Differential Effect of Environmental Adversity by Gender: Rutter's Index of Adversity in a Group of Boys and Girls With and Without ADHD
Biederman J, Faraone SV, Monuteaux MC
Objective: The effect of gender in mediating the association between environmental adversity and risk of attention-deficit hyperactivity disorder (ADHD) and associated impairments was examined in this study. Method: 280 probands with ADHD and 242 healthy comparison probands of both sexes aged 6 to 17 years were studied. The association between Rutter's indicators of adversity (e.g., family conflict, social class, family size, maternal psychopathology, and paternal criminality) and ADHD, comorbidity, and functioning was tested. Results: In both genders, higher levels of environmental adversity were associated with a greater risk for ADHD and other comorbidity in a dose-dependent manner (i.e., the risk for ADHD increased as the number of risk factors increased). Gender did, however, modify learning disability and global functioning, as more detrimental effects were observed in boys than in girls. Low social class, maternal psychopathology, and family conflict were significantly associated with functional impairment and psychopathology in the probands, with control for maternal smoking during pregnancy, proband ADHD status, parental ADHD, and gender. Conclusions: Risk for ADHD and associated morbidity was increased by psychosocial adversity in general and by low social class, maternal psychopathology, and family conflict in particular independent of gender and other risk factors. However, gender did modify the risk for adverse cognitive and interpersonal outcomes in that boys were more vulnerable to ADHD than girls. Separating the effects of genetics from those of the environment is difficult; thus, these results must be seen as provisional until they are confirmed by twin and adoption studies.
(Am J Psychiatry. 2002;159:1556–1562. doi: 10.1176/appi.ajp.159.9.1556.)
Sleep Dynamic Therapy for Cerro Grande Fire Evacuees With Posttraumatic Stress Symptoms: A Preliminary Report
Krakow BJ, Melendrez DC, Johnston LG, et al.
Background: Sleep disturbance is common among disaster survivors with posttraumatic stress symptoms but is rarely addressed as a primary therapeutic target. Sleep Dynamic Therapy (SDT), an integrated program of primarily evidence-based, nonpharmacologic sleep medicine therapies coupled with standard clinical sleep medicine instructions, was administered to a large group of fire evacuees to treat posttraumatic insomnia and nightmares and determine effects on posttraumatic stress severity. Method: The trial was an uncontrolled, prospective pilot study of SDT for 66 adult men and women, 10 months after exposure to the Cerro Grande Fire. SDT was provided to the entire group in 6, weekly, 2-hour sessions. Primary and secondary outcomes included validated scales for insomnia, nightmares, posttraumatic stress, anxiety, and depression, assessed at 2 pretreatment baselines on average 8 weeks apart, weekly during treatment, posttreatment, and 12-week follow-up. Results: Sixty-nine participants completed both pretreatment assessments, demonstrating small improvement in symptoms prior to starting SDT. Treatment and posttreatment assessments were completed by 66 participants, and 12-week follow-up was completed by 59 participants. From immediate pretreatment (second baseline) to posttreatment, all primary and secondary scales decreased significantly (all p values < .0001) with consistent medium-sized effects (Cohen's d = 0.29 to 1.09), and improvements were maintained at follow-up. Posttraumatic stress disorder subscales demonstrated similar changes: intrusion (d = 0.56), avoidance (d = 0.45), and arousal (d = 0.69). Fifty-three patients improved, 10 worsened, and 3 reported no change in posttraumatic stress. Conclusion: In an uncontrolled pilot study, chronic sleep symptoms in fire disaster evacuees were treated with SDT, which was associated with substantive and stable improvements in sleep disturbance, posttraumatic stress, anxiety, and depression 12 weeks after initiating treatment.
(J Clin Psychiatry. 2002;63:673–684. doi: 10.4088/jcp.v63n0804.)
