Am J Psychiatry current issue

In This Issue [In This Issue]

Mon, 02 Nov 2009 10:01:54 PST

Postpartum Mood Disorders: Genetic Progress and Treatment Paradigms [Editorials]

Hatters Friedman, S. — Mon, 02 Nov 2009 10:01:53 PST

Closing the Gap Between Guidelines for Bipolar Disorder Treatment and Clinical Practice [Editorials]

Giese, A. A. — Mon, 02 Nov 2009 10:01:53 PST

Identifying Neighborhood Stressors in Assessment of Drug Treatment Continuity and Relapse [Editorials]

Latkin, C. — Mon, 02 Nov 2009 10:01:53 PST

Expanding Treatment Options for Cocaine Dependence [Editorials]

Brady, K. T. — Mon, 02 Nov 2009 10:01:53 PST

New Models of Collaboration Between Criminal Justice and Mental Health Systems [Commentary]

Morrissey, J. P., Fagan, J. A., Cocozza, J. J. — Mon, 02 Nov 2009 10:01:53 PST

Conclusion: Mental Health in the Mainstream of Public Policy [Commentary]

Goldman, H. H., Glied, S. A., Alegria, M. — Mon, 02 Nov 2009 10:01:53 PST

Bipolar II Postpartum Depression: Detection, Diagnosis, and Treatment [Treatment in Psychiatry]

Sharma, V., Burt, V. K., Ritchie, H. L. — Mon, 02 Nov 2009 10:01:53 PST

Research on postpartum mood disorders has focused primarily on major depressive disorder, bipolar I disorder, and puerperal psychosis and has largely ignored or neglected bipolar II disorder. Hypomanic symptoms are common after delivery but frequently unrecognized. DSM-IV does not consider early postpartum hypomania as a significant diagnostic feature. Although postpartum hypomania may not cause marked impairment in social or occupational functioning, it is often associated with subsequent, often disabling depression. Preliminary evidence suggests that bipolar II depression arising in the postpartum period is often misdiagnosed as unipolar major depressive disorder. The consequences of the misdiagnosis can be particularly serious because of delayed initiation of appropriate treatment and the inappropriate prescription of antidepressants. Moreover, no pharmacological or psychotherapeutic studies of bipolar postpartum depression are available to guide clinical decision making. Also lacking are screening instruments designed specifically for use before or after delivery in women with suspected bipolar depression. It is recommended that the treatment of postpartum bipolar depression follow the same guidelines as the treatment of nonpuerperal bipolar II depression, using medications that are compatible with lactation.

Clinical Trials Design Lessons From the CATIE Study [Reviews and Overviews]

Kraemer, H. C., Glick, I. D., Klein, D. F. — Mon, 02 Nov 2009 10:01:53 PST

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study was funded by the National Institute of Mental Health to compare the effectiveness of drugs for schizophrenia. The focus here is not on its conclusions but on the knotty issues of design and methods, in order to support appropriate clinical interpretation of the conclusions, and on using the CATIE experience to indicate directions for improvement of future clinical trials. While many of the CATIE design and implementation decisions are excellent and serve as models for future research, other decisions resulted in a study with a large study group but inadequate power. Multiple treatment interventions, unbalanced randomization within and across clinical sites, and multiple secondary outcomes are among the issues that require even more serious consideration in future large multisite clinical trials. Moreover, it is crucial to clarify whether the intent of a study is to establish superiority of some treatments or to establish equivalence, for the appropriate designs and analyses differ in these situations. If the study is designed, as was CATIE, to demonstrate some treatments’ superiority, statistically nonsignificant results should not be misinterpreted as evidence of "equivalence." For establishing either superiority or equivalence, future treatment comparisons might better be designed with fewer sites, more subjects per site, fewer treatments, and fewer outcomes, in order to have the power for definitively establishing superiority or equivalence at a lower cost.

