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Showing papers in "Archives of General Psychiatry in 1996"


Journal ArticleDOI
TL;DR: A limited range of diagnoses--most commonly a mood disorder alone or in combination with conduct disorder and/or substance abuse--characterizes most suicides among teenagers.
Abstract: Background: The age, sex, and ethnic distribution of adolescents who commit suicide is significantly different from that of the general population. The present study was designed to examine psychiatric risk factors and the relationship between them and demographic variables. Methods: A case-control, psychologic autopsy study of 120 of 170 consecutive subjects (age, Results: By using parent informants only, 59% of subjects who committed suicide and 23% of control subjects who metDSM-IIIcriteria for a psychiatric diagnosis, 49% and 26%, respectively, had had symptoms for more than 3 years, and 46% and 29%, respectively, had had previous contact with a mental health professional. Best-estimate rates, based on multiple informants for these parameters, for suicides only, were 91%, 52%, and 46%, respectively. Previous attempts and mood disorder were major risk factors for both sexes; substance and/or alcohol abuse was a risk factor for males only. Mood disorder was more common in females, substance and/or alcohol abuse occurred exclusively in males (62% of 18-to 19-year-old suicides). The prevalence of a psychiatric diagnosis and, in particular, substance and/or alcohol abuse increased with age. Conclusion: A limited range of diagnoses—most commonly a mood disorder alone or in combination with conduct disorder and/or substance abuse—characterizes most suicides among teenagers.

1,243 citations


Journal ArticleDOI
TL;DR: This first comprehensive morphometric analysis is consistent with hypothesized dysfunction of right-sided prefrontal-striatal systems in ADHD.
Abstract: Background: Anatomic magnetic resonance imaging (MRI) studies of attention-deficit hyperactivity disorder (ADHD) have been limited by small samples or measurement of single brain regions. Since the neuropsychological deficits in ADHD implicate a network linking basal ganglia and frontal regions, 12 subcortical and cortical regions and their symmetries were measured to determine if these structures best distinguished ADHD. Method: Anatomic brain MRIs for 57 boys with ADHD and 55 healthy matched controls, aged 5 to 18 years, were obtained using a 1.5-T scanner with contiguous 2-mm sections. Volumetric measures of the cerebrum, caudate nucleus, putamen, globus pallidus, amygdala, hippocampus, temporal lobe, cerebellum; a measure of prefrontal cortex; and related right-left asymmetries were examined along with midsagittal area measures of the cerebellum and corpus callosum. Interrater reliabilities were.82 or greater for all MRI measures. Results: Subjects with ADHD had a 4.7% smaller total cerebral volume ( P =.02). Analysis of covariance for total cerebral volume demonstrated a significant loss of normal right>left asymmetry in the caudate ( P =.006), smaller right globus pallidus ( P =.005), smaller right anterior frontal region ( P =.02), smaller cerebellum ( P =.05), and reversal of normal lateral ventricular asymmetry ( P =.03) in the ADHD group. The normal age-related decrease in caudate volume was not seen, and increases in lateral ventricular volumes were significantly diminished in ADHD. Conclusion: This first comprehensive morphometric analysis is consistent with hypothesized dysfunction of right-sided prefrontal-striatal systems in ADHD.

1,214 citations


Journal ArticleDOI
TL;DR: Poverty was the strongest demographic correlate of diagnosis, in both urban and rural children, in this rural sample of children.
Abstract: Background: The Great Smoky Mountains Study of youth focuses on the relationship between the development of psychiatric disorder and the need for and use of mental health services. Methods: A multistage, overlapping cohorts design was used, in which 4500 of the 11 758 children aged 9, 11, and 13 years in an 11-country area of the southeastern United States were randomly selected for screening for psychiatric symptoms. Children who scored in the top 25% on the screening questionnaire, together with a 1 in 10 random sample of the rest, were recruited for 4 waves of intensive, annual interviews (n=1015 at wave 1). In a parallel study, all American Indian children aged 9, 11, and 13 years were recruited (N=323 at wave 1). Results: The 3-month prevalence (±SE) of any DSMIII-R axis I disorder in the main sample, weighted to reflect population prevalence rates, was 20.3%±1.7%. The most common diagnoses were anxiety disorders (5.7%±1.0%), enuresis (5.1%±1.0%), tic disorders (4.2%±0.9%), conduct disorder (3.3%±0.6%), oppositional defiant disorder (2.7%±0.4%), and hyperactivity (1.9%±0.4%). Conclusions: The prevalence of psychiatric disorder in this rural sample was similar to rates reported in other recent studies. Poverty was the strongest demographic correlate of diagnosis, in both urban and rural children.

