Evidence-Based Recommendations for the Prescription of Exercise for Major Depressive Disorder
RETHORST, CHAD D. PhD; TRIVEDI, MADHUKAR H. MD
Major depressive disorder (MDD) is a source of great disease burden, due in part to the limited accessibility and effectiveness of current treatments. Although current treatments are efficacious in a segment of the population with MDD, there is a clear need for alternative and augmentation treatment strategies. Exercise is one such alternative treatment option. Research has shown exercise to be efficacious as both a stand-alone and an augmentation therapy. As a result, exercise is now included in the American Psychiatric Association’s treatment recommendations. The purpose of this article is to provide clinicians with a knowledge base to prescribe exercise to their patients. The authors describe the evidence supporting the use of exercise in the treatment of MDD, provide evidence-based recommendations for prescribing exercise, and address practical considerations related to prescribing exercise in real-world treatment settings.
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Posted to Members in the News & Publications on May 15, 2013
Pain conditions among veterans with schizophrenia or bipolar disorder
Denis G. Birgenheir, Ph.D., Mark A. Ilgen, Ph.D., Amy S.B. Bohnert, Ph.D., Kristen M. Abraham, Ph.D., Nicholas W. Bowersox, Ph.D., Karen Austin, M.P.H., Amy M. Kilbourne, Ph.D., M.P.H.
Objective The purpose of this study was to assess the rates of chronic, noncancer pain conditions in patients with schizophrenia or bipolar disorder within the Veterans Health Administration (VHA) System.
Method This cross-sectional study used administrative data extracted from VHA treatment records of all individuals receiving VHA services in fiscal year 2008 (N=5,195,551). The associations between severe psychiatric disorders (schizophrenia and bipolar disorder) and chronic pain (arthritis, back pain, chronic pain, migraine, headache, psychogenic and neuropathic) were evaluated using a series of logistic regression analyses.
Results Veterans with schizophrenia [odds ratio (OR)=1.21] and bipolar disorder (OR=2.17) were significantly more likely to have chronic pain overall relative to veterans without these psychiatric conditions. These associations were slightly lower than for the association between depression and pain in this sample (OR=2.61). The highest associations between specific psychiatric diagnosis and pain condition were found with chronic pain, headache and psychogenic pain.
Conclusions Noncancer pain conditions occur in elevated rates among patients with schizophrenia and bipolar disorder. Future research could further examine possible barriers to adequate pain treatment among people with serious mental illness, as well as the extent to which chronic pain might impact mental health recovery.
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Posted to Members in the News & Publications on May 08, 2013
Seasonal variation of manic and depressive symptoms in bipolar disorder
Ahmed Akhter, Jess G Fiedorowicz, Tao Zhang, James B Potash, Joseph Cavanaugh, David A Solomon, William H Coryell
Objectives Analyses of seasonal variation of manic and depressive symptoms in bipolar disorder in retrospective studies examining admission data have yielded conflicting results. We examined seasonal variation of mood symptoms in a prospective cohort with long-term follow-up: the Collaborative Depression Study (CDS).
Methods The CDS included participants from five academic centers with a prospective diagnosis of bipolar I or II disorder. The sample was limited to those who were followed for at least 10 years of annual or semi-annual assessments. Time series analyses and autoregressive integrated moving average (ARIMA) models were used to assess seasonal patterns of manic and depressive symptoms.
Results A total of 314 individuals were analyzed (bipolar I disorder, n = 202; bipolar II disorder, n = 112), with both disorders exhibiting the lowest frequency of depressive symptoms in summer and the highest around the winter solstice, though the winter peak in symptoms was statistically significant only with bipolar I disorder. Variation of manic symptoms was more pronounced in bipolar II disorder, with a significant peak in hypomanic symptomatology in the months surrounding the fall equinox.
Conclusions Significant seasonal variation exists in bipolar disorder, with manic/hypomanic symptoms peaking around the fall equinox and depressive symptoms peaking in the months surrounding the winter solstice in bipolar I disorder.
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Posted to Members in the News & Publications on May 02, 2013
Provider Barriers to Telemental Health: Obstacles Overcome, Obstacles Remaining
Elizabeth Brooks, PhD, Carolyn Turvey, PhD, and Eugene F. Augusterfer, LCSW
Many providers are hesitant to use telemental health technologies. When providers are queried, various barriers are presented, such as the clinician's skepticism about the effectiveness of telemental health (TMH), viewing telehealth technologies as inconvenient, or reporting difficulties with medical reimbursement. Provider support for TMH is critical to its diffusion because clinicians often serve as the initial gatekeepers to telehealth implementation and program success. In this article, we address provider concerns in three broad domains: (1) personal barriers, (2) clinical workflow and technology barriers, and (3) licensure, credentialing, and reimbursement barriers. We found evidence that, although many barriers have been discussed in the literature for years, advancements in TMH have rapidly reduced obstacles for its use. Improvements include extensive opportunities for training, a growing evidence base supporting positive TMH outcomes, and transformations in technologies that improve provider convenience and transmission quality. Recommendations for further change are discussed within each domain. In particular, it is important to grow and disseminate data underscoring the promise and effectiveness of TMH, integrate videoconferencing capabilities into electronic medical record platforms, expand TMH reimbursement, and modify licensure standards.
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Posted to Members in the News & Publications on April 23, 2013
Challenges in the Treatment of Major Depressive Disorder With Psychotic Features
Anthony J. Rothschild
Psychotic depression is associated with significant morbidity and mortality but is underdiagnosed and undertreated. In recent years, there have been several studies that have increased our knowledge regarding the optimal treatment of patients with psychotic depression. The combination of an antidepressant and antipsychotic is significantly more effective than either antidepressant monotherapy or antipsychotic monotherapy for the acute treatment of psychotic depression. Most treatment guidelines recommend either the combination of an antidepressant with an antipsychotic or ECT for the treatment of an acute episode of unipolar psychotic depression. The optimal maintenance treatment after a person responds to either the antidepressant/antipsychotic combination or the ECT is unclear particularly as it pertains to length of time the patient needs to take the antipsychotic medication. Little is known regarding the optimal treatment of a patient with bipolar disorder who has an episode of psychotic depression or the clinical characteristics of responders to medication treatments vs ECT treatments.
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Posted to Members in the News & Publications on April 23, 2013
Gender differences in health-related quality of life in patients with bipolar disorder
Maria Syl D. de la Cruz, Zongshan Lai, David E. Goodrich, Amy M. Kilbourne
Health-related quality of life (HRQOL) is a widely accepted measure of illness state that is related to morbidity and mortality. Findings from various populations show that women report lower HRQOL than men. We analyzed baseline HRQOL data for gender differences from a multisite, randomized controlled study for adults with bipolar disorder. HRQOL was assessed using the 12-item Short Form (SF-12) physical component summary (PCS) and mental component summary (MCS) health scales. Multivariate linear and bivariate regression models examined differences in self-reported data on demographics, depressive symptoms (nine-item Patient Health Questionnaire), bipolar disorder symptoms (Internal State Scale), and medical comorbidities. Out of 384 enrolled (mean age = 42 years), 256 were women (66.7 %). After controlling for sociodemographic characteristics and clinical factors, women had lower SF-12 PCS scores than men [β = −1.78, standard error (SE) = 0.87, p < 0.05], indicating worse physical health, but there were no gender differences in MCS scores. After controlling for patient factors including medical and behavioral comorbidities, the association between gender and PCS score was no longer significant. Of the medical comorbidities, pain was associated with lower PCS scores (β = −4.90, SE = 0.86, p < 0.0001). Worse physical HRQOL experienced by women with bipolar disorder may be explained by medical comorbidity, particularly pain, suggesting the importance of gender-tailored interventions addressing physical health conditions.
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Posted to Members in the News & Publications on April 23, 2013
Dr. Deligiannidis Receives NIMH K23 Award to Examine Neuroendocrine & Neuroimaging Endophenotypes in Postpartum Depression
Postpartum depression (PPD) affects 1 in 8 women and significantly impairs mother and infant. PPD negatively impacts infant attachment, development and behavior: PPD can be fatal as maternal suicide accounts for up to 20% of postpartum deaths in depressed women. Emerging evidence suggests that biological factors, including female sex hormones, contribute to the pathophysiology of PPD. Kristina M. Deligiannidis, MD, Assistant Professor of Psychiatry and Obstetrics & Gynecology at UMass Medical School and Director of the Depression Specialty Clinic, will use hormone and brain imaging investigations (i.e. Magnetic Resonance Spectroscopy, resting-state functional connectivity MRI) to learn why women develop PPD so they can establish ways to identify which women are at high risk of developing the disorder and initiate early interventions to prevent PPD before it develops.
The NIMH K23 is the bridge (i.e. pathway for training and mentorship) for this early stage investigator to develop into an independently-funded physician-scientist. The K23 will advance Dr. Deligiannidis’ knowledge of reproductive endocrinology with an emphasis on developing novel investigative techniques and train her in neuroimaging to investigate the interactions of the reproductive endocrine system on neural circuitry in depression so to elucidate the pathophysiology of depression during times of reproductive flux with the goal of developing gender-specific treatments.
Posted to Members in the News & Publications on April 08, 2013
Conflict monitoring and adaptation in individuals at familial risk for developing bipolar disorder
Luis R Patino, Caleb M Adler, Neil P Mills, Stephen M Strakowski, David E Fleck, Jeffrey A Welge, Melissa P DelBello
Objective To examine conflict monitoring and conflict-driven adaptation in individuals at familial risk for developing bipolar disorder.
Methods We recruited 24 adolescents who had a parent with bipolar disorder and 23 adolescents with healthy parents. Participants completed an arrow version of the Eriksen Flanker Task that included trials with three levels of conflict: neutral, congruent, and incongruent flanks. Differences in performance were explored based upon the level of conflict in the current and previous trials.
Results Individuals at risk for developing bipolar disorder performed more slowly than youth with healthy parents in all trials. Analyses evaluating sequential effects revealed that at-risk subjects responded more slowly than youth of healthy parents for all trial types when preceded by an incongruent trial, for incongruent trials preceded by congruent trials, and for neutral and congruent trials when preceded by neutral trials. In contrast to the comparison group, at-risk adolescents failed to display a response time advantage for incongruent trials preceded by an incongruent trial. When removing subjects with attention-deficit hyperactivity disorder (ADHD), differences between groups in response time fell below significant level, but a difference in sequence modulation remained significant. Subjects at risk for bipolar disorder also displayed greater intra-subject response time variability for incongruent and congruent trials compared with the comparison adolescents. No differences in response accuracy were observed between groups.
Conclusions Adolescents at risk for developing bipolar disorder displayed specific deficits in cognitive flexibility, which might be useful as a potential marker related to the development of bipolar disorder.
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Posted to Members in the News & Publications on April 02, 2013
The Mothers, Omega-3, and Mental Health Study: a double-blind, randomized controlled trial
Ellen L. Mozurkewich, MD, Chelsea M. Clinton, MD, Julie L. Chilimigras, MPH, Susan E. Hamilton, MS, Lucy J. Allbaugh, MS, Deborah R. Berman, MD, Sheila M. Marcus, MD, Vivian C. Romero, MD, Marjorie C. Treadwell, MD, Kristie L. Keeton, MD, Anjel M. Vahratian, PhD, Ronald M. Schrader, PhD, Jianwei Ren, MD, Zora Djuric, PhD
Objectives Maternal deficiency of the omega-3 fatty acid, docosahexaenoic acid (DHA), has been associated with perinatal depression, but there is evidence that supplementation with eicosapentaenoic acid (EPA) may be more effective than DHA in treating depressive symptoms. This trial tested the relative effects of EPA- and DHA-rich fish oils on prevention of depressive symptoms among pregnant women at an increased risk of depression.
Study Design We enrolled 126 pregnant women at risk for depression (Edinburgh Postnatal Depression Scale score 9-19 or a history of depression) in early pregnancy and randomly assigned them to receive EPA-rich fish oil (1060 mg EPA plus 274 mg DHA), DHA-rich fish oil (900 mg DHA plus 180 mg EPA), or soy oil placebo. Subjects completed the Beck Depression Inventory (BDI) and Mini-International Neuropsychiatric Interview at enrollment, 26-28 weeks, 34-36 weeks, and at 6-8 weeks' postpartum. Serum fatty acids were analyzed at entry and at 34-36 weeks' gestation.
Results One hundred eighteen women completed the trial. There were no differences between groups in BDI scores or other depression endpoints at any of the 3 time points after supplementation. The EPA- and DHA-rich fish oil groups exhibited significantly increased postsupplementation concentrations of serum EPA and serum DHA respectively. Serum DHA- concentrations at 34-36 weeks were inversely related to BDI scores in late pregnancy.
Conclusion EPA-rich fish oil and DHA-rich fish oil supplementation did not prevent depressive symptoms during pregnancy or postpartum.
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Posted to Members in the News & Publications on April 01, 2013
Bipolar Depression in Pediatric Populations
Victoria E. Cosgrove, Donna Roybal, Kiki D. Chang
Depression in children and adolescents with bipolar disorder is more commonly observed than mania or hypomania, and is associated with significant functional disability in multiple environmental realms. Optimal management of pediatric bipolar depression is often defined by its multimodal nature with emphasis on both psychopharmacological and psychosocial treatment. This article provides a brief overview of the epidemiology and clinical course of pediatric bipolar depression, a clinically-oriented guide to the evidence-based psychopharmacological and psychosocial management of bipolar depression in youth, and suggestions on how best to integrate medication and therapy. Recommended treatment for bipolar depression in pediatric populations usually includes both medication and psychosocial interventions given a paucity of double-blind, placebo-controlled psychopharmacological studies. Lithium and lamotrigine are feasible and tentatively efficacious options; however, treatment with quetiapine monotherapy may be no better than placebo. Furthermore, some youth may be at heightened risk for developing manic symptoms after treatment with selective serotonin reuptake inhibitors (SSRIs). Psychotherapy, either alone or adjunctively with medications, provides practitioners with a safe and feasible alternative. Interpersonal and Social Rhythm Therapy for Adolescents (IPSRT-A), Child- and Family-Focused Cognitive Behavioral Therapy (CFF-CBT), Dialectical Behavior Therapy for Adolescents (DBT-A), family psychoeducation, and Family Focused Therapy for Adolescents (FFT-A) are evidence-based treatments available to clinicians treating youth with bipolar depression.
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Posted to Members in the News & Publications on April 01, 2013
Transforming Systems for Parental Depression and Early Childhood Developmental Delays
Dana Schultz, Kerry Reynolds, Lisa Sontag-Padilla, Susan L. Lovejoy, Ray Firth, Harold Alan Pincus
Many families experience the often co-occurring challenges of parental depression and early childhood developmental delays. The Helping Families Raise Healthy Children initiative, implemented in Allegheny County, Pennsylvania, addressed these challenges by mobilizing and aligning the early intervention and behavioral health systems. The initiative focused on three components of service delivery: (1) screening and identification of families at risk for parental depression, (2) referrals for those identified as being at risk, and (3) engagement in relationship-based services provided by both the early intervention and behavioral health systems that addressed the needs of parents and young children in a parent-child relationship context. More than 4,000 caregivers (primarily mothers) received formal screening for depression through the initiative, representing a screening rate of 63 percent. In addition to formal screening, some self-identified or were identified by community partners as being at risk for depression. In total, nearly 700 caregivers at risk for depression were identified. Among these, the referral rate was 62 percent; 71 percent of those referred engaged in services. These high rates of referral and engagement likely reflect several important components of the initiative that were designed to reduce barriers to obtaining services, including the provision of mobile services, an emphasis on the parent-child relationship in both early intervention and behavioral health settings, and improvement of cross-system communication and collaboration. The Helping Families Raise Healthy Children initiative demonstrates the potential gains associated with improved cross-system care, and could serve as a model for similar initiatives in a variety of domains.
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Posted to Members in the News & Publications on March 27, 2013
Dissemination and Implementation of Prolonged Exposure Therapy for Posttraumatic Stress Disorder
Carmen P. McLean, Edna B. Foa
Posttraumatic stress disorder (PTSD) is a highly prevalent, often chronic and disabling psychiatric disorder that is associated with significant adverse health and life consequences. Although several evidence-based treatments (EBTs), including Prolonged Exposure therapy (PE), have been found effective and efficacious in reducing PTSD symptomology, the majority of individuals with this disorder receive treatments of unknown efficacy. Thus, it is imperative that EBTs such as PE be made available to PTSD sufferers through widespread dissemination and implementation. We will review some of the efforts to increase the availability of PE and the common barriers to successful dissemination and implementation. We also discuss novel dissemination strategies that are harnessing technology to overcome barriers to dissemination.
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Posted to Members in the News & Publications on March 27, 2013
Therapist Factors and Outcomes in CBT for Anxiety in Youth
Podell, Jennifer L.; Kendall, Philip C.; Gosch, Elizabeth A.; Compton, Scott N.; March, John S.; Albano, Anne-Marie; Rynn, Moira A.; Walkup, John T.; Sherrill, Joel T.; Ginsburg, Golda S.; Keeton, Courtney P.; Birmaher, Boris; Piacentini, John C.
This study examined the relationship between therapist factors and child outcomes in anxious youth who received cognitive–behavioral therapy (CBT) as part of the Child–Adolescent Anxiety Multimodal Study (CAMS). Of the 488 youth who participated in the CAMS project, 279 were randomly assigned to one of the CBT conditions (CBT only or CBT plus sertraline). Participants included youth (ages 7–17; M = 10.76) who met criteria for a principal anxiety disorder. Therapists included 38 cognitive–behavioral therapists. Therapist style, treatment integrity, and therapist experience were examined in relation to child outcome. Child outcome was measured via child, parent, and independent evaluator report. Therapists who were more collaborative and empathic, followed the treatment manual, and implemented it in a developmentally appropriate way had youth with better treatment outcomes. Therapist “coach” style was a significant predictor of child-reported outcome, with the collaborative “coach” style predicting fewer child-reported symptoms. Higher levels of therapist prior clinical experience and lower levels of prior anxiety-specific experience were significant predictors of better treatment outcome. Findings suggest that although all therapists used the same manual-guided treatment, therapist style, experience, and clinical skills were related to differences in child outcome. Clinical implications and recommendations for future research are discussed.
