Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression

BACKGROUND

Electroconvulsive therapy (ECT) and subanesthetic intravenous ketamine are both currently used for treatment-resistant major depression, but the comparative effectiveness of the two treatments remains uncertain.

METHODS

We conducted an open-label, randomized, noninferiority trial involving patients referred to ECT clinics for treatment-resistant major depression. Patients with treatment-resistant major depression without psychosis were recruited and assigned in a 1:1 ratio to receive ketamine or ECT. During an initial 3-week treatment phase, patients received either ECT three times per week or ketamine (0.5 mg per kilogram of body weight over 40 minutes) twice per week. The primary outcome was a response to treatment (i.e., a decrease of ≥50% from baseline in the score on the 16-item Quick Inventory of Depressive Symptomatology-Self-Report; scores range from 0 to 27, with higher scores indicating greater depression). The noninferiority margin was -10 percentage points. Secondary outcomes included scores on memory tests and patient-reported quality of life. After the initial treatment phase, the patients who had a response were followed over a 6-month period.

RESULTS

A total of 403 patients underwent randomization at five clinical sites; 200 patients were assigned to the ketamine group and 203 to the ECT group. After 38 patients had withdrawn before initiation of the assigned treatment, ketamine was administered to 195 patients and ECT to 170 patients. A total of 55.4% of the patients in the ketamine group and 41.2% of those in the ECT group had a response (difference, 14.2 percentage points; 95% confidence interval, 3.9 to 24.2; P<0.001 for the noninferiority of ketamine to ECT). ECT appeared to be associated with a decrease in memory recall after 3 weeks of treatment (mean [±SE] decrease in the T-score for delayed recall on the Hopkins Verbal Learning Test-Revised, -0.9±1.1 in the ketamine group vs. -9.7±1.2 in the ECT group; scores range from -300 to 200, with higher scores indicating better function) with gradual recovery during follow-up. Improvement in patient-reported quality-of-life was similar in the two trial groups. ECT was associated with musculoskeletal adverse effects, whereas ketamine was associated with dissociation.

CONCLUSIONS

Ketamine was noninferior to ECT as therapy for treatment-resistant major depression without psychosis. (Funded by the Patient-Centered Outcomes Research Institute; ELEKT-D ClinicalTrials.gov number, NCT03113968.).

National Network of Depression Centers' Recommendations on Harmonizing Clinical Documentation of Electroconvulsive Therapy

ABSTRACT

Electroconvulsive therapy (ECT) is a highly therapeutic and cost-effective treatment for severe and/or treatment-resistant major depression. However, because of the varied clinical practices, there is a great deal of heterogeneity in how ECT is delivered and documented. This represents both an opportunity to study how differences in implementation influence clinical outcomes and a challenge for carrying out coordinated quality improvement and research efforts across multiple ECT centers. The National Network of Depression Centers, a consortium of 26+ US academic medical centers of excellence providing care for patients with mood disorders, formed a task group with the goals of promoting best clinical practices for the delivery of ECT and to facilitate large-scale, multisite quality improvement and research to advance more effective and safe use of this treatment modality. The National Network of Depression Centers Task Group on ECT set out to define best practices for harmonizing the clinical documentation of ECT across treatment centers to promote clinical interoperability and facilitate a nationwide collaboration that would enable multisite quality improvement and longitudinal research in real-world settings. This article reports on the work of this effort. It focuses on the use of ECT for major depressive disorder, which accounts for the majority of ECT referrals in most countries. However, most of the recommendations on clinical documentation proposed herein will be applicable to the use of ECT for any of its indications.

A biomarker-authenticated model of schizophrenia implicating NPTX2 loss of function

Schizophrenia is a polygenetic disorder whose clinical onset is often associated with behavioral stress. Here, we present a model of disease pathogenesis that builds on our observation that the synaptic immediate early gene NPTX2 is reduced in cerebrospinal fluid of individuals with recent onset schizophrenia. NPTX2 plays an essential role in maintaining excitatory homeostasis by adaptively enhancing circuit inhibition. NPTX2 function requires activity-dependent exocytosis and dynamic shedding at synapses and is coupled to circadian behavior. Behavior-linked NPTX2 trafficking is abolished by mutations that disrupt select activity-dependent plasticity mechanisms of excitatory neurons. Modeling NPTX2 loss of function results in failure of parvalbumin interneurons in their adaptive contribution to behavioral stress, and animals exhibit multiple neuropsychiatric domains. Because the genetics of schizophrenia encompasses diverse proteins that contribute to excitatory synapse plasticity, the identified vulnerability of NPTX2 function can provide a framework for assessing the impact of genetics and the intersection with stress.

ElectroConvulsive therapy Cognitive Assessment (ECCA) tool: A new instrument to monitor cognitive function in patients undergoing ECT

BACKGROUND

Electroconvulsive therapy (ECT) is a well-established treatment for severe depression but may result in adverse cognitive effects. Available cognitive screening instruments are nonspecific to the cognitive deficits associated with ECT. An ECT-cognitive assessment tool which can be easily administered was developed and validated in a clinical setting.

METHODS

One hundred and thirty-six participants were enrolled. The ElectroConvulsive therapy Cognitive Assessment (ECCA) and the Montreal Cognitive Assessment (MoCA) were administered prospectively to 55 participants with major depressive disorder (MDD) undergoing ECT at three time points: pre-treatment, before the sixth treatment and one-week post-treatment. The psychometric properties of the total and domain scores were evaluated at all three time points. Forty demographically comparable participants with MDD who did not receive ECT, and 41 healthy, age-matched controls were evaluated at a single time point.

