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This Month in Archives of General Psychiatry
May 1998

This Month in Archives of General Psychiatry

Arch Gen Psychiatry. 1998;55(5):389-390. doi:10.1001/archpsyc.55.5.389

The belief that mental disorder is linked to violence drives much of mental health policy. Steadman et alArticle compare violence by people discharged from acute psychiatric facilities with violence by other residents of the same neighborhoods. No differences were found between the violence rate of patients without symptoms of substance abuse and that of their neighbors. Substance abuse raised violence rates in both groups and a higher portion of patients than residents reported such symptoms. These findings indicate that community violence by people discharged from psychiatric facilities varies considerably according to presence of co-occurring substance abuse.

A commentary by Link and Stueve appears in this issue.Article

It is difficult to interpret sex ratio differences in rates of depression because studies have used different methods of sample selection and case identification. Gater et alArticle report from the World Health Organization Study of Psychological Problems in General Health Care, which used a consistent method in 15 centers around the world. There was a consistent female preponderance for current depression and agoraphobia. In contrast, the sex ratio for generalized anxiety varied between centers, suggesting that local differences may contribute to the sex difference in rates for this disorder.

Obsessive-compulsive disorder (OCD), unipolar depression, and panic disorder are psychiatric conditions that share similar neuropsychological deficits. However, the specific nature of cognitive deficits for each of these disorders remains largely unknown. Purcell et alArticle report that patients with OCD are impaired for visual memory, executive functioning (higher-level processing), and motor speed, in contrast to patients with unipolar depression and panic disorder who perform normally on these tasks. These findings suggest that the selective deficits observed in patients with OCD are related to the specific illness processes that are associated with the disorder.

Binge eating disorder is a new diagnostic concept. The cardinal feature is binge eating but, in contrast to bulimia nervosa, the binge eating is not accompanied by inappropriate compensatory behavior such as self-induced vomiting and the misuse of laxatives. In a study of the causes of binge eating disorder, Fairburn et alArticle found that its antecedent risk factors consisted primarily of adverse childhood experiences, parental depression, negative self-evaluation, and childhood obesity. In contrast, perfectionism and pronounced vulnerability to obesity seemed to be especially characteristic of bulimia nervosa. These findings provide support for the validity of the distinction between binge eating disorder and bulimia nervosa.

Neuropathological studies in schizophrenia have implicated limbic structures paralleling the neuropsychological deficits reported in memory. However, quantitative magnetic resonance imaging studies have yielded mixed results. Nelson et alArticle used meta-analysis to evaluate 18 volumetric magnetic resonance imaging studies of the hippocampal formation in schizophrenia, which included 522 patients and 426 controls. Meta-analytic effects indicated bilateral hippocampal reduction in patients compared with controls. The hippocampal size for patients was, on average, 4% less than that of controls. Additional analyses indicated similar reduction in the amygdala and examined the role of scan variables, sample characteristics, and other study features that might explain the variability across volumetric studies. This meta-analytic report provides strong evidence of medial temporal volume reduction in schizophrenia.

Schizophrenia is associated with several polysomnographic abnormalities, notably variable reductions in delta sleep. Keshavan et alArticle applied both visually scored and automated analyses of sleep polysomnographic data in medication-free schizophrenic patients. Robust reductions in delta sleep were seen in these patients, as well as in the subset of patients who were neuroleptic naive. These findings suggest that the functional integrity of thalamocortical circuits, which mediate delta sleep, may be abnormal in schizophrenia.

There have been few outcome studies of psychotherapy for human immunodeficiency virus–positive patients. Markowitz et alArticle conducted a 4-cell, 16-week trial comparing interpersonal psychotherapy, cognitive behavioral therapy, supportive psychotherapy, and imipramine plus supportive psychotherapy as treatments for human immunodeficiency virus–positive patients with depressive symptoms. Symptoms diminished across cells, but pharmacotherapy and interpersonal psychotherapy were statistically superior to the other conditions.

Providing cost-effective community-based care for persons with severe mental illness is an important challenge. Rosenheck et alArticle tested a Veterans Affairs program of intensive community care, based on the Wisconsin Assertive Community Treatment (ACT) model, that emphasized frequent contacts, small caseloads, and high continuity. At neuropsychiatric (long-stay) facilities the model reduced total societal costs by $34,197 per patient for 2 years but did not improve clinical outcomes. At short-stay facilities the program was cost neutral when implemented as intended and improved 2-year outcomes. This study demonstrates the importance of considering institutional context and monitoring model adherence in the evaluation of intensive community treatment.

Depression is a common and serious disorder. Lyons et alArticle interviewed more than 3000 male twin pairs. More severe depression seemed to be influenced by genetic factors and the nonfamily environment, but not the family environment; less severe forms were influenced by the family and nonfamily environments, but not genetic factors. When major depression was divided into early-onset and later-onset cases, there was a stronger genetic influence on early-onset cases. Thus, environmental factors seem to play a more important role when depression is milder and starts later, while genetic influences play a relatively greater role when depression is more severe and starts earlier.

The link between adverse early experiences and adult psychopathology is widely recognized. In an earlier study by Coplan et alArticle infant primates were nursed by mothers randomly assigned to variable foraging demand (VFD) or nonvariable foraging conditions (non-VFD). The VFD group demonstrated elevations of cerebrospinal fluid corticotropin-releasing factor and decreased cortisol concentrations vs those in the non-VFD group. Follow-up cisternal taps revealed elevated concentrations of serotonin and dopamine metabolites and of somatostatin in the VFD vs non-VFD groups. Positive correlations between corticotropin-releasing factor and each elevated neurochemical were noted in the VFD group but not in the non-VFD group. The findings support the hypothesis that adverse early rearing has long-standing effects on primate neurochemicals relevant to emotional regulation.