The effects of anxiety, substance use and conduct disorders on risk of major depressive disorder

The difference in volumetric alternations of the orbitofrontal-limbic-striatal system between major depressive disorder and anxiety disorders: A systematic review and voxel-based meta-analysis

BACKGROUND

Major depressive disorder (MDD) and anxiety disorders (ANX) are psychiatric disorders with high mutual comorbidity rates that might indicate some shared neurobiological pathways between them, but they retain diverse phenotypes that characterize themselves specifically. However, no consistent evidence exists for common and disorder-specific gray matter volume (GMV) alternations between them.

METHODS

A systematic review and meta-analysis on voxel-based morphometry studies of patients with MDD and ANX were performed. The effect of comorbidity was explicitly controlled during disorder-specific analysis and particularly investigated in patient with comorbidity.

RESULTS

A total of 45 studies with 54 datasets comprising 2196 patients and 2055 healthy participants met the inclusion criteria. Deficits in the orbitofrontal cortex, striatum, and limbic regions were found in MDD and ANX. The disorder-specific analyses showed decreased GMV in the bilateral anterior cingulate cortex, right striatum, hippocampus, and cerebellum in MDD, while decreased GMV in the left striatum, amygdala, insula, and increased cerebellar volume in ANX. A totally different GMV alternation pattern was shown involving bilateral temporal and parietal gyri and left fusiform gyrus in patients with comorbidity.

LIMITATIONS

Owing to the design of included studies, only partial patients in the comorbid group had a secondary comorbidity diagnosis.

CONCLUSION

Patients with MDD and ANX shared a structural disruption in the orbitofrontal-limbic-striatal system. The disorder-specific effects manifested their greatest severity in distinct lateralization and directionality of these changes that differentiate MDD from ANX. The comorbid group showed a totally different GMV alternation pattern, possibly suggesting another illness subtype that requires further investigation.

Relationships between worry and depressive symptoms during two group therapies for generalized anxiety disorder

ABSTRACT Objective: Generalized anxiety disorder (GAD) is a chronic and disabling disorder associated with various impairments and shows a significant prevalence in the worldwide and Brazilian populations. This study aimed to investigate the longitudinal relationship of two symptoms relevant to the disorder (worry and depressive symptoms) in the context of a randomized clinical trial (RCT) by using a cross-lagged panel model (CLPM) analysis. Methods: A total of 92 adult patients with GAD were randomized to receive ten sessions of either acceptance‐based group behavioral therapy (ABBT) or nondirective supportive group therapy (NDST). Treatment had four time-point measures. Worries were measured using the Penn State Worry Questionnaire (PSWQ), and depression was measured using the Depression Anxiety Stress Scales (DASS-D). Results: The NDST model revealed significant paths from worry to depression (first wave) and from depression to worry (second wave). There was no other significant cross-lagged effect. These data show that there was an influence between symptoms only during one of the treatment groups, and without a homogeneous and constant pattern in any of the cross-lagged routes. Conclusion: A supportive group psychotherapy potentially interferes with the pattern of the direct relationship between worries and depressive symptoms in adults with GAD.

Efficacy of an acceptance-based group behavioral therapy for generalized anxiety disorder

BACKGROUND

Generalized anxiety disorder (GAD) shows the weakest treatment response among anxiety disorders. This study aimed at examining whether an acceptance-based group behavioral therapy (ABBT) for patients in a Brazilian anxiety disorders program, combining mindfulness and exposure strategies, can improve clinical outcome when compared with a standard nondirective supportive group therapy (NDST).

METHODS

Ninety-two individuals diagnosed with GAD were randomized to receive 10 sessions of either ABBT or NDST. Assessments at pretreatment, midtreatment, posttreatment, and 3-month follow-up comprised the following outcome measures: Hamilton Anxiety Rating Scale (HAM-A), Penn State Worry Questionnaire (PSWQ), Depression Anxiety and Stress Scale (DASS), and the Clinical Global Impressions (CGI). The World Health Organization Quality of Life (WHOQOL) was administered at pretreatment and posttreatment.

RESULTS

The mixed-effects regression models for DASS-stress, Hamilton Anxiety Interview, and CGI showed a significant effect for Time and the Time × Treatment effect, but not for the Treatment main effect. Similarly, there was a significant Time × Treatment effect for the PSWQ, but not main effects of Time or Treatment. Altogether, these data indicate that symptoms decreased in both conditions across treatment and follow-up, and that the rate of change was more rapid for those participants in the ABBT condition. We found no differences between groups from pretreatment to posttreatment in DASS-anxiety or any secondary outcome measure, but for the physical health domain of WHOQOL, which was faster in ABBT.

CONCLUSIONS

Both groups showed good clinical outcomes, but in general, participants of the ABBT group improved faster than those in the NDST group.

Sexual Performance Anxiety

INTRODUCTION

Sexual performance anxiety (SPA) is one of the most prevalent sexual complaints; yet, no diagnosis is recognized for either gender. Thus, research into treatment has been minimal.

AIM

Review the prevalence of SPA and its relation to sexual dysfunctions and anxiety disorders. Compare SPA to (non-sexual) performance anxiety and social anxiety (PA/SA). Apply pharmacologic principles to the known properties of drugs and phytotherapies to hypothesize treatments for SPA.

METHODS

Review SPA and PA/SA through PubMed searches for relevant literature from 2000 to 2018.

MAIN OUTCOME MEASURE

Prevalence was estimated using population-representative surveys. For treatment results, controlled clinical trial results were prioritized over open-label trial results.

RESULTS

SPA affects 9-25% of men and contributes to premature ejaculation and psychogenic erectile dysfunction (ED). SPA affects 6-16% of women and severely inhibits sexual desire. Cognitive behavior therapy and mindfulness meditation training have been proven effective for PA/SA and are recommended for SPA, but controlled studies are lacking. Phosphodiesterase type 5 inhibitors are effective for psychogenic ED and premature ejaculation, both of which include SPA as a major element. Drugs proven for PA/SA have adverse sexual and sedative effects, but serotonergic anxiolytics with prosexual effects (buspirone ± testosterone, trazodone ± bupropion) may have potential, and sage, passionflower, l-theanine, and bitter orange are anxiolytic. Nitric oxide boosters (l-citrulline, l-arginine, Panax ginseng) have the potential for increasing genital tumescence and lubrication, and plant-based alpha-adrenergic antagonists may aid sexual arousal (yohimbine/yohimbe, Citrus aurantium/p-synephrine).

CONCLUSION

SPA causes or maintains most common sexual dysfunction. No treatments are well proven, although cognitive behavior therapy, mindfulness meditation training, and serotonergic anxiolytics (buspirone, trazodone, gepirone) have potential, and phosphodiesterase type 5 inhibitors are effective for psychogenic ED and premature ejaculation. Several phytotherapies also appear to have potential. Pyke RE. Sexual Performance Anxiety. J Sex Med 2020;8:183-190.