1,092 citations


Journal ArticleDOI
TL;DR: The first empirical test of whether behavioral differences among children in the first 3 years of life are linked to specific adult psychiatric disorders: anxiety and mood disorders, antisocial personality disorder, recidivistic and violent crime, alcoholism, and suicidal behavior was provided by.
Abstract: Background: This study provides, to our knowledge, the first empirical test of whether behavioral differences among children in the first 3 years of life are linked to specific adult psychiatric disorders: anxiety and mood disorders, antisocial personality disorder, recidivistic and violent crime, alcoholism, and suicidal behavior. Methods: In a longitudinal-epidemiological study, 3-year-old children were classified into groups based on examiner observations of their behavior. At age 21 years, they were reassessed for psychopathologic functioning using standardized interviews based on DSM-IIJ-R criteria. Results: Although effect sizes were small,undercontrolled(includes children who are impulsive, restless, and distractible) andinhibited(includes children who are shy, fearful, and easily upset) children differed significantly from comparison children in young adulthood. Undercontrolled 3-year-olds were more likely at 21 years to meet diagnostic criteria for antisocial personality disorder and to be involved in crime. Inhibited 3-year-olds were more likely at 21 years to meet diagnostic criteria for depression. Both groups were more likely to attempt suicide, and boys in both groups had alcohol-related problems. Controls for family social class did not change the findings. Conclusions: Some forms of adult psychopathologic abnormality are meaningfully linked, albeit weakly, to behavioral differences observed among children in the third year of life.

986 citations


Journal ArticleDOI
TL;DR: The results suggest that emotions associated with the PTSD symptomatic state are mediated by the limbic and paralimbic systems within the right hemisphere.
Abstract: Background: Previous studies have used symptom provocation and positron emission tomography to delineate the brain systems that mediate various anxiety states. Using an analogous approach, the goal of this study was to measure regional cerebral blood flow changes associated with posttraumatic stress disorder (PTSD) symptoms. Methods: Eight patients with PTSD, screened as physiologically responsive to a script-driven imagery symptom provocation paradigm, were exposed sequentially to audiotaped traumatic and neutral scripts in conjunction with positron emission tomography. Heart rate and subjective measures of emotional state were obtained for each condition. Statistical mapping techniques were used to determine locations of significant brain activation. Results: Increases in normalized blood flow were found for the traumatic as compared with control conditions in rightsided limbic, paralimbic, and visual areas; decreases were found in left inferior frontal and middle temporal cortex. Conclusions: The results suggest that emotions associated with the PTSD symptomatic state are mediated by the limbic and paralimbic systems within the right hemisphere. Activation of visual cortex may correspond to the visual component of PTSD reexperiencing phenomena.

956 citations


Journal ArticleDOI
TL;DR: Phobias are common, increasingly prevalent, often associated with serious role impairment, and usually go untreated, but barriers to help seeking need to be investigated.
Abstract: Background: Data are presented on the general population prevalences, correlates, comorbidities, and impairments associated with DSM-III-R phobias. Methods: Analysis is based on the National Comorbidity Survey. Phobias were assessed with a revised version of the Composite International Diagnostic Interview. Results: Lifetime (and 30-day) prevalence estimates are 6.7% (and 2.3%) for agoraphobia, 11.3% (and 5.5%) for simple phobia, and 13.3% (and 4.5%) for social phobia. Increasing lifetime prevalences are found in recent cohorts. Earlier median ages at illness onset are found for simple (15 years of age) and social (16 years of age) phobias than for agoraphobia (29 years of age). Phobias are highly comorbid. Most comorbid simple and social phobias are temporally primary, while most comorbid agoraphobia is temporally secondary. Comorbid phobias are generally more severe than pure phobias. Despite evidence of role impairment in phobia, only a minority of individuals with phobia ever seek professional treatment. Conclusions: Phobias are common, increasingly prevalent, often associated with serious role impairment, and usually go untreated. Focused research is needed to investigate barriers to help seeking.

948 citations


Journal ArticleDOI
TL;DR: A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression.
Abstract: Background: This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care. Methods: One hundred fifty-three primary care patients with current depression were entered into a randomized controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received "usual" care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time. Results: At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients. Conclusion: A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.

822 citations


Journal ArticleDOI
TL;DR: Previous retrospective results indicating that children with ADHD are at high risk of developing a wide range of impairments affecting multiple domains of psychopathology such as cognition, interpersonal, school, and family functioning are confirmed.
Abstract: Background: Previous cross-sectional data showed that children and adolescents with attention-deficit hyperactivity disorder (ADHD) are at increased risk of comorbid conduct, mood, and anxiety disorders as well as impairments in cognitive, social, family, and school functioning. However, longitudinal data were needed to confirm these initial impressions. Methods: Using DSM-III-R structured diagnostic interviews and raters blinded as to diagnosis, we reexamined psychiatric diagnoses at 1- and 4-year follow-ups in children with ADHD and controls. In addition, subjects were evaluated for cognitive, achievement, social, school, and family functioning. Results: Analyses of follow-up findings revealed significant differences between children with ADHD and controls in rates of behavioral, mood, and anxiety disorders, with these disorders increasing markedly from baseline to follow-up assessments. In addition, children with ADHD had significantly more impaired cognitive, family, school, and psychosocial functioning than did controls. Baseline diagnosis of conduct disorder predicted conduct disorder and substance use disorders at follow-up, major depression at baseline predicted major depression and bipolar disorder at follow-up, and anxiety disorders at baseline predicted anxiety disorders at follow-up. Conclusions: These results confirm and extend previous retrospective results indicating that children with ADHD are at high risk of developing a wide range of impairments affecting multiple domains of psychopathology such as cognition, interpersonal, school, and family functioning. These findings provide further support for the value of considering psychiatric comorbidity in both clinical assessment and research protocols involving children with ADHD.

