Principles of antipsychotic prescribing for policy makers, circa 2008. Translating knowledge to promote individualized treatment

Findings from 2 pivotal government-funded studies of comparative antipsychotic effectiveness undermine assumptions about the marked superiority of the more expensive second-generation "atypical" medications in comparison to the less expensive first-generation "typical" drugs. Because this assumption was the basis for the almost universal recommendation that these newer antipsychotics be used preferentially resulting in a 10-fold increase in state governmental expenditures on this class of medications over the past decade, a reassessment of policy is called for. To address the issue, the Medical Directors Council of the National Association of State Mental Health Program Directors critically reviewed findings of these studies in the context of other data and considered policy implications in the light of the obligations of state government to make available best possible and individually optimized treatment that is cost-effective. The Medical Directors Council unanimously adopted a set of recommendations to promote appropriate access, efficient utilization, and best practice use. We present our policy statement, in which we provide a succinct background, articulate general principles, and describe a set of 4 broad recommendations. We then summarize our understanding of the current state of knowledge about comparative antipsychotic effectiveness, best antipsychotic practice, and considerations for state policy that represent the basis of our position statement.

Atypical depression: retrospective self-reporting of treatment effectiveness

OBJECTIVE

Earlier studies demonstrated that those with atypical depression show a differentially superior response to monoamine oxidase inhibitor (MAOI) antidepressants. This study compares ratings of effectiveness for a range of treatments, amongst depressed subjects with and without atypical features.

METHOD

In an on-line survey, individuals experiencing likely clinical depression rated symptoms experienced when depressed, including 'atypical features' and the effectiveness of previous treatments. Mean treatment effectiveness ratings were compared amongst those with 'atypical depression' (n = 338) and 'non-atypical depression' (n = 377).

RESULTS

There were few significant differences between the 'atypical depression' and 'non-atypical depression' groups in effectiveness ratings for drug treatments, and none for psychological treatments. The 'atypical depression' group had significantly lower mean effectiveness ratings for some selective serotonin reuptake inhibitor antidepressants. Few respondents had trialed MAOIs.

CONCLUSION

While MAOIs are rarely prescribed, a range of non-MAOI drug and psychological treatments are of some perceived benefit for depressed patients with atypical features.

REDUCED LITTER SIZES FOLLOWING 48-H OF PRENATAL EXPOSURE TO 5 nT TO 10 nT,0.5 HZ MAGNETIC FIELDS: IMPLICATIONS FOR SUDDEN INFANT DEATHS

To test the hypothesis that a narrow intensity band of geomagnetic activity contributes to Sudden Infant Death, 32 pregnant rats were exposed for two to three days before expected parturition either to a coil that generated 0.5 Hz sine-wave, 5 to 10 nanoTesla magnetic fields, or to a reference coil (<1 nT) in the same room. The field was off for 30 min every 4 h during the exposure. The orientation of the coils was perpendicular in space and activated alternately in four blocks of experiments. The litters born to the exposed mothers contained significantly fewer pups (M = 14.1,SD= 2.1) than those exposed to the control conditions (M = 16.2, SD = 2.7). There were significantly fewer numbers of males and fewer numbers of females in litters exposed to the fields generated in the east-west and north-south directions, respectively. These results support the hypothesis that a specific temporal configuration of brief periods of geomagnetic activity can produce an increased incidence of nonvital fetuses, neonates, or infants.

Measuring melancholia: the utility of a prototypic symptom approach

BACKGROUND

Melancholia has long resisted classification, with many of its suggested markers lacking specificity. The imprecision of depressive symptoms, in addition to self-report biases, has limited the capacity of existing measures to delineate melancholic depression as a distinct subtype. Our aim was to develop a self-report measure differentiating melancholic and non-melancholic depression, weighting differentiation by prototypic symptoms and determining its comparative classification success with a severity-based strategy.

METHOD

Consecutively recruited depressed out-patients (n=228) rated 32 symptoms by prototypic or 'characteristic' relevance (using the Q-sort strategy) and severity [using the Severity-based Depression Rating System (SDRS) strategy]. Clinician diagnosis of melancholic/non-melancholic depression was the criterion measure, but two other formal measures of melancholia (Newcastle and DSM-IV criteria) were also tested.