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Posted to Members in the News & Publications on March 27, 2013
Treatment-Resistant Depression and Risk of Suicide
Paul N. Pfeiffer MD, Hyungjin M. Kim ScD, Dara Ganoczy MPH, Kara Zivin PhD, Marcia Valenstein MD
We evaluated whether treatment-resistant depression (TRD) as measured by the Massachusetts General Hospital (MGH) staging method was associated with suicide in a large U.S. health system. Data from the Veterans Health Administration and the National Death Index were used to conduct a case–control study of patients newly diagnosed with depression who received antidepressant treatment between 2003 and 2006. Suicide cases (N = 499) were matched with nonsuicide controls (N = 1994). Conditional logistic regression was used to assess whether MGH stage at time of suicide (or matched date) was associated with case status, adjusting for patient demographic characteristics, comorbidity, and service use. Results indicated 11.6% of suicide cases had MGH stage 3 or greater (indicating at least two antidepressant trials) compared to 6.4% of controls (p < .001). In adjusted analyses, suicide was not significantly more likely among patients with stage 3 or greater (OR 1.52; 95% CI: 0.98, 2.37) or stages 1.5–2.5 (OR 1.19; 95% CI: 0.91, 1.55) compared to patients with stage 1 or less (<10 weeks of antidepressant medication). Staging TRD using MGH criteria is unlikely to substantially improve suicide risk assessment of depressed patients beyond existing measures contained in health system records.
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Posted to Members in the News & Publications on March 27, 2013
Post-Acute Effectiveness of Lithium in Pediatric Bipolar I Disorder
Robert L Findling, MD, MBA, Vivian Kafantaris, MD, Mani Pavuluri, MD, PhD, Nora K McNamara, MD, Jean A Frazier, MD, Linmarie Sikich, MD, Robert Kowatch, MD, PhD, Brieana M Rowles, MA, Traci E Clemons, PhD, and Perdita Taylor-Zapata, MD
Objective This study examined the long-term effectiveness of lithium for the treatment of pediatric bipolar disorder within the context of combination mood stabilizer therapy for refractory mania and pharmacological treatment of comorbid psychiatric conditions.
Methods Outpatients, ages 7–17 years, meeting American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) diagnostic criteria for bipolar disorder I (BP-I) (manic or mixed) who demonstrated at least a partial response to 8 weeks of open-label treatment with lithium (Phase I) were eligible to receive open-label lithium for an additional 16 weeks (Phase II). Up to two adjunctive medications could be prescribed to patients experiencing residual symptoms of mania or comorbid psychiatric conditions, following a standardized algorithm.
Results Forty-one patients received continued open-label long-term treatment with lithium for a mean of 14.9 (3.0) weeks during Phase II. The mean weight-adjusted total daily dose at end of Phase II was 27.8 (6.7) mg/kg/day, with an average lithium concentration of 1.0 (0.3) mEq/L. Twenty-five of the 41 patients (60.9%) were prescribed adjunctive psychotropic medications for residual symptoms. The most frequent indications for adjunctive medications were refractory mania (n=13; 31.7%) and attention-deficit/hyperactivity disorder (ADHD) (n=15; 36.6%). At the end of this phase 28 (68.3%) patients met a priori criteria for response (≥50% reduction from Phase I baseline in Young Mania Rating Scale [YMRS] summary score and a Clinical Global Impressions-Improvement [CGI-I] score of 1 or 2), with 22 (53.7%) considered to be in remission (YMRS summary score≤12 and CGI-Severity score of 1 or 2). These data suggest that patients who initially responded to lithium maintained mood stabilization during continuation treatment, but partial responders did not experience further improvement during Phase II, despite the opportunity to receive adjunctive medications. The most commonly reported (≥20%) adverse events associated with lithium treatment were vomiting, headache, abdominal pain, and tremor.
Conclusions Lithium may be a safe and effective longer-term treatment for patients with pediatric bipolar disorder who respond to acute treatment with lithium. Partial responders to acute lithium did not appear to experience substantial symptom improvement during the continuation phase, despite the possibility that adjunctive medications could be prescribed.
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Posted to Members in the News & Publications on March 27, 2013
UMass May Day Mental Health Summit!
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Posted to Events on March 21, 2013
Anxiety, Depression May Triple Risk of Death for Heart Patients: Study
Features Lana L. Watkins, PhD, BS, Duke University
Anxiety and depression coupled with heart disease triples the risk of death compared to cardiac trouble alone, researchers have found.
Among heart patients, anxiety can double the risk of dying from any cause, the study authors noted, and depression further raises those odds.
"Patients with heart disease who experience high anxiety during the stressors of everyday life may benefit from treatments designed to reduce anxiety, such as medications targeting anxiety or stress management," said lead researcher Lana Watkins, an associate professor of psychiatry and behavioral sciences at Duke University Medical Center in Durham, N.C.
"Benefits from stress-reducing interventions would potentially be greatest in patients where anxiety is found in combination with depression," she added.
Posted to Members in the News & Publications on March 20, 2013
Complicated Grief Symptoms in Anxiety Disorders: Prevalence and Associated Impairment
Luana Marques Ph.D., Eric Bui M.D., Ph.D., Nicole LeBlanc B.S., Eliora Porter B.A., Donald Robinaugh M.A., M. Taylor Dryman B.A., Mireya Nadal-Vicens M.D., Ph.D., John Worthington M.D., Naomi Simon M.D., M.Sc.
Background Previous research has identified high rates of comorbid anxiety disorders among individuals presenting with primary CG. In the present study, we examined the prevalence of comorbid CG in bereaved primary anxiety disorder (AD) patients compared to bereaved healthy controls. We also examined the impairment associated with comorbid CG in AD.
Methods Participants were 242 bereaved adults (mean (SD) age = 41.5 (13.1), 44.2% women) with a primary AD diagnosis, including generalized anxiety disorder (GAD; n = 57), panic disorder (PD; n = 49), posttraumatic stress disorder (PTSD; n = 29), and generalized social anxiety disorder (GSAD; n = 107), as well as 155 bereaved healthy controls with no current DSM-IV Axis I diagnosis (mean (SD) age = 43.0 (13.6), 51.0% women). CG symptoms were measured using the 19-item inventory of complicated grief (ICG), with threshold CG defined as an ICG score of ≥30. Quality of life and functional impairment were assessed with the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and the Range of Impaired Functioning Tool (LIFE-RIFT), respectively.
Results Participants with primary ADs had significantly higher rates of threshold CG symptoms than bereaved controls (12.0% vs. 0.65%; Fisher's Exact P < 0.001). Rates of threshold CG were significantly elevated for each AD when compared to bereaved controls. After adjustment for age, sex, education, and comorbid major depressive disorder, threshold CG was associated with lower quality of life (β = −0.140, P = 0.023) and greater impairment (β = 0.141, P = 0.035) among individuals with AD.
Conclusions Our findings suggest that threshold CG is of clinical relevance in bereaved individuals with a primary anxiety disorder. Screening for CG in patients with ADs may be warranted.
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Posted to Members in the News & Publications on March 19, 2013
Changes: VA Psychiatrists’ Attitudes About Work Environment & Turnover During MH Service Enhancement
David C. Mohr, Ph.D.; Mark S. Bauer, M.D.; Robert B. Penfold, Ph.D.
Objective The Veterans Health Administration (VHA) has undergone significant organizational transformation as part of a comprehensive strategic plan to enhance mental health services. Organizational change can create stress and decrease employee morale, even if the change is beneficial for patients and the organization. The study examined whether psychiatrists’ work satisfaction and work environment perceptions changed during a period of transformation. Facility-level turnover rate was also examined.
Methods Data were analyzed from 7,218 psychiatrists who responded to an annual organizational survey between 2004 and 2010 (excluding 2005) conducted with 139 facilities. Survey ratings were regressed on individual and facility-level characteristics in a multilevel model. Adjusted mean scores for the measures were compared with Tukey post hoc tests to identify significant differences by year.
Results Most satisfaction ratings on measures improved after the initial actions for strategic reform and stabilized in 2006. Turnover rates and intention to leave were also consistent during this time. Positive linear trends over time were observed for pay satisfaction, management for achievement, skill development, workplace civility, and satisfaction with senior management.
Conclusions Extensive reorganization of VHA mental health services was associated with improvements in psychiatrists’ workplace satisfaction, and these increases were sustained over time. In the current climate of rapid transformation under health care reform nationally, the VHA experience may inform the broader national process and organizational strategies to improve and maintain the morale of the health care workforce.
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Posted to Members in the News & Publications on March 19, 2013
Telephone care coordination for smokers in VA mental health clinics…
Protocol for a hybrid type-2 effectiveness-implementation trial
Erin Rogers, Senaida Fernandez, Colleen Gillespie, David Smelson, Hildi J Hagedorn, Brian Elbel, David Kalman, Alfredo Axtmayer, Karishma Kurowski and Scott E Sherman
This paper describes an innovative protocol for a type-II hybrid effectiveness-implementation trial that is evaluating a smoking cessation telephone care coordination program for Veterans Health Administration (VA) mental-health clinic patients. As a hybrid trial, the protocol combines implementation science and clinical trial methods and outcomes that can inform future cessation studies and the implementation of tobacco cessation programs into routine care. The primary objectives of the trial are (1) to evaluate the process of adapting, implementing, and sustaining a smoking cessation telephone care coordination program in VA mental health clinics, (2) to determine the effectiveness of the program in promoting long-term abstinence from smoking among mental health patients, and (3) to compare the effectiveness of telephone counseling delivered by VA staff with that delivered by state quitlines.
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Posted to Members in the News & Publications on March 19, 2013
Multiple Mediation of Trauma and Parenting Stress in Mothers in Home Visiting
Robert T. Ammerman, Chad E. Shenk, Angelique R. Teeters, Jennie G. Noll, Frank W. Putnam, Judith B. Van Ginkel
Parenting stress is associated with poor maternal and child outcomes. Multiple contributors to parenting stress have been proposed, but disaggregation of distinct pathways has been relatively unexplored. In addition, the contribution of maternal experience of childhood trauma has been inadequately considered. Childhood trauma and parenting stress are common in mothers in home visiting programs. Understanding the relation between childhood trauma and parenting stress holds promise for improvement of home visiting approaches. This study examined the relation between childhood trauma and parenting stress, with a focus on the mediating roles of depression and social support. Participants consisted of 208 first-time mothers enrolled in a home visiting program who were assessed at about 5 months’ postpartum. Measures of maternal childhood trauma, depression, social support, and parenting stress were administered. A multiple mediator model revealed that childhood trauma was related to parenting stress, and the relation between childhood trauma and parenting stress was separately mediated by both depression and social support. Depression and social support uniquely and distinctly accounted for the association between childhood trauma and parenting stress. Home visiting programs may improve their impact on parenting stress by augmenting or modifying strategies to more effectively address maternal depression and social support.
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Posted to Members in the News & Publications on March 14, 2013
Announcing the Updated Agenda!
The Inaugural National Research Summit
on Reserve Component Military Families
April 25 & 26, 2013
University of Michigan
Ann Arbor, Michigan
The National Network of Depression Centers is pleased to be a partner with M-SPAN (Military Support Programs and Networks) at the University of Michigan in two-day interdisciplinary conference on reserve component military families. This conference is intended to stimulate discussion and understanding of the latest research, effective mental health interventions, and innovative dissemination strategies specific to the needs of National Guard and Reserve families. To learn more about this conference, visit the M-SPAN website at http://m-span.org/conferences/national-research-summit-on-reserve-component-military-families/#sponsors.
Register now to be a part of this seminal event!
Click HERE to Register!
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For further information, please contact:
Patty White, Conference Coordinator, pbwhite@umich.edu - (734) 998-5825
Michelle Kees, PhD, Conference Chair, mkees@umich.edu - (734) 764-7328
Visit our website for registration information and details:
http://m-span.org/conferences/national-research-summit-on-reserve-component-military-families/
Please share this information with others who may be interested in attending the National Research Summit on Reserve Component Military Families!
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The National Research Summit is presented by M-SPAN (Military Support Programs and Network) at the University of Michigan, with support from the Department of Psychiatry and Depression Center at the University of Michigan, and in collaboration with the National Network of Depression Centers and the Welcome Back Veterans initiative. Funding for this event is provided by the McCormick Foundation, National Institute of Child Health & Development (1 R13 HD072720-01), and Michigan Institute for Clinical Health & Research (MICHR).
Posted to Events on March 14, 2013
Premenstrual Dysphoric Disorder and the Brain
C. Neill Epperson, M.D.
In early December 2012, the APA Board of Trustees approved the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). With this vote, the board made history with respect to the classification of premenstrual disorders. By moving premenstrual dysphoric disorder (PMDD) from DSM-IV-TR Appendix B, “Criterion Sets and Axes Provided for Further Study,” to a full diagnosis with a distinct diagnostic code under the category of mood disorders, the long-suspected biological and brain basis of this disorder has been emphasized. Since the time of Hippocrates (Figure 1), philosophers, physicians, and scientists have written about the links between menstruation, the brain, and behavior (1). However, recent decades have witnessed a backlash against the inclusion of PMDD and its previous diagnostic versions in the DSM. The argument is typically based on the concern that a formal diagnosis of premenstrual syndrome (PMS) or PMDD would pathologize the normal premenstrual physical and behavioral changes experienced by the majority of women or would suggest that all women are somehow compromised by the menstrual cycle.
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Posted to Members in the News & Publications on March 05, 2013
A Rational Insurance Coverage Policy for rTMS for Major Depression
Reti, Irving M. MBBS
Although most health insurance plans do not cover repetitive transcranial magnetic stimulation (rTMS) for the treatment of major depression, coverage is increasing, with approval often granted on a case-by-case basis. Accordingly, it is important for physicians who are advocating for coverage on behalf of their patients to provide cogent arguments based on published data. Most patients presenting for rTMS have medication resistance that is beyond the Food and Drug Administration-approved indication of one failed but adequate trial of an antidepressant medication. However, recent naturalistic studies lend support to the proposition that rTMS is efficacious for more medication-resistant patients.
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Posted to Members in the News & Publications on March 05, 2013
Sources of parenting support in early fatherhood: Perspectives of United States Air Force members
Shawna J. Lee, Tova B. Neugut, Katherine L. Rosenblum, Richard M. Tolman, Wendy J. Travis, Margaret H. Walker
We conducted semi-structured focus groups with men in the United States Air Force (N = 39) to examine fathers’ access to parenting information during the transition to parenthood, and to determine methods for engaging fathers in intervention. Results of content analysis highlight the fathers’ motivation to develop and maintain positive relationships with their partners and their children despite substantial challenges, including multiple deployments, family moves, and demanding work responsibilities. Fathers emphasize the importance of information in facilitating the transition to parenthood, especially in the key domains of effective co-parenting and communication, children's developmental milestones, and appropriate use of discipline. Results underscore that men tend to rely more on informal sources of parenting information (e.g., spouse/ partner, family members, friends) than on formal sources of information (e.g., pediatricians, social workers).
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Posted to Members in the News & Publications on March 05, 2013
Providers’ Attitudes Towards Treating Depression… in HIV Outpatient Care
Kiana D. Bess, Julie Adams, Melissa H. Watt, Julie K. O'Donnell, Bradley N. Gaynes, Nathan M. Thielman, Amy Heine, Anne Zinski, James L. Raper, and Brian W. Pence
Depression is highly prevalent among HIV-infected patients, yet little is known about the quality of HIV providers' depression treatment practices. We assessed depression treatment practices of 72 HIV providers at three academic medical centers in 2010–2011 with semi-structured interviews. Responses were compared to national depression treatment guidelines. Most providers were confident that their role included treating depression. Providers were more confident prescribing a first antidepressant than switching treatments. Only 31% reported routinely assessing all patients for depression, 13% reported following up with patients within 2 weeks of starting an antidepressant, and 36% reported systematically assessing treatment response and tolerability in adjusting treatment. Over half of providers reported not being comfortable using the full FDA-approved dosing range for antidepressants. Systematic screening for depression and best-practices depression management were uncommon. Opportunities to increase HIV clinicians' comfort and confidence in treating depression, including receiving treatment support from clinic staff, are discussed.
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Posted to Members in the News & Publications on March 05, 2013
rTMS of the Dorsolateral Prefrontal Cortex Reduces Nicotine Cue Craving
Xingbao Li, Karen J. Hartwell, Max Owens, Todd LeMatty, Jeffrey J. Borckardt, Colleen A. Hanlon, Kathleen T. Brady, Mark S. George
Background Repetitive transcranial magnetic stimulation (rTMS) can noninvasively stimulate the brain and transiently amplify or block behaviors mediated through a region. We hypothesized that a single high-frequency rTMS session over the left dorsolateral prefrontal cortex (DLPFC) would reduce cue craving for cigarettes compared with a sham TMS session.
Methods Sixteen non-treatment-seeking, nicotine-dependent participants were randomized to receive either real high-frequency rTMS (10 Hz, 100% resting motor threshold, 5-sec on, 10-sec off for 15 min; 3000 pulses) or active sham (eSham) TMS over the DLPFC in two visits with 1 week between visits. The participants received cue exposure before and after rTMS and rated their craving after each block of cue presentation.
