Personality Assessment Inventory suicidality scales: Suicidal Ideation (SUI), Suicide Potential Index (SPI), and S_Chron in an Afghanistan/Iraq-era active and Veteran military sample

INTRODUCTION

This study validated Personality Assessment Inventory (PAI) Suicidal Ideation (SUI), Suicide Potential Index (SPI), and S_Chron scales against chronic and acute suicide risk factors and symptom validity measures.

METHODS

Afghanistan/Iraq-era active-duty and Veteran participants completed a prospective study on neurocognition (N = 403) that included the PAI. The Beck Depression Inventory-II (specifically item 9) administered at two time points assessed acute and chronic suicide risk; the Beck Scale for Suicide Ideation item 20 identified history of suicide attempts. Major depressive disorder (MDD), posttraumatic stress disorder (PTSD), and traumatic brain injury (TBI) were evaluated using structured interviews and questionnaires.

RESULTS

All three PAI suicide scales were significantly related to independent indicators of suicidality, with the largest effect for SUI (AUC 0.837-0.849). All three suicide scales were significantly related to MDD (r = 0.36-0.51), PTSD (r = 0.27-0.60), and TBI (r = 0.11-0.30). The three scales were not related to suicide attempt history for those with invalid PAI protocols.

CONCLUSIONS

Although all three suicide scales do show significant relationships to other indicators of risk, SUI showed the highest association and greatest resistance to response bias.

Neuroanatomical substrates of depression in the elderly

The etiology of depression in the elderly is poorly understood. In this study, magnetic resonance imaging was used to evaluate the role of subcortical structures in the pathophysiology of depression in the elderly. Elderly depressed patients were found to have smaller caudate nuclei, smaller putaminal complexes and in increased frequency of subcortical hyperintensities compared with normal, healthy controls. These findings were more pronounced in patients with late-onset depression. Based on these findings, the authors discuss the role of the basal ganglia in the pathophysiology of depression in the elderly.

Severity of subcortical gray matter hyperintensity predicts ECT response in geriatric depression

OBJECTIVE

To determine the effect of subcortical white and gray matter lesions on ECT outcome.

METHOD

41 geriatric psychiatric inpatients underwent an MRI scan during their ECT work-up. Periventricular, deep white matter, and subcortical gray matter hyperintensities were graded. The associations of low versus high hyperintensity ratings and symptom scores, Clinical Global Impression severity (CGS) ratings, Montgomery-Asberg Depression Scale score, and number of treatments were examined using t-tests and repeated measures ANOVA.

RESULTS

Patients with more severe subcortical gray hyperintensities (SCG) had significantly less improvement as measured by CGS ratings.

CONCLUSIONS

SCG severity may limit the improvement of patients receiving ECT. Further studies are needed to examine differences based on electrode placement and to determine whether patients with severe SCG may require more ECT treatments in an index course.

Fluoxetine in post-traumatic stress disorder. Randomised, double-blind study

BACKGROUND

Most pharmacotherapy trials in post-traumatic stress disorder (PTSD) have been conducted upon male combat veterans. Outcome studies relating to civilians are therefore needed.

AIMS

To demonstrate that fluoxetine is more effective than placebo in treating PTSD.

METHOD

Civilians with PTSD (n = 53) were treated for 12 weeks with fluoxetine (up to 60 mg/day) or placebo. Assessments of PTSD severity, disability, stress vulnerability, and high end-state function were obtained.

RESULTS

Fluoxetine was more effective than placebo on most measures at week 12, including global improvement (much or very much improved: fluoxetine 85%, placebo 62%, difference 0.24, 95% CI 0.01-0.47; very much improved: fluoxetine 59%, placebo 19%, difference 0.40, 95% CI 0.16-0.64), and high end-state function (fluoxetine 41%, placebo 4%, difference 0.37, 95% CI 0.17-0.57).

CONCLUSIONS

Fluoxetine was superior for measures of PTSD severity, disability, stress vulnerability, and high end-state function. The placebo-group response was low when viewed as a broad outcome based on a portfolio of ratings, but was higher with a traditional global rating criterion.

Hyperintense lesions on magnetic resonance images in bipolar disorder

BACKGROUND

To examine the magnetic resonance (MR) images of bipolar patients across a wide age range for the presence of hyperintense lesions compared to age- and gender-matched control subjects.

