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Barrigon ML, Cegla-Schvartzman F. Sex, Gender, and Suicidal Behavior. Curr Top Behav Neurosci 2020; 46:89-115. [PMID: 32860593 DOI: 10.1007/7854_2020_165] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This chapter reviews gender differences in suicide, commonly known as the gender paradox in suicide. While men are more likely to complete suicide, suicide attempts are more frequent in women. Although there are exceptions, this paradox occurs in most countries over the world, and it is partially explained by the preference of men for more lethal methods. Nevertheless, there are differences in the known risk factors for suicide between men and women, and this chapter summarizes the more relevant findings for the gender paradox. Apart from previous attempts, which still is the strongest predictor of death by suicide, with a higher rate in males than in females, we will emphasize in the role of male depression. It is commonly recognized that over 90% of people who die by suicide had a psychiatric diagnosis, mostly depression, and male depression seems to be a distinct clinical phenotype challenging to recognize, which might contribute to the gender paradox. Finally, in light of all the information reviewed, some recommendations on prevention of suicide from a gender perspective in the clinical setting will be made.
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Albert U, Marazziti D, Di Salvo G, Solia F, Rosso G, Maina G. A Systematic Review of Evidence-based Treatment Strategies for Obsessive- compulsive Disorder Resistant to first-line Pharmacotherapy. Curr Med Chem 2019; 25:5647-5661. [PMID: 29278206 DOI: 10.2174/0929867325666171222163645] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/19/2017] [Accepted: 11/22/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Serotonin reuptake inhibitors (SRIs) and cognitive-behavioral psychotherapy (CBT) are first-line treatments for obsessive-compulsive disorder (OCD). However, a significant proportion of patients do not respond satisfactorily to first-choice treatments. Several options have been investigated for the management of resistant patients. OBJECTIVE The aim of the present paper is to systematically review the available literature concerning the strategies for the treatment of resistant adult patients with OCD. METHOD We first reviewed studies concerning the definition of treatment-resistant OCD; we then analyzed results of studies evaluating several different strategies in resistant patients. We limited our review to double-blind, placebo-controlled studies performed in adult patients with OCD whose resistance to a first adequate (in terms of duration and dosage) SRI trial was documented and where outcome was clearly defined in terms of decrease in Yale-Brown Obsessive-Compulsive Scale (YBOCS) scores and/or response/ remission rates (according to the YBOCS). RESULTS We identified five strategies supported by positive results in placebo-controlled randomized studies: 1) antipsychotic addition to SRIs (16 RCTs, of them 10 positive; 4 head-to-head RCTs); among antipsychotics, available RCTs examined the addition of haloperidol (butyrophenone), pimozide (diphenyl-butylpiperidine), risperidone (SDA: serotonin- dopamine antagonist), paliperidone (SDA), olanzapine (MARTA: multi-acting receptor targeted antipsychotic), quetiapine (MARTA) and aripiprazole (partial dopamine agonist); 2) CBT addition to medication (2 positive RCTs); 3) switch to intravenous clomipramine (SRI) administration (2 positive RCTs); 4) switch to paroxetine (SSRI: selective serotonin reuptake inhibitor) or venlafaxine (SNRI: serotonin-norepinephrine reuptake inhibitor) when the first trial was negative (1 positive RCT); and 5) the addition of medications other than an antipsychotic to SRIs (18 RCTs performed with several different compounds, with only 4 positive studies). CONCLUSION Treatment-resistant OCD remains a significant challenge to psychiatrists. To date, the most effective strategy is the addition of antipsychotics (aripiprazole and risperidone) to SRIs; another effective strategy is CBT addition to medications. Other strategies, such as the switch to another first-line treatment or the switch to intravenous administration are promising but need further confirmation in double-blind studies. The addition of medications other than antipsychotics remains to be studied, as several negative studies exist and positive ones need confirmation (only 1 positive study).
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Affiliation(s)
- Umberto Albert
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Donatella Marazziti
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Gabriele Di Salvo
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Francesca Solia
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Gianluca Rosso
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
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Albert U, Di Salvo G, Solia F, Rosso G, Maina G. Combining Drug and Psychological Treatments for Obsessive- Compulsive Disorder: What is the Evidence, When and for Whom. Curr Med Chem 2019; 25:5632-5646. [PMID: 28707590 DOI: 10.2174/0929867324666170712114445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 04/11/2017] [Accepted: 05/30/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Serotonin reuptake inhibitors (SRIs) and cognitive-behavioral psychotherapy (CBT) are first-line treatments for obsessive-compulsive disorder (OCD). Since response is often inadequate, in recent years researchers investigated whether combining CBT and SRIs, either ab initio or sequentially, results in a greater reduction of obsessivecompulsive symptoms. OBJECTIVE The aims of the present paper are to assess if combination treatment seems adding benefits as compared to either monotherapy alone and if sequential strategies may be effective in converting partial or non responders to a first-line treatment into responders. METHOD We reviewed available literature on pharmacological and CBT combination and sequential treatments for adult and pediatric OCD patients and then we conducted a separate analysis for studies concerning these two promising strategies. Search results included openlabel trials and randomized controlled trials (RCTs). RESULTS We identified ten controlled studies assessing the efficacy of combination treatments ab initio versus CBT alone and six evaluating combination strategies ab initio versus medications alone. Eleven studies, only two of which were RCTs, have been published on sequential treatments. The combination ab initio of CBT and SRIs has not been found to be clearly superior to either monotherapy alone in most studies conducted on this topic, except for patients with severe depression who might benefit more from the combination versus only CBT. A sequential administration of CBT after medications has been found useful in promoting remission in patients who partially responded to drugs and in promoting response in resistant patients. CONCLUSION OCD patients with comorbid major depression should receive medication firstly, eventually associated with CBT; for all remaining patients there is clear evidence from the literature of no additive benefits of combining ab initio CBT and medication. Therefore, the routine use of a combination approach in all adult patients affected by OCD is not supported by the literature. The available evidence supports the effectiveness of the sequential addition of CBT to SRIs.
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Affiliation(s)
- Umberto Albert
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Gabriele Di Salvo
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Francesca Solia
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Gianluca Rosso
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
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Immediate Effects of Transcranial Direct Current Stimulation on Obsession-Induced Anxiety in Refractory Obsessive-Compulsive Disorder: A Pilot Study. J ECT 2018; 34:e51-e57. [PMID: 29240023 DOI: 10.1097/yct.0000000000000473] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Studies have shown that transcranial direct current stimulation (tDCS) has immediate effects on brain activity. The aim of this study was to investigate the potential use of tDCS to regulate obsession-induced anxiety immediately after symptom provocation in patients with refractory obsessive-compulsive disorder (OCD). METHODS Twelve patients with refractory OCD received cathode, anode, and sham transcranial direct current stimulation over the medial prefrontal cortex conjugant to pharmacological treatment in a crossover design. Before and after the DC stimulation, patients graded the intensity of their anxiety after a short exposure to a provoking stimulus using the visual analogue scale. Clinical questionnaires assessing symptoms severity were also applied before each stimulation mode. RESULTS We found a statistically significant decrease in the severity of the obsession-induced anxiety (decreased visual analogue scale) as a result of cathode tDCS in comparison with the anode and sham stimulation. Reduction in obsession-induced anxiety was consistent, yet short lasting, and was independent of symptom severity. CONCLUSIONS Cathode tDCS could be potentially used to regulate obsession-induced anxiety in refractory OCD patients. Further studies are warranted to confirm our results as well as to determine whether tDCS can achieve prolonged benefits in OCD and be of aid in behavioral treatments based on exposure.
