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Jackson M, Lemay J, Yang K, Leung M, Gitlin M, Wessler Z. PMS8 Estimating the Future Clinical and Economic Benefits of Improving Osteoporosis Diagnosis and Treatment Rates Among Women in South Korea: A Simulation Projection Model from 2020-2040. Value Health Reg Issues 2020. [DOI: 10.1016/j.vhri.2020.07.347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Unnanuntana A, Jackson M, Lemay J, Leung M, Gitlin M, Wessler Z. PMS9 Expected Benefits over the Next 20 Years of Osteoporotic Secondary Fracture Prevention Policies Amongst Women in Thailand. Value Health Reg Issues 2020. [DOI: 10.1016/j.vhri.2020.07.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rock M, Rosim R, Rigolon J, Dort T, Snyder S, Gitlin M. PND11 ECONOMIC IMPACT OF INITIATING DIMETHYL FUMARATE VERSUS OTHER DISEASE MODYFING THERAPIES IN PUBLICLY INSURED BRAZILIAN PATIENTS WITH RELAPSING-REMITTING MULTIPLE SCLEROSIS. Value Health Reg Issues 2019. [DOI: 10.1016/j.vhri.2019.08.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Markopoulos C, Hochheiser L, Hornberger J, Hytopoulos E, Stoppler M, Gitlin M. The clinical impact of substituting multigene assays: Comparative clinical analysis of PAM50-ROR versus 21-gene assay. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz095.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
This investigation studied the effect of maternal region of birth and education on the psychomotor development of 512 two-year-old children born in Jerusalem. Children of immigrants from Western countries scored significantly higher in the Brunet-Lézine test than children whose parents came from Eastern countries. No statistically significant differences were found in the scores of children of Israeli-born mothers whether they originated from Eastern or Western countries. Mothers' education was significantly related to the developmental quotient (DQO of the child, whereas the effect of region of birth of mother was not significant when education was statistically controlled. A rise in education and acculturation of immigrants from Eastern countries in Israel may explain the lack of difference in the DQ score in the second-generation Israel children studied.
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Affiliation(s)
- Hava Palti
- The Hebrew University-Hadassah Medical School, Hadassah University Hospital
| | - M. Gitlin
- The Hebrew University-Hadassah Medical School, Hadassah University Hospital
| | - Rivka Zloto
- The Hebrew University-Hadassah Medical School, Hadassah University Hospital
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Guillemin F, Martinez L, Calvert M, Cooper C, Ganiats T, Gitlin M, Horne R, Marciniak A, Pfeilschifter J, Shepherd S, Tosteson A, Wade S, Macarios D, Freemantle N. Fear of falling, fracture history, and comorbidities are associated with health-related quality of life among European and US women with osteoporosis in a large international study. Osteoporos Int 2013; 24:3001-10. [PMID: 23754200 PMCID: PMC3818139 DOI: 10.1007/s00198-013-2408-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 05/06/2013] [Indexed: 12/21/2022]
Abstract
UNLABELLED We studied 7,897 women with postmenopausal osteoporosis to assess factors that influence health-related quality of life (HRQoL). An increased number of comorbidities, fear of falling, and previous vertebral fracture were associated with significant reductions in HRQoL. Understanding the factors that affect HRQoL may improve management of these patients. INTRODUCTION HRQoL is impaired in women treated for postmenopausal osteoporosis (PMO). The objective of this study was to examine the relationship between clinical characteristics, comorbidities, medical history, patient demographics, and HRQoL in women with PMO. METHODS Baseline data were obtained and combined from two large and similar multinational observational studies: Prospective Observational Scientific Study Investigating Bone Loss Experience in Europe (POSSIBLE EU®) and in the US (POSSIBLE US™) including postmenopausal women in primary care settings initiating or switching bone loss treatment, or who had been on bone loss treatment for some time. HRQoL measured by health utility scores (EQ-5D™) were available for 7,897 women (94 % of study participants). The relationship between HRQoL and baseline clinical characteristics, medical history and patient demographics was assessed using parsimonious, multivariable, mixed-model analyses. RESULTS Median health utility score was 0.80 (interquartile range 0.69-1.00). In multivariable analyses, young age, low body mass index, previous vertebral fracture, increased number of comorbidities, high fear of falling, and depression were associated with reduced HRQoL. Regression-based model estimates showed that previous vertebral fracture was associated with lower health utility scores by 0.08 (10.3 %) and demonstrated the impact of multiple comorbidities and of fear of falling on HRQoL. CONCLUSIONS In this large observational study of women with PMO, there was substantial interindividual variability in HRQoL. An increased number of comorbidities, fear of falling, and previous vertebral fracture were associated with significant reductions in HRQoL.