Results Stimulation of the left DLFPC with real, but not sham, rTMS reduced craving significantly from baseline (64.1±5.9 vs. 45.7±6.4, t = 2.69, p = .018). When compared with neutral cue craving, the effect of real TMS on cue craving was significantly greater than the effect of sham TMS (12.5±10.4 vs. –9.1±10.4; t = 2.07, p = .049). More decreases in subjective craving induced by TMS correlated positively with higher Fagerström Test for Nicotine Dependence score (r = .58, p = .031) and more cigarettes smoked per day (r = .57, p = .035).
Conclusions One session of high-frequency rTMS (10 Hz) of the left DLPFC significantly reduced subjective craving induced by smoking cues in nicotine-dependent participants. Additional studies are needed to explore rTMS as an aid to smoking cessation.
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Posted to Members in the News & Publications on March 04, 2013
The serotonergic system in mood disorders and suicidal behaviour
J. John Mann
A stress-diathesis explanatory model of suicidal behaviour has proved to be of heuristic value, and both clinical and neurobiological components can be integrated into such a model. A trait deficiency in serotonin input to the anterior cingulate and ventromedial prefrontal cortex is found in association with suicide, and more recently non-fatal suicidal behaviour, and is linked to decision-making and suicide intent by imaging and related studies in vivo. The same neural circuitry and serotonin deficiency may contribute to impulsive aggressive traits that are part of the diathesis for suicidal behaviour and are associated with early onset mood disorders and greater risk for suicidal behaviour. Other brain areas manifest deficient serotonin input, that is, a trait related to recurrent major depressive disorder and bipolar disorder. Thus the serotonin system is involved in both the diathesis for suicidal behaviour in terms of decision-making, and to a major stressor, namely episodes of major depression.
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Posted to Members in the News & Publications on March 04, 2013
Association Between Smoking and Heart Rate Variability Among Individuals with Depression
Harte CB, Liverant GI, Sloan DM, Kamholz BW, Rosebrock LE, Fava M, Kaplan GB
Background Both depression and smoking have been independently associated with lower heart rate variability (HRV), suggesting dysregulation of cardiac autonomic function. However, no studies have systematically explored the effects of smoking on HRV among depressed patients.
Purpose This study examined differences in HRV based on smoking status among depressed individuals.
Methods Electrophysiological data were examined among 77 adult outpatients without a history of myocardial infarction, who met criteria for major depressive disorder or dysthymia. Frequency domain [low frequency (LF), high frequency (HF), LF/HF ratio, respiratory sinus arrhythmia (RSA)] parameters of HRV, and heart rate and inter-beat interval (IBI) data were compared between depressed smokers (n = 34) and depressed nonsmokers (n = 44).
Results After controlling for covariates, depressed smokers, compared to depressed nonsmokers, displayed significantly lower LF, HF, and RSA.
Conclusions Among depressed patients, smoking is associated with significantly lower HRV, indicating dysregulated autonomic modulation of the heart.
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Posted to Members in the News & Publications on March 04, 2013
Bipolar Disorder Through Pregnancy and Postpartum
Wendy K. Marsh & Adele Viguera
This article reviews the literature on pregnancy and postpartum care of women with bipolar disorder, with a focus on mood stabilizer teratogenicity, perinatal complications and neurodevelopmental outcomes, and exposure during lactation. This review highlights findings published since 2004.
Discussion of treatment of bipolar disorder in pregnancy and postpartum with reproductive-age women is critical and needs to highlight: a) fetal exposure risk; b) risk of mood episode recurrence if untreated; and c) risk of mood episode recurrence with mood stabilizer discontinuation. The goal of medication treatment is to use minimum effective dose as all psychotropic medications pass through the placenta as well as into breast milk. Given the significantly increased risk of mood episodes in the postpartum period, prophylactic mood stabilization is recommended. If a woman plans to breast-feed, it is recommended she remain on the medication used during pregnancy to avoid multiple exposures to her infant. However, there is considerable uncertainty regarding the relative safety of particular psychotropic drugs during lactation, and about the degree to which nursing infants are exposed to these medications.
Evidence-based guidelines are lacking in the treatment of bipolar disorder during the perinatal period. Fetal exposure occurs for all bipolar mood stabilizers and yet the risks of untreated illness often necessitate treatment during pregnancy and especially postpartum. Detailed discussion with the patient is critical in deciding treatment choice.
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Posted to Members in the News & Publications on March 04, 2013
Mapping Mindfulness Facets onto Dimensions of Anxiety and Depression
Alethea Desrosiersa, David H. Klemanski, Susan Nolen-Hoeksema
Background Mindfulness has been associated with anxiety and depression, but the ways in which specific facets of mindfulness relate to symptoms of anxiety and depression remains unclear. The purpose of the current study was to investigate associations between specific facets of mindfulness (e.g., observing, describing, nonjudging, acting with awareness, and nonreactivity) and dimensions of anxiety and depression symptoms (e.g., anxious arousal, general distress-anxiety, general distress-depression, and anhedonic depression) while controlling for shared variance among variables.
Methods Participants were 187 treatment-seeking adults. Mindfulness was measured using the Five Facet Mindfulness Questionnaire and symptoms of depression and anxiety were measured using the Mood and Anxiety Symptom Questionnaire.
Results Bivariate correlations showed that all facets of mindfulness were significantly related to all dimensions of anxiety and depression with two exceptions: describing was unrelated to general distress-anxiety, and observing was unrelated to all symptom clusters. Path analysis was used to simultaneously examine associations between mindfulness facets and depression and anxiety symptoms. Significant and marginally significant pathways were retained to construct a more parsimonious model and model fit indices were examined. The parsimonious model indicated that nonreactivity was significantly inversely associated with general distress anxiety symptoms. Describing was significantly inversely associated with anxious arousal, while observing was significantly positively associated with it. Nonjudging and nonreactivity were significantly inversely related to general distress-depression and anhedonic depression symptomatology. Acting with awareness was not significantly associated with any dimensions of anxiety or depression.
Conclusions Findings support associations between specific facets of mindfulness and dimensions of anxiety and depression and highlight the potential utility of targeting these specific aspects of mindfulness in interventions for anxiety and mood disorders.
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Posted to Members in the News & Publications on March 04, 2013
PTSD symptoms common among ICU survivors
Features Dave Needham, MD, PhD & O. Joseph Bienvenu, MD, PhD
One in three people who survived stays in an intensive care unit (ICU) and required use of a mechanical ventilator showed substantial post-traumatic stress disorder (PTSD) symptoms that lasted for up to two years, according to a new Johns Hopkins study of patients with acute lung injury.
Because acute lung injury (ALI) -- a syndrome marked by excessive fluid in the lungs and frequent multi-organ failure -- is considered an archetype for critical illness, the researchers suspect PTSD is common among other ICU survivors as well.
"We usually think of PTSD as something you develop if you go to war, are sexually assaulted or suffer a similar emotional trauma," says Dale Needham, M.D., Ph.D., a critical care specialist at the Johns Hopkins University School of Medicine and senior author of the study published online in Psychological Medicine. "Instead, it may be as common, or more common, in ICU patients as in soldiers, but it’s something many doctors -- including psychiatrists -- don’t fully appreciate."
Posted to Members in the News & Publications on March 01, 2013
Knowledge, attitudes, & practices of emer. dept. providers in the care of suicidal patients
Marian E. Betz M.D., M.P.H., Ashley F. Sullivan M.S., M.P.H., Anne P. Manton Ph.D., A.P.R.N., Janice A. Espinola M.P.H., Ivan Miller Ph.D., Carlos A. Camargo Jr. M.D. Dr.P.H., Edwin D. Boudreaux Ph.D.
Background We sought to examine the knowledge, attitudes, and practices of emergency department (ED) providers concerning suicidal patient care and to identify characteristics associated with screening for suicidal ideation (SI).
Methods Six hundred thirty-one providers at eight EDs completed a voluntary, anonymous survey (79% response rate).
Results The median participant age was 35 (interquartile range: 30–44) years and 57% of the participants were females. Half (48%) were nurses and half were attending (22%) or resident (30%) physicians. More expressed confidence in SI screening skills (81–91%) than in skills to assess risk severity (64–70%), counsel patients (46–56%), or create safety plans (23–40%), with some differences between providers. Few thought mental health provider staffing was almost always sufficient (6–20%) or that suicidal patient treatment was almost always a top ED priority (15-21%). More nurses (37%, 95% confidence interval [CI] 31–42%) than physicians (7%, 95% CI 4–10%) reported screening most or all patients for SI; this difference persisted after multivariable adjustment. In multivariable analysis, other factors associated with screening most or all patients for SI were self-confidence in skills, (odds ratio [OR] 1.60, 95% CI 1.17–2.18), feeling that suicidal patient care was a top ED priority (OR 1.73, 95% CI 1.11–2.69) and 5+ postgraduate years of clinical experience (OR 2.06, 95% CI 1.03–4.13).
Conclusions ED providers reported confidence in suicide screening skills but gaps in further assessment, counseling, or referral skills. Efforts to promote better identification of suicidal patients should be accompanied by a commensurate effort to improve risk assessment and management skills, along with improved access to mental health specialists.
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Posted to Members in the News & Publications on February 26, 2013
Preliminary analysis: Age of illness onset effects on symptom profiles in major depressive disorder
Rebecca A. Charlton, Melissa Lamar, Olusola Ajilore, Anand Kumar
Objective Major depressive disorder (MDD) is prevalent across the lifespan, but relatively little is known about how age of illness onset impacts the cognitive and affective presentation of MDD.
Method We explore depressive symptoms and cognition in 70 adults (30–89 years old) with MDD. Participants were divided into three groups on the basis of age of MDD onset: early (<30 years), midlife (30–49.9 years), and late (>50 years). Symptoms were assessed using the Hamilton Depression Rating Scale; principal component analysis was used to create symptom component scores. Cognitive functions were measured.
Results The late-onset group were significantly older than the early-onset and midlife-onset groups. Analysis controlled for age and hemoglobin A1c levels, as some participants had diabetes. The late-onset group demonstrated greater weight loss and gastrointestinal symptoms compared with the early-onset group. Suicidal thoughts and sleep disturbance were higher in both the early-onset and late-onset groups compared with the midlife-onset group. Correlations between symptom components and cognitive domains varied by age-of-onset group.
Discussion This preliminary analysis demonstrates cognitive and affective profiles that are both unique to age of onset and common across MDD. Symptom profiles may assist in identifying factors influencing depression and enhance the clinical evaluation and care of individuals struggling with the effects of depression across the lifespan.
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Posted to Members in the News & Publications on February 26, 2013
Screening for Suicidal Ideation & Attempts among Emer. Dept. Medical Patients: Instrument & Results
Screening for Suicidal Ideation and Attempts among Emergency Department Medical Patients: Instrument and Results from the Psychiatric Emergency Research Collaboration
Michael H. Allen MD, Beau W. Abar PhD, Mark McCormick MD, Donna H. Barnes PhD, Jason Haukoos MD, MSc, Gus M. Garmel MD, FACEP, FAAEM, Edwin D. Boudreaux PhD
Joint Commission National Patient Safety Goal 15 calls for organizations “to identify patients at risk for suicide.” Overt suicidal behavior accounts for 0.6% of emergency department (ED) visits, but incidental suicidal ideation is found in 3%–11.6%. This is the first multicenter study of suicide screening in EDs. Of 2,243 patients in six diverse emergency settings, 1,068 (47.7%) were screened with a brief instrument. Depression was endorsed by 369 (34.5%); passive suicidal ideation by 79 (7.3%); and active suicidal ideation by 24 (2.3%). One hundred thirty-seven (12.8%) reported prior attempts, including 35 (3.3%) with current suicidal ideation. Almost half of those with current ideation had a prior attempt (43.8%) versus those without current ideation, 10.3%, χ2 (1) = 75.59, p < .001. Twenty cases (25%) were admitted to medical services, but only 10 (12.5%) received mental health assessment; none were admitted directly to a psychiatry service. The prevalence of suicidal ideation here is similar to previous studies but the frequency of prior attempts has not been reported. The 35 cases with current ideation and prior attempt are at risk. As they did not present psychiatrically, they would likely have gone undetected. Despite reporting these cases to clinical staff, few received risk assessment.
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Posted to Members in the News & Publications on February 21, 2013
Melancholic features & hostility are associated w. suicidality risk in Asian patients w. MDD
Hong Jin Jeon, Daihui Peng, Hong Choon Chua, Manit Srisurapanont, Maurizio Fava, Jae-Nam Bae, Sung Man Chang, Jin Pyo Hong
Background Suicide rates are higher in East-Asians than other populations, and especially high in Koreans. However, little is known about suicidality risk and melancholic features in Asian patients with major depressive disorder (MDD).
Method Drug-free MDD outpatients were included from 13 centers across five ethnicities consisting of Chinese (n=290), Korean (n=101), Thai (n=102), Indian (n=27), and Malay (n=27). All were interviewed using the Mini-International Neuropsychiatric Interview (M.I.N.I.), the Montgomery–Åsberg Depression Rating Scale (MADRS), and the Symptoms Checklist 90-Revised (SCL-90-R).
Results Of 547 subjects, 177 MDD patients showed melancholic features (32.4%). These melancholic MDD patients revealed significantly higher suicidality risk (p<0.0001), hostility (p=0.037), and severity of depression (p<0.0001) than those MDD patients without melancholic features. Suicidality risk was significantly higher in MDD with melancholic features than those without in subjects with lower hostility, whereas it showed no difference in higher hostility. Adjusted odds ratios of melancholic features and hostility for moderate to high suicidality risk were 1.79 (95% CI=1.15–2.79) and 2.45 (95% CI=1.37–4.38), after adjusting for age, sex, education years, and depression severity. Post-hoc analyses showed that suicidality risk was higher in Korean and Chinese than that of Thai, Indian and Malay in MDD subjects with melancholic features, although depression severity showed no significant differences among the ethnicities.
Conclusions Suicidality risk is associated with both melancholic features and hostility and it shows cross-ethnic differences in Asian MDD patients, independent of depression severity.
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Posted to Members in the News & Publications on February 19, 2013
Negative Emotion Interference During Synonym Matching Task in Pediatric Bipolar Disorder w & wo ADHD
Alessandra M. Passarotti, Jacklynn M. Fitzgerald, John A. Sweeney and Mani N. Pavuluri
This study examined whether processing of emotional words impairs cognitive performance in acutely ill patients with pediatric bipolar disorder (PBD), with or without comorbid attention-deficit hyperactivity disorder (ADHD), relative to healthy controls (HC). Forty youths with PBD without ADHD, 20 youths with PBD and ADHD, and 29 HC (mean age = 12.97 ± 3.13) performed a Synonym Matching task, where they decided which of two probe words was the synonym of a target word. The three words presented on each trial all had the same emotional valence, which could be negative, positive, or neutral. Relative to HC both PBD groups exhibited worse accuracy for emotional words relative to neutral ones. This effect was greater with negative words and observed regardless of whether PBD patients had comorbid ADHD. In the PBD group without ADHD, manic symptoms correlated negatively with accuracy for negative words, and positively with reaction time (RT) for all word types. Our findings suggest a greater disruptive effect of emotional valence in both PBD groups relative to HC, reflecting the adverse effect of altered emotion processing on cognitive function in PBD. Future studies including an ADHD group will help clarify how ADHD symptoms may affect emotional interference independently of PBD.
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Posted to Members in the News & Publications on February 19, 2013
A Systematic Review of Treatments for Refractory Depression in Older People
Claudia Cooper, Ph.D., M.R.C.Psych.; Cornelius Katona, M.D., F.R.C.Psych.; Kostas Lyketsos, M.D., M.H.S.; Dan Blazer, M.D., Ph.D.; Henry Brodaty, M.D., F.R.A.N.Z.C.P.; Peter Rabins, M.D., M.P.H.; Carlos Augusto de Mendonça Lima, M.D., D.Sci.; Gill Livingston, M.D., F.R.C.Psych.
Objective The authors systematically reviewed the management of treatment-refractory depression in older people (defined as age 55 or older).
Method The authors conducted an electronic database search and reviewed the 14 articles that fit predetermined criteria. Refractory depression was defined as failure to respond to at least one course of treatment for depression during the current illness episode. The authors rated the validity of studies using a standard checklist and calculated the pooled proportion of response to any treatment reported by at least three studies.
Results All the studies that met inclusion criteria investigated pharmacological treatment. Most were open-label studies, and the authors found no double-blind randomized placebo-controlled trials. The overall response rate for all active treatments investigated was 52% (95% CI=42–62; N=381). Only lithium augmentation was assessed in more than two trials, and the response rate was 42% (95% CI=21–65; N=57). Only two studies included comparison groups receiving no additional treatment, and none of the participants in these groups responded. In single randomized studies, extended-release venlafaxine was more efficacious than paroxetine, lithium augmentation more than phenelzine, and selegiline more than placebo.
Conclusions Half of the participants responded to pharmacological treatments, indicating the importance of managing treatment-refractory depression actively in older people. The only treatment for which there was replicated evidence was lithium augmentation. Double-blind randomized controlled trials for management of treatment-refractory depression in older people, encompassing pharmacological and nonpharmacological therapies and populations that reflect the levels of physical and cognitive impairment present in the general older population with depression, are needed.
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Posted to Members in the News & Publications on February 18, 2013
Do Menopausal Status and Use of Hormone Therapy Affect Antidepressant Treatment Response?
Susan G. Kornstein, Marisa Toups, A. John Rush, Stephen R. Wisniewski, Michael E. Thase, James Luther, Diane Warden, Maurizio Fava, and Madhukar H. Trivedi
Background: Menopausal status and use of hormonal contraception or menopausal hormone therapy (HT) may affect treatment response to selective serotonin reuptake inhibitors (SSRIs). This report evaluates whether menopausal status and use of hormonal contraceptives or menopausal HT affect outcome in women treated with citalopram.