METHODS

Consecutive admissions to a mood disorders unit over a 2-year period were evaluated retrospectively for the presence of bipolar disorder by DSM-III-R criteria and whether they received an MR scan. Bipolar patients (n = 70, mean age = 49.9 +/- 19.7 years) were age- and gender-matched to control subjects (n = 70, mean age = 53.2 +/- 18.1 years) and the MR scans were rated to assess for the presence of hyperintensites.

RESULTS

Compared to control subjects, the bipolar patients demonstrated hyperintense lesions in the subependymal region, subcortical gray nuclei, and the deep white matter.

CONCLUSIONS

Hyperintense lesions in bipolar patients are found in both the subcortical white matter and gray nuclei and may play an important role in the etiology of bipolar illness.

Magnetic-resonance morphometry in patients with major depression

Magnetic-resonance morphometry performed on 72 patients with major depression compared with 38 control subjects replicated previously reported, statistically significant reductions in the volumes of the caudate (P < 0.03) and putamen (P < 0.05) in depressed patients. Borderline statistical significance was observed for whole-brain (P < 0.07) and frontal volume (P < 0.10) in a subsample of 32 patients matched on age and sex with 32 control subjects, whereas statistical significance was observed for the full sample (P < 0.007 and P < 0.03, respectively). Chronological age was related to volume of the frontal lobes (P < 0.0002), caudate (P < 0.0001), putamen (P < 0.008), thalamus (P < 0.002), cerebellum (P < 0.007), lateral ventricles (P < 0.0001), and ratios of [whole brain]/[whole brain + cerebrospinal fluid (CSF)] (P < 0.0001) and [frontal]/[frontal + CSF] (P < 0.0001). Age of first depressive episode was related to putamen volume after accounting for chronological age (R2= 0.16, P < 0.005), and a correlation of 0.26 (P < 0.04) was observed between caudate volume and global mental status. Results are in accord with previous reports of basal-ganglia abnormalities in depressed patients and support the role of subcortical structures in mediating affective disorder.

Magnetic resonance imaging correlates of depression in early- and late-onset Alzheimer's disease

BACKGROUND

Depressive symptoms are frequent complications of Alzheimer's disease (AD). We hypothesized that AD patients with depression would be more likely than nondepressed AD patients to show deep white-matter, subcortical gray-matter, and periventricular hyperintensities on magnetic resonance imaging (MRI).

METHODS

In a retrospective study of 31 AD patients, depression was characterized by clinical diagnosis (DSM-III-R major depression, depressive symptoms, or no depression), a clinician-rated depression scale, and informant ratings of premorbid (before memory disorder) as well as current depression using the NEO Personality Inventory (NEO-PI), and related to qualitative and quantitative ratings of MRI hyperintensities.

RESULTS

In contrast to reports in nondemented elderly patients, there was no relationship between clinical diagnosis of major depressive episode and hyperintensities; however, clinician-rated depressive symptoms were higher in subjects with large anterior hyperintensities. In the early-onset AD group only, MRI abnormalities were related to greater premorbid depression, and less increase in depression after the onset of dementia, as rated by informants on the NEO-PI.

CONCLUSIONS

Results highlight the need to consider early- and late-onset AD separately when assessing relationships between personality and MRI abnormalities, and to consider premorbid personality style when drawing conclusions about the etiology of depressive features seen in AD.

Discontinuation of clonazepam in the treatment of social phobia

Patients with social phobia who responded well to 6 months of open-label treatment with clonazepam were assigned to receive either continuation treatment (CT) with clonazepam for another 5 months, or to undergo discontinuation treatment (DT) using a clonazepam taper at the rate of 0.25 mg every 2 weeks, with double-blind placebo substitution. Clinical efficacy was compared between the CT and DT groups using three different social phobia scales. Benzodiazepine withdrawal symptoms were also measured. Relapse rates were 0 and 21.1% in the CT and DT groups, respectively. Subjects in the CT group generally showed a more favorable clinical response at midpoint and/or endpoint, although even in the DT group clinical response remained good. With respect to withdrawal symptoms, the rates were low in both groups (12.5% for CT and 27.7% for DT) with no real evidence suggesting significant withdrawal difficulties. At the end of 11 months of treatment with clonazepam, however, a more rapid withdrawal rate was associated with greater distress. This study offers preliminary evidence to suggest that continuation therapy with clonazepam in the treatment of social phobia is safe and effective, producing a somewhat greater clinical benefit than a slow-taper discontinuation regime. However, even in the DT group, withdrawal symptoms were not found to be a major problem. The study can be taken as supportive of benefit for longterm clonazepam treatment in social phobia, as well as being compatible with a reasonably good outcome after short-term treatment and slow taper.