Association between School Membership and Substance Use among Adolescents

BACKGROUND

Substance use among adolescents is a major problem worldwide, producing many health and economic consequences. Even though there are well-known personal, familial, and social factors associated with drug use, less is known about the effect of school-related factors. School membership is a recognized variable affecting academic performance among students; however, its effect on substance use is less understood.

AIMS

The primary aim of this study was to explore the association between school membership and cigarette, alcohol, and cannabis use among a representative sample of secondary students from municipal state-funded schools in Santiago of Chile, and secondly, to test the hypothesis that depressive or anxiety symptoms mediate this association.

METHODS

A total of 2,508 students from 22 state-funded schools in Santiago, Chile, answered a questionnaire. This instrument included an abbreviated version of the psychological sense of school membership (PSSM), questions regarding the use of alcohol, tobacco, and cannabis and scales of psychological functioning (depression, anxiety, self-concept, and problem-solving). The association analyses were performed using adjusted regression models for each outcome using all independent variables while controlling for gender and age. For the mediation effect, a combination of ordinary least square and logistic regression analyses was conducted.

RESULTS

There was an association between a strong PSSM and low risk for smoking (OR 0.57; 95% CI 0.46-0.72), drinking (0.65; 95% CI: 0.51-0.83), and cannabis use (0.52; 95% CI 0.37-0.74). We also found that depressive and anxiety symptoms do not fully mediate the association between school membership and any substance use, and 73% of this effect in the case of smoking, 80% in the case of drinking, and 78.5% in the case of cannabis use, was direct.

CONCLUSION

This is the first study in Latin America exploring the association between school membership and substance use among secondary students. School membership seems to be an important and independent factor to be included in preventive interventions. Therefore, these results support future research aiming to test interventions at increasing the sense of school membership to prevent substance use among adolescents.

CLINICAL TRIAL REGISTRATION

ISRCTN19466209. Retrospectively registered.

Emotion regulation as a transdiagnostic factor in the development of internalizing and externalizing psychopathology: Current and future directions

In response to rapidly growing rates of comorbidity among psychiatric disorders, clinical scientists have become interested in identifying transdiagnostic processes that can help explain dysfunction across diagnostic categories (e.g., Kring & Sloan, 2009). One factor that has received a great deal of attention is that of emotion regulation, namely, the ability to modulate the intensity and/or duration of emotional states (e.g., Cicchetti, Ackerman, & Izard, 1995; Gross, 1998). Recent theoretical and empirical work has begun to emphasize the role that emotion regulation plays in the temporal comorbidity between internalizing and externalizing conditions (e.g., Aldao & De Los Reyes, 2015; De Los Reyes & Aldao, 2015; Drabick & Kendall, 2010; Jarrett & Ollendick, 2008; Patrick & Hajcak, 2016). However, close inspection of this work reveals two very pertinent areas of growth: (a) this literature is characterized by mixed findings that are likely explained, in part, by methodological heterogeneity; and (b) emotion regulation tends to be studied in relatively narrow terms. To address these issues, we provide a series of recommendations for facilitating cross-study comparisons and leveraging multifaceted approaches to studying emotion regulation processes within a developmental psychopathology framework. We hope that our perspective can enhance the organization and growth of this very important area of inquiry, and ultimately result in more effective prevention and treatment programs.

Genetic and environmental influences on the codevelopment among borderline personality disorder traits, major depression symptoms, and substance use disorder symptoms from adolescence to young adulthood

Although borderline personality disorder (BPD) traits decline from adolescence to adulthood, comorbid psychopathology such as symptoms of major depressive disorder (MDD), alcohol use disorder (AUD), and drug use disorders (DUDs) likely disrupt this normative decline. Using a longitudinal sample of female twins (N = 1,763), we examined if levels of BPD traits were correlated with changes in MDD, AUD, and DUD symptoms from ages 14 to 24. A parallel process biometric latent growth model examined the contributions of genetic and environmental factors to the relationships between developmental components of these phenotypes. Higher BPD trait levels predicted a greater rate of increase in AUD and DUD symptoms, and higher AUD and DUD symptoms predicted a slower rate of decline of BPD traits from ages 14 to 24. Common genetic influences accounted for the associations between BPD traits and each disorder, as well as the interrelationships of AUD and DUD symptoms. Both genetic and nonshared environmental influences accounted for the correlated levels between BPD traits and MDD symptoms, but solely environmental influences accounted for the correlated changes between the two over time. Results indicate that higher levels of BPD traits may contribute to an earlier onset and faster escalation of AUD and DUD symptoms, and substance use problems slow the normative decline in BPD traits. Overall, our data suggests that primarily genetic influences contribute to the comorbidity between BPD features and substance use disorder symptoms. We discuss our data in the context of two major theories of developmental psychopathology and comorbidity.

The nosologic relationship between generalized anxiety disorder and major depression

Generalized anxiety disorder (GAD) has undergone a series of revisions in its diagnostic criteria that has moved it, nosologically, away from its original affiliation with panic disorder (PD) and closer to major depressive disorder (MDD). This, together with its high comorbidity and putative shared genetic risk with MDD, has brought into question its place in future psychiatric nosology, prompting the planners of Diagnostic and Statistical Manual-V (DSM-V) and International Classification of Diseases-11 (ICD-11) to set up a workgroup tasked to better understand the relationship between GAD and MDD. This review attempts to summarize the extant data to compare GAD and MDD on a series of research validators to explore this relationship. Although insufficient data currently exist for GAD in several key validator classes, tentative conclusions can be drawn on the diagnostic status of GAD in relation to MDD. Although GAD possesses substantial overlap with MDD in the areas of genetics, childhood environment, demographics, and personality traits, this tends to hold true for other anxiety disorders (ADs) as well, with the strongest evidence for PD. Data from life events, personality disorders, biology, comorbidity, and pharmacology are mixed, showing some areas of similarity between GAD and MDD but some clear differences, again with a moderate degree of nonspecificity. Thus, although the bulk of evidence supports a close underlying relationship between them, the relatively nonspecific nature of these findings provides little more reason to question the nosologic validity of GAD in relation to MDD than that of some other anxiety disorders.

The relationship between depression and generalized anxiety during intensive psychological and pharmacological treatment

BACKGROUND

In the present study we examined the relationship between depressive symptoms and generalized anxiety symptoms during intensive cognitive-behavioral and pharmacological treatment.

METHOD

Individuals (n = 157) with major depressive disorder (MDD; n = 83), generalized anxiety disorder (GAD; n = 29) and their combination (n = 45) who attended an intensive partial hospital treatment program, completed daily self-report measures of depression and generalized anxiety. Treatment included empirically-based cognitive-behavioral interventions in both individual and group format, as well as pharmacotherapy.

RESULTS

Multilevel linear modeling indicated that for all diagnostic groups, changes in depressive symptoms led to changes in generalized anxiety symptoms to a greater extent than vice versa during treatment. Moreover, changes in depressive symptoms fully mediated changes in generalized anxiety symptoms, whereas changes in generalized anxiety symptoms only partially mediated the changes in depressive symptoms.