Methods: In the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, 896 premenopausal and 544 postmenopausal women were treated with citalopram for 12–14 weeks. Baseline demographic and clinical characteristics were used in adjusted analysis of the effect of menopausal status and use of hormonal contraceptives or menopausal HT on outcomes. Remission was defined as final Hamilton Rating Scale for Depression-17 (HRSD17) ≤7 or Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16) score ≤5 and response as ≥50% decrease from the baseline QIDS-SR16 score.
Results: Premenopausal and postmenopausal women differed in multiple clinical and demographic baseline variables but did not differ in response or remission rates. Premenopausal women taking hormonal contraceptives had significantly greater unadjusted remission rates on the HRSD17 and the QIDS-SR16 than women not taking contraception. Response and remission rates were not different between postmenopausal women taking vs. not taking HT. Adjusted results showed no significant difference in any outcome measure across menopause status in women who were not taking contraception/HT. There were no significant differences in adjusted results across HT status in premenopausal or postmenopausal women.
Conclusions: In this study, citalopram treatment outcome was not affected by menopausal status. Hormonal contraceptives and HT also did not affect probability of good outcome.
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Posted to Members in the News & Publications on February 18, 2013
Depression in Late-Life: A Focus on Prevention
Olivia I. Okereke, M.D., S.M.; Jeffrey M. Lyness, M.D.; Francis E. Lotrich, M.D., Ph.D.; Charles F. Reynolds, M.D.
Depression is a leading cause of disease burden, disability, and distress for millions of older adults. Thus, prevention of late-life depression is a priority research area. This article addresses the science of late-life depression prevention with the following: 1) an introduction to the Institute of Medicine framework of universal, selective, and indicated prevention as it pertains to late-life depression, with particular attention to successes of indicated and selective prevention in primary care; 2) a discussion of how biomarkers can be integrated into prevention research, using interferon-alpha-induced depression as a model; 3) an outline for expansion of prevention to nonspecialist care delivery systems in low- and middle-income countries, thus extending the reach of current successful approaches; and 4) a description of a novel approach to simultaneous testing of universal, selective, and indicated prevention in late-life depression, with emphasis on study design features required to achieve practical, scalable tests of health impact.
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Posted to Members in the News & Publications on February 18, 2013
Identifying psychiatrists’ practice patterns when managing depression in patients with bipolar I
Glauser TA, Cerenzia W, Wiley S, Howson A, Thase M.
Objective: The purpose of this study was to describe practice patterns of US psychiatrists with regard to the diagnosis and management of depression in adults with bipolar I disorder and to identify relevant gaps in clinical knowledge and competence. Methods: Two focus groups were conducted using nominal group technique via a web interface and teleconference to elicit barriers that psychiatrists face in managing depression in patients with bipolar I disorder. These results framed a case-based survey that was administered to 200 US-based psychiatrists to explore and quantitatively assess their knowledge and practice patterns with respect to the diagnosis and management of depression in patients with bipolar I disorder. We completed all statistical analyses with PASW Statistics 18 and used descriptive statistics to summarize survey responses. Results: To identify previously undiagnosed mania, 67% of clinician respondents said that they asked depressed patients if they had previously experienced all Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision mania-defining symptoms. To treat a patient with symptoms of depression and no other risk factors for bipolar I disorder, 85% of the respondents said that they would use an antidepressant; 55% of respondents were not concerned that their choice of treatment would lead to a manic episode; 5% thought that there was no greater risk of treatment-emergent mood disorder when treating depression in patients with bipolar I disorder compared with major depressive disorder. If the patient had depression and risk factors for bipolar I disorder, 54% of the respondents said that they would still prescribe an antidepressant as monotherapy. Conclusion: The clinician responses were not adherent to evidence-based practice based on clinical trial results or current guideline recommendations. There is an unmet need for education to enable psychiatrists to differentiate between unipolar and bipolar depression, to identify the risk of treatment-emergent mood disorders with the use of antidepressants, and to effectively manage patients at risk for bipolar I disorder.
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Posted to Members in the News & Publications on February 14, 2013
Personalised intervention for people with depression and severe COPD
George S. Alexopoulos, Dimitris N. Kiosses, Jo Anne Sirey, Dora Kanellopoulos, Richard S. Novitch, Samiran Ghosh, Joanna K. Seirup and Patrick J. Raue
Chronic obstructive pulmonary disease (COPD) is often complicated by depression and exemplifies the challenge in managing chronic illnesses that require active patient participation in care. In a clinical trial (NCT00151372), we compared a novel personalised intervention for depression and COPD (PID-C) targeting treatment adherence with treatment as usual (TAU). In 138 patients with major depression and severe COPD, PID-C led to a higher remission rate and a greater reduction in depressive symptoms and in dyspnoea-related disability than TAU over 28 weeks and 6 months after the last session. If replicated, PID-C may serve as a care model for patients with both depression and medical illnesses with a deteriorating course.
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Posted to Members in the News & Publications on February 12, 2013
A Clinical Trial of In-Home CBT for Depressed Mothers in Home Visitation
Robert T. Ammerman, Frank W. Putnam, Mekibib Altaye, Jack Stevens, Angelique R. Teeters, Judith B. Van Ginkel
Despite negative outcomes for depressed mothers and their children, no treatment specifically designed to address maternal depression in the context of home visitation has emerged. In-Home Cognitive Behavioral Therapy (IH-CBT) is an adapted treatment that is delivered in the home, focuses on the needs of new mothers, and leverages ongoing home visiting to optimize engagement and outcomes. This study examined the efficacy of IH-CBT using a randomized clinical trial. Subjects were 93 new mothers in a home visiting program. Mothers with major depressive disorder identified at 3 months postpartum were randomized into IH-CBT and ongoing home visitation (n = 47) or standard home visitation (SHV; n = 46) in which they received home visitation alone and could obtain treatment in the community. Depression was measured at pre- and post-treatment, and three month follow-up using interviews, clinician ratings, and self-report. Mothers receiving IH-CBT showed improvements in all indicators of depression relative to the SHV condition and these gains were maintained at follow-up. For example, 70.7% of mothers receiving IH-CBT were no longer depressed at post-treatment in terms of meeting criteria for major depressive disorder compared to 30.2% in the SHV group. These findings suggest that IH-CBT is an efficacious treatment for depressed mothers in home visitation programs.
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Posted to Members in the News & Publications on February 11, 2013
Associations between vascular risk and mood in euthymic older adults: Preliminary findings
Rebecca A. Charlton, PhD, Melissa Lamar, PhD, Olusola Ajilore, MD PhD, Anand Kumar, MD
Objectives Vascular risk has been associated with late life depression but it is less certain whether it is also associated with the endorsement of depressive symptoms among euthymic older adults. In the current study we explore whether increased vascular risk is linked to increased endorsement of depressive symptoms among euthymic older adults and associations with cognitive function.
Design, Participants and Measures Fifty-seven adults, 50-89 years old were assessed for i) vascular risk using the Framingham Stroke Risk Profile (FSRP); ii) depressive mood with the Center for Epidemiological Studies Depression (CESD) self-rating questionnaire and Hamilton Depression Rating Scale (HDRS) clinical interview; and iii) cognitive domains including Learning and Memory (L-M), Attention and Information Processing (AIP), Executive Function (EF) and Semantic Language (SL).
Results Significant correlations were observed between FSRP and both depression scales, independent of age. No significant correlations were observed between HDRS and any cognitive domain; in contrast, CESD correlated significantly with L-M, AIP and EF, but not with SL. FSRP correlated significantly with L-M and EF measures only. Regression analyses revealed that 11.5% of the variance in HDRS scores was explained by FSRP only; whereas CESD scores were explained by EF (20.8% of variance).
Conclusions Vascular risk is associated with endorsement of depressive symptoms in euthymic older adults. However, the patterns of associations observed for the two depression scales are distinct and may reflect both differences in administration (self-report questionnaire versus interview) and item characteristics. A limitation of this study is the exclusion of individuals with subclinical depression leading to a restricted range on depression scales; future studies should include a full population sample to more fully explore low mood in late-life.
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Posted to Members in the News & Publications on February 05, 2013
Childhood Abuse History, Posttraumatic Stress Disorder, Postpartum Mental Health, and Bonding
Julia S. Seng CNM, PhD, Mickey Sperlich CPM, MA, MSW, Lisa Kane Low CNM, PhD, David L. Ronis PhD, Maria Muzik MD, Israel Liberzon MD
Introduction: Research is needed that prospectively characterizes the intergenerational pattern of effects of childhood maltreatment and lifetime posttraumatic stress disorder (PTSD) on women's mental health in pregnancy and on postpartum mental health and bonding outcomes. This prospective study included 566 nulliparous women in 3 cohorts: PTSD-positive, trauma-exposed resilient, and not exposed to trauma.
Methods: Trauma history, PTSD diagnosis, and depression diagnosis were ascertained using standardized telephone interviews with women who were pregnant at less than 28 gestational weeks. A 6-week-postpartum interview reassessed interim trauma, labor experience, PTSD, depression, and bonding outcomes.
Results: Regression modeling indicates that posttraumatic stress in pregnancy, alone, or comorbid with depression is associated with postpartum depression (R2= .204; P < .001). Postpartum depression alone or comorbid with posttraumatic stress was associated with impaired bonding (R2= .195; P < .001). In both models, higher quality of life ratings in pregnancy were associated with better outcomes, while reported dissociation in labor was a risk for worse outcomes. The effect of a history of childhood maltreatment on both postpartum mental health and bonding outcomes was mediated by preexisting mental health status.
Discussion: Pregnancy represents an opportune time to interrupt the pattern of intergenerational transmission of abuse and psychiatric vulnerability. Further dyadic research is warranted beyond 6 weeks postpartum. Trauma-informed interventions for women who enter care with abuse-related PTSD or depression should be developed and tested.
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Posted to Members in the News & Publications on February 05, 2013
Antidepressant Treatment Reduces Serotonin-1A Autoreceptor Binding in Major Depressive Disorder
Neil A. Gray, Matthew S. Milak, Christine DeLorenzo, R. Todd Ogden, Yung-yu Huang, J. John Mann, Ramin V. Parsey
Background Chronic selective serotonin reuptake inhibitor (SSRI) administration to rodents desensitizes or downregulates raphe 5-hydroxytryptamine 1A (5-HT1A) autoreceptors. We previously found elevated 5-HT1A binding in antidepressant-naive and not recently medicated major depressive disorder (MDD) and now report the effect of SSRI treatment on 5-HT1A autoreceptors in depressed patients.
Methods 5-HT1A binding (BPF) was quantified in medication-free subjects using positron emission tomography (PET) with [11C]-WAY-100635 before and after treatment of MDD with an SSRI for 5 to 9 weeks (mean 47±8 days). Nineteen subjects without recent history of antidepressant pharmacotherapy completed both [11C]WAY-100635 PET scans with a metabolite-corrected arterial input function and depression severity was rated before and after the treatment course.
Results 5-HT1A autoreceptor BPF in the raphe was reduced 18% on SSRI treatment (df = 1,18; F = 5.12; p = .036). However, the degree of reduction in 5-HT1A autoreceptor BPF was unrelated to improvement in depression (df = 1,16; F = 1.27; p = .276).
Conclusions Downregulation of 5-HT1A autoreceptor binding by SSRI treatment of major depression is consistent with animal studies. This may be a necessary but insufficient requirement for clinical response to SSRIs. A PET agonist ligand that binds selectively to the high-affinity conformation of this receptor can determine whether SSRIs also cause desensitization of the autoreceptor as reported by some rodent studies and whether that effect may be related to clinical response.
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Posted to Members in the News & Publications on February 05, 2013
Loebsack holds roundtable discussion on issues regarding mental health
Features James Potash, MD, MPH, University of Iowa
The group of mental health professionals filling a University of Iowa hospitals conference room all agree on one thing:
"We know that there are serious problems of inadequate access for people who are suffering from these tragic conditions," said Dr. Jimmy Potash, University Iowa Hospitals and Clinics professor and head of psychiatry.
The tragedy at Sandy Hook Elementary has spurred conversations about providing better services for people suffering from mental illness.
That means better funding for the system, which in Iowa, many believe is under-funded by a substantial amount.
"We would probably need about $120 million more in the state than exists right now," Potash said.
Representative Dave Loebsack, (D-Iowa), heard from some of the state's leaders in the field Wednesday about the current barriers that exist to receiving care.
Posted to Members in the News & Publications on February 04, 2013
Pregnant African American women’s attitudes toward perinatal depression prevention
Goodman, Sherryl H.; Dimidjian, Sona; Williams, Kristen G.
Depression during the perinatal period is common, debilitating, and consequential for women and their children, particularly among low income African American women. Viable approaches to prevention of depression have emerged. Yet little is known about women's preferences for approaches to preventing depression. A sample of 60 pregnant, low-income African American women seeking routine prenatal care was presented with standardized descriptions of three approaches to depression prevention (pharmacotherapy and two psychosocial approaches) and measures of preferences, perceived credibility, and personal reactions to each approach. Women also completed measures of perceived barriers and facilitators and current depression. Consistent with expectations, both of the psychosocial approaches were rated as more strongly preferred, more credible, and associated with more positive personal reactions relative to the pharmacotherapy approach. Depression did not alter women's preferences among the approaches. Contrary to prediction, women with clinically significant levels of depression did not find the pharmacotherapy approach to be more credible or to have more favorable personal reactions to it than women with low depression symptom levels. Exploration of women's perceptions of barriers revealed the importance of logistics, beliefs, and stigma barriers whereas women reported that concern about depression being impairing and ease of pragmatics would both facilitate engagement with preventive interventions. The findings suggest the need to examine the role of preferences in tests of the effectiveness of approaches to the prevention of perinatal depression in order to enhance service delivery among low income African American women.
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Posted to Members in the News & Publications on February 04, 2013
Mass. General study clarifies antidepressant contribution to arrhythmia risk
Features Roy Perlis, MD, Massachusetts General Hospital
A 2011 warning from the U.S. Food and Drug Administration about the popular antidepressant citalopram (Celexa) left many patients and physicians with more questions than answers. Now an analysis of the medical records of more than 38,000 patients by Massachusetts General Hospital (MGH) investigators clarifies the contribution of citalopram and other antidepressants to lengthening of the QT interval, an aspect of the heart's electrical activity that – when prolonged – may increase the risk of dangerous arrhythmias. The study supported the FDA's warning that higher doses of citalopram were associated with a prolonged QT interval but also found that the effects of some other antidepressants were quite different.
"It was important to confirm the effects of citalopram – one of the most widely prescribed antidepressants in the U.S. – because the FDA warning really gave us minimal clinical guidance," says Roy Perlis, MD, of the MGH Department of Psychiatry, corresponding author of the report that will appear in the journal BMJ and is being released online. "The impetus for this study came directly from the phone calls we received from colleagues and from patients taking citalopram asking what they should do. We realized that to get a satisfying answer, we needed to get more data."
Many medications – including some older antidepressants – are known to increase the QT interval, which is the time from the beginning of electrical activation of the heart to the end of electrical relaxation. While the vast majority of individuals with QT prolongation have no heart rhythm abnormalities, it is a recognized risk factor for a rare but dangerous arrhythmia called torsades de pointes. To get a better idea of the real-world prevalence of QT prolongation associated with citalopram and other antidepressants, the MGH team embarked on an analysis of the medical records of thousands of patients treated at the MGH and other Partners HealthCare facilities.
Posted to Members in the News & Publications on January 31, 2013
Sustaining remission of psychotic depression: rationale, design and methodology of STOP-PD
Flint, AJ, Meyers, BS, Rothschild, AJ, Whyte, EM, Mulsant, BH, Rudorfer, MV & Marino, P
Background
Psychotic depression (PD) is a severe disabling disorder with considerable morbidity and mortality. Electroconvulsive therapy and pharmacotherapy are each efficacious in the treatment of PD. Expert guidelines recommend the combination of antidepressant and antipsychotic medications in the acute pharmacologic treatment of PD. However, little is known about the continuation treatment of PD. Of particular concern, it is not known whether
antipsychotic medication needs to be continued once an episode of PD responds to pharmacotherapy. This issue has profound clinical importance. On the one hand, the unnecessary continuation of antipsychotic medication exposes a patient to adverse effects, such as weight gain and metabolic disturbance. On the other hand, premature discontinuation of antipsychotic medication has the potential risk of early relapse of a severe disorder.
Methods/design
The primary goal of this multicenter randomized placebo-controlled trial is to assess the risks and benefits of continuing antipsychotic medication in persons with PD once the episode of depression has responded to treatment with an antidepressant and an antipsychotic. Secondary goals are to examine age and genetic polymorphisms as predictors or moderators of treatment variability, potentially leading to more personalized treatment of PD. Individuals aged 18-85 years with unipolar psychotic depression receive up to 12 weeks of open-label treatment with sertraline and olanzapine. Participants who achieve remission of psychosis and remission/near-remission of depressive symptoms continue with 8 weeks of open-label treatment to ensure stability of remission. Participants with stability of remission are then randomized to 36 weeks of double-blind treatment with either sertraline and olanzapine or sertraline and placebo. Relapse is the primary outcome. Metabolic changes are a secondary outcome.