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Affiliation(s)
- F Guillemin
- Université de Lorraine, Université Paris Descartes, EA 4360 Apemac, Nancy, France,
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Freemantle N, Cooper C, Diez-Perez A, Gitlin M, Radcliffe H, Shepherd S, Roux C. Response to comments on: Results of indirect and mixed treatment comparison of fracture efficacy for osteoporosis treatments: a meta-analysis. Osteoporos Int 2013; 24:1931-2. [PMID: 23408019 DOI: 10.1007/s00198-013-2299-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 01/07/2013] [Indexed: 11/27/2022]
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Freemantle N, Cooper C, Diez-Perez A, Gitlin M, Radcliffe H, Shepherd S, Roux C. Results of indirect and mixed treatment comparison of fracture efficacy for osteoporosis treatments: a meta-analysis. Osteoporos Int 2013; 24:209-17. [PMID: 22832638 PMCID: PMC3662000 DOI: 10.1007/s00198-012-2068-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 06/04/2012] [Indexed: 11/24/2022]
Abstract
UNLABELLED Network meta-analysis techniques (meta-analysis, adjusted indirect comparison, and mixed treatment comparison [MTC]) allow for treatment comparisons in the absence of head-to-head trials. In this study, conditional estimates of relative treatment efficacy derived through these techniques show important differences in the fracture risk reduction profiles of marketed pharmacologic therapies for postmenopausal osteoporosis. INTRODUCTION This study illustrates how network meta-analysis techniques (meta-analysis, adjusted indirect comparison, and MTC) can provide comparisons of the relative efficacy of postmenopausal osteoporosis therapies in the absence of comprehensive head-to-head trials. METHODS Source articles were identified in MEDLINE; EMBASE; Cochrane Central Register of Controlled Trials (CENTRAL) via Wiley Interscience; and Cumulative Index to Nursing and Allied Health Literature (CINAHL) between April 28, 2009 and November 4, 2009. Two reviewers identified English-language articles reporting randomized controlled trials (RCTs) with on-label dosing of marketed osteoporosis agents and fracture endpoints. Trial design, population characteristics, intervention and comparator, fracture outcomes, and adverse events were abstracted for analysis. Primary analyses included data from RCTs with fracture endpoints. Sensitivity analyses also included studies with fractures reported through adverse event reports. Meta-analysis compared fracture outcomes for pharmacological therapies vs. placebo (fixed and random effects models); adjusted indirect comparisons and MTC assessed fracture risk in postmenopausal women treated with denosumab vs. other agents. RESULTS Using data from 34 studies, random effects meta-analysis showed that all agents except etidronate significantly reduced the risk of new vertebral fractures compared with placebo; denosumab, risedronate, and zoledronic acid significantly reduced the risk for nonvertebral and hip fracture, while alendronate, strontium ranelate, and teriparatide significantly reduced the risk for nonvertebral fractures. MTC showed denosumab to be more effective than strontium ranelate, raloxifene, alendronate, and risedronate in preventing new vertebral fractures. CONCLUSIONS The conditional estimates of relative treatment efficacy indicate that there are important differences in fracture risk reduction profiles for marketed pharmacological therapies for postmenopausal osteoporosis.
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Affiliation(s)
- N Freemantle
- Department of Primary Care and Population Health, University College London, London, NW3 2PF, UK.
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Lippuner K, Popp AW, Schwab P, Gitlin M, Schaufler T, Senn C, Perrelet R. Fracture hospitalizations between years 2000 and 2007 in Switzerland: a trend analysis. Osteoporos Int 2011; 22:2487-97. [PMID: 21153020 DOI: 10.1007/s00198-010-1487-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 10/21/2010] [Indexed: 10/18/2022]
Abstract
UNLABELLED In Switzerland, the total number and incidence of hospitalizations for major osteoporotic fractures increased between years 2000 and 2007, while hospitalizations due to hip fracture decreased. The cost impact of shorter hospital stays was offset by the increasing cost per day of hospitalization. INTRODUCTION The aim of the study was to establish the trends and epidemiological characteristics of hospitalizations for major osteoporotic fractures (MOF) between years 2000 and 2007 in Switzerland. METHODS Sex- and age-specific trends in the number and crude and age-standardized incidences of hospitalized MOF (hip, clinical spine, distal radius, and proximal humerus) in women and men aged ≥45 years were analyzed, together with the number of hospital days and cost of hospitalization, based on data from the Swiss Federal Statistical Office hospital database and population statistics. RESULTS Between 2000 and 2007, the absolute number of hospitalizations for MOF increased by 15.9% in women and 20.0% in men, mainly due to an increased number of non-hip fractures (+37.7% in women and +39.7% in men). Hospitalizations for hip fractures were comparatively stable (-1.8% in women and +3.3% in men). In a rapidly aging population, in which the number of individuals aged ≥45 years grew by 11.1% (women) and 14.6% (men) over the study period, the crude and age-standardized incidences of hospitalizations decreased for hip fractures and increased for non-hip MOF, both in women and men. The length of hospital stay decreased for all MOF in women and men, the cost impact of which was offset by an increase in the daily costs of hospitalization. CONCLUSIONS Between years 2000 and 2007, hospitalizations for MOF continued to increase in Switzerland, driven by an increasing number and incidence of hospitalizations for non-hip fractures, although the incidence of hip fractures has declined.