A family study of chronic post-traumatic stress disorder following rape trauma

There is evidence that familial factors serve as determinants of risk for post-traumatic stress disorder (PTSD), especially familial anxiety. This study investigates the relationship between chronic PTSD and family psychiatric morbidity. The sample was drawn from 81 female rape survivors with or without lifetime PTSD, 31 major depressive disorder controls, 20 anxiety disorder controls and 39 healthy controls. First-degree family members were directly interviewed (n = 285) and diagnoses assigned of major depressive, anxiety and alcohol or substance use disorder. Information was also available by family history for 639 relatives. In the directly interviewed sample, no consistently increased morbidity risk was observed for anxiety, PTSD, or alcohol/substance abuse in the rape survivor groups, but there was an increase in depression relative to the anxiety in healthy control groups. When comorbid depression in rape survivor probands was taken into account post hoc, an increased risk for depression was noted in family members of PTSD probands with depression, but not in relatives of PTSD probands without lifetime depression. Among rape survivor probands with non-comorbid PTSD, rates by history of familial anxiety and depression were negligible. In a logistic regression analysis, individual vulnerability to depression served as an independent predictor of chronic PTSD, along with specific trauma-related variables. In the family history group, results were consistent with those obtained from the directly interviewed group. Our findings clearly support the view that PTSD following rape is associated with familial vulnerability to major depression, which may thus serve as a risk factor for developing PTSD. The exact nature of this predisposition calls for further inquiry and there is a need to expand this study to include other PTSD populations. PTSD may on occasion represent a form of depression which is induced and/or modified neurobiologically and phenomenologically by extreme stress. Our findings may be a reflection of the sample composition, the current conceptualization of PTSD, or be related to study limitations.

Magnetic resonance imaging signal hypointensity and iron content of putamen nuclei in elderly depressed patients

We previously introduced a semiquantitative scale for assessment of iron content of putamen nuclei as determined by magnetic resonance imaging (MRI)--the Signal Hypointensity in the Putamen (SHIP) scale. Such hypointensity may be related to putamen nuclei iron content, although this suggestion remains controversial, especially in the elderly. In the present study, we apply the SHIP scale to a sample of 68 elderly depressed patients (diagnosed with DSM-IV major depression using the Diagnostic Interview Schedule and clinical interview) and a group of 28 age-matched non-depressed control subjects. MRI scans were conducted on a single 1.5-T General Electric Signa system with axial acquisitions obtained parallel to the canthomeatal line. Technical parameters were as follows: (1) repetition time (TR) = 500 ms and echo time (TE) = 15 ms for T1-weighted images; (2) TR = 2500 ms and TE = 30 ms for proton-density-weighted images; and (3) TR = 2500 ms and TE = 80 ms for T2-weighted images. Among depressed patients, older age of depression onset and greater severity of depression were associated with increased putamen nuclei iron deposition. When depressed patients were compared with control subjects, the patient group demonstrated greater putamen nuclei iron, but the finding was significant only for the left hemisphere. Our findings support previous neuroimaging studies linking both changes in the basal ganglia and greater left-sided brain pathology to late-life depression.

Metabolic brain mapping in Alzheimer's disease using proton magnetic resonance spectroscopy

Alzheimer's disease (AD) is a progressive disorder associated with disruption of neuronal function and neuronal loss. N-acetylaspartate (NAA) is a marker of neuronal content and can be assessed using proton (1H) magnetic resonance spectroscopy (MRS). We utilized 1H-MRS (two-dimensional chemical-shift imaging) to assess amplitudes and areas of NAA, as well as choline moieties (Cho), creatine (Cr) and myo-inositol (mI), in 15 AD patients compared with 14 control subjects. Voxels were classified as predominantly cortical gray matter (CGM), subcortical gray matter (SGM), or white matter (WM). Compared with control subjects, AD patients exhibited decreased NAA/Cho and NAA/Cr amplitudes, whereas an increase was observed in Cho/Cr and in amplitude ratios involving mI. Area ratios were significant in the same direction for NAA/Cho, NAA/Cr, mI/Cr and mI/NAA. No significant effects of tissue type were observed; however, significant group x tissue type interactions were noted for Cho/Cr and mI/Cr amplitudes. Our study confirms that 1H-MRS can identify distinct physicochemical alterations in AD patients, reflecting membrane changes and diminished neuronal function. These alterations can be used as longitudinal markers for the disease.