LIMITATIONS

Partial hospital setting.

CONCLUSIONS

Our results suggest that depressive symptoms may play a prominent role in the process of change in both MDD and GAD. This has implications for the classification of GAD as well as for choosing early treatment targets for individuals with comorbid MDD and GAD.

Oral self-administration of EtOH: sex-dependent modulation by running wheel access in C57BL/6J mice

BACKGROUND

The effects of stress, including neuroendocrine and behavioral sequelae aimed at maintaining homeostasis, are associated with increased alcohol consumption. Because both stress and drinking are multifactorial, the mechanisms underlying the relationship are difficult to elucidate. We therefore employed an animal model investigating the influence of blocked access to a running wheel on drinking in C57BL/6J (B6) mice.

METHODS

In the first experiment, naïve, adult male and female subjects were individually housed for 2 weeks with 24-hour access to a running wheel and 12% ethanol (EtOH) in a 2-bottle, free choice paradigm. After determining baseline consumption and preference, experimental subjects had the running wheel placed in a locked position for 6 hours, and the EtOH bottle was removed during the first half of this period. Two subsequent experiments, again in adult, naïve B6 mice, examined the influence of locked running wheels on self-administration of 20% EtOH in a limited access paradigm, and blood EtOH concentrations (BECs) were determined on the final day of this protocol.

RESULTS

In all 3 studies, using both between- and within-subject analyses, females showed transient yet reliable increases in alcohol drinking during blocked access to a rotating activity, while drinking in male mice was largely insensitive to this manipulation, although both sexes showed appreciable BECs (>130 mg/dl in females and 80 mg/dl in males) following a 2-hour EtOH access period.

CONCLUSIONS

These data add to a burgeoning literature suggesting that the factors contributing to excessive alcohol use differ between males and females and that females may be especially sensitive to the influence of wheel manipulation. Elucidating the sex-dependent mechanisms mediating differences in alcohol sensitivity and response is critical to understanding the causes of alcoholism and in developing effective treatments and interventions.

Secondary depression in severe anxiety disorders: a population-based cohort study in Denmark

BACKGROUND

Depression and anxiety disorders are highly comorbid conditions and a worldwide disease burden; however, large-scale studies delineating their association are scarce. In this retrospective study, we aimed to assess the effect of severe anxiety disorders on the risk and course of depression.

METHODS

We did a population-based cohort study with prospectively gathered data in Denmark using data from three Danish population registers: The Danish Civil Registration System, the Danish Psychiatric Central Register, and the Danish National Hospital Registry. We selected the cohort from people born in Denmark between Jan 1, 1955, and Dec 31, 2002, who we followed up from Jan 1, 1994, to Dec 31, 2012. The cohort was restricted to individuals with known parents. First, we investigated the effect of specific anxiety diagnoses on risk of single depressive episodes and recurrent depressive disorder. Second, we investigated the effect of comorbid anxiety on risk of readmission for depression, adjusting for sex, age, calendar year, parental age, place at residence at time of birth, and the interaction of age with sex.

FINDINGS

We included 3,380,059 individuals in our study cohort. The adjusted incidence rate ratio (IRR) for single depressive episodes was 3·0 (95% CI 2·8-3·1, p<0·0001) and for recurrent depressive disorder was 5·0 (4·8-5·2) in patients with severe anxiety disorders compared with the general population. Compared with control individuals, the offspring of parents with anxiety disorders were more likely to be diagnosed with single depressive episodes (1·9, 1·8-2·0) or recurrent depressive disorder (2·1, 1·9-2·2). Comorbid anxiety increased the readmission rates in both patients with single depressive episodes and patients with recurrent depressive disorder.

INTERPRETATION

Severe anxiety constitutes a significant risk factor for depression. Focusing on specific anxiety disorders might help to identify individuals at risk of depression, thereby providing new insights for prevention and treatment.

FUNDING

The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH).

Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings

IMPORTANCE

The period prevalence of depression among women is 21.9% during the first postpartum year; however, questions remain about the value of screening for depression.

OBJECTIVES

To screen for depression in postpartum women and evaluate positive screen findings to determine the timing of episode onset, rate and intensity of self-harm ideation, and primary and secondary DSM-IV disorders to inform treatment and policy decisions.

DESIGN

Sequential case series of women who recently gave birth.

SETTING

Urban academic women's hospital.

PARTICIPANTS

During the maternity hospitalization, women were offered screening at 4 to 6 weeks post partum by telephone. Screen-positive women were invited to undergo psychiatric evaluations in their homes.

MAIN OUTCOMES AND MEASURES

A positive screen finding was an Edinburgh Postnatal Depression Scale (EPDS) score of 10 or higher. Self-harm ideation was assessed on EPDS item 10: "The thought of harming myself has occurred to me" (yes, quite often; sometimes; hardly ever; never). Screen-positive women underwent evaluation with the Structured Clinical Interview for DSM-IV for Axis I primary and secondary diagnoses.

RESULTS

Ten thousand mothers underwent screening, with positive findings in 1396 (14.0%); of these, 826 (59.2%) completed the home visits and 147 (10.5%) completed a telephone diagnostic interview. Screen-positive women were more likely to be younger, African American, publicly insured, single, and less well educated. More episodes began post partum (40.1%), followed by during pregnancy (33.4%) and before pregnancy (26.5%). In this population, 19.3% had self-harm ideation. All mothers with the highest intensity of self-harm ideation were identified with the EPDS score of 10 or higher. The most common primary diagnoses were unipolar depressive disorders (68.5%), and almost two-thirds had comorbid anxiety disorders. A striking 22.6% had bipolar disorders.

CONCLUSIONS AND RELEVANCE

The most common diagnosis in screen-positive women was major depressive disorder with comorbid generalized anxiety disorder. Strategies to differentiate women with bipolar from unipolar disorders are needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00282776.

β-endorphin modulates the effect of stress on novelty-suppressed feeding

Although stress is implicated in the pathophysiology of mood and anxiety disorders, not all individuals who suffer stressful life events develop psychopathology. Differential susceptibility to stress may be influenced by genetically mediated differences in hypothalamic-pituitary-adrenal (HPA) axis activity and moderation of the stress response by the opioid peptide β-endorphin (β-E). The present study investigated genetic contributions to coping behavior by examining anxious behavior of transgenic mice with varying capacities to synthesize β-E [B6.129S2-Pomc^tm1Low/J; regulated by insertion of a premature stop codon into one or both copies of the proopiomelanocortin (POMC) gene], both under normal conditions and following 3 min of forced swim (FS). Ten minutes after this stress exposure or a control manipulation, acutely food-deprived female and male transgenic mice were subjected to a novelty-suppressed feeding (NSF) test, during which their interaction with an almond slice located in the center of an open field box was measured. There was an interaction between genotype and stress for latency to approach the almond and whether or not the almond was approached, such that mice with low or absent β-E displayed a stronger aversion to novelty-feeding after stress exposure than did mice with normal levels. These data provide evidence for a moderating effect of β-E on the behavioral response to stress. Genotypic differences in anxious behavior emerged when mice were stressed prior to behavioral assessment, suggesting that β-E plays a role in coping behavior. These findings indicate that genetic variability in sensitivity of the β-E system to stress may contribute, at least in part, to heritable differences in stress reactivity as well as vulnerability to stress-related psychopathology.