RESULTS

The prevalence of 'melancholia' ranged from 20.9% to 54.2% across the subtyping measures. The Q-sort measure had the highest overall correct classification rate in differentiating melancholic and non-melancholic depression (81.6%), with such decisions supported by validation analyses.

CONCLUSIONS

In differentiating a melancholic subtype or syndrome, prototypic symptoms should be considered as a potential alternative to severity-based ratings.

Pain during depression and relationship to rejection sensitivity

OBJECTIVE

Approximately 50% of patients with depression report symptoms of pain, yet the clinical and biological mechanisms underlying this association remain unclear. Recent neuroimaging studies, however, support the contention that depression, as well as pain distress and rejection distress, share the same neurobiological circuits. In this study, we aimed to examine the hypothesis that perception of increased pain during depression is related to increased rejection sensitivity.

METHOD

The present study analysed data from a study of 186 treatment-resistant depressed patients who met DSM-IV criteria for depression and had completed a self-report questionnaire regarding currently perceived pain and rejection sensitivity.

RESULTS

A major increase in the experience of pain during depression was predicted by a major increase in rejection sensitivity during depression.

CONCLUSION

The experience of increased pain during depression is related to increased rejection sensitivity. Research to further elucidate this relationship is required.

Brief antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depression and anxiety: a randomised controlled trial

BACKGROUND

The majority of randomised controlled trials examining the effectiveness of antenatal group interventions at preventing postnatal depression in "at risk" women have used a "psychoeducational" intervention. The aim of the present study is to evaluate the effectiveness of an antenatal cognitive behavioural group intervention in a primary care setting for pregnant women identified with mild to moderate symptoms in pregnancy and/or at risk of developing depression or anxiety in the perinatal period.

METHOD

Subjects were randomised to a CBT group intervention or control condition (information booklet) and administered the EPDS and STAI at pre (Time 1) and post intervention (Time 2), and at 2 months (Time 3) and 4 months postpartum (Time 4). MINIs were administered at Times 1, 3 and 4.

RESULTS

Of the 774 women approached, 277 accepted and were suitable; thus 191 were randomised to the CBT intervention and 86 to the control condition. The subsequent 52% drop-out left 89 women "completing" the CBT groups and 43 in the control group; these two groups were well matched on demographic variables. Intention to treat analyses revealed relatively low mean baseline EPDS scores (means 6.88 -8.16) with no reduction in EPDS scores in either group from Time 1 to Time 4. MINI depression criteria were fulfilled by 19% of all participants at Time 1 but there was no reduction in depression in either group; in contrast those with MINI anxiety diagnoses reduced from 28% in late pregnancy to 16% at four months postpartum in the CBT group with similar reductions in the control group. Analyses on the 132 "completers" showed significant symptomatic improvement over time for both the CBT group and control condition. Depression scores in the most symptomatic women (EPDS>12; N=19) decreased steadily by over 50% over the total time course but there were no differences in improvement between the CBT and control groups.

LIMITATIONS

A number of methodological factors may have obscured our results including a tendency to natural remission in mildly symptomatic subjects and the possibility that our control condition was therapeutic in itself.

CONCLUSION

While a modest reduction in depression scores was noted in study "completers", both the CBT group intervention control condition were equally beneficial. The reasons for this finding include the low symptom level at baseline; the potential effectiveness of the control condition; and the brevity of the intervention.

Perception of rejecting and neglectful parenting in childhood relates to lifetime suicide attempts for females--but not for males

OBJECTIVE

To examine the hypothesis that lifetime suicide attempts in a sample of depressed individuals is greater among those who remember their parents as rejecting or neglecting in childhood.

METHOD

Database analyses of patients referred to a public hospital Mood Disorders Unit in Sydney, over a consecutive 10-year period. Patients met DSM-IV criteria for depression, had completed a self-report questionnaire regarding perception of parental rearing, and had responded to a probe question assessing lifetime suicide attempts (n = 343).

RESULTS

Female patients who perceived themselves as rejected/neglected by either parent in childhood had a greater chance of making at least one lifetime suicide attempt. No such associations were found for males.

CONCLUSION

Perception of rejecting/neglectful parents was associated with lifetime suicide attempts in females only, inviting research explicating any such gender specificity.