Age and sex effects on brain morphology

1. Brain morphology can be assessed readily in vivo using magnetic resonance imaging (MRI). 2. In this study, the effects of age and sex on whole-brain morphology were examined using an operator-controlled computer-segmentation protocol. 3. Results indicated that age was associated with gray-matter volume reduction. 4. Brain-size differences between males and females were primarily attributable to white-matter volume. 5. This study confirms the importance of controlling for age and sex in brain-morphology studies.

A repeat proton magnetic resonance spectroscopy study in social phobia

Peak spectral amplitudes for choline moieties (Cho), creatine (Cr), N-acetylaspartate (NAA), and myo-inositol (mI) were examined using proton magnetic resonance spectroscopy in 19 social-phobia patients and 10 controls. Compared with controls, social phobics demonstrated significantly lower NAA/Cho and higher Cho/Cr, mI/Cr, and mI/NAA amplitudes in cortical gray matter. Higher mI/Cr and mI/NAA amplitudes for social phobics were also observed in subcortical gray matter. Minimal between-group differences were noted for white matter. Symptom severity correlated inversely with amplitudes primarily in subcortical gray matter, and to a lesser extent in cortical gray matter. Inclusion of age and sex in statistical modeling strengthened comparisons with controls but eliminated those for symptom severity. No changes were observed in any amplitude measure following at least 8 weeks of clonazepam treatment, nor was a relationship observed between amplitudes and cumulative clonazepam dose. The possible psychobiological implications of our findings in social phobia are discussed.

Screening for trauma history on an inpatient affective-disorders unit: a pilot study

Psychiatric inpatients (N = 343) admitted to an affective-disorders unit were administered a self-rating Trauma Questionnaire (TQ) to evaluate life history of traumatic experiences. Eighty four percent of the sample identified at least one traumatic-event category (M = 2.27 categories/patient). Symptoms consistent with posttraumatic stress disorder (PTSD), were highly prevalent. However, only six patients received a chart diagnosis of posttraumatic stress disorder. Female patients evidenced more PTSD symptoms than males, in contrast to an equal number of event categories identified by the two sexes. Age correlated negatively with number of symptoms endorsed. Implications for trauma screening in affective-disorder patients are discussed.

Assessment of a new self-rating scale for post-traumatic stress disorder

BACKGROUND

In post-traumatic stress disorder (PTSD) there is a need for self-rating scales that are sensitive to treatment effects and have been tested in a broad range of trauma survivors. Separate measures of frequency and severity may also provide an advantage.

METHODS

Three hundred and fifty-three men and women completed the Davidson Trauma Scale (DTS), a 17-item scale measuring each DSM-IV symptom of PTSD on 5-point frequency and severity scales. These subjects comprised war veterans, survivors of rape or hurricane and a mixed trauma group participating in a clinical trial. Other scales were included as validity checks as follows: Global ratings, SCL-90-R, Eysenck Scale, Impact of Event Scale and Structured Clinical Interview for DSM-III-R.

RESULTS

The scale demonstrated good test-retest reliability (r = 0.86), internal consistency (r = 0.99). One main factor emerged for severity and a smaller one for intrusion. In PTSD diagnosed subjects, and the factor structure more closely resembled the traditional grouping of symptoms. Concurrent validity was obtained against the SCID, with a diagnostic accuracy of 83% at a DTS score of 40. Good convergent and divergent validity was obtained. The DTS showed predictive validity against response to treatment, as well as being sensitive to treatment effects.

CONCLUSIONS

The DTS showed good reliability and validity, and offers promised as a scale which is particularly suited to assessing symptom severity, treatment outcome and in screening for the likely diagnosis of PTSD.

The Brief Social Phobia Scale: a psychometric evaluation

The Brief Social Phobia Scale (BSPS) is an observer-rated scale designed to assess the characteristic symptoms of social phobia, using three subscales-fear, avoidance, and physiological arousal-which may be combined into a total score. Each of 18 BSPS items is anchored to a 5-point rating scale. Psychometric evaluation of the BSPS in a sample of 275 social-phobia patients yielded a high level of reliability and validity. Test-retest reliability was excellent, as was internal consistency. The fear and avoidance subscales demonstrated highly significant correlations with remaining item totals; however, the physiological subscale did not. The BSPS also demonstrated significant relationships with other established scales that assess anxiety and disability, and it proved sensitive to treatment effects in a trial of a 5-HT3 antagonist and placebo. Factor analysis yielded six meaningful factors. We conclude that the BSPS provides a reliable, valid, and sensitive measure for the evaluation of social phobia.

