Am J Psychiatry current issue

[In This Issue] In This Issue

2009-07-01

[Editorials] The Randomized Controlled Trial as a Demonstration Project: An Ethical Perspective

Miller, F. G. — 2009-07-01

[Editorials] Grief and Depression: Treatment Decisions for Bereaved Children and Adults

Shear, M. K. — 2009-07-01

[Editorials] New Possibilities in Cognition Enhancement for Schizophrenia

Green, M. F. — 2009-07-01

[Editorials] Validating Novel Targets for Pharmacological Interventions in Schizophrenia

Wroblewska, B., Lewis, D. A. — 2009-07-01

[Commentary] The Role of Psychiatrists Who Write for Popular Media: Experts, Commentators, or Educators?

Friedman, R. A. — 2009-07-01

[Introspections] If I Deliver the Baby Now

Piwowarczyk, L. — 2009-07-01

[Clinical Case Conference] Diagnosis and Treatment of PTSD-Related Compulsive Checking Behaviors in Veterans of the Iraq War: The Influence of Military Context on the Expression of PTSD Symptoms

Tuerk, P. W., Grubaugh, A. L., Hamner, M. B., Foa, E. B. — 2009-07-01

This case study presents an overview of the conceptualization and treatment of two veterans of the Iraq War who presented for combat-related treatment at a Veterans Administration Medical Center. In addition to posttraumatic stress disorder (PTSD) symptoms of reexperiencing, arousal, and avoidance, the veterans exhibited compulsive checking behaviors that appear to be influenced by theater-specific combat duties and traumatic events. These cases represent what the authors believe to be an increasingly common expression of PTSD in veterans of the Iraq and Afghanistan wars. Both veterans were treated with prolonged exposure therapy, which includes imaginal and in vivo exposure to anxiety-provoking stimuli, processing of traumatic events, and self-assessment of anxiety. Treatment also included in vivo exposure with response prevention techniques borrowed from the literature on obsessive-compulsive disorder to address compulsive checking behaviors within the ecological context of each patient’s symptom presentation. Measures related to PTSD and depression were obtained before, during, and after treatment. Treatment was associated with significant declines in symptom severity and improved functioning for both veterans. The unique nature of the conflict in the Middle East represents role challenges for soldiers that affect symptom presentation. Variations in symptom presentation can in turn complicate efforts to identify and appropriately address PTSD-related health concerns in this population. Thus, clinicians and researchers must remain cognizant of how theater-specific duties influence the manifestation and treatment of PTSD in order to provide optimal care to a new generation of veterans.

[Reviews and Overviews] Exploring the Convergence of Posttraumatic Stress Disorder and Mild Traumatic Brain Injury

McAllister, T. W. — 2009-07-01

The authors examine the relationship of the two signature injuries experienced by military personnel serving in Afghanistan and Iraq: posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mild TBI). Studies show that a substantial minority of those serving develop persistent emotional sequelae (such as PTSD and other psychological health problems) and/or somatic or cognitive sequelae (postconcussive symptoms) of traumatic exposure. Remarkably, the mechanism (emotional versus biomechanical) and locus (head versus other regions) of injury are weak determinants of whether an individual develops PTSD, persistent postconcussive symptoms, or both. Preexisting or traumatically acquired cognitive dysfunction can increase the risk for these syndromes, probably by reducing cognitive reserve. Structural and functional neuroimaging studies can be interpreted to explain part of the shared symptomatic and functional variance in these syndromes, but this literature is far from consistent and serves mainly to raise new, challenging questions about mutual pathophysiology. The frequent confluence of PTSD and persistent postconcussive symptoms in military personnel strains the bounds of these constructs. New studies are needed to improve our understanding of how emotional and biomechanical stressors can yield these adverse outcomes and how such outcomes can be prevented and treated.

