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This Month in Archives of General Psychiatry
October 2002

This Month in Archives of General Psychiatry

Arch Gen Psychiatry. 2002;59(10):872-873. doi:10.1001/archpsyc.59.10.872

Kraemer et al Article suggest that, as important as it is to establish whether a treatment is effective in a randomized clinical trial, it is almost as vital to understand on whom treatments work or do not (moderators), and why treatments work or do not(mediators). This report suggests analytic strategies by which moderators and mediators of a treatment might be sought in exploratory or hypothesis-generating activities after completion of a randomized clinical trial, and urges that such analyses follow every randomized clinical trial.

Currently the biological basis of Asperger syndrome is unknown. Thus Murphy et al Article used in vivo 1H-magnetic resonance spectroscopy (1H-MRS) to examine the neuronal integrity of adults with Asperger syndrome and controls. People with Asperger syndrome had a significantly higher prefrontal lobe concentration of N-acetyl aspartate, creatine + phosphocreatine, and choline. Metabolite differences were significantly correlated with obsessional behavior and social abnormalities. These data suggest that clinical symptoms in people with Asperger syndrome are caused by abnormalities in programmed cell death and metabolism.

The community-based study by Angold et al Article of 9- to 17-year-olds from central North Carolina found that a little more than 20% of youth in these rural communities had a psychiatric disorder. Although overall rates of disorder were very similar in African American and white children, the latter were twice as likely to have received specialty mental health services. However, services provided by schools showed no such ethnic disparity. The effect of child symptoms on parents was the strongest correlate of receipt of specialty mental health care in both African American and white children.

While the association between bipolar I disorder and syndromal level panic disorder is well documented, surprisingly little attention has been focused on the prognostic significance of this association. Frank et al Article have examined the impact of a more broadly defined lifetime condition that they refer to as panic spectrum on outcomes of patients being treated for an acute bipolar episode. They find that panic spectrum is associated with higher levels of depressive symptoms, more suicidal ideation, and a remarkable (6-month) delay in time of remission of an acute episode, suggesting that clinicians should be alert for the presence of both typical and atypical panic symptoms throughout the patient's life and adjust their interventions accordingly.

New approaches are needed to treat depressed patients who do not respond to standard therapy. The omega-3 fatty acid derivative, ethyl-eicosapentaenoate, was tested by Peet et al Article in a dose-ranging, placebo-controlled study. A low dose of 1g/d proved highly effective on both physician- and patient-rated scales in patients who had not responded to the usual drugs. None of the side effects often observed with standard antidepressants were reported with the omega-3 fatty acid.

Treatment of the prodromal or prepsychotic phase of schizphrenia has been a tantalizing goal. Based on naturalistic research that developed operational criteria highly predictive of early progression from the so-called "ultra-high risk" state to first-episode psychosis, McGorry et al Article show in a randomized trial that it may be possible to at least delay and perhaps even prevent progression in a proportion of subthreshold cases. In a 6-month trial, low-dose risperidone and cognitive therapy significantly reduced the risk of progression. Good adherence to risperidone during the active treatment phase was associated with a continuing reduction in risk for a further 6 months, even after antipsychotic therapy was withdrawn.

Hall et al Article compared bupropion, nortriptyline and placebo treatment with and without a psychological intervention over a 52-week period in 220 cigarette smokers. Psychological intervention produced higher point prevalence abstinence than drug treatment, but the 2 treatments did not differ on sustained abstinence at 1 year. Similarly, both nortriptyline and bupropion were more efficacious than placebo on point prevalence, but not on sustained abstinence. Both nortriptyline and bupropion are efficacious in aiding abstinence in cigarette smokers; but psychological intervention is more effective than drug treatment. Both drugs and the psychological intervention have limited efficacy in sustaining abstinence. The data also suggest that combining a psychological intervention with an antidepressant drug may not be more effective than antidepressant drug alone.

Do therapeutic work programs for homeless persons with addiction disorders lead to better health outcomes? Kashner et al Article demonstrated with a randomized trial that work therapy programs were associated with greater use of addiction care, with fewer reported addiction problems, physical symptoms related to substance use, and episodes of homelessness and criminal incarceration, and with preventing further deterioration over time in physical functioning. However, no effect on psychiatric outcomes was found.

Tiraboschi et al Article compared the timing of cholinergic dysfunction in Alzheimer disease and dementia with Lewy bodies. Although cholinergic deficits were seen in both, it was less severe and occurred later in the course of Alzheimer disease. In dementia with Lewy bodies, cholinergic losses were already prominent in the earliest stages of the illness, suggesting that cholinergic replacement therapy may be more effective in this entity than in Alzheimer disease, especially in mild disease.