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Defining cognitive-behavior therapy response and remission in pediatric OCD: a signal detection analysis of the Children's Yale-Brown Obsessive Compulsive Scale. Eur Child Adolesc Psychiatry 2017; 26:47-55. [PMID: 27209422 PMCID: PMC6167060 DOI: 10.1007/s00787-016-0863-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 05/04/2016] [Indexed: 12/25/2022]
Abstract
The objective of the study was to examine the optimal Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) percent reduction and raw cutoffs for predicting cognitive-behavioral treatment (CBT) response among children and adolescents with obsessive-compulsive disorder (OCD). The sample consisted of children and adolescents with OCD (N = 241) participating in the first step of the Nordic long-term OCD treatment study and receiving 14 weekly sessions of CBT in the form of exposure and response prevention. Evaluations were conducted pre- and post-treatment, included the CY-BOCS, Clinical Global Impressions-severity/improvement. The results showed that the most efficient CY-BOCS cutoffs were 35 % reduction for treatment response, 55 % reduction for remission, and a post-treatment CY-BOCS raw total score of 11 for treatment remission. Overall, our results diverge from previous research on pediatric OCD with more conservative cutoffs (higher cutoff reduction for response and remission, and lower raw score for remission). Further research on optimal cutoffs is needed.
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Albert U, Aguglia A, Bogetto F, Cieri L, Daniele M, Maina G, Necci R, Parena A, Salvati L, Tundo A. Effectiveness of cognitive-behavioral therapy addition to pharmacotherapy in resistant obsessive-compulsive disorder: a multicenter study. PSYCHOTHERAPY AND PSYCHOSOMATICS 2013; 81:383-5. [PMID: 22964775 DOI: 10.1159/000336873] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 01/30/2012] [Indexed: 11/19/2022]
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Stein DJ, Koen N, Fineberg N, Fontenelle LF, Matsunaga H, Osser D, Simpson HB. A 2012 evidence-based algorithm for the pharmacotherapy for obsessive-compulsive disorder. Curr Psychiatry Rep 2012; 14:211-9. [PMID: 22527872 DOI: 10.1007/s11920-012-0268-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
There is a need to synthesize the growing body of literature on the pharmacotherapeutic management of patients with obsessive-compulsive disorder for clinicians working at a primary care level. We have aimed to generate a simple, easy-to-follow algorithm for the primary care practitioner. This seven-step algorithm addresses diagnosis of obsessive-compulsive disorder, initiation of pharmacotherapy, monitoring and maintenance treatment, and guidelines for the management of patients who are resistant to initial therapy. In creating this algorithm, we have drawn on the body of published evidence, as well as on expert opinion.
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Affiliation(s)
- Dan J Stein
- University of Cape Town Department of Psychiatry, Groote Schuur Hospital, Cape Town, South Africa.
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Tundo A, Salvati L, Di Spigno D, Cieri L, Parena A, Necci R, Sciortino S. Cognitive-behavioral therapy for obsessive-compulsive disorder as a comorbidity with schizophrenia or schizoaffective disorder. PSYCHOTHERAPY AND PSYCHOSOMATICS 2012; 81:58-60. [PMID: 22123432 DOI: 10.1159/000329455] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 05/17/2011] [Indexed: 12/12/2022]
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Wetterneck CT, Little TE, Rinehart KL, Cervantes ME, Hyde E, Williams M. Latinos with obsessive-compulsive disorder: Mental healthcare utilization and inclusion in clinical trials. J Obsessive Compuls Relat Disord 2012; 1:85-97. [PMID: 29057210 PMCID: PMC5647138 DOI: 10.1016/j.jocrd.2011.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Previous research has documented that ethnic minorities, particularly Latinos, obtain fewer mental health services than Caucasians (Kearney, Draper, & Baron 2005; Sue, Fujino, Hu, Takeuchi, & Zane, 1991). Conceivably, this may be due to a wide array of cultural issues (e.g., negative stigma attached to mental health, and language, socio-economic, and acculturation barriers), symptom disparities across Caucasian and Latino groups, or lack of effective outreach methods by clinicians and researchers. However, research is limited. As a result, Latinos may be insufficiently represented in clinical studies for OCD, making it unclear whether evidence-based treatments demonstrate the same efficacy and effectiveness for Latinos as has been demonstrated for Caucasians. The current study takes an in-depth analysis of 98 efficacy and effectiveness studies for OCD from across the Western hemisphere and reports the rates of Latino inclusion from each sample. Ninety clinical studies in the US and Canada, as well as eight clinical studies in Mexico and Central America were reviewed. Findings showed that only 11 (24%) US and Canadian studies included Latino participants, illustrating an overwhelming underrepresentation of Latinos in clinical studies for OCD. Further explanation of the results and their implications are discussed, along with suggestions for effectively improving access to mental health research and appropriate treatments.
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Affiliation(s)
- Chad T Wetterneck
- University of Houston-Clear Lake, 2700 Bay Area Blvd., Houston, TX 77058, United States
| | - Tannah E Little
- University of Houston-Clear Lake, 2700 Bay Area Blvd., Houston, TX 77058, United States
| | - Kimberly L Rinehart
- University of Houston-Clear Lake, 2700 Bay Area Blvd., Houston, TX 77058, United States
| | - Maritza E Cervantes
- University of Houston-Clear Lake, 2700 Bay Area Blvd., Houston, TX 77058, United States
| | - Emma Hyde
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, United States
| | - Monnica Williams
- University of Louisville, Center for Mental Health Disparities, Department of Psychological & Brain Sciences, 2301 South Third St., Louisville, KY 40292, United States
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Anand N, Sudhir PM, Math SB, Thennarasu K, Janardhan Reddy YC. Cognitive behavior therapy in medication non-responders with obsessive-compulsive disorder: a prospective 1-year follow-up study. J Anxiety Disord 2011; 25:939-45. [PMID: 21689902 DOI: 10.1016/j.janxdis.2011.05.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 05/23/2011] [Accepted: 05/25/2011] [Indexed: 11/25/2022]
Abstract
Evidence of efficacy of cognitive behavior therapy (CBT) in obsessive-compulsive disorder (OCD) non-responsive to multiple trials of serotonin reuptake inhibitors (SRI) is limited. We examined the efficacy of CBT in 31 adult patients with DSM-IV OCD who were non-responders to at least two SRI trials. They received 20-25 sessions of CBT over 3-month duration. The primary outcome measure was "response" to treatment [Clinical Global Impressions-Improvement score 1 or 2 and ≥35% reduction in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) severity score]. Patients were assessed at baseline, post-treatment and at 3-, 6- and 12-month follow-up. Twenty-six (84%) patients completed treatment and number of responders at post-treatment, 3-, 6- and 12-month follow-up were 23 (74%), 20 (64%), 20 (64%) and 19 (61%) respectively. Quality of homework compliance and baseline Y-BOCS severity predicted remission (Y-BOCS<16) to CBT. CBT is useful in OCD non-responsive to multiple trials of SRI.
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Affiliation(s)
- Nitin Anand
- Department of Clinical Psychology National Institute of Mental Health & Neuro Sciences, Hosur Road, Bangalore, India
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Rodrigues H, Figueira I, Gonçalves R, Mendlowicz M, Macedo T, Ventura P. CBT for pharmacotherapy non-remitters--a systematic review of a next-step strategy. J Affect Disord 2011; 129:219-28. [PMID: 20863573 DOI: 10.1016/j.jad.2010.08.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Revised: 08/20/2010] [Accepted: 08/26/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Non-remission rates to pharmacotherapy for anxiety disorders are related to higher relapse rates, decreased quality of life and greater functional impairment. Here we sought to investigate the efficacy of cognitive-behavior therapy (CBT) as a next-step strategy in the treatment of patients with anxiety disorders who did not remit after a pharmacological intervention. METHOD We carried out a systematic review in the ISI, Pubmed and PsycINFO/PsychLit databases. Studies that did not use CBT and that did not focus on resistance to drug therapy were excluded. We considered resistant patients who failed to respond (did not fully remit) to an adequate trial of pharmacotherapy and still exhibited residual symptoms of anxiety disorder. RESULTS We identified 603 references in our survey, of which 17 were included: eight were on OCD, five on panic disorder, and four on PTSD. No studies were found on social anxiety disorder and generalized anxiety disorder. We observed a lack of standardization of terminology and of definitions of resistance, which makes comparison of results difficult. Finally, all of the identified studies showed benefits from the addition of CBT as a next-step strategy. LIMITATIONS A limited number of randomized controlled studies were found. CONCLUSIONS CBT seems to be a promising next-step strategy for patients with anxiety disorders who did not remit with drug-based therapies. However, further clinical trials with strong methodological designs are needed to definitely establish its efficacy in this population.