[Articles] Institutional Rearing and Psychiatric Disorders in Romanian Preschool Children

2009-07-01

OBJECTIVE: There is increasing interest in the relations between adverse early experiences and subsequent psychiatric disorders. Institutional rearing is considered an adverse caregiving environment, but few studies have systematically examined its effects. This study aimed to determine whether removing young children from institutional care and placing them with foster families would reduce psychiatric morbidity at 54 months of age. METHOD: Young children living in institutions in Bucharest were enrolled when they were between 6 and 30 months of age. Following baseline assessment, 136 children were randomly assigned to care as usual (continued institutional care) or to removal and placement in foster care that was created as part of the study. Psychiatric disorders, symptoms, and comorbidity were examined by structured psychiatric interviews of caregivers of 52 children receiving care as usual and 59 children in foster care when the children were 54 months of age. Both groups were compared to 59 typically developing, never-institutionalized Romanian children recruited from pediatric clinics in Bucharest. Foster care was created and supported by social workers in Bucharest who received regular consultation from U.S. clinicians. RESULTS: Children with any history of institutional rearing had more psychiatric disorders than children without such a history (53.2% versus 22.0%). Children removed from institutions and placed in foster families were less likely to have internalizing disorders than children who continued with care as usual (22.0% versus 44.2%). Boys were more symptomatic than girls regardless of their caregiving environment and, unlike girls, had no reduction in total psychiatric symptoms following foster placement. CONCLUSIONS: Institutional rearing was associated with substantial psychiatric morbidity. Removing young children from institutions and placing them in families significantly reduced internalizing disorders, although girls were significantly more responsive to this intervention than boys.

[Articles] The Incidence and Course of Depression in Bereaved Youth 21 Months After the Loss of a Parent to Suicide, Accident, or Sudden Natural Death

Brent, D., Melhem, N., Donohoe, M. B., Walker, M. — 2009-07-01

OBJECTIVE: This study examined effects of bereavement 21 months after a parent’s death, particularly death by suicide. METHOD: The participants were 176 offspring, ages 7–25, of parents who died by suicide, accident, or sudden natural death. They were assessed 9 and 21 months after the death, along with 168 nonbereaved subjects. RESULTS: Major depression and alcohol or substance abuse 21 months after the parent’s death were more common among bereaved youth than among comparison subjects. Offspring with parental suicide or accidental death had higher rates of depression than comparison subjects; those with parental suicide had higher rates of alcohol or substance abuse. Youth with parental suicide had a higher incidence of depression than those bereaved by sudden natural death. Bereavement and a past history of depression increased depression risk in the 9 months following the death, which increased depression risk between 9 and 21 months. Losing a mother, blaming others, low self-esteem, negative coping, and complicated grief were associated with depression in the second year. CONCLUSIONS: Youth who lose a parent, especially through suicide, are vulnerable to depression and alcohol or substance abuse during the second year after the loss. Depression risk in the second year is mediated by the increased incidence of depression within the first 9 months. The most propitious time to prevent or attenuate depressive episodes in bereaved youth may be shortly after the parent’s death. Interventions that target complicated grief and blaming of others may also improve outcomes in symptomatic youth with parental bereavement.

[Articles] Four-Year Longitudinal Course of Children and Adolescents With Bipolar Spectrum Disorders: The Course and Outcome of Bipolar Youth (COBY) Study

2009-07-01

OBJECTIVE: The authors sought to assess the longitudinal course of youths with bipolar spectrum disorders over a 4-year period. METHOD: At total of 413 youths (ages 7–17 years) with bipolar I disorder (N=244), bipolar II disorder (N=28), and bipolar disorder not otherwise specified (N=141) were enrolled in the study. Symptoms were ascertained retrospectively on average every 9.4 months for 4 years using the Longitudinal Interval Follow-Up Evaluation. Rates and time to recovery and recurrence and week-by-week symptomatic status were analyzed. RESULTS: Approximately 2.5 years after onset of their index episode, 81.5% of the participants had fully recovered, but 1.5 years later 62.5% had a syndromal recurrence, particularly depression. One-third of the participants had one syndromal recurrence, and 30% had two or more. The polarity of the index episode predicted that of subsequent episodes. Participants were symptomatic during 60% of the follow-up period, particularly with subsyndromal symptoms of depression and mixed polarity, with numerous changes in mood polarity. Manic symptomatology, especially syndromal, was less frequent, and bipolar II was mainly manifested by depressive symptoms. Overall, 40% of the participants had syndromal or subsyndromal symptoms during 75% of the follow-up period, and 16% of the participants experienced psychotic symptoms during 17% the follow-up period. Twenty-five percent of youths with bipolar II converted to bipolar I, and 38% of those with bipolar disorder not otherwise specified converted to bipolar I or II. Early onset, diagnosis of bipolar disorder not otherwise specified, long illness duration, low socioeconomic status, and family history of mood disorders were associated with poorer outcomes. CONCLUSIONS: Bipolar spectrum disorders in youths are characterized by episodic illness with subsyndromal and, less frequently, syndromal episodes with mainly depressive and mixed symptoms and rapid mood changes.