Discussion
This trial will provide clinicians with much-needed evidence to guide the continuation and maintenance treatment of one of the most disabling and lethal of psychiatric disorders
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Posted to Members in the News & Publications on January 29, 2013
Relationship Between Therapeutic Alliance & Treatment Outcome in Two Distinct Psychotherapies…
The Relationship Between the Therapeutic Alliance and Treatment Outcome in Two Distinct Psychotherapies for Chronic Depression
Arnow, Bruce A.; Steidtmann, Dana; Blasey, Christine; Manber, Rachel; Constantino, Michael J.; Klein, Daniel N.; Markowitz, John C.; Rothbaum, Barbara O.; Thase, Michael E.; Fisher, Aaron J.; Kocsis, James H.
Objective This study tested whether the quality of the patient-rated working alliance, measured early in treatment, predicted subsequent symptom reduction in chronically depressed patients. Secondarily, the study assessed whether the relationship between early alliance and response to treatment differed between patients receiving cognitive behavioral analysis system of psychotherapy (CBASP) vs. brief supportive psychotherapy (BSP).
Method 395 adults (57% female; Mage = 46; 91% Caucasian) who met criteria for chronic depression and did not fully remit during a 12-week algorithm-based, open-label pharmacotherapy trial were randomized to receive either 16–20 sessions of CBASP or BSP in addition to continued, algorithm-based antidepressant medication. Of these, 224 patients completed the Working Alliance Inventory-Short Form at Weeks 2 or 4 of treatment. Blind raters assessed depressive symptoms at 2-week intervals across treatment using the Hamilton Rating Scale for Depression. Linear mixed models tested the association between early alliance and subsequent symptom ratings while accounting for early symptom change.
Results A more positive early working alliance was associated with lower subsequent symptom ratings in both the CBASP and BSP, F(1, 1236) = 62.48, p < .001. In addition, the interaction between alliance and psychotherapy type was significant, such that alliance quality was more strongly associated with symptom ratings among those in the CBASP treatment group, F(1, 1234) = 8.31, p = .004.
Conclusions The results support the role of the therapeutic alliance as a predictor of outcome across dissimilar treatments for chronic depression. Contrary to expectations, the therapeutic alliance was more strongly related to outcome in CBASP, the more directive of the 2 therapies.
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Posted to Members in the News & Publications on January 29, 2013
China, U.S. mental health research collaborative announced
Features Emory University
On December 17, 2012, Shanghai Jiao Tong University and Emory University formally opened the Shanghai Mental Health Center-Emory University Collaborative Center for Global Mental Health.
The new Collaborative Center, housed on the campus of the Shanghai Mental Health Center, was developed to advance shared research projects among faculty members at the two institutions. Shanghai Mental Health Center, which is one of the largest mental health institutions in China, is responsible for coordinating clinical services for the 22 million residents of Shanghai, and treats an astonishing one million patients per year. Emory University's Woodruff Health Sciences Center is known for its prominence in research related to mental health and the neurosciences.
"This collaboration will help researchers and clinicians in China to keep up-to-date with the exciting, cutting-edge research being conducted at Emory's Department of Psychiatry and Behavioral Sciences," explains Michael Phillips, who was named the director of the Collaborative Center.
Posted to Members in the News & Publications on January 28, 2013
Effect of Sertraline on Risk of Falling in Older Adults with Psychotic Depression on Olanzapine
Alastair J. Flint, MB, Andrea Iaboni, MD, DPhil., Benoit H. Mulsant, MD, Anthony J. Rothschild, MD, Ellen M. Whyte, MD, Barnett S. Meyers, MD
Objective Observational studies report that selective serotonin reuptake inhibitor (SSRI) antidepressants are associated with an increased risk of falls in the elderly, but these studies may over-estimate drug-specific risk because of confounding. A randomized controlled trial (RCT) is the optimal way to assess the causal relationship between use of an SSRI and falls. We therefore analyzed data from a RCT of the treatment of psychotic depression, to examine whether combined olanzapine and sertraline interacted with older age to increase the risk of falling compared with olanzapine plus placebo.
Design Double-blind placebo-controlled RCT.
Setting Four academic medical centers.
Participants Two hundred and fifty nine patients with major depressive disorder with psychotic features (n=117 aged 18-59 years and n=142 aged 60 years or older).
Intervention Twelve weeks of randomized double-blind treatment with olanzapine plus sertraline or olanzapine plus placebo.
Measurements Proportion of participants who fell at least once.
Results Older participants were significantly more likely than younger participants to fall. Among older participants, the odds ratio of falling with olanzapine plus sertraline versus olanzapine plus placebo was 1.56 (95% CI 0.63-3.83). There was not a statistically significant treatment effect or treatment x age interaction with respect to the proportion of participants falling. These negative results may have been due to low statistical power.
Conclusion Evaluating the association between SSRIs and falls in a RCT is limited by the large sample size that is required. An alternative approach is to examine the effect of an SSRI on measures of postural stability and gait that are valid markers of risk of falling.
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Posted to Members in the News & Publications on January 28, 2013
2013 NNDC Conference: Save The Date!
Hotel reservation link: http://bit.ly/Wu45cs
Posted to Annual Conference on January 25, 2013
Promoting effective self-care in college students with mental illnesses
Features John Greden, MD, University of Michigan
Rather than seeking out healthy treatment options, many college students experiencing symptoms of depression or anxiety too often resort to unhealthy coping practices like drug use, drinking, or self-injury.
The University of Michigan Depression Center will host its 11th-annual Depression on College Campuses Conference on Feb. 26-27, with an emphasis on discussing strategies to promote and advocate for healthy self-care. Clinicians, students, researchers, and U-M community members will come together to discuss how campuses can better identify students who may be using unhealthy coping mechanisms, and support these students in moving toward better self-management and treatment.
The conference has been a forum for school counselors, researchers, advocacy members, academic advisors and others from across the country to discuss the latest findings and practices related to the prevention of depression and its consequences during the high-stakes college years.
Posted to Members in the News & Publications on January 25, 2013
Neurogenesis and Anxiety Disorders
Features Rene Hen, PhD, Columbia University
People with anxiety disorders such as post-traumatic stress disorder (PTSD) often have impaired pattern separation—the process by which similar experiences are transformed into distinct memories. They often react to events that resemble their original trauma, even when in safe situations. In a recent review in Nature Neuroscience, Rene Hen, PhD, of Columbia’s Department of Psychiatry and the New York State Psychiatric Institute, and colleagues suggest that drugs that promote neurogenesis—the production of new neurons—may play a potential role in treating impaired pattern separation.
In the hippocampus, the dentate gyrus—which uses pattern separation to form new memories—is one of two areas of the brain where neurogenesis takes place. Although the extent of adult neurogenesis in humans, as well as its role in stress responses, is controversial, Hen and his team think that a reduction of hippocampal neurogenesis contributes to the impaired pattern separation underlying anxiety disorders. Structural MRI studies of the brains of PTSD patients have shown decreased volume of the dentate gyrus. Two potential approaches to improving pattern separation are to increase the number of adult-generated neurons or to modify the mature neurons so they are better able to process information.
Posted to Members in the News & Publications on January 24, 2013
Role of childhood adversity in the development of medical co-morbidities associated with bipolar…
Robert M. Post, Lori L. Altshuler, Gabriele S. Leverich, Mark A. Frye, Trisha Suppes, Susan L. McElroy, f, Paul E. Keck Jr., Willem A. Nolen, Ralph W. Kupka, Heinz Grunze, Mike Rowe
Objective
A role for childhood adversity in the development of numerous medical conditions in adults has been described in the general population, but has not been examined in patients with bipolar disorder who have multiple medical comorbidities which contribute to their premature mortality.
Methods
More than 900 outpatients (average age 41) with bipolar disorder completed questionnaires that included information about the occurrence of verbal, physical, or sexual abuse in childhood and whether their parents had a mood or substance abuse disorder, or a history of suicidality. These factors were combined to form a total childhood adversity score, which was then related to one or more of 30 medical conditions patients rated as present or absent.
Results
The child adversity score was significantly related to the total number of medical comorbidities a patient had (p<.001), as well as to 11 specific medical conditions that could be modeled in a logistic regression (p<.03). These included: asthma, arthritis, allergies, chronic fatigue syndrome, chronic menstrual irregularities, fibromyalgia, head injury (without loss of consciousness), hypertension, hypotension, irritable bowel syndrome, and migraine headaches.
Limitations
The contribution of parental diagnosis to childhood adversity is highly inferential.
Conclusions
These data link childhood adversity to the later occurrence of multiple medical conditions in adult outpatients with bipolar disorder. Recognition of these relationships and early treatment intervention may help avert a more severe course of not only bipolar disorder but also of its prominent medical comorbidities and their combined adverse effects on patients’health, wellbeing, and longevity.
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Posted to Members in the News & Publications on January 24, 2013
Group Interpersonal and Social Rhythm Therapy for Bipolar Depression
Astrid A. Hoberg, DNP, RN, Julie Ponto, PhD, RN, Pamela J. Nelson, PhD, RN, Mark A. Frye, MD
Purpose
To evaluate the feasibility of 2-week interpersonal and social rhythm therapy group (IPSRT-G) for bipolar depression.
Design and Methods
Participants with bipolar depression received two individual sessions, six IPSRT-G sessions, and a 12-week telephone call. The Inventory of Depressive Symptomatology-Clinician Rated (IDS-C), Young Mania Rating Scale (YMRS), Sheehan Disability Scale (SDS), and Clinical Global Impressions-Bipolar Version (CGI-BP) were used.
Findings
IDS-C and SDS scores improved significantly at 12 weeks. YMRS and CGI-BP scores improved but did not reach statistical significance.
Practice Implications
The promising antidepressive response supports further study of IPSRT-G for bipolar depression.
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Posted to Members in the News & Publications on January 22, 2013
Increase in Suicide by Hanging/Suffocation in the U.S., 2000–2010
Susan P. Baker, MPH, Guoqing Hu, PhD, Holly C. Wilcox, PhD, Timothy D. Baker, MD, MPH
Background
Recently, suicide exceeded motor vehicle crashes as the leading cause of injury death in the U.S. However, details of this change in suicide methods and the relationship to individual demographics, such as age and societal influences, have not been reported.
Purpose
To determine the characteristics of the changes in suicide rates between 2000 and 2010.
Methods
Data came from CDC's Web-Based Injury Statistics Query and Reporting System (WISQARS™). Line charts were plotted to reveal changes in suicide rates by firearm, poisoning, and hanging/suffocation (ICD-10 codes: X72–X74, X60–X69, and X70). The measure of change used is the percentage change in suicide rate between 2000 and 2010.
Results
The overall suicide rate increased from 10.4 to 12.1 per 100,000 population between 2000 and 2010, a 16% increase. The majority of the increase was attributable to suicide by hanging/suffocation (52%) and by poisoning (19%). Subgroup analysis showed: (1) suicide by hanging/suffocation increased by 104% among those aged 45–59 years and rose steadily in all age groups except those aged ≥70 years; (2) the largest increase in suicide by poisoning (85%) occurred among those aged 60–69 years; and (3) suicide by firearm decreased by 24% among those aged 15–24 years but increased by 22% among those aged 45–59 years. The case fatality rates for suicide by hanging/suffocation during 2000–2010 ranged from 69% to 84%, close to those for suicide by firearm. Analyses were conducted in 2012.
Conclusions
Substantial increases in suicide by hanging/suffocation and poisoning merit attention from policymakers and call for innovations and changes in suicide prevention approaches.
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Posted to Members in the News & Publications on January 22, 2013
Mouse Research Links Adolescent Stress and Severe Adult Mental Illness
Features Akira Sawa, MD, PhD, Johns Hopkins University
Findings could have implications in human depression and psychosis
Working with mice, Johns Hopkins researchers have established a link between elevated levels of a stress hormone in adolescence - a critical time for brain development - and genetic changes that, in young adulthood, cause severe mental illness in those predisposed to it.
The findings, reported in the journal Science, could have wide-reaching implications in both the prevention and treatment of schizophrenia, severe depression and other mental illnesses.
"We have discovered a mechanism for how environmental factors, such as stress hormones, can affect the brain’s physiology and bring about mental illness," says study leader Akira Sawa, M.D., Ph.D., a professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. "We’ve shown in mice that stress in adolescence can affect the expression of a gene that codes for a key neurotransmitter related to mental function and psychiatric illness. While many genes are believed to be involved in the development of mental illness, my gut feeling is environmental factors are critically important to the process."
Posted to Members in the News & Publications on January 21, 2013
A Pilot Randomized Controlled Trial of Cognitive Behavioral Therapy for Perinatal Depression…
Heather O'Mahen Ph.D., Joseph A. Himle Ph.D., Gina Fedock M.A., Erin Henshaw Ph.D., Heather Flynn Ph.D.
Background
Perinatal women with identified depression in prenatal care settings have low rates of engagement and adherence with depression-specific psychotherapy. We report the feasibility and symptom outcomes of Cognitive Behavioral Therapy (CBT) modified (mCBT) to address the needs of perinatal, low-income women with Major Depressive Disorder (MDD).
Methods
Pregnant women (n = 1421) were screened for depressive symptoms in obstetrics clinics in conjunction with prenatal care visits. A total of 59 women met diagnostic criteria for MDD; 55 women were randomly assigned to mCBT or Treatment as Usual (TAU). The mCBT intervention included an initial engagement session, outreach, specific perinatal content and interpersonal components. Measures were gathered at pre-treatment, 16 week post-randomization, and 3-month follow-up.
Results
Most participants attended at least one CBT session and met study criteria for treatment adherence. Active research staff outreach promoted engagement and retention in the trial. Treatment satisfaction was rated as very good. In both observed and multiple imputation results, women who received mCBT demonstrated greater improvement in depressed mood than those in TAU at 16-week post-randomization and 3-month follow-up, Cohen's d = –0.71 (95% CI –4.93, –5.70).
Conclusions
Modified CBT offers promise as a feasible and acceptable treatment for perinatal women with low-incomes in prenatal care settings. Targeted delivery and content modifications are needed to engage populations tailored to setting and psychosocial challenges specific to the perinatal period.
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Posted to Members in the News & Publications on January 21, 2013
Tissue-Specific Differences in Brain Phosphodiesters in Late-Life Major Depression
David G. Harper, Ph.D., J. Eric Jensen, Ph.D., Caitlin Ravichandran, Ph.D., Yusuf Sivrioglu, M.D., Marisa Silveri, Ph.D., Dan V. Iosifescu, M.D., Perry F. Renshaw, M.D., Ph.D., Brent P. Forester, M.D.
Objective
Late-life depression has been hypothesized to have a neurodegenerative component that leads to impaired executive function and increases in subcortical white matter hyperintensities. Phosphorus magnetic resonance spectroscopy (MRS) can quantify several important phosphorus metabolites in the brain, particularly the anabolic precursors and catabolic metabolites of the constituents of cell membranes, which could be altered by neurodegenerative activity.
Methods
Ten patients with late-life major depression who were medication free at time of study and 11 aged normal comparison subjects were studied using 31P MRS three-dimensional chemical shift imaging at 4 Tesla. Phosphatidylcholine and phosphatidylethanolamine comprise 90% of cell membranes in brain but cannot be quantified precisely with 31P MRS. We measured phosphocholine and phosphoethanolamine, which are anabolic precursors, as well as glycerophosphocholine and glycerophosphoethanolamine, which are catabolic metabolites of phosphatidylcholine and phosphatidylethanolamine.
Results
In accordance with our hypotheses, glycerophosphoethanolamine was elevated in white matter of depressed subjects, suggesting enhanced breakdown of cell membranes in these subjects. Glycerophosphocholine did not show any significant difference between comparison and depressed subjects but both showed an enhancement in white matter compared with gray matter. Contrary to our hypotheses, neither phosphocholine nor phosphoethanolamine showed evidence for reduction in late-life depression.
Conclusion
These findings support the hypothesis that neurodegenerative processes occur in white matter in patients with late-life depression more than in the normal elderly population.
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Posted to Members in the News & Publications on January 21, 2013
A Model of Placebo Response in Antidepressant Clinical Trials
Bret R. Rutherford, M.D.; Steven P. Roose, M.D.
Abstract Placebo response in clinical trials of antidepressant medications is substantial and has been increasing. High placebo response rates hamper efforts to detect signals of efficacy for new antidepressant medications, contributing to trial failures and delaying the delivery of new treatments to market. Media reports seize upon increasing placebo response and modest advantages for active drugs as reasons to question the value of antidepressant medication, which may further stigmatize treatments for depression and dissuade patients from accessing mental health care. Conversely, enhancing the factors responsible for placebo response may represent a strategy for improving available treatments for major depressive disorder. A conceptual framework describing the causes of placebo response is needed in order to develop strategies for minimizing placebo response in clinical trials, maximizing placebo response in clinical practice, and talking with depressed patients about the risks and benefits of antidepressant medications. In this review, the authors examine contributors to placebo response in antidepressant clinical trials and propose an explanatory model. Research aimed at reducing placebo response should focus on limiting patient expectancy and the intensity of therapeutic contact in antidepressant clinical trials, while the optimal strategy in clinical practice may be to combine active medication with a presentation and level of therapeutic contact designed to enhance treatment response.
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Posted to Members in the News & Publications on January 21, 2013
Using Facebook in screening for major depressive disorder among college students
Soo Jeong Youn, Nhi-Ha Trinh, Irene Shyu, Trina Chang, Maurizio Fava, Joseph Kvedar, Albert Yeung
This study explored the feasibility of using Internet social networking media in an online program for Major Depressive Disorder (MDD) screening and psychoeducation targeting college students. A Facebook advertisement targeted students at five colleges in the United States to complete a mental health research survey that screened for MDD using the Patient Health Questionnaire-9 (PHQ-9). Students who screened positive for MDD were offered an eightweek follow-up survey. Of the 259 students who consented to participate in the study, 26.7% screened positive for MDD, while only 14.2% were receiving treatment. The use of Facebook to advertise for online screening for MDD required very little start-up time, and the average cost
was $11.45 per subject recruited. It is feasible to use online, commercially available social networking media such as Facebook for online screening for MDD among college students. However, conducting online screening and offering treatment resources alone did not increase treatment rate in this population.