723 citations


Journal ArticleDOI
TL;DR: Prenatal nutritional deficiency may play a role in the origin of some cases of schizophrenia, and among all birth cohorts of 1944 through 1946, the risk for schizophrenia clearly peaked in this exposed cohort.
Abstract: Background: Suggestive findings of an earlier study that prenatal nutritional deficiency was a determinant of schizophrenia prompted us to undertake a second test of the hypothesis using more precise data on both exposure and outcome. Methods: Among persons born in the cities of western Netherlands during 1944 through 1946, we compared the risk for schizophrenia in those exposed and unexposed during early gestation to the Dutch Hunger Winter of 1944/1945. The frequency of hospitalized patients with schizophrenia at age 24 to 48 years in the exposed and unexposed birth cohorts was ascertained from a national psychiatric registry. Results: The most exposed birth cohort, conceived at the height of the famine, showed a twofold and statistically significant increase in the risk for schizophrenia (relative risk [RR] = 2.0; 95% confidence interval [CI] = 1.2 to 3.4;P Conclusion: Prenatal nutritional deficiency may play a role in the origin of some cases of schizophrenia.

708 citations


Journal ArticleDOI
TL;DR: Substantial psychiatric morbidity among female jail detainees is suggested, except for schizophrenia, which was arrested for nonviolent crimes.
Abstract: Background: There are little epidemiologic data on psychiatric disorders of women in jails. Accurate data on female jail detainees are critical because of their increasing numbers and their unique treatment needs. Methods: Using the Diagnostic Interview Schedule, independent interviewers assessed a randomly selected, stratified sample of 1272 female jail detainees awaiting trial in Chicago, Ill. We tabulated lifetime and 6-month prevalence rates of disorders by race or ethnicity (African American, non-Hispanic white, Hispanic), age, and education and compared the jail rates with general population rates for women in the Epidemiologic Catchment Area program. We also examined whether or not psychiatric disorder was associated with the severity of the detainee's current arrest charges. Results: Over 80% of the sample met criteria for one or more lifetime psychiatric disorders; 70% were symptomatic within 6 months of the interview. The most common disorders were drug abuse or dependence, alcohol abuse or dependence, and post-traumatic stress disorder. Major depressive episode was the most prevalent major mental disorder. Rates were generally highest among non-Hispanic whites and among older detainees. Rates for all disorders were significantly higher than general population rates, except for schizophrenia. Most detainees with psychiatric disorders were arrested for nonviolent crimes. Conclusion: These results suggest substantial psychiatric morbidity among female jail detainees.

702 citations


Journal ArticleDOI
TL;DR: Although results using computer algorithms were similar in the National Comorbidity Survey and Epidemiologic Catchment Area studies, diagnoses so obtained agreed poorly with clinical diagnoses.
Abstract: Background: We seek to estimate lifetime prevalence and demographic correlates of nonaffective psychosis in the US population assessed by a computer-analyzed structured interview and a senior clinician. Methods: In the National Comorbidity Survey, a probability subsample of 5877 respondents were administered a screen for psychotic symptoms. Based on the response to this screening, detailed follow-up interviews were conducted by mental health professionals (n=454). The initial screen and clinical reinterview were reviewed by a senior clinician. Results are presented for narrowly (schizophrenia or schizophreniform disorder) and broadly (all nonaffective psychoses) defined psychotic illness. Results: One or more psychosis screening questions were endorsed by 28.4% of individuals. By computer algorithm, lifetime prevalences of narrowly and broadly defined psychotic illness were 1.3% and 2.2%, respectively. Of those assigned a narrow diagnosis by the computer, the senior clinician assigned narrow and broad diagnoses to 10% and 37%, respectively. By clinician diagnosis, lifetime prevalence rates of narrowly and broadly defined psychosis were 0.2% and 0.7%, respectively. A clinician diagnosis of nonaffective psychosis was significantly associated with low income; unemployment; a marital status of single, divorced, or separated; and urban residence. Clinician confirmation of a computer diagnosis was predicted by hospitalization, neuroleptic treatment, duration of illness, enduring impairment, and thought disorder. Conclusions: Lifetime prevalence estimates of psychosis in community samples are strongly influenced by methods of assessment and diagnosis. Although results using computer algorithms were similar in the National Comorbidity Survey and Epidemiologic Catchment Area studies, diagnoses so obtained agreed poorly with clinical diagnoses. Accurate assessment of psychotic illness in epidemiologic samples may require collection of extensive contextual information for clinician review.

Journal ArticleDOI
TL;DR: Findings in this study replicate and extend previous findings of changes in caudate nucleus function with behavior therapy for obsessive-compulsive disorder.
Abstract: Background: We sought to determine in a new patient sample whether symptomatic improvement in obsessivecompulsive disorder treated with behavior modification is accompanied by significant changes in glucose metabolic rates in the caudate nucleus, measured with positron emission tomography, as seen in a previous study. Second, by combining samples from this and the previous study, we also examined whether there were pathologic correlational relationships among brain activity in the orbital cortex, caudate nucleus, and thalamus that obtained before behavioral treatment of obsessivecompulsive disorder, but that decreased significantly with symptom improvement. Methods: Nine patients with obsessive-compulsive disorder were studied with positron emission tomography before and after 10 weeks of structured exposure and response prevention behavioral and cognitive treatment. Results were analyzed both alone and combined with those from nine similar subjects from the previous study. Results: Behavior therapy responders had significant (P Conclusions: These results replicate and extend previous findings of changes in caudate nucleus function with behavior therapy for obsessive-compulsive disorder. A prefrontal cortico-striato-thalamic brain system is implicated in mediation of symptoms of obsessivecompulsive disorder.

