Changes in cognitive functioning following treatment of late-life depression

OBJECTIVE

Knowledge of the relationship between various clinical characteristics and cognitive functioning is advancing, but little is known about the cognitive response to treatment for geriatric depression. The purpose of this study was to examine the cognitive response to treatment for patients with late-life depression.

METHOD

Subjects included 45 nondemented, elderly depressed patients who achieved remission after 12 weeks of antidepressant treatment and 20 elderly comparison subjects. All subjects were administered a battery of clinical measures, including cognitive screening instruments, before and after treatment.

RESULTS

As a group, the elderly depressed patients showed a small improvement in overall cognitive functioning after treatment. Among depressed patients with concomitant cognitive impairment at baseline, performance on the Mattis Dementia Rating Scale domains of conceptualization and initiation/perseveration improved significantly relative to those of depressed patients with normal cognition. Despite the improvement following treatment, the overall level of cognitive functioning in the elderly depressed patients with cognitive impairment at baseline remained mildly impaired, especially in the memory and initiation/perseveration domains.

CONCLUSIONS

Elderly depressed patients with cognitive impairment may experience improvement in specific domains following antidepressant treatment but may not necessarily reach normal levels of performance, particularly in memory and executive functions. This subgroup of late-life depression patients is likely at high risk of developing progressive dementia.

Using a health concerns checklist as a bridge from reason for encounter to diagnosis of girls attending an adolescent health service

OBJECTIVE

We assessed the extent to which a health concerns checklist (HCC) helps bridge the gap between the reason for encounter (RFE) described by girls entering an adolescent health service and the ultimate diagnosis.

METHODS

The sample, 547 consecutive 12- to 18-year-old girls visiting an adolescent health service, first underwent a structured intake procedure, including a self-administered form on which they described their RFEs and other health concerns, as well as a psychosocial interview and medical evaluation performed by staff members. The RFEs, HCC items, and diagnoses, grouped into somatic, sexuality-related, and psychosocial categories, were then compared.

RESULTS

Among the 399 girls expressing specific RFEs on entering the clinic, one-third were diagnosed with psychosocial disorders and one-fifth with sexuality-related concerns. Of the patients receiving a sexuality-related diagnosis, 57% presented with a sexuality-related request; another 26% noted it on the checklist. For those diagnosed with psychosocial problems, 22% stated this as the RFE, and another 50% indicated it on the HCC. The contribution of the HCC to the diagnosis was higher among adolescents not stating a specific RFE.

CONCLUSION

The findings highlight the HCC's contribution in identifying health problems, especially among adolescents who find it difficult to verbalize sensitive issues.

Major depressive disorder and marital transition among mothers: results from a national panel study

This analysis employs a national panel study to examine the relationship between marital transition and depression among mothers within the framework of selection and causation processes. The data come from the two-wave, longitudinal National Population Health Survey (NPHS) by Statistics Canada collected in 1994 and again in 1996 focusing on women between 20 and 65 years of age with children living at home (N = 2169). Compared with mothers who remain married, mothers making the transition into single-parenthood had a significantly higher rate of major depression at Time 1, which increased, but not significantly, at Time 2. This suggests that a selection effect may explain the elevated levels of depression among mothers experiencing a marital disruption. Rates of depression among single-parent mothers making the transition into a marital relationship did not decrease significantly between waves nor did the rate differ significantly from stable single-parent mothers at Time 1 or Time 2, suggesting that movement into marriage is not a protective factor.

Schizophrenia-associated idiopathic unconjugated hyperbilirubinemia (Gilbert's syndrome)

BACKGROUND

Idiopathic unconjugated hyperbilirubinemia (Gilbert's syndrome) is a benign hyperbilirubinemia found in the general population. There has been only 1 previous report of Gilbert's syndrome occurring in schizophrenic patients. The present study was conducted to determine the frequency of Gilbert's syndrome in schizophrenic patients relative to patients with other psychiatric disorders.

METHOD

Plasma bilirubin concentrations of every patient admitted to the psychiatric hospital during a 3-year period were collected, and patients were examined to exclude all other causes of hyperbilirubinemia. In addition, the psychiatric symptoms of schizophrenic patients (ICD-10 criteria) with hyperbilirubinemia were evaluated by the Positive and Negative Syndrome Scale (PANSS).

