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This Month in Archives of General Psychiatry
July 1998

This Month in Archives of General Psychiatry

Arch Gen Psychiatry. 1998;55(7):578-579. doi:10.1001/archpsyc.55.7.578

Major depression and depressive symptoms, although commonly encountered in medical populations, are frequently underdiagnosed and undertreated in patients with cardiovascular disease (CVD). Several studies have shown depression to be a major risk factor in both the development of CVD and in death after an index myocardial infarction. Musselman et alArticle show that certain pathophysiological alterations in depressed patients may contribute to their increased vulnerability to CVD, including increased platelet reactivity and decreased heart rate variability. Treatment of depression in patients with CVD improves their dysphoria and quality of life. Future studies will determine whether treatment of depression in patients with CVD improves their long-term survival.

Nielsen et alArticle have partially replicated an association of a tryptophan hydroxylase (TPH) genetic marker with suicidality in impulsive Finnish offenders. In a new group of Finnish offenders, Nielsen et al again find significant association of TPH with suicidality, but not with cerebrospinal fluid 5-HIAA. The suicidality association becomes more robust when severe suicide attempts were examined. In exploratory analysis, TPH was found to be genetically linked to both alcoholism and personality socialization score in families of these alcoholic offenders.

Vulnerability factors for eating disorders were investigated by examining patterns of psychiatric disorders among the families of women with anorexia nervosa, bulimia nervosa, and women without eating disorders. Lilenfeld et alArticle found that eating disorders run in families. Although depression, anxiety, and substance use disorders are also common among these families, these disorders do not seem to play a role in causing eating disorders. In contrast, obsessive-compulsive personality traits may play a role in the development of anorexia nervosa.

Consumers and policymakers are increasingly concerned about how managed care technologies might affect the quality of publicly funded mental health care. Young et alArticle developed a method for measuring quality and evaluated care at 2 clinics. They found that poor-quality medication management and psychosocial care were quite common, and that quality differed between the clinics. In most cases, poor care was potentially correctable, suggesting that quality improvement interventions are needed.

Rosenheck et alArticle examine the role of participation in psychosocial treatment as a mediator of the clinical effectiveness of clozapine in refractory schizophrenia. In a 12-month trial of clozapine and haloperidol, a broker case-management intervention was used to encourage participation in psychosocial treatment. Patients assigned to clozapine were more likely to accept treatment recommendations and to participate in psychosocial treatment. Structural equation modeling showed that the effectiveness of clozapine at reducing symptoms and improving quality of life was partially mediated by participation in psychosocial treatment. Psychosocial rehabilitation should be offered concomitantly with clozapine.

Previous epidemiologic surveys overstate the risk of posttraumatic stress disorder (PTSD) following traumas by focusing on events nominated by respondents as the worst they had ever experienced. Breslau et alArticle report on DSM-IV PTSD in a sample of 2181 persons in the Detroit, Mich, area. Incidence of PTSD was assessed for traumas randomly selected from the complete lists of traumas reported by each respondent. The conditional risk of PTSD is 9.2%. The highest risk is associated with assaultive violence. However, the most frequent precipitating trauma among PTSD cases is sudden unexpected death of a loved one because of its high rate in the community.

In the first such double-blind study of adult patients with autistic disorder to date, McDougle et alArticle report that risperidone was more effective than placebo in reducing repetitive behavior, aggression, anxiety/nervousness, depression, irritability, and the overall behavioral symptoms of autism. Objective, measurable change in social behavior and language did not occur. Other than mild, transient sedation, risperidone was well tolerated, with no evidence of extrapyramidal adverse effects, cardiac events, or seizures. Controlled studies of risperidone are needed to determine the safety and effectiveness of this drug in children and adolescents with the disorder.

A Commentary by Leventhal et alArticle is included.

Given the changes in the health care delivery system, there is increased interest in the cost-effectiveness of medical treatments. Lave et alArticle assessed the cost-effectiveness of 2 standardized treatments for depression (pharmacotherapy using nortriptyline and interpersonal psychotherapy). They found that, relative to the usual care received by primary care patients, patients receiving standardized treatments had better outcomes but also incurred higher overall medical care costs. However, the cost per quality of life-year gained for the standardized pharmacotherapy was comparable to that for other treatments provided in routine practice.

Little is known about the mechanisms by which sexual arousal is facilitated or inhibited in women. Recent research suggests that activation of the sympathetic nervous system may play an important role in initiating the beginning stages of sexual arousal in women. Using a double-blind, placebo-controlled design, Meston and HeimanArticle conducted the first empirical investigation of the effects of ephedrine, a drug that increases sympathetic nervous system activity, on subjective and vaginal pulse amplitude responses in women. Moderate doses of ephedrine (50 mg) significantly increased vaginal pulse stimulus responses to an erotic, but not a neutral film stimulus. These findings have implications for developing new methods of treatment for women with sexual arousal difficulties.