Alcohol-use disorder severity predicts first-incidence of depressive disorders

BACKGROUND

Previous studies suggest that alcohol-use disorder severity, defined by the number of criteria met, provides a more informative phenotype than dichotomized DSM-IV diagnostic measures of alcohol use disorders. Therefore, this study examined whether alcohol-use disorder severity predicted first-incident depressive disorders, an association that has never been found for the presence or absence of an alcohol use disorder in the general population.

METHOD

In a national sample of persons who had never experienced a major depressive disorder (MDD), dysthymia, manic or hypomanic episode (n=27 571), we examined whether a version of DSM-5 alcohol-use disorder severity (a count of three abuse and all seven dependence criteria) linearly predicted first-incident depressive disorders (MDD or dysthymia) after 3-year follow-up. Wald tests were used to assess whether more complicated models defined the relationship more accurately.

RESULTS

First-incidence of depressive disorders varied across alcohol-use disorder severity and was 4.20% in persons meeting no alcohol-use disorder criteria versus 44.47% in persons meeting all 10 criteria. Alcohol-use disorder severity significantly predicted first-incidence of depressive disorders in a linear fashion (odds ratio 1.14, 95% CI 1.06-1.22), even after adjustment for sociodemographics, smoking status and predisposing factors for depressive disorders, such as general vulnerability factors, psychiatric co-morbidity and subthreshold depressive disorders. This linear model explained the relationship just as well as more complicated models.

CONCLUSIONS

Alcohol-use disorder severity was a significant linear predictor of first-incident depressive disorders after 3-year follow-up and may be useful in identifying a high-risk group for depressive disorders that could be targeted by prevention strategies.

Pilot multimodal twin imaging study of generalized anxiety disorder

BACKGROUND

Generalized anxiety disorder (GAD) is a common chronic condition that is relatively understudied compared to other psychiatric syndromes. Neuroimaging studies have begun to implicate particular neural structures and circuitry in its pathophysiology; however, no genetically informative research has examined the potential sources of reported brain differences.

METHODS

We acquired spectroscopic, volumetric, and diffusion tensor magnetic resonance imaging data from a pilot study of 34 female subjects selected from monozygotic twin pairs based upon their affection status for GAD, and examined brain regions previously implicated in fear and anxiety for their relationship with affection status and genetic risk.

RESULTS

Lifetime GAD associated with increased creatine levels in the amygdala, smaller left hippocampal volume, and lower fractional anisotropy in the uncinate fasciculus which connects amygdala and frontal cortex. In addition, GAD genetic risk predicted increases in myo-inositol in the amygdala and, possibly, glutamate/glutamine/GABA alterations in the hippocampus. The association of lifetime GAD with smaller hippocampal volume was independent of major depression and might represent a common genetic risk marker for internalizing disorders.

CONCLUSIONS

These preliminary data suggest that GAD and its genetic risk factors are likely correlated with volumetric and spectroscopic changes in fear-related limbic structures and their connections with the frontal cortex.

Psychiatric disorders as assessed with SCID in chronic pain patients: the anxiety disorders precede the onset of pain

OBJECTIVE

The aim of the study was to determine the prevalence of psychiatric disorders in patients referred to a tertiary pain clinic. The temporal relationship between the onset of pain and depression and anxiety and the association of psychiatric disorders with pain intensity were also analyzed.

METHOD

One hundred consecutive outpatients underwent a psychiatric assessment using the Structured Clinical Interview and Statistical Manual of Mental Disorders Axis I.

RESULTS

The psychiatric disorders diagnosed for the past 12 months included major depressive (37%), anxiety (25%) and substance use disorder (12%). The prevalence of any lifetime psychiatric disorder was 75%. Most anxiety disorders (77%) had been present before pain onset, whereas 63% of the depressive disorders appeared after the onset of pain. Psychiatric morbidity was associated with increased pain intensity.

CONCLUSIONS

Chronic pain patients have a remarkable psychiatric morbidity. A structured diagnostic interview, covering a large range of psychiatric diagnoses, allows a more comprehensive approach to the assessment of the patient. This should improve the management of chronic pain. However, prospective studies are needed to show this.

Might the inability to feel pleasure (anhedonia) explain the symptoms of major depression and schizophrenia, including unmotivated anxiety, delusions and hallucinations?

Inability to enjoy normally pleasurable experiences (anhedonia) is a symptom common both to major depression and schizophrenia. It also regularly accompanies and follows stress, and its presence in the two mental illnesses could depend on the fact that both are facilitated and often preceded by stressful events. Anhedonia might possibly accompany stress because the loss of the pleasure of aiming for a goal and achieving it (including defending oneself and escaping from a danger) could lead to immobility, and immobility (playing dead) offers the extreme chance of safety when an animal is facing the worst possible stressful situation--being seized by a predator--as in this case any movement can further stimulate the predator's aggressiveness. Perceiving and connecting sensory information also gives pleasure, and this appears to enhance the clarity of sensations and is an important factor in learning. We propose that anhedonia, by reducing or eliminating the pleasure, might jeopardize the usual appearance of the environment, which must not only be clearly perceived but also continuously interpreted (for instance a foreshortening, or something far off seen as small, must not be seen as a real deformation; the same holds for words, where the meaning has to be grasped from the single letters, and so on). Consequently, anhedonia could in some cases make the environment's image strange, distorted and frightening, and this could cause anxiety, confusion, and give problems in contacts with people and things. As correct information about images and sounds can inhibit visual and auditory hallucinations (considering them, like delusions, as attempts to reconstruct and make sense again of a world that is becoming confused and alien), we propose that anhedonia, interfering with the correct perceiving and processing of sensations, may facilitate them.

Recent advances in depression across the generations

This Editorial presents recent research on the transmission of depression across three generations and discusses the implications for improving detection, treatment and prevention and for identifying important subgroups for biological studies. It reports a case-control study of three generations at high or low risk for major depression. The first two generations were followed longitudinally for 20 years and were assessed blind to the clinical status of the other generations. Depression is highly familial across three generations. Over 60% of grandchildren (average age 12 yrs.) with two generations affected with depression already have some psychopathology. Anxiety disorders are usually the first presentation before puberty with an increase in depression in adolescents, especially among girls. New opportunities for early detection and treatment exist. Families with three generations affected with depression present a potentially important group for biological, genetic and neuroimaging studies.