Inhibition of calcium-independent phospholipase A impairs agonist-induced calcium entry in keratinocytes

Background

In many cells, depletion of intracellular calcium (Ca²⁺) reservoirs triggers Ca²⁺ entry through store-operated Ca²⁺ channels in the plasma membrane. However, the mechanisms of agonist-induced calcium entry (ACE) in keratinocytes are not fully understood.

Objectives

This study was designed to determine if pharmacological inhibition of calcium-independent phospholipase A (iPLA₂) impairs ACE in normal human epidermal keratinocytes.

Methods

Confocal laser scanning microscopy was used to monitor the dynamics of Ca²⁺ signalling in keratinocytes loaded with the calcium-sensitive dye Fluo-4. Cells were stimulated with extracellular nucleotides [adenosine triphosphate (ATP) or uridine triphosphate (UTP)] or with lysophosphatidic acid (LPA), a bioactive lipid that regulates keratinocyte proliferation and differentiation.

Results

Both ATP and UTP induced Ca²⁺ release in primary human keratinocytes. This was not followed by robust Ca²⁺ influx when the experiments were performed in low Ca²⁺ (70 μmol L⁻¹) medium. Upon elevation of extracellular Ca²⁺ to 1·2 mmol L⁻¹, however, a biphasic response consisting of an initial Ca²⁺ peak followed by an elevated plateau was observed. The plateau phase was inhibited when cells were treated with bromoenol lactone, a specific pharmacological inhibitor of iPLA₂. These findings indicate that iPLA₂ activity is required for ACE in keratinocytes. LPA also evoked Ca²⁺ release in keratinocytes but failed to induce sustained Ca²⁺ entry even when extracellular Ca²⁺ was elevated to 1·2 mmol L⁻¹.

Conclusion

Our results demonstrate for the first time an important role for iPLA₂ in regulating ACE in primary human keratinocytes.

Dysglycemia in a community sample of people treated for schizophrenia: the Diabetes in Schizophrenia in Central-South Ontario (DiSCO) study

OBJECTIVE

Despite increasing recognition of schizophrenia as a risk factor for diabetes, the prevalence and correlates of dysglycemia in people with schizophrenia have not been adequately studied. Discerning the modifiable risk factors is crucial for developing diabetes prevention strategies in schizophrenia.

METHODS

Socio-demographic, clinical and recent laboratory data were compiled from the case records and supplemental sources of 1123 people treated for schizophrenia who were living across five different communities in the region.

RESULTS

Screening rates for fasting plasma glucose (FPG) varied between 63-100% across the five communities, while other metabolic indices were monitored less frequently. 39 subjects (3.5%) in the sample had an existing diagnosis of type 2 diabetes. Among the others, 845 (78%) had FPG measured in the preceding 6 months, with the following results: FPG < or = 5.6 mmol/l in 474 (56%), 5.6-6.9 mmol/l in 268 (31%), and > or = 7 mmol/l in 103 (12.2%) subjects. Dysglycemia (FPG > or = 5.6 mmol/l) was significantly associated with older age (odds ratio [OR] 1.031), longer duration of schizophrenia (OR 1.062), self reported family history of diabetes (OR 8.87), body mass index (OR 1.081), excess weight (OR 1.014) and independent living status (OR 1.779), while European ethnicity (OR 0.706) and regular physical activity (OR 0.958) lowered the risk. No statistically significant correlations were noted with gender, level of education or functioning, or the type of antipsychotic drug prescribed.

CONCLUSIONS

There was a two-fold increase in the prevalence of dysglycemia, while there was a substantial under-recognition of and intervention for, diabetes and pre-diabetes in this sample of people treated for schizophrenia.

Cognition, functioning and quality of life in schizophrenia treatment: results of a one-year randomized controlled trial of olanzapine and quetiapine

BACKGROUND

Cognitive deficits are recognized as a critical determinant of functional outcomes in schizophrenia; and second generation antipsychotic drugs have been touted for their potential to enhance cognitive functioning and community tenure.

OBJECTIVES

The study examined the relative merits of olanzapine and quetiapine in improving cognitive deficits and enhancing psychosocial functioning in a sample of community dwelling adults previously treated with first generation antipsychotic drugs for schizophrenia.

