[Axis I "illness experience and treatment preconditions" of operational psychodynamic diagnosis (OPD). Experiences in clinical practice]

In a selective survey, results on psychometric properties and aspects of application of the axis I, "illness experience and treatment preconditions" of the Operational Psychodynamic Diagnoses (OPD) are described. Following remarks on the role of defense and coping theories in the conceptualisation of the axis, its structure and contents are outlined. After a brief summary of findings on its interrater reliability, several aspects of validity are discussed. Results on discriminative validity show that axis I items are useful in the statistical discrimination of subsamples differing in age, clinical diagnoses, and diagnostic setting (psychotherapy outpatient vs. psychosomatic consultation-liasion services). The contribution of axis I items to prediction of treatment outcomes, moreover, reveals high degree of predictive or treatment validity. After an integrative discussion of these findings, implications of patient personality and coping behaviour for axis I ratings are highlighted as important objectives for future OPD research.

Auditory sensory dysfunction in schizophrenia: imprecision or distractibility?

BACKGROUND

Schizophrenia is associated with large effect-size deficits in auditory sensory processing, as reflected in impaired delayed-tone matching performance. The deficit may reflect either impaired sensory precision, which would be indicative of neural dysfunction within auditory sensory (temporal) regions, or of increased distractibility, which would be indicative of impaired prefrontal function. The present study evaluates susceptibility of schizophrenic subjects to same-modality distraction to determine whether patients fit a "bitemporal" or "prefrontal" model of sensory dysfunction.

METHODS

Tone-matching ability was evaluated in 15 first-episode patients, 18 outpatients with chronic illness, and 21 patients in long-term residential care, relative to 32 nonpsychiatric controls of a similar age. A staircase procedure determined individual thresholds for attaining criterion level correct performance.

RESULTS

Tone-matching thresholds in the absence of distractors were significantly elevated in patients in long-term residential care relative to all other groups (P<.001). The effect size (d) of the difference relative to controls was extremely large (SD, 1.95). Schizophrenic patients, even those with elevated tone-matching thresholds, showed no increased susceptibility to auditory distraction (P =.42). Deficits in tone-matching performance in subjects with chronic illness could not be attributed to medication status or level of symptoms.

CONCLUSIONS

These findings suggest that sensory processing dysfunction in schizophrenia is particularly severe in a subgroup of patients who can be considered poor-outcome based on their need for long-term residential treatment. Furthermore, the absence of increased auditory distractibility argues against prefrontal dysfunction as an origin for auditory sensory imprecision in schizophrenia. Arch Gen Psychiatry. 2000;57:1149-1155.

Reliability and concurrent validity of DSM-IV subclinical symptom ratings for alcohol use disorders among adolescents

BACKGROUND

The concurrent validity of subclinical ratings for psychiatric symptoms can help refine symptom definitions and threshold criteria. However, virtually no research has examined subclinical ratings for DSM-IV symptoms in psychiatric diagnostic interviews. This study examined the frequency, reliability, and concurrent validity of subclinical ratings for 11 symptoms of alcohol use disorders among adolescents.

METHODS

Subjects were 239 male and 164 female adolescents ages 14 to 18 recruited from treatment and community sources. Symptoms and diagnoses were made with an adapted version of the Structured Clinical Interview for the DSM-IV.

RESULTS

Subclinical ratings showed acceptable to high interrater reliability. The proportion of subclinical ratings tended to decrease with increasing levels of alcohol problems. For 10 of the 11 symptoms, subjects with subclinical ratings were distinguished from those with absent and/or those with present ratings. Subjects with subclinical ratings were often distinct from those with present ratings but less often distinct from those with absent ratings.

CONCLUSIONS

For most of the DSM-IV alcohol use disorder symptoms, subclinical ratings appear to be reliable and valid and provide information beyond dichotomous symptom classifications for adolescents. Threshold criteria appear to be appropriate in many cases, but boundaries between absent and subclinical ratings are "fuzzy." Practical and research implications are discussed.