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Affiliation(s)
- Helga Rodrigues
- Institute of Psychiatry, Universidade Federal do Rio de Janeiro (IPUB-UFRJ), Brazil.
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Lewin AB, De Nadai AS, Park J, Goodman WK, Murphy TK, Storch EA. Refining clinical judgment of treatment outcome in obsessive-compulsive disorder. Psychiatry Res 2011; 185:394-401. [PMID: 20846725 DOI: 10.1016/j.psychres.2010.08.021] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 08/17/2010] [Accepted: 08/18/2010] [Indexed: 10/19/2022]
Abstract
This research aimed to provide clinicians and investigators with optimal treatment outcome criteria for accurately predicting response and remission in both research studies and clinical practice. Data from 153 adult OCD outpatients (ages 18-79) who had participated in a treatment outcome study were examined. Signal detection analysis was conducted to compare levels of Yale-Brown Obsessive Compulsive Scale (Y-BOCS) symptom percent reductions and post treatment absolute scores with Clinical Global Impression (CGI) ratings of symptom improvement and severity. Optimal cutoff criteria were based on sensitivity, specificity and efficiency and were assessed via the Quality Receiver Operating Characteristic curve. A Y-BOCS reduction of 45% was observed to be the most efficient for predicting response in research trials, whereas a reduction of 35% may be optimal for clinical use. A 55% Y-BOCS reduction was determined to be the optimal cutoff for predicting remission in both clinical and research settings. A Y-BOCS absolute raw score of 12 or less was optimal for predicting remission in a clinical setting and a raw score of 14 or below was most favorable in research trials. This research provides the first empirical contrast of optimal outcome criteria in OCD based on differing ideals of both research and practice.
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Affiliation(s)
- Adam B Lewin
- Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida College of Medicine, Saint Petersburg, FL, USA.
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Defining treatment response and remission in obsessive-compulsive disorder: a signal detection analysis of the Children's Yale-Brown Obsessive Compulsive Scale. J Am Acad Child Adolesc Psychiatry 2010; 49:708-17. [PMID: 20610140 DOI: 10.1016/j.jaac.2010.04.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 04/11/2010] [Accepted: 04/14/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the optimal Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) percent reduction cutoffs for predicting treatment response and clinical remission among children and adolescents with obsessive-compulsive disorder (OCD). METHOD Youth with OCD (N = 109; range 7 to 19 years) received 14 sessions of weekly or intensive family-based CBT as part of previously published studies or through the standard clinical flow at our facility. Assessments were conducted before and after treatment and included the CY-BOCS, response and remission status on the Clinical Global Impressions Scale, and the Child Obsessive-Compulsive Impact Scale. RESULTS Maximally efficient CY-BOCS cutoffs were observed at a 25% reduction for treatment response, a 45% to 50% reduction for symptom remission, and a CY-BOCS score of 14 when considering raw scores. OCD-related impairment improved as a function of treatment response and symptom remission. CONCLUSIONS These data indicate that a CY-BOCS reduction of 25% appears to be optimal for determining treatment response, a reduction of 45% to 50% appears to be optimal for detecting symptom remission, and a CY-BOCS raw score of 14 best reflects remission after treatment. Clinical trials should employ a consistent definition of treatment response for cross-study comparability. Clinicians can use these values for treatment planning decisions.
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Cordioli AV. [Cognitive-behavioral therapy in obsessive-compulsive disorder]. BRAZILIAN JOURNAL OF PSYCHIATRY 2009; 30 Suppl 2:s65-72. [PMID: 19039446 DOI: 10.1590/s1516-44462008000600003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe the cognitive-behavioral therapy in the treatment of the symptoms of obsessive-compulsive disorder. METHOD Through the revision of text books and articles the origins and fundamentals of cognitive-behavioral therapy in the treatment of the symptoms of obsessive-compulsive disorder are presented. Through the review of randomized clinical trials and meta-analysis in Medline the evidences of effectiveness of cognitive-behavioral therapy in obsessive-compulsive disorder are highlighted. RESULTS AND CONCLUSIONS The cognitive-behavioral therapy is effective in reducing symptoms of obsessive-compulsive disorder by approximately 70% of patients who adhere to treatment. The challenges ahead are to clarify the reasons why many patients do not respond to this kind of treatment and develop new strategies to increase its effectiveness.
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Keks NA, Hill C, Sundram S, Graham A, Bellingham K, Dean B, Opeskin K, Dorissa A, Copolov DL. Evaluation of treatment in 35 cases of bipolar suicide. Aust N Z J Psychiatry 2009; 43:503-8. [PMID: 19440881 DOI: 10.1080/00048670902873680] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate clinical factors relevant to suicide prevention (including treatment) in cases of bipolar suicide with available therapeutic histories. METHOD Victorian Coroner's Office data enabled identification of suicides that occurred between March 1993 and December 2001. Cases involving sufficient clinical notes to enable diagnosis of DSM-IV bipolar disorder and review of treatment were de-identified and assessed by an expert clinical panel. RESULTS From 3752 suicides, 35 eligible bipolar subjects (22 men, 13 women) aged 40.3 +/- 1.8 years were identified. Duration of illness was 11.9 +/- 1.1 years. A total of 86% had made at least one previous suicide attempt, and 83% were in the depressed phase of illness. A total of 63% manifested psychosis at some time during lifetime illness. Fourteen per cent were inpatients, and 26% suicided within 6 weeks of hospital discharge. The panel's retrospective risk assessment concluded that only 48% of cases could have been assessed as high risk. In the 4 weeks prior to suicide, treatment was rated as not reaching benchmark standards in 60% of cases. Electroconvulsive therapy had been given to 11%, lithium to 43% (but definitely therapeutic in only 11%), 31% had never been treated with lithium, and psychosocial interventions did not reach adequate standards in 57% during the previous year. CONCLUSIONS In the majority of bipolar suicide cases in the present case series the subjects did not receive treatment at or above a benchmark standard, often due to illness and situational factors, but also possibly due to inadequate clinical interventions. Strategies to improve treatment may reduce suicide in bipolar disorder.
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Affiliation(s)
- Nicholas A Keks
- Mental Health Research Institute of Victoria, Melbourne, Victoria, Australia.
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Gruber J, Johnson SL. Positive Emotional Traits and Ambitious Goals among People at Risk for Mania: The Need for Specificity. Int J Cogn Ther 2009; 2:176-187. [PMID: 20360995 DOI: 10.1521/ijct.2009.2.2.176] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recent psychosocial theories implicate disturbances in reward pursuit among individuals putatively at risk for mania. The present study examined associations of a measure of risk for mania (the Hypomanic Personality Scale; HPS) with both four trait positive emotions (joy, pride, compassion, and love) and ambitious life goals in five domains (fame, wealth, political influence, family, and friends) among 302 participants from two university settings. Findings indicated that higher HPS scores were related to reward (joy) and achievement-focused (pride) positive emotions, with weaker relations to prosocial (compassion, love) positive emotions. HPS scores were more robustly related to extrinsic (fame, politics) as compared to other-oriented (friends, family) ambitious life goals, with the exception of wealth. These effects were independent of current symptoms of mania and depression. Discussion focuses on the implications of elevated reward and achievement-related positive emotions and goals in understanding risk factors for mania.