RESULTS

ECCA and MoCA scores were not statistically different at baseline. Prior to the sixth and final ECT session, total ECCA scores were significantly lower than the MoCA total scores. The ECCA domains of subjective memory, informant-assessed memory, attention, autobiographical memory and delayed verbal recall were significantly lower post-ECT compared to pre-ECT.

LIMITATIONS

The ECCA was compared only to the MoCA rather than to a more comprehensive neuropsychological testing. This limitation reflected the real-life clinical burden of performing full neuropsychological testing at three time points during the treatment course.

CONCLUSIONS

The ECCA is a brief, reliable, bedside cognitive screening assessment tool that may be useful to monitor cognitive function in patients treated with ECT. The test can be downloaded from fuquacenter.org/ecca.

Non-suicidal self-injury and electroconvulsive therapy: Outcomes in adolescent and young adult populations

BACKGROUND

Electroconvulsive (ECT) therapy is a highly effective treatment for severe depression. Although the clear majority of patients respond to ECT, not all do, and we still lack good predictors for ECT outcome, especially in adolescents and young adults. One clinical variable that has been associated with reduced likelihood of ECT antidepressant response in adults is comorbid borderline personality disorder. As self-injurious behavior is often a feature of borderline personality disorder, we hypothesized that adolescent and young adult patients with a history of non-suicidal self-injury (NSSI), who were being treated for major depression with ECT, would have a poorer response than patients without such a history.

METHODS

We conducted a retrospective chart review of 48 patients treated with ECT for depression at The Johns Hopkins Hospital between the ages of 14 and 25.

RESULTS

Initial analyses showed that the presence of NSSI was not associated with ECT outcomes. However, sub-group analyses suggested that it was associated with response to ECT and overall remission among female patients. Specifically, the results suggested that in adolescent and young adult female ECT patients, the presence of NSSI was associated with lower odds of response (OR: 0.04; 95% CI: 0.0004, 0.81, p = 0.03) and remission (OR: 0.09; 95% CI: 0.0000, 0.81, p = 0.03), and a greater mean number of treatments (5.83; 95% CI: 0.27, 11.39, p = 0.04) compared with patients without NSSI.

CONCLUSIONS

Clearly, the finding that NSSI may be associated with poorer ECT outcomes among female patients needs to be replicated. Nonetheless, our data suggest caution when considering an adolescent or young adult woman for a course of ECT.

Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression

OBJECTIVE

To provide expert recommendations for the safe and effective application of repetitive transcranial magnetic stimulation (rTMS) in the treatment of major depressive disorder (MDD).

PARTICIPANTS

Participants included a group of 17 expert clinicians and researchers with expertise in the clinical application of rTMS, representing both the National Network of Depression Centers (NNDC) rTMS Task Group and the American Psychiatric Association Council on Research (APA CoR) Task Force on Novel Biomarkers and Treatments.

EVIDENCE

The consensus statement is based on a review of extensive literature from 2 databases (OvidSP MEDLINE and PsycINFO) searched from 1990 through 2016. The search terms included variants of major depressive disorder and transcranial magnetic stimulation. The results were limited to articles written in English that focused on adult populations. Of the approximately 1,500 retrieved studies, a total of 118 publications were included in the consensus statement and were supplemented with expert opinion to achieve consensus recommendations on key issues surrounding the administration of rTMS for MDD in clinical practice settings.

CONSENSUS PROCESS

In cases in which the research evidence was equivocal or unclear, a consensus decision on how rTMS should be administered was reached by the authors of this article and is denoted in the article as "expert opinion."

CONCLUSIONS

Multiple randomized controlled trials and published literature have supported the safety and efficacy of rTMS antidepressant therapy. These consensus recommendations, developed by the NNDC rTMS Task Group and APA CoR Task Force on Novel Biomarkers and Treatments, provide comprehensive information for the safe and effective clinical application of rTMS in the treatment of MDD.

A review of repetitive transcranial magnetic stimulation for adolescents with treatment-resistant depression

This review examines the efficacy and safety of repetitive transcranial magnetic stimulation (rTMS) as a treatment for treatment-resistant depression in adolescents. A systematic review of six databases was conducted. Ten multi-subject trials, all uncontrolled, and five case reports met inclusion criteria. Twelve studies focused on treatment efficacy, whereas three studies focused exclusively on adverse events. All efficacy studies focused on adolescents only; 10 of these studies indicated that rTMS may demonstrate some benefit. Improvement within 2-8 weeks was reported in most studies, with a few studies indicating potential long-term benefits. A variety of adverse events occurred including scalp pain, which was the most common, as well as seizures. Controlled studies of rTMS are warranted to further examine whether this treatment is a potential option for adolescents with treatment-resistant depression.

