Biological component of the NIMH clinical research branch collaborative program on the psychobiology of depression: I. Background and theoretical considerations

There are many reports which suggest that patients with effective illness (mania and/or depression) have abnormalities in the functioning of one or more neurobiological systems. At a conference convened by the Clinical Research Branch, Division of Extramural Research Programs, National Institute of Mental Health, these findings were reviewed and some of the factors impeding movement towards a more complete and integrated view of the functioning of neurobiological systems in patients with mania or depression were identified. As a result, a multi-research centre, collaborative approach to the study of the psychobiology of affective disorders was developed. In this collaborative programme, which has now been underway for several years, the focus has been upon: (a) the assessment of the functioning of several different types of biological systems in the same patient, both before and during treatment; (b) obtaining a reasonably large number of patients and comparison subjects; and (c) the use within and across centres of standardized diagnostic categories and behavioural rating methodologies. In this paper the history, background, and rationale for this collaborative effort are reviewed. Those biological systems chosen for study are noted, and issues such as reliability and validity of diagnoses, measurement of state variables, assessment of change with treatment, and logistical and coordinating problems are discussed.

Priorities in psychiatric residency training

The authors surveyed 22 psychiatric educators to determine their views of the basic knowledge and skills that should be required for all psychiatric residents. A comprehensive document of educational objectives facilitated practical differentiation of responses. Diagnostic, problem-solving, and treatment-dispositional skills were particularly highly ranked. Such data may be useful in defining the profession of psychiatry as well as in curriculum planning.

Mental health attitudes and treatment expectations as treatment variables

Evaluated 60 patients just before their initial assessment in a community mental health clinic. A series of questions about mental health attitudes and treatment expectation were asked each patient. The Psychiatric Evaluation Form was administered both before evaluation and after five treatment visits. Patients with harsh, pessimistic views about mental illness had more severe psychopathology and did less well over the period of follow-up. Expectation of medication was associated strongly with lower education, greater severity of illness, lower satisfaction with treatment, greater frequency of dropping out of treatment, and less improvement.

Computerized tomographic evidence of cerebral atrophy in heavy drinkers

Of 50 heavy drinkers referred for nonalcoholic psychiatric problems, 56% had computerized tomographic evidence of cerebral atrophy. This contrasted with a rate of 6% in patients with schizophrenia and affective illnesses who had taken psychotropic drugs for at least ten years. Further, the severity of atrophy was greater in the group of heavy drinkers. The results support a role for computerized tomography in assessment of patients with chronic alcoholic problems.

A correlation between dropout status and improvement in a psychiatric clinic

Sixty psychiatric outpatients were independently evaluated before treatment in a mental health center and again after they had either completed five treatment visits or dropped out. Dropouts were older, more likely to be female, more severely ill, and more likely to expect medications. They improved less on scales of drug use, denial of illness, and grandiosity. Dropouts who did improve were more likely to have situational reactions. Better-educated patients had better outcomes. Patients who were satisfied with the treatment they received were the most likely to have improved.

Arrests before and during methadone maintenance

The effect of methadone maintenance on criminal behavior remains ambiguous, in part because of major methodological problems with most studies. We attempted to approach the problem more precisely than previous studies by comparing official police arrest records of 100 heroin addicts for 1 year before admission with those for 1 year after admission. The total number of criminal charges decreased from 189 before admission to 129 after admission. Excluding vagrancy, because of a change in police arrest practice, we found only a 14% reduction in criminal charges. A statistically significant decrease of 40% occurred in one category, burglary and theft. Arrest frequencies were generally correlated with other outcome measures such as employment status and continuation in methadone treatment. The results suggest a modest reduction in criminal behavior as a result of methadone maintenance, with insignificant reduction in crime not directly related to narcotic addiction.

Methadone dispensing by community pharmacies

This study reports 1 year follow-up data of 96 patients who received methadone at selected community pharmacies instead of traditional program dispensaries. Outcomes are comparable to those reported for traditional programs. Security measures were not a problem. The results indicate that most patients can begin methadone maintenance at a pharmacy without a period of stabilization at a program unit. Of several factors studied, arrest record, both preceding and during treatment, based on official police data was the single factor significantly associated with employment and continuation in methadone treatment. Community pharmacy dispensing of methadone is a useful means of operating a methadone treatment program.

Managing depression in the '70s

Depression is among the most common of clinical conditions. Like problems such as anemia, it is not one disease, but a constellation of signs and symptoms which may occur as the result of several psychopatho-physiologic processes. This paper summarizes the recent dramatic advances in research into the neurochemistry of the major affective diseases, provides a conceptual way of viewing depressions, and summarizes current fundamentals of managment.

A survey of information sources used by psychiatrists

To study the information sources of psychiatrists, we sent a questionnaire to 400 randomly selected members of the American Psychiatric Association. Seventy-four percent responded. Journals and books (in that order) were the most important information sources. The average number of journals regularly read was 4.3. An average of 9.1 books had been read during the preceding twelve months. Twenty-eight percent of books were obtained through a library. Sixty-nine percent of the respondents use a medical library at least monthly. Important differences were found by type of practice. For example, academicians reported reading almost 19 books the preceding year; private practitioners, 6.4. We conclude that a major aim in the postgraduate education of psychiatrists should be instruction in the use of all information services. In addition, abstracts and an authoritative annual review should help psychiatrists keep up in areas outside their special interest.