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Affiliation(s)
- K Lippuner
- Osteoporosis Policlinic, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
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Roux C, Cooper C, Díez-Pérez A, Martinez L, Ortolani S, Gitlin M, Möller G, Shepherd S, Freemantle N. Prevalence of osteoporosis and fractures among women prescribed osteoporosis medication in five European countries: the POSSIBLE EU study. Osteoporos Int 2011; 22:1227-36. [PMID: 20628731 DOI: 10.1007/s00198-010-1321-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 06/03/2010] [Indexed: 01/01/2023]
Abstract
UNLABELLED European observational 1-year study assessed osteoporosis and fracture patterns in 3,402 postmenopausal women prescribed osteoporosis medication. Almost 40% of patients had a previous fracture, while 25% had neither fracture nor dual energy X-ray absorptiometry (DXA) diagnosis and were prescribed medication, probably due to other risk factors. INTRODUCTION This analysis assessed osteoporosis and fracture prevalence in postmenopausal women prescribed osteoporosis treatment in the Prospective Observational Study Investigating Bone Loss Experience in Europe(POSSIBLE EU). METHODS Women in this observational, multicenter 1-year study were categorized by fracture history and location at baseline. Baseline characteristics were analyzed according to no DXA and DXA diagnosis (osteoporosis or osteopenia). Fractures occurring during the 1-year follow-up period were recorded. RESULTS Of the 3,402 women enrolled, 39% had a previous fracture, of whom 30% had ≥ 2 fractures. One thousand seven hundred and eighty-four (52%) patients had a DXA diagnosis (osteoporosis 68%, osteopenia 31%, and unknown 1%). Among the osteoporosis patients, 37% had a previous fracture (hip 2.9%, vertebral 8.8%, and non-hip, non-vertebral 25%) and 35% had fractures associated with major trauma. Of the 3,402 women, 1,476 (43%) had no DXA diagnosis; of these, 57% had no fracture (25% of all women). Risk factors varied across patients with and without DXA diagnosis. During the 1-year follow-up period, the fracture incidence in patients with or without a previous fracture at baseline was 4.7% and 1.6%, respectively. CONCLUSION Almost 40% of patients prescribed osteoporosis medication had a previous fracture, highlighting a population with advanced disease. In contrast, 25% of patients had neither a previous fracture nor DXA diagnosis and were prescribed treatment, probably due to other risk factors. There is a need for continued improvement of disease management in European women.
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Affiliation(s)
- C Roux
- Department of Rheumatology, Paris Descartes University, Cochin Hospital, Paris, France.
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11
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Li L, Roddam A, Gitlin M, Taylor A, Shepherd S, Jick S, Baskar S, Obrenovic K, Hirsch G, Paul A, Lanyon P, Erb N, Rowe IF, Roddy E, Zwierska I, Dawes P, Hider SL, Jordan KP, Packham J, Stevenson K, Hay E, Saeed A, Khan M, Morrissey S, Fraser A, Walmsley S, Williams AE, Ravey M, Graham A. Concurrent Oral 8 - Innovations [OP54-OP58]: OP54. Non-Persistence to Anti-Osteoporosis Medications in the UK using the General Practice Research Database (GPRD). Rheumatology (Oxford) 2010. [DOI: 10.1093/rheumatology/keq708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Spiegel DM, Evans RW, Gitlin M, Mayne TJ. Psychometric evaluation of the National Kidney Dialysis and Kidney Transplantation Study symptom checklist: reliability and validity. Nephrol Dial Transplant 2008; 24:619-25. [DOI: 10.1093/ndt/gfn523] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Gitlin M, Hollenbeak C, Mayne T. 90: The Impact on the US Blood Supply of Blood Transfusions in Dialysis. Am J Kidney Dis 2008. [DOI: 10.1053/j.ajkd.2008.02.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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14
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Muirhead N, Keown P, Gitlin M, Mayne T, Churchill D. 177: A Reanalysis of the Canadian Erythropoietin Study Group (CESG) Patient-Reported Outcomes (PRO) Trial. Am J Kidney Dis 2008. [DOI: 10.1053/j.ajkd.2008.02.186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Muirhead N, Keown P, Lei L, Gitlin M, Mayne T, Churchill D. 161: The Relationship Between Achieved Hemoglobin (HB) & Exercise Tolerance. American Journal of Kidney Diseases 2008. [DOI: 10.1053/j.ajkd.2008.02.170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Despite the remarkable increase in medications validated as effective in bipolar disorder, treatment is still plagued by inadequate response in acute manic or depressive episodes or in long-term preventive maintenance treatment. Established first-line treatments include lithium, valproate and second-generation antipsychotics (SGAs) in acute mania, and lithium and valproate as maintenance treatments. Recently validated treatments include extended release carbamazapine for acute mania and lamotrigine, olanzapine and aripiprazole as maintenance treatments. For treatment-resistant mania and as maintenance treatments, a number of newer anticonvulsants, and one older one, phenytoin, have shown some promise as effective. However, not all anticonvulsants are effective and each agent needs to be evaluated individually. Combining multiple agents is the most commonly used clinical strategy for treatment resistant bipolar patients despite a relative lack of data supporting its use, except for acute mania (for which lithium or valproate plus an SGA is optimal treatment). Other approaches that may be effective for treatment-resistant patients include high-dose thyroid augmentation, clozapine, calcium channel blockers and electroconvulsive therapy (ECT). Adjunctive psychotherapies show convincing efficacy using a variety of different techniques, most of which include substantial attention to education and enhancing coping strategies. Only recently, bipolar depression has become a topic of serious inquiry with the dominant controversy focusing on the place of antidepressants in the treatment of bipolar depression. Other than mood stabilizers alone or the combination of mood stabilizers and antidepressants, most of the approaches for treatment-resistant bipolar depression are relatively similar to those used in unipolar depression, with the possible exception of a more prominent place for SGAs, prescribed either alone or in combination with antidepressants. Future work in the area needs to explore the treatments commonly used by clinicians with inadequate research support, such as combination therapy and the use of antidepressants as both acute and adjunctive maintenance treatments for bipolar disorder.