Journal ArticleDOI
TL;DR: Results of functional magnetic resonance imaging were consistent with past studies of obsessive-compulsive disorder that used other functional neuroimaging modalities, however, paralimbic and limbic activations were more prominent in the present study.
Abstract: Background: The new technique of functional magnetic resonance imaging was used to investigate the mediating neuroanatomy of obsessive-compulsive disorder symptoms. Methods: Ten patients with obsessive-compulsive disorder and 5 normal subjects were studied via functional magnetic resonance imaging during control and provoked conditions. Data analysis entailed parametric and nonparametric statistical mapping. Results: Statistical maps (nonparametric;P Conclusions: Results of functional magnetic resonance imaging were consistent with past studies of obsessive-compulsive disorder that used other functional neuroimaging modalities. However, paralimbic and limbic activations were more prominent in the present study.

Journal ArticleDOI
TL;DR: In this sample of moderately functional white men, the development of alcoholism occurred in relationship to an FH of alcoholism, but alcohol abuse or dependence was unrelated to prior psychiatric disorders.
Abstract: Background: Between 1978 and 1988, 453 sons (age range, 18 to 29 years) of alcoholic and control subjects were evaluated for their level of reaction (LR) to alcohol. This article presents the results of the 8.2-year follow-up of 450 of these men. The three goals were (1) to attempt to replicate results of the follow-up of the first 223 subjects, (2) to evaluate the potential impact of the quantity and frequency of drinking at the time of the original study on the relationship between LR and alcoholic outcome (ALC), and, most importantly, (3) to test if the relationship between family history (FH) and ALC might be mediated by LR in a subset of the sample. Methods: Face-to-face structured follow-up interviews were carried out with the subjects and separately with an additional informant, and blood samples, as well as urine specimens, were obtained for determination of state markers of heavy drinking and drug toxicology screens. Results: First, the rate of development of DSM-III-R abuse and dependence on alcohol was 14.1% and 28.6%, respectively, for family history positive (FHP) subjects, compared with 6.6% and 10.8%, respectively, for family history negative (FHN) men. Second, neither consideration of the quantity nor the frequency of drinking at the time of the original study, nor their combination, effectively diminished the relationships between LR and ALC. Third, among men who drank and demonstrated the 15% highest and lowest scores on LR at about the age of 20 years (ie, 30% of the relevant population), the correlation between FH and ALC was greatly reduced when LR was considered, but the correlation between LR and ALC was not greatly diminished when the impact of FH was evaluated. Conclusions: In this sample of moderately functional white men, the development of alcoholism occurred in relationship to an FH of alcoholism, but alcohol abuse or dependence was unrelated to prior psychiatric disorders. For this group, LR at the age of 20 years was associated with future alcoholism in a manner that was independent of the drinking practices at the time of the original study. At least among those men with clearly high and low LR scores, these data are consistent with the conclusion that LR might be a mediator of the alcoholism risk.

Journal ArticleDOI
TL;DR: The overall effect size on increasing suicide risk of the psychosocial factors is comparable with that for diagnostic factors, highlighting the importance of considering socioenvironmental factors when assessing suicide risk.
Abstract: Background: Few psychosocial risk factors for completed suicide in children and adolescents have been studied systematically. The present study was designed to examine the environmental, social, and familial characteristics of a large representative sample of child and adolescent suicides. Methods: A case-control, psychological autopsy of 120 of 170 consecutive suicides younger than 20 years and 147 community age-, sex-, and ethnically matched control participants in the greater New York, NY, area. Results: There was a significant independent impact of the psychosocial factors on increasing suicide risk among children and adolescents, beyond that risk attributable to psychiatric illness. The most notable risks were derived from school problems, a family history of suicidal behavior, poor parent-child communication, and stressful life events. Sex, ethnicity, and age modified the relationships of a few of the psychosocial factors. Conclusions: Socioenvironmental circumstances add significantly to a teenager's risk of suicide. The overall effect size on increasing suicide risk of the psychosocial factors is comparable with that for diagnostic factors, highlighting the importance of considering socioenvironmental factors when assessing suicide risk.