[Articles] Using Neuroplasticity-Based Auditory Training to Improve Verbal Memory in Schizophrenia

Fisher, M., Holland, C., Merzenich, M. M., Vinogradov, S. — 2009-07-01

OBJECTIVE: Impaired verbal memory in schizophrenia is a key rate-limiting factor for functional outcome, does not respond to currently available medications, and shows only modest improvement after conventional behavioral remediation. The authors investigated an innovative approach to the remediation of verbal memory in schizophrenia, based on principles derived from the basic neuroscience of learning-induced neuroplasticity. The authors report interim findings in this ongoing study. METHOD: Fifty-five clinically stable schizophrenia subjects were randomly assigned to either 50 hours of computerized auditory training or a control condition using computer games. Those receiving auditory training engaged in daily computerized exercises that placed implicit, increasing demands on auditory perception through progressively more difficult auditory-verbal working memory and verbal learning tasks. RESULTS: Relative to the control group, subjects who received active training showed significant gains in global cognition, verbal working memory, and verbal learning and memory. They also showed reliable and significant improvement in auditory psychophysical performance; this improvement was significantly correlated with gains in verbal working memory and global cognition. CONCLUSIONS: Intensive training in early auditory processes and auditory-verbal learning results in substantial gains in verbal cognitive processes relevant to psychosocial functioning in schizophrenia. These gains may be due to a training method that addresses the early perceptual impairments in the illness, that exploits intact mechanisms of repetitive practice in schizophrenia, and that uses an intensive, adaptive training approach.

[Articles] Differential Expression of Metabotropic Glutamate Receptors 2 and 3 in Schizophrenia: A Mechanism for Antipsychotic Drug Action?

Ghose, S., Gleason, K. A., Potts, B. W., Lewis-Amezcua, K., Tamminga, C. A. — 2009-07-01

OBJECTIVE: Preclinical and clinical data implicate the group II metabotropic glutamate receptors mGluR2 and mGluR3 in the pathophysiology of schizophrenia. Moreover, a recent phase II clinical trial demonstrated the antipsychotic efficacy of a mGluR2/mGluR3 agonist. The purpose of the present study was to distinguish the expression of mGluR2 and mGluR3 receptor proteins in schizophrenia and to quantify glutamate carboxypeptidase II (GCP II) in order to explore a role for the metabotropic receptors in schizophrenia therapeutics. GCP II is an enzyme that metabolizes N-acetyl-aspartyl-glutamate (NAAG), which is the only known specific endogenous agonist of mGluR3 in the mammalian brain. METHOD: The normal expression levels of mGluR2, mGluR3, and GCP II were determined for 10 regions of the postmortem human brain using specific antibodies. Differences in expression levels of each protein were examined in the dorsolateral prefrontal cortex, temporal cortex, and motor cortex in 15 postmortem schizophrenia subjects and 15 postmortem matched normal comparison subjects. Chronic antipsychotic treatment in rodents was conducted to examine the potential effect of antipsychotic drugs on expression of the three proteins. RESULTS: Findings revealed a significant increase in GCP II protein and a reduction in mGluR3 protein in the dorsolateral prefrontal cortex in schizophrenia subjects, with mGluR2 protein levels unchanged. Chronic antipsychotic treatment in rodents did not influence GCP II or mGluR3 levels. CONCLUSIONS: Increased GCP II expression and low mGluR3 expression in the dorsolateral prefrontal cortex suggest that NAAG-mediated signaling is impaired in this brain region in schizophrenia. Further, these data implicate the mGluR3 receptor in the antipsychotic action of mGluR2/mGluR3 agonists.