Key updates in the clinical application of electroconvulsive therapy

ECT is the oldest and most effective therapy available for the treatment of severe major depression. It is highly effective in individuals with treatment resistance and when a rapid response is required. However, ECT is associated with memory impairment that is the most concerning side-effect of the treatment, substantially contributing to the controversy and stigmatization surrounding this highly effective treatment. There is overwhelming evidence for the efficacy and safety of an acute course of ECT for the treatment of a severe major depressive episode, as reflected by the recent FDA advisory panel recommendation to reclassify ECT devices from Class III to the lower risk category Class II. However, its application for other indications remains controversial, despite strong evidence to the contrary. This article reviews the indication of ECT for major depression, as well as for other conditions, including catatonia, mania, and acute episodes of schizophrenia. This study also reviews the growing evidence supporting the use of maintenance ECT to prevent relapse after an acute successful course of treatment. Although ECT is administered uncommonly to patients under the age of 18, the evidence supporting its use is also reviewed in this patient population. Finally, memory loss associated with ECT and efforts at more effectively monitoring and reducing it are reviewed.

A naturalistic, multi-site study of repetitive transcranial magnetic stimulation therapy for depression

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) was approved in 2008 in the United States, and there are relatively few studies describing its use in regular clinical practice since approval.

METHODS

From April 2011 to October 2014, ten sites within the National Network of Depression Centers (NNDC) provided data on 62 evaluable patients with a depressive episode. Treatment was determined naturalistically. Response was assessed by the Quick Inventory of Depressive Symptoms, Self-Report (QIDS-SR) as the primary outcome, and the Patient Health Questionnaire-9 (PHQ-9) and the clinician-rated Clinical Global Impression (CGI) as secondary depression measures.

RESULTS

Enrolled patients exhibited significant treatment resistance, with 70.2% reporting more than 4 prior depressive episodes. Most patients received treatment with standard parameters (10Hz over the left dorsolateral prefrontal cortex), although 22.6% of the patients received 1 or 5Hz stimulation at some point. Over 6 weeks of treatment, response and remission rates were 29.4% and 5.9%, respectively, for the QIDS-SR; 39.2% and 15.7%, respectively, for the PHQ-9; and 50.9% and 17.9%, respectively, for the CGI. Moderator analyses revealed no effect of prior depressive episodes, history of ECT or gender, although early life stress predicted a better response to rTMS therapy.

LIMITATIONS

The study was an open-label, registry trial, with relatively coarse clinical data, reflecting practice only in academic, depression-specialty centers. Because of the relatively small size and heterogeneity of the sample, type 2 errors are possible and positive findings are in need of replication.

CONCLUSION

rTMS demonstrates effectiveness in clinical practice within the NNDC, although remission rates appear slightly lower in comparison with other recent naturalistic studies.

Mediating the effects of drug abuse: the role of Narp in synaptic plasticity

There has been remarkable progress in deciphering the molecular mechanisms that mediate synaptic plasticity. Advances have stimulated interest in determining whether these plasticity mechanisms also mediate the long-lasting behavioral effects induced by drugs of abuse. The observation that drugs of abuse, such as cocaine or morphine, can elicit robust immediate early gene (IEG) responses similar to those induced by long-term potentiation stimulation has provided important support for this hypothesis. Evidence that repeated administration of cocaine produces alterations in expression and trafficking of AMPA receptors, processes that play a central role in synaptic plasticity, has also bolstered this view. Neuronal activity-regulated pentraxin (Narp), an IEG, has emerged as an attractive candidate to mediate long-term effects of drugs of abuse because it encodes a secreted protein that binds to the extracellular surface of AMPA receptors and regulates their trafficking. In this review we provide background information on Narp and closely related proteins, the neuronal pentraxins, and summarize studies of Narp knockout mice demonstrating that this IEG modulates long-term behavioral responses to drugs of abuse.

Transcranial magnetic stimulation: A potential new treatment for depression associated with traumatic brain injury

BACKGROUND

Each year, more than 1.7 million Americans suffer a traumatic brain injury (TBI) and the lifetime prevalence of major depressive disorder following TBI is between 25-50%. There are no validated established strategies to treat TBI depression. Repetitive transcranial magnetic stimulation (rTMS) is a novel putative treatment option for post-TBI depression, which, compared with standard pharmacological agents, may provide a more targeted treatment with fewer side-effects. However, TBI is associated with an increased risk of both early and late spontaneous seizures, a significant consideration in evaluating rTMS as a potential treatment for TBI depression. Whilst the risk of seizure from rTMS is low, underlying neuropathology may somewhat increase that risk.

REVIEW

This review focuses on the safety aspects of rTMS in TBI patients. The authors review why low frequency rTMS might be less likely to trigger a seizure than high frequency rTMS and propose low frequency rTMS as a safer option in TBI patients. Because there is little data on the safety of rTMS in TBI, the authors also review the safety of rTMS in patients with other brain pathology.

CONCLUSION

It is concluded that pilot safety and tolerability studies should be first conducted in persons with TBI and neuropsychiatric comorbidities. These results could be used to help design larger randomized controlled trials.

Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial

Major depressive disorder (MDD) is a prevalent and disabling condition, and many patients do not respond to available treatments. Deep transcranial magnetic stimulation (dTMS) is a new technology allowing non-surgical stimulation of relatively deep brain areas. This is the first double-blind randomized controlled multicenter study evaluating the efficacy and safety of dTMS in MDD. We recruited 212 MDD outpatients, aged 22-68 years, who had either failed one to four antidepressant trials or not tolerated at least two antidepressant treatments during the current episode. They were randomly assigned to monotherapy with active or sham dTMS. Twenty sessions of dTMS (18 Hz over the prefrontal cortex) were applied during 4 weeks acutely, and then biweekly for 12 weeks. Primary and secondary efficacy endpoints were the change in the Hamilton Depression Rating Scale (HDRS-21) score and response/remission rates at week 5, respectively. dTMS induced a 6.39 point improvement in HDRS-21 scores, while a 3.28 point improvement was observed in the sham group (p=0.008), resulting in a 0.76 effect size. Response and remission rates were higher in the dTMS than in the sham group (response: 38.4 vs. 21.4%, p=0.013; remission: 32.6 vs. 14.6%, p=0.005). These differences between active and sham treatment were stable during the 12-week maintenance phase. dTMS was associated with few and minor side effects apart from one seizure in a patient where a protocol violation occurred. These results suggest that dTMS constitutes a novel intervention in MDD, which is efficacious and safe in patients not responding to antidepressant medications, and whose effect remains stable over 3 months of maintenance treatment.

