Mind & Brain, The Journal of Psychiatry Vol I Issue 2

Treating Anxiety Disorders with Anticonvulsant Drugs: Is There Any Evidence?

INTRODUCTION

Anxiety disorders are chronic conditions that may require long-term drug treatments. Antidepressants represent the current gold standard but they fail in up to one-third of patients. Moreover, benzodiazepines, currently used in the acute treatment, are limited by the high risk of tolerance, dependence, and abuse.

OBJECTIVES

This paper is aimed at reviewing international literature on the use of anticonvulsant drugs in anxiety disorders.

METHODS

References were identified by searches of Medline/PubMed and PsychINFO. Only papers published in English were reviewed.

RESULTS

Despite a considerable number of open studies and anecdotal reports, the number of controlled studies is scanty. The majority of publications have several methodological limitations including inadequate sample size; lack of placebo control; the use of different outcome measures; and lack of controlling for patient variables such as comorbidity, diagnostic subtype, and concomitant medications. Pregabalin is the only anticonvulsant with good evidence in generalized anxiety disorder. Pregabalin and gabapentin may be promising in social phobia but further controlled studies are needed. A number of compounds are still at an early stage of evidence and may deserve further controlled trials: topiramate in posttraumatic stress disorder and obsessive compulsive disorder, valproate and gabapentin in panic disorder.

CONCLUSION

Anticonvulsant drugs may be valuable options in some selected patients with difficult to treat anxiety disorders refractory to first-line agents. Further studies are warranted to identify specific clinical phenotypes where anticonvulsants may be successfully used in the acute and long-term treatment of anxiety disorders.

Age-at-Onset of 648 Patients with Major Affective Disorders: Clinical and Prognostic Implications

BACKGROUND AND OBJECTIVE

Onset-age reportedly differs among affective disorders and may be a simple, objective means of supporting diagnosis, prognosis, and treatment-selection. We compared onset-age in Argentine patients diagnosed with the Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-IV) major mood disorders (bipolar [BPD] types I, II, or unspecified [NOS], or unipolar-major depressive disorder [UP-MDD]).

METHODS

Adult patients (n=648) were diagnosed with a DSM-IV-TR BPD (243 type-I, 199 type-II, and 88 NOS), or UP-MDD (118) and skewed onset-age distributions were compared nonparametrically. We also examined associations of onset-age with demographic and clinical characteristics, tested the ability of onset-age to distinguish BPD from UP-MDD patients, and predicted later morbidity or disability.

RESULTS

By diagnosis, onset-age (median with interquartile range [IQR]) ranked: BP-I (25.0 [14.0])=BP-II (25.0 [15.8])<bpd-nos></bpd-nos>

DISCUSSION

Onset was younger among BPD than UP-MDD patients, generally confirming recent findings in other world regions. Older onset was associated with some functional outcomes (marriage and work) but not an index of morbidity (recurrence rate), suggesting a complex relationship to later illness-course and disability.

Psychopharmacological Treatments for Emotion Dysregulation in Borderline Personality Disorder

The drug treatment of affective symptoms in borderline personality disorder (BPD) has been the subject of four recent meta-analyses of randomized controlled studies (RCTs). This paper reviews the current evidence-based recommendations for the psychopharmacological treatment of the affective symptoms in BPD: affective instability, anger, depression, and anxiety. There was not enough data on affective instability as an outcome measure to make a good conclusion. Most of the evidence point to a large reduction of anger with mood stabilizers and antipsychotics. Mood stabilizers are also moderately effective against depressed mood and anxiety. Contrary to prior guidelines, selective serotonin reuptake inhibitors (SSRIs) were shown to be minimally effective against depression in BPD. Omega 3 fatty acids helped reduce depression. These results suggest that clinicians should raise their threshold for prescribing medication for affective instability, anxiety, and depression, but not for anger. Clinicians must also weigh the benefits of medication over their side effects in the neurologic and metabolic domains. The meta-analyses were limited by the heterogeneity in methodology, by the small number of RCTs for each drug and small sample sizes, and by the exclusion of patients with comorbidities that are common in this population.

A Review of Psychotherapy for Obsessive-Compulsive Disorder

Cognitive-behavioral therapy (CBT) is a first-line treatment for obsessive-compulsive disorder (OCD) in adults and children due to its efficacy, maintenance of therapeutic gains after treatment withdrawal, safety, and tolerability. The current article reviews research regarding the theoretical underpinnings of CBT, pragmatics regarding CBT implementation, and efficacy findings, while also highlighting barriers to efficacious treatment (ie, age, comorbidity, geography), methods of addressing such issues, and areas in need of further study.

