Severe Tourette's syndrome that cannot be managed with medication is now being experimentally treated with deep brain stimulation. Ten of 11 patients in a series from Cannon et al. (p. 860) reported 48% reduction in motor tics and 56% reduction in phonic tics. Effects were sustained for at least 3 months, and only two patients still required pharmacotherapy. One patient discontinued the treatment because of intolerability, two patients had anxiety, and one had an electronic malfunction. The stimulating electrodes were targeted to the anteromedial globus pallidus interna. Tourette's syndrome is thought to result from a defect in the cortical-basal ganglia-thalamic-cortical neuronal circuit. Stimulation in the thalamus, pallidum, ventral caudate, and anterior internal capsule has been investigated by other centers.
Ten of 11 adults with severe Tourette's syndrome reported improvement in tic severity after DBS (Cannon et al., p. 860)
Woltmann et al. (p. 790) reviewed 57 trials of model collaborative chronic care programs that included elements such as patient self-management support, clinical information systems, delivery system redesign, decision support, organizational support, and community resource linkages. Across disorders and primary care and behavioral health care settings, there were significant moderate effects in depression, mental and physical quality of life, and social role function, compared to control conditions. Total health care costs did not differ from control conditions.
Schizotypal personality disorder, a cluster of characteristics similar to those of schizophrenia but less severe, has been linked to malnutrition in early childhood, but this association may hinge on an intermediate relationship with IQ. In a 20-year study, Venables and Raine (CME, p. 822) found that physical stunting, anemia, and psychosocial adversity at age 3 were related to nonverbal IQ at age 11, which in turn was related to two dimensions of schizotypal personality at age 23. In an editorial (p. 777), Susser points out that success in reducing child mortality in developing countries has left millions of child survivors in poor living conditions with neurodevelopmental delays and disabilities.
Clinical Guidance: N-Acetylcysteine for Cannabis-Dependent Adolescents
In an 8-week double-blind randomized placebo-controlled trial for treatment-seeking cannabis-dependent adolescents, Gray et al. (CME, p. 805) added N-acetylcysteine (1,200 mg twice a day) to contingency management intervention and very brief weekly cessation counseling. The rate of negative urine cannabinoid tests was 41% in the N-acetylcysteine group, compared to 27% for placebo. Missing urine samples were assumed positive for cannabinoids. At the posttreatment follow-up visit, 19% of the urine tests in the N-acetylcysteine group were negative, compared to 10% in the placebo group. Adverse events were not common and included vivid dreams and heartburn. Bukstein in an editorial (p. 771) notes that N-acetylcysteine is being investigated for a wide range of psychiatric illnesses. Its up-regulation of the cysteine-glutamate exchanger may have widespread brain effects, because glutamate is the brain's most commonly used neurotransmitter.
Clinical Guidance: Metformin for Amenorrhea and Weight Gain in First-Episode Schizophrenia
Women who experienced amenorrhea during their first antipsychotic treatment for schizophrenia also received metformin, 1,000 mg/day, for 6 months in a double-blind placebo-controlled study by Wu et al. (p. 813). Most patients received risperidone. Two-thirds of metformin-treated patients, compared to 5% of placebo-treated patients, resumed menstruation. Metformin-treated patients had a mean decrease in body mass index (BMI) of 0.93 and a mean change in insulin resistance index of 2.04. In contrast, placebo-treated patients had a mean increase in BMI of 0.85. Prolactin, luteinizing hormone, and testosterone levels and the ratio of luteinizing hormone to follicle-stimulating hormone decreased significantly with metformin. Metformin had no significant adverse effects. Smith (p. 774) comments in an editorial that although most trials of metformin in schizophrenia are relatively short, diabetes studies support much longer-term safety and efficacy.