Selective expression of Narp in primary nociceptive neurons: role in microglia/macrophage activation following nerve injury

Neuronal activity regulated pentraxin (Narp) is a secreted protein implicated in regulating synaptic plasticity via its association with the extracellular surface of AMPA receptors. We found robust Narp immunostaining in dorsal root ganglia (DRG) that is largely restricted to small diameter neurons, and in the superficial layers of the dorsal horn of the spinal cord. In double staining studies of DRG, we found that Narp is expressed in both IB4- and CGRP-positive neurons, markers of distinct populations of nociceptive neurons. Although a panel of standard pain behavioral assays were unaffected by Narp deletion, we found that Narp knockout mice displayed an exaggerated microglia/macrophage response in the dorsal horn of the spinal cord to sciatic nerve transection 3days after surgery compared with wild type mice. As other members of the pentraxin family have been implicated in regulating innate immunity, these findings suggest that Narp, and perhaps other neuronal pentraxins, also regulate inflammation in the nervous system.

Electroconvulsive therapy pre-treatment with low dose propofol: comparison with unmodified treatment

BACKGROUND

Whilst electroconvulsive therapy (ECT) is routinely administered under anesthesia in developed nations, in many developing countries, ECT is still administered unmodified. This practice has attracted considerable scrutiny with calls to ban unmodified ECT. However, there are no affordable alternatives for many poor, acutely ill psychiatric patients. We evaluated whether administration of intravenous propofol 0.5 mg/kg for sedation by the ECT psychiatrist just prior to otherwise unmodified treatment improved acceptance of and reduced anxiety surrounding the treatment.

METHOD

We conducted an open label trial at The King George's Medical University in Lucknow, India. Forty-nine patients received propofol pre-treatment and 50 patients received unmodified treatment as usual.

RESULTS

Socio-demographic profiles, diagnoses and clinical responses were comparable. Patients who received propofol experienced less anxiety monitored by the State-Trait Anxiety Inventory just prior to ECT (p < 0.001), and had a more favorable attitude towards treatment assessed by an established questionnaire (Freeman and Kendell, 1980). Propofol patients were less likely to experience post-ictal delirium monitored by the CAM-ICU (p = 0.015) and had fewer cognitive side-effects on the MMSE (p = 0.004). There were no adverse events associated with propofol administration.

CONCLUSION

Whilst unmodified ECT should never be used when modified ECT under anesthesia is available, we have found low dose propofol can be safely administered by the ECT psychiatrist to sedate patients pre-treatment who would otherwise receive completely unmodified treatment. The intervention was associated with reduced anxiety and a more positive attitude towards ECT, without compromising efficacy. A randomized double blind controlled study is necessary to confirm these benefits.

Narp knockout mice show normal reactivity to novelty but attenuated recovery from neophobia

Narp knockout (KO) mice demonstrate cognitive inflexibility and addictive behavior, which are associated with abnormal reactivity to a novel stimulus. To assess reactivity to novelty, we tested Narp KO and wild-type (WT) mice on a neophobia procedure. Both Narp KO and WT mice showed a similar decrease in consumption upon initial exposure to a novel flavor, but Narp KO mice did not increase consumption with subsequent exposures to the novel flavor like the WT mice. Therefore, Narp KO mice do not have abnormal reactivity to novelty but show deficits in adapting behavior to reflect the updated value of a stimulus.

ECT treatment outcomes following performance improvement changes

Differences in electroconvulsive therapy (ECT) outcomes were explored following changes in ECT administration at our institution. Two changes were introduced: (a) switching the anesthetic agent from propofol to methohexital, and (b) using a more aggressive ECT charge dosing regimen for right unilateral (RUL) electrode placement. Length of stay (LOS) and number of treatments administered per patient were monitored. A retrospective analysis was performed of two inpatient groups treated on our Mood Disorders Unit: those who underwent ECT in the 12 months prior to the changes (n = 40) and those who underwent treatment in the 12 months after the changes (n = 38). Compared with patients receiving ECT with RUL placement prior to the changes, patients who received RUL ECT after the changes had a significantly shorter inpatient LOS (27.4 versus 18 days, p = 0.028). Treatment efficacy monitored by the Montgomery Asberg Depression Rating Scale was not impacted. The change in anesthetic agent and charge dosing each accounted for 11% of the variance in LOS among patients receiving RUL ECT. The implemented changes in ECT administration positively impacted outcome for patients receiving treatment with RUL electrode placement.