Conduct disorder and psychosocial outcomes at age 30: early adult psychopathology as a potential mediator

Conduct disorder (CD) is associated with a number of adverse psychosocial outcomes in adulthood. There is consistent evidence that CD is predictive of antisocial behavior, but mixed evidence that CD is predictive of other externalizing and internalizing disorders. Further, externalizing and internalizing disorders are often associated with similar psychosocial outcomes as CD. However, relatively little work has examined whether forms of psychopathology (e.g., externalizing and/or internalizing disorders) mediates the relationship between youth CD and adult psychosocial outcomes. The present study examined associations between youth CD and adult psychosocial outcomes and sought to identify forms of psychopathology that may potentially mediate this relationship. Participants completed self-report measures of psychosocial functioning and semi-structured diagnostic interviews during adolescence and young adulthood. Analyses found that most domains of adult psychosocial functioning were associated with youth CD. Adult antisocial behavior was the only form of psychopathology predicted by CD. Adult antisocial behavior appeared to mediate the relationship between CD and marital status, life satisfaction, and being in jail and partially mediated the relationship between CD and family support and global functioning. These data suggest that reducing the progression to adult antisocial behavior may improve multiple psychosocial outcomes among those with a history of CD.

Attitudes, Perceived Ability, and Knowledge About Depression Screening: A Survey of Certified Nurse-Midwives/Certified Midwives

A survey of certified nurse-midwives/certified midwives (CNMs/CMs) attending the 2004 American College of Nurse-Midwives (ACNM) annual meeting was undertaken to describe the depression screening practices of CNMs/CMs and to examine factors associated with depression screening. A relationship was found between attitude, perceived ability, knowledge, education level, and depression screening, with attitude and perceived ability having the strongest positive relationship to screening. Attitude, perceived ability, knowledge, and education accounted for 20% of the variance in depression screening conducted by CNMs/CMs. These findings suggest that the management of depression is not fully integrated into the practice of many CNMs/CMs. Further research is needed to assess screening methods, interventions for the treatment of depression, and evaluation of institutional barriers to depression screening.

The importance of modeling comorbidity using an intra-individual, time-series approach

We suggest that the network approach to comorbidity (Cramer et al.) is best examined by using longitudinal, multi-measurement, intra-individual data. Employment of time-series analysis to the examination of the generalized anxiety disorder and major depressive disorder comorbidity enables a detailed appreciation of fluctuations and causal trajectories in terms of both symptoms and cognitive vulnerability.

Work functioning in persons with depressive and anxiety disorders: the role of specific psychopathological characteristics

BACKGROUND

Depressive and anxiety disorders affect work functioning and cause high labour costs.

AIMS

To examine and compare psychopathological characteristics of depressive and anxiety disorders in their effect on work functioning.

METHOD

In 1876 working participants of the Netherlands Study of Depression and Anxiety (NESDA) associations of presence, severity, comorbidity, duration and type of DSM-IV anxiety and depressive disorders with both absenteeism (<2 weeks and >2 weeks) and work performance (reduced and impaired) were assessed.

RESULTS

People with current depressive disorders had 7.10 times greater odds for the risk of >2 weeks work-absence and 5.67 greater odds for the risk of impaired work performance, while persons with current anxiety disorders had 1.84 and 2.13 greater odds for the risk of >2 weeks absence and impaired work performance, respectively. Even when persons were recovered from depressive and anxiety disorders, they still had a higher risk of poor work functioning. Persons with comorbidity, chronic depressive disorder, a generalized anxiety disorder, and more severity of both anxiety and depressive disorder had higher odds for the risk of absenteeism and decreased work performance.

CONCLUSION

Anxiety disorders have significant negative impact on work functioning, although smaller than the effect of depressive disorders. Comorbidity, severity, type and duration of the disorder, differentiate the risk of poor work functioning.

Longitudinal associations between depressive symptoms and alcohol problems: The influence of comorbid delinquent behavior

OBJECTIVE

Although numerous studies have demonstrated a positive association between depressive symptoms and alcohol problems and related disorders, it remains unclear whether this link can be explained by the joint co-occurrence of these disorders with delinquent behavior. This study examined the longitudinal associations between depressive symptoms and alcohol problems from early adolescence through early adulthood, while accounting for delinquent behavior and the potential interaction effects between delinquent behavior and each of these problems.

METHOD

The National Longitudinal Study of Adolescent Health sample of 20,728 adolescents, followed for 6 years, was used. Males and females were examined separately. Multilevel modeling was used to predict both initial levels and rate of change in alcohol problems based on levels of depressive symptoms and delinquent behavior (and their interaction), and initial level and rate of change in depressive symptoms based on alcohol problems and delinquent behavior (and their interaction).

RESULTS

Once delinquent behavior was included in the model, the reciprocal positive associations between alcohol problems and depressive symptoms tended to remain significant. Some interactive effects between delinquent behavior and these problems were found, mainly in females.

CONCLUSIONS

The reciprocal positive associations between alcohol problems and depressive symptoms over time are not fully due to their joint co-occurrence with delinquent behavior, though delinquent behavior does moderate these links in some cases.

Beta-endorphin mediates behavioral despair and the effect of ethanol on the tail suspension test in mice

BACKGROUND

The opioid peptide beta-endorphin (beta-E) is synthesized and released in response to stressful stimuli as well as acute alcohol administration. The release of beta-E following exposure to an inescapable aversive situation may mediate behaviors that contribute to allostasis of the stress response. The present study examines the effects of beta-E on immobility in assays involving inescapable stress, both under basal conditions and after acute administration of EtOH.

METHODS

Female and male transgenic mice with varying capacities to translate beta-E were subjected to either the forced swim (FST, Experiment 1) or the tail suspension test (TST, Experiment 2). In Experiment 3, mice were divided into three groups based on hormonal status (male, female-estrous, and female-nonestrous) and injected with either 1 g/kg EtOH or equivolume saline 14 minutes prior to behavioral assessment on the TST.

RESULTS

Experiments 1 and 2 demonstrated a direct relationship between beta-E levels and immobility. There were also sex differences in behavior in these tests, with males displaying more immobility than females. A main effect of genotype in Experiment 3 replicated findings in Experiments 1 and 2. There was also an effect of EtOH (increasing immobility) and a significant interaction reflecting a particularly robust effect of the drug in mice with low beta-E. In addition, there were interactions between beta-E, EtOH effects, and hormonal status.

CONCLUSIONS

These findings support the contention that beta-E moderates behavioral responses to stressful stimuli and suggest a role for this peptide in coping behavior. Furthermore, the effects of EtOH on the response to stress may be mediated by beta-E. Sex differences in this influence may contribute to sex differences in disease susceptibility and expression.

Longitudinal associations between depression and substance dependence from adolescence through early adulthood

AIMS

The association between depression and substance dependence is poorly understood; examinations of these two disorders over time during key developmental periods can provide insight into how these problems relate to each other. The goal of the present study was to examine longitudinal associations between depression and substance (alcohol and illicit drug) dependence during the period from adolescence through early adulthood.