Journal ArticleDOI
TL;DR: Depressed mood moderately increased the risk of developing dementia, primarily Alzheimer's disease.
Abstract: Background: It remains unclear whether depression increases the risk for dementia in the elderly. We evaluated the relationship between depressed mood at baseline and the incidence of dementia, particularly Alzheimer's disease, in the elderly living in the community. Methods: A total of 1070 elderly individuals, aged 60 years or older, were identified as part of a registry for dementia in the Washington Heights community of North Manhattan, NY. In a prospective, longitudinal design with follow-up for 1 to 5 years, annual physician evaluation and neuropsychological testing were used to assess levels of cognitive impairment and to diagnose dementia. Depressive symptoms were evaluated with the 17-item Hamilton Rating Scale for Depression. Based on clinical considerations and a validity study, a positive score for the depressed mood item was used in statistical analyses. To confirm the results, the total Hamilton Rating Scale for Depression score was also evaluated as the "depression" variable. Results: Of the 1070 subjects, 218 met criteria for dementia at baseline evaluation. In the 852 subjects without dementia, depressed mood was more common in individuals with greater cognitive impairment. In a follow-up study of 478 of these subjects without dementia (mean±SD, 2.54±1.12 years of follow-up), the effect of baseline depressed mood on the end-point diagnosis of dementia (93% had possible or probable Alzheimer's disease) was evaluated in a Cox proportional hazards model. Depressed mood at baseline was associated with an increased risk of incident dementia (relative risk, 2.94; 95% confidence interval, 1.76 to 4.91;P Conclusions: Depressed mood moderately increased the risk of developing dementia, primarily Alzheimer's disease. Whether depressed mood is a very early manifestation of Alzheimer's disease, or increases susceptibility through another mechanism, remains to be determined.

Journal ArticleDOI
TL;DR: Significant sex differences in aging of brain areas that are essential to higher cognitive functioning are found and may explain some of the age-sex differences in human cognition and response to brain injury and disease.
Abstract: Background: There are significant age and sex effects in cognitive ability and brain disease. However, sex differences in aging of human brain areas associated with nonreproductive behavior have not been extensively studied. We hypothesized that there would be significant sex differences in aging of brain areas that subserve speech, visuospatial, and memory function. Methods: We investigated sex differences in the effect of aging on human brain morphometry by means of volumetric magnetic resonance imaging and on regional cerebral metabolism for glucose by positron emission tomography. In the magnetic resonance imaging study, we examined 69 healthy right-handed subjects (34 women and 35 men), divided into young (age range, 20 to 35 years) and old (60 to 85 years) groups. In the positron emission tomography study, we investigated 120 healthy right-handed subjects (65 women and 55 men) aged 21 to 91 years. Results: In the magnetic resonance imaging study, age-related volume loss was significantly greater in men than women in whole brain and frontal and temporal lobes, whereas it was greater in women than men in hippocampus and parietal lobes. In the positron emission tomography study, significant sex differences existed in the effect of age on regional brain metabolism, and asymmetry of metabolism, in the temporal and parietal lobes, Broca's area, thalamus, and hippocampus. Conclusions: We found significant sex differences in aging of brain areas that are essential to higher cognitive functioning. Thus, our findings may explain some of the age-sex differences in human cognition and response to brain injury and disease.

Journal ArticleDOI
TL;DR: Fluvoxamine is more effective than placebo in the short-term treatment of the symptoms of autistic disorder in adults and controlled studies of fluvoxamine and other potent and selective serotonin uptake inhibitors seem warranted in children and adolescents with autism.
Abstract: Background: Autistic disorder is characterized by a fundamental disturbance in social interaction, impairments in communication, and a markedly restricted repertoire of activities and interests. Abnormalities in the serotonin neurotransmitter system have been identified in some persons with autism. No consistently effective and safe drugs have been developed for treating the symptoms of autism. Methods: Thirty adults with autistic disorder completed a 12-week double-blind, placebo-controlled trial of the potent and selective serotonin uptake inhibitor fluvoxamine maleate. Behavioral ratings were obtained at baseline and after 4, 8, and 12 weeks of treatment. Results: Eight (53%) of 15 patients in the fluvoxamine-treated group were categorized as responders compared with none of 15 in the placebo group ( P =.001). Fluvoxamine was superior to placebo in reducing repetitive thoughts and behavior ( P P P P P Conclusions: Fluvoxamine is more effective than placebo in the short-term treatment of the symptoms of autistic disorder in adults. Controlled studies of fluvoxamine and other potent and selective serotonin uptake inhibitors seem warranted in children and adolescents with autism.

Journal ArticleDOI
TL;DR: These findings confirm those from 2 other post-World War II Scandinavian birth cohorts that have found an association between psychiatric hospitalization and criminal convictions and concur with findings that patients discharged from psychiatric wards are more likely than other persons living in the same community to commit crimes.
Abstract: Background: Evidence has accumulated since the mid 1960s from a number of different countries indicating an association between mental disorder and crime and particularly between the major mental disorders and violence. Registries in Denmark were used to identify a birth cohort and to document all psychiatric admissions and all criminal proceedings of the 324 401 members of this cohort up to the age of 43 years. Methods: Persons who had been admitted to a psychiatric ward were assigned to a diagnostic category according to a hierarchy of principal discharge diagnoses. They were compared with persons never admitted to a psychiatric ward as to the prevalence, type, and frequency of criminal convictions. Results: Women and men who had been hospitalized in psychiatric wards were more likely to have been convicted of a criminal offense than persons with no history of psychiatric hospitalization. The offenders who were hospitalized committed all types and, on average, as many offenses as did the never-hospitalized group of the same sex. Conclusions: These findings confirm those from 2 other post-World War II Scandinavian birth cohorts that have found an association between psychiatric hospitalization and criminal convictions. They also concur with findings that patients discharged from psychiatric wards are more likely than other persons living in the same community to commit crimes and with results from North America showing elevated rates of major mental disorders among incarcerated offenders. Generalization of these findings is limited to nations with similar criminal justice, mental health, and social welfare systems.