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Affiliation(s)
- M Gitlin
- Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA.
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Gitlin M, Nuechterlein K, Subotnik KL, Ventura J, Mintz J, Fogelson DL, Bartzokis G, Aravagiri M. Clinical outcome following neuroleptic discontinuation in patients with remitted recent-onset schizophrenia. Am J Psychiatry 2001; 158:1835-42. [PMID: 11691689 DOI: 10.1176/appi.ajp.158.11.1835] [Citation(s) in RCA: 170] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The goal of this report was to examine the clinical course following neuroleptic discontinuation of patients with recent-onset schizophrenia who had been receiving maintenance antipsychotic treatment for at least 1 year. METHOD Fifty-three volunteer patients with recent-onset schizophrenia who had been clinically stabilized on a maintenance regimen of fluphenazine decanoate for a mean of 16.7 months had their antipsychotic medications withdrawn under clinical supervision. Participants initially entered a 24-week, double-blind crossover trial in which fluphenazine and placebo were administered for 12 weeks each. For those who did not experience symptom exacerbation or relapse during this period, fluphenazine was openly withdrawn; participants were then followed for up to 18 additional months. RESULTS When a low threshold for defining symptom reemergence was used, 78% (N=39 of 50) of the patients experienced an exacerbation or relapse within 1 year; 96% (N=48 of 50) did so within 2 years. Mean time to exacerbation or relapse was 235 days. When hospitalization was used as a relapse criterion, only six of 45 of individuals (13%) experiencing an exacerbation or relapse who continued in treatment in the clinic were hospitalized, demonstrating the sensitivity of the psychotic exacerbation criterion. CONCLUSIONS The vast majority of clinically stable individuals with recent-onset schizophrenia will experience an exacerbation or relapse after antipsychotic discontinuation, even after more than a year of maintenance medication. However, clinical monitoring and a low threshold for reinstating medications can prevent hospitalization for the majority of these patients.
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Affiliation(s)
- M Gitlin
- UCLA Department of Psychiatry and Biobehavioral Sciences, 90095, USA
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Altshuler L, Kiriakos L, Calcagno J, Goodman R, Gitlin M, Frye M, Mintz J. The impact of antidepressant discontinuation versus antidepressant continuation on 1-year risk for relapse of bipolar depression: a retrospective chart review. J Clin Psychiatry 2001; 62:612-6. [PMID: 11561933 DOI: 10.4088/jcp.v62n0807] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Current treatment guidelines recommend discontinuation of an antidepressant within 3 to 6 months after remission of depression in patients with bipolar illness. Yet few studies directly compare the impact of antidepressant discontinuation versus antidepressant continuation on the risk for depressive relapse in patients with bipolar disorder who have been successfully treated for a depressive episode. METHOD In a retrospective chart review, patients with DSM-IV bipolar disorder who were treated for an index episode of depression by adding antidepressant medication to ongoing mood stabilizer medications were identified. The risk of depressive relapse in 25 subjects who stopped antidepressant medications after improvement was compared with the risk of depressive relapse in 19 subjects who continued antidepressants after improvement. RESULTS Termination of antidepressant medication significantly increased the risk of a depressive relapse. Antidepressant continuation was not significantly associated with an increased risk of mania. CONCLUSION While this study may have been limited by the retrospective nature of the chart review, nonrandomized assignment of treatment, and reliance on unstructured progress notes, it suggests that antidepressant discontinuation may increase the risk of depressive relapse in some patients with bipolar disorder. Further research is needed to clarify whether maintenance antidepressant treatment may be warranted in some patients with bipolar disorder, especially in those with frequent recurrent depressive episodes.
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Affiliation(s)
- L Altshuler
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA.
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Abstract
This study explored the clinical and psychosocial predictors of work adjustment in 52 Bipolar I patients over a 2-year longitudinal period and examined associations between work functioning and social relationships, personality features, stressful life events, and clinical variables. Analyses indicated that psychosocial variables (personality disorder symptoms and social functioning) added significantly to prediction of work functioning after clinical variables were entered. Stressful life events were not associated with work adjustment. Overall, presence of a good quality supportive relationship was the strongest unique predictor of work. The results highlight the need to study functional outcomes in patients, especially because they appear only modestly associated with clinical status.
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Affiliation(s)
- C Hammen
- Department of Psychology, UCLA 90095, USA.
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20
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Abstract
This study explored the clinical and psychosocial predictors of work adjustment in 52 Bipolar I patients over a 2-year longitudinal period and examined associations between work functioning and social relationships, personality features, stressful life events, and clinical variables. Analyses indicated that psychosocial variables (personality disorder symptoms and social functioning) added significantly to prediction of work functioning after clinical variables were entered. Stressful life events were not associated with work adjustment. Overall, presence of a good quality supportive relationship was the strongest unique predictor of work. The results highlight the need to study functional outcomes in patients, especially because they appear only modestly associated with clinical status.
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Affiliation(s)
- C Hammen
- Department of Psychology, UCLA 90095, USA.