PARTICIPANTS

Participants in the Minnesota Twin Family Study, a community-based sample of 1252 youth and their families, were used. Youth were first assessed at age 17; they returned to the study at ages 20 and 24.

MEASUREMENTS

Major depression and drug and alcohol dependence were assessed via structured interviews. Gender was examined as a possible moderator.

FINDINGS

The results indicated that both substance dependence and depression showed stability over time--that is, each disorder was associated with increased risk for the same disorder later. Substance dependence between ages 17 and 20 predicted increased risk of depression between ages 20 and 24. These associations did not differ significantly by gender.

CONCLUSIONS

Substance dependence during late adolescence predicts the subsequent occurrence of major depression.

Stress-related neuropeptides and alcoholism: CRH, NPY, and beyond

This article summarizes the proceedings of a symposium held at the conference on "Alcoholism and Stress: A Framework for Future Treatment Strategies" in Volterra, Italy, May 6-9, 2008. Chaired by Markus Heilig and Roberto Ciccocioppo, this symposium offered a forum for the presentation of recent data linking neuropetidergic neurotransmission to the regulation of different alcohol-related behaviors in animals and in humans. Dr. Donald Gehlert described the development of a new corticotrophin-releasing factor receptor 1 antagonist and showed its efficacy in reducing alcohol consumption and stress-induced relapse in different animal models of alcohol abuse. Dr. Andrey Ryabinin reviewed recent findings in his laboratory, indicating a role of the urocortin 1 receptor system in the regulation of alcohol intake. Dr. Annika Thorsell showed data supporting the significance of the neuropeptide Y receptor system in the modulation of behaviors associated with a history of ethanol intoxication. Dr. Roberto Ciccocioppo focused his presentation on the nociceptin/orphanin FQ (N/OFQ) receptors as treatment targets for alcoholism. Finally, Dr. Markus Heilig showed recent preclinical and clinical evidence suggesting that neurokinin 1 antagonism may represent a promising new treatment for alcoholism. Collectively, these investigators highlighted the significance of neuropeptidergic neurotransmission in the regulation of neurobiological mechanisms of alcohol addiction. Data also revealed the importance of these systems as treatment targets for the development of new medication for alcoholism.

Increased acid sphingomyelinase activity in peripheral blood cells of acutely intoxicated patients with alcohol dependence

BACKGROUND

Acid sphingomyelinase (ASM; EC 3.1.4.12) hydrolyses membrane sphingomyelin into the bioactive lipid ceramide and is thus involved in different cellular processes such as differentiation, immunity, or cell death. Activation of ASM has been reported in particular in conjunction with the cellular stress response to several external stimuli, and increased ASM activity was observed in a variety of human diseases. Ethanol-induced activation of ASM has been observed in different cell culture systems, thus raising the question about the effect of alcohol intoxication in human subjects on ASM activity in vivo.

METHODS

We determined ASM activity in peripheral blood mononucleated cells of 27 patients suffering from alcohol dependence. Patients were classified according to their blood alcohol concentration at admission, and ASM activity was determined repeatedly from all patients during alcohol withdrawal.

RESULTS

Acutely intoxicated patients displayed significantly higher ASM activity than patients in early abstinence (Mann-Whitney U test: Z = - 2.6, p = 0.009). ASM activity declined in acutely intoxicated patients to normal values with the transition from the intoxicated state to early abstinence (Wilcoxon test: Z = -2.7, p = 0.007). At the end of withdrawal, ASM activity was significantly increased again compared to the early phase of abstinence in both patient groups (Wilcoxon test: Z = -2.691, p = 0.007 and Z = -2.275, p = 0.023, respectively).

CONCLUSIONS

Alcohol-induced activation of ASM occurs in human subjects and might be responsible for deleterious effects of ethanol intoxication. Chronic alcohol abuse may induce deregulation of sphingomyelin metabolism in general, and this impairment may cause side effects during withdrawal from alcohol.

Risk factors for depressive disorders in the Lundby cohort--a 50 year prospective clinical follow-up

BACKGROUND

Depressive disorders are common and disabling. The Lundby Study is a prospective study of a community sample that started in 1947 (N=2550). In 1957, 1013 newcomers were added. The latest field investigation was carried out in 1997.

AIM

To identify risk factors for depressive disorders.

METHOD

The Lundby database contains clinical assessments of the subjects made by psychiatrists. It also includes information about socio-demographic factors and episodes of somatic and mental disorders. Two different but partly overlapping cohorts from the same geographical area in 1947 (N=2470) and in 1957 (N=3310) were investigated. During follow-up 418 individuals experienced their first depressive disorder. For each cohort, possible risk factors were analysed by means of Cox regression analyses for the whole sample and for each sex separately.

CONCLUSION

The personality trait nervous/tense and anxiety disorders were statistically significant risk factors for depression for both genders. For males, the diagnoses alcohol disorders and tiredness disorder were risk factors. The personality trait subvalidity (low grade of energy) and nervous symptoms as a child were also risk factors for males. For females personality traits such as being easily hurt, abnormal/antisocial and tired/distracted were associated with depressive disorders.

CLINICAL RELEVANCE

Knowledge of risk factors may help to reduce incidence of depression.

Lifetime comorbidities between phobic disorders and major depression in Japan: results from the World Mental Health Japan 2002-2004 Survey

BACKGROUND

Although often considered of minor significance in themselves, evidence exists that early-onset phobic disorders might be predictors of later more serious disorders, such as major depressive disorder (MDD). The purpose of this study is to investigate the association of phobic disorders with the onset of MDD in the community in Japan.

METHODS

Data from the World Mental Health Japan 2002-2004 Survey were analyzed. A total of 2,436 community residents aged 20 and older were interviewed using the WHO Composite International Diagnostic Interview 3.0 (response rate, 58.4%). A Cox proportional hazard model was used to predict the onset of MDD as a function of prior history of DSM-IV specific phobia, agoraphobia, or social phobia, adjusting for gender, birth-cohort, other anxiety disorders, education, and marital status at survey.

RESULTS

Social phobia was strongly associated with the subsequent onset of MDD (hazard ratio [HR]=4.1 [95% CI: 2.0-8.7]) after adjusting for sex, birth cohort, and the number of other anxiety disorders. The association between agoraphobia or specific phobia and MDD was not statistically significant after adjusting for these variables.

CONCLUSIONS

Social phobia is a powerful predictor of the subsequent first onset of MDD in Japan. Although this finding argues against a simple neurobiological model and in favor of a model in which the cultural meanings of phobia play a part in promoting MDD, an elucidation of causal pathways will require more fine-grained comparative research.

Predictors of first lifetime episodes of major depression in midlife women

BACKGROUND

Little is known about factors that predict first lifetime episodes of major depression in middle-aged women. It is not known whether health-related factors and life stress pose more or less of a risk to the onset of clinical depression than does the menopausal transition.

METHOD

The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was used to assess diagnoses of lifetime, annual and current major depression in a community-based sample of premenopausal or early perimenopausal African American and White women. Menstrual cycle characteristics, psychosocial and health-related factors, and blood samples for assay of reproductive hormones were obtained annually. Two hundred and sixty-six women without a history of major depression at baseline constituted the cohort for the current analyses.