RESULTS

Schizophrenic patients showed a significantly higher incidence of hyperbilirubinemia (p < .05) relative to patients suffering from other psychiatric disorders, and schizophrenic patients with hyperbilirubinemia showed significantly higher scores on the positive and general psychiatric subscales of the PANSS (p < .0001) than patients without hyperbilirubinemia.

CONCLUSION

The apparently higher frequency of Gilbert's syndrome in schizophrenic patients may reflect a relationship between hyperbilirubinemia and schizophrenic psychosis. Hypothetical explanations, such as a possible genetic disposition for Gilbert's syndrome, an increased vulnerability of red cell membranes, and the role of estrogens in schizophrenic patients, are discussed.

Use of quantitative rating scales to assess outcome in schizophrenia prevention studies

OBJECTIVE

To present a summary of quantitative scales relevant to schizophrenia prevention studies.

METHOD

Fifteen scales were reviewed and summarised in terms of structure, domains assessed, previous use and psychometric properties. Instruments of symptom measurement, role functioning and global functioning were considered, along with multidimensional instruments and other scales of potential interest to research in schizophrenia prevention.

RESULTS AND CONCLUSIONS

No scales of potential value in measuring premorbid risk for schizophrenia have been sufficiently tested for reliability and validity in the context of primary prevention of schizophrenia. The absence of a sufficiently sensitive and specific means for identifying those at high risk of schizophrenia before the onset of psychosis is a major barrier to valid measurement of the outcome of attempts at primary prevention. However, there have been advances in the development of instruments relevant to the goals of secondary and tertiary prevention. Most studies use instruments developed for patients with established psychoses and have applied them to early psychosis groups with some success, although possible 'floor' effects may confound measurement in the 'prodromal' period.

Borderline personality: traits and disorder

Although the 5-factor model (FFM) has been advocated as an alternative to representing the construct of borderline personality, some argue that this diagnosis carries essential information that is not well captured by the FFM. The present study examined antecedent, concurrent, and predictive markers of construct validity in a sample of 362 patients with personality disorders. The results indicated that neuroticism best distinguished borderline and nonborderline patients, whereas the FFM as a whole captured a sizable proportion of the variance in the borderline diagnosis. However, the residual of the borderline diagnosis that was not explained by the FFM was found to be significantly related to childhood abuse history, family history of mood and substance use disorders, concurrent symptoms, and 2-year and 4-year outcomes. Thus, some elements of the borderline diagnosis may not be fully captured in a 5-factor representation.

Treatment of dysthymia with sertraline: a double-blind, placebo-controlled trial in dysthymic patients without major depression

BACKGROUND

The selective serotonin reuptake inhibitor sertraline has been shown to be efficacious and well tolerated for the treatment of major depressive disorder. Relatively few trials, however, have examined the role of pharmacotherapy in dysthymia without concurrent major depression. The current investigation focuses on the use of sertraline for the treatment of dysthymia.

METHOD

In this 12-week, multicenter, double-blind study, 310 patients with a DSM-III-R diagnosis of dysthymic disorder without concurrent major depression were randomly assigned to receive either sertraline (N = 158) or placebo (N = 152). Sertraline was initiated at a dose of 50 mg daily, with titration permitted to a maximum of 200 mg daily. The primary evaluation criteria were the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorder Version (SIGH-SAD), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Clinical Global Impressions-Severity of Illness (CGI-S) and -Improvement (CGI-I) scales.

RESULTS

Mean percentage reductions for the intent-to-treat population in SIGH-SAD scores were 44.6% for the sertraline-treated group and 33.2% for the placebo-treated group (p = .03); MADRS scores, 43.6% and 33.0% (p = .02); and CGI-S scores, 32.8% and 22.8% (p = .02). A significantly greater proportion of the sertraline-treated group was classified as responders (defined for HAM-D and MADRS scores as a 50% score reduction and for CGI-I as a score of 1 or 2 by the final visit) and remitters (SIGH-SAD score < or = 8) relative to the placebo-treated group by the final visit. In addition, sertraline-treated patients experienced greater improvements in all 9 domains of the Battelle Quality of Life Questionnaire than placebo-treated patients did, with a significant difference observed in favor of sertraline in 8 of the 9 domains. The life satisfaction and social interaction quality of life domains showed significantly greater response in sertraline responders compared with placebo SIGH-SAD responders. Sertraline was well tolerated. Thirteen percent of the sertraline-treated group versus 8% of the placebo-treated group withdrew from therapy owing to adverse events (p = .14).