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Simpson HB, Foa EB, Liebowitz MR, Ledley DR, Huppert JD, Cahill S, Vermes D, Schmidt AB, Hembree E, Franklin M, Campeas R, Hahn CG, Petkova E. A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. Am J Psychiatry 2008; 165:621-30. [PMID: 18316422 PMCID: PMC3945728 DOI: 10.1176/appi.ajp.2007.07091440] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Although serotonin reuptake inhibitors (SRIs) are approved for the treatment of obsessive-compulsive disorder (OCD), most OCD patients who have received an adequate SRI trial continue to have clinically significant OCD symptoms. The purpose of this study was to examine the effects of augmenting SRIs with exposure and ritual prevention, an established cognitive-behavioral therapy (CBT) for OCD. METHOD A randomized, controlled trial was conducted at two academic outpatient clinics to compare the effects of augmenting SRIs with exposure and ritual prevention versus stress management training, another form of CBT. Participants were adult outpatients (N=108) with primary OCD and a Yale-Brown Obsessive Compulsive Scale total score > or = 16 despite a therapeutic SRI dose for at least 12 weeks prior to entry. Participants received 17 sessions of CBT (either exposure and ritual prevention or stress management training) twice a week while continuing SRI pharmacotherapy. RESULTS Exposure and ritual prevention was superior to stress management training in reducing OCD symptoms. At week 8, significantly more patients receiving exposure and ritual prevention than patients receiving stress management training had a decrease in symptom severity of at least 25% (based on Yale-Brown Obsessive Compulsive Scale scores) and achieved minimal symptoms (defined as a Yale-Brown Obsessive Compulsive Scale score < or = 12). CONCLUSIONS Augmentation of SRI pharmacotherapy with exposure and ritual prevention is an effective strategy for reducing OCD symptoms. However, 17 sessions were not sufficient to help most of these patients achieve minimal symptoms.
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Affiliation(s)
- Helen Blair Simpson
- Anxiety Disorders Clinic, New York State Psychiatric Institute, Unit 69, 1051 Riverside Dr., New York, NY 10032, USA.
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Storch EA, Bagner DM, Geffken GR, Adkins JW, Murphy TK, Goodman WK. Sequential cognitive-behavioral therapy for children with obsessive-compulsive disorder with an inadequate medication response: a case series of five patients. Depress Anxiety 2008; 24:375-81. [PMID: 17044015 DOI: 10.1002/da.20260] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Few data have been reported on the efficacy of cognitive-behavioral therapy (CBT) for youth with obsessive-compulsive disorder (OCD) who have not responded to prior treatment with medication. Given this, we report an open trial of CBT for children who have remained symptomatic following medication trials. Five children with OCD who had an inadequate response to psychotropic medications (e.g., limited response and/or unable to be titrated to a complete dose due to side effects) received treatment in a 3-week intensive CBT program. Assessments were conducted at baseline and after treatment. All participants were classified as treatment responders (much improved or very much improved) and the severity of clinician-rated OCD symptoms and impairment significantly decreased after the intervention. Although a number of limitations of this preliminary report exist, this study provides preliminary support for the utility of an intensive intervention for youth with OCD who have had an inadequate response and/or adverse side effects.
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Affiliation(s)
- Eric A Storch
- Department of Psychiatry, University of Florida, Gainesville, Florida 326110, USA.
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20
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Abstract
AIMS Obsessive-compulsive disorder (OCD) preferentially responds to a class of antidepressants called serotonin reuptake inhibitors (SRI). This review discusses certain issues unique to pharmacological treatment of OCD: choice of SRI, dose and duration of treatment, options after first failed SRI trial and treatment of SRI non-responders. METHODS We performed a MEDLINE search for pharmacotherapy studies published until December 2006. In addition, the reference sections of major articles, and reviews were also screened. We also considered clinical guidelines and narrative reviews in writing this review. RESULTS The SRIs are equally effective in treating OCD. Meta-analyses suggest that clomipramine may be superior to other SRIs. OCD tends to respond to higher doses of SRIs than that used to treat depression. Response to treatment is usually delayed and may take up to 8-12 weeks. Atypical antipsychotics are the only proven augmenting agents in SRI non-responders. Cognitive behaviour therapy (CBT) is an effective treatment strategy in treating OCD and possibly has a role in treating SRI non-responders. DISCUSSION Side effect profile and drug-drug interactions largely determine the choice of SRI. Those who fail to respond to one SRI trial may well respond to another SRI trial. Clomipramine is recommended if 2-3 trials of SRIs fail to produce response. Atypical antipsychotics are the first-line augmenting agents in SRI non-responders. CBT should be considered in all patients with OCD and is a potential option in SRI non-responders. CONCLUSION OCD is a chronic and debilitating disorder. In responders, SRIs have to be continued in the same doses (if possible) for a minimum of 1-2 years and may be lifelong in those with persistent symptoms and in those with multiple relapses. CBT has to be offered in combination with SRIs wherever facilities for CBT exist.
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Affiliation(s)
- S B Math
- OCD clinic, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, India
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Tolin DF, Hannan S, Maltby N, Diefenbach GJ, Worhunsky P, Brady RE. A randomized controlled trial of self-directed versus therapist-directed cognitive-behavioral therapy for obsessive-compulsive disorder patients with prior medication trials. Behav Ther 2007; 38:179-91. [PMID: 17499084 DOI: 10.1016/j.beth.2006.07.001] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Accepted: 07/14/2006] [Indexed: 11/28/2022]
Abstract
Cognitive-behavioral therapy incorporating exposure and response prevention (ERP) is widely considered a first-line psychosocial treatment for patients with obsessive-compulsive disorder (OCD). However, a number of obstacles prevent many patients from receiving this treatment, and self-administered ERP may be a useful alternative or adjunct. Forty-one adult outpatients with a primary diagnosis of OCD, who reported at least 1 current or previous adequate medication trial, were randomly assigned to self-administered or therapist-administered ERP. Patients in both treatment conditions showed statistically and clinically significant symptom reduction. However, patients receiving therapist-administered ERP showed a superior response in terms of OCD symptoms and self-reported functional impairment. We discuss several potential reasons for the superiority of therapist-administered treatment, and propose a stepped-care integration of self-administered and therapist-administered interventions for OCD.
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Affiliation(s)
- David F Tolin
- Institute of Living/Hartford Hospital, Hartford, CT 06106, USA.
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Fontenelle LF, Nascimento AL, Mendlowicz MV, Shavitt RG, Versiani M. An update on the pharmacological treatment of obsessive-compulsive disorder. Expert Opin Pharmacother 2007; 8:563-83. [PMID: 17376013 DOI: 10.1517/14656566.8.5.563] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The purpose of this article is to introduce the reader to an updated evidence-based drug treatment algorithm to be employed in patients with obsessive-compulsive disorder (OCD). Relevant studies were identified through a comprehensive review and classified according to the type of patients enrolled, the quality of the study design and the invasiveness, availability and complexity of the therapeutic approach. When ineffective, therapeutic trials with first-line strategies (such as the selective serotonin re-uptake inhibitors [SSRIs] and venlafaxine) should be followed by treatment approaches such as clomipramine, augmentation with antipsychotics or pindolol, SSRI megadoses or cognitive behavioral therapy. These therapeutic strategies are expected to help most patients with OCD. Additional approaches include intravenous clomipramine, oral morphine, 'heroic drug strategies', deep brain stimulation and functional neurosurgery. Independent studies are urgently needed to help identify the most promising drug treatment sequences for OCD.
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Affiliation(s)
- Leonardo F Fontenelle
- Anxiety and Depression Research Program, Institute of Psychiatry, Universidade Federal of Rio de Janeiro (IPUB/UFRJ), Icaraí, Niterói, RJ, Brazil.