Interpersonal Dysfunction in Depressed Women: Impairments Independent of Depressive Symptoms
Hammen C, Brennan PA
Background: The generality of interpersonal impairments in depressed women and the extent of their independence of current depression were assessed in this study. Method: Formerly depressed, currently depressed, and never-depressed women in the community (N = 812) were compared on a variety of indices of interpersonal behavior and beliefs. Information from their spouses, adolescent children, and raters was also gathered. The study controlled for current depressive mood and sociodemographic factors that might affect social functioning. Results: Formerly but not currently depressed women showed significantly more impairment on most measures, supporting the hypothesis that interpersonal difficulties are not merely the consequence of depressive symptoms. Formerly depressed women reported more stressful life events with interpersonal and conflict content, were less likely to be stably married, reported greater spouse coercion and physical injury, had poorer marital satisfaction, were more insecure in their beliefs about other people, and had more problematic relationships with their children, friends, and extended family. Spouses and boyfriends of formerly depressed women also reported more problems and were more likely to have diagnosable disorders. No difference between groups was found, however, in the perceptions of maternal warmth or hostility among offspring. Limitations: Only women were studied. Ascertainment of the causal direction of the relationship between depression and interpersonal impairment was precluded by the cross-sectional design of the study. Clinical depression is often followed by subthreshold symptoms that are not captured by diagnostic instruments; these symptoms in turn are difficult to differentiate from preceding or coexisting interpersonal problems. Conclusions: Interpersonal impairment is a stable feature of depression and represents a formidable challenge to treatment. Such impairment may reflect underlying vulnerability to the onset and recurrence of depression.
(J Affect Disord. 2002;72:145–156. doi: 10.1016/s0165-0327(01)00455-4.)
Chronic Depression in Women
Kornstein SG
Chronic depression represents an important public health concern for women. It is underrecognized and undertreated and is associated with significant functional impairment and high rates of comorbidity. Moreover, recent research suggests that chronic depression may affect women more seriously than men; for example, women may experience illness onset at an earlier age and experience more severe psychosocial impairment compared with men. Recent studies have demonstrated the efficacy of both antidepressant medications and psychotherapy in treating chronic depression, with differential responsiveness to some treatments between women and men. Young women should be screened carefully and treated vigorously to prevent the serious consequences of this condition.
(J Clin Psychiatry. 2002;63:602–609. doi: 10.4088/jcp.v63n0713.)
A Review of Interventions to Reduce the Prevalence of Parasuicide
Comtois KA
Objective: Parasuicide is a major risk factor for completed suicide. Studies of treatments for parasuicide were reviewed in order to further the development and improvement of interventions for parasuicide and to help decrease its prevalence. Method: Studies on parasuicide, which was defined as any nonfatal self-injury (including suicide attempts and self-mutilation), were identified via a literature search of the MEDLINE and PsycINFO databases for the years 1970 to 2001. The current review included only experimental and quasi-experimental controlled trials of treatment for parasuicidal individuals. Results and Conclusions: Parasuicide was identified in 4% to 5% the U.S. population and was found to be a significant predictor of completed suicide, which is the ninth leading cause of death in the United States and is responsible for 50% more deaths than homicide. Within the limited literature on treatments for parasuicide, several treatments have received empirical support, although studies of usual care show that these treatments are rarely used and that standard treatments, especially hospitalization, are very expensive. On the basis of the literature and established health services strategies, the following 8 steps for improving services to parasuicidal individuals are recommended: (1) establishing case registries, (2) evaluating the quality of care for parasuicidal individuals, (3) evaluating training in empirically supported treatments for parasuicide, (4) ensuring faithfulness to treatment models, (5) evaluating treatment outcomes, (6) identifying local programs for evaluation, (7) providing infrastructural supports to treating clinicians, and (8) implementing quality improvement projects.
(Psychiatr Serv. 2002;53:1138–1144. doi: 10.1176/appi.ps.53.9.1138.)
Venlafaxine Treatment of Binge-Eating Disorder Associated With Obesity: A Series of 35 Patients
Malhotra S, King KH, Welge JA, et al.