Sertraline treatment of panic disorder: response in patients at risk for poor outcome

BACKGROUND

More than one third of panic disorder patients have a chronic and/or recurrent form of the disorder, accounting for much of the individual and societal cost associated with the illness. Six clinical variables have been most consistently identified as high-risk predictors of poor outcome: (1) panic severity, (2) presence of agoraphobia, (3) comorbid depression, (4) comorbid personality disorder, (5) duration of illness, and (6) female sex. No published research has systematically examined the differential antipanic efficacy of selective serotonin reuptake inhibitors in patients at high risk for poor outcome.

METHOD

Data were pooled (N = 664) from 4 double-blind, placebo-controlled studies of the efficacy of sertraline for the treatment of DSM-III-R panic disorder. Two of the studies were 12-week fixed-dose studies with starting daily doses of sertraline, 50 mg, and 2 were 10-week flexible-dose studies with starting daily doses of sertraline, 25 mg. All other study design features were the same, except for the exclusion of women of childbearing potential in the 2 fixed-dose studies. Exclusion of patients with marked personality disorders and depression meant that only 4 of the poor-outcome variables could be evaluated.

RESULTS

Clinical improvement was similar for patients treated with sertraline whether or not they carried an agoraphobia diagnosis, had a duration of illness > 2 years, or were female. Patients with high baseline panic severity had significantly (p = .01) less improvement on the endpoint Clinical Global Impressions-Improvement (CGI-I) scale than patients with moderate severity, although the Clinical Global Impressions-Severity of Illness scale change score was higher in the patients with high severity (-2.00 vs. -1.31). For patients with 3 or more high-risk variables, there was a modest, but statistically significant, tendency for reduced global improvement (endpoint CGI-I score of 2.7 for the high-risk vs. 2.4 for the non-high-risk group; p = .017), although the high-risk group actually had a similar endpoint reduction in frequency of panic attacks (82%) compared with the non-high-risk group (78%).

CONCLUSION

Treatment of panic disorder with sertraline was generally effective, even in the presence of baseline clinical variables that have been associated with poor treatment response. The main limitations of the analysis were the reliance on pooled data from 4 studies (even if the designs were similar) and our inability to examine the impact of depression and personality disorders on response to treatment because of the exclusion criteria of the clinical trials.

Two-year outcome of preschool children with autism or Asperger's syndrome

OBJECTIVE

DSM-IV specifies that Asperger's disorder is a type of pervasive developmental disorder without clinically significant cognitive or language delay. There are no data, however, on the outcome of children with Asperger's disorder or on whether their outcome differs from that of children with autism. The objectives of this study were to compare the outcome of groups of children with these disorders over a period of 2 years on variables independent of the defining criteria and to identify variables that might account for these differences.

METHOD

All children 4-6 years of age who came for assessment or were currently in treatment at a pervasive developmental disorder service of one of several centers in a large geographic region were identified. Children who received a diagnosis of autism (N=46) or Asperger's syndrome (N=20) on the basis of a diagnostic interview and had an IQ in the nonretarded range were given a battery of cognitive, language, and behavioral tests. Families were contacted roughly 2 years after the date of their enrollment in the study, and many of the tests were readministered.

RESULTS

Children with Asperger's syndrome had better social skills and fewer autistic symptoms 2 years after study enrollment than the children with autism. The differences in outcome could not be explained by initial differences in IQ and language abilities. Children with autism who had developed verbal fluency at follow-up were very similar to the children with Asperger's syndrome at study enrollment.

CONCLUSIONS

Although the exact mechanism for the differences in outcome remain to be determined, it appears that Asperger's disorder and autism represent parallel but potentially overlapping developmental trajectories.

Cognitive factors related to suicidal ideation and resolution in psychiatrically hospitalized children and adolescents

OBJECTIVE

This study was conducted to determine whether there are changes in the cognitive factors of attributional style, hopelessness, and self-esteem when suicidal ideation fades in psychiatrically hospitalized children and adolescents.