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Abstract
Several lines of evidence suggest a meaningful association between obsessive-compulsive disorder and Tourette syndrome, including comorbidity, phenomenologic overlap, evidence from family and genetic studies, and the possible role of basal ganglia circuitry in both conditions. Obsessive-compulsive behaviors occur frequently in patients who have Tourette syndrome and tend to have a later onset than tics. Despite commonalities, the approaches to treating tics and obsessive-compulsive symptoms are actually quite distinct. A specialized form of cognitive behavior therapy and pharmacotherapy with a potent serotonin reuptake inhibitor are the two established first-line therapies for obsessive-compulsive disorder. An adequate trial of a serotonin reuptake inhibitor is 10 to 12 weeks in duration at doses near the upper end of the recommended range for age and weight. Cases of obsessive-compulsive disorder that do not sufficiently improve with serotonin reuptake inhibitors might benefit from adjunctive low-dose antipsychotic (eg, risperidone) medication whether or not tics are present. Warnings about an increased risk of suicidality among children and adolescents taking antidepressants for pediatric depression extend to those taking the medications for obsessive-compulsive disorder, but the risk-to-benefit ratio is more favorable in this latter population because several serotonin reuptake inhibitors have been shown to be efficacious in obsessive-compulsive disorder.
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Affiliation(s)
- Wayne K Goodman
- Department of Psychiatry, University of Florida, Gainesville, FL 32610, USA.
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Abstract
OBJECTIVE Lamotrigine and electroconvulsive therapy (ECT) are both safe and effective treatments for bipolar depression. Concerns exist that anticonvulsants may interfere with seizure expression during ECT or may exacerbate cognitive side effects, potentially affecting clinical response. This report examines the clinical use of concurrent ECT and lamotrigine for acute bipolar depression and the transition to maintenance therapy. METHODS Nine patients with acute bipolar depression were simultaneously treated with a course of ECT while titrating lamotrigine for maintenance therapy. We compared mean stimulus intensity, mean seizure duration, and mean time to orientation after treatment for each patient during treatment with their highest and lowest lamotrigine dose. RESULTS All 9 patients were treated to remission. From the lowest daily dose to the highest daily dose, mean increase in lamotrigine was 102.8 mg. Clinically adequate seizures were obtained in each patient. Lamotrigine had minimal effect on each measured ECT parameter. The interval between ECT treatments was spaced to a mean of 15.2 days. The treatment combination was well tolerated, with no serious adverse events, no rashes, and no worsening of cognitive side effects. CONCLUSIONS Concurrent use of lamotrigine with ECT in bipolar depression seems safe, did not interfere with routine ECT practice, and allowed for transition to maintenance pharmacotherapy.
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Affiliation(s)
- Heath R Penland
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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Pittenger C, Krystal JH, Coric V. Glutamate-modulating drugs as novel pharmacotherapeutic agents in the treatment of obsessive-compulsive disorder. NeuroRx 2006; 3:69-81. [PMID: 16490414 PMCID: PMC3593363 DOI: 10.1016/j.nurx.2005.12.006] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
SUMMARY Obsessive-compulsive disorder (OCD) is a common psychiatric disorder that produces significant morbidity. The introduction of serotonin reuptake inhibitors in the 1980s represented an important advance in the treatment of OCD. However, few patients show complete remission of their symptoms, and some patients show minimal improvement with existing treatments. We review current treatment strategies and initial data supporting the efficacy of glutamate modulating agents as a novel class of pharmaceuticals for the treatment of OCD. Functional neuroimaging studies repeatedly reported metabolic hyperactivity in the cortico-striato-thalamo-cortical circuitry in patients with OCD. Recent magnetic resonance spectroscopy studies provide evidence of elevated glutamate levels in several brain regions in patients suffering from OCD. These findings raised the possibility that agents that reduce glutamate hyperactivity or its consequences in the CNS might be efficacious as novel therapeutic interventions. Indeed, initial evidence from our group suggests that the antiglutamatergic agent riluzole (Rilutek), which was developed for the treatment of amyotrophic lateral sclerosis, is effective in treatment-resistant OCD. Case reports suggest that other agents that modulate glutamatergic activity may likewise be effective. This new application of glutamate modulating agents holds promise for the treatment of this disabling and often inadequately treated disease.
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Pallanti S, Quercioli L. Treatment-refractory obsessive-compulsive disorder: methodological issues, operational definitions and therapeutic lines. Prog Neuropsychopharmacol Biol Psychiatry 2006; 30:400-12. [PMID: 16503369 DOI: 10.1016/j.pnpbp.2005.11.028] [Citation(s) in RCA: 225] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2005] [Indexed: 01/20/2023]
Abstract
While controlled trials with SRIs have demonstrated a selective efficacy in obsessive-compulsive disorder (OCD), up to 40-60% of patients do not have a satisfactory outcome. Non-response to treatment in OCD is associated with serious social disability. There are a large number of non-responsive patients, and they are difficult to cluster due to ambiguities in diagnostic criteria, possibility of subtypes and a high rate of comorbidity. Moreover, the findings of current studies of "so-called" non-responsive cases are currently non-generalizable because of the lack of an operational definition of non-response. The result has been that a cumulative body of data on a reasonably homogeneous sample of non-responders has not been developed. The aims of the research in this area are to clarify some of the obstacles in defining stages of response and levels of non-response and, through a comprehensive analysis, to propose a systematic nosology for this rather common condition. Better characterization of which patients respond and do not respond to various treatments will enable more accurate clustering of patients, and help facilitate multisite data collection for future research trials. The authors reviewed also the more recent therapeutic pharmacological and psychological lines for the treatment of refractoriness in OCD.
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Koran LM, Aboujaoude E, Ward H, Shapira NA, Sallee FR, Gamel N, Elliott M. Pulse-loaded intravenous clomipramine in treatment-resistant obsessive-compulsive disorder. J Clin Psychopharmacol 2006; 26:79-83. [PMID: 16415712 DOI: 10.1097/01.jcp.0000195112.24769.b3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Small studies have suggested that intravenous clomipramine (CMI) may be more effective and induce faster improvement in obsessive-compulsive disorder than do orally administered serotonin reuptake inhibitors. OBJECTIVE To test these hypotheses, we conducted a randomized, double-blind, double-dummy study of pulse-loaded intravenous versus oral CMI, followed by open-label oral CMI for 12 weeks. METHODS We enrolled a volunteer and referred group of 34 adults with a primary diagnosis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition obsessive-compulsive disorder of > or =1-year duration and Yale-Brown Obsessive Scale score of > or =20. Eligible subjects had failed > or =2 adequate serotonin reuptake inhibitor trials. Subjects received pulse loaded CMI 150 mg by vein or by mouth on day 1 and 200 mg on day 2. Oral CMI began on day 6 at 200 mg/d and was increased by 25 mg every 4 days to 250 mg/d, as tolerated, for 12 weeks. RESULTS Adverse events led to one withdrawal during oral pulse loading and 5 during open-label oral treatment. Intravenous pulse loading did not induce a more rapid or greater Yale-Brown Obsessive Scale score decrease than oral pulse loading at day 6 or by week 12. Day 6 and week 12 improvement were unrelated to plasma drug or metabolite concentrations. Pulse loading itself seemed to induce more rapid and greater improvement than expected in treatment-resistant obsessive-compulsive disorder. CONCLUSIONS Further investigation of oral pulse-loading regimens in treatment-resistant obsessive-compulsive disorder is warranted.
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Affiliation(s)
- Lorrin M Koran
- Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center, Stanford, CA 94305, USA.