Role of medial prefrontal cortex Narp in the extinction of morphine conditioned place preference

Narp knockout (KO) mice demonstrate an impaired extinction of morphine conditioned place preference (CPP). Because the medial prefrontal cortex (mPFC) has been implicated in extinction learning, we tested whether Narp cells in this region play a role in the extinction of morphine CPP. We found that intracranial injections of adenoassociated virus (AAV) expressing wild-type (WT) Narp into the mPFC of Narp KO mice rescued the extinction and the injection of AAV expressing a dominant negative form of Narp (NarpN) into the mPFC of WT mice impaired the extinction of morphine CPP. These findings suggest that Narp in the mPFC mediates the extinction of morphine CPP.

Stability of intellectual functioning during maintenance electroconvulsive therapy

We describe the stability of neuropsychologic testing in a 16-year-old boy with cerebellar dysgenesis who received 61 acute and maintenance electroconvulsive therapy treatments for malignant catatonia. Measures of nonverbal intelligence and visual memory before treatment onset and after 61 electroconvulsive therapy treatments indicated no evidence of decline in intellectual functioning and acute or delayed memory. This case offers further support for the safety and efficacy of maintenance electroconvulsive therapy in both pediatric and developmentally disabled populations.

Concordance between personality disorder assessment methods

BACKGROUND

Studies have criticized the low level of agreement between the various methods of personality disorder (PD) assessment. This is an important issue for research and clinical purposes.

METHOD

Seven hundred and forty-two participants in the Hopkins Epidemiology of Personality Disorders Study (HEPS) were assessed on two occasions using the Personality Disorder Schedule (PDS) and the International Personality Disorder Examination (IPDE). The concordance between the two diagnostic methods for all DSM-IV PDs was assessed using standard methods and also two item response analytic approaches designed to take account of measurement error: a latent trait-based approach and a generalized estimating equations (GEE)-based approach, with post-hoc adjustment.

RESULTS

Raw criteria counts, using the intraclass correlation coefficient (ICC), κ and odds ratio (OR), showed poor concordance. The more refined statistical methods showed a moderate to moderately high level of concordance between the methods for most PDs studied. Overall, the PDS produced lower prevalences of traits but higher precision of measurement than the IPDE. Specific criteria within each PD showed varying endorsement thresholds and precision for ascertaining the disorder.

CONCLUSIONS

Concordance in the raw measurement of the individual PD criteria between the two clinical methods is lacking. However, based on two statistical methods that adjust for differential endorsement thresholds and measurement error in the assessments, we deduce that the PD constructs themselves can be measured with a moderate degree of confidence regardless of the clinical approach used. This may suggest that the individual criteria for each PD are, in and of themselves, less specific for diagnosis, but as a group the criteria for each PD usefully identify specific PD constructs.

Association between a serotonin transporter promoter polymorphism (5HTTLPR) and personality disorder traits in a community sample

BACKGROUND

The serotonin transporter (SERT) polymorphism (5HTTLPR) has been reported to be associated with several psychiatric conditions. Specific personality disorders could be intermediate factors in the known relationship between 5HTTLPR and psychiatric disorders. This is the first study to test the association between this polymorphism and dimensions of all DSM-IV personality disorders in a community sample.

METHODS

374 white participants were assessed by clinical psychologists using the International Personality Disorder Examination (IPDE). Associations between dimensions of each DSM-IV personality disorder and the long (l) and short (s) alleles of the 5HTTLPR were evaluated using non-parametric tests and regression models.

RESULTS

The s allele of the 5HTTLPR polymorphism was significantly associated with higher avoidant personality trait scores in the whole sample. Males with the s allele had a significantly lower likelihood of higher obsessive-compulsive personality disorder (OCPD) trait scores, whereas females with the s allele were likely to have higher OCPD personality trait scores.

CONCLUSION

This paper provides preliminary data on the relationship between personality disorders and the 5HTTLPR polymorphism. The relationship of the s allele and avoidant PD is consistent with findings of a nonspecific relationship of this polymorphism to anxiety and depressive disorders. Concerning the unusual sexual dimorphic result with OCPD, several hypotheses are presented. These findings need further replication, including a more detailed study of additional variants in SERT.

Monoamine oxidase A regulates antisocial personality in whites with no history of physical abuse

OBJECTIVE

Preclinical and human family studies clearly link monoamine oxidase A (MAOA) to aggression and antisocial personality (ASP). The 30-base pair variable number tandem repeat in the MAOA promoter regulates MAOA levels, but its effects on ASP in humans are unclear.

METHODS

We evaluated the association of the variable number tandem repeat of the MAOA promoter with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, ASP disorder (ASPD) traits in a community sample of 435 participants from the Hopkins Epidemiology of Personality Disorders Study.

RESULTS

We did not find an association between the activity of the MAOA allele and ASPD traits; however, among whites, when subjects with a history of childhood physical abuse were excluded, the remaining subjects with low-activity alleles had ASPD trait counts that were 41% greater than those with high-activity alleles (P < .05).

CONCLUSION

The high-activity MAOA allele is protective against ASP among whites with no history of physical abuse, lending support to a link between MAOA expression and antisocial behavior.

Electroconvulsive therapy for catatonia in a boy with hydrocephalus and an arachnoid cyst

We report on the successful use of electroconvulsive therapy in a 13-year-old boy with congenital hydrocephalus, a history of multiple shunt revisions, and a stable prepontine arachnoid cyst, who experienced profound catatonic deterioration. After initial shunt placement at age 20 months, the patient had followed normal motor, cognitive, and social developmental trajectories. Two uncomplicated shunt revisions were performed at ages 10 and 13 years. Three months after the last revision, the patient demonstrated multiple psychomotor signs, culminating in hospital admission for rigidity, posturing, waxy flexibility, stupor, mutism, and cessation of all oral intake. An extensive neurologic workup related to his preexisting conditions produced negative results, and a course of electroconvulsive therapy for acute catatonia was pursued, with outstanding improvement.