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Posted to Members in the News & Publications on January 17, 2013
Impact of Reproductive Status and Age on Response of Depressed Women to Cognitive Therapy
Anna R. Brandon, PhD, MS, Abu Minhajuddin, PhD, Michael E. Thase, MD, and Robin B. Jarrett, PhD
Objective: Previous research suggests that reproductive hormones are potential affective modulators in mood disorders and may influence response to antidepressant medications. To our knowledge, there are no data on relationships between hormonal status and response to psychotherapy for recurrent major depressive disorder (MDD).
Methods: At two sites, female outpatients (n=353), aged 18–70, with recurrent MDD received 12–14 weeks of cognitive therapy (CT). Menopausal status and age were based on self-report. In the parent study, nonresponse to therapy was defined as persistence of a major depressive episode (MDE) as defined by the DSM-IV or a final Hamilton Rating Scale for Depression-17-Item (HRSD17) score of ≥ 12 or both. More traditional definitions of response (at least a 50% reduction in pretreatment HRSD17) and remission (a final HRSD17 ≤ 6) were also examined.
Results: Controlling for pretreatment HRSD17 scores, there were no significant differences found in the rates of response to CT or symptom status among premenopausal, perimenopausal, and postmenopausal women.
Conclusions: We found no support for the hypotheses that response to CT or the rates of change in depressive symptoms are moderated by reproductive status. The findings, however, are limited by the absence of early follicular phase serum sampling/analysis to estimate hormone levels and the reliance on self-report to establish menopausal status. These data motivate a full investigation of the effects of reproductive status on response to psychosocial interventions.
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Posted to Members in the News & Publications on January 15, 2013
Depression Not Likely to Cause Cognitive Impairment
Features José Alejandro Luchsinger, MD, MPH, Columbia University
A new study suggests that depression often accompanies cognitive impairment but does not precede it.
"Traditionally, cognitive complaints and impairment in the presence of depression has been considered to be caused by the depression. Our study suggests that depression is not a cause of dementia but accompanies the onset of cognitive impairment," José Alejandro Luchsinger, MD, MPH, associate professor of medicine and epidemiology, Columbia University Medical Center, New York City, told Medscape Medical News.
The study was published online December 31, 2012 in Archives of Neurology.
Posted to Members in the News & Publications on January 08, 2013
A Simple Question Answered: Adding Moderate-Dosage Lithium Does Not Help Patients w Bipolar Disorder
Boadie W. Dunlop, M.D., M.S.; Jeffrey J. Rakofsky, M.D.; Mark Hyman Rapaport, M.D.
Bipolar disorder is conventionally defined by the presence of discrete episodes of mania (or hypomania in the case of bipolar II disorder) and depression, but this definition does not fully encompass the true character and course of the syndrome. The majority of patients with bipolar disorder experience persistent interepisode mood symptoms and an intrinsic vulnerability to affective lability (1, 2). Thus, the lives of many patients with bipolar disorder (as well as those who love them) are complicated—and to a certain extent limited—by this persistent mood burden. It leads to markedly diminished quality of life, functioning, and productivity both for the patients (3, 4) and for their family and friends (5).
Effective pharmacotherapy for patients with bipolar disorder began in 1949 with Cade’s original article (6) describing the salutary effects of lithium carbonate for the treatment of patients with acute mania. This report led to double-blind active comparator studies that confirmed lithium’s efficacy as an acute antimanic agent (7). We now have a variety of pharmacological agents for treating acute mania, ranging from lithium to anticonvulsants to atypical antipsychotics. Effective pharmacotherapies and psychotherapies are also available for the acute treatment of bipolar depression, and many agents are effective against the recurrence of full mood episodes. However, we do not have evidence-based treatment strategies for eliminating persistent mood symptoms in bipolar patients or successful pharmacological strategies that decrease their vulnerability to mood lability. Currently, the majority of patients with bipolar disorder take multiple mood-stabilizing medications (8). Polypharmacy is costly, increases the side effect burden, increases the risk of untoward medication interactions, and greatly complicates the lives of our patients.
In this issue, Nierenberg et al. (9) report the primary results of the Lithium Treatment Moderate-Dose Use Study for bipolar disorder (LiTMUS), an effectiveness trial designed to determine if low-dosage lithium added to an optimized personalized treatment (OPT) regimen improves clinical outcome for bipolar I and bipolar II patients. There is some level of uncertainty about the minimum effective lithium level required for the treatment and prophylaxis of mood episodes in bipolar disorder, with several trials indicating that serum concentrations ≥0.8 mEq/L are associated with improved outcomes (10–12). However, clinicians frequently use low-to-moderate dosages of lithium in addition to other medications as a strategy to maximize mood stability and reduce suicidality (13). Before LiTMUS, the question of whether this common clinical strategy offers meaningful therapeutic benefit had not been carefully addressed.
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Posted to Members in the News & Publications on January 08, 2013
Lithium Treatment Moderate-Dose Use Study (LiTMUS) for Bipolar Disorder
Andrew A. Nierenberg, M.D.; Edward S. Friedman, M.D.; Charles L. Bowden, M.D.; Louisa G. Sylvia, Ph.D.; Michael E. Thase, M.D.; Terence Ketter, M.D.; Michael J. Ostacher, M.D., M.P.H.; Andrew C. Leon, Ph.D.; Noreen Reilly-Harrington, Ph.D.; Dan V. Iosifescu, M.D.; Michael Pencina, Ph.D.; Joanne B. Severe, M.S.; Joseph R. Calabrese, M.D.
Objective Lithium salts, once the mainstay of therapy for bipolar disorder, have tolerability issues at a higher dosage that often limit adherence. The authors investigated the comparative effectiveness of more tolerable dosages of lithium as part of optimized personalized treatment (OPT).
Method The authors randomly assigned 283 bipolar disorder outpatients to 6 months of open, flexible, moderate dosages of lithium plus OPT or to 6 months of OPT alone. The primary outcome measures were the Clinical Global Impression Scale for Bipolar Disorder–Severity (CGI-BP-S) and “necessary clinical adjustments” (medication adjustments per month). Secondary outcome measures included mood symptoms and functioning. The authors also assessed sustained remission (defined as a CGI-BP-S score ≤2 for 2 months) and treatment with second-generation antipsychotics. The authors hypothesized that lithium plus OPT would result in greater clinical improvement and fewer necessary clinical adjustments.
Results The authors observed no statistically significant advantage of lithium plus OPT on CGI-BP-S scores, necessary clinical adjustments, or proportion with sustained remission. Both groups had similar outcomes across secondary clinical and functional measures. Fewer patients in the lithium-plus-OPT group received second-generation antipsychotics compared with the OPT-only group (48.3% and 62.5%, respectively).
Conclusions In this pragmatic comparative effectiveness study, a moderate but tolerated dosage of lithium plus OPT conferred no symptomatic advantage when compared with OPT alone, but the lithium-plus-OPT group had less exposure to second-generation antipsychotics. Only about one-quarter of patients in both groups achieved sustained remission of symptoms. These findings highlight the persistent and chronic nature of bipolar disorder as well as the magnitude of unmet needs in its treatment.
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Posted to Members in the News & Publications on January 08, 2013
Mental Health in American Colleges and Universities: Variation Across Student Subgroups & Across…
Eisenberg, Daniel PhD, Hunt, Justin MD, MS, Speer, Nicole PhD
Abstract: We estimated the prevalence and correlates of mental health problems among college students in the United States. In 2007 and 2009, we administered online surveys with brief mental health screens to random samples of students at 26 campuses nationwide. We used sample probability weights to adjust for survey nonresponse. A total of 14,175 students completed the survey, corresponding to a 44% participation rate. The prevalence of positive screens was 17.3% for depression, 4.1% for panic disorder, 7.0% for generalized anxiety, 6.3% for suicidal ideation, and 15.3% for nonsuicidal self-injury. Mental health problems were significantly associated with sex, race/ethnicity, religiosity, relationship status, living on campus, and financial situation. The prevalence of conditions varied substantially across the campuses, although campus-level variation was still a small proportion of overall variation in student mental health. The findings offer a starting point for identifying individual and contextual factors that may be useful to target in intervention strategies.
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Posted to Members in the News & Publications on January 07, 2013
Do Serum Cholesterol Values and DST Results Comprise Independent Risk Factors for Suicide?
William Coryell, MD
7.1 SUICIDE AND HPA AXIS HYPERACTIVITY
7.1.1 General Measures of HPA Axis Hyperactivity
Findings that link hypothalamic–pituitary–adrenal (HPA) axis hyperactivity to risks for later suicide date to 1965 when Bunney and Fawcett 1 described 36 depressed patients who had supplied serial 24 h urine samples for 17-hydroxycorticosteroid (17-OHCS) determinations during extended stays on a research ward. Three committed suicide on pass or shortly after discharge, two made serious attempts, and all five were among the 18 who had had consistently or intermittently high 17-OHCS values (Fisher’s exact test, p = 0.023). In a subsequent series of 145 patients assessed in similar fashion, the five who committed suicide all had had mean 17-OHCS values that fell in the top 10% of the values for the overall group. 2 At least two more reports also associated high urinary corticosteroid measures with later suicide. 3,4
Subsequent lines of evidence likewise showed HPA axis hyperactivity to be a risk factor for a completed suicide. In postmortem studies, suicide victims had, in comparison to control subjects, greater adrenal weights, 5–7 greater adrenal cholesterol concentrations, 8 and greater adrenal volumes. 9 Others showed suicide victims to have higher cerebrospinal fluid (CSF) concentrations of corticotropin-releasing hormone (CRH), 10,11 higher amounts of CRH immunoreactivity in specific brain regions, 12,13 and lower numbers of CRF binding sites. 14 Some, though, found no differences in CRF receptor number 15 or in levels of immunoreactivity 16 between individuals dead by suicide and control subjects dead from other causes.
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Posted to Members in the News & Publications on January 07, 2013
Genetic association of FKBP5 and CRHR1 with cortisol response to acute psychosocial stress in…
Genetic association of FKBP5 and CRHR1 with cortisol response to acute psychosocial stress in healthy adults
Mahon PB, Zandi PP, Potash JB, Nestadt G, Wand GS
RATIONALE:
Chronic dysregulation of hypothalamus-pituitary-adrenal (HPA) axis activity is related to several neuropsychiatric disorders. Studies suggest that cortisol response to stress has a strong genetic etiology, and that FK506 binding protein 5 (FKBP5) and G-protein coupled type-I CRH receptor (CRHR1) are key proteins regulating response. Variations in the genes encoding these proteins, FKBP5 and CRHR1, have been associated with several neuropsychiatric disorders.
OBJECTIVES:
We examined variation in these genes in relation to cortisol response to psychological stress in one of the largest Trier Social Stress Test (TSST) cohorts yet examined.
METHODS:
A total of 368 healthy, young adults underwent the TSST. Salivary cortisol was measured at multiple time points before and after the stressor. Nine variants in FKBP5 and four in CRHR1 were assessed. Single marker analyses were conducted. Secondary analyses assessed haplotypes and interaction with stress-related variables.
RESULTS:
The strongest association was for rs4713902 in FKBP5 with baseline cortisol (p (dom) = 0.0004). We also identified a male-specific effect of FKBP5 polymorphisms on peak response and response area under the curve (p = 0.0028 for rs3800374). In CRHR1, rs7209436, rs110402, and rs242924 were nominally associated with peak response (p (rec) = 0.0029-0.0047). We observed interactions between trait anxiety and rs7209436 and rs110402 in CRHR1 in association with baseline cortisol (p (LRT) = 0.0272 and p (LRT) = 0.0483, respectively).
CONCLUSIONS:
We show association of variants in FKBP5 and CRHR1 with cortisol response to psychosocial stress. These variants were previously shown to be associated with neuropsychiatric disorders. These findings have implications for interindividual variation in HPA axis activity and potentially for the etiology of neuropsychiatric disorders.
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Posted to Members in the News & Publications on January 07, 2013
University of Louisville Building Hope: The Secret to Making Every Day Brighter, January 17, 2013
As part of its outreach and education mission, the University of Louisville Depression Center sponsors free, public lectures quarterly. January's Building Hope presenter will be Dr. Clifford C. Kuhn, MD, Professor in the University of Louisville School of Medicine Department of Psychiatry and Behavioral Sciences. Drawing upon the model of light’s power to diminish darkness, this presentation will illuminate humor’s power to diminish stress. Dr. Kuhn’s demonstrations will provide participants with a first-hand experience of the healing effects available to everyone from effective and responsible humor.
The event will be taking place on Thursday, January 17, 2013 from 7-8pm at the Second Presbyterian Church in Louisville, KY.
For more information, please click here for an event flyer.
Posted to on January 04, 2013
The hemodynamics of emotional response in psychotropic-naïve patients w. adolescent bipolar disorder
Ezra Wegbreita, Alessandra M. Passarotti, James A. Ellis, Minjie Wu, Nicole Witowski, Jacklynn M. Fitzgerald, Michael C. Stevens, Mani N. Pavuluri
Background
In response to emotional faces, patients with adolescent bipolar disorder (ABD) exhibit increased neural activity in subcortical emotional processing regions (e.g., amygdala, ventral striatum) and variable prefrontal activity. We extend previous research by identifying cortical and subcortical regions showing altered hemodynamic response shapes in ABD relative to healthy controls (HC).
Methods
ABD (N=65) and matched HC (N=79) completed a slow event-related affective hemodynamic probe task that required indicating the gender of fearful and neutral faces. An informed basis set in SPM8 evaluated shape variations of the hemodynamic responses to these faces.
Results
Patients with ABD showed higher activity for fearful relative to neutral faces in the amygdala and prefrontal cortex and a delayed hemodynamic response to fearful faces in dorsolateral and ventrolateral prefrontal cortices (PFC), as well as bilateral amygdala and caudate. Furthermore, the ABD group, relative to HC, showed a prolonged response to fearful faces in right dorsolateral PFC. Clinical measures of mania and depression severity correlated with increased processing delays in the amygdala and striatum.
Limitations
By design, the task contained fewer, more widely-spaced stimuli, possibly reducing its power to detect group differences. The use of fearful faces makes comparisons with prior literature in ABD somewhat more difficult.
Conclusions
The ABD group engaged in enhanced neural processing of the fearful faces which was associated with increasingly severe manic/mixed mood states. These exploratory findings could help elucidate a “biosignature” of emotion–attention interactions in ABD and present a potential target for reversal with medication treatment.
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Posted to Members in the News & Publications on January 04, 2013
Adolescent Fathers in the Justice System: Hoping for a Boy and Making Him a Man
Kate Shade, Susan Kools, Howard Pinderhughes, Sandra J. Weiss
Using a constructivist grounded theory approach, we explored the development of father identity among boys involved in the juvenile justice system. Youth were recruited from a juvenile detention center and school district in a northern California county with a high teen birth rate. The participants were expecting a child or parenting an infant and had been arrested, incarcerated, or had committed a crime. We collected data through observations and individual interviews. Using constant comparative and dimensional analysis, we found that expectant adolescent fathers hoped for a boy and envisioned their central role as father to be making their son a man. This article contributes to greater understanding of father identity development for youth involved in the justice system. We suggest that teen parenting policies and programs include interventions sensitized by gender, accounting for the influence masculine ideals of manhood have on the development of father identity and the father–child relationship.
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Posted to Members in the News & Publications on January 04, 2013
Suicide Risk Protocols: Addressing Needs of High Risk Youths Identified through Suicide Prevention
Nicole Heilbron PhD, David Goldston PhD, Christine Walrath PhD, Michael Rodi PhD, Richard McKeon PhD, MPH
Several agencies have emphasized the importance of establishing clear protocols or procedures to address the needs of youths who are identified as suicidal through suicide prevention programs or in emergency department settings. What constitutes optimal guidelines for developing and implementing such protocols, however, is unclear. At the request of the Substance Abuse and Mental Health Services Administration, we provide an overview of recommendations, as well as steps taken in conjunction with selected prevention programs and in emergency department settings to address the needs and improve the care of these youths.
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Posted to Members in the News & Publications on January 04, 2013
Nutrition, Omega-3 Fatty Acids and Depression
Marlene P. Freeman, M.D.
The effects of nutrition and dietary composition have been studied in the area of mental health. Epidemiological studies have focused either on cross-sectional analyses or longitudinal analysis on intake of particular nutrients or patterns of intake. Treatment studies have used dietary supplementation for psychiatric disorders, particularly major depressive disorder (MDD).
Depression and anxiety disorders are more prevalent in women than men.1 MDD consists of episodes that are of at least two weeks’ duration and is characterized by either a depressed or low mood or a loss of interest or pleasure.2 In addition to sadness, low mood, or loss of interest or pleasure, individuals may experience sleep changes, appetite increases or decreases, low energy, low self esteem or guilt, and thoughts of death or suicidal thoughts or plans.2 The World Health Organization has identified depression among all illnesses as having the greatest disease burden for women worldwide.3 Because of the prevalence and impact upon functioning, prevention of depression is a crucial priority.
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Posted to Members in the News & Publications on January 04, 2013
Dosing patterns of aripiprazole and quetiapine for adjunctive treatment of major depressive disorder
Jing, Yonghua; Guo, Zhenchao; Kalsekar, Iftekhar; Forbes, Robert A.; Hebden, Tony; Thase, Michael E.