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Abstract
In studies made in the last decade, patients consulting doctors because of depression and anxiety have very often turned out to suffer from bipolar type II and similar conditions with alternating depression and hypomania/mania (the bipolar spectrum disorders - BP). Specifically, about every second patient seeking consultation because of depression has been shown to suffer from BP, mainly bipolar type II. BP is often concealed by other psychiatric conditions, e.g. recurrent depression, psychosis, anxiety, addiction, personality disorder, attention-deficit hyperactivity disorder and eating disorder. BP shows strong heredity. Relatives of patients with BP also have a high frequency of the psychiatric conditions just mentioned. Conversion ("switching") from recurrent unipolar depressions (recurrent UP) to BP is common in very long longitudinal studies (over decades). Mood-stabilizing medicines are recommended to a great extent in the treatment of BP, since anti-depressive medicines are often not effective and involve a substantial risk of inducing mood swings. Particularly in the long-term pharmacological treatment of depression in BP anti-depressive medicines may worsen the condition, e.g. inducing a symptom triad of dysphoria, irritability and insomnia: ACID (antidepressant-associated chronic irritable dysphoria).
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Affiliation(s)
- Peter Skeppar
- Department of Adult Psychiatry, Sunderby Hospital, SE-971 80, Lule, Sweden.
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Bodner E, Ben-Artzi E, Kaplan Z. Soldiers who kill themselves: the contribution of dispositional and situational factors. Arch Suicide Res 2006; 10:29-43. [PMID: 16287694 DOI: 10.1080/13811110500318299] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The present study compared characteristics of combatant and non-combatant Israeli soldiers (ages 18-21), who committed suicide (N = 429) with others who did not commit suicide (N = 499). Measures of pre-military psychological characteristics and data reflecting adjustment to service were culled from army records. Findings indicated that, in comparison to non-suicide soldiers (NS-soldiers), soldiers who committed suicide (S-soldiers) had greater behavioral adjustment and motivation to serve. In addition, as compared to non-combatant S-soldiers, combatant S-soldiers had fewer referrals for psychological evaluation, higher sense of duty and autonomy scores and fewer unit changes. Excessive motivation to excel in the army, and the tendency to be autonomous and independent, may account for suicide among combatant S-soldiers, whereas personality weaknesses may have an impact on suicide among non-combatants. Practical implications for the disclosure of suicide risk and for preventive efforts in both groups are discussed.
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Affiliation(s)
- Ehud Bodner
- Interdisciplinary Department of Social Sciences, Bar-Ilan University, Ramat-Gan, Israel.
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Braga DT, Cordioli AV, Niederauer K, Manfro GG. Cognitive-behavioral group therapy for obsessive-compulsive disorder: a 1-year follow-up. Acta Psychiatr Scand 2005; 112:180-6. [PMID: 16095472 DOI: 10.1111/j.1600-0447.2005.00559.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the results of cognitive-behavioral group therapy (CBGT) for obsessive-compulsive disorder (OCD) over a 1-year follow-up period. METHOD Forty-two OCD patients, who completed 12 sessions of CBGT, were followed for 1 year. Measures of the severity of symptoms were obtained at the end of the acute treatment and at 3, 6, and 12 months post-treatment using the Yale-Brown obsessive-compulsive scale (Y-BOCS) and the clinical global impression (CGI). RESULTS The reduction in the severity of symptoms observed at the end of the treatment was maintained during 1 year (F2,41=1.1; P=0.342). Eleven patients (35.5%) relapsed in the follow-up period. The intensity of improvement (log rank=12.97, GL=1, P=0.0003) and full remission (log rank=6.17; GL=1; P=0.001) were strong predictors for non-relapsing. CONCLUSION The CBGT is an effective treatment for OCD and its results are maintained for 1 year. However, further long-term randomized controlled trials are needed in order to confirm this finding.
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Affiliation(s)
- D T Braga
- Anxiety Disorders Program, Department of Psychiatry, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Biondi M, Picardi A. Increased maintenance of obsessive-compulsive disorder remission after integrated serotonergic treatment and cognitive psychotherapy compared with medication alone. PSYCHOTHERAPY AND PSYCHOSOMATICS 2005; 74:123-8. [PMID: 15741763 DOI: 10.1159/000083172] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Both medication and psychotherapy are effective in obsessive-compulsive disorder (OCD). However, they both have disadvantages. We aimed at studying the long-term effectiveness of integrated treatment compared with medication alone. METHODS A private practice sample of 20 consecutive patients with OCD (DSM-III-R) who achieved remission or marked improvement [Yale-Brown Obsessive-Compulsive Scale (YBOCS) score < or =10 and Global Assessment of Functioning (GAF) scale score > or =70] after drug treatment (clomipramine or selective serotonin reuptake inhibitors for 12-24 months) with or without concurrent cognitive psychotherapy were followed up. In the integrated treatment group, psychotherapy was started on the second or third visit and was timed to end after medication. Efforts were applied to integrate treatments within a biopsychosocial theoretical framework. As randomisation was not feasible in the study setting, treatment allocation was based on patients' preference. Patients were assessed before treatment, after treatment and at each follow-up contact with the YBOCS, the Hamilton Depression Rating Scale, and the GAF scale. Kaplan-Meier survival analysis was performed on the time to OCD relapse. RESULTS Of the factors studied (gender, age, duration of disorder, severity of OCD symptoms at baseline), only treatment was associated with outcome. Of 10 patients treated with medication alone, 8 relapsed. Of 10 patients who received integrated treatment, only 1 relapsed. The estimated mean survival time was significantly higher (p < 0.001) in the integrated treatment group (132 months, 95% CI 107-157) than in the medication group (25 months, 95% CI 12-38). CONCLUSIONS Although our results need confirmation by further, more robust studies, the long-term superiority of integrated treatment over medication alone was large. Patients with OCD might have viable options other than long-term drug treatment.
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Affiliation(s)
- Massimo Biondi
- Psychiatric Clinic III, University of Rome La Sapienza, Italy.
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Singh J, Zarate CA, Krystal AD. Case report: Successful riluzole augmentation therapy in treatment-resistant bipolar depression following the development of rash with lamotrigine. Psychopharmacology (Berl) 2004; 173:227-8. [PMID: 14722708 DOI: 10.1007/s00213-003-1756-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2003] [Accepted: 12/05/2003] [Indexed: 10/26/2022]
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Aouizerate B, Guehl D, Cuny E, Rougier A, Bioulac B, Tignol J, Burbaud P. Pathophysiology of obsessive–compulsive disorder. Prog Neurobiol 2004; 72:195-221. [PMID: 15130710 DOI: 10.1016/j.pneurobio.2004.02.004] [Citation(s) in RCA: 226] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2003] [Accepted: 02/19/2004] [Indexed: 11/16/2022]
Abstract
Obsessive-compulsive disorder (OCD) is characterized by repetitive intrusive thoughts and compulsive time-consuming behaviors classified into three to five distinct symptom dimensions including: (1) aggressive/somatic obsessions with checking compulsions; (2) contamination concerns with washing compulsions; (3) symmetry obsessions with counting/ordering compulsions; (4) hoarding obsessions with collecting compulsions; and (5) sexual/religious concerns. Phenomenologically, OCD could be thought of as the irruption of internal signals centered on the erroneous perception that "something is wrong" in a specific situation. This generates severe anxiety, leading to recurrent behaviors aimed at reducing the emotional tension. In this paper, we examine how the abnormalities in brain activity reported in OCD can be interpreted in the light of physiology after consideration of various approaches (phenomenology, neuropsychology, neuroimmunology and neuroimagery) that contribute to proposing the central role of several cortical and subcortical regions, especially the orbitofrontal cortex (OFC), the anterior cingulate cortex (ACC), the dorsolateral prefrontal cortex (DLPC), the head of the caudate nucleus and the thalamus. The OFC is involved in the significance attributed to the consequences of action, thereby subserving decision-making, whereas the ACC is particularly activated in situations in which there are conflicting options and a high likelihood of making an error. The DLPC plays a critical part in the cognitive processing of relevant information. This cortical information is then integrated by the caudate nucleus, which controls behavioral programs. A dysfunction of these networks at one or several stages will result in the emergence and maintenance of repetitive thoughts and characteristic OCD behavior.