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Abstract
By modulating the activity of central neurotransmitters, psychotropic agents may affect reproductive functioning in men and women. Many neurotransmitters influence the hypothalamic-pituitary-gonadal (HPG) axis and can consequently affect menstrual cycling in women and spermatogenesis in men. Emotional state similarly may disrupt reproductive functioning through the effects of stress hormones on the HPG axis. While some data exist on the relationship between stress and menstrual cyclicity in women of reproductive age, little is known regarding the potential effect of emotional state on reproductive function in men. This paper will review: (1) aspects of male reproductive function that may be vulnerable to medication-induced influences; (2) the impact of emotional state on male reproductive function; and (3) the literature on the possible effects of antidepressant medications on male fertility.
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Affiliation(s)
- V Hendrick
- UCLA Neuropsychiatric Institute and Hospital 90095, USA.
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22
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Altshuler LL, Keck PE, McElroy SL, Suppes T, Brown ES, Denicoff K, Frye M, Gitlin M, Hwang S, Goodman R, Leverich G, Nolen W, Kupka R, Post R. Gabapentin in the acute treatment of refractory bipolar disorder. Bipolar Disord 1999; 1:61-5. [PMID: 11256659 DOI: 10.1034/j.1399-5618.1999.10113.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Gabapentin, a new anti-epileptic agent, has been anecdotally reported to be effective in the treatment of mania. We systematically assessed the response rate in bipolar patients being treated adjunctively with gabapentin for manic symptoms, depressive symptoms, or rapid cycling not responsive to standard treatments. METHOD Twenty-eight bipolar patients experiencing manic (n = 18), depressive (n = 5), or rapid-cycling (n = 5) symptoms inadequately responsive to at least one mood stabilizer were treated in an open fashion with adjunctive gabapentin. Illness response was assessed using the Clinical Global Impression Scale modified for bipolar disorder (CGI-BP). A 'positive response' was operationalized as a CGI response of much or very much improved. RESULTS Fourteen of the 18 (78%) treated for hypomania or mania had a positive response to a dosage range of 600-3,600 mg/day. Patients with hypomania responded fastest, with a positive response achieved in 12.7 +/- 7.2 days. Patients with classic mania had a mean time to positive response of 25 +/- 12 days, and in patients with mixed mania it was 31.8 +/- 20.9 days. All of the five patients treated for depression had a positive response within 21 +/- 13.9 days. Only one of five patients with rapid cycling had a positive response. Gabapentin was well tolerated by all patients, with the most common side-effect being sedation. CONCLUSIONS Gabapentin appears to have acute anti-manic and anti-depressant properties as an adjunctive agent for refractory bipolar illness. Prospective double-blind studies are needed to further delineate its acute efficacy when used as monotherapy and its prophylactic efficacy as monotherapy or in conjuction with other mood stabilizers.
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Affiliation(s)
- L L Altshuler
- UCLA Mood Disorders Research Program, UCLA Medical Plaza, CA 90095-7057, USA.
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23
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Abstract
Despite the availability of alternative agents, lithium continues to be the standard against which all mood stabilisers, prescribed for acute and maintenance treatment of bipolar (and, to a lesser extent, unipolar) mood disorders, are compared. As a medication often used on a maintenance basis for a lifelong disorder, the potential for lithium to cause long term organ toxicity has generated appropriate concern. Foremost among these concerns are its renal effects. Lithium adversely affects renal tubular function, causing polyuria secondary to a deficit in urine concentrating ability. This effect is probably progressive for the first decade of lithium therapy, i.e. it correlates with duration of lithium therapy. Although this effect of lithium is probably functional and reversible early in treatment, it may become structural and irreversible over time. In contrast, the effect of lithium on glomerular function is not progressive. Conclusions in this area are hampered by the evidence that patients with psychiatric disorders who are not receiving lithium also show defects in certain aspects of renal function. Despite the generally sanguine data on glomerular function, a very small group of patients may develop renal insufficiency due to lithium (possibly in conjunction with other somatic factors) in the form of interstitial nephritis. However, for the vast majority of patients, the renal effects of lithium are benign. Current strategies for minimising the renal effects of lithium include: (i) assiduously avoiding episodes of renal toxicity; (ii) monitoring serum lithium concentrations in order to achieve optimal efficacy at the lowest possible concentration; (iii) monitoring serum creatinine levels on a yearly basis, getting further medical evaluation when the serum creatinine level consistently rises above 140 mmol/L (1.6 mg/dl); and (iv) possibly administering lithium once a day.
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Affiliation(s)
- M Gitlin
- University of California, Los Angeles, Department of Psychiatry, USA.
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Abstract
The objective of this study was to predict suicidality in people with schizophrenia. Ninety-six patients with recent-onset schizophrenia were rated every 2 weeks for 1 year to examine (1) the temporal course of suicidal ideation and suicide attempts and (2) the extent to which anxiety, depression, and mild suicidal ideation were followed by significant suicidal ideation or a suicide attempt. The severity of suicidality changed rapidly. Low levels of suicidal ideation increased the risk for significant suicidal ideation or a suicide attempt during the subsequent 3 months. Depression was moderately correlated with concurrent suicidality, but not independently associated with future suicidality. Therefore, low levels of suicidal ideation may predict future suicidal ideation or behavior better than depressed mood in individuals with schizophrenia.