Journal ArticleDOI
TL;DR: Lability to suicidal behavior might be familially transmitted as a trait independent of Axis I and II disorders.
Abstract: BACKGROUND: While previous studies have shown an increased rate of suicidal behavior in the relatives of suicide victims, it is unclear if this is attributable merely to increased familial rates of psychiatric disorders. Therefore, we conducted a family study of adolescent suicide victims (suicide probands) and community control probands (controls) to determine if the rates of suicidal behavior were higher in the relatives of adolescent suicide probands even after adjusting for differences in the familial rates of psychiatric disorders. METHOD: The relatives of 58 adolescent suicide probands and 55 demographically similar controls underwent assessment for Axis I and II psychiatric disorders, lifetime history of aggression, and history of suicidal behavior (attempts and completions) using a combination of family study and family history approaches. RESULTS: The rate of suicide attempts was increased in the first-degree relatives of suicide probands compared with the relatives of controls, even after adjusting for differences in rates of proband and familial Axis I and II disorders (odds ratio, 4.3; 95% confidence intervals, 1.1-16.6). On the other hand, the excess rate of suicidal ideation found in the relatives of suicide probands was explained by increased familial rates of psychiatric disorders. Among suicide probands, higher ratings of aggression were associated with higher familial loading for suicide attempts. CONCLUSIONS: Liability to suicidal behavior might be familially transmitted as a trait independent of Axis I and II disorders. The transmitted spectrum of suicidal behavior includes attempts and completions, but not ideation, and the transmission of suicidal behavior and aggression are related. Language: en

Journal ArticleDOI
TL;DR: The OCDS scores appear to be sensitive to alcoholism severity and change during abstinence and relapse drinking, and its ease of use, reliability, validity, and analytic capabilities support its utility as a tool to measure severity and improvement during alcoholism treatment trials.
Abstract: Background: The 14-item Obsessive Compulsive Drinking Scale (OCDS) is a quick and reliable self-rating instrument that provides a total and two subscale scores that measure some cognitive aspects of alcohol "craving." This study validated further its utility as an alcoholism severity and treatment outcome instrument. Methods: Alcoholism severity and analogue craving scales were administered at baseline, and the OCDS was given at baseline and weekly to 41 alcohol-dependent individuals who participated in a 12-week pharmacologic and cognitive-behavioral treatment trial. Repeated-measures analysis of variance was used to examine group differences in the OCDS scores of those individuals who remained abstinent or drank during the trial. Results: At baseline, the OCDS was correlated with the alcohol composite score of the addiction severity index (r=.48), the alcohol dependence scale (r=.42), the analogue craving measures (range r=.40 to.57), and prestudy alcohol consumption (r=.60). Most importantly, the OCDS total and subscale scores were significantly different between individuals who had relapse drinking, who had "slip" drinking, and who remained abstinent, with relapsers showing the highest scores. Conclusions: The OCDS scores appear to be sensitive to alcoholism severity and change during abstinence and relapse drinking. Since the shared variance with analogue craving measures is only about 20% to 30%, it appears to be measuring a largely independent dimension of alcohol dependence. Its ease of use (5 minutes per self-rating), reliability, validity, and analytic capabilities support its utility as a tool to measure severity and improvement during alcoholism treatment trials.

Journal ArticleDOI
TL;DR: The results support the view that a single deficit in the processing of context information may underlie various cognitive impairments observed in schizophrenia and suggest that such an impairment is associated with positive rather than negative symptoms, and that it may worsen with the course of the illness as in the kraepelinian view of schizophrenia.
Abstract: Background: Schizophrenic patients show various deficits in cognitive functions that have been difficult to understand in terms of a common unifying hypothesis. Previously described neural network models of cognitive tasks suggest that several schizophrenic performance deficits may be related to a single function—an impairment in maintaining contextual information over time and in using that information to inhibit inappropriate responses. Methods: We tested first-episode schizophrenic patients and patients later in the course of their illness on a new variant of the Continuous Performance Test designed specifically to elicit deficits in the processing of contextual information. Results: Unmedicated schizophrenic patients showed a deterioration of their signal detection performance that followed the pattern predicted by the context hypothesis, ie, they responded inappropriately when correct responding required the maintenance of context information over time to inhibit the expression of a habitual response. This deficit correlated with positive symptoms. The results also suggested that the deficit may be worse in unmedicated patients who have had a longer course of illness. Medicated patients showed a more diffuse performance deficit. Conclusions: These results support the view that a single deficit in the processing of context information may underlie various cognitive impairments observed in schizophrenia. They also suggest that such an impairment is associated with positive rather than negative symptoms, and that it may worsen with the course of the illness as in the kraepelinian view of schizophrenia.