The stability of DSM personality disorders over twelve to eighteen years

BACKGROUND

Stability of personality disorders is assumed in most nomenclatures; however, the evidence for this is limited and inconsistent. The aim of this study is to investigate the stability of DSM-III personality disorders in a community sample of eastern Baltimore residents unselected for treatment.

METHODS

Two hundred ninety four participants were examined on two occasions by psychiatrists using the same standardized examination twelve to eighteen years apart. All the DSM-III criteria for personality disorders were assessed. Item-response analysis was adapted into two approaches to assess the agreement between the personality measures on the two occasions. The first approach estimated stability in the underlying disorder, correcting for error in trait measurement, and the second approach estimated stability in the measured disorder, without correcting for item unreliability.

RESULTS

Five of the ten personality disorders exhibited moderate stability in individuals: antisocial, avoidant, borderline, histrionic, and schizotypal. Associated estimated ICCs for stability of underlying disorder over time ranged between approximately 0.4 and 0.7-0.8. A sixth disorder, OCPD, exhibited appreciable stability with estimated ICC of approximately 0.2-0.3. Dependent, narcissistic, paranoid, and schizoid disorders were not demonstrably stable.

CONCLUSIONS

The findings suggest that six of the DSM personality disorder constructs themselves are stable, but that specific traits within the DSM categories are both of lesser importance than the constructs themselves and require additional specification.

ECT for self-injury in an autistic boy

OBJECTIVE

Self-injurious behavior presents a significant challenge in autism, and first-line psychopharmacological and behavioral interventions have limited efficacy in some patients. These intractable cases may be responsive to electroconvulsive therapy.

CLINICAL PICTURE

This article presents an eight-year-old boy with autism, mental retardation, prominent mood lability and a five-year history of extreme self-injurious behavior towards his head, averaging 109 self-injurious attempts hourly. The patient was at high risk for serious head trauma, and required usage of bilateral arm restraints and protective equipment (i.e., padding on shoulders, arms, and legs). All areas of daily functioning were profoundly impacted by dangerous self-injury.

TREATMENT

Fifteen bilateral ECT treatments resulted in excellent mood stabilization and reduction of self-injury to 19 attempts hourly, and maintenance ECT was pursued. The patient was able to return to developmentally-appropriate educational and social activities.

CONCLUSION

ECT should be considered in the treatment algorithm of refractory cases of severe self-injury in autism.

Nicotine and Delta(9)-tetrahydrocannabinol withdrawal induce Narp in the central nucleus of the amygdala

The central nucleus of the amygdala plays a key role in mediating aversive responses to drug withdrawal, effects thought to contribute to continued drug use. In previous studies, we found that the immediate early gene Narp, which encodes a secreted protein that binds to AMPA receptors, is induced in this nucleus following opiate withdrawal. Furthermore, Narp deletion alters the acquisition and extinction of aversive conditioning induced by opiate withdrawal. We now report that Narp is also induced in the central nucleus following withdrawal from other drugs of abuse, nicotine and Delta(9)-tetrahydrocannabinol, indicating that Narp is a common component of the transcriptional response triggered by drug withdrawal.

Narp regulates long-term aversive effects of morphine withdrawal

Although long-lasting effects of drug withdrawal are thought to play a key role in motivating continued drug use, the mechanisms mediating this type of drug-induced plasticity are unclear. Because Narp is an immediate early gene product that is secreted at synaptic sites and binds to alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, it has been implicated in mediating enduring forms of synaptic plasticity. In previous studies, the authors found that Narp is selectively induced by morphine withdrawal in the extended amygdala, a group of limbic nuclei that mediate aversive behavioral responses. Accordingly, in this study, the authors evaluate whether long-term aversive effects of morphine withdrawal are altered in Narp knockout (KO) mice. The authors found that acute physical signs of morphine withdrawal are unaffected by Narp deletion. However, Narp KO mice acquire and sustain more aversive responses to the environment conditioned with morphine withdrawal than do wild type (WT) controls. Paradoxically, Narp KO mice undergo accelerated extinction of this heightened aversive response. Taken together, these studies suggest that Narp modulates both acquisition and extinction of aversive responses to morphine withdrawal and, therefore, may regulate plasticity processes underlying drug addiction.

Activity-dependent secretion of neuronal activity regulated pentraxin from vasopressin neurons into the systemic circulation

Neuronal activity regulated pentraxin (Narp) is a secreted, synaptic protein that has been implicated in modulating synaptic transmission. However, it is unclear how Narp secretion is regulated. Since we noted prominent Narp immunostaining in vasopressin neurons of the hypothalamus and in the posterior pituitary, we assessed whether it, like vasopressin, is released into the systemic circulation in an activity-dependent fashion. Consistent with this hypothesis, electron microscopic studies of the posterior pituitary demonstrated that Narp is located in secretory vesicles containing vasopressin. Using affinity chromatography, we detected Narp in plasma and found that these levels are markedly decreased by hypophysectomy. In addition, we confirmed that injection of a viral Narp construct into the hypothalamus restores plasma Narp levels in Narp knockout mice. In checking for activity-dependent secretion of Narp from the posterior pituitary, we found that several stimuli known to trigger vasopressin release, i.e. hypovolemia, dehydration and endotoxin, elevate plasma Narp levels. Taken together, these findings provide compelling evidence that Narp is secreted from vasopressin neurons in an activity-dependent fashion.