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Affiliation(s)
- Bruno Aouizerate
- Service de Neurophysiologie Clinique, Centre Hospitalier Pellegrin, Université Victor Segalen Bordeaux 2, CNRS UMR 5543, Place Amélie-Raba Léon, 33076 Bordeaux, France
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Chioqueta AP, Stiles TC. Suicide Risk in Outpatients with Specific Mood and Anxiety Disorders. CRISIS 2003. [DOI: 10.1027//0227-5910.24.3.105] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Summary: The present study examined the relationships between specific anxiety, mood disorders, levels of hopelessness, and suicide ideation. The sample consisted of 606 outpatients recruited from several psychiatric settings. It was found that dysthymia was significantly associated with hopelessness. Patients presenting major depressive episode with higher anxiety symptoms had significantly increased scores on the hopelessness scale. Major depressive episode and bipolar disorder, but not dysthymia, were significantly associated with higher levels of suicide ideation. Increased levels of anxiety symptoms in patients with dysthymia were associated with increased levels of suicide ideation, while increased depressive symptoms in patients with specific phobia and generalized anxiety disorder were associated with significantly lower levels of suicide ideation. The findings suggest that depressive disorders, but not anxiety disorders, constitute risk for suicide. Moreover, the differentiation between a depressive and an anxiety disorder as the principal diagnosis, as well as the assessment of anxiety-level symptoms in patients with major depressive episode and dysthymia, seems of special relevance when assessing suicide risk.
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Affiliation(s)
| | - Tore C. Stiles
- Norwegian University of Science and Technology, Trondheim, Norway
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Lo A, Shalansky S, Leung M, Hollander Y, Raboud J. Patient characteristics associated with nonprescription drug use in intentional overdose. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2003; 48:232-6. [PMID: 12776389 DOI: 10.1177/070674370304800406] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Over-the-counter (OTC) medications remain freely available to suicidal patients, despite their potential lethality and common use in suicide. The study's main objective was to identify patient characteristics, particularly psychiatric diagnosis associated with the use of OTC medications in intentional overdose. METHODS We retrospectively reviewed 95 charts from patients who presented to St Paul's Hospital from August 1, 1997, to July 31, 1998, with a discharge diagnosis of intentional drug overdose. Univariate analysis was carried out to identify potential risk markers for OTC medication use, and logistic regression was performed using these variables. RESULTS When the variables age, sex, and concurrent psychiatric diagnoses were controlled, use of OTC medications in overdose was significantly lower in patients with a DSM-IV diagnosis of substance abuse (OR 0.11, P = 0.005) and in those who possessed prescription medications at the time of overdose (OR 0.18, P = 0.007). Most patients in this cohort (82%) had at least 1 of these 2 traits. Although not statistically significant, younger patients appeared more likely to choose OTC medications for overdose. CONCLUSION Suicide-prone patients with a diagnosis of substance abuse and who possess prescription medications are unlikely to use OTC medications in overdose. For this cohort, this represents a relatively small proportion of patients whom clinicians should consider to be at greater risk for attempting suicide when using OTC medication, especially acetaminophen.
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Affiliation(s)
- Andre Lo
- Department of Pharmacy, St Paul's Hospital, Providence Health Care, 1081 Burrard Street, Vancouver, BC V6Z 1Y6.
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Maina G, Albert U, Ziero S, Bogetto F. Antipsychotic augmentation for treatment resistant obsessive-compulsive disorder: what if antipsychotic is discontinued? Int Clin Psychopharmacol 2003; 18:23-8. [PMID: 12490771 DOI: 10.1097/00004850-200301000-00004] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of the present study was to retrospectively review the charts of obsessive-compulsive disorder (OCD) patients who responded to the addition of an antipsychotic to the seroronin reuptake inhibitor (SRI), and who subsequently discontinued the antipsychotic, in order to evaluate whether antipsychotic discontinuation resulted in a relapse of the disorder. Charts of patients with a principal diagnosis of OCD (DSM-IV) treated with pharmacotherapy were reviewed in order to select patients who: (i) did not respond to a trial with a first-line drug (clomipramine or a selective SRI); (ii) received an antipsychotic at low doses (haloperidol, pimozide, risperidone or olanzapine) in order to potentiate the SRI; (iii) responded to this augmentation strategy; and (iv) discontinued the antipsychotic drug for any reason while continuing the SRI at the same dose. Relapse was defined as a worsening of Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) total score >/= 35% with respect to last evaluation before antipsychotic discontinuation or, for patients with a Y-BOCS < 16 at the end of the combination period, as a Y-BOCS total score >/= 16 at any time after antipsychotic discontinuation. According to our definition of relapse, 15 patients out of 18 (83.3%) relapsed after antipsychotic discontinuation, with a mean worsening of symptoms of 6.6 +/- 1.7 points in the Y-BOCS total score. Thirteen patients out of the 15 who relapsed did so by week 8 after discontinuation. Two subjects relapsed at the end of the 1-year study. Although retrospective, our study provides initial evidence that antipsychotic augmentation has to be maintained for patients who respond to this strategy, because the vast majority of subjects who discontinue the antipsychotic relapse within 2 months.
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Affiliation(s)
- Giuseppe Maina
- Anxiety and Mood Disorders Unit, University of Turin, Italy.
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Kampman M, Keijsers GPJ, Hoogduin CAL, Verbraak MJPM. Addition of cognitive-behaviour therapy for obsessive-compulsive disorder patients non-responding to fluoxetine. Acta Psychiatr Scand 2002; 106:314-9. [PMID: 12225499 DOI: 10.1034/j.1600-0447.2002.01261.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Selective serotonin re-uptake inhibitors (SSRIs) and cognitive behaviour therapy (CBT) have both proven to be effective in the treatment of obsessive compulsive disorder (OCD). It is generally recommended that adequate but unsuccessful SSRI treatment is supplemented with CBT, although only one empirical study was conducted to verify this recommendation. The present study examined the effects of supplemental CBT to continued fluoxetine treatment in OCD patients non-responding to fluoxetine alone. METHOD After 12 weeks of fluoxetine, 14 of 56 out-patients had a reduction rate less than 25% on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and were classified as non-responders. They subsequently received 12 sessions CBT additional to the continued fluoxetine treatment. RESULTS The mean symptom reduction as rated by the Y-BOCS, for the patients who completed both treatment phases, was 8.5% in the first phase and 41% in the second phase. CONCLUSION Supplemental CBT for OCD patients, after initial, unsuccessful fluoxetine treatment is shown to be effective.
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Affiliation(s)
- M Kampman
- Department of Clinical Psychology, University of Nijmegen and Anxiety Disorders Outpatient Clinic, Nijmegen, The Netherlands.
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39
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Cordioli AV, Heldt E, Bochi DB, Margis R, Sousa MBD, Tonello JF, Teruchkin B, Kapczinski F. Cognitive-behavioral group therapy in obsessive-compulsive disorder: a clinical trial. BRAZILIAN JOURNAL OF PSYCHIATRY 2002. [DOI: 10.1590/s1516-44462002000300004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: To develop a cognitive-behavioral group therapy protocol and to verify its efficacy to reduce obsessive-compulsive symptoms. Methods: An open clinical trial with 32 obsessive-compulsive patients was performed, in which a cognitive-behavioral group therapy protocol of 12 weekly sessions of two hours, in 5 consecutive groups, was applied. The severity of symptoms was rated with the Yale-Brown Obsessive-Compulsive (Y-BOCS), Hamilton Anxiety (HAM A) and Hamilton Depression (HAM D) scales. The patients were followed up for 3 months after the end of the treatment. Results: There was a significant reduction in the scores of Y-BOCS, HAM A and HAM D scales with the treatment regardless the use of anti-obsessive medications. The rate of improved patients (decrease of > or = 35% in Y-BOCS) was 78.1%. Two patients (6.25%) dropped out from the study. The effect size calculated for the Y-BOCS scale was 1.75. Conclusions: This study suggests that cognitive-behavioral group therapy reduces obsessive-compulsive symptoms. In addition, patients presented good compliance.