METHODS

In a prospective, rater-blinded study, 86 participants were randomized to receive either olanzapine or quetiapine, and assessed at baseline and after 3, 6, 9 and 12 months. Outcome measures included, besides symptoms and side effects rating scales, the subjective scale to investigate cognition in schizophrenia (SSTICS), a computer-assisted cognitive test battery (COGLAB), the sickness impact profile (SIP), the global assessment of functioning (GAF) scale, and the drug attitude inventory (DAI).

RESULTS

Both olanzapine and quetiapine were equally effective in improving symptom severity and decreasing the neurological side effects. Quetiapine was significantly better tolerated (p=0.002), improved self-rated cognitive dysfunction (p=0.002) and subjects' performance on selected neurocognitive tasks (p=0.01). Olanzapine use was associated with greater symptom stability, fewer drop outs (p=0.01) and frequent metabolic aberrations (p=0.001). The accrued benefits of drug therapy, however, were not reflected as significant gains in daily functioning and quality of life.

CONCLUSIONS

Quetiapine is noted to have specific cognition enhancing properties in schizophrenia that warrants further exploration. The observed clinical and cognitive benefits associated with quetiapine may likely be attributable to its loose binding to, and fast dissociation from the dopamine receptors. Olanzapine has proved to be a reliable antipsychotic drug with a greater liability to cause metabolic abnormalities.

Defining melancholia: the primacy of psychomotor disturbance

OBJECTIVE

To argue that melancholia is a categorically distinct depressive condition, able to be differentiated from other depressive conditions by a neuropathological marker [observable psychomotor disturbance (PMD)] and having a differential response to various antidepressant treatments.

METHOD

The above statements are addressed by review of a wide body of research, which identified observable PMD as the cardinal marker of melancholia and developed the CORE measure as a strategy for assessing PMD and its severity. Properties of the CORE measure, including reliability, validity and treatment prediction, are overviewed.

RESULTS

A case is made for defining melancholia and a strategy for establishing its probability.

CONCLUSION

Melancholia is positioned as a categorical entity capable of being circumscribed by its cardinal feature of PMD.

The validity and utility of patients' daily ratings of mood and impairment in clinical trials of bipolar disorder

OBJECTIVE

Traditional cross-sectional clinician-rated measures have limited use in clinical trials of bipolar disorder. We examine the validity and usefulness of patients' daily ratings of mood and functional impairment during a treatment trial.

METHOD

Ten subjects with bipolar II disorder completed daily ratings of depression severity, depression, hypomania and functional impairment over a 9-month trial. Ratings were correlated with clinician-rated measures at nine time points to determine validity. Mood ratings were contrasted with cross-sectional data for one subject to determine usefulness of such fine-grained data.

RESULTS

Moderate to large correlations were found between patients' and clinicians' ratings of mood and impairment for most of the nine time points. The utility of the patients' ratings relative to clinician-rated cross-sectional measures was also illustrated.

CONCLUSION

Results support the validity and usefulness of patients' daily mood ratings.

Treating depression with the evidence-based psychotherapies: a critique of the evidence

OBJECTIVE

While Cognitive Behaviour Therapy (CBT) and Interpersonal Therapy (IPT) have been positioned as first-line evidence-based treatments for depression, we suggest that limitations to the 'evidence' deserve wider appreciation.

METHOD

A systematic literature search was undertaken, and limitations to the evidence base discussed.

RESULTS

The review suggests that the specificity of CBT and IPT treatments for depression has yet to be demonstrated and details likely reasons.

CONCLUSION

The superiority of CBT and IPT may well be able to be demonstrated across defined rather than universal circumstances. To achieve this aim, outcome research should move away from testing treatments as if they have universal application for heterogeneous disorder categories. Findings have distinct implications for the clinical management of depressive disorders, and particularly in relation to the utility of psychotherapy.