[Articles] Performance-Based Measurement of Functional Disability in Schizophrenia: A Cross-National Study in the United States and Sweden

2009-07-01

OBJECTIVE: Recent advances in the assessment of disability in schizophrenia have separated the measurement of functional capacity from real-world functional outcomes. The authors examined the similarity of performance-based assessments of everyday functioning, real-world disability, and achievement of milestones in people with schizophrenia in the United States and Sweden. METHOD: The UCSD Performance-Based Skills Assessment–Brief Version (UPSA-B) and a neuropsychological assessment were administered to schizophrenia patients living in rural areas in Sweden (N=146) and in the New York City area (N=244), and patients’ functioning was rated by their case managers. Information from records and case managers was used to determine the frequency of living independently, working, and having ever experienced a stable romantic relationship. RESULTS: Performance on the UPSA-B was essentially identical in the two samples (New York, mean score=13.84; Sweden, mean score=13.30), as were scores on the case manager ratings of everyday activities (New York, mean=49.0; Sweden, mean=48.8). The correlations between UPSA-B score, neuropsychological test performance, and case manager ratings did not differ across the two samples. The proportion of patients who had never had a close relationship and the rate of vocational disability were also nearly identical. However, while 80% of the Swedish patients were living independently, only 46% of the New York patients were. CONCLUSIONS: While scores on performance-based measures of everyday living skills were similar in people with schizophrenia across cultures, real-world residential outcomes were very different. These data suggest that cultural and social support systems can lead to divergent real-world outcomes among individuals who show evidence of the same levels of ability and potential.

[Letters to the Editor] More Aggressive Treatment for Depression?

NICHOLAS, J. R. — 2009-07-01

[Letters to the Editor] The Effects of Treatment-Resistant Depression and First-Ever Depression on Mortality Following Acute Coronary Syndrome: Interactive or Independent?

ZUIDERSMA, M., de JONGE, P. — 2009-07-01

[Letters to the Editor] Drs. Carney and Freedland Reply

CARNEY, R. M., FREEDLAND, K. E. — 2009-07-01

[Letters to the Editor] The Use of Short Half-Life Antidepressants in the Treatment of Bipolar Depression

LIEBOWITZ, N. R. — 2009-07-01

[Letters to the Editor] Drs. Frye and Helleman Reply

FRYE, M. A., HELLEMANN, G. — 2009-07-01

[Letters to the Editor] Dr. Goldberg Replies

GOLDBERG, J. F. — 2009-07-01

[Letters to the Editor] Analysis of Mechanisms Underlying Depressive and Addictive Comorbid Disorders in Adolescents Should Not Ignore Nicotine Use and Dependence

SCHUTZ, C. G., SEPEHRY, A. A. — 2009-07-01

[Letters to the Editor] Drs. Rao, Hammen, and Poland Reply

RAO, U., HAMMEN, C. L., POLAND, R. E. — 2009-07-01

[Letters to the Editor] Persistent Psychosis Associated With Salvia Divinorum Use

PRZEKOP, P., LEE, T. — 2009-07-01

[Book Forum] The Age of Anxiety: A History of America's Turbulent Affair With Tranquilizers

BALON, R. — 2009-07-01

[Book Forum] Images of Psychiatry: The Caribbean

ESCOBAR, J. I. — 2009-07-01

[Book Forum] Philosophy of Psychopharmacology

DUBOVSKY, S. L. — 2009-07-01

[Book Forum] Psychiatry, Third Edition

PAVULURI, M., LEVENTHAL, B. — 2009-07-01

[Books Received]

2009-07-01

[Corrections]

2009-07-01