Background: Binge-eating disorder is a newly recognized eating disorder characterized by recurrent episodes of binge eating without extreme weight loss behaviors. It commonly co-occurs with overweight and obesity. To preliminarily explore the effectiveness and tolerability of venlafaxine in binge-eating disorder, we retrospectively reviewed the response of 35 consecutive overweight or obese outpatients with binge-eating disorder presenting at the University of Cincinnati Physicians Weight Management Program, Cincinnati, Ohio, to clinical treatment with venlafaxine. Method: The medical charts of 35 consecutive outpatients with binge-eating disorder (DSM-IV criteria) and overweight (body mass index [BMI] = 25.0–29.9) or obesity (BMI · 30.0) who received clinical treatment with venlafaxine at a weight management program were reviewed. Response of binge-eating disorder symptoms was assessed by weekly binge frequency (the number of binges reported by the patient the week before the clinic appointment), the Clinical Global Impressions-Severity of Illness (CGI-S) scale, and categorical response (no response, mild, moderate, marked, or remission). Weight, BMI, waist circumference, comorbid Axis I diagnoses, vital signs, and side effects also were collected. Results: Twenty-nine patients (83%) received venlafaxine as monotherapy and 6 (17%) received the drug adjunctively for a median of 120 days (range, 28–300 days). The mean ± SD venlafaxine treatment dose was 222 ± 63 mg/day (range, 75–300 mg/day). In the 33 patients who were actively binge eating at the time venlafaxine was begun, weekly binge frequency, severity of binge-eating and mood symptoms as measured by the CGI-S scale, weight, BMI, waist circumference, and diastolic blood pressure all showed statistically significant decreases over time (p < .05). Of these 33 patients, 29 (88%) displayed a moderate (50% reduction) or better response of binge-eating episodes. Fifteen (43%) of the 35 patients lost 5% or more of their baseline weight. In general, venlafaxine was well tolerated, with dry mouth, sexual dysfunction, insomnia, and nausea being the most frequently reported side effects. Sustained increases in blood pressure seen in 6 patients (17%) were considered clinically insignificant. No patients discontinued the drug. Conclusion: Venlafaxine may be an effective treatment for binge-eating disorder associated with overweight or obesity. Controlled studies of venlafaxine in binge-eating disorder appear warranted.
(J Clin Psychiatry. 2002;63:802–806. doi: 10.4088/jcp.v63n0909.)
Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status
Kataoka SH, Zhang L, Wells KB
Objective: Although a lack of use of mental health services among youths has been emphasized in policy discussions concerning the mental health needs of children, national estimates are few. Using 3 national data sets, this study provides such estimates by examining ethnic disparities in unmet need (i.e., having a need for mental health evaluation but not utilizing services during a 1-year period). Method: Data from 3 nationally representative household surveys given from 1996 through 1998—the National Health Interview Survey, the National Survey of American Families, and the Community Tracking Survey—received a secondary analysis. Rates of use of mental health services by children and adolescents aged 3 to 17 years and differences by ethnicity and insurance status were determined. Children in need of mental health services were defined as such by an estimator of mental health problems (selected items from the Child Behavior Checklist). Among these children, the association of unmet need with ethnicity and insurance status was examined. Results: During a 12-month period, mental health services were used by 2% to 3% of children aged 3 to 5 years and by 6% to 9% of children and adolescents aged 6 to 17 years. Almost 80% of children and adolescents aged 6 to 17 years defined as needing mental health services did not receive such services. The rate of unmet need (with control for other factors) was higher in Latino than in white children and in uninsured than in publicly insured children. Conclusions: The majority of children who need mental health services do not receive them, especially Latino children and uninsured children. Preschool children have very low rates of mental health service use. Policy and clinical programs could be informed by research that clarifies the reasons for high rates of unmet need in specific groups.
(Am J Psychiatry. 2002;159:1548–1555. doi: 10.1176/appi.ajp.159.9.1548.)
The Grief Experiences and Needs of Bereaved Relatives and Friends of Older People Dying Through Suicide: A Descriptive and Case-Control Study
Harwood D, Hawton K, Hope T, et al.