Genome-Wide Linkage and Follow-Up Association Study of Postpartum Mood Symptoms [Articles]

Mon, 02 Nov 2009 10:01:53 PST

OBJECTIVE: Family studies have suggested that postpartum mood symptoms might have a partly genetic etiology. The authors used a genome-wide linkage analysis to search for chromosomal regions that harbor genetic variants conferring susceptibility for such symptoms. The authors then fine-mapped their best linkage regions, assessing single nucleotide polymorphisms (SNPs) for genetic association with postpartum symptoms. METHOD: Subjects were ascertained from two studies: the NIMH Genetics Initiative Bipolar Disorder project and the Genetics of Recurrent Early-Onset Depression. Subjects included women with a history of pregnancy, any mood disorder, and information about postpartum symptoms. In the linkage study, 1,210 women met criteria (23% with postpartum symptoms), and 417 microsatellite markers were analyzed in multipoint allele sharing analyses. For the association study, 759 women met criteria (25% with postpartum symptoms), and 16,916 SNPs in the regions of the best linkage peaks were assessed for association with postpartum symptoms. RESULTS: The maximum linkage peak for postpartum symptoms occurred on chromosome 1q21.3-q32.1, with a chromosome-wide significant likelihood ratio Z score (Z_LR) of 2.93 (permutation p=0.02). This was a significant increase over the baseline Z_LR of 0.32 observed at this locus among all women with a mood disorder (permutation p=0.004). Suggestive linkage was also found on 9p24.3-p22.3 (Z_LR=2.91). In the fine-mapping study, the strongest implicated gene was HMCN1 (nominal p=0.00017), containing four estrogen receptor binding sites, although this was not region-wide significant. CONCLUSIONS: This is the first study to examine the genetic etiology of postpartum mood symptoms using genome-wide data. The results suggest that genetic variations on chromosomes 1q21.3-q32.1 and 9p24.3-p22.3 may increase susceptibility to postpartum mood symptoms.

Anxiety and Outcome in Bipolar Disorder [Articles]

Mon, 02 Nov 2009 10:01:53 PST

OBJECTIVE: Important differences exist between bipolar disorder with and without comorbid anxiety, but little is known about the long-term prognostic significance of coexisting anxiety in bipolar disorder. The authors sought to identify the anxiety features most predictive of subsequent affective morbidity and to evaluate the persistence of the prognostic relationship. METHOD: Probands with bipolar I or II disorder from the National Institute of Mental Health Collaborative Depression Study were followed prospectively for a mean of 17.4 years (SD=8.4) and were characterized according to various manifestations of anxiety present at baseline. A series of general linear model analyses examined the relationship between these measures and the proportion of follow-up weeks in episodes of major depression and in episodes of mania or hypomania. RESULTS: Patients whose episode at intake included a depressive phase spent nearly three times as many weeks in depressive episodes than did those whose intake episode was purely manic. Psychic and somatic anxiety ratings, but not the presence of panic attacks or of any lifetime anxiety disorder, added to the predictive model. Combined ratings of psychic and somatic anxiety were associated in a stepwise fashion with a greater proportion of weeks in depressive episodes, and this relationship persisted over the follow-up period. CONCLUSIONS: The presence of higher levels of anxiety during bipolar mood episodes appears to mark an illness of substantially greater long-term depressive morbidity.

Enhancing Multiyear Guideline Concordance for Bipolar Disorder Through Collaborative Care [Articles]