Narp immunostaining of human hypocretin (orexin) neurons: Loss in narcolepsy

OBJECTIVE

To investigate whether neuronal activity-regulated pentraxin (Narp) colocalizes with hypocretin (Hcrt or orexin) in the normal human brain and to determine if Narp staining is lost in the narcoleptic human brain.

BACKGROUND

Human narcolepsy is characterized by a loss of the peptide hypocretin in the hypothalamus. This loss could result from the degeneration of neurons containing hypocretin or from a more specific loss of the ability of these neurons to synthesize Hcrt. Narp has been found to colocalize with hypocretin in the rat hypothalamus.

METHODS

We investigated the distribution of Narp in three normal and four narcoleptic human postmortem brains using immunohistochemistry with an antibody to Narp. Colocalization studies of Narp and hypocretin were also performed in two normal brains using immunohistochemistry with an antibody to Narp and an antibody to hypocretin.

RESULTS

We found that Narp colocalizes with hypocretin in the lateral hypothalamic area (LHA), the dorsomedial hypothalamus (DMH), the dorsal hypothalamic area (DHA), and the posterior hypothalamic area (PHA) of the normal human. The number of Narp-positive neurons was reduced by 89% in these areas of the narcoleptic hypothalamus. In contrast, Narp staining in the paraventricular (Pa) and supraoptic nuclei (SO) of the human hypothalamus did not differ between normal and narcoleptic brains.

CONCLUSIONS

This finding supports the hypothesis that narcolepsy results from the specific loss of hypocretin neurons. Loss of hypothalamic Narp may contribute to the symptoms of narcolepsy.

Anxiety and depressive disorders and the five-factor model of personality: a higher- and lower-order personality trait investigation in a community sample

We describe in detail normal personality traits in persons with psychiatrist-ascertained anxiety and depressive disorders in a general population sample. We investigated Revised NEO Personality Inventory traits in 731 community subjects examined by psychiatrists with the Schedules for Clinical Assessment in Neuropsychiatry. All of the lifetime disorders of interest (simple phobia, social phobia, agoraphobia, panic disorder, obsessive-compulsive disorder (OCD), generalized anxiety disorder, major depressive disorder (MDD), and dysthymia) were associated with high neuroticism. Social phobia, agoraphobia, and dysthymia were associated with low extraversion, and OCD was associated with high openness to experience. In addition, lower-order facets of extraversion (E), openness (O), agreeableness (A), and conscientiousness (C) were associated with certain disorders (specifically, low assertiveness (E) and high openness to feelings (O) with MDD, low trust (A) with social phobia and agoraphobia, low self-discipline (C) with several of the disorders, and low competence and achievement striving (C) with social phobia). Neuroticism in particular was related to acuity of disorder. Longitudinal study is necessary to differentiate state versus pathoplastic effects.

Opiate withdrawal induces Narp in the extended amygdala

The negative affective states associated with drug withdrawal produce long-lasting behavioral effects thought to play a central role in the development and maintenance of dependence. However, little is known about the molecular mechanisms mediating the long-term effects of drug withdrawal. Neuronal activity-regulated pentraxin (Narp) is a secreted neuronal immediate early gene (IEG) product that regulates AMPA receptor clustering at synapses. As both IEGs and changes in AMPA receptor trafficking mediate enduring forms of neuronal plasticity, we have assessed whether Narp could be involved in the molecular adaptations accompanying drug withdrawal. To this end, we checked the effect of opiate withdrawal on Narp expression in the extended amygdala, a brain region closely linked to the aversive effects of drug withdrawal. We found a marked increase in the number of Narp-positive cells in this region following opiate withdrawal triggered by either low doses of opiate antagonists or by 'natural withdrawal', removal of the morphine pellets used to induce dependence. In contrast, Arc, another 'effector' IEG, was not induced by opiate withdrawal. As expected, pretreatment of animals with clonidine, which blocks opiate withdrawal, suppresses Narp induction in this paradigm. These results implicate Narp in mediating the long-term, aversive behavioral effects induced by opiate withdrawal.

Prominent expression of Narp in central vestibular pathways: selective effect of labyrinth ablation

Recent in vitro studies demonstrated that Narp, a secreted immediate early gene (IEG) product, induces AMPA receptor clustering. Accordingly, Narp has been implicated in mediating activity-dependent changes in synaptic efficacy. To help define the role of Narp in vivo, we conducted immunohistochemical studies of Narp in rat brain. Unexpectedly, we found robust Narp expression in several discrete areas linked to the vestibular system: the anterodorsal nucleus (ADN) of the thalamus, which relays head orientation information to the cortex, the lateral vestibulospinal (Deiters') nucleus and Purkinje cells in the flocculonodular lobe of the cerebellum. Although strong Narp expression in Deiters' nucleus and the cerebellum was present consistently, Narp expression in the ADN displayed a high degree of variability among animals. To check if this variability in ADN Narp expression reflects its dependence on fluctuating levels of vestibular input, we monitored Narp immunostaining following bilateral labyrinth ablation. This procedure significantly suppressed Narp immunostaining in the ADN, indicating that it is stimulated by naturally occurring vestibular input. In contrast, labyrinth ablation did not affect Narp staining in Deiters' nucleus or the flocculonodular lobe of the cerebellum, presumably because these areas are driven by inputs from multiple systems. As previous studies implicate Narp in synaptic plasticity, these findings suggest that this IEG may mediate ongoing adjustments in synaptic strength or connectivity in several pathways linked to the vestibular system.