Background: The grief experiences of individuals bereaved through the suicide of older persons are for the most part unstudied. A possible source of distress may be the legal procedures that follow such suicides. Guilt feelings, as well as a sense of rejection, shame, or stigma, have been suggested to be more common in relatives bereaved through suicide than in relatives bereaved through other modes of death. Method: In 85 relatives and friends bereaved through the suicide of a person aged 60 years or older, grief experiences and problems experienced during legal procedures after the death were examined. The bereavement reactions in a subgroup of 46 individuals were compared with the reactions in a control group bereaved by the natural death of an older person. Interviews, which included a semistructured assessment of problems following the death, the Grief Experience Questionnaire (GEQ), and the Montgomery-Asberg Depression Rating Scale, were conducted 6 to 21 months after the deaths. Results: Of those bereaved through suicide, 36 (42.4%) reported problems in their dealings with the coroner's office and 33 (38.8%) described having distress due to media reporting of the inquest. Individuals bereaved through suicide had depression scores similar to those of individuals bereaved through natural causes, although those bereaved through suicide scored higher on GEQ subscales measuring stigmatization, shame, sense of rejection, and “unique reactions.” Limitations: Especially in the control group, the participation rate of potential subjects was low. There were differences between the study and control groups in the proportions of different kinships to the deceased. Conclusions: Relatives bereaved through suicide are frequently distressed by problems in media reporting of coroners' inquests and in inquest procedures. Because themes of stigma, shame, and sense of rejection in bereavement are common in relatives bereaved through suicide, they should be specifically addressed as part of the counseling of these relatives.
(J Affect Disord. 2002;72:185–194. doi: 10.1016/s0165-0327(01)00462-1.)
Use of Psychotropic Medication in the General Population of France, Germany, Italy, and the United Kingdom
Ohayon MM, Lader MH
Background: The use of psychotropic medications and its association with sleep and psychiatric and physical illnesses were studied in the general population. Method: A cross-sectional telephone survey was carried out using the Sleep-EVAL knowledge-base system. A representative sample of the noninstitutionalized general populations of France, Germany, Italy, and the United Kingdom, aged 15 years or over, was interviewed (N = 18,679; participation rate: 78.8%; target population: 204,605,391 inhabitants). Questions were asked about psychotropic medication intake (name of medication, indication, dosage, duration of intake, prescriber), sociodemographics, physical illnesses, and DSM-IV mental disorders. Results: At the time of the interview, 6.4% of the subjects took a psychotropic medication. Anxiolytics were reported by 4.3% of the sample, hypnotics by 1.5%, antidepressants by 1.0%, and neuroleptics and other psychotropics by less than 1.0%. Hypnotics and anxiolytics were mostly used as a sleep disorder treatment. Antidepressants were taken appropriately for a depressive illness in only 44.1% of cases. Low doses of hypnotics and anxiolytics were found in about 10% of cases and low doses of antidepressants in 31.7% of cases. Subjects with a psychiatric disorder received a psychotropic treatment only infrequently (between 10% to 40.4%, depending on the disorder). All psychiatric disorders, including mood disorders, were treated mainly with an anxiolytic. A concomitant physical illness increased the likelihood of using a psychotropic treatment and was a strong predictor of adequate psychotropic dosage. Conclusion: Psychiatric pathology and sleep disorders remained mostly untreated or inadequately managed in the general population. Depression is underdiagnosed by the physicians and is treated with antidepressant in only 7% of cases. By contrast, anxiolytics are extensively prescribed, especially in France and Italy. The co-occurrence of organic and psychiatry disorders increases the frequency of medical consultations and the likelihood of being given a prescription for the mental disorder.
(J Clin Psychiatry. 2002;63:817–825. doi: 10.4088/jcp.v63n0912.)
Nationwide Longitudinal Study of Psychological Responses to September 11
Silver RC, Holman EA, McIntosh DN, et al.