Bauer, M. S., Biswas, K., Kilbourne, A. M. — Mon, 02 Nov 2009 10:01:53 PST

OBJECTIVE: Implementation of evidence-based care for serious mental illnesses such as bipolar disorder has been suboptimal. Improving and sustaining concordance with clinical practice guidelines has been a cornerstone of efforts to enhance evidence-based care and improve outcomes. For bipolar disorder, however, there has been only one regional controlled trial reporting guideline concordance, and no data are available for time periods longer than 1 year. In a multiregion effectiveness trial in veterans with bipolar disorder, the authors assessed the effects of a collaborative care model for this disorder on guideline concordance in care over a 3-year period. METHOD: A total of 306 participants with bipolar disorder were randomly assigned at hospital discharge to 3 years of follow-up treatment with a collaborative care model or to usual care. The collaborative care model included provider support through simplified practice guidelines, patient skills management enhancement through group psychoeducation, and facilitated access and continuity via nurse care management. Concordance with guideline-recommended antimanic pharmacotherapy was assessed at baseline and prospectively over six 6-month epochs. Group differences were assessed with generalized estimating equations that controlled for relevant covariates. RESULTS: The collaborative care model achieved significantly higher rates of guideline-concordant antimanic treatment than usual care over the entire follow-up period. Baseline guideline concordance, but not patient age or bipolar type, was associated with higher concordance. CONCLUSIONS: Multicomponent collaborative care models, which include not only provider support for guideline implementation but also patient self-management skill enhancement and facilitated treatment access and continuity, can improve guideline concordance over the long term, even in severely impaired patients.

Association of Pre-Onset Cannabis, Alcohol, and Tobacco Use With Age at Onset of Prodrome and Age at Onset of Psychosis in First-Episode Patients [Articles]

Mon, 02 Nov 2009 10:01:53 PST

OBJECTIVE: Several reports suggest that cannabis use is associated with an earlier age at onset of psychosis, although not all studies have operationalized cannabis use as occurring prior to onset of symptoms. This study addressed whether pre-onset cannabis use, alcohol use, and tobacco use are associated with an earlier age at onset of prodromal and psychotic symptoms. Effects of the progression of frequency of use were examined through time-dependent covariates in survival analyses. METHOD: First-episode patients (N=109) hospitalized in three public-sector inpatient psychiatric units underwent in-depth cross-sectional retrospective assessments. Prior substance use and ages at onset of prodromal and psychotic symptoms were determined by standardized methods, and analyses were conducted using Cox regression modeling. RESULTS: Whereas classifying participants according to maximum frequency of use prior to onset (none, ever, weekly, or daily) revealed no significant effects of cannabis or tobacco use on risk of onset, analysis of change in frequency of use prior to onset indicated that progression to daily cannabis and tobacco use was associated with an increased risk of onset of psychotic symptoms. Similar or even stronger effects were observed when onset of illness or prodromal symptoms was the outcome. A gender-by-daily-cannabis-use interaction was observed; progression to daily use resulted in a much larger increased relative risk of onset of psychosis in females than in males. CONCLUSIONS: Pre-onset cannabis use may hasten the onset of psychotic as well as prodromal symptoms. Age at onset is a key prognostic factor in schizophrenia, and discovering modifiable predictors of age at onset is crucial.

The Influence of Neighborhood Environment on Treatment Continuity and Rehospitalization in Dually Diagnosed Patients Discharged From Acute Inpatient Care [Articles]

Stahler, G. J., Mennis, J., Cotlar, R., Baron, D. A. — Mon, 02 Nov 2009 10:01:53 PST

OBJECTIVE: Environmental contingencies inherent in neighborhoods and communities have been shown to affect individual behavior. The authors analyzed neighborhood and individual factors predicting initial outpatient treatment attendance and rehospitalization within 1 year among patients who were dually diagnosed with at least one mental disorder and a substance use disorder and discharged from an acute psychiatric inpatient care unit. METHOD: Stepwise-forward logistic regression modeling and a geographic information system were utilized to assess data extracted from the medical records of 380 patients who, upon hospital admission, had one or more mental health disorders and a positive urine drug screen for prototypical illicit drugs. Geographic data on patients’ neighborhood environment were obtained from public sources. Outcome variables were whether a patient attended the first outpatient treatment appointment within 30 days of hospital discharge and whether a patient was readmitted to the inpatient unit within 1 year of discharge. Predictor variables were features relating to individual-level patient characteristics and features associated with neighborhood environment. RESULTS: Factors that decreased the likelihood of attending the initial outpatient treatment were returning home following hospitalization (versus returning to an institutional setting), residing in an area with a high vacant housing rate, residing in an area far from an Alcoholics Anonymous meeting location, having the chief complaint of bizarre behavior (i.e., grossly inappropriate behavior), and having a urine drug screen positive for heroin. The likelihood of being rehospitalized within 1 year was greater for Hispanic patients, patients who had at least one prior hospital admission, and patients who lived in close proximity to a Narcotics Anonymous meeting location. Patients living in areas with higher educational attainment had a reduced likelihood of rehospitalization. CONCLUSIONS: A more explicit focus on the neighborhood and community context represents an important area in psychiatry, in terms of both research and clinical practice, which can potentially enhance long-term care and treatment planning for psychiatric patients. Future research is needed to better understand the influence of the neighborhood environment to help predict important clinical outcomes.