Assessment of a new self-rating scale for post-traumatic stress disorder

BACKGROUND

In post-traumatic stress disorder (PTSD) there is a need for self-rating scales that are sensitive to treatment effects and have been tested in a broad range of trauma survivors. Separate measures of frequency and severity may also provide an advantage.

METHODS

Three hundred and fifty-three men and women completed the Davidson Trauma Scale (DTS), a 17-item scale measuring each DSM-IV symptom of PTSD on 5-point frequency and severity scales. These subjects comprised war veterans, survivors of rape or hurricane and a mixed trauma group participating in a clinical trial. Other scales were included as validity checks as follows: Global ratings, SCL-90-R, Eysenck Scale, Impact of Event Scale and Structured Clinical Interview for DSM-III-R.

RESULTS

The scale demonstrated good test-retest reliability (r = 0.86), internal consistency (r = 0.99). One main factor emerged for severity and a smaller one for intrusion. In PTSD diagnosed subjects, and the factor structure more closely resembled the traditional grouping of symptoms. Concurrent validity was obtained against the SCID, with a diagnostic accuracy of 83% at a DTS score of 40. Good convergent and divergent validity was obtained. The DTS showed predictive validity against response to treatment, as well as being sensitive to treatment effects.

CONCLUSIONS

The DTS showed good reliability and validity, and offers promised as a scale which is particularly suited to assessing symptom severity, treatment outcome and in screening for the likely diagnosis of PTSD.

A 2-year follow-up of social phobia. Status after a brief medication trial

Although social phobia is thought to be a chronic disorder, little is known about its long-term course in patients who engage in brief treatment studies. We, therefore, conducted a follow-up study of social phobics who had participated in a brief, placebo-controlled treatment trial of clonazepam. Of the original 75 subjects, 56 were assessed through telephone interview and self-report questionnaires that evaluated current social phobia symptoms. Information was also gathered about treatment received in the 2-year interval since the initial pharmacotherapy trial. The group as a whole showed maintenance of the gains acquired during initial treatment. On a number of symptom scales, subjects initially treated with clonazepam exhibited significantly less severe scores compared with placebo subjects. This study provides evidence of long-term benefit for social phobics when treated with a brief medication trial.

Magnetic resonance imaging changes in putamen nuclei iron content and distribution in normal subjects

To study patterns of iron deposition in the putamen in aging, we reviewed brain magnetic resonance imaging (MRI) scans of 56 normal subjects. We developed the Signal Hypointensity in the Putamen (SHIP) Scale, a semiquantitative measure, to evaluate putamen nuclei for extent of iron deposition relative to the globus pallidus. The SHIP score was highly reliable (kappa = 0.76) and significantly correlated with age (P < 0.0001). We found that age-related iron deposition in putamen nuclei follows a characteristic pattern along a posterolateral-to-anteromedial gradient. This gradient may be related to the microvasculature of the putamen. Other studies are needed to replicate our findings in patients with affective and other neuropsychiatric disorders and to clarify the pathophysiological mechanisms that govern these changes.

MRI morphometric analysis and neuropsychological function in patients with neurofibromatosis

Volumes of cerebral gray and white matter were measured in 22 children with neurofibromatosis type 1 (NF1) and in 20 controls. Judgment of Line Orientation (JLO) and the Developmental Test of Visual-Motor Integration (DTVMI) were administered to 16 of the NF1 patients. General linear models analysis of covariance revealed significantly larger brain volumes in NF1 children than in controls, particularly in white matter, and particularly in girls. JLO and DTVMI performance were positively related to right-hemisphere gray-matter volume. The results implicate a failure of growth control in NF1, leading to aberrant neurodevelopment. Our findings also suggest a basis for refined understanding of learning disabilities, which are a prominent feature of NF1.