METHOD

The cognitive factors of attributional style, hopelessness, and self-esteem were assessed in subjects aged 7-17 years (50 with and 50 without suicidal ideation) at admission and discharge from a psychiatric hospital.

RESULTS

For subjects with suicidal ideation, attributional style became significantly more positive and hopelessness was decreased from admission to discharge, by which time suicidal ideation had faded. There was no association between self-esteem and suicidal ideation after control for depression. These changes in cognitive factors were not seen in the group without suicidal ideation. There were no significant differences between children and adolescents in the pattern of results.

CONCLUSIONS

Change in attributional style was shown to be a factor significantly related to the resolution of suicidal ideation in children and adolescents. This cognitive style could be specifically addressed in psychotherapy with depressed children and adolescents as a means of reducing suicidal ideation. These results may have an implication for reducing the length of psychiatric inpatient stays.

Comparison of different clinical criteria (DSM-III, ADDTC, ICD-10, NINDS-AIREN, DSM-IV) for the diagnosis of vascular dementia. National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurosciences

BACKGROUND AND PURPOSE

The criteria for vascular dementia (VaD) include definition of the cognitive syndrome and the vascular cause. Different criteria for dementia identify different frequencies and clusters of patients. In addition, variation in defining the cause and etiology may have an effect. We compared different clinical criteria for VaD in series of patients with poststroke dementia.

METHODS

The study group comprised 107 patients fulfilling the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) definition for dementia from a cohort of consecutive patients with ischemic stroke who completed a comprehensive neuropsychological test battery and MRI. The mean age (SD) of the patients was 71.4 (7.6) years. The definitions of vascular cause of VaD were those of the DSM-III (1980), Alzheimer's Disease Diagnostic and Treatment Centers (ADDTC; 1992), International Statistical Classification of Diseases, 10th Revision (ICD-10; 1992), National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN; 1993), and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; 1994).

RESULTS

The number of cases that could be classified as VaD according to the different criteria varied considerably: 36.4% (n=39) by DSM-III, 86.9% (n=93) by ADDTC, 32.7% (n=35) by NINDS-AIREN, 36.4% (n=39) by ICD-10, and 91.6% (n=98) by DSM-IV criteria. The concordance between DSM-III/ICD-10 was perfect (100%; kappa=1.0), between ICD-10/NINDS-AIREN and ADDTC/DSM-IV good to moderate (85.0% and 87. 3%; kappa=0.87 and 0.37, respectively), but otherwise poor between the other criteria. Only 31 patients fulfilled all the criteria for VaD applied. Major discriminating factors between the criteria were requirement of (1) focal neurological signs, (2) unequal distribution of deficits in higher cortical functions, and (3) evidence of relevant CVD based on brain imaging findings.

CONCLUSIONS

Current criteria of VaD identify different frequencies and clusters of patients and are not interchangeable. Optimally, prospective studies with clinicopathological correlation could identify new criteria. Meanwhile, focus on more homogeneous subtypes (eg, small-vessel subcortical VaD) and detailed neuroimaging criteria could improve the diagnostics.

Familial aggregation of ADHD characteristics

Patterns of familial aggregation of ADHD symptoms in parents of ADHD and non-ADHD children were examined. Within the ADHD sample, symptom aggregation was examined as a function of biological relationship, parent and child gender, and children's comorbid diagnoses. Participants consisted of parents of 579 children with ADHD, Combined Type participating in the multimodal treatment study of children with ADHD and parents of 288 normal control participants. Adult symptoms of ADHD were measured by both self-report and report of a significant other. Results indicated that the parents of children with ADHD had higher ratings of inattention/cognitive problems, hyperactivity/restlessness, impulsivity/emotional lability, and lower self-concept than parents of children without ADHD on both self-report and other-report ratings. Within the ADHD sample of children, other-report ratings of inattention/cognitive problems and impulsivity/emotional lability were higher for biological parents compared to nonbiological parents whereas self-ratings were not related to biological status. These findings support previous research documenting familial aggregation of ADHD and appear to strengthen the hypothesis that there is a genetic contribution to ADHD.