CONCLUSION

Sertraline is efficacious and well tolerated in the short-term treatment of dysthymia without concurrent major depression.

Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire

OBJECTIVE

Bipolar spectrum disorders, which include bipolar I, bipolar II, and bipolar disorder not otherwise specified, frequently go unrecognized, undiagnosed, and untreated. This report describes the validation of a new brief self-report screening instrument for bipolar spectrum disorders called the Mood Disorder Questionnaire.

METHOD

A total of 198 patients attending five outpatient clinics that primarily treat patients with mood disorders completed the Mood Disorder Questionnaire. A research professional, blind to the Mood Disorder Questionnaire results, conducted a telephone research diagnostic interview by means of the bipolar module of the Structured Clinical Interview for DSM-IV.

RESULTS

A Mood Disorder Questionnaire screening score of 7 or more items yielded good sensitivity (0.73) and very good specificity (0.90).

CONCLUSIONS

The Mood Disorder Questionnaire is a useful screening instrument for bipolar spectrum disorder in a psychiatric outpatient population.

Children into DSM don't go: a comparison of classification systems for eating disorders in childhood and early adolescence

OBJECTIVE

To evaluate the reliability of diagnostic classification systems for eating disorders when applied to children and young adolescents.

METHOD

Eighty-one patients were randomly selected from a population of 226 children (age 7-16) presenting with eating difficulties to a specialist clinic. Diagnoses were assigned according to three classification systems: the 10th edition of the International Classification of Diseases (ICD 10), the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), and Great Ormond Street (GOS) criteria. Ratings were performed by two clinicians blind to the diagnosis of the other.

RESULTS

Interrater reliability values (kappa) for the three systems were 0.357 (ICD 10), 0.636 (DSM-IV), and 0.879 (GOS). Using DSM criteria, more than 50% of children were classified as eating disorder not otherwise classified (EDNOS) or could not be classified.

DISCUSSION

DSM-IV and ICD 10 criteria are of little value in the classification of the eating difficulties of children. The GOS criteria, which were developed for this age range, are more reliable. The classification of eating disorders in childhood needs reevaluation.

[Differences between psychopathological evaluation in German and Turkish language of Turkish immigrants]

The elevated rate of schizophrenia among migrants has been explained, among others, with misdiagnosis due to symptoms' being misinterpreted as psychotic. Previous studies have shown both higher and lower rates of psychotic symptoms of these patients when interviewed in their mother tongues, compared to being interviewed in the second language. In this study, 91 patients of Turkish origin and 50 of German origin with a paranoid-hallucinatory syndrome at admission were examined by an one interviewer each of Turkish and German origins using a standardized psychopathological instrument. In spite of comparative samples, correlation of psychopathological evaluation as well as diagnostic agreement between the two interviewers was significantly higher in the German patient group. Within the Turkish patient group, correlation was higher for those with good German language knowledge than for those with poor knowledge, yet only on a few items and without an effect on diagnostic agreement. The greatest difficulties lie in the evaluation of delusions. In spite of higher disagreement on psychopathology, the potential misdiagnoses cannot sufficiently explain the higher rate of schizophrenia among migrants.

Fluoxetine versus sertraline and paroxetine in major depressive disorder: changes in weight with long-term treatment

BACKGROUND

The effects of extended selective serotonin reuptake inhibitor (SSRI) treatment on weight are not well characterized. Also unknown is whether different agents have differential effects. To examine these questions, we assessed weight changes in patients randomly assigned to long-term treatment with fluoxetine, sertraline, or paroxetine.

METHOD

Patients (N = 284) with major depressive disorder (DSM-IV) were randomly assigned to double-blind treatment with fluoxetine (N = 92), sertraline, (N = 96), or paroxetine (N = 96) for a total of 26 to 32 weeks. The mean percent change in weight was compared for each group, as was the number of patients who had > or = 7% weight increase from baseline.

RESULTS

Patients (fluoxetine, N = 44; sertraline, N = 48; paroxetine, N = 47) who completed the trial were included in these analyses. Paroxetine-treated patients experienced a significant weight increase, fluoxetine-treated patients had a modest but nonsignificant weight decrease, and patients treated with sertraline had a modest but nonsignificant weight increase. The number of patients whose weight increased > 7% from baseline was significantly greater for paroxetine-treated compared with either fluoxetine-treated or sertraline-treated patients.