Journal ArticleDOI
TL;DR: Severity of depressive symptoms was reduced more rapidly and more effectively among patients randomized to pharmacotherapy or psychotherapy than among patients assigned to a physician's usual care.
Abstract: Background: We studied whether standardized treatments of major depression whose efficacy was established with psychiatric patients are equally effective when provided to primary care patients, and whether standardized treatments are more effective than a primary care physician's usual care. Methods: A randomized controlled trial was conducted, in which primary care patients meeting DSM-III-R criteria for a current major depression were assigned to nortriptyline (n=91) or interpersonal psychotherapy (n=93) provided within well-structured parameters, or a physician's usual care (n=92). The main outcome measures were degree and rate of improvement in severity of depressive symptoms and proportion of patients recovered at 8 months. Results: Severity of depressive symptoms was reduced more rapidly and more effectively among patients randomized to pharmacotherapy or psychotherapy than among patients assigned to a physician's usual care. Among treatment completers, approximately 70% of patients participating in the full pharmacotherapy or psychotherapy protocol but only 20% of usual care patients were judged as recovered at 8 months. Conclusions: Pharmacotherapy and psychotherapy effectively treat major depression among primary care patients when provided within specific parameters and for the full acute and continuation phases. Treatment principles recommended by the Depression Guideline Panel of the Agency for Health Care Policy and Research are supported.

Journal ArticleDOI
TL;DR: Acamprosate proved to be a safe and effective aid in treating alcohol-dependent patients and in maintaining the abstinence of patients during 2 years.
Abstract: Background The effectiveness acamprosate (calcium bisacetylhomotaurinate) as a treatment to maintain abstinence in alcohol-dependent patients was assessed for 1 year. Methods: After short-term detoxification, 272 patients participated in a randomized, double-blind, placebo-controlled study. Patients received routine counseling and either the study medication or placebo for 48 weeks; they were followed up for another 48 weeks without medication. Statistical analysis was performed according to the intention-to-treat principle. Results: Patients who were receiving acamprosate showed a significantly higher continuous abstinence rate within the first 60 days of treatment compared with patients who were assigned to placebo treatment (67% vs 50%) until completion of the treatment period (43% vs 21%, log rankP=.005), and they had a significantly longer mean abstinence duration of 224 vs 163 days, or 62% vs 45% days abstinent (P Conclusion: Acamprosate proved to be a safe and effective aid in treating alcohol-dependent patients and in maintaining the abstinence of patients during 2 years.

Journal ArticleDOI
TL;DR: High rates of substance abuse, psychiatric disorder, and psychological distress associated with exposure to traumatic events suggest that women in prison have a need for treatment for substance abuse and other mental health problems.
Abstract: Background: No unbiased estimates of the rates of psychiatric disorder among women prison inmates are available. Nonetheless, available data suggest that some psychiatric disorders are prevalent in this population. The objective of the study was to determine the rates, risk factors, and outcomes of specific psychiatric disorders among women prison inmates. Methods: A virtual census of women felons (N=805) entering prison in North Carolina was assessed using in-person interviews. Assessments were conducted for 8 disorders, using the Composite International Diagnostic Interview as the primary assessment measure. For validation purposes, one quarter of the inmates were reassessed for 2 of these disorders, using structured clinical interviews. Results: Inmates were found to have high rates of substance abuse and dependence and antisocial and borderline personality disorders compared with women in community epidemiologic studies. Rates among inmates were also somewhat elevated for mood disorders but not for anxiety disorders. The rate of reports of lifetime exposure to traumatic events was also high. Rates of disorder tended to be higher among white than among African American women. Conclusion: High rates of substance abuse, psychiatric disorder, and psychological distress associated with exposure to traumatic events suggest that women in prison have a need for treatment for substance abuse and other mental health problems.

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TL;DR: Research in nonhuman primates demonstrating that norepinephrine can enhance the cognitive functioning of the prefrontal cortex through actions at α2A-adrenergic receptors postjunctional to noradrenaline terminals is reviewed.
Abstract: This article aims to review research in nonhuman primates demonstrating that norepinephrine can enhance the cognitive functioning of the prefrontal cortex through actions at α2A-adrenergic receptors postjunctional to noradrenergic terminals. As prefrontal cortex cognitive deficits are prominent in several psychiatric disorders, including attention-deficit hyperactivity disorder, these basic findings may have relevance for the development of novel pharmacotherapies.

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TL;DR: In this paper, the numbers of AVP-immunoreactive (IR) and OXT-IR neurons were determined in the paraventricular nucleus (PVN) of the human hypothalamus.
Abstract: Background: Cerebrospinal fluid levels of arginine vasopressin (AVP) and oxytocin (OXT) have been found to change in mood disorders. In the present study, the numbers of AVP-immunoreactive (IR) and OXT-IR neurons were determined in the paraventricular nucleus (PVN) of the human hypothalamus. Methods: Postmortem brain tissue was fixed in formalin, embedded in paraffin, and stained for AVP and OXT using immunocytochemical techniques. The number of IR neurons in the PVN was estimated by morphometry in eight depressed patients ranging in age from 21 to 85 years and eight age-matched controls ranging in age from 23 to 88 years. Results: The numbers of AVP-IR and OXT-IR neurons in the PVN of patients with mood disorder were increased by 56% and 23%, respectively. No differences were found in AVP-IR or OXT-IR cell numbers between three patients with major depression and three patients with bipolar depression. The numbers of AVP-IR and OXT-IR neurons in two patients with depression not otherwise specified were within the same range as in the six other patients with a mood disorder. Conclusions: The AVP and OXT neurons were activated in the PVN in patients with major depression or bipolar disorder. This activation may be associated with activation of the hypothalamic-pituitary-adrenal axis in these patients, since both AVP and OXT are known to potentiate the effects of corticotropin-releasing hormone. Because of their central effects, activation of AVP and OXT neurons may also be related to symptoms of major depression or bipolar disorder.