A brief assessment of psychosocial functioning of subjects with bipolar I disorder: the LIFE-RIFT. Longitudinal Interval Follow-up Evaluation-Range Impaired Functioning Tool

Those afflicted with bipolar disorder often suffer from substantial functional impairment both when in episode and when in remission. This study examined the psychometric properties of a brief assessment of psychosocial functioning, the Range of Impaired Functioning Tool (LIFE-RIFT), among subjects with bipolar I disorder. The study sample consisted of 163 subjects who presented with bipolar I disorder at intake into the NIMH Collaborative Depression Study (CDS). All LIFE-RIFT items come from the Longitudinal Interval Follow-up Evaluation (LIFE). Follow-up data that were used to examine the reliability and validity of the scale come from assessments of psychosocial functioning that were conducted 6, 12, 18, and 24 months after intake into the CDS. The results of factor analyses indicate that the scale items are measures of one construct, psychosocial functioning. The interrater agreement on the scale score was very good with an intraclass correlation coefficient was 0.94. The internal consistency reliability among the scale items was uniformly satisfactory over the four assessment periods, with coefficient alpha ranging from 0.78 to 0.84. Mixed-effect regression analyses showed that during mood episodes subjects were significantly more impaired than those in recovery. In conclusion, the psychometric properties of the LIFE-RIFT were examined in subjects with bipolar I disorder. The analyses from this longitudinal, observational study provide empirical support for the reliability and validity of the scale. The LIFE-RIFT provides a brief, inexpensive alternative to scales currently used to assess psychosocial functioning and can be easily added to semistructured assessments that are used in clinical and treatment outcome studies.

A controlled study of behavioral inhibition in children of parents with panic disorder and depression

OBJECTIVE

"Behavioral inhibition to the unfamiliar" has been proposed as a precursor to anxiety disorders. Children with behavioral inhibition are cautious, quiet, introverted, and shy in unfamiliar situations. Several lines of evidence suggest that behavioral inhibition is an index of anxiety proneness. The authors sought to replicate prior findings and examine the specificity of the association between behavioral inhibition and anxiety.

METHOD

Laboratory-based behavioral observations were used to assess behavioral inhibition in 129 young children of parents with panic disorder and major depression, 22 children of parents with panic disorder without major depression, 49 children of parents with major depression without panic disorder, and 84 children of parents without anxiety disorders or major depression (comparison group). A standard definition of behavioral inhibition based on previous research ("dichotomous behavioral inhibition") was compared with two other definitions.

RESULTS

Dichotomous behavioral inhibition was most frequent among the children of parents with panic disorder plus major depression (29% versus 12% in comparison subjects). For all definitions, the univariate effects of parental major depression were significant (conferring a twofold risk for behavioral inhibition), and for most definitions the effects of parental panic disorder conferred a twofold risk as well.

CONCLUSIONS

These results suggest that the comorbidity of panic disorder and major depression accounts for much of the observed familial link between parental panic disorder and childhood behavioral inhibition. Further work is needed to elucidate the role of parental major depression in conferring risk for behavioral inhibition in children.

Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization

BACKGROUND

Based on findings of stress-induced neural disturbances in animals and smaller hippocampal volumes in humans with posttraumatic stress disorder), we hypothesized that patients with borderline personality disorders (BPD), who often are victims of early traumatization, have smaller volumes of the hippocampus and the amygdala. We assumed that volumes of these brain regions are negatively correlated with traumatic experiences and with neuropsychological deficits.

METHODS

We studied 21 female patients with BPD and a similar group of healthy controls. We performed clinical assessments, a modified version of the Childhood Trauma Questionnaire, and magnetic resonance imaging volumetric measurements of the hippocampus, amygdala, temporal lobes, and prosencephalon. Neuropsychological testing included scales on which disturbances in BPD were previously reported.

