Real-world treatment of schizophrenia is being scrutinized in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). In phase 1, a conventional antipsychotic and several newer, “atypical,” antipsychotics all had high rates of treatment discontinuation. Simulating clinical practice, phase 2 switched these patients to a different antipsychotic, one of several atypicals. Two 18-month trials were undertaken, targeting patients who discontinued treatment because of intolerable side effects and those who quit because of inefficacy. Discontinuation rates were again high, but there were noteworthy differences between drugs. Clozapine was included in one of the two trials, described by McEvoy et al. (p. 600). As expected, it produced less discontinuation (56% versus 71%–93%) and more time in treatment (10.5 months versus 2.7–3.3 months). Agranulocytosis and eosinophilia each developed in one of the 45 patients, confirming the need for safety monitoring. In a trial that excluded clozapine, reported by Stroup et al. (p. 611), discontinuation rates were 64%-84%, but olanzapine and risperidone produced longer median times to discontinuation (6.3 and 7.0 months) than quetiapine and ziprasidone (4.0 and 2.8 months) (see figure above). Ziprasidone had the highest rate of serious adverse events. The results for olanzapne illustrate the need to tailor treatment to the individual-in phases 1 and 2 it produced longer treatment continuation, but the effects on weight, cholesterol, and triglycerides rule it out for certain patients. An editorial by Carol Tamminga on treatment of schizophrenia is on p. 563.

Dissociation from one’s usual identity, such as amnesia or multiple personality disorder, is strongly associated with traumatic experiences. In a group of poor inner-city psychiatric outpatients with high rates of childhood physical abuse (40%) and childhood sexual abuse (42%), the prevalence of dissociative disorders was 29%. Most of the patients diagnosed by Foote et al. (p. 623) as having dissociative disorders did not have a dissociative diagnosis in their charts. Underrecognition of dissociative disorders is supported by mounting evidence and precludes proper treatment. Dissociative disorders are difficult to treat, but appreciation of their prevalence might be the first step to better therapies. An editorial by David Spiegel on these disorders and their treatment is on p. 566.

Widespread underdiagnosis of posttraumatic stress disorder (PTSD) in preschool children is suggested by the findings of Scheeringa et al. (p. 644). PTSD was assessed in patients ages 0–6, 7–11, and 12–18 years who had been hospitalized in a trauma center 2 months previously. Only one of the children ages 0–6 met the standard requirement for three symptoms of emotional numbing or avoidance (five had one symptom). In addition, parental underreporting was detected by comparing the symptoms reported by the 7–11-year-olds with symptoms identified by their parents. For all age groups, threat to a caregiver was a risk factor for PTSD, especially in children who had had problems in externally directed behaviors before the trauma. These factors are not captured by the adult criteria for PTSD. Without developmentally sensitive diagnostic instruments, PTSD in preschool children may be overlooked.

Attention deficit hyperactivity disorder (ADHD) among adults apparently still receives insufficient clinical attention. In a nationally representative survey, the National Comorbidity Survey Replication, the prevalence of adult ADHD was 4.4%, within the range in previous studies of small samples and extrapolations from childhood estimates. Kessler et al. (p. 716) report, however, that survey respondents diagnosed as having adult ADHD had high rates of disability in all assessed dimensions of functioning. Most troubling was the finding that only 25% of the people with ADHD who had previously sought help had received treatment for that condition. Other psychiatric illnesses were common and may camouflage ADHD unless clinicians specifically look for it.