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Affiliation(s)
- A S Young
- Department of Psychiatry, University of California, Los Angeles, USA
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25
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Abstract
OBJECTIVE Two questions were posed: Does stress precipitate episodes of bipolar I disorder, and does sensitivity to stress differ in episodes later in the course of illness compared to early ones? METHOD Fifty-two patients with bipolar I disorder were followed longitudinally for up to 2 years; clinical course was monitored, and interview assessments of life events were made every 3 months. RESULTS The patients who had episodes of illness during follow-up had experienced significantly more severe stressors and more total stress in the preceding 6 months, and more total stress in the preceding 3 months, than those without episodes. Inconsistent with Post's stress "sensitization" hypothesis, patients with more prior episodes were more likely to have episodes following major stressors, and they relapsed more rapidly. CONCLUSIONS Stressors may precipitate episodes of bipolar illness, especially for patients with more prior episodes. Different versions of the stress sensitization model remain to be tested.
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Affiliation(s)
- C Hammen
- Department of Psychology, University of California, Los Angeles, 90095-160, USA.
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26
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Abstract
OBJECTIVE Given concerns about use of psychotropic medication during pregnancy, the authors reviewed the literature regarding the effects of prenatal exposure to psychotropic medications on fetal outcome. METHOD A MEDLINE search of all articles written in English from 1966 to 1995 was performed to review information on the effects of psychotropic drug use during pregnancy on fetal outcome. Where sufficient data were available and when methodologically appropriate, meta-analyses were performed to assess risk of fetal exposure by psychotropic medication class. RESULTS Three primary effects are associated with medication use during pregnancy: 1) teratogenicity, 2) perinatal syndromes (neonatal toxicity), and 3) postnatal behavioral sequelae. For many drug classes there are substantial data regarding risk for teratogenicity. Tricyclic antidepressants do not seem to confer increased risk for organ dysgenesis. The available data indicate that first-trimester exposure to low-potency phenothiazines, lithium, certain anticonvulsants, and benzodiazepines may increase the relative risk for congenital anomalies. However, the absolute risk of congenital malformations following prenatal exposure to most psychotropics is low. CONCLUSION Exposure to certain psychotropic drugs in utero may increase the risk for some specific congenital anomalies, but the rate of occurrence of these anomalies even with the increased risk remains low. Use of psychotropic medications during pregnancy is appropriate in many clinical situations and should include thoughtful weighing of risk of prenatal exposure versus risk of relapse following drug discontinuation. The authors present disorder-based guidelines for psychotropic drug use during pregnancy and for psychiatrically ill women who wish to conceive.
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27
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Abstract
OBJECTIVE The authors examined individual differences in stress reactivity as well as whether features of the illness itself or psychological characteristics differentiate between patients with bipolar disorder who are highly stress reactive and those who are not. METHOD They assessed stressors and bipolar episodes in 58 patients with bipolar disorder followed for at least 1 year. RESULTS Not only did stress level predict relapse, so did personality variables such as introversion and obsessionality and their interaction with stress. Number of previous episodes of bipolar illness, however, did not affect stress response. CONCLUSIONS These results are not consistent with the view that episodes of bipolar disorder become increasingly independent of stressors after initial episodes. However, psychological traits may affect reactivity to stressors.
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Affiliation(s)
- J Swendsen
- Department of Psychology, UCLA 90024-1563, USA
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28
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Abstract
BACKGROUND Tonic electrodermal measures have been widely used to index autonomic abnormalities in schizophrenia, whereas phasic electrodermal nonresponsiveness has been frequently used to index attentional orienting abnormalities. The primary objective of the present study was to assess whether these electrodermal abnormalities are episode indicators or vulnerability indicators. METHODS Twenty patients with a recent first episode of schizophrenia were tested during symptomatically remitted states and psychotic states. Twenty demographically matched normal controls were tested at two comparable intervals. Testing for stability of abnormalities across remitted and psychotic states allowed us to determine whether tonic and phasic electrodermal measures qualify as episode indicators or vulnerability indicators. RESULTS Tonic electrodermal activity was abnormally elevated only during the psychotic state, which indicates that it is an episode indicator in schizophrenia. Phasic hyporesponsiveness relative to levels of general activation was present in both the remitted and the psychotic states, most strikingly during the psychotic state, and the proportion of patients who were electrodermally nonresponsive tended to be abnormally high during the remission test. CONCLUSION Tonic electrodermal hyperarousal appears to be a state-sensitive episode indicator, whereas phasic electrodermal hyporesponsiveness to innocuous stimuli relative to activation level appears to be a mediating vulnerability factor.
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Affiliation(s)
- M E Dawson
- Department of Psychology, University of Southern California
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29
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Nuechterlein KH, Dawson ME, Ventura J, Gitlin M, Subotnik KL, Snyder KS, Mintz J, Bartzokis G. The vulnerability/stress model of schizophrenic relapse: a longitudinal study. Acta Psychiatr Scand Suppl 1994; 382:58-64. [PMID: 8091999 DOI: 10.1111/j.1600-0447.1994.tb05867.x] [Citation(s) in RCA: 133] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A tentative model for conceptualizing the interplay of vulnerability factors, stressors, and protective factors in the course of schizophrenia is discussed. A study of the initial years after a first schizophrenic episode is testing the predictive role of key factors. During an initial 1-year period of depot antipsychotic medication, independent life events and expressed emotion were found to predict the likelihood of psychotic relapse. Initial analyses indicate that independent life events play less of a role in relapse prediction during a medication-free period. These results suggest that maintenance antipsychotic medication raises the threshold for return of psychotic symptoms, such that relapses are less likely unless major environmental stressors occur. A low expressed emotion environment may be a protective factor.