Reproducibility of high spatial resolution proton magnetic resonance spectroscopic imaging in the human brain

The application of proton (1H) magnetic resonance spectroscopic imaging (MRSI) allows for noninvasive, localized analyses of brain biochemistry; however, minimal work has been devoted to the evaluation of 1H MRSI reproducibility. This study examined the reproducibility of 1H MRSI from five normal subjects on two occasions, separated by 10 days. Reproducibility of the MR signal was evaluated in the context of automated shimming, automated processing, and accurate subject repositioning. Reliability measures for physicochemical indices (choline moieties, creatine, N-acetylaspartate, and myo-inositol) were moderately concordant across repeat studies. Gain variation and repositioning results were excellent. It has been concluded that 1H MRSI reproducibility is adequate for serial studies of brain metabolism.

Reliability of the Rey-Osterrieth Complex Figure in use with memory-impaired patients

Rater reliability was evaluated for the system most widely used to assess copy and recall of the Rey Complex Figure: the Osterrieth (1944) 18-item scoring system. The study sample consisted of 95 subjects (49 males, 46 females), most of whom were elderly individuals (M = 59.83, SD = 15.21 years) suffering from memory impairment. Four raters rated copy and delayed-recall protocols, and three raters re-rated the protocols after an interval of 3 months. Results revealed excellent inter- and intra-rater reliability coefficients (.85-.97) for total scores. However, reliabilities for the 18 individual items ranged from poor (.14) to excellent (.96). Differences in both reliability and level of subject performance were observed as a function of item and conditions of copy versus recall. It is concluded that the Osterrieth scoring system supports excellent reliability in use with memory-impaired patients using total scores. Nevertheless, individual-item reliability would benefit from enhancement, for example, via amplified delineation of relevant decision criteria.

Clinical and phenomenological comparisons of late-onset and early-onset depression

OBJECTIVE

The authors examined the relationship between age at onset of first depressive episode and clinical features in elderly depressed patients.

METHOD

They used data on age at onset and clinical features in 246 elderly depressed patients treated at the National Institute of Mental Health Clinical Research Center for the Study of Depression in Later Life, located at Duke University.

RESULTS

Two variables--loss of interest and number of depressive episodes--were related to age at onset in all analyses.

CONCLUSIONS

This study confirms the hypothesis that apathy is more prominent in late-onset than in early-onset depression.

Alcohol pharmacodynamics in young-elderly adults contrasted with young and middle-aged subjects

Effects of aging on ethyl alcohol (EtOH) pharmacodynamics were examined over progressive dosing schedules (0.4, 0.6, 0.8, 1.0 g/kg) in groups of young (25.0 +/- 2.9 years), middle-aged (41.1 +/- 6.6 years), and young-elderly adults (60.9 +/- 2.6 years) using three computerized cognitive-neuromotor tasks: digit-symbol substitution (DSS), keypad reaction time (KRT), and subcritical tracking (SCT). Hysteresis curves of performance impairment (adjusted for pre-drug baseline) as a function of blood alcohol concentration (BAC) were examined for time-course effects, and regression analyses were performed to assess the contribution of age beyond that accounted for by BAC. Results reflected differences in the patterning but not magnitude of impairment for elderly subjects, with earlier decrements and more rapid acute tolerance observed for DSS, in conjunction with less pharmacodynamic sensitivity for SCT. Regression analyses furthermore indicated that age and impairment were negatively related, arguing against synergistic intoxication effects as a function of aging. Analyses specifically comparing performance at baseline versus legally intoxicating BACs (> 1.0 mg/ml) likewise reflected a lack of interactive effects involving the elderly. Elderly subjects nevertheless exhibited significantly lower baseline performance for DSS and KRT than young subjects and achieved higher BACs with equivalent doses. These latter findings support the exercise of caution by elderly individuals consuming EtOH prior to engaging in neuromotor pursuits such as driving.

Emergency department patterns in psychiatric visits during the holiday season

STUDY OBJECTIVE

To determine the prevalence of psychopathology during the holiday season and which subpopulations are at greatest risk for holiday decompensation.

DESIGN

A retrospective analysis of emergency department records.

SETTING

ED of a university-affiliated hospital located in a mixed urban-agricultural catchment area in North Carolina.

PARTICIPANTS

Eight thousand seven hundred fifty-six patient visits to the ED, with subsequent triage for psychiatric evaluation, for a 6-year period (1987 to 1993), were analyzed.

RESULTS

We observed seasonal patterns in visits, with a general decrease in visits preceding holidays followed by an increase afterward. Substance abusers, men, and black patients were more likely to visit the ED than expected, particularly during the weeks surrounding Christmas.