Randomized, Double-Blind, Placebo-Controlled Trial of Vigabatrin for the Treatment of Cocaine Dependence in Mexican Parolees [Articles]

Mon, 02 Nov 2009 10:01:53 PST

OBJECTIVE: Cocaine dependence is associated with severe medical, psychiatric, and social morbidity, but no pharmacotherapy is approved for its treatment in the United States. The atypical antiepileptic vigabatrin (-vinyl gamma-aminobutyric acid [GABA]) has shown promise in animal studies and open-label trials. The purpose of the present study was to assess the efficacy of vigabatrin for short-term cocaine abstinence in cocaine-dependent individuals. METHOD: Participants were treatment seeking parolees who were actively using cocaine and had a history of cocaine dependence. Subjects were randomly assigned to a fixed titration of vigabatrin (N=50) or placebo (N=53) in a 9-week double-blind trial and 4-week follow-up assessment. Cocaine use was determined by directly observed urine toxicology testing twice weekly. The primary endpoint was full abstinence for the last 3 weeks of the trial. RESULTS: Full end-of-trial abstinence was achieved in 14 vigabatrin-treated subjects (28.0%) versus four subjects in the placebo arm (7.5%). Twelve subjects in the vigabatrin group and two subjects in the placebo group maintained abstinence through the follow-up period. The retention rate was 62.0% in the vigabatrin arm versus 41.5% in the placebo arm. Among subjects who reported prestudy alcohol use, vigabatrin, relative to placebo, was associated with superior self-reported full end-of-trial abstinence from alcohol (43.5% versus 6.3%). There were no differences between the two groups in drug craving, depressed mood, anxiety, or Clinical Global Impression scores, and no group differences in adverse effects emerged. CONCLUSIONS: This first randomized, double-blind, placebo-controlled trial supports the safety and efficacy of short-term vigabatrin treatment of cocaine dependence.

Randomized, Single-Blind, Controlled Trial of a Specialist Behavior Therapy Team for Challenging Behavior in Adults With Intellectual Disabilities [Articles]

Mon, 02 Nov 2009 10:01:53 PST

OBJECTIVE: Community-based specialist behavior therapy teams may be helpful in managing challenging behavior, but evidence of their effectiveness is limited. This study was designed to examine the effectiveness and costs associated with treatment by a specialist behavior therapy team. METHOD: This was a parallel-group, randomized, single-blind controlled trial carried out in an intellectual disabilities service in England. Participants were 63 male and female service users with mild to severe intellectual disability who presented with challenging behavior. The interventions were standard treatment plus applied behavioral analysis (N=32) and standard treatment only (N=31). The primary outcome measure was challenging behavior, as measured by total and subscale scores on the Aberrant Behavior Checklist 3 and 6 months after randomization. Secondary outcome measures were psychiatric comorbidity assessed at 3 and 6 months using the Psychiatric Assessment Schedule for Adults With a Developmental Disability Checklist (PAS-ADD) and total costs recorded at 6 months. Multilevel modeling was used to compare square root transformations of Aberrant Behavior Checklist scores. RESULTS: Significant differences were found in the transformed total scores on the Aberrant Behavior Checklist (difference=–0.89, 95% CI=–1.74 to –0.04) and transformed lethargy and hyperactivity subscale scores (common intervention effect=–0.56, 95% CI=–0.97 to –0.15). Standard care participants fared worse on the PAS-ADD comorbid organic disorder subscale. There was a clear trend for lower overall costs of the intervention. CONCLUSIONS: Use of a specialist behavior therapy team in addition to standard treatment appears to be more effective in improving challenging behavior and may have financial advantages over standard treatment.

