Gang members and other violent men in a large random sample of young British men had higher rates of most types of psychopathology than nonviolent men, and they were more likely to have themselves been victims of violent crimes. Compared to other violent men, the gang members had higher rates of frequent violent ruminations, substance dependence, antisocial personality disorder, suicide attempts, and mental health services. In locations with high levels of gang activity, Coid et al. (p. 985) recommend that mental health care providers inquire about gang membership. Further, adds Monahan in an editorial (p. 942), asking a gang member about violence potential may increase collaboration and enhance public safety (Psych Serv 2013; 64:410–415). Martone et al. (p. 994) report that the rate of substance use disorders was high, 47%, in an unselected sample of homicide defendants in a U.S. urban county and that other psychiatric diagnoses were most common among defendants over age 40. In children, violence can be a manifestation of the anger and irritability characteristic of Asperger’s disorder, as described in a Clinical Case Conference by Frank (p. 963).
Clinical Guidance: Prazosin for Soldiers With PTSD-Related Nightmares
Prazosin, an inexpensive alpha-noradrenergic blocker prescribed primarily for high blood pressure, reduced nightmares and other symptoms in 64% of active-duty soldiers with posttraumatic stress disorder (PTSD), compared with 26% on placebo in a randomized controlled clinical trial. Prazosin has a short duration of action and was administered twice a day in the trial by Raskind et al. (CME, p. 1003). Editorialist Friedman (p. 944) applauds the rational step of using prazosin to target the well-known disturbance in norepinephrine in PTSD. Both authors note that prazosin was less effective in patients already taking SSRIs. Whether these are sicker patients or whether there is a drug interaction remains to be investigated.
Clinical Guidance: Comparison of CBT and Psychodynamic Therapy for Depression
Cognitive-behavioral therapy (CBT) and short-term psychodynamic psychotherapy provide similar outcomes for patients with a major depressive episode, but remission rates at the end of treatment are low for both treatments. The rates in the trial by Driessen et al. (p. 1041) were less than 25% for patients referred to psychiatric clinics, who may be more difficult to treat than most primary care depressed patients. However, emphasizes Thase in an editorial (p. 953), the similarity in outcomes adds to the evidence for using both psychodynamic psychotherapy and CBT with depressed outpatients.
Clinical Guidance: Antipsychotics and Alzheimer’s Disease
Long-term observations of 957 outpatients with probable Alzheimer’s disease indicate that neither conventional nor atypical antipsychotics increase the likelihood of nursing home admission or death. Instead, these adverse outcomes are related to psychosis and agitation, the conditions for which antipsychotics are prescribed in Alzheimer’s disease patients. The study by Lopez et al. (CME, p. 1051) included patients who were not institutionalized when the study began. Devanand cautions in an editorial (p. 957) that if antipsychotics are needed for patients with dementia, the dose should start low and should be increased slowly.