Background: A unique opportunity to examine longitudinally the process of adjusting to a traumatic event was afforded by the terrorist attacks on the United States on September 11, 2001. This study assessed the extent to which psychological outcomes over time are predicted by mental and physical health history, demographic characteristics, lifetime exposure to stressful events, experiences related to September 11, and coping strategies used shortly after the attacks. Method: A Web-based survey was administered to a national probability sample of 3496 adults, of whom 2729 (78%) completed it between 9 and 23 days (75% of these respondents completed it within 9 to 14 days) after the attacks. From these 2729 respondents, a random sample of 1069 individuals who lived outside New York, N.Y., were selected to receive a second survey approximately 2 months after the attacks, which was completed by 933 (87%). A third survey was completed by 787 panelists about 6 months after the attacks. The main outcome measures were symptoms of acute stress, posttraumatic stress, and global distress related to September 11. Results: Symptoms of posttraumatic stress related to September 11 were reported by 17% of the U.S. population outside of New York City 2 months after the attacks and by 5.8% 6 months after the attacks. High levels of symptoms of posttraumatic stress were associated with several factors: female sex (odds ratio [OR] = 1.64, 95% CI = 1.17 to 2.31), marital separation (OR = 2.55, 95% CI = 1.06 to 6.14), pre–September 11 diagnosis of depression or anxiety disorder (OR = 1.84, 95% CI = 1.33 to 2.56) or physical illness (OR = 0.93, 95% CI = 0.88 to 0.99), severity of exposure to the attacks (OR = 1.31, 95% CI = 1.11 to 1.55), and early disengagement from coping efforts (e.g., giving up: OR = 1.68, 95% CI = 1.27 to 2.20; denial: OR = 1.33, 95% CI = 1.07 to 1.64; and self-distraction: OR = 1.31, 95% CI = 1.07 to 1.59). Global distress was associated with severity of loss due to the attacks (β = .07, p = .008) and early coping strategies (e.g., increased with denial: β = .08, p = .005; and giving up: β = .05, p = .04; and lessened with active coping: β = –.08, p = .002) as well as with demographic and pre–September 11 health variables. Conclusions: When a major national trauma occurs, psychological effects are not limited to those who experience the trauma directly, nor can degree of response be predicted only by objective measures of exposure to or loss related to the traumatic event. Symptoms over time are instead associated with use of particular coping strategies shortly after the event occurs, with disengagement from coping efforts serving as a signal for the likelihood of psychological problems up to 6 months posttrauma.
(JAMA. 2002;288:1235–1244. doi: 10.1001/jama.288.10.1235.)
What Research Suggests for Depressed Women With Children
Weissman MM, Jensen P
Background: The strong association between maternal and offspring depression has been observed in numerous studies. Understanding this association has implications for early intervention and prevention. Method: Findings from our community-based epidemiologic studies and high-risk and longitudinal studies of families with depression are reviewed. Results and Conclusions: The childbearing years are the high-risk period for major depression in women. The offspring of depressed women are at high risk for depression. The risk begins before puberty in the offspring and is transmitted to the grandchildren. Depression that begins in childhood or adolescence is continuous and is associated with considerable morbidity. Despite the availability of efficacious treatment, the majority of depressed adults and children remain untreated. Without a clear commitment to mental health parity and an effective service system for intervention, little progress will occur in improving the treatment of depression. There are numerous opportunities for research on the etiology, treatment, and prevention of depression in mothers and their children.
(J Clin Psychiatry. 2002;63:641–647. doi: 10.4088/jcp.v63n0717.)
Childhood Adversity, Gender and Depression Over the Life-Course
Wainwright NWJ, Surtees PG
Background: The separate risks of first onset and recurrent episodes of depression must be considered in any comprehensive investigation of hypotheses regarding early risk factors and episodes of depression in adulthood. Method: Data were obtained via retrospective assessment of lifetime history of (putative) major depressive disorder and of adverse experiences in childhood from a sample of participants in a large-scale population study (N = 3491). Investigation of gender differences in lifetime depression and the impact of adversities in childhood on adult depression was done using a statistical model based on Poisson regression, which combined both the survival distribution of first onset times with the subsequent rate of episode recurrence. Results: Women were found to be at increased risk for first onset of depression; however, this gender difference decreased with increasing age and was no longer apparent in individuals over 50 years of age. An increased risk of first onset of depression in younger adults (−30 years) was associated with experience of either a frightening event or physical abuse in childhood. Limitations: Caution in the interpretation of substantive findings of this study is warranted due to the methods of data collection that were used. Conclusions: The relationships between the risk for early and late first onset of depression and the risk of recurrence may imply different causal pathways for the associations between risk factors early in life and prevalence of depression in adulthood. Greater understanding of the origins of depression in adulthood can be gained by taking full account of episode history.