Selective expression of Narp, a secreted neuronal pentraxin, in orexin neurons

Recent studies have provided compelling evidence demonstrating that orexin (also known as hypocretin) neurons play a central role in the pathophysiology of narcolepsy. However, targeted deletion of orexin does not fully mimic the functional deficits induced by selective ablation of these neurons; implying that other secreted signaling molecules expressed in these neurons mediate key aspects of their function. In this study, we demonstrate that orexin neurons display robust expression of neuronal activity-regulated pentraxin (Narp), a secreted neuronal pentraxin, implicated in regulating clustering of alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate (AMPA) receptors. Furthermore, we have found that hypothalamic melanin-concentrating hormone (MCH) neurons, which form a peptidergic pathway thought to oppose the effects of the orexin system, express another neuronal pentraxin, NP1. Thus, these findings suggest that these pathways utilize neuronal pentraxins, in addition to neuropeptides, as synaptic signaling molecules.

Influences of parenting on normal personality traits

There is a considerable literature linking aspects of experienced parenting to later personality disorders. Because dimensionally measured personality disorders are associated with variations in normal personality traits, it is important to understand the contribution of parenting experienced in childhood to later normal personality traits. In this report, 742 community-based individuals, subjects from the Hopkins Epidemiology of Personality Disorders Study, were assessed for normal personality traits, as measured by the Revised NEO Personality Inventory (NEO-PI-R) and the Temperament and Character Inventory (TCI), and for parental behavior experienced as children, as measured by the Parental Bonding Instrument (PBI). The PBI dimensions were significantly, but moderately, correlate with measures of normal personality, the strongest associations being with the NEO-PI-R factors, neuroticism and conscientiousness, and with the TCI factors, self-directedness and harm avoidance. Subjects who reported lower parental care and higher parental intrusiveness were more likely to be higher in neuroticism, lower in conscientiousness, lower in self-directedness, and higher in harm avoidance. Also, trends emerged suggesting both parent-specific and gender-specific differences in the relationship between the PBI dimensions and normal adult personality traits. As variations in normal personality traits are associated with dimensionally measured personality disorders, it is conceivable that the role of parenting in later personality disorder may be mediated by associations between parenting and normal personality traits.

Adult antisocial personality traits are associated with experiences of low parental care and maternal overprotection

OBJECTIVE

To investigate the role of parenting in the development of adult antisocial personality traits.

METHOD

A total of 742 community-based subjects were assessed for adult DSM-IV antisocial personality disorder traits and for measures of parental behavior experienced as children, including by the Parental Bonding Instrument (PBI).

RESULTS

Three fundamental dimensions of parental behavior - care, behavioral restrictiveness and denial of psychological autonomy - were derived by factor analysis from the PBI. These dimensions significantly correlated with measures of parental behavior considered influential in later antisocial behavior. Adult antisocial traits in males were associated with low maternal care and high maternal behavioral restrictiveness, and in females, antisocial traits were associated with low paternal care and high maternal denial of psychological autonomy. These dimensions did not, however, explain all variance parental behavior has on adult antisocial personality traits.

CONCLUSION

Adult antisocial personality traits are associated with experiences of low parental care and maternal overprotection.

Prominent Narp expression in projection pathways and terminal fields

Narp (neuronal activity regulated pentraxin) is a secreted immediate early gene product that is induced by synaptic activity. Recent studies have indicated that Narp may be an extracellular aggregating factor for AMPA receptors. Immunohistochemical studies have revealed prominent expression of Narp in the mossy fiber pathway of the dentate gyrus, suggesting it may be released pre-synaptically. However, in vitro studies using recombinant Narp indicate that Narp may act when expressed by either pre- or post-synaptic elements. To help define Narp's mode of action, we have examined its localization in the habenula-interpeduncular pathway which also displays robust Narp expression. Focusing on this pathway as well as hippocampal and cortical Narp expression, we found prominent Narp staining in projection pathways and terminal fields. In contrast, Narp expression in dendrites was minimal in these neuronal populations. These findings indicate that, under physiological conditions, Narp is targeted to the synapse from pre- rather than post-synaptic elements. Our results also suggest that future studies focusing on these projection pathways that express high levels of Narp, in vivo, may help to understand the regulation and function of endogenous Narp.

Sustained increase in Narp protein expression following repeated electroconvulsive seizure

The delayed response to many psychiatric treatment regimens has focused attention on identifying enduring changes in gene expression following repeated stimulation that may contribute to these responses. Recent studies have identified Narp protein as a neuronal immediate early gene product that remains elevated in the hippocampus nearly 24 hours after a single episode of electroconvulsive seizure (ECS). To examine how Narp expression responds to repeated stimulation, we have examined the effect of repeated ECS on Narp expression in the hippocampus. We report that Narp protein levels remain elevated, about six-fold higher than basal levels, at 48 hours after the last of a series of five or six ECS given every other day. As Narp protein appears to play a key role in regulating AMPA receptor clustering at synaptic sites, sustained increases in Narp may contribute to changes in excitatory synaptic transmission induced by chronic neuronal stimulation.