CONCLUSION

Risk of weight gain during extended SSRI treatment differs depending on which SSRI is used.

Relationship of physical symptoms to posttraumatic stress disorder among veterans seeking care for gulf war-related health concerns

OBJECTIVES

Studies of the relationship of posttraumatic stress disorder (PTSD) to physical symptoms in war veterans consistently show a positive relationship. However, traumatic experiences causing PTSD may correlate with other war exposures and medical illnesses potentially accounting for those symptoms.

METHODS

We analyzed data obtained from 21,244 Gulf War veterans seeking care for war-related health concerns to assess the relationship of PTSD to physical symptoms independent of environmental exposure reports and medical illness. At assessment, veterans provided demographic information and checklists of 15 common physical symptoms and 20 wartime environmental exposures. Up to seven ICD-9 provider diagnoses were ranked in order of estimated clinical significance. The relationship of provider-diagnosed PTSD to various physical symptoms and to the total symptom count was then determined in bivariate and multivariate analyses.

RESULTS

Veterans diagnosed with PTSD endorsed an average of 6.7 (SD = 3.9) physical symptoms, those with a non-PTSD psychological condition endorsed 5.3 (3.5), those with medical illness endorsed 4.3 (3.4), and a group diagnosed as "healthy" endorsed 1.2 (2.2). For every symptom, the proportion of veterans reporting the symptom was highest in those with PTSD, second highest in those with any psychological condition, third highest in those with any medical illness, and lowest in those labeled as healthy. The PTSD-symptom count relationship was independent of demographic characteristics, veteran-reported environmental exposures, and comorbid medical conditions, even when symptoms overlapping with those of PTSD were excluded.

CONCLUSIONS

PTSD diminishes the general health perceptions of care-seeking Gulf War veterans. Clinicians should carefully consider PTSD when evaluating Gulf War veterans with vague, multiple, or medically unexplained physical symptoms.

A double-blind, placebo-controlled, prophylaxis study of lamotrigine in rapid-cycling bipolar disorder. Lamictal 614 Study Group

BACKGROUND

Patients with rapid-cycling bipolar disorder are often treatment refractory. This study examined lamotrigine as maintenance monotherapy for rapid-cycling bipolar disorder.

METHOD

Lamotrigine was added to patients' current psychotropic regimens and titrated to clinical effect during an open-label treatment phase. Stabilized patients were tapered off other psychotropics and randomly assigned to lamotrigine or placebo monotherapy for 6 months. Time to additional pharmacotherapy for emerging symptoms was the primary outcome measure. Secondary efficacy measures included survival in study (time to any premature discontinuation), percentage of patients stable without relapse for 6 months, and changes in the Global Assessment Scale and Clinical Global Impressions-Severity scale. Safety was assessed from adverse event, physical examination, and laboratory data.

RESULTS

324 patients with rapid-cycling bipolar disorder (DSM-IV criteria) received open-label lamotrigine, and 182 patients were randomly assigned to the double-blind maintenance phase. The difference between the treatment groups in time to additional pharmacotherapy did not achieve statistical significance in the overall efficacy population. However, survival in study was statistically different between the treatment groups (p = .036). Analyses also indicated a 6-week difference in median survival time favoring lamotrigine. Forty-one percent of lamotrigine patients versus 26% of placebo patients (p = .03) were stable without relapse for 6 months of monotherapy. Lamotrigine was well tolerated; there were no treatment-related changes in laboratory parameters, vital signs, or body weight. No serious rashes occurred.

CONCLUSION

This was the largest and only prospective placebo-controlled study of rapid-cycling bipolar disorder patients to date; results indicate lamotrigine monotherapy is a useful treatment for some patients with rapid-cycling bipolar disorder.

Mental disorders and the use of alternative medicine: results from a national survey

OBJECTIVE

The study examined the relationship between mental disorders and the use of complementary and alternative medicine.

METHOD

Data from a national household telephone survey conducted in 1997-1998 (N=9,585) were used to examine the relationships between use of complementary and alternative medicine during the past 12 months and several demographic variables and indicators of mental disorders. Structured diagnostic screening interviews were used to establish diagnoses of probable mental disorders.

RESULTS

Use of complementary and alternative medicine during the past 12 months was reported by 16.5% of the respondents. Of those respondents, 21.3% met diagnostic criteria for one or more mental disorders, compared to 12.8% of respondents who did not report use of alternative medicine. Individuals with panic disorder and major depression were significantly more likely to use alternative medicine than those without those disorders. Respondents with mental disorders who reported use of alternative medicine were as likely to use conventional mental health services as respondents with mental disorders who did not use alternative medicine.