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Abstract
Obsessive-compulsive disorder is a frequent, chronic, costly, and disabling disorder that presents in several medical settings, but is under-recognised and undertreated. For many years, obsessive-compulsive neurosis was seen as a disorder that provided an important window on the workings of the unconscious mind. Today, obsessive-compulsive disorder is viewed as a good example of a neuropsychiatric disorder, mediated by pathology in specific neuronal circuits, and responsive to specific pharmacotherapeutic and psychotherapeutic interventions. In the future we can expect more precise delineation of the origins of this disorder, with integration of data from neuroanatomical, neurochemical, neuroethological, neurogenetic, and neuroimmunological research.
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Affiliation(s)
- Dan J Stein
- Department of Psychiatry, University of Stellenbosch, Cape Town, South Africa.
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41
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Petkova E, Teresi J. Some statistical issues in the analyses of data from longitudinal studies of elderly chronic care populations. Psychosom Med 2002; 64:531-47. [PMID: 12021427 DOI: 10.1097/00006842-200205000-00018] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This article discusses broad statistical issues common to much medical research: intent-to-treat analysis vs. completers analysis; clustered hierarchical and repeated-measures data; missing data and dropouts; and assessment of direct, indirect, and total effects. Traditional approaches and statistical techniques are reviewed and contrasted with modern methods for analysis of medical studies. METHOD The concepts are introduced and discussed in general terms; they are illustrated with an example. The example comes from a study of the effect of residence in special care units (SCUs) for demented elderly on the daily function of nursing homes residents. More than 700 residents from 22 nursing facilities, residing in either an SCU or a non-SCU were assessed three times at approximate 6-month intervals. RESULTS Results from both the application of traditional statistical techniques and modern methods for the analysis of repeated-measures of hierarchical multicenter data are presented, interpreted, and compared. Advantages and shortcomings of these approaches are discussed. CONCLUSION This article advocates the use of mixed models and proper causal reasoning and terminology in the analysis and publication of results from studies on aging and life course.
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Affiliation(s)
- Eva Petkova
- New York State Psychiatric Institute and Columbia University, Department of Biostatistics, New York, New York 10032, USA.
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42
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Abstract
A selective literature review was conducted to determine the link between mood disorders and suicide in children and adolescents. On-line searches of Medline and PubMed were performed and research articles from 1978 to 2001 were reviewed. Mood disorders are reported to be the most common psychiatric illnesses in children and adolescents who attempt or commit suicide. Reports suggest that depression co-morbid with any other psychiatric illness, externalizing disorders, or substance abuse further increases the risk for suicide completion. Mood disorders in children and adolescents are frequently underdiagnosed, misdiagnosed, and undertreated. Data suggest that very early identification combined with aggressive and sustained treatment of mood disorders in youth may actually lessen the risk for suicide.
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Affiliation(s)
- L E Sanchez
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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43
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Tolin DF. Case study: bibliotherapy and extinction treatment of obsessive-compulsive disorder in a 5-year-old boy. J Am Acad Child Adolesc Psychiatry 2001; 40:1111-4. [PMID: 11556636 DOI: 10.1097/00004583-200109000-00021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cognitive-behavioral therapy (CBT) is an effective treatment for childhood obsessive-compulsive disorder (OCD). However, no case studies of children younger than 7 years old have been published. This case report describes a 5-year-old boy with severe OCD. Treatment consisted of parent- and teacher-directed extinction of compulsive reassurance-seeking, and bibliotherapy with an age-appropriate book on OCD. Compulsive behavior decreased rapidly and remained at a low level through the remainder of treatment. At posttreatment and at 1- and 3-month follow-up assessments, the patient's OCD symptoms were markedly improved. This report suggests that very young children may respond well to brief CBT.
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Affiliation(s)
- D F Tolin
- The Institute of Living and University of Connecticut School of Medicine, Hartford, 06106, USA.
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Romano S, Goodman W, Tamura R, Gonzales J. Long-term treatment of obsessive-compulsive disorder after an acute response: a comparison of fluoxetine versus placebo. J Clin Psychopharmacol 2001; 21:46-52. [PMID: 11199947 DOI: 10.1097/00004714-200102000-00009] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Few controlled studies have evaluated the long-term continuation of pharmacotherapy for relapse prevention in patients with obsessive-compulsive disorder (OCD). This study assessed efficacy and safety of fluoxetine versus placebo in preventing relapse of OCD during a 52-week period in responders to short-term administration of fluoxetine. Patients who met DSM-IV criteria for OCD and had a Yale-Brown Obsessive Compulsive Scale score > or = 19 were treated with single-blind fluoxetine 20, 40, or 60 mg/day (based on physician assessment of response and tolerability). After 20 weeks, responders were randomly assigned to receive continued treatment with fluoxetine or placebo and were monitored for relapse for up to 52 weeks. Of 130 patients who entered the study, 71 (55%) were randomly assigned to receive fluoxetine (N = 36) or placebo (N = 35). Patients who received fluoxetine had numerically lower relapse rates compared with those who received placebo, although the difference was not significant (Kaplan-Meier 1-year relapse rates: fluoxetine, 20.6%; placebo, 31.9%; one-tailed p value = 0.137). In additional analyses evaluating patients on the basis of fluoxetine dose at randomization, patients who continued treatment with fluoxetine 60 mg/day (N = 52) had significantly lower rates of relapse than those who were switched to placebo (Kaplan-Meier 1-year relapse rates: fluoxetine, 17.5%; placebo, 38.0%; one-tailed p value = 0.041). Those who responded to the acute treatment phase with 40 (N = 18) or 20 (N = 1) mg/day had low overall rates of relapse, and the difference between continued fluoxetine and placebo treatment for these patients was not significant. For responders to the 60 mg/day dosage, those patients who continued treatment with fluoxetine were provided greater protection against relapse than those patients switched to placebo.
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Affiliation(s)
- S Romano
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285, USA
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45
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46
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Kochan LD, Qureshi AI, Fallon BA. Therapeutic approaches to the treatment of refractory obsessive-compulsive disorder. Curr Psychiatry Rep 2000; 2:327-34. [PMID: 11122977 DOI: 10.1007/s11920-000-0077-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a debilitating condition that afflicts approximately 1% to 3% of the world population. The primary treatments are selective serotonin reuptake inhibitors and behavioral therapy. Despite therapy, approximately 30% to 40% of patients continue to suffer from disabling OCD symptoms. This article addresses the range of treatment options for patients with refractory OCD, focusing upon novel strategies and the most recent research.
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Affiliation(s)
- L D Kochan
- Anxiety Disorders Clinic, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA
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Meisler N, McKay CD, Gold PB, Schales-Elkins P, Benasutti R, Santos AB. Using principles of ACT to integrate community care for people with mental retardation and mental illness. J Psychiatr Pract 2000; 6:77-83. [PMID: 15990476 DOI: 10.1097/00131746-200003000-00002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors describe the use of an Assertive Community Treatment (ACT) approach in a community living program for persons with both mental retardation and mental illness. The development of the program occurred in the context of a statewide project to serve more than 1,000 dually diagnosed persons who were members of a class action lawsuit against the State of North Carolina. The use of ACT principles marked a substantive departure from the residential supervision and brokered service model employed for the Class throughout the State. The authors describe the public policy context within which the program was developed, discuss the rationale for selecting the ACT model, describe its implementation, and summarize service utilization and outcome information. Changes by the funding agency in its expectations of program staffing and reimbursement methodology that were made after the program was approved led to its early demise. Although the program lasted less than 2 years, during its tenure most participants realized marked improvement in symptoms and community adjustment. Results may cautiously be interpreted as indicating that ACT may reduce the reliance on 24-hour residential and community supervision for many persons with both mental retardation and mental illness.
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Affiliation(s)
- N Meisler
- Medical University of South Carolina, Charleston 29425, USA
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