that a deficit in serotonergic projections to the orbitofrontal cortex is involved in susceptibility to suicidal behavior. The orbitofrontal cortex has been implicated in decision making, a cognitive function dealing with complex choices that may be under serotonergic modulation. In this preliminary study, the authors assessed decision making in suicide attempters. Method: The authors used the Iowa Gambling Task to investigate patients with a history of violent (N=32) or nonviolent (N=37) suicidal behavior, patients suffering from affective disorders with no history of suicidal behavior (N=25), and healthy comparison subjects (N=82). Patients were assessed when they were not suffering from a current axis I disorder. The authors also assessed the correlation of Iowa Gambling Task performance with psychometric measures of impulsivity, hostility, anger, aggression, and emotional instability. Results: Both groups of suicide attempters scored significantly lower than healthy comparison subjects, and violent suicide attempters performed significantly worse than affective comparison subjects. No significant differences were observed between the groups of suicide attempters or between the two comparison groups. The differences in performance could not be accounted for by age, intellectual ability, educational level, number of suicide attempts, age at first suicide attempt, history of axis I disorder, or medication use. Iowa Gambling Task performances were correlated positively with affective lability and with anger expression but not with impulsivity. Conclusions: Impaired decision making, possibly due to emotional dysfunction, may be a neuropsychological risk factor for suicidal behavior.
TL;DR: Emotionally supportive social relationships are substantially more protective against major depression for women than for men, and effects cannot explain sex effects on the prevalence of major depression, but they do suggest important sex differences in pathways of risk.
Abstract: Objective: Compared to men, women have larger and more intimate social networks and higher rates of major depression. Prior studies have suggested that women are more sensitive to the depressogenic effects of low social support, but most of these studies had substantial methodologic limitations. Method: In two interview waves at least 1 year apart, 1,057 pairs of opposite-sex dizygotic twin pairs ascertained from a population-based register were assessed. The authors predicted risk of major depression in the year before the wave 2 interview from levels of social support assessed at wave 1. Results: Women reported higher levels of global social support than their twin brothers. Global social support at wave 1 predicted risk for major depression at wave 2 significantly more strongly in female than in male members of these pairs, and the same effect was seen when the analysis controlled for the history of major depression in the year prior to wave 1. Women were more sensitive than men to the depressogenic effects of low levels of social support, particularly from the co-twin, other relatives, parents, and spouses. Levels of social support did not explain the sex difference in risk for major depression. Conclusions: Emotionally supportive social relationships are substantially more protective against major depression for women than for men. While these effects cannot explain sex effects on the prevalence of major depression, they do suggest important sex differences in pathways of risk. Clarification of the nature of the causal links between low social support and depression in women is needed.
TL;DR: While genetic liability and gene-environment interactions may account for some outcomes, maternal risk factors and biological and behavioral concomitants of severe mental illness appear to be major determinants of increases in reproductive pathology in this cohort.
Abstract: OBJECTIVE: This study ascertained the incidence of complications during pregnancy, labor, and delivery and the neonatal characteristics of infants born to women with schizophrenia, bipolar disorder, or major depression in a population-based cohort. METHOD: Based on records linkage across a psychiatric case register and prospectively recorded obstetric data, the study comprised women with schizophrenia or major affective disorders who had given birth to 3,174 children during 1980–1992 in Western Australia. A comparison sample of 3,129 births to women without a psychiatric diagnosis was randomly selected from women giving birth during 1980–1992. Complications were scored with the McNeil-Sjostrom Scale. Odds ratios were calculated for specific reproductive events. RESULTS: Both schizophrenic and affective disorder patients had increased risks of pregnancy, birth, and neonatal complications, including placental abnormalities, antepartum hemorrhages, and fetal distress. Women with schizophrenia were significan...