RESULTS

The patients with BPD had nearly 16% smaller volumes of the hippocampus (P<.001) and 8% smaller volumes of the amygdala (P<.05) than the healthy controls. The results for both hemispheres were nearly identical and were controlled for the volume of the prosencephalon and for head tilts. The volumes of the hippocampus were negatively correlated with the extent and the duration of self-reported early traumatization only when BPD and control subjects were considered together. Levels of neuropsychological functioning were associated with the severity of depression but not with the volumes of the hippocampus.

CONCLUSION

In female patients with BPD, we found reduction of the volumes of the hippocampus (and perhaps of the amygdala), but the association of volume reduction and traumatic experiences remains unclear. Arch Gen Psychiatry. 2000;57:1115-1122.

Comorbidity of borderline personality disorder with other personality disorders in hospitalized adolescents and adults

OBJECTIVE

The authors examined the comorbidity of borderline personality disorder with other personality disorders in a series of consecutively admitted adolescents. For comparison, the comorbidity of borderline personality disorder with other personality disorders was also examined in a series of adults consecutively admitted to the same hospital during the same period.

METHOD

A total of 138 adolescents and 117 adults were reliably assessed with the Personality Disorder Examination, a semistructured diagnostic interview for DSM-III-R personality disorders. Sixty-eight adolescents and 50 adults met the diagnostic criteria for borderline personality disorder. The co-occurrence of other personality disorders in the group of subjects with borderline personality disorder was statistically compared to that in the group without borderline personality disorder, for adolescents and adults separately.

RESULTS

For the adults, Bonferroni-corrected chi-square analysis revealed significant diagnostic co-occurrence with borderline personality disorder for antisocial personality disorder only. For the adolescents, borderline personality disorder showed significant co-occurrence with schizotypal and passive-aggressive personality disorders.

CONCLUSIONS

In the adults, borderline personality disorder was significantly comorbid only with another cluster B disorder. The adolescents, by comparison, displayed a broader pattern of comorbidity of borderline personality disorder, encompassing aspects of clusters A and C. These results suggest that the borderline personality disorder diagnosis may represent a more diffuse range of psychopathology in adolescents than in adults.

Attempted suicide and alcoholism in bipolar disorder: clinical and familial relationships

OBJECTIVE

This study examined the clinical and familial relationships between comorbid alcoholism and attempted suicide in affectively ill relatives of probands with bipolar I disorder.

METHOD

In 71 families ascertained for a genetic linkage study, 337 subjects with major affective disorder were assessed by using the Schedule for Affective Disorders and Schizophrenia-Lifetime Version.

RESULTS

Subjects with bipolar disorder and alcoholism had a 38.4% lifetime rate of attempted suicide, whereas those without alcoholism had a 21.7% rate. Attempted suicide among subjects with bipolar disorder and alcoholism clustered in a subset of seven families. Families with alcoholic and suicidal probands had a 40.7% rate of attempted suicide in first-degree relatives with bipolar disorder, whereas other families had a 19.0% rate.

CONCLUSIONS

Comorbid alcoholism was associated with a higher rate of attempted suicide among family members with bipolar disorder. Attempted suicide and alcoholism clustered in a subset of families. These relationships may have a genetic origin and may be mediated by intoxication, mixed states, and/or temperamental instability.

The 5-year clinical course of high-functioning men with DSM-IV alcohol abuse or dependence

OBJECTIVE

One goal of diagnostic criteria is to predict the course of clinically relevant future problems. This study evaluated the ability of the DSM-IV categories of alcohol abuse and alcohol dependence to predict the onset and cessation of the 11 DSM-IV abuse/dependence criterion items.

METHOD

The DSM-IV categorical approach was used to determine alcohol diagnoses for 435 highly educated young adult men, who constituted 97.3% of the 447 men appropriate for this study. Structured face-to-face follow-up interviews were administered 5 years later.