An fMRI Study of the Effects of Psychostimulants on Default-Mode Processing During Stroop Task Performance in Youths With ADHD [Articles]

Mon, 02 Nov 2009 10:01:54 PST

OBJECTIVE: The authors examined the effect of psychostimulants on brain activity in children and adolescents with ADHD performing the Stroop Color and Word Test. METHOD: The authors acquired 52 functional MRI scans in 16 youths with ADHD who were known responders to stimulant medication and 20 healthy comparison youths. Participants with ADHD were scanned on and off medication in a counterbalanced design, and comparison subjects were scanned once without medication. RESULTS: Stimulant medication significantly improved suppression of default-mode activity in the ventral anterior cingulate cortex in the ADHD group. When off medication, youths with ADHD were unable to suppress default-mode activity to the same degree as comparison subjects, whereas when on medication, they suppressed this activity to comparison group levels. Greater activation of the lateral prefrontal cortex when off medication predicted a greater reduction in ADHD symptoms when on medication. Granger causality analyses demonstrated that activity in the lateral prefrontal and ventral anterior cingulate cortices mutually influenced one another but that the influence of the ventral anterior cingulate cortex on the lateral prefrontal cortex was significantly reduced in youths with ADHD off medication relative to comparison subjects and increased significantly to normal levels when ADHD youths were on medication. CONCLUSIONS: Psychostimulants in youths with ADHD improved suppression of default-mode activity in the ventral anterior cingulate and posterior cingulate cortices, components of a circuit in which activity has been shown to correlate with the degree of mind-wandering during attentional tasks. Stimulants seem to improve symptoms in youths with ADHD by normalizing activity within this circuit and improving its functional interactions with the lateral prefrontal cortex.

Dropouts and Missing Data in Psychiatric Clinical Trials [Letters to the Editor]

POTKIN, S. G., SIU, C. O. — Mon, 02 Nov 2009 10:01:54 PST

Drs. Hamer and Simpson Reply [Letters to the Editor]

HAMER, R. M., SIMPSON, P. M. — Mon, 02 Nov 2009 10:01:54 PST

Drs. Damaraju, Olson, and Canuso Reply [Letters to the Editor]

DAMARAJU, C.V., OLSON, W., CANUSO, C. M. — Mon, 02 Nov 2009 10:01:54 PST

Perinatal Akathisia: Implications for Pharmacokinetic Changes During Pregnancy [Letters to the Editor]

PROWLER, M. L., KIM, D. R. — Mon, 02 Nov 2009 10:01:54 PST

Venous Thromboembolism Prophylaxis on Inpatient Psychiatry Units [Letters to the Editor]

PING TSAO, C. I. — Mon, 02 Nov 2009 10:01:54 PST

Ziprasidone and Citalopram Use in Pregnancy and Lactation in a Woman With Psychotic Depression [Letters to the Editor]

WERREMEYER, A. — Mon, 02 Nov 2009 10:01:54 PST

Patients and Text Messaging: A Boundary Issue [Letters to the Editor]

NEIMARK, G. — Mon, 02 Nov 2009 10:01:54 PST

[Corrections]

Mon, 02 Nov 2009 10:01:54 PST

Patient Tales: Case Histories and the Uses of Narrative in Psychiatry [Book Forum]

SERITAN, A. L. — Mon, 02 Nov 2009 10:01:54 PST

Philosophical Issues in Psychiatry [Book Forum]

NEIMARK, G. — Mon, 02 Nov 2009 10:01:54 PST

Understanding Addiction as Self Medication: Finding Hope Behind the Pain [Book Forum]

ADINOFF, B. — Mon, 02 Nov 2009 10:01:54 PST

Before Prozac: The Troubled History of Mood Disorders in Psychiatry [Book Forum]

BROWN, W. A. — Mon, 02 Nov 2009 10:01:54 PST

[Books Received]

Mon, 02 Nov 2009 10:01:54 PST