Substance Use Disorder in Adult Tourette Syndrome: Frequency, Profile, and Comorbidities

INTRODUCTION

Previous studies have suggested that substance use disorder (SUD) may be over-represented in patients with Tourette syndrome (TS). Nevertheless, this association has received relatively little attention, despite the presence in both conditions of psychic urges or cravings and the prominence in TS of symptoms commonly associated with addiction, including mood and impulse-control dysregulation. The profile of SUD in TS is of both theoretical and practical interest, in view of the differential impact of certain common drugs of abuse on tics and other TS-related symptomatology.

OBJECTIVES

To assess the frequency, pattern, and comorbidities of SUD in a clinic population of adult TS subjects.

METHODS

Clinical records of adult TS patients followed at a University neurology clinic, which included formal ratings of tic and OCD severity, as well as information from a modified version of the Centre for Addiction and Mental Health Concurrent Disorders Screener (CAMH-CDS), were reviewed retrospectively. Patients with and without a history of SUD were compared with respect to severity of tics and comorbid psychiatric disorders.

RESULTS

Fifteen of the 66 TS patients (23%) had a history of SUD. Abused substances included not only those which might alleviate tics, such as cannabis and benzodiazepines, but also cocaine, with its strong tic-aggravating potential. Mood and impulse dysregulation in the form of panic disorder and rage attacks predicted SUD. Obsessive-compulsive disorder was not associated with SUD, consistent with the conceptual separation of both substance and behavioral addictions from obsessive-compulsive spectrum disorders.

CONCLUSIONS

SUD, primarily involving non-alcoholic substances, may be twice as common in symptomatic TS adults as in the general population, may be predicted by mood and impulse dysregulation and, in specific instances, may either drive or be driven by tics. These findings are considered in the context of dysfunction involving frontal-subcortical circuits and their modulating neurotransmitter systems, a pathobiology common to TS, SUD and linked psychiatric disorders. Management implications for TS patients at potential risk for SUD are discussed.

Contribution of Disulfiram Use to Retain Alcohol-Dependent Outpatients in Treatment: A Focus on Gender

Specificity of Predictors for “Psychosis” and “Neurosis”: A Comparison in a 50-Year Follow-Up of the Unselected Lundby Community Population

Bogren M, Mattisson C; Specificity of Predictors for “Psychosis” and “Neurosis”: A Comparison in a 50-Year Follow-Up of the Unselected Lundby Community Population. Mind & Brain, the Journal of Psychiatry, August 2010; 1(2):  1-12

ORIGINAL ARTICLE


Mats Bogren and Cecilia Mattisson

Affiliation : Department of Clinical Sciences, Division of Psychiatry, the Lundby Study, Lund University Hospital, Lund, Sweden

ABSTRACT

Premorbid anomalies related to personality and behavior may confer an increased risk of developing psychosis. Prospective studies have found that social anxiety, social adjustment problems, deviance in emotional reactivity, high neuroticism, low extraversion, psychoticism, features of schizotypy, neurocognitive impairment, and anhedonia are associated with an increased risk of developing schizophrenia spectrum disorders. As some of these factors—e.g., anxiety, neuroticism, and psychoticism—have also been found to be associated with depression, however, it is possible that such deviances related to personality and behavior may reflect an increased risk of developing any mental disorder, thus raising the question whether there are any premorbid traits that are specifically related to psychosis. We studied whether certain clusters of premorbid behavioral and personality-related signs and symptoms were predictors of “nonaffective and/or affective psychosis” and “neurosis,” respectively, in a 50-year prospective study of a complete general community population (n = 3563). Although we found that most personality-related predictors are probably shared between “psychosis” and “neurosis” outcomes, the result also suggested that premorbid proneness to anxiety, impairment in experiencing pleasure, affective flattening, cluster A resembling traits, hypersensitiveness, and distractibility may be more strongly related to the risk of developing “psychosis” than “neurosis.” Furthermore, impairments in experiencing pleasure and affective flattening may show some superior specificity for the risk of developing “psychosis” in comparison with “neurosis,” which accords with the hypothesis that psychosis proneness may be related to a salience disorder.

Keywords: Community Population, Prospective Study, Vulnerability, Risk Factors, Nonaffective Psychosis, Affective Psychosis, Neurosis
Correspondence: Mats Bogren, Department of Clinical Sciences, Division of Psychiatry, the Lundby Study, Lund University Hospital, St Lars,
SE-221 85 Lund, Sweden. Tel: +46 46 174321 ; Fax: +46 46 174647; e-mail: mats.bogren@med.lu.se

Self-Protective Organization in Children with Conversion Symptoms: A Cross-Sectional Study Looking at Psychological and Biological Correlates

Kozlowska K, Williams LM; Self-Protective Organization in Children with Conversion Symptoms: A Cross-Sectional Study Looking at Psychological and Biological Correlates. Mind & Brain, the Journal of Psychiatry, August  2010; 1(2):  43-58