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TL;DR: Homicidal behavior in a country with a relatively low crime rate appears to have a statistical association with some specific mental disorders classified according to DSM-III-R classifications.
Abstract: Background: Owing to the fact that Finnish police have been able to solve about 95% of all homicides during recent decades and because most homicide offenders are subjected to an intensive psychiatric evaluation, it was possible to examine data on 693 of 994 homicide offenders during an 8-year period. Methods: The prevalences of mental disorders of the homicide offenders were used to calculate odds ratios (ORs) for the statistical increase in risk associated with specific mental disorders. Results: The results indicate that schizophrenia increases the OR of homicidal violence by about 8-fold in men and 6.5-fold in women. Antisocial personality disorder increases the OR over 10-fold in men and over 50-fold in women. Affective disorders, anxiety disorders, dysthymia, and mental retardation did not elevate the OR to any significant extent (OR Conclusion: Homicidal behavior in a country with a relatively low crime rate appears to have a statistical association with some specific mental disorders classified according toDSM-III-Rclassifications.

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TL;DR: Voucher-based reinforcement contingencies can produce sustained cocaine abstinence in injecting polydrug abusers and the overall treatment quality significantly higher than controls.
Abstract: Background: Chronic cocaine abuse remains a serious and costly public health problem. This study assessed the effectiveness of a voucher-based reinforcement contingency in producing sustained cocaine abstinence. Methods: A randomized controlled trial compared voucherbased reinforcement of cocaine abstinence to noncontingent voucher presentation. Patients were selected from 52 consecutively admitted injecting heroin abusers in a methadone maintenance treatment program. Patients with heavy cocaine use during baseline period (N=37) participated. Except where otherwise indicated, the term cocaine abuse is used in this article in a generic sense and not according to the DSM-III-R definition. Patients exposed to abstinence reinforcement received a voucher for each cocaine-free urine sample (ie, negative for benzoylecgonine) provided three times per week throughout a 12-week period; the vouchers had monetary values that increased as the number of consecutive cocaine-free urine samples increased. Control patients received noncontingent vouchers that were matched in pattern and amount to the vouchers received by patients in the abstinence reinforcement group. Results: Patients receiving vouchers for cocaine-free urine samples achieved significantly more weeks of cocaine abstinence ( P =.007) and significantly longer durations of sustained cocaine abstinence ( P =.001) than controls. Nine patients (47%) receiving vouchers for cocaine-free urine samples achieved between 7 and 12 weeks of sustained cocaine abstinence; only one control patient (6%) achieved more than 2 weeks of sustained abstinence. Among patients receiving vouchers for cocaine-free urine samples, those who achieved sustained abstinence (≥5 weeks) had significantly lower concentrations of benzoylecgonine in baseline urine samples than those who did not achieve sustained abstinence ( P ≤.01). Patients receiving voucher reinforcement rated the overall treatment quality significantly higher than controls ( P =.002). Conclusion: Voucher-based reinforcement contingencies can produce sustained cocaine abstinence in injecting polydrug abusers.

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TL;DR: Buprenorphine maintenance at 8 mg/d appears to be less than optimally efficacious under the conditions of the present study, and continued research is needed to reconcile these findings with the more positive results reported by other investigative groups.
Abstract: Background: Buprenorphine is a partial agonist at the μ-opioid receptor that has been proposed as an alternative to traditional full agonist maintenance therapy for the treatment of opioid addiction. We report on a clinical trial in which the relative safety and efficacy of long-term fixeddose buprenorphine maintenance was examined in comparison to low- and high-dose methadone maintenance. Methods: Two hundred twenty-five treatment-seeking opioid addicts (46 women, 179 men) were randomly assigned to receive, in a double-blind manner, either 8 mg/d of buprenorphine, 30 mg/d of methadone, or 80 mg/d of methadone maintenance over a 1-year period. Objective and subjective measures of efficacy (urine toxicology, retention, craving, and withdrawal symptoms) were examined at the study midpoint and at termination, and safety data were tabulated over the entire 52-week study period. Results: Patients assigned to high-dose methadone maintenance performed significantly better on measures of retention, opioid use, and opioid craving than either the low-dose methadone or the buprenorphine group at both 26-week and 52-week time points. Performance on these measures was virtually identical between the latter two groups. No serious adverse health effects attributable to buprenorphine were noted. Conclusions: Buprenorphine maintenance at 8 mg/d appears to be less than optimally efficacious under the conditions of the present study. Continued research is needed to reconcile these findings with the more positive results reported by other investigative groups. There are no apparent health risks associated with long-term buprenorphine maintenance at this dosage.