RESULTS

Over 7 years of follow-up, 42 (15.8%) women met criteria for a diagnosis of major depression. Frequent vasomotor symptoms (VMS; hot flashes and/or night sweats) (HR 2.14, p=0.03) were a significant predictor of major depression in univariate analyses. After simultaneous adjustment for multiple predictors in Cox proportional hazards analyses, frequent VMS were no longer significant; lifetime history of an anxiety disorder (HR 2.20, p=0.02) and role limitations due to physical health (HR 1.88, p=0.07) at baseline and a very stressful life event (HR 2.25, p=0.04) prior to depression onset predicted a first episode of major depression.

CONCLUSIONS

Both earlier (e.g. history of anxiety disorders) and more proximal factors (e.g. life stress) may be more important than VMS in contributing to a first episode of major depression during midlife.

Disruptive behavior disorders in offspring of parents with major depression: associations with parental behavior disorders

OBJECTIVE

Although the offspring of parents with major depressive disorder (MDD) are at increased risk to develop disruptive behavior disorders (DBD) in addition to MDD, it remains unclear whether this heightened risk is due to MDD or to comorbid DBD in the parents.

METHOD

In a secondary analysis of longitudinal data from offspring at risk for MDD and panic disorder and comparison children, we stratified 169 children of parents who had been treated for MDD based upon presence (n=50) or absence (n=119) of parental history of DBD (ADHD, oppositional disorder, and conduct disorder) and contrasted them with children of parents with DBD but without MDD (n=19) and children whose parents had neither MDD nor DBD (n=106). The children had been assessed in middle childhood using structured diagnostic interviews.

RESULTS

Offspring of parents with MDD + DBD had significantly higher rates of MDD, DBD in general, and ADHD in particular, compared with offspring of parents with MDD alone. Offspring of parents with MDD + DBD also had higher rates of mania than controls. Both parental MDD and DBD conferred independent risk for MDD and DBD in the offspring. However, only parental DBD conferred independent risk for conduct disorder and ADHD and only parental MDD conferred independent risk for oppositional defiant disorder.

CONCLUSION

Elevated rates of DBD in the offspring of parents with MDD appear to be due in part to the presence of DBD in the parents. Further studies of samples not selected on the basis of parental panic disorder are needed to confirm these results.

Longitudinal associations between alcohol problems and depressive symptoms: early adolescence through early adulthood

BACKGROUND

Alcohol use-related problems and depressive symptoms are clearly associated with each other, but results regarding the nature of this association have been inconsistent. In addition, the possible moderating effects of age and gender have not been comprehensively examined. The goals of this study were to clarify: (i) how depressive symptoms affect the levels and trajectory of alcohol use-related problems, (ii) how alcohol use-related problems affect the levels and trajectory of depressive symptoms, and (iii) whether there are differences in these associations at different points in development or between males and females.

METHODS

Participants for this study were drawn from the National Longitudinal Study of Adolescent Health (AddHealth) data set, a community-based sample of 20,728 adolescents followed from adolescence through early adulthood. Multilevel models were used to assess how each problem affected the level and rate of change in the other problem over time; gender was considered as a possible moderator of these associations.

RESULTS

The results indicated that alcohol use-related problems and depressive symptoms had reciprocal, positive associations with each other during the period from early adolescence through early adulthood; however, these effects differed somewhat by gender and age. High levels of depressive symptoms were associated with higher initial levels of alcohol problems (particularly among females), as well as faster increases in alcohol problems over time among males. High levels of alcohol problems were associated with higher initial levels of depressive symptoms (particularly among females), as well as less curvature in the slope of depressive symptoms so that although there was a large difference between people with high and low depressive symptoms in early adolescence, by early adulthood the difference was smaller (particularly among females).

CONCLUSIONS

These results highlight the importance of examining gender and age in studies on the associations between affective disorders and substance use disorders.

Finding gene-environment interactions for phobias

Phobias are common disorders causing a great deal of suffering. Studies of gene-environment interaction (G x E) have revealed much about the complex processes underlying the development of various psychiatric disorders but have told us little about phobias. This article describes what is already known about genetic and environmental influences upon phobias and suggests how this information can be used to optimise the chances of discovering G x Es for phobias. In addition to the careful conceptualisation of new studies, it is suggested that data already collected should be re-analysed in light of increased understanding of processes influencing phobias.

Prevalence, comorbidity, and service utilization for mood disorders in the United States at the beginning of the twenty-first century

The results of recent community epidemiological research are reviewed, documenting that major depressive disorder (MDD) is a highly prevalent, persistent, and often seriously impairing disorder, and that bipolar disorder (BPD) is less prevalent but more persistent and more impairing than MDD. The higher persistence and severity of BPD results in a substantial proportion of all seriously impairing depressive episodes being due to threshold or subthreshold BPD rather than to MDD. Although the percentage of people with mood disorders in treatment has increased substantially since the early 1990s, a majority of cases remain either untreated or undertreated. An especially serious concern is the misdiagnosis of depressive episodes due to BPD as due to MDD because the majority of depression treatment involves medication provided by primary care doctors in the absence of psychotherapy. The article closes with a discussion of future directions for research.

Assessment and diagnosis of personality disorder: perennial issues and an emerging reconceptualization

This chapter reviews recent (2000-2005) personality disorder (PD) research, focusing on three major domains: assessment, comorbidity, and stability. (a) Substantial evidence has accrued favoring dimensional over categorical conceptualization of PD, and the five-factor model of personality is prominent as an integrating framework. Future directions include assessing dysfunction separately from traits and learning to utilize collateral information. (b) To address the pervasiveness and extent of comorbidity, researchers have begun to move beyond studying overlapping pairs or small sets of disorders and are developing broader, more integrated common-factor models that cross the Axis I-Axis II boundary. (c) Studies of PD stability have converged on the finding that PD features include both more acute, dysfunctional behaviors that resolve in relatively short periods, and maladaptive temperamental traits that are relatively more stable-similar to normal-range personality traits-with increasing stability until after 50 years of age. A new model for assessing PD-and perhaps all psychopathology-emerges from integrating these interrelated reconceptualizations.

Childhood depressive symptoms and early onset of alcohol use

OBJECTIVES

Few studies have assessed the relationship between depressive symptoms and early onset of alcohol use in children and early adolescents. We aimed to determine whether depressive symptoms in children are associated with subsequent initiation of alcohol use and, if so, whether this association is merely a result of demographic, parental, and/or individual risk factors shared by depression and alcohol use or independent of these shared risk factors.

METHODS

Analyses were based on a subsample of 10- to 13-year-old children (N = 1119) from the Boricua Youth Study, a longitudinal study of psychopathology among Puerto Rican children and early adolescents. Children in the study were assessed over 3 waves between 2000 and 2004. In-person structured interviews were conducted with both parents and children.