REVIEW ARTICLE


Kasia Kozlowska^1,2 and Leanne M Williams²

Affiliations : ¹Department of PsychologicalMedicine, The Children’s Hospital atWestmead,Westmead, NSW, Australia and ²Brain Dynamics Centre, Sydney Medical School and Westmead Millennium Institute at Westmead Hospital, Westmead, NSW, Australia

ABSTRACT

Conversion disorder remains a long-standing puzzle concerning the interconnections of brain, mind, and body. Contemporary psychological assessments and neurophysiological techniques create a new window for investigating those interconnections, but the widely varying presentations of conversion disorder have made it difficult to isolate clinically well-defined groups for controlled studies. To overcome such difficulties, we propose an integrative framework to link the conceptualization of symptoms with levels of organization, as assessed by brain–body measures. We conceptualize conversion symptoms as the motor-sensory components of broader self-protective patterns of response—integrated sets of reactions involving physiological, motor-sensory, and psychological subcomponents—or their unwanted consequences. We describe a research program aimed at testing these relationships in children presenting with acute “conversion symptoms,” including somatoform pain. These relationships are examined using a standardized test battery that includes psychological measures (symptoms, attachment strategy, distress, daily function, life-event profile), measures of cognitive performance (on both general and emotional domains), and neurophysiological measures of brain and body function (including electroencephalogram, event-related potentials, heart rate, and skin conductance). Enrollment is under way for a minimum target of 40 children with acute conversion symptoms, 40 children with medically unexplained pain, and 40 healthy, matched controls. Our expectation is that these data will advance our understanding of conversion disorder and also improve the clinical care of this patient population.

Keywords: Conversion disorder, Somatoform pain disorder, Medically unexplained symptoms, Self-protective organization, Biologicalmarkers,
Emotion processing, Dynamic-Maturational Model of attachment, Integrative neuroscience
Correspondence: Kasia Kozlowska, Department of Psychological Medicine, The Children’s Hospital atWestmead, Locked Bag 4001,Westmead,
NSW 2145, Australia. Tel: 61-2-9845-2005; Fax: 61-2-9845-2009; e-mail: kasiak@chw.edu.au

Using Neuroimaging to Predict Outcome in Patients with Major Depressive Disorder

Ramasubbu  R, MacQueen G; Using Neuroimaging to Predict Outcome in Patients with Major Depressive Disorder. Mind & Brain, the Journal of Psychiatry, August  2010; 1(2):  59-68

REVIEW ARTICLE


Rajamannar Ramasubbu and Glenda MacQueen

Affiliation : Department of Psychiatry and Clinical Neurosciences, Faculty of Medicine, University of Calgary, Hotchkiss Brain Institute, Calgary, Alberta, Canada

ABSTRACT

Variability in treatment response is a major challenge in the treatment of patients with major depression, and there are few reliable predictors of clinical outcomes. Recent advances in brain-imaging technologies offer promise that neural markers might be useful in the prediction of treatment outcomes. Emerging evidence suggests that hippocampal and anterior cingulate volumes and brain activity in the subgenual cingulate and amygdala may predict treatment response in depression. There are some obvious limitations to the routine use of imaging as a tool for predicting who will respond to a course of treatment. Nonetheless, it is reasonable to consider whether non-invasive brain-imaging methods such as magnetic resonance imaging and electroencephalography combined with sensitive clinical measures of early treatment changes will someday be routinely applied to guide treatment selection for people with depression.

Keywords: Major Depression, Antidepressants, Predictors of Treatment Response, Brain Imaging, Neural Markers
Correspondence: Dr Rajamannar Ramasubbu, Department of Psychiatry and Clinical Neurosciences, Special Services Building, 403-29th Street
N.W., Calgary, Alberta T2N 2T9, Canada. Tel: 403-944-1235; Fax: 403-270-3451; e-mail: rramasub@ucalgary.ca

Responses to Facial Expressions of Emotions in Social Anxiety Disorder: A Review of fMRI and ERP Studies from a Developmental Psychopathology Perspective

Biomarkers and Autism

Health Inequality and Social Exclusion in Schizophrenia

The Cost of Relapse in Schizophrenia

Psychosocial Interventions to Improve the School Performance of Students with Attention-Deficit/Hyperactivity Disorder

Tresco KE, Lefler EK, Power TJ; Psychosocial Interventions to Improve the School Performance of Students with Attention-Deficit/Hyperactivity Disorder. Mind & Brain, the Journal of Psychiatry, August  2010; 1(2):  69-74

REVIEW ARTICLE


Katy E Tresco, Elizabeth K. Lefler and Thomas J Power

Affiliation : The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

ABSTRACT

Children with attention-deficit/hyperactivity disorder (ADHD) typically show impairments throughout the school day. A number of interventions have been demonstrated to address both the academic and behavioral impairments associated with this disorder. Although the focus of research has been on classroom-based strategies of intervention for children with ADHD, school-based interventions applicable for nonclassroom environments such as lunchrooms and playgrounds are beginning to emerge. This paper provides a brief description of the guiding principles of behavioral intervention, identifies selected strategies to address behavioral and academic concerns, discusses how school contextual factors have an effect on intervention selection and implementation, and considers the effects of using psychosocial interventions in combination with medication.

