In This Issue

“Extended-Release” Therapies for Personality Disorders

Both short-term dynamic psychotherapy and cognitive therapy show modest success with anxious-fearful personality disorders. About 25% of patients receiving each treatment had improved symptoms and interpersonal relations at the end of 40 sessions. At 2-year follow-up the rates had risen to 38%–54%. Core personality pathology improved minimally during treatment, but 2 years later improvement was evident in 35%–38% of the patients. This comparison by Svartberg et al. (p. 810) is one of the few controlled studies of psychotherapy for cluster C personality disorders, which include avoidant, obsessive-compulsive, dependent, and passive-aggressive personality disorders. The two treatments were tailored to personality disorders, and the differences between them in outcomes were minimal. The significant, ongoing improvement seen with either type may indicate that many patients made the therapeutic dialogue their own and used it successfully after termination.

How to Compare Antidepressants

Antidepressants classified as selective serotonin reuptake inhibitors (SSRIs) appear to work by blocking serotonin transporters, cellular structures that convey serotonin. Knowing the degree to which the various SSRIs block these transporters, and at which doses, could guide dosing by clinicians and set a benchmark for future antidepressants. Meyer et al. (p. 826) measured serotonin transporter occupancy in the striatum of healthy subjects taking subclinical doses of five common SSRIs and depressed patients taking therapeutic doses. For all five antidepressants, occupancy increased with increasing dose but reached a plateau at 76%–85% occupancy just beyond the minimum therapeutic dose. This consistency suggests that 80% occupancy is important for antidepressant effect. Clinical possibilities to be explored include potentially greater response from higher-occupancy treatment and prevention of intolerable side effects by combining subtherapeutic doses of two drugs.

Psychiatric Symptoms in Lewy Body Dementia

Dementia with Lewy bodies has been called a variant of Alzheimer’s disease, but Ballard et al. (p. 843) report differences in the neuropathological basis of psychiatric symptoms. Depression, delusions, and hallucinations were assessed yearly in patients with dementia. After the patients died, autopsies were conducted to quantify neuritic plaques, neurofibrillary tangles, and Lewy bodies; Lewy body dementia was diagnosed in 112 patients and Alzheimer’s disease in 90 patients. All three psychiatric symptoms were more common in Lewy body dementia, and greater Lewy body pathology was related to persistent delusions and persistent visual hallucinations. Conversely, the presence of fewer tangles correlated with persistent visual hallucinations. Patients with Lewy body dementia who had extensive tangles were more similar clinically to patients with Alzheimer’s disease and had fewer neocortical Lewy bodies. Depression was unrelated to brain pathology. The different neuropathologies underlying hallucinations and delusions in the two patient groups suggest their responses to treatment are also likely to differ.

Extended Relief for Caregivers of Alzheimer’s Disease Patients

Programs to lessen depression among spouses who care for patients with Alzheimer’s disease are known to be effective. Mittelman et al. (p. 850) demonstrate that the benefits extend well beyond a year and are apparent even after the death or nursing home placement of the patient. Half of 406 spouse-caregivers received standard assistance, i.e., information and access to support groups and counseling. The other half received enhanced services: individual and family counseling, a regular support group, and access to additional ad hoc counseling as needed. In the first year, depressive symptoms gradually decreased among caregivers receiving enhanced treatment but increased in those receiving usual care. The difference between groups decreased gradually over a 5-year period and was significant for 3 years. This success indicates a path for reducing depression and disability in the 52 million Americans who provide care to people age 20 or older who are ill or disabled, approximately 5 million of whom have Alzheimer’s disease or another form of dementia.

Traces of Attention in Schizophrenia

Selectively paying attention depends on “top-down” control processes initiated in the frontal lobes, modulating responses to stimuli starting at early sensory-perceptual stages of information processing. Auditory selective attention and frontal lobe integrity are compromised in schizophrenia, but it is not known whether the attentional impairment results from a general failure of frontal-executive systems to initiate attentional control or a specific failure to sustain it. Mathalon et al. (p. 872) used event-related potentials from EEG recordings to track attentional modulation of auditory processing in schizophrenia patients during a task involving selective attention to auditory or visual stimuli. The patients exerted normal attentional enhancement of the early sensory response at 50 msec, with a failure to sustain this attentional enhancement at 100–300 msec. Thus, early executive control of auditory selective attention appears to be intact in schizophrenia. Subsequent loss of control in the information processing stream may reflect dysfunctions of frontotemporal circuits or neuronal groups that filter sound at different processing stages.

Images in Psychiatry

Virginia Woolf, 1882–1941 (p. 809)