RESULTS

At the beginning of the study, 14.5% (N=63) of the subjects were alcohol dependent, 18.2% (N=79) reported alcohol abuse, and 67.4% (N=293) carried no alcohol diagnosis. Across these three diagnostic groups, 68.3%, 46.8%, and 15.4%, respectively, experienced at least one of the 11 DSM-IV abuse/dependence criterion items over the next 5 years. Only 11.4% of those who reported alcohol abuse went on to develop alcohol dependence. In addition to their diagnosis, characteristics that predicted subsequent problems with alcohol included a family history of alcoholism, higher levels of alcohol intake and a greater number of alcohol problems in the 10 years preceding the diagnosis, and a history of drug use.

CONCLUSIONS

Even in this highly educated and high-functioning group of men, alcohol abuse and dependence predicted the onset and cessation of alcohol-related problems.

Increased neocortical neurofibrillary tangle density in subjects with Alzheimer disease and psychosis

BACKGROUND

Psychosis is common in patients with Alzheimer disease. While the relationship between psychosis and clinical variables has been examined frequently, few studies have examined the relationship between psychosis and the 2 major neuropathological hallmarks of Alzheimer disease: neurofibrillary tangles and senile plaques. We characterized the occurrence of psychosis in relation to dementia severity and determined if subjects with Alzheimer disease and psychosis had a greater neurofibrillary tangle or senile plaque burden than subjects with Alzheimer disease and no psychosis.

METHODS

One hundred nine subjects with Alzheimer disease were followed longitudinally with semistructured assessments in order to assign a Clinical Dementia Rating and determine whether psychosis was present. After the subjects died, their brains were obtained for histological examination. Analysis of variance was used to compare the densities of neurofibrillary tangles, total senile plaques, and cored senile plaques in subjects with psychosis vs subjects without psychosis, in several neocortical regions, the hippocampus, and the entorhinal cortex.

RESULTS

Psychosis occurred commonly in Alzheimer disease, affecting 63% of subjects. The frequency of psychosis increased with increasing dementia severity. More importantly, we found that subjects with psychosis had a 2.3-fold (95% confidence interval, 1.2-3.9) greater density of neocortical neurofibrillary tangles than did subjects without psychosis. The increase was independent of dementia severity. No similar relationship with psychosis was seen for total senile plaques or cored senile plaques.

CONCLUSIONS

The increase in psychosis frequency that occurs with the progression of dementia severity and the independent association between psychosis and neurofibrillary tangle density suggest the possibility that some common underlying process or processes specific to Alzheimer disease may regulate both phenomena. Arch Gen Psychiatry. 2000;57:1165-1173.

Depression and anxiety in elderly outpatients with chronic obstructive pulmonary disease: prevalence, and validation of the BASDEC screening questionnaire

OBJECTIVES

Depressive and anxiety symptoms are common in elderly patients with chronic obstructive pulmonary disease (COPD). However, true prevalence of clinical depression and anxiety is uncertain. We thus aimed to assess prevalence of clinical depression and/or anxiety in elderly COPD patients using the Geriatric Mental State Schedule (GMS) and determine severity of clinical depression by the Montgomery Asberg Depression Rating Scale (MADRS). We also aimed to validate the Brief Assessment Schedule Depression Cards (BASDEC) screening test for depressive symptoms against GMS.

SETTING

A university teaching hospital.

PARTICIPANTS

Subjects comprised 137 (69 men) outpatients with COPD, aged 60 - 89 (mean 73) years. Exclusion criteria were acute respiratory exacerbation or use of oral corticosteroid within 6 weeks, known psychosis, acute or chronic confusion.

MEASUREMENTS

A GMS score > or =3 is diagnostic of clinical depression, and a BASDEC score > or =7 is classed as "case". GMS was taken as gold standard. Severity of depression was assessed by the MADRS:

RESULTS

Mean (SD) one second forced expiratory volume was 0.89 (0.3) litres. Sixty-two subjects (46%) scored as a "case" on BASDEC and 57 subjects (42%) were identified as clinically depressed on GMS. In the depressed the prevalence of anxiety was 37% and in the non-depressed 5%. BASDEC performed well against GMS, having a sensitivity of 100%; a specificity of 93%; a positive predictive value of 91% and a negative predictive value of 100%. Assessment of severity of depression by MADRS showed that 17 subjects (30%) were mildly depressed, 39 (68%) were moderately depressed and one (2%) was severely depressed.