Keywords: ADHD, School, Intervention, Behavior, Psychosocial, Academic, RTI
Correspondence: Thomas J Power, The Children’s Hospital of Philadelphia, 34th St. & Civic Center Blvd., 3535 Market Street-Room 1471, Philadelphia, PA 19104, USA. e-mail: power@email.chop.edu

Societal Costs of Non-Adherence in Schizophrenia: Homicide/Suicide

Reichhart T, Kissling W; Societal Costs of Non-Adherence in Schizophrenia: Homicide/Suicide. Mind & Brain, the Journal of Psychiatry, August  2010; 1(2):  29-32

REVIEW ARTICLE


Tatjana Reichhart and Werner Kissling

Affiliation : Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der lsar, Technische Universität München, Möhlstrasse 26, 81675 München, Germany

ABSTRACT

The long-term management of schizophrenia poses a major public health challenge. The case for integrating multiple therapeutic approaches and modalities is clear, especially with the issues faced by schizophrenia patients in terms of suicide, homicide, and violent behavior. This non-systematic review of published literature about this topic shows that schizophrenia and other psychoses are associated with violence and violent offending, particularly homicide. Most of the excess risk appears to be mediated by substance abuse comorbidity. The risk in these patients with comorbidity is similar to that for substance abuse without psychosis, and schizophrenia patients who adhere to prescribed medication are no more likely than the general population to commit violent crimes, unless drugs and alcohol are involved. Suicide is the leading cause of death in patients with schizophrenia—the rate of committed suicide in patients with schizophrenia is approximately 10%. Poor adherence to medication has been shown to be a risk factor for completed suicide in schizophrenia. Long-acting medications delivered using depot method may be one approach to improving adherence to medication and thus reducing the risk of suicide and violent behavior in patients with schizophrenia.

Keywords: schizophrenia, adherence, violence, homicide, suicide, long-acting medication
Correspondence: Werner Kissling, Leiter des Centrums für Disease Management, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universität München, Möhlstrasse 26, 81675 München, Germany. Tel: 0049/(0)89/4140-4207; Fax: 0049/(0)89/4140-4894; e-mail:W.Kissling@lrz.tu-muenchen.de

The True Cost of Non-Adherence in Schizophrenia

Emsley R; The True Cost of Non-Adherence in Schizophrenia. Mind & Brain, the Journal of Psychiatry, August  2010; 1(2):  17-22

REVIEW ARTICLE


Robin Emsley

Affiliation : Department of Psychiatry, University of Stellenbosch in Cape Town, South Africa

ABSTRACT

Non-adherence to prescribed antipsychotic drugs by schizophrenia patients is a major cause of treatment failure and poor functional outcomes, and increases the likelihood of psychiatric hospitalization, which in turn increases the overall cost of care. Non-adherence to therapy has also been associated with a greater propensity to violent acts, including suicide, substance abuse, and related behavior. Moreover, with persistence of symptoms, people with schizophrenia find it hard to remain employed and become increasingly socially excluded. It is particularly important to ensure adherence to therapy during the early phase of the disease process, as this may greatly impact long-term treatment outcomes. As treatment adherence is a complex phenomenon affected by interacting parameters, such as psychopathology, poor insight, medication-related factors, social support, comorbidities, associated substance abuse, and patient–physician relationship, a multifaceted approach to improving treatment compliance that includes both psychosocial and pharmacological therapeutic measures is required. Long-acting injectable (LAI) formulations of antipsychotic drugs have the potential to reduce non-adherence and consequently improve clinical outcomes. In particular, LAI risperidone, a second-generation antipsychotic agent, has yielded significant improvements in overall symptoms, quality of life and patient satisfaction, and reduced hospitalization, compared to oral antipsychotics, in patients with schizophrenia. When used in early psychosis, LAI risperidone has been associated with sustained remission in a majority of cases. Inadequate adherence to antipsychotic drugs compromises treatment outcomes in schizophrenia patients. LAI preparations of antipsychotic drugs have the potential to improve adherence to therapy and treatment outcomes in these patients.

Keywords: adherence, antipsychotic, depot, hospitalization, injectable, non-adherence, schizophrenia
Correspondence: Robin Emsley, Department of Psychiatry, Faculty of Health Sciences, University of Stellenbosch, Tygerberg, 7500 Cape Town, South Africa. Tel: +27 21 9389227; Fax: +27 21 9389738; e-mail: rae@sun.ac.za