In This Issue
Valproate was similar to lithium in its effect on suicide-related events (Oquendo et al., p. 1050)
Clinical Guidance: Lithium and Valproate Treatment—A Prospective Comparison of Effects on Suicide Attempts
A 2.5-year randomized trial of lithium versus valproate treatment for patients with bipolar disorder who had made a previous suicide attempt found no difference in subsequent attempts between the two treatment groups, as reported by Oquendo et al. (p. Original article: 1050). Fourteen of the 35 participants made at least one suicide attempt, six from the lithium group and eight from the valproate group. While the data seem to exclude a very large effect of drug (figure), the study does not have sufficient size to exclude smaller, but perhaps clinically significant effects. An editorial by Perlis (p. Original article: 1009) points out that the high rates of suicide attempts in both medication groups underscore the challenge of caring for very suicidal patients.
Clinical Guidance: Safety Guideline for Longer-Term T3 Augmentation Treatment of Major Depressive Disorder
Rosenthal et al. (p. Original article: 1035) point out that no long-term data on the efficacy of T3 augmentation for SSRI treatment exist beyond the 12-week STAR*D trial (Original article: 2006; 163:1519-1530). However, the procedure is frequently used successfully in clinical practice, and therefore safety guidelines are needed. In addition to baseline measurements and informed consent with a risk-benefit analysis, Rosenthal et al. suggest endocrine evaluation at 3 and 6 months and then yearly. The TSH level should generally be at least 0.4 μIU/ml, the lower limit of normal; the T3 level can be at the upper limit of normal. The patient should be clinically evaluated for hyperthyroidism. Bone density should be monitored every 2 years in postmenopausal women.
Studying Gene-Environment Interactions
Research on how interactions between candidate genes and environmental factors influence psychiatric illnesses has generated enthusiasm but not many replicable findings. Duncan and Keller (p. Original article: 1041) discovered that the more closely a replication study matched the original research, the less likely it was to have similar results. Publication bias toward positive findings was apparent both in reports of novel findings and in replication studies. Another contributor to false discoveries in many studies of candidate genes is low statistical power due to small study groups or other design factors.
Antipsychotics for Anxiety Disorders
Prescription of antipsychotic medications during visits for anxiety disorders doubled between 1996 and 2007 among office-based psychiatrists, from 10.6% to 21.3% of visits. The nationwide data analyzed by Comer et al. (CME, p. Original article: 1057) demonstrate increases for comorbid FDA-approved indications, such as bipolar disorder, and for nonapproved indications. The greatest increase was among patients with panic disorder or agoraphobia. In an editorial, Breier (p. Original article: 1012) considers whether these findings indicate an unmet need for treatments for refractory anxiety disorders.
Brain Structure and Functioning Related in Late-Life Depression
The difference in brain activation during emotional processing between elderly patients with and without major depressive disorder was greater for depressed patients with more white matter lesions. Aizenstein et al. (p. Original article: 1075) performed both structural and functional magnetic resonance imaging (MRI) of elderly subjects as they matched pictures of facial expressions. Although the findings support the hypothesis of “vascular depression,” the levels of white matter hyperintensities were similar in the depressed and nondepressed elderly subjects.
Parkinson's-Related Depression Responds to Cognitive-Behavioral Therapy
Depression scores declined more for depressed patients with Parkinson's disease who received 10 weeks of cognitive-behavioral therapy (CBT) plus clinical monitoring than for those who received clinical monitoring only. The study of 80 patients by Dobkin et al. (CME, p. Original article: 1066) also showed greater improvements in anxiety, quality of life, coping, and Parkinson's disease symptoms in the CBT group. The editorial by Black (p. Original article: 1015) notes the high rate of depressive syndromes in Parkinson's disease and the greater possibility of antidepressant-related side effects and drug interactions.