The aim of this study was to investigate the dosing patterns of adjunctive quetiapine or adjunctive aripiprazole in the treatment of major depressive disorder from 2006 to 2010, and to evaluate the impact of Food and Drug Administration (FDA) approval on these dosing patterns. Patients included in the study were adults diagnosed with major depressive disorder, and treated with adjunctive aripiprazole or quetiapine between the years 2006 and 2010. The average daily dose and dose distribution were calculated and assessed statistically over the same time period. The mean daily dose for patients treated with adjunctive aripiprazole decreased from 13.5 mg/day in 2006 to 6.9 mg/day in 2010, whereas the mean daily dose for patients treated with quetiapine increased from 129 mg/day in 2006 to 139 mg/day in 2007, decreasing to 123 mg/day in 2010. The proportion of patients receiving FDA-recommended doses increased significantly for aripiprazole (86.3% in 2006 to 94.5% in 2010; P<0.001) and remained relatively stable for quetiapine (21.3% in 2006 to 24.0% in 2010; NS). The majority of patients treated with quetiapine received doses below those recommended by the FDA throughout the study period. Aripiprazole was mostly prescribed at therapeutic doses (pre-FDA and post-FDA approval), although the mean dose decreased significantly over time.
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Posted to Members in the News & Publications on January 04, 2013
Peripheral Biomarkers for Suicide
Ghanshyam N. Pandey and Yogesh Dwivedi
20.1 INTRODUCTION
Suicide is a major public health concern. Almost 30,000 people die of suicide each year in the United States, and 1 million people die worldwide. In the teenage population, it is the second leading cause of death. Early identification of suicidal behavior is crucial for its treatment and the prevention of completed suicide. Chemical, behavioral, and psychological risk factors are important in identifying these patients; however, many times they produce a false positive or a false negative diagnosis. Several studies suggest that abnormal biology may be a risk factor for suicidal behavior. Therefore, a combination of biological factors with psychosocial factors might more accurately predict suicidal behavior and identify suicidal patients. It is thus important to develop biomarkers for suicidal behavior. A useful biomarker should not only reflect the psychopathology, in this case suicidal behavior, but it should also be measured in a noninvasive manner.
Because of the inaccessibility of the human brain, initial studies of the biology of suicidal behavior and development of biomarkers focused on peripheral tissues such as cerebrospinal fluid (CSF), urine, platelets, serum, etc. In this chapter, we discuss studies pertaining to the use of peripheral tissues for the studies of pathophysiology of suicidal behavior and their potential role as biomarkers.
Initial studies of peripheral tissues focused on the levels of neurotransmitters and their metabolites in suicidal behavior. Most recent studies have found functional abnormalities of these neurotransmitters—for example, in the receptors and receptor-linked signaling systems for the serotonin (5-hydroxytryptamine [5HT]) and norepinephrine (NE) neurotransmitters.
The intent of this chapter is not to exhaustively review all the studies pertaining to these two monoamines (5HT and NE), their metabolites, their receptors, and the related signal transduction mechanisms in all peripheral tissues. Instead, this chapter focuses on those studies of peripheral tissues that examined and found potential peripheral markers primarily for suicidal behavior.
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Posted to Members in the News & Publications on January 04, 2013
Suicide in Late Life
Olusola A. Ajilore and Anand Kumar
17.1 INTRODUCTION
Suicide in late life merits special attention for many reasons. Epidemiologically, one of the groups most at-risk for suicide is older adults. It has long been recognized that in the United States, elderly white males have the highest suicide rates. In a review published by Hawton and van Heeringen, it was noted that suicide rates are also highest in the elderly in most countries around the world [1]. The elderly are not only a vulnerable population, but suicide has a more severe impact in this demographic group. For example, one study showed that suicide in late life tends to be associated with less warning and more lethality compared to attempts in younger populations [2]. This has also been shown in a study demonstrating that elderly suicide victims are more likely to have more serious intent with less warning [3]. These epidemiological studies highlight the importance of understanding suicide in late life. Thus, a small but prolific number of researchers have examined why the prevalence of suicide is higher in the elderly. Crucial to this understanding of suicidality in the elderly is the identification of risk factors for proper evaluation and intervention.
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Posted to Members in the News & Publications on January 04, 2013
Comparative accuracies of two common screening instruments for classification of Alzheimer’s…
David R. Roalfa, Paul J. Moberga, Sharon X. Xiec, David A. Wolkb, Stephen T. Moeltere, Steven E. Arnold
Background
The aim of this study was to compare the utility and diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) in the diagnosis of Alzheimer's disease (AD) and mild cognitive impairment (MCI) in a clinical cohort.
Methods
Three hundred twenty-one AD, 126 MCI, and 140 older adults with healthy cognition (HC) were evaluated using the MMSE, the MoCA, a standardized neuropsychologic battery according to the Consortium to Establish a Registry of Alzheimer's Disease (CERAD-NB), and an informant-based measure of functional impairment, the Dementia Severity Rating Scale (DSRS). Diagnostic accuracy and optimal cut-off scores were calculated for each measure, and a method for converting MoCA to MMSE scores is presented.
Results
The MMSE and MoCA offer reasonably good diagnostic and classification accuracy as compared with the more detailed CERAD-NB; however, as a brief cognitive screening measure, the MoCA was more sensitive and had higher classification accuracy for differentiating MCI from HC. Complementing the MMSE or the MoCA with the DSRS significantly improved diagnostic accuracy.
Conclusion
The findings support recent data indicating that the MoCA is superior to the MMSE as a global assessment tool, particularly in discerning earlier stages of cognitive decline. In addition, we found that overall diagnostic accuracy improves when the MMSE or MoCA is combined with an informant-based functional measure. Finally, we provide a reliable and easy conversion of MoCA to MMSE scores. However, the need for MCI-specific measures is still needed to increase the diagnostic specificity between AD and MCI.
Posted to Members in the News & Publications on January 04, 2013
Eszopiclone Treatment for Insomnia: Effect Size Comparisons in Patients With Primary Insomnia…
Andrew D. Krystal, MD, MS, W. Vaughn McCall, MD, MS, Maurizio Fava, MD, Hadine Joffe, MD, MSc, Claudio N. Soares, MD, PhD, Holly Huang, PhD, Todd Grinell, AB, Jacqueline Zummo, MPH, MBA, William Spalding, MS, and Randall Marshall, MD
Objective: The purpose of this post hoc analysis was to compare the treatment effect size of eszopiclone 3 mg for insomnia in patients with a diagnosis of primary insomnia and in several of the psychiatric and medical conditions that are most commonly comorbid with insomnia.
Method: Data were analyzed from 5 large, multicenter, randomized, double-blind, placebo-controlled studies of adult outpatients of at least 1 month duration published between 2006 and 2009. Diary-derived indices of sleep and daytime functioning and the Insomnia Severity Index were compared for patients with primary insomnia (DSM-IV-TR criteria, n = 828) and for those with insomnia comorbid with major depressive disorder (MDD, DSM-IV-TR criteria, n = 545), generalized anxiety disorder (GAD, DSM-IV-TR criteria, n = 595), perimenopause/postmenopause (Stages of Reproductive Aging Workshop criteria, n = 410), and rheumatoid arthritis (American College of Rheumatology criteria, n = 153). Cohen d effect sizes were calculated for each individual study as the between-treatment difference score divided by the pooled standard deviation.
Results: Effect sizes ranged from 0.40 to 0.69 (small–medium) as early as week 1 and were maintained at 0.26–0.63 at week 4 for sleep latency, wake time after sleep onset, and total sleep time. Sleep latency and total sleep time effect sizes increased from week 1 to week 4 in the primary insomnia group. At week 4, effect sizes on all 3 parameters and the Insomnia Severity Index tended to be highest for the primary insomnia patients and tended to be lowest for patients with comorbid GAD and MDD. The effect sizes for daytime functioning were small for all insomnia patient groups.
Conclusions: Eszopiclone 3 mg is an effective treatment for insomnia across 5 clinically diverse patient populations; however, magnitude of effect is mediated by underlying comorbidity and their treatments, with largest measures of effect seen in primary insomnia and lowest in MDD and GAD. These consistent results, and the fact that clinical trials were conducted in patients being treated as appropriate for their comorbid clinical conditions, support the results’ real-world generalizability and utility to clinical practice.
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Posted to Members in the News & Publications on January 04, 2013
A Wraparound Treatment Engagement Intervention for Homeless Veterans With Co-Occurring Disorders
Smelson, David A.; Kline, Anna; Kuhn, John; Rodrigues, Stephanie; O'Connor, Kathryn; Fisher, William; Sawh, Leon; Kane, Vincent
This article reports the results of a low-intensity wraparound intervention, Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION), to augment Treatment as Usual (TAU) and engage and retain homeless veterans with a co-occurring disorder (COD) in care. Using a quasi-experimental design, 333 homeless veterans were enrolled, 218 who received MISSION along with TAU and 115 who received TAU alone. Group assignment was based on MISSION treatment slot availability at time of enrollment. Compared with TAU alone, individuals receiving MISSION demonstrated greater outpatient session attendance within the 30 days before the 12-month follow up assessment and a larger decline from baseline in the number of psychiatric hospitalization nights. Individuals in the MISSION and TAU-only groups both showed statistically significant improvements in substance use and related problems at 12 months, with those in MISSION less likely to drink to intoxication and experience serious tension or anxiety. Although this study confirmed that compared with TAU alone, MISSION along with TAU is effective in augmenting usual care and engaging and retaining homeless veterans in treatment, some caution is warranted as this study did not involve random assignment. These results, however, are similar to a recent study involving a briefer version of the intervention which included random assignment. Based on these findings, MISSION is being further studied in the joint Department of Housing and Urban Development (HUD) – Department of Veterans Affairs (VA) Supportive Housing (HUD-VASH) program, which offers rapid housing placement and case management to aid in housing maintenance.
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Posted to Members in the News & Publications on January 04, 2013
Medication in Suicide Prevention: Insights from Neurobiology of Suicidal Behavior
J. John Mann and Dianne Currier
21.1 LOW SEROTONERGIC ACTIVITY IS A BIOLOGICAL TRAIT RELATED TO SUICIDAL BEHAVIOR
More than 30 years ago, Åsberg et al. observed that depressed individuals who had either attempted suicide by violent means or subsequently died by suicide were more likely to have lower cerebrospinal fluid 5-hydroxyindoleacetic acid (CSF 5-HIAA) levels indicative of less serotonin release [2]. Since that time, the function of the serotonergic system in suicide and attempted suicide has been examined in many paradigms, and while not all studies agree there is substantial consensus that individuals who die by suicide, or make serious nonfatal suicide attempts, exhibit a deficiency in regional brain serotonin neurotransmission such as in the orbital prefrontal cortex.
Evidence of serotonin impairment or hypofunction comes from CSF studies in living patients and from postmortem brain tissue studies. 5-HIAA is the major metabolite of serotonin and the level of CSF 5-HIAA is a guide to serotonin activity in parts of the brain including the prefrontal cortex. There have been over 20 studies of CSF 5-HIAA and suicidal behavior in mood disorder patients, and a meta-analysis of prospective studies of 5-HIAA found that in mood disorders lower CSF 5-HIAA increased the chance of death by suicide by about 4.6-fold over follow-up periods of between 1 and 14 years [3]. Lower concentration of CSF 5-HIAA has also been reported in patients with other psychiatric disorders such as schizophrenia, bipolar disorder, and personality disorders who have made suicide attempts compared with nonattempter psychiatric controls. Some report that low CSF 5-HIAA characterizes those who use violent methods to suicide or who make nonfatal attempts of higher lethality [4–6]. These results are consistent with reports of low levels of 5-HT and/or 5-HIAA in the brainstem of suicides that is similar in magnitude across diagnostic categories [7]. Finding the same serotonin system deficit in several psychiatric disorders sharing the common feature of a suicide or suicide attempt indicates that this biological abnormality is related to the suicidal behavior and not to a specific psychiatric disorder [7]. Once this was understood, many studies have since addressed the state of the serotonin system in suicidal behavior and how it may relate to clinical and cognitive aspects of the diathesis for suicidal behavior.
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Posted to Members in the News & Publications on January 04, 2013
Depression in Elderly May Predict Dementia
Features Jose A. Luchsinger, MD, MPH, Columbia University
Depression is common among older people who go on to develop Alzheimer’s disease, leading to widespread speculation that it may be one possible cause for age-related dementias.
Now, a new study suggests that rather than being a cause of memory decline, depression in older people may be an early symptom of dementia.
When researchers evaluated 2,000 elderly New Yorkers for depression and then followed them, they found that depression accompanied memory declines but did not necessarily come first.
Having memory problems that are not severe enough to be diagnosed as dementia, but that are more pronounced than the changes associated with normal aging, is known as mild cognitive impairment. Many people with MCI develop dementia, but some do not.
The new research shows that having mild cognitive impairment along with depression doubled the risk of developing full-blown dementia.
Posted to Members in the News & Publications on January 02, 2013
“Protecting” Psychiatric Medical Records Puts Patients at Risk of Hospitalization
Features Adam I. Kaplin, MD, PhD, Johns Hopkins University
Medical centers that elect to keep psychiatric files private and separate from the rest of a person's medical record may be doing their patients a disservice, a Johns Hopkins study concludes.
In a survey of psychiatry departments at 18 of the top American hospitals as ranked by U.S. News & World Report's Best Hospitals in 2007, a Johns Hopkins team learned that fewer than half of the hospitals had all inpatient psychiatric records in their electronic medical record systems and that fewer than 25 percent gave non-psychiatrists full access to those records.
Strikingly, the researchers say, psychiatric patients were 40 percent less likely to be readmitted to the hospital within the first month after discharge in institutions that provided full access to those medical records.
"The big elephant in the room is the stigma," says Adam I. Kaplin, M.D., Ph.D., an assistant professor of psychiatry and behavioral sciences and neurology at the Johns Hopkins University School of Medicine and leader of the study published online in the International Journal of Medical Informatics. "But there are unintended consequences of trying to protect the medical records of psychiatric patients. When you protect psychiatric patients in this way, you’re protecting them from getting better care. We’re not helping anyone by not treating these diseases as we would other types of maladies. In fact, we're hurting our patients by not giving their medical doctors the full picture of their health."
Posted to Members in the News & Publications on January 02, 2013
Acclaimed Mental Health Program for Kindergarten and First Grade Students Expands in New Jersey
Montclair State University to administer school-based “Zippy’s Friends” curriculum to help thousands of New Jersey children develop healthy coping and social skills
“In the face of the devastation of Superstorm Sandy and the Sandy Hook Elementary School tragedy, our youngest children must find ways to share their thoughts and feelings about such traumatic events. It is imperative that we address the mental and emotional well-being of young children.”
-- Dr. Gerard Costa, Director, Center for Autism and Early Childhood Mental Health, Montclair State University
Montclair, NJ, December, 20, 2012: Zippy’s Friends, an internationally acclaimed school-based program, which was developed in the United Kingdom and is currently in use in 32 countries helping nearly a million children around the world, is now expanding into schools throughout New Jersey, the first state in the nation to offer the mental health program designed especially for kindergarten and first grade students. The curriculum, which is based on extensive research and endorsed by the World Health Organization, is taught by specially trained teachers to help young children develop healthy coping and social skills.
The program was created by the Partnership for Children in the United Kingdom whose staff has designated Montclair State University as the sole licensed provider of Zippy’s Friends in the United States. The University’s Center for Autism and Early Childhood Mental Health will administer the program, which is being funded through the generous support of the Todd Ouida Children’s Foundation, Novartis Pharmaceuticals Corporation and Montclair State University.
“The international response from teachers, counselors, parents and children to this effective mental health program has been exceptional,” said Dr. Gerard Costa, Director of the Center for Autism and Early Childhood Mental Health in the College of Education and Human Services at Montclair State University. “Now, with a $10,000 grant from the Todd Ouida Children’s Foundation, which was matched by Novartis Pharmaceuticals Corporation, special training in the use of the curriculum will be made available to 30 additional kindergarten and first grade teachers from several New Jersey school districts, most of which are members of the Montclair State University Network for Educational Renewal (MSUNER).” Zippy’s Friends was first introduced in New Jersey by Youth Consultation Service Inc. which provided training for 75 educators in 12 elementary schools in Paterson, River Edge, Wayne and Paramus reaching more than 4,600 children.
According to Costa, the data collected from implementing the curriculum in these new districts will provide support for further grant opportunities. In turn, those districts will serve as models for replicating the curriculum across the state to reach thousands of additional children and to expand the program nationwide.
“Kindergarten and first grade are both vulnerable and formative years for young children,” said Dr. Costa, “As they are learning reading, writing, math and science, it’s crucial that we teach them how to cope with issues, such as friendship, feeling lonely, bullying, loss, transition to school and facing new experiences, which every five- to seven-year old has to cope with almost daily.”
Montclair State’s Center for Autism and Early Childhood Mental Health will begin training more teachers on how to implement the Zippy’s Friends program in January 2013. The curriculum is delivered by kindergarten and first grade teachers, who will lead 24 weekly lessons that cover six core social and emotional themes: feelings, communication, making and breaking relationships, conflict resolution, dealing with change and loss, and coping. While the program is particularly helpful to children with emotional difficulties, it is designed for all children. For more information, contact Gerard Costa, Ph.D., Director, Center for Autism and Early Childhood Mental Health, Montclair State University at 973-655-6685 or caecmh@montclair.edu
Todd Ouida Children’s Foundation, which was created by the Ouida family in memory of 25-year-old Todd Ouida who died on September 11, 2001, provides financial support for psychological services and other mental health initiatives for children of families in need. The foundation aims to raise awareness and reduce the stigma of anxiety and depression disorders in children, recognizing the need for early intervention. www.mybuddytodd.org.