CONCLUSIONS

We found relatively high rates of use of complementary and alternative medicine among respondents who met criteria for common mental disorders. Practitioners of alternative medicine should look for these disorders in their patients, and conventional medical providers should ask their depressed and anxious patients about the use of alternative medicine. More research is needed to determine if individuals with mental disorders use alternative medicine because conventional medical care does not meet their health care needs.

[The Eppendorf Schizophrenia Inventory (ESI). Development and evaluation of a questionnaire for assessment of characteristic self perception of cognitive dysfunctions by schizophrenic patients]

This study explored characteristic subjective experiences of schizophrenia. A questionnaire for self-assessment of disturbances in several cognitive and perceptual areas (the Eppendorf Schizophrenia Inventory, or ESI) was constructed and administered to first-episode schizophrenics (SCHe, n = 45), negative syndrome schizophrenics (SCHn, n = 45), remitted schizophrenics (SCHr, n = 24), depressives (DEP, n = 43), alcoholics (ALK, n = 48), obsessive-compulsive patients (ZWA, n = 46), and healthy controls (KON, n = 57). Comparisons between the SCHe, SCHn, DEP, ALK, and ZWA groups and a subsequent factor analysis revealed four schizophrenia-specific dimensions: attention and speech impairment (AS), ideas of reference (IR), auditory uncertainty (AU), and deviant perception (DP). Further analyses suggested that the AS syndrome may represent a mediating vulnerability factor while IR, AU, and DP probably are reversible episode indicators. The results may contribute to refinements in the measurement of specific prepsychotic signs, thus facilitating the development of early intervention approaches.

[Identity measurement with the Frankfurt self concept scales and their relationship to parental bonding]

Psychiatric inpatients and nonpatients were compared using the Frankfurt Self-Concept Scales (FSKN). Firstly, we tried to validate FSKN as a measure of identity using the DSM-III-R identity rating as an external criterion. Then the FSKN ratings of patients and nonpatients were compared. Lastly, we correlated individual FSKN ratings with certain demographic variables, clinical diagnoses, and the two dimensions of the Parental Bonding Instrument (PBI). All FSKN scores of patients with identity disorders differentiated significantly from those without identity disorder, thus confirming FSKN validity. The most significant differences were found in practically all FSKN results comparing patients with nonpatients of both sexes, always in favor of nonpatients. Male patients presented better self-concepts than female patients, whereas practically no significant relationships were found between FSKN scales and sex in nonpatients or between FSKN, vocational category, and diagnosis. Also, the relationship between the scales and age appears to be slight, showing positive in patients and negative in nonpatients. Many significant correlations were found between FSKN scales and PBI dimensions which were negative between the scales and PBI "control" and positive between the scales and PBI "care", both especially in men with regard to their relationship with the father.

Criterion validity of the multiaxial assessment of eating disorders symptoms

OBJECTIVE

The purpose of this investigation was to establish the criterion validity of the Multiaxial Assessment of Eating Disorders Symptoms (MAEDS). The MAEDS is a brief, comprehensive, self-report measure for the evaluation of eating disorders treatment outcome. It assesses six symptoms associated with eating disorders with subscales for binge eating, purgative behavior, avoidance of forbidden foods, restrictive eating, fear of fatness, and depression.

METHOD

To establish criterion validity, we compared the subscale scores of the MAEDS across four eating disorder diagnoses, specified by subtype (bulimia nervosa, purging type; anorexia nervosa, binge-eating/purging type; anorexia nervosa, restricting type; and binge eating disorder). Participants who did not meet the full diagnostic criteria for an eating disorder, but who did meet criteria for a partial syndrome eating disorder, were grouped with the full eating disorder diagnostic subtypes.

RESULTS

The criterion validity of the MAEDS was supported by the pattern of subscale scores for the different eating disorder diagnostic groups. Also, with few exceptions, persons diagnosed with anorexia nervosa, bulimia nervosa, and binge eating disorder, in comparison to subthreshold cases of anorexia nervosa, bulimia nervosa, and binge eating disorder, had equivalent scores on the subscales of the MAEDS.

DISCUSSION

These findings support the criterion validity of the MAEDS and add to a growing literature that questions differences in severity of eating disorder symptoms in full syndrome versus partial syndrome cases.