CONCLUSION

Clinical depression and anxiety are common in elderly patients with COPD, though clinical anxiety seems mainly confined to those who also suffer clinical depression. Of those depressed, two-thirds scored in the moderately depressed range. BASDEC is a valid screening tool in this patient group.

Efficacy and response time to sertraline versus fluoxetine in the treatment of unipolar major depressive disorder

BACKGROUND

Few studies have compared the treatment efficacy of the 2 selective serotonin reuptake inhibitors sertraline and fluoxetine.

METHOD

A randomized, single-blind, parallel-group study of 10 weeks' duration comparing the efficacy of sertraline, 50 mg/day; sertraline, 100 mg/day; and fluoxetine, 20 mg/day, was conducted in 44 psychiatric outpatients with DSM-IV unipolar major depressive disorder. Antidepressant dosages were doubled at 6 weeks for subjects who had not achieved remission. Primary outcome measurements included the 21-item Hamilton Rating Scale for Depression (HAM-D) and the Clinical Global Impressions-Improvement scale (CGI-I), with scores of < or = 7 on the HAM-D and < or = 2 on the CGI-I representing a positive treatment response, i.e., remission.

RESULTS

At 4 weeks, significant differences in rate of positive treatment response were noted, with 0% for sertraline, 50 mg; 46% for sertraline, 100 mg; and 31% for fluoxetine, 20 mg (p = .023). At 6 weeks, positive treatment response rates were 21%, 43%, and 31% for subjects taking 50 mg of sertraline, those taking 100 mg of sertraline, and those taking 20 mg of fluoxetine, respectively, with treatment groups no longer differing significantly from each other. In subjects for whom antidepressant dose was doubled at week 6, response rates at week 10 (4 weeks on increased dose) were 40% for sertraline, 100 mg; 43% for sertraline, 200 mg; and 55% for fluoxetine, 40 mg.

CONCLUSION

Subjects taking sertraline, 100 mg, and fluoxetine, 20 mg, demonstrated an earlier treatment response compared with subjects taking sertraline, 50 mg. For patients without a positive response at 6 weeks, an increased antidepressant dose resulted in remission for a substantial proportion of patients when assessed 4 weeks later.

The psychiatric symptoms of rheumatic fever

OBJECTIVE

This study examined the frequency and age at onset of psychiatric disorders among children with rheumatic fever, Sydenham's chorea, or both and a comparison group.

METHOD

Twenty children with rheumatic fever, 22 with Sydenham's chorea, and 20 comparison children were assessed by means of a semistructured interview and rating scales for tic disorders and obsessive-compulsive disorder.

RESULTS

Obsessive-compulsive symptoms were more frequent in both the Sydenham's chorea and rheumatic fever groups than in the comparison group. The Sydenham's chorea group had a higher frequency of major depressive disorder, tic disorders, and attention deficit hyperactivity disorder (ADHD) than both the comparison and rheumatic fever groups. ADHD symptoms were associated with a higher risk of developing Sydenham's chorea.

CONCLUSIONS

Both the rheumatic fever and Sydenham's chorea groups were associated with a higher risk of developing neuropsychiatric disorders than the comparison group. ADHD appears to be a risk factor for Sydenham's chorea in children with rheumatic fever.