CONCLUSION

These results support the existence of a "Christmas effect" on ED visitations by patients with psychiatric symptoms. Understanding of these patterns may help emergency physicians predict the seasonal variation of such patient visits and apply preventive measures accordingly.

Treatment of social phobia with benzodiazepines

Although social phobia is a common and highly treatable anxiety disorder, the majority of social phobics do not receive treatment. Without intervention, it is unlikely that patients will attain significant relief from the symptoms and disability associated with the disease. The authors review the results of studies concerning the use of high-potency benzodiazepines in the treatment of social phobia. These studies, which include open trials as well as a double-blind, placebo-controlled evaluation of clonazepam, have demonstrated clinical efficacy and suggest a therapeutic role for this drug class in the treatment of social phobia. Developmental work with the Davidson Brief Social Phobia Scale is described, along with predictors of treatment outcome for clonazepam and placebo and relapse data upon discontinuation of both treatments. Finally, the authors discuss general issues concerning the relapse of patients upon drug discontinuation, the long-term use of benzodiazepines, and other important issues concerning the use of these agents for the treatment of social phobia.

Hypercortisolemia and hippocampal changes in depression

Hypercortisolemia is a frequently observed abnormality in patients with major depression. It has been hypothesized that the hippocampus, as a major feedback site for glucocorticoids, is involved in the pathophysiology of hypercortisolemia. Some have in fact posited that the hippocampus is marked by diminished size in depressed patients with hypercortisolemia. We tested this hypothesis by examining the relationship between hippocampal volume, assessed with magnetic resonance imaging, and hypercortisolemia using the dexamethasone suppression test (DST) in a group of 19 depressed patients. No differences in hippocampal volume were observed between patients and control subjects (n = 30). Within the patient group, DST suppressors did not differ from DST nonsuppressors in hippocampal volume. However, a relationship between hippocampal volume and 11 p.m. cortisol concentration was observed after covariance adjustment for age and sex. Furthermore, significant negative correlations were observed between hippocampal volume and both age of depressive onset and number of hospitalizations. The results of this study therefore provide limited support for the hypothesis regarding an essential role of the hippocampus in the neuroendocrine elevation of glucocorticoids in depression.

The Neurobehavioral Cognitive Status Examination: psychometric properties in use with psychiatric inpatients

The present investigation sought to enhance clinical utility of the Neurobehavioral Cognitive Status Examination (NCSE; Northern California Neurobehavioral Group, Inc.) by providing reference scores for an inpatient psychiatric sample and assessing construct validity. A total of 866 patients (aged 15-92 years) received an NCSE 2 to 4 days after admission. Examination of means, standard deviations, z scores, and percent who passed each screening item revealed consistently poorer performance for psychiatric patients relative to the original normative sample. Pearson product-moment correlations between age and each NCSE subtest similarly yielded significant negative correlations, particularly on tests predicted to be differentially sensitive to aging. Intercorrelations between subtests, however, failed to yield expected patterns of performance. We conclude that the NCSE provides a moderately valid screening instrument for cognitive impairment.

Neuropsychological importance of subcortical white matter hyperintensity

Subcortical hyperintensity on magnetic resonance imaging is a common incidental finding in healthy elderly subjects. The relationship of such changes to cognitive functioning remains unclear, however, because only a small number of studies have examined this issue with conflicting results. We therefore assessed 66 healthy adult volunteers (mean [+/- SD] age, 61.8 +/- 15.8 years) with magnetic resonance imaging scans rated for subcortical hyperintensity, and with two neuropsychological instruments selected a priori on the basis of previous reports in the literature. Findings were highly significant for both the Benton Facial Recognition Test and the Wechsler Adult Intelligence Scale-Revised Digit Symbol. However, in both cases, the majority of variance was accounted for by age and educational level. Effects of subcortical hyperintensity were not significant. We conclude that subcortical hyperintensity in healthy adults does not relate to cognitive functioning, at least with these two instruments.

On the independence of physical and nominal codes: a correlational analysis

In studies of college students, normal children at three grades, and learning-disabled children, physical and nominal matching procedures were highly correlated, (range .72-.96). In each instance, expected time differences favoring physical matches were replicated. Comparable results were found with both tachistoscopic and paper-and-pencil methods. In two studies where relevant data were available, correlations were not significantly attenuated when the effects of motor speed were partialled out. The results challenge the premise that nominal and physical matching measures are empirically independent, invalidate their application as measures of independent types of information processing, and help explain inconsistent findings in hemispheric specialization research.