Is post-Lipiodol CT better than i.v. contrast CT scan for early detection of HCC? A single liver transplant center experience

Hepatocellular carcinoma is a highly vascular neoplasm usually arising from a cirrhotic liver. Delayed, noncontrast, computed tomography (CT) imaging after 7 to 14 days reveals an oil-based contrast agent to be concentrated in the tumor but not in normal hepatic parenchyma. The aim of this study was to retrospectively correlate the post Lipiodol CT scan findings with respect to tumor size in the explanted liver. We retrospectively reviewed adult patients who had undergone orthotopic liver transplantation between November 1995 and December 2004 and also had an hepatic arteriogram with Lipiodol injection as part of their pretransplant workup. We calculated sensitivity, specificity, false-negativity, false-positivity, and accuracy of the test, as well as positive and negative predictive values. Lipiodol CT exam had sensitivity of 1.0; specificity of 0.6 with a calculated positive predictive value of 0.89 and a negative predictive value of 1.0. Overall accuracy of Lipiodol CT scan test was found to be 0.91, which was superior to an intravenous contrast CT alone. In conclusion, because of the higher sensitivity and accuracy values, hepatic arterial Lipiodol injection can be considered during the pretransplantation workup of high-risk cirrhotic patients, since the current model for End-stage Liver Disease scoring system for hepatocellular carcinoma is built on the ultimate bulk of the tumor. Further multicenter, controlled, large-volume prospective studies are warranted to verify this observation.

Actions taken to cope with depression in patients seeking specialist care

OBJECTIVE

To assess the rates and perceived effectiveness of actions used to cope with depression and the factors influencing these in an outpatient sample seeking help for depression.

METHOD

One hundred and seventy-six patients (74 male, 102 female) aged 16-82 years (M = 42, SD = 14.4 years) with a major depressive episode (DSM-IV criteria) were assessed using a number of measures that covered sociodemographics, history of psychiatric illness, actions taken to alleviate depression and their perceived effectiveness. Logistic regression analyses assessed age, gender and illness characteristics associated with the use and perceived effectiveness of strategies adopted to manage depression.

RESULTS

Medical interventions were used and perceived to be effective in alleviating depressive symptoms by most of the sample, as were self-help and complementary therapies. Sociodemographic and illness-related characteristics had a significant influence, with younger age and having experienced an episode of anxiety disorder found to be the strongest predictors for the use of coping strategies. Being female was the strongest predictor for their effectiveness.

CONCLUSION

A range of actions for depression, including medical and complementary interventions, were used and found to be helpful in a sample that had sought professional help for depression. Gender, age, depression and anxiety factors were all found to predict the use and perceived effectiveness of these strategies.

Sleeping in? The impact of age and depressive sub-type on hypersomnia

BACKGROUND

While early morning wakening is held to be a classic feature of melancholia, we investigate the clinical observation that young patients with melancholia and bipolar depression tend to be more likely to report hypersomnia.

METHODS

We examine age-related rates of those two sleep disturbance patterns in a consecutive set of out-patients with differing depressive sub-types assessed over a 20-year period.

RESULTS

Hypersomnia was more likely to be reported than early morning wakening across all age bands by those with non-melancholic depression. Hypersomnia was also more likely than early morning wakening in younger patients with melancholia and bipolar disorder but, with age, early morning wakening became the dominant pattern.

LIMITATIONS

The study was retrospective, undertaken in a sample attending a tertiary referral unit and artefactual determinants of the associations were not pursued.

CONCLUSIONS

We speculate that hypersomnia may be a non-specific homeostatic coping response to stress and thus to the non-melancholic depressive disorders, but that this pattern is overruled by an early morning wakening pattern in the more biological depressive sub-types as the individual ages, perhaps reflecting a noradrenergic contribution.

Self-harming in depressed patients: pattern analysis

OBJECTIVE

As deliberate self-harm (DSH) is a common concomitant of depressive disorders, we undertook a study examining the relevance of possible determinants and correlates of DSH.

METHOD

Three separate samples of depressed outpatients were studied to determine consistency of identified factors across samples, with principal analyses involving gender, age and diagnosis-matched DSH and non-DSH subjects.

RESULTS

Across the samples, some 20% of subjects admitted to episodes of DSH. Women reported higher rates and there was a consistent trend for higher rates in bipolar patients. Univariate analyses examined the relevance of several sociodemographic variables, illicit drug and alcohol use, past deprivational and abusive experiences, past suicidal attempts and disordered personality functioning. Multivariate analyses consistently identified previous suicide attempts and high 'acting out' behaviours across the three samples, suggesting the relevance of an externalizing response to stress and poor impulse control.

CONCLUSIONS

Results assist the identification and management of depressed patients who are at greater risk of DSH behaviours.