RESULTS

Depressive symptoms and alcohol use shared some significant risk and protective factors, such as parental psychopathology, parenting, child exposure to violence, and antisocial behaviors. After controlling for these factors, the association between depressive symptoms and alcohol use was reduced, but childhood depressive symptoms were still positively associated with subsequent alcohol use initiation. Children with medium or high levels of depressive symptoms were more than twice as likely to use alcohol as those with <2 depressive symptoms.

CONCLUSIONS

The finding of the current study that early life depressive symptoms may lead to earlier onset of alcohol use indicates the importance of identifying and treating depressive symptoms in preadolescent children. It also demonstrates the importance of examining shared risk and protective factors for understanding the relationship between depressive symptoms and alcohol use.

Temperament as a unifying basis for personality and psychopathology

Personality and psychopathology long have been viewed as related domains, but the precise nature of their relations remains unclear. Through most of the 20th century, they were studied as separate fields; within psychopathology, clinical syndromes were separated from personality disorders in 1980. This division led to the revelation of substantial overlap among disorders both within and across axes and to the joint study of normal and abnormal personality. The author reviews these literatures and proposes an integrative framework to explain personality-psychopathology relations: Three broad, innate temperament dimensions--negative affectivity, positive affectivity, and disinhibition--differentiate through both biologically and environmentally based developmental processes into a hierarchical personality trait structure and, at their extremes, are risk factors (diatheses) for psychopathology, especially given adverse life experiences (stress).

Adolescent outcome of disruptive behaviour disorder in children who had been treated in in-patient and day-treatment settings

Although several studies have been conducted on the longitudinal course of childhood disruptive behaviours in community samples and in general psychiatric samples, little is known about adolescent adjustment in psychiatrically treated disruptive behaviour disorder (DBD) children. We examined a sample of adolescents (n = 47) who had been treated as children in an in-patient and/or day-treatment setting because of their severely disruptive behaviour. At follow-up, we found that half of the adolescents had a DBD diagnosis, and on average higher numbers of participants ever used soft drugs, had ever been in court, were not attending school when this was mandatory, and were smoking on a daily basis, as compared to comparison groups. There was, however, a large variance among the adolescents of our sample. When outcome was defined in terms of DBD diagnosis, living status, delinquency, school attendance, and smoking behaviour, 38 % had a positive outcome and 34 % had a poor outcome. For clinical purposes, it is important to recognise that there are large individual differences in outcome.

Pharmacological aspects of the treatment of conduct disorder in children and adolescents

In recent years, the rates of psychosocial disorders in children and adolescents have increased, with behavioural manifestations of conduct disorder being one of the most common reasons for referrals to community psychiatrists. Childhood conduct problems are associated with a variety of psychiatric disorders in adult life that extend beyond antisocial behaviour. An increased awareness of the costs of conduct disorder to individuals, families and society has led to advancements in the pharmacological and nonpharmacological therapeutic modalities for this disorder. Despite this, patients with conduct disorder are difficult to treat as the patterns of maladaptive behaviours they exhibit are diverse and can vary as a function of age and sex. A multidisciplinary approach to the treatment of conduct disorder, which includes behavioural parent training, interpersonal skills training, family therapy and the use of psychotropic agents targeted at a particular cluster of symptoms, can increase the overall effectiveness of each of the applied interventions. Aggression, hyperactivity, impulsivity and mood symptoms are the most sensitive proximal targets. Evidence suggests that antipsychotics, antidepressants, mood stabilisers, antiepileptic drugs, stimulants and adrenergic drugs can be well tolerated and effective therapeutic options for individuals with conduct disorder and comorbid psychiatric conditions. However, the most successful therapeutic outcomes are likely to be achieved by combining the current advances in psychopharmacology with behavioural and psychosocial interventions, aimed at modifying the excessive patterns of maladaptive behaviours observed in conduct disorder.

A 6-months assessment of the alcohol-related clinical burden at emergency rooms (ERs) in 11 acute care hospitals of an urban area in Germany

Background

The purpose of the study was to identify and to profile alcohol-related attendances to emergency rooms (ERs) of 11 hospitals of various medical specialties covering a large urban population, to assess risk factors associated with short-stay cases, repeat attendances and higher degree of alcohol consumption and to estimate their impact on the alcohol-related burden at ERs.

Methods

A 6-months study was carried out to obtain clinical and administrative data on single and multiple attendances at ERs in 11 governmental acute hospitals in a large city in Germany. All alcohol-related attendances at ERs of study hospitals were eligible. A broad definition of alcohol-related attendances independently from alcohol diagnosis and various demographic, clinical and administrative measures were used. Odds ratios for the associations of these measures with duration of stay, repeat attendances and higher degrees of alcohol consumption were derived from multivariate binomial and multinomial logistic regression models.

Results

1,748 patients with symptoms of alcohol consumption or withdrawal (inclusion rate 83.8%) yielded 2,372 attendances (3% of all medical admissions), and resulted in 12,629 inpatient-days. These patients accounted for 10.7 cases per 1,000 inhabitants. The average duration of inpatient stay was 10 days. 1,451 of all patients (83%) presented once, whereas the median of repeat attendances was three for the remaining 297 patients. Short-stay cases (<24 hours) were significantly linked with male gender, alcohol misuse, trauma (or suspicion of a trauma) and medical specialties. Increased levels of alcohol consumption at first attendance were significantly associated with repeat attendances in due course. In a multinomial logistic regression model higher degrees of alcohol consumption were significantly associated with male gender, trauma, short-stays, attendance outside regular working time, and with repeat attendances and self-discharge.

Conclusion

Apart from demographic factors, the alcohol-related clinical burden is largely determined by short-stay cases, repeat attendances and cases with higher levels of alcohol consumption at first attendance varying across medical specialties. These findings could be relevant for the planning of anti-alcoholic interventions at ERs.

The role of corticotropin-releasing factor-like peptides in cannabis, nicotine, and alcohol dependence

The corticotropin-releasing factor (CRF)-like peptides, which include the mammalian peptides CRF, urocortin 1, urocortin 2, and urocortin 3, play an important role in orchestrating behavioral and physiological responses that may increase an organism's chance of survival when confronted with internal or external stressors. There is, however, evidence that a chronic overactivity of brain CRF systems under basal conditions may play a role in the etiology and maintenance of psychiatric disorders such as depression and anxiety disorders. In addition, there is evidence of a role for CRF-like peptides in acute and protracted drug abstinence syndromes and relapse to drug-taking behavior. This review focuses on the role of CRF-like peptides in the negative affective state associated with acute and protracted withdrawal from three widely abused drugs, cannabis, nicotine, and alcohol. In addition, we discuss the high comorbidity between stress-associated psychiatric disorders and drug dependence. A better understanding of the brain stress systems that may underlie psychiatric disorders, acute and protracted drug withdrawal, and relapse to drug-taking behavior may help in the development of new and improved pharmacotherapies for these widespread psychiatric disorders.