(J Affect Disord. 2002;72:33–44. doi: 10.1016/s0165-0327(01)00420-7.)
A Randomized Controlled Trial of Fluvoxamine in Prostatodynia, a Male Somatoform Pain Disorder
Turkington D, Grant JBF, Ferrier IN, et al.
Background: Prostatodynia is a common and often disabling condition that affects males and has the characteristics of a somatoform pain disorder. It presents with urogenital pain and urinary symptoms. Failure of conventional treatment and a successful uncontrolled pilot study with fluvoxamine in this condition prompted this study. Method: In a randomized double-blind trial, 42 patients with prostatodynia were assigned to receive either fluvoxamine (N = 21) or placebo (N = 21) for up to 8 weeks. Doses were adjusted according to therapeutic need. The median dose of fluvoxamine was 150 mg (range, 50–300 mg). Self-rated pain scores, urinary flow rates, and depression and anxiety scores were measured at baseline and several times throughout the study period. Results: The groups were similar at baseline, and the results were examined by intent-to-treat analysis either using the last observation carried forward or, in the case of dichotomous measures, counting treatment dropouts as treatment failures. Fluvoxamine was significantly more likely to reduce pain intensity (p = .01) and normalize urinary flow rates (p = .03) with a clinically significant number needed to treat value of 1.5 (confidence interval = 1.12 to 5.50). This therapeutic effect could not be attributed to change in mood, as the 2 groups did not differ with respect to affective ratings at the end of the study. The fluvoxamine-treated group had significantly lower (p = .02) final scores on the General Health Questionnaire, indicating an overall benefit from pain relief. Conclusion: Fluvoxamine is a viable treatment for prostatodynia. Dose-ranging studies and longer trials are needed to evaluate this agent further.
(J Clin Psychiatry. 2002;63:778–781. doi: 10.4088/jcp.v63n0905.)
Predicting Adolescent Violence: Impact of Family History, Substance Use, Psychiatric History, and Social Adjustment
Tarter RE, Kirisci L, Vanyukov M, et al.
Objective: This study sought to provisionally develop an efficient screen for identifying adolescents who are most susceptible to commit violent acts by the time they are young adults. It also aimed to combine use of this screening instrument with data related to child and parent psychopathology and substance abuse to ascertain the accuracy of predictions of violent outcomes. Method: Study probands were men with a lifetime history of DSM-III-R substance use disorder (N = 38) and men with no psychiatric disorder in adulthood (N = 61). The biological sons of the probands were studied at 2 timepoints. When the offspring were 12 to 14 years of age, the offspring completed a 13-item Violence Proneness Scale, derived from the revised Drug Use Screening Inventory. When the offspring were 19 years old, the occurrence of violent acts was assessed at a follow-up evaluation. Results: A violent outcome by age 19 in the offspring was predicted by presence of a DSM-III-R Axis I disorder and a Violence Proneness Scale score of 10 or higher at age 12 to 14. An overall accuracy of prediction of 77% was found; sensitivity was 81%, and specificity was 76%. Neither substance abuse disorder or psychopathology in the probands nor substance use frequency in the offspring contributed to the prediction of violence. Conclusions: The Violence Proneness Scale measures school and peer adjustment. Its use in combination with a childhood psychiatric history may prove to be an efficient screen for identifying youths at high risk for committing violent acts.
(Am J Psychiatry. 2002;159:1541–1547. doi: 10.1176/appi.ajp.159.9.1541.)