Disability pension for major depression in Finland

OBJECTIVE

The authors' goal was to investigate the treatment received before receipt of a disability pension for major depression in a representative sample of depressed patients.

METHOD

The medical statements for a random sample of 277 subjects drawn from the Disability Pension Register of the Social Insurance Institution were examined. The subjects selected represented individuals in Finland who were granted a disability pension because of DSM-III-R major depression during a 12-month period in 1993-1994.

RESULTS

For 254 (92%) of the subjects, the statements regarding pension eligibility were written either by a psychiatrist or a psychiatric resident for patients who were currently being treated in psychiatric settings. There was an additional diagnosis of a comorbid mental disorder or a somatic disease contributing to disability in two-thirds of the statements. Overall, the statements indicated that 242 (87%) of the subjects were prescribed antidepressant medication, but only 24 (9%) received weekly psychotherapy, and only 11 (4%) received ECT.

CONCLUSIONS

Most subjects granted a disability pension for major depression in Finland have comorbid mental or physical disorders contributing to their disability. Before receiving their pension, most received antidepressant treatment, but few received the established nonpharmacological treatments.

Reliability and validity of DSM-IV axis V

OBJECTIVE

The authors investigated the reliability and convergent and discriminant validity of the DSM-IV Global Assessment of Functioning Scale and two experimental DSM-IV axis V global rating scales, the Global Assessment of Relational Functioning Scale and the Social and Occupational Functioning Assessment Scale.

METHOD

Forty-four patients admitted to a university-based outpatient community clinic were rated by trained clinicians on the three DSM-IV axis V scales. Patients also completed self-report measures of DSM-IV symptoms as well as measures of relational, social, and occupational functioning.

RESULTS

The Global Assessment of Functioning Scale, Global Assessment of Relational Functioning Scale, and Social and Occupational Functioning Assessment Scale all exhibited very high levels of interrater reliability. Factor analysis revealed that the Global Assessment of Relational Functioning Scale and the Social and Occupational Functioning Assessment Scale are each more related to the Global Assessment of Functioning Scale individually than they are to each other. The Global Assessment of Functioning Scale was significantly related to concurrent patient responses on the SCL-90-R global severity index. The Social and Occupational Functioning Assessment Scale was significantly related to concurrent patient responses on the SCL-90-R global severity index and to a greater degree with both the Social Adjustment Scale global score and the Inventory of Interpersonal Problems total score. Although the Global Assessment of Relational Functioning Scale was not significantly related to any of the three self-report measures, it was related to the presence of clinician-rated axis II pathology.

CONCLUSIONS

The three axis V scales can be scored reliably. The Global Assessment of Relational Functioning Scale and the Social and Occupational Functioning Assessment Scale evaluate different constructs. These findings support the validity of the Global Assessment of Functioning Scale as a scale of global psychopathology; the Social and Occupational Functioning Assessment Scale as a measure of problems in social, occupational, and interpersonal functioning; and the Global Assessment of Relational Functioning Scale as an index of personality pathology. The authors discuss further refinement and use of the three axis V measures in treatment research.

Lack of association between duration of untreated illness and severity of cognitive and structural brain deficits at the first episode of schizophrenia

OBJECTIVE

The purpose of the study was to determine whether the duration of illness before antipsychotic drug treatment for schizophrenia was associated with the severity of cognitive deficits and volumetric brain structure anomalies observed in some patients with a first episode of schizophrenia.

METHOD

Duration of psychotic symptoms and of other symptoms marking a behavioral change was estimated from structured interviews with 50 patients who had a first episode of schizophrenia and their family members. Interviews were conducted within a month of the patients' hospitalization. Duration of untreated psychotic symptoms and of behavioral change was correlated with neuropsychological summary scores from a comprehensive cognitive battery and with measurements of lateral ventricular, temporal lobe, and cerebral hemispheric volumes.

RESULTS

No significant correlations were observed between measures of untreated illness and the severity of either cognitive or structural brain deficits at baseline.

CONCLUSIONS

The duration of untreated symptoms of schizophrenia, for which an association with an uncontrolled toxic brain process has been proposed, is unlikely to explain why first-episode patients with schizophrenia have widespread deficits in cognitive functioning and have detectable ventricular enlargement and some loss of cortical mass.