Short-term spontaneous improvement rates in depressed outpatients

The objectives of the present report were: a) to determine the spontaneous remission rate in depressed outpatients who do not receive antidepressant medication; b) to develop a novel method for obtaining a control group that can be used to gauge the effectiveness of antidepressant medication in clinical practice; and c) to compare response rates from the present sample with outcomes of depressed patients in our practice who were treated with antidepressant medications. By using a naturalistic design, prospective assessments were made on all depressed outpatients. Twenty-five patients who met full criteria for a major depressive episode ended up not taking antidepressant medication for a variety of reasons. "Response" rates to a no-treatment trial were determined with standard outcome criteria using the Clinical Global Impression-Improvement scale. Eight patients (32.0%) had a positive response, 5 patients (20.0%) had a partial response, and 12 patients (48.0%) were nonresponders to a no-treatment trial. These response rates were higher than expected, but significantly lower than what we had found in a cohort of depressed patients who underwent an antidepressant trial (p = .02). Likewise, treatment-resistant patients fared better on pharmacotherapy, though this difference was not statistically significant. These results suggest that the occurrence of spontaneous remissions may be common in clinical practice, and therefore the specific short-term benefits of antidepressant medication in clinical practice may frequently be overestimated. Despite the high rate of spontaneous remission in our sample, the present study allowed us to confirm the effectiveness of antidepressant medication in clinical practice using a novel method for obtaining a control comparison group.

Memory, attention, function, and mood among patients with chronic posttraumatic stress disorder

We report a study of memory, attention, function, and mood among 36 male Vietnam War Veterans suffering from chronic posttraumatic stress disorder (PTSD). PTSD subjects (N = 36) were in good physical health, suffering from moderate depression, and not knowingly suffering from other mental disorders. Control subjects (N = 18) were in good physical health, not knowingly suffering from a mental disorder, and matched with PTSD subject for age, sex, and level of education. Assessment instruments for PTSD subjects included the PostTraumatic Stress Diagnostic Scale (clinician administered), the Hamilton Depression Rating Scale (clinician administered), and the Cognitive Evaluation Protocol (CEP), a touchscreen computer assessment instrument that is self-administered by subjects. CEP was administered twice to PTSD subjects 1 month apart; other instruments were administered at the beginning of the study. Control subjects took CEP once and were administered the Hamilton Depression Rating Scale and the PostTraumatic Stress Diagnostic Scale once. Compared with control subjects, PTSD subjects performed significantly less well on CEP for the three cognitive domains of attention, memory, and function and had highly elevated depression scores. An interaction between depression and memory was found but not with depression and attention. There was no evidence of reduced information processing speed among PTSD subjects. Comparisons between the three assessment instruments showed a high degree of cross-assessment agreement. The findings are consistent with reports that chronic PTSD is associated with compromised memory, attention, and function. The study documents the feasibility of using self-administrated touchscreen computer programs to evaluate and track features of mental disorders.

[Aggressive and auto-aggressive behavior of acute geriatric psychiatry admissions--an empirical contribution]

We investigated the extent of aggressiveness of 494 psychiatric patients at the time of admission. This group was divided into two subgroups according to age: 58 patients were more than 65 years old and the remaining 436 patients were less than 65 years old. The two groups were similar as far as kind and frequency of aggressive behaviour against self or others at the time of admission were concerned. There was an important difference in handling the aggressive behaviour as this was significantly easier with the older patients. Furthermore it was possible to describe psychopathological profiles of risk for both allo- and autoaggressive behaviour. Sociodemographic factors could be identified which were linked with the extent of aggressive behaviour by calculating odds ratios.

Patient compliance to a new enteric-coated weekly formulation of fluoxetine during continuation treatment of major depressive disorder

BACKGROUND

A new formulation of enteric-coated fluoxetine given once weekly could be a useful option for the long-term treatment of depression, but compliance to once-weekly fluoxetine treatment has not been assessed.

METHOD

Patients were adults from the United Kingdom who had responded to fluoxetine treatment for a current episode of depression (DSM-IV criteria). In the baseline assessment phase, all patients (N = 117) were continued on 20 mg of open-label fluoxetine once daily for 4 weeks. In the follow-up phase, patients (N = 109) were randomly assigned to once-weekly or once-daily fluoxetine for 3 months. Patient compliance was monitored by electronic devices during both phases of the study.

RESULTS

Compliance to once-weekly fluoxetine treatment was higher than compliance to once-daily fluoxetine (85.9% vs. 79.4%, respectively).

CONCLUSION

Once-weekly fluoxetine treatment allows for new flexibility for both the clinician and the patient, and this study alleviates the concern that patients will forget weekly doses.