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Affiliation(s)
- K H Nuechterlein
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles 90024-6968
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30
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Guze BH, Gitlin M. New antidepressants and the treatment of depression. J Fam Pract 1994; 38:49-57. [PMID: 8289052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Depression is a common and significant health problem associated with impairment in a patient's ability to function. The development of new antidepressant medications represents progress in its treatment. These new agents work through the selective blockade of the reuptake of serotonin into the presynaptic neuron, thereby increasing the availability of this neurotransmitter at the synaptic cleft and enhancing its effectiveness. While no more effective than traditional tricyclic antidepressant drugs, the new agents are generally safer than traditional medications used to treat depression: they are well tolerated and, in case of overdose, less harmful than tricyclic antidepressants.
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Affiliation(s)
- B H Guze
- Department of Psychiatry and Biobehavioral Sciences, School of Medicine, University of California, Los Angeles
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31
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Abstract
Attempts to elucidate the pathophysiology of symptom production in mood disorders can be enhanced by information from two sources. First, insights into localization can be gained from the secondary mood disorders; these clinical problems suggest the brain regions that, when altered, are associated with specific symptoms. Second, both structural and functional brain imaging suggest specific regions where abnormalities are associated with mood disorders. Data that emerge from these sources implicate the basal ganglia, frontal cortex, and temporal lobes in the production of mood disorder symptoms. However, the specific neuroanatomic subregions involved and the associated biochemical changes await full elucidation.
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Affiliation(s)
- B H Guze
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles
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32
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Abstract
Research with schizophrenic out-patients has shown that antipsychotic medication reduces relapse rates. This protective factor may operate partially by raising the threshold for relapse in the face of environmental stressors such as life events and high levels of familial expressed emotion. A prospective, longitudinal design was employed in the monthly collection of life-events data with 23 recent-onset schizophrenic out-patients. In a between-subjects ANOVA, a significantly higher frequency of independent life events was found in the month prior to a relapse for ten patients on medication, as compared with the analogous month for 13 drug-free patients. These findings suggest that neuroleptic medication may produce a prophylactic effect by raising a patient's threshold of vulnerability to relapse.
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Affiliation(s)
- J Ventura
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles 90024-6968
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33
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Hammen C, Davila J, Brown G, Ellicott A, Gitlin M. Psychiatric history and stress: predictors of severity of unipolar depression. J Abnorm Psychol 1992. [PMID: 1537972 DOI: 10.1037//0021-843x.101.1.45] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Unipolar depression is frequently a recurrent or chronic disorder. In studies on predicting its course, outcomes are typically linked to either psychiatric features or stressful life events. In order to integrate the 2 approaches, 51 unipolar patients were assessed periodically over at least 1 year for symptoms, stressful events, and chronic stressors. It was hypothesized that adverse family history and early age of onset impair role functioning and coping capabilities, thereby contributing to stressful circumstances that predict severity of depressive reactions. Results of causal modeling analyses supported a model in which background factors were associated with severity of depressive outcomes as mediated by their effects on stress variables. Such a model implicates the self-perpetuating nature of clinical depression, both for the individual and across generations.
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Affiliation(s)
- C Hammen
- University of California, Los Angeles 90024
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34
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Nuechterlein KH, Dawson ME, Gitlin M, Ventura J, Goldstein MJ, Snyder KS, Yee CM, Mintz J. Developmental Processes in Schizophrenic Disorders: longitudinal studies of vulnerability and stress. Schizophr Bull 1992; 18:387-425. [PMID: 1411329 DOI: 10.1093/schbul/18.3.387] [Citation(s) in RCA: 325] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The Developmental Processes in Schizophrenic Disorders project is a longitudinal study of schizophrenic patients who have recently had a first episode of psychosis. The project focuses on discriminating characteristics of schizophrenic patients that are "stable vulnerability indicators," "mediating vulnerability factors," and "episode indicators" by comparing normal subjects to schizophrenic patients assessed in clinically remitted and psychotic states. A parallel project goal is to identify predictors of relapse, social and work impairment, and illness course among potential psychobiological vulnerability factors and environmental potentiating factors. Hypothesized vulnerability factors and potential environmental stressors are examined first under standardized maintenance antipsychotic medication conditions for at least 1 year. Patients showing stable remission of psychosis after 1 year of maintenance antipsychotic medication are invited to enter drug crossover and withdrawal protocols to determine the need for continuous antipsychotic medication. Vulnerability and stress factors are again assessed. A summary of results to date is presented. Deficits in early components of processing visual arrays and in sustained discrimination of successive ambiguous perceptual inputs are relatively stable across psychotic and clinically remitted states in the schizophrenic patients. Performance on a vigilance task demanding active, working memory also remains abnormal during clinical remission but covaries significantly with psychotic state and is a candidate for a mediating vulnerability factor. Autonomic activation level does not appear to be an enduring vulnerability factor, but it predicts the extent of short-term symptomatic recovery and may mediate the impact of stressors. Under conditions of standardized, injectable antipsychotic medication, independent stressful life events and highly critical attitudes toward the patient in the social environment predict relapse risk. Prospective data suggest that signs and symptoms prodromal to psychotic relapse may be present in about 60 percent of patients.