Novartis Pharmaceuticals Corp provides innovative healthcare solutions that address the evolving needs of patients and societies. Part of the mission of Novartis is to view community engagement as a key component of that commitment to corporate responsibility, and actively support local communities. http://www.novartis.com/index.shtml
Montclair State University offers a comprehensive array of undergraduate and graduate programs to a highly diverse population of 18,500 students in an expansive university setting just 14 miles from New York City. The university’s Center for Autism and Early Childhood Mental Health offers professional development, education, clinical services and research in the areas of autism, infant and early childhood development and mental health. http://www.montclair.edu/cehs/
### Note:
Photos Available
Contacts: Suzanne Bronski, bronskis@mail.montclair.edu / 973-655-4334
Herb Ouida Houida99@aol.com / 201-265-7765, 201-803-1366 (cell)
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Posted to on December 20, 2012
Peers & Peer-Based Interventions in Supporting Reintegration & Mental Health Among National Guard…
Pfeiffer, Paul N.; Blow, Adrian J.; Miller, Erin; Forman, Jane; Dalack, Gregory W.; Valenstein, Marcia
National Guard soldiers experience high levels of mental health symptoms following deployment to Iraq and Afghanistan, yet many do not seek treatment. We interviewed 30 National Guard soldiers with prior deployments to Iraq or Afghanistan to assess mental health treatment barriers and the role of peers in treatment engagement. Interview transcripts were analyzed by a multidisciplinary research team using techniques drawn from grounded theory. The following themes were identified: (1) personal acceptance of having a mental health problem rather than treatment access is the major barrier to treatment entry; (2) tightly connected, supportive peer networks can decrease stigma related to mental health problems and encourage treatment; however, soldiers in impoverished or conflicted peer networks are less likely to receive these benefits; and (3) soldiers are generally positive about the idea of peer-based programs to improve treatment engagement, although they note the importance of leadership support, peer assignment, and unit specialty in implementing these programs. We conclude that some, but not all, naturally occurring peer networks serve to overcome stigma and encourage mental health treatment seeking by soldiers. Formal peer-based programs may assist soldiers not sufficiently benefitting from natural peer networks, although there are barriers to implementation.
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Posted to Members in the News & Publications on December 20, 2012
...Subcallosal Cingulate White Matter Deep Brain Stimulation for Treatment Resistant Depression
Patricio Riva-Posse, MD, Paul E. Holtzheimer, MD, Steven J. Garlow, MD, PhD, Helen S. Mayberg, MD
Deep brain stimulation (DBS) is being investigated in the past decade as a viable intervention for treatment-resistant depression (TRD). Several anatomical targets have been tested, with the most extensive published experience available for the subcallosal cingulate (SCC) white matter. This article reviews the current state of clinical research of SCC DBS for TRD, including an overview of the rationale for targeting SCC, practical considerations for subject recruitment and evaluation, surgical planning and stimulation parameters. Clinical management of patients in the initial and long-term naturalistic phases of treatment, including the potential role for psychotherapeutic rehabilitation, is discussed.
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Posted to Members in the News & Publications on December 18, 2012
The association between late-life depression, mild cognitive impairment and dementia…
The association between late-life depression, mild cognitive impairment and dementia: is inflammation the missing link?
Adriana P Hermida, William M McDonald, Kyle Steenland and Allan Levey
Depression, mild cognitive impairment (MCI) and dementia are highly prevalent conditions that are increasing exponentially with similarly expanding social, medical and economic burdens. While there is a clear clinical connection between these three disorders, the mechanism of action that links them is less well understood. The lack of well-accepted biomarkers results in high levels of diagnostic subjectivity, which then greatly impacts research results when attempting to further explore their association. There is also a variety of clinical presentations of depressive syndromes, particularly in the elderly; each one may be associated with a different risk in the progression from MCI to different types of dementia. The diagnostic challenges, the importance of biomarkers and the discussion of inflammation as a possible link between depression, MCI and dementia are examined in this article.
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Posted to Members in the News & Publications on December 18, 2012
Fatal Strokes Strike Distressed Seniors
Features Jess Fiedorowicz, MD, PhD, University of Iowa
Depression, stress, and a negative outlook on life among older individuals appears to predict their risk of dying from a stroke, a longitudinal study showed.
The most distressed seniors were 2.97-fold more likely to die from a stroke, while the next highest quartile was at 1.98-fold elevated risk compared with the least distressed quartile (P<0.0001 and 0.0091, respectively), Susan Everson-Rose, PhD, MPH, of the University of Minnesota in Minneapolis, and colleagues reported online in Stroke.
That association persisted after full adjustment for other stroke risk factors and was largely accounted for by hemorrhagic rather than ischemic strokes among community-dwelling seniors followed in the Chicago Health and Aging Project.
Posted to Members in the News & Publications on December 17, 2012
Parents Bereaved by Offspring: Suicide A Population-Based Longitudinal Case-Control Study
James M. Bolton, MD; Wendy Au, BSc; William D. Leslie, MSc, MD; Patricia J. Martens, PhD; Murray W. Enns, MD; Leslie L. Roos, PhD; Laurence Y. Katz, MD; Holly C. Wilcox, PhD; Annette Erlangsen, PhD; Dan Chateau, PhD; Randy Walld, BSc; Rae Spiwak, MSc; Monique Seguin, PhD; Katherine Shear, MD; Jitender Sareen, MD
Context Suicide bereavement remains understudied and poorly understood.
Objectives To examine outcomes of parents bereaved by the suicide death of their offspring and to compare these with both nonbereaved parent controls and parents who had offspring die in a motor vehicle crash (MVC).
Design Population-based case-control study. Suicide-bereaved parents were compared with nonbereaved matched control parents in the general population (n = 1415) and with MVC-bereaved parents (n = 1132) on the rates of physician-diagnosed mental and physical disorders, social factors, and treatment use in the 2 years after death of the offspring. Adjusted relative rates (ARRs) were generated by generalized estimating equation models and adjusted for confounding factors.
Setting Manitoba, Canada.
Participants All identifiable parents who had an offspring die by suicide between 1996 and 2007 (n = 1415).
Main Outcome Measures Mental and physical disorders, social factors, and treatment use.
Results Suicide bereavement was associated with an increased rate of depression (ARR, 2.14; 95% CI, 1.88-2.43), anxiety disorders (ARR, 1.41; 95% CI, 1.24-1.60), and marital breakup (ARR, 1.18; 95% CI, 1.13-1.23) in the 2 years after the suicide of an offspring, as compared with the 2 years prior to the death. Suicide-bereaved and MVC-bereaved parents had very few differences on predeath to postdeath outcomes. Depression rate increases were greater for MVC-bereaved parents (19.9%) compared with suicide-bereaved parents (15.9%; P = .005), whereas suicide-bereaved parents had higher rate increases of hospitalization for mental illness (P = .049). Suicide-bereaved parents were more likely than their MVC-bereaved counterparts to have depression (ARR, 1.30; 95% CI, 1.06-1.61), physical disorders (ARR, 1.32; 95% CI, 1.19-1.45), and low income (ARR, 1.34; 95% CI, 1.18-1.51) before their offspring's death.
Conclusions Suicide bereavement is associated with adverse mental health and social outcomes. These consequences appear similar to those associated with MVC bereavement. Parents who lose offspring to suicide appear to be a vulnerable group even prior to their offspring's death.
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Posted to Members in the News & Publications on December 17, 2012
Time to Hospitalization for Suicide Attempt by the Timing of Parental Suicide During Offspring Early
S. Janet Kuramoto, PhD, MHS; Bo Runeson, MD, PhD; Elizabeth A. Stuart, PhD; Paul Lichtenstein, PhD; Holly C. Wilcox, PhD
Context Previous studies have suggested that children who experience parental suicide at earlier ages are at higher risk of future hospitalization for suicide attempt. However, how the trajectories of risk differ by offspring age at the time of parental suicide is currently unknown.
Objective To study time at risk to suicide attempt hospitalization among offspring of suicide decedents as compared with offspring of unintentional injury decedents by their developmental period at the time of parental death.
Design Population-based retrospective cohort study.
Setting Sweden.
Participants Twenty-six thousand ninety-six offspring who experienced parental suicide and 32 395 offspring of unintentional injury decedents prior to age 25 years between the years 1973 and 2003.
Main Outcome Measure Parametric survival analysis was used to model the time to hospitalization for suicide attempt among offspring who lost a parent during early childhood (0-5 years old), later childhood (6-12 years old), adolescence (13-17 years old), and young adulthood (18-24 years old).
Results The risk in offspring who lost a parent to suicide or an unintentional injury during childhood surpassed the other age groups' risk approximately 5 years after the origin and, for the youngest group, continued to rise over decades. Offspring who lost a parent during adolescence or young adulthood were at greatest risk within 1 to 2 years after parental death, and risk declined over time. Offspring who lost a parent to suicide in childhood and young adulthood had earlier onset of hospitalization for suicide attempt compared with offspring who lost a parent to an unintentional injury.
Conclusions The hospitalization risk for suicide attempt in offspring who lost a parent during their childhood is different from those who lost a parent later in development. The results suggest critical windows for careful monitoring and intervention for suicide attempt risk, especially 1 to 2 years after parental death for the older age groups and over decades for childhood survivors of parental death.
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Posted to Members in the News & Publications on December 17, 2012
Maternal antenatal depression and infant disorganized attachment at 12 months
Lisa J. Hayes, Sherryl H. Goodman & Elizabeth Carlson
Although high rates of attachment disorganization have been observed in infants of depressed mothers, little is known about the role of antenatal depression as a precursor to infant attachment disorganization. The primary aim of this study was to examine associations between maternal antenatal depression and infant disorganization at 12 months in a sample of women (N = 79) at risk for perinatal depression. A secondary aim was to test the roles of maternal postpartum depression and maternal parenting quality as potential moderators of this predicted association. Among women with histories of major depressive episodes, maternal depressive symptoms were assessed at multiple times during pregnancy and the first year postpartum, maternal parenting quality was measured at three months postpartum, and attachment disorganization was assessed at 12 months postpartum. Results revealed that infants classified as disorganized had mothers with higher levels of depressive symptoms during pregnancy compared to infants classified as organized. Maternal parenting quality moderated this association, as exposure to higher levels of maternal depressive symptoms during pregnancy was only associated with higher rates of infant disorganized attachment when maternal parenting at three months was less optimal. These findings suggest that enhancing maternal parenting behaviors during this early period in development has the potential to alter pathways to disorganized attachment among infants exposed to antenatal maternal depressive symptoms, which could have enduring consequences for child wellbeing.
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Posted to Members in the News & Publications on December 17, 2012
Evaluating Preschool Children’s Attitudes and Beliefs About Intimate Partner Violence
Howell, Kathryn H.; Miller, Laura E.; Graham-Bermann, Sandra A.
Few studies have considered how intimate partner violence (IPV) impacts children's overarching attitudes and beliefs about the prevalence and acceptability of aggression. This pilot study included 92 preschool children exposed to IPV who reported on attitudes and beliefs about violence using a new, theoretically driven measure. Findings illustrate that preschoolers were able to respond reliably on this measure, and that most report at least one maladaptive attitude or belief about violence. Maternal posttraumatic avoidance symptoms, increased child aggression, and decreased child self-blame were associated with maladaptive attitudes and beliefs. These findings, although preliminary, indicate that clinicians may need to address both children's individual adjustment following violence exposure as well as their attitudes and beliefs concerning the acceptability of violence in interpersonal relationships.
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Posted to Members in the News & Publications on December 13, 2012
Anticonvulsant Promising for Comorbid PTSD, Alcohol Abuse
Features Steven L. Batki, MD, University of California San Francisco
An anticonvulsant approved for the treatment of epilepsy and migraine is also showing promise in the treatment of alcohol dependence, new research shows.
Investigators at the University of California, San Francisco, and San Francisco Veterans Administration (VA) found that in veterans with posttraumatic stress disorder (PTSD), topiramate significantly reduced alcohol consumption.
Combat exposure is a known risk for both PTSD and alcohol or other substance use, said study investigator Steven L. Batki, MD.
Posted to Members in the News & Publications on December 11, 2012
Medical Food Aids in the Treatment of Major Depression
Features George Papakostas, MD, Massachusetts General Hospital
Adjunctive L-methylfolate is safe, effective, and "relatively well tolerated" for patients with major depressive disorder (MDD) who are resistant to selective serotonin reuptake inhibitors (SSRIs) alone, new research suggests.
A randomized controlled trial (RCT) of 75 adults with MDD showed that the participants who received 15 mg/day of L-methylfolate in addition to continued SSRI treatment showed significantly higher response rates and depression symptom score changes than those who received placebo plus continued SSRI therapy.
In this trial, "15 mg/day of adjunctive L-methylfolate appeared to result in a treatment outcome (efficacy) superior to continued SSRI therapy plus placebo in both primary outcome measures," write George Papakostas, MD, from the Center for Treatment-Resistant Depression at Massachusetts General Hospital in Boston and from Harvard Medical School, and colleagues.
Posted to Members in the News & Publications on December 11, 2012
Bipolar Mixed States: An International Society for Bipolar Disorders Task Force Report…
Bipolar Mixed States: An International Society for Bipolar Disorders Task Force Report of Symptom Structure, Course of Illness, and Diagnosis
Alan C. Swann, MD; Beny Lafer, MD; Giulio Perugi, MD; Mark A Frye, MD; Michael Bauer, MD; Won-Myong Bahk, MD; Jan Scott, MD; Kyooseob Ha, MD; Trisha Suppes, MD, PhD
Objective Episodes of bipolar disorder are defined as depressive or manic, but depressive and manic symptoms can combine in the same episode. Coexistence or rapid alternation of depressive and manic symptoms in the same episode may indicate a more severe form of bipolar disorder and may pose diagnostic and treatment challenges. However, definitions of mixed states, especially those with prominent depression, are not well established.
Method The authors performed literature searches for bipolar disorder, multivariate analyses, and the appearance of the terms “mixed” in any field; references selected from the articles found after the search were combined after a series of conferences among the authors.
Results The authors reviewed the evolution of the concept of mixed states and examined the symptom structure of mixed states studied as predominantly manic, predominantly depressive, and across both manic and depressive episodes, showing essentially parallel structures of mixed states based on manic or depressive episodes. The authors analyzed the relationships between mixed states and a severely recurrent course of illness in bipolar disorder, with early onset and increased co-occurring anxiety-, stress-, and substance-related disorders, and they used this information to derive proposed diagnostic criteria for research or clinical use.
Conclusions The definitions and properties of mixed states have generated controversy, but the stability of their characteristics over a range of clinical definitions and diagnostic methods shows that the concept of mixed states is robust. Distinct characteristics related to the course of illness emerge at relatively modest opposite polarity symptom levels in depressive or manic episodes.
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Posted to Members in the News & Publications on December 11, 2012
Life Goals Collaborative Care for Patients With Bipolar Disorder and Cardiovascular Disease Risk
Features Amy Kilbourne, PhD, MPH, University of Michigan & Jeanette Waxmonsky, PhD, University of Colorado Denver
Objective This pilot study compared Life Goals Collaborative Care (LGCC) with enhanced treatment as usual in reducing cardiometabolic risk factors and improving outcomes for persons with bipolar disorder.
Methods Participants were randomly assigned to LGCC (N=34) or enhanced treatment as usual (N=34). LGCC included four weekly self-management sessions and monthly telephone contacts for six months thereafter. Enhanced treatment as usual included wellness mailings. Outcomes were blood pressure, body mass index (BMI), quality of life, functioning, and symptoms.
Results Compared with enhanced treatment as usual, LGCC was not associated with reductions in cardiometabolic risk factors in 12-month repeated-measures analyses. Among patients with a BMI of ≥30 or systolic blood pressure of ≥140, LGCC was associated with improvements in functioning (beta=–2.2 and beta=–3.8, respectively, p=.04) and reduced depressive symptoms (beta=–2.0 and –3.5, respectively, p=.04).
Conclusions Further research is needed to determine whether LGCC improves outcomes for patients with elevated cardiometabolic risk.
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Posted to Members in the News & Publications on December 10, 2012
Handbook for Military Social Work
Features Bruce Capehart, MD, MBA, Duke University
Designed to help social workers gain the knowledge they need to better serve the population of active duty service members, National Guard and Reserve personnel, veterans, and their families, this important book covers the foundational knowledge of military social work, including the history of military social work, the unique culture of the military and how that affects interventions and treatments, ethical issues, women in the military, and secondary trauma. Social workers treating military personnel, veterans, and their families will benefit from the relevant topics covered, including PTSD, co-occuring disorders, traumatic brain injury, substance abuse, and suicide prevention.
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Posted to Members in the News & Publications on December 06, 2012
Although Valuable, Brain Imaging Alone Cannot Diagnose Autism
Features Nicholas Lange, ScD, McLean Hospital
In a column appearing in the current issue of the journal Nature, McLean Hospital biostatistician Nicholas Lange, ScD, cautions against heralding the use of brain imaging scans to diagnose autism and urges greater focus on conducting large, long-term multicenter studies to identify the biological basis of the disorder.
"Several studies in the past two years have claimed that brain scans can diagnose autism, but this assertion is deeply flawed," said Lange, an associate professor of Psychiatry and Biostatistics at Harvard Medical School. "To diagnose autism reliably, we need to better understand what goes awry in people with the disorder. Until its solid biological basis is found, any attempt to use brain imaging to diagnose autism will be futile."
While cautioning against current use of brain imaging as a diagnostic tool, he is a strong proponent of using this technology to help scientists better understand autism. Through the use of various brain imaging techniques, including functional magnetic resonance imaging (MRI), positron emission tomography (PET), and volumetric MRI, Lange points out that researchers have made important discoveries related to early brain enlargement in the disorder, how those with autism focus during social interaction and the role of serotonin in someone with autism.
Posted to Members in the News & Publications on December 05, 2012
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