Quality-of-life and behavioral outcome measures in randomized controlled trials of antiepileptic drugs: a systematic review of methodology and reporting standards

PURPOSE

To review the methodology and use of quality-of-life and behavioral measures used in randomized controlled trials (RCTs) of antiepileptic drugs in patients with epilepsy.

METHODS

Trial reports were found by searching a previously developed comprehensive database of epilepsy RCTs and searching through journals by hand. Inclusion and exclusion criteria were applied, and methodological and quality-of-life and behavioral measure data were extracted.

RESULTS

There were 52 different measures used in 46 trials, with the Profile of Mood States, the Minnesota Multiphasic Personality Inventory, and the Washington Psychosocial Seizure Inventory being applied the most frequently. Overall, evidence of the reliability, validity, and sensitivity of measures used in populations of people with epilepsy was sparse. There was also little information on the clinical interpretation of the results.

CONCLUSION

Our results highlight a consistent failure to apply quality-of-life and behavioral measures in RCTs in a systematic way. We found repeated evidence of researchers' failure to review the use of previous measures and selection of measures without evidence of their appropriateness for use in a population with epilepsy. We recommend the use of quality-of-life and behavioral measures in RCTs with proven psychometric properties in a population with epilepsy.

Treatment for depression following the 1996 National Depression Screening Day

OBJECTIVE

Characteristics of the subsequent treatment received by people who screened positive for depression in the 1996 National Depression Screening Day were investigated.

METHOD

A follow-up telephone survey was completed by 1,502 randomly selected participants from 2,800 sites.

RESULTS

Of 927 people for whom additional evaluation was recommended, 602 (64.9%) obtained evaluations and 503 (83.6%) received treatment. Of these 503, 260 (51.7%) received psychotherapy and medication, 130 (25.8%) received medication only, and 93 (18.5%) received psychotherapy only. Compared with people without health or mental health insurance, individuals with health insurance (66.7% versus 57.5%) and mental health insurance (74.6% versus 55.3%) were more likely to comply with the recommendation to obtain follow-up evaluation.

CONCLUSIONS

One-half of the people treated for depression received a combination of psychotherapy and medication. Lack of insurance was associated with not following the recommendation to obtain further evaluation and treatment.

The efficacy and safety of a new enteric-coated formulation of fluoxetine given once weekly during the continuation treatment of major depressive disorder

BACKGROUND

A simple, once-weekly dosing regimen could be a convenient alternative for many patients during long-term treatment of depression. Such a strategy might also be effective for improving medication compliance and the outcome of continuation treatment. The safety and effectiveness of a new formulation of enteric-coated fluoxetine (90 mg) given once weekly was tested during the continuation treatment of major depressive disorder.

METHOD

Patients meeting DSM-IV criteria for major depressive disorder with modified 17-item Hamilton Rating Scale for Depression (HAM-D-17) scores > or = 18 and Clinical Global Impressions-Severity of Illness scale (CGI-S) scores > or = 4 were treated 13 weeks with open-label 20 mg/day of fluoxetine in a multicenter U.S. study. Responders (N = 501) were randomly assigned to receive 20 mg of fluoxetine daily, placebo, or 90 mg of enteric-coated fluoxetine weekly for 25 weeks of double-blind continuation treatment. The primary efficacy measure was the percentage of patients who relapsed. Time to relapse was tested over the 25-week continuation period using log-rank analyses of the Kaplan-Meier estimates of relapse rates. Additional analyses of efficacy included comparison of change from baseline to endpoint for the HAM-D-17, CGI-S, and HAM-D-28 subscales by last observation carried forward (LOCF). Safety measures included comparison of treatment-emergent adverse events, both spontaneous and solicited (using the Association for Methodology of Documentation in Psychiatry-Module 5), vital signs, and laboratory measures.

RESULTS

Relapse rates for patients assigned to fluoxetine, either 20 mg daily or 90 mg weekly, were significantly lower than for placebo by log-rank analysis and LOCF analyses of secondary efficacy measures. Efficacy did not significantly differ between the 2 active drug groups by these measures. Enteric-coated fluoxetine at a once-weekly dose of 90 mg was well tolerated, and its safety profile was similar to that of daily 20 mg of fluoxetine.

CONCLUSION

The formulation of enteric-coated fluoxetine taken once weekly is effective, safe, and well tolerated for continuation treatment of depression in patients who responded to acute treatment with 20 mg/day of fluoxetine. Monitoring during long-term treatment for evidence of sustained remission is important regardless of dosing regimen.