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Affiliation(s)
- K H Nuechterlein
- Dept. of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles 90024-6968
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35
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Hammen C, Davila J, Brown G, Ellicott A, Gitlin M. Psychiatric history and stress: Predictors of severity of unipolar depression. Journal of Abnormal Psychology 1992; 101:45-52. [PMID: 1537972 DOI: 10.1037/0021-843x.101.1.45] [Citation(s) in RCA: 85] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Unipolar depression is frequently a recurrent or chronic disorder. In studies on predicting its course, outcomes are typically linked to either psychiatric features or stressful life events. In order to integrate the 2 approaches, 51 unipolar patients were assessed periodically over at least 1 year for symptoms, stressful events, and chronic stressors. It was hypothesized that adverse family history and early age of onset impair role functioning and coping capabilities, thereby contributing to stressful circumstances that predict severity of depressive reactions. Results of causal modeling analyses supported a model in which background factors were associated with severity of depressive outcomes as mediated by their effects on stress variables. Such a model implicates the self-perpetuating nature of clinical depression, both for the individual and across generations.
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Affiliation(s)
- C Hammen
- University of California, Los Angeles 90024
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36
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Abstract
The authors examined the impact of life stress on the course of bipolar disorder over a 2-year period in a group of 61 outpatients. The patients were followed prospectively with ongoing assessments of stressful life events, symptoms, levels of maintenance medication, and compliance with treatment regimens. As predicted, survival analyses indicated a significant association between life events and relapse or recurrence of the disorder. These effects could not be explained by differences in levels of medication or compliance. Further research is recommended to examine which specific subgroups of bipolar patients are most susceptible to stress.
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Affiliation(s)
- A Ellicott
- Department of Psychology, University of California, Los Angeles 90024
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37
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Hammen C, Ellicott A, Gitlin M, Jamison KR. Sociotropy/autonomy and vulnerability to specific life events in patients with unipolar depression and bipolar disorders. J Abnorm Psychol 1989. [PMID: 2708658 DOI: 10.1037//0021-843x.98.2.154] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Followed samples of unipolar and bipolar patients for a 6-month period, with independent assessment of symptoms and life events. Patients were initially categorized into subtypes using Beck's Sociotropy/Autonomy Scale, with the prediction that onset or exacerbation of symptoms, as well as more total symptoms, would occur for sociotropic individuals experiencing more negative interpersonal events than achievement events, and for autonomous-achievement patients experiencing more achievement events than interpersonal events. Results were confirmed for unipolars, indicating that the course of disorder was associated with the occurrence of personally meaningful life events, but not for bipolars. Further research is recommended to examine whether the effect is equally robust for both subtypes of unipolars, whether longer study duration may be required for bipolars, and whether a cognitive self-schema mechanism may account for the specific vulnerability to a subset of stressful events.
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38
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Hammen C, Ellicott A, Gitlin M, Jamison KR. Sociotropy/autonomy and vulnerability to specific life events in patients with unipolar depression and bipolar disorders. Journal of Abnormal Psychology 1989; 98:154-60. [PMID: 2708658 DOI: 10.1037/0021-843x.98.2.154] [Citation(s) in RCA: 147] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Followed samples of unipolar and bipolar patients for a 6-month period, with independent assessment of symptoms and life events. Patients were initially categorized into subtypes using Beck's Sociotropy/Autonomy Scale, with the prediction that onset or exacerbation of symptoms, as well as more total symptoms, would occur for sociotropic individuals experiencing more negative interpersonal events than achievement events, and for autonomous-achievement patients experiencing more achievement events than interpersonal events. Results were confirmed for unipolars, indicating that the course of disorder was associated with the occurrence of personally meaningful life events, but not for bipolars. Further research is recommended to examine whether the effect is equally robust for both subtypes of unipolars, whether longer study duration may be required for bipolars, and whether a cognitive self-schema mechanism may account for the specific vulnerability to a subset of stressful events.
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39
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Tamir D, Gitlin M, Mansur R. [A community program for the prevention of anemia in infants]. Harefuah 1983; 104:411-3. [PMID: 6674055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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40
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Palti H, Peritz E, Flug D, Gitlin M, Adler B. Comparison of head circumference in an Israeli child population with United States and British standards. Ann Hum Biol 1983; 10:195-8. [PMID: 6838166 DOI: 10.1080/03014468300006351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The head circumference (HC) growth pattern of infants from 1 to 24 months of age was studied in a Jerusalem community. The means of HC of the study population are smaller for each age and sex group than those of the National Center of Health Statistics, USA reference population, London children and the Nellhaus standard. The regression of HC on length explains about 20% of the variance. In an analysis of variance controlling for social class, birth order and length, the differences by region of origin of the mother were not significant. The smaller HC of the study population is probably due to these children being shorter and lighter than the above-mentioned western populations. Malnutrition as a factor for small HC was excluded.
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41
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Gitlin M. Questioning a contraindication of propranolol. Am J Psychiatry 1981; 138:1261-2. [PMID: 7270745 DOI: 10.1176/ajp.138.9.aj13891261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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42
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43
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Palti H, Adler B, Flug D, Gitlin M, Shamir Z, Tepper D, Kark SL. Community diagnosis of psychomotor development in infancy. Isr Ann Psychiatr Relat Discip 1977; 15:223-31. [PMID: 74369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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44
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Palty H, Gitlin M, Shamir Z. [Anemia in infancy--a community program for survey and evaluation of treatment]. Harefuah 1